HILLINGDON PRIMARY CARE TRUST

Transcription

1 HILLINGDON PRIMARY CARE TRUST ORAL HEALTH NEEDS ASSESSMENT OCTOBER 2006 Caroline Bowles (Public Health Information Analyst) Public Health Directorate For Further Information on the General Dental Services (GDS) Contract please contact: Helen Delaitre Primary Care Directorate Tel: Hillingdon PCT Kirk House High Street Yiewsley West Drayton UB7 7HJ October 2006

2 CONTENTS Summary 1. Policy Context A vision for improving dentistry in the NHS A New Contractual Framework The New General Dental Services (ngds) Contract Using the ngds to Reduce Inequalities Benefits of reform London Initiative Choosing Better Oral Health Scope of the oral health needs assessment Methodology Measuring needs Epidemiological needs assessment Provision of current service Identifying gaps in service provision Results Local priorities The recommendations of Director of Public Health Oral Health Needs Epidemiological Approach Mapping Current provision of Dental services Current location Size of dental practices Mapping current services against needs Access to services Current unmet need Current services and need Current services offered by dental practices Vulnerable/ at risk groups Children and Young Adults Older adults, the elderly and other vulnerable groups Young Adults Risk Factors to Poor Oral Health Lack of Oral Hygiene Poor Diet Smoking and Alcohol Consumption Oral Cancer Conclusions and Recommendations Maps Appendices... 40

3 SUMMARY a) This needs assessment was undertaken in order to inform general dental practitioners (GDPs) and the PCT where best to focus effort to improve oral health to reduce inequalities. It draws on data from: The 2001 census and other related data, such as that on deprivation Synthetic estimates of lifestyle behaviours that are oral ill-health risk factors such as smoking and poor diet PCT-held data on previous uptake of service based on registrations with GDPs and on smoking cessation Surveys of decayed, missing and filled teeth in 5 (dmft) and 11 year old (DMFT) children A survey of local GDPs and the range and volume of NHS services provided as well as disabled access and opening hours. b) Tables and maps are provided to detail the local distribution of factors affecting oral health (socio-economic factors, access to practices, vulnerable groups and risk factors). The following areas of Hillingdon had the highest overall oral health needs: Hayes and Harlington: - Botwell, Heathrow Villages, Yeading and Charville Uxbridge: - Yiewsley, West Drayton, Brunel and Uxbridge South c) There are 42 dental practices currently offer NHS general dental services in Hillingdon, but this can range from 10% to 100% NHS. In general, dental service provision was greater in areas of Hillingdon which were less deprived and where oral health was better. These areas are mostly in the north of Hillingdon, within the Ruislip and Northwood locality. Wards with no major areas of identified and unmet need were: Eastcote and East Ruislip, Ickenham, Northwood Hills and Uxbridge North. d) Dental registrations in Hillingdon were below the national average for adults and children and declining, the proportion of adults and children registered with a NHS dentist correlated inversely with the assessed oral health need. The rate appeared slightly higher than expected in Townfield ward, possibly attributed to the local Surestart scheme. e) The decayed missing and filled teeth (dmft) data showed that the oral health of 5 year old children has been worsening over the last few years with a mean dmft of 1.69 in 2003/04 and 2.36 dmft in 2005/06. The care Index is also low showing low provision of service with only 11% of dental caries being restored in this age group. f) This needs assessment should be used to form the basis of the commissioning strategy and to direct PCT investment into areas of greatest need. It should also be a useful resource for GDPs wishing to further develop their NHS services. The PCT intends to revisit the assessment in 12 months to incorporate data from secondary care, community dental and out of hour s services as well as specialist services in primary care.

4 1. Policy Context 1.1. A vision for improving dentistry in the NHS Improving oral health is part of the government s wider public health strategy and they aim to reduce inequalities by enabling people to take control of their own oral health. The new General Dental Services (GDS) contract is part of the governments modernising NHS agenda. The Department of Health has clearly indicated that improving NHS dentistry is a key priority. In 2000 they published Modernising NHS Dentistry: Implementing the NHS Plan 1 which showed the importance of developing a preventive focus within dentistry and commitment to tackle oral health inequalities. Then in 2002 came NHS Dentistry Options for Change. 2 This identified prevention as a key function allowing General Dental Practitioners (GDPs) to focus on preventive measures to combat dental disease and to tackle the serious oral health inequalities particularly in children A New Contractual Framework The new General Dental Services (GDS) Contract (with effect from April 2006) has been developed to help address these issues, reduce oral health inequalities and in particular promote a more preventative approach in dentistry The New General Dental Services (ngds) Contract: Until April 2006 the GDS contract did not allow the NHS to secure services in the mid- or long-term. Nor could the services be targeted on oral health inequalities. These issues are beginning to be addressed through local commissioning of services which was introduced with the Health and Social Care (Community Health and Standards) Act This legislated for far-reaching reform of NHS dental services to deliver the Options for Change objectives, one of which was to assess local oral health needs and commission appropriate services. The new GDS contract is intended to: Improve access to services for NHS patients, Promote clinical effectiveness and best practice Improve the quality of dentists working lives Free-up dentists time for a more preventative approach. All NHS General Dental Practitioners after April 2006 now provide mandatory services which are services generally undertaken by a dentist excluding specialist services. Specialist services are those that fall outside of the mandatory and include orthodontics, oral surgery, sedation and domiciliary. The new GDS contract focuses on preventative care and a significant part of the overall reform is a new system of dental charges. Previously NHS 1 Modernising NHS Dentistry: Implementing the NHS Plan. Department of Health, London, NHS Dentistry: Options for Change. Office of the Chief Dental Officer, Department of Health, London,

5 dental services were paid for on an item of service basis which was seen to encourage quantity rather than quality. The new contract has moved away from this, dentists now enter into new fixed value contracts based on a requirement that they deliver an agreed target of units of dental activity (UDAs), translated from historic data. These units are linked to three bands of patient charges. This is a new national charging structure to provide a greater transparency and clarity about the cost of treatment, providing three bands of patient charges to replace over 400 different charges as was previously the case. Dentists have to accumulate within 4% of their target UDAs or be in breach of their contract Using the ngds to Reduce Inequalities: Under the 2003 Act PCTs have a number of responsiblities and opportunities in reducing oral health inequalities: PCT responsibilities for dental services will extend the remit to assessing local oral health needs and commissioning the appropriate services to tackle long standing oral health inequalities. Dentists will be paid to meet oral health needs and not according to activity with a greater emphasis on oral health and preventative work (e.g. smoking cessation, diet and healthy schools). PCTs will have specific functions in relation to dental public health, including oral health promotion, surveys and school screening to make a real contribution to reducing oral health inequalities Benefits of reform: Dentists will be able to provide more appropriate clinical care, expand overall capacity and spend more time with each patient. The previous system offered dentists little incentive to undertake oral health promotion, but the new contract gives primary care dentists the opportunity to focus on prevention and health promotion, as well as treatment within their contracts with the NHS. The choices for patients also become much more transparent and they should receive more appropriate services as resources for dentistry will become more closely aligned with local need London Initiative: The London Dental Health and Education Strategic Partnership (HESP) produced a consultation paper in June which outlined a future vision to improve the oral health needs of Londoners and reduce inequalities. The consultation proposed 10 key goals for London 2016: Better oral health and reduced health inequalities Improved access to, uptake of, oral and dental care High Quality oral and dental care An integrated system of oral and dental care Care provided by an incentivised workforce with appropriate skill mix Services delivered in dental premises that are fit for purpose Robust Information 3 A Vision for Londoners Oral Health Consultation paper developed by the London Dental Health and Education Strategic Partnership (June 2006). 2

6 Innovation Internationally excellent research Optimal use of resources within health and education 1.3. Choosing Better Oral Health Last year the Department of Health published Choosing Better Oral Health. 4 This identified that maximum improvements in oral health are to be achieved by adopting the common risk factor approach. Interventions to tackle inequalities in general health such as diet, nutrition, tobacco cessation, accident prevention would improve oral health and vice versa. This is reinforced by the implementation of the new contractual arrangements for dentistry and aims: To reduce prevalence of oral disease across all age groups in England To reduce oral health inequalities across all age groups in England To provide NHS, dental practices and other organisations with the information and guidance needed to improve oral health 2. Scope of the oral health needs assessment The overall aim of the oral health needs assessment is to provide evidence based guidance and recommendations for commissioning of dental services under the new contract. The scope of this oral health needs assessment is: To identify current provision of dental services from dental practices To measure the oral health needs of the community especially in vulnerable at risk groups against the provision of services. To identify local gaps in current service provision To identify and map the risk factors for poor oral health against current service provision To support the goals for London from the consultation paper A Vision for Londoners oral health 2016, especially in reducing inequalities and improving access to dental care. 3. Methodology 3.1. Measuring needs: what are the oral health needs of the local communities? An epidemiological approach was used to map the oral health needs Epidemiological needs assessment The needs were assessed using the following information: i. Demographic profile: The oral health needs are associated with age gender and ethnicity. The public health directorate has previously published a report on health and social profile of communities resident 4 Choosing better oral health: An oral health plan for England. Department of Health

7 ii. iii. in Hillingdon based on the 2001 Census 5 and recently published ward profiles 6 for each ward in Hillingdon. These reports were used to assess the needs at small neighbourhood level ( houses, known as output area) based on demographic composition. Socioeconomic profile: The health needs of communities are associated with the socioeconomic profile of the community. The needs of people living in more deprived areas are usually greater than those from the more affluent areas. Unequal access and provision to healthcare according to need can lead to health inequalities. The Annual Public Health Report (APHR) 2003 focused on health inequalities in Hillingdon, the APHR 2005 looked at a preliminary oral health needs assessment focusing on deprivation and registrations. Both reports have been used to assess needs based on relative deprivation. Public health indicators: Dental registration, Decayed Missing Filled Teeth (DMFT) data, synthetic estimates (ONS) of risk factors were all used as proxies to prevalence. The different measures were used against service provision of dental practices to determine any gaps in access to services and where there may be a high need in terms of poor oral health. All data sources used in this needs assessment can be found in Appendix B Provision of current service of the general dental practitioners A postal survey of all Hillingdon dental premises was carried out by the PCT dental team in October The questionnaire (Appendix C) was designed to gather information to help in preparing for the new GDS contract, on dental opening times, staffing, waiting times, and services provided for each NHS dental practice within Hillingdon. There was a good response rate (85%) to the survey with only 7 dental practices not responding including those set up after the survey was carried out Identifying gaps in service provision Main aim: To identify if there are any areas where the current NHS dental provision does not meet the needs of the communities living in the area as described by the new contract, the specialised and additional services provided and by identifying risk factors to poor oral health. The oral health needs were mapped using the geographical information system Arcview version 9 against the current NHS dental provision of the general dental practitioners. This provided a visual map of where the access needs are met and where there are gaps in current provision. 5 Census 2001: Health and Society in Hillingdon: Health Information Report Hillingdon PCT (2003). 6 Ward Profiles. Hilligndon PCT (2006). 4

8 4. Results 4.1. Local Priorities What is recommended by the Director of Public Health (DPH) The DPH s annual report 2003 and ward profiles demonstrated that although Hillingdon is healthier than the UK or London average, considerable inequity within Hillingdon can be demonstrated at locality and ward level and between practice populations. There are pockets of relative deprivation and affluence in many wards, affecting health status. In order to balance up the opportunities for all to have good health, health and related services would have to be distributed according to need. To have a fair share, some populations need and should receive more. The PCT s Vision for Health and its Inequalities Strategy seek to address the health inequalities resulting from poorer access to the wider determinants of good health, including access to health and social care, for its local population. The Annual Public Health Report (APHR) included a chapter on reducing oral health inequalities in Hillingdon which has acted as a preliminary needs assessment for this document and The APHR 2006 will include some additional results and information about this needs assessment Oral Health needs Epidemiological Approach The health Information report 2003, the Annual Public Health Report 2003 and Ward Profiles have detailed the demographic, social and health profile of the communities living in Hillingdon and so are only summarised here. Needs based on demography The London borough of Hillingdon has twenty two electoral wards within three localities in Hillingdon, Ruislip and Northwood, Uxbridge, and Hayes and Harlington (Figure 1). Hillingdon Primary Care Trust covers a population of approximately 246,000 (2001 Census) with urban areas in the southern part but a semi-rural area in the north, yielding a relatively low overall density for a London PCT. The table below shows the total population for the three localities. Each locality had roughly one third of the Hillingdon population residing within their boundaries. The distribution of the Hillingdon population within the 22 wards was fairly uniform (4-5% of total population residing in each ward except for Harefield. The population of Harefield accounted for 3% of the total Hillingdon population. Table 1: Total populations in the three localities 7 Annual Public Health Report 2005; Vision. Hillingdon PCT (2005). 5

9 Ruilsip and Northwood Uxbridge Hayes and Harlington Total population Locality population as % 34.2% 32.2% 33.6% of Total Hillingdon population Age The heath care needs of a population are age dependent. The elderly and the young have different needs. The 2001 Census data show that in Hillingdon, the northern locality of Ruislip and Northwood has a higher proportion of the elderly population. Ickenham in Uxbridge locality has the highest number of over 65 year population. On the other hand, the wards in the south of the borough have a higher proportion of young people. The needs of the communities in these wards will therefore be different from that of the north. There are different oral health needs for different ages: Adult Oral Health: Tooth decay still affects a large proportion of the UK population and one of the most vulnerable groups are the older adults and elderly populations: A significant proportion of people over the age of 75 are still without any natural teeth and the number of adults aged 65 with no teeth is high compared to some EU countries 8. The most recent adult dental health survey 9 found that 54% of adults aged over 16 had moderate signs of periodontal disease in one or more teeth and the more severe form was found in 5% of the population, the majority of whom were aged over 65 years. Children s Oral Health: Many children enjoy good oral health, older children in England now have the best oral health in Europe, as measured by the World Health Organisation (WHO) global database. However, oral disease is still very common in children, especially younger children and there is a gap in the oral health of children in lower socio-economic groups and children in higher socioeconomic groups: The British Association for the study of community dentistry (BASCD) Survey Reports seek to monitor the dental health of children. The recent study 10 shows that there has been no overall improvement in the dental health of 5-year-old children over the last 2 years, sizable groups remain who have a clinically significant burden of preventable dental disease. 8 Choosing Better Oral Health: An Oral Health Plan for England, DoH Nov Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E and White D (2000). Adult dental health survey: oral health in the UK London: The Stationary Office. 10 BASCD Survey Report 2003/04 6

10 The National Survey of Child Dental Health 11 highlights inequalities by social background, for example obvious decay in primary teeth is approximately 50% higher in lower social groups than in the highest social group. The main condition affecting children is dental caries (tooth decay) Too many disadvantaged children carry the avoidable burden of pain, distress and disfigurement associated with severe tooth decay and its treatment. 12 Children and older adults have been identified as vulnerable groups for poor oral health. Their oral health needs and current service provision in Hillingdon are included in more detail later in the report. Population projections to 2011 In October 2005 the Greater London Authority (GLA) released ward level population projections [2005 Round-based Interim Ward Projections 17 th October 2005 (Scenario 8.07)] and these estimate that by 2006 the population of Hillingdon will rise to around 247,422 and by 2011 to 247,981 an increase of 1% on the 2001 mid-year estimate of 245,616. This predicted increase is not distributed evenly throughout the Borough with some wards having a reduction in population while others, such as Brunel, having a projected increase in population of about 7%. In large, the decrease in ward populations occurs in the north of the Borough. Round-Based Ward Population: Projected Changes % Brunel Yeading Yiewsley Eastcote and East Ruislip Botwell Barnhill Pinkwell Heathrow Villages West Drayton West Ruislip Uxbridge South Townfield Uxbridge North Harefield Northwood Charville Hillingdon East Northwood Hills South Ruislip Ickenham Manor Cavendish Ward 11 Children s Dental Health Survey (2003) London Health Observatory (LHO) 7

11 Ethnicity About 20% of the communities that are resident in Hillingdon are from non-white ethnic minorities. The graph below shows that Hayes and Harlington have a higher proportion of communities from non white ethnic background compared to the north locality. Hence in addition to the needs of the younger population, in the south the needs of the ethnic minority groups will have to be considered. Figure A: Ethnic communities in Localities of Hillingdon % of locality population White Mixed Asian Black Chinese Ruislip & Northwood Uxbridge Hayes & Harlington White Mixed Asian Black Chinese Needs based on socioeconomic profile Socio-economic factors are recognised as being key determinants of oral health inequalities. As shown in Figure 2, deprivation is clearly associated in Hillingdon with living in certain areas. These are principally in Hayes and Harlington, but there are also pockets in Uxbridge and West Drayton and to a lesser extent Ruislip and Harefield. Even though the population in Hayes and Harlington is younger than that in the other localities, a higher proportion self-reported to have ill-health in the 2001 Census. The oral health of both children and adults is improving across the country. Advances in medical science, use of fluoride toothpaste, better nutrition and increased awareness of dental health issues have aided this 13. However this is not the case across all sections of society. People living in areas of material and social deprivation and other vulnerable groups have poorer oral health and they often access dental services less frequently. Geographic 13 Understanding Primary Care Dentistry. National Primary and Care Trust Development Programme (NatPact) PEC Papers (2005) papers can be downloaded at 8

12 variation in oral health is marked at both the local and national levels for both adult and children s oral health. Deprivation and Registrations Location of dental practices in deprived areas reduces inequalities in access to dental care. 14 Across Hillingdon PCT there are less dental practices situated in the more deprived areas as shown in figure 2. Proportion of ward population registered with a dental practice (average for ) against deprivation ranking of the ward % of residents registered with dental practice R 2 = R 2 = Adult Child Linear (Adult) Linear (Child) More deprived Deprivation ranking Under the new contract (from April 2006) people are no longer registered with a dentist. However previous registration figures give a good indication of the population that were not accessing dental care and show areas where need is highest for access to services and oral health promotion. 15 The graph above shows overall those living in the poorest wards have the lowest number of dental practices and the lowest uptake of dental services compared to those living in the more affluent wards. However the most deprived ward (Townfield) has higher registrations than the other deprived wards in the borough which could be due to the sure start programme in the ward. The higher registrations indicate an improving oral health in this sure start area. Table 4: Proportion of adults and children registered to NHS dentists for Hillingdon and England in 2003 and December 2003 December 2005 Hillingdon England Hillingdon England Adults registered Children Registered Buck, D. Dental Health, population size and distribution of general Dental Practitioners in England. Community Dental Health : The registration figures are for Hillingdon residents registered to any NHS dentist within or outside the PCT. They do not include people living outside the PCT accessing Hillingdon dental services or information on private practices. 9

13 Table 4 shows in December 2003 Hillingdon s proportion of adults registered with a NHS dentist was 43.5% of the population compared to 45% for England. By December 2005 the England average had rose slightly to 45.8; however the proportion of the population in Hillingdon fell to 41.4% for adults. There is a higher proportion of children (0-17 year olds) registered with NHS dentists compared to adults. In 2003 Hillingdon s proportion of children registered with a NHS dentist was 54.5% of the population compared to 60.7% for England. Similarly to adults this proportion fell in 2005 for Hillingdon to 53.6% of the 0-17 year old population but rose nationally to 62.8%. Overall England has seen a slight rise in registrations over the last few years however Hillingdon has seen below average registrations for both adults and children and this has been decreasing further over the last few years. Figures 3(a) and (b) show which wards have the highest proportions of the adult and child populations not registered with any NHS dentist between 2001 and Both maps show the north of the borough has the highest registrations in than the rest of Hillingdon, especially in Ickenham, West Ruislip, Eastcote and East Ruislip, Cavendish and Manor wards. The south of the borough has very high proportions of adults and children not registered to a NHS dentist. In some wards this is as high as 67-71% of the 18 year old and over population, mainly in the south of the Uxbridge locality (Yiewsley, West Drayton, Uxbridge South and Heathrow Villages) and 53-58% of the under 18 year old population, mainly in the Hayes and Harlington Locality (Heathrow Villages, Barnhill, Yeading and Yiewsley). Unmet need deprivation and registration The populations from the north of the borough, which have higher levels of registrations and low deprivation, may also be accessing private dentists. However this is unlikely in areas in the south of the borough with high deprivation and very low proportions of their population registered to NHS dentists. Therefore this suggests there may be a large proportion of this population not accessing any dentists. This could be due to a number of reasons including a lack of access to appropriate services for the population, a lack of understanding of the importance of maintaining good oral health and confusion of the system which leads to an unwillingness to attend a dentist. Overall, Uxbridge locality has the highest unmet need for adults not registering with NHS dentists and higher deprivation and Hayes and Harlington has the highest unmet need for children. The specific wards within these localities with the highest unmet need are Heathrow Villages, Yiewsley (for adults and children), West Drayton, Uxbridge South, Brunel (for adults), Barnhill and Yeading (for children). Oral health needs are greater in the pockets of greater deprivation. The new General Dental Services contract should be used to proactively reduce the health inequalities across Hillingdon. 10

14 4.3. Mapping Current Provision of Dental services Current Location of dental services Hillingdon has 42 dental practices offering NHS services of some kind (including orthodontics). This varies in terms of commitment across the practices with some offering only 10% of its service to NHS patients and others offering 100% (figure 4). Out of the 42 practices the majority (22) are in Ruislip and Northwood locality followed by 12 in Uxbridge and only 8 in Hayes and Harlington (as shown in Table 2 and Figure 2). This highlights one of the biggest dental problems in Hillingdon which is access to appropriate NHS dental services. Figures 6a) and 7 also show that the population density is the least in the north meaning that the more densely populated areas in the south have fewer dental practices. Table 2: Distribution of NHS dental Practices across Hillingdon (excluding 4 solely orthodontic practices) Locality No. of Dental Resident Resident Practices Population** population per Dental Practice Hayes and 7* 81,701 11,672 Harlington Uxbridge 11* 78,196 7,109 Ruislip and 20* 83,109 4,155 Northwood Hillingdon 38* 243,006 6,395 * Hayes and Harlington and Uxbridge plus one sole orthodontic practice each and Ruislip and Northwood plus two sole orthodontic practices. ** Resident population based on 2001 Census resident population figures from ONS. A recent report 16 showed the average number of persons per NHS dentist in England was 2,373. In Hillingdon the average number of people per dental practice is much higher at 6,395 and there are large variations within the borough. There is a difference of resident population per dental practice of 7,517 people between Hayes and Harlington with 11,672 residents per dental practice and Ruislip and Northwood with 4,155 residents per practice Size of Dental Practices Table 3: Average number of dentists per NHS dental practice and population in Hillingdon* Locality Number of dentists Average per dental practice Average per 10,000 population** Hayes and Harlington Uxbridge Ruislip and Northwood Hillingdon * However only a small proportion may be spending their time as NHS dentists, this does not take into account the number of hours of NHS work they do a week. ** this is a crude rate and does not take into account WTE for dentists that do not work full-time or proportion of NHS work carried out by dentists 16 NHS Dental Activity and Workforce Report, England: 31 March The Information Centre for Health and Social Care (2006). 11

15 Boulos and Phillips (2004) 17 provide a national comparison within their study of the distribution of dentists in all PCTs. They found in 2002 that the average number of NHS dentists per 10,000 population in England was 3.7. In this study Hillingdon s average was between 4 to 5 dentists per 10,000 of the population which was higher than nationally and has since risen to 6.1 in This is still based on 2001 Census population figures to enable an investigation of rates within Hillingdon at ward level. Using 2005 mid-year borough population estimates from ONS shows the rate falls only slightly to 5.8 dentists. Ruislip and Northwood have the highest number of dentists (67) in Hillingdon. However, Hayes and Harlington have on average a higher number of dentists per dental practice, with an average of 4.8 dentists per practice compared to 3 in Ruislip and Northwood; this indicates larger practices in Hayes and Harlington. There are benefits to having larger practices as they can have more diverse staff groups and a greater potential for efficiency. Ruislip and Northwood have the highest number of single handed practices (5) with 2 in Uxbridge and 1 in Hayes and Harlington. Despite this there is still a large shortfall of practices and dentists in the south of the borough compared to the north with on average 8.1 dentists per 10,000 of the population in Ruislip and Northwood compared to only 4.7 per 10,000 population in Hayes and Harlington. Tables 2 and 3 show that Hillingdon has a high number of dentists per resident population however, a much lower number of dental practices compared nationally. This indicates the shortfall is not in the number of dentists but access to dental practices, which is evident in the south of the borough. Access to services covers many domains which are explored in more detail in the following section Mapping current services against needs Access to services Although there are more dentists than ever before they are spending less of their time on NHS work. Some people are unable to get routine treatment they want on the NHS unless they are able to travel. 18 The socio-economic approach in the previous section focused on deprivation and previous uptake of service (registrations to dental practices). The following section looks at the picture in Hillingdon focusing on and the factors that contribute to a poor or good level of access, i.e. travelling distance to dental practices, opening hours and the proportion of dental practices patients that are NHS. 17 Boulos, M.N., & Phillips, G.P. (2004). Is NHS dentistry in crisis? Traffic light maps of dentists distribution in England and Wales. International Journal of Health Geographics 2004, 3:10 18 Understanding Primary Care Dentistry. National Primary and Care Trust Development Programme (NatPact) PEC Papers (2005) papers can be downloaded at 12

16 NHS Commitment In the local postal survey (appendix C) Hillingdon NHS dental practices were asked what their percentage of NHS commitment was. This ranged from 10% to 100% across practices (9 dental practices did not provide information on this). Figure 4 shows that the dental practices with 100% NHS commitment and no private work are situated in the north of the borough. The majority of dental practices across the borough have a high percentage of commitment to NHS. Those with low commitment to NHS are mixed across the three localities; however the lowest of 10% commitment is situated in Uxbridge. Units of Dental Activity Under the new GDS contract Units of Dental Activity (UDAs) are the only means of measuring dentists activity. They replace item of service, capitation and registration. There is also a Unit of Orthodontic Activity (UOAs), which applies in Personal Dental Service (PDS) practices where they see orthodontic patients. Figure 5(a) shows the contracts which have been agreed with each dental practice. It shows there are two with 0 value contracts one in Northwood Hills and the other an orthodontic practice in Uxbridge which set up outside the reference period. There are three practices with child only contracts, offering UDAs only to children, situated in the northern part of the borough in Manor, West Ruislip and Uxbridge North. There are 36 practices offering solely UDAs and 4 offering solely UOAs. However there are 5 practices in total offering an orthodontic service of some kind. In Hillingdon all the dental practices that entered into new fixed value contracts were allocated UDAs based on their historic data in the old system. They correspond to the amount of work each dentist must carry out and give a good indication of provision of service. The number of UDAs (excluding practices offering solely UOAs and those with 0 value contracts) range from under a 1000 to 35,000. Figure 5(b) shows all practices with agreed UDAs and their value across the borough. The greatest number of UDAs is situated in practices in Uxbridge and Hayes and Harlington. The practice with the largest number of UDAs is situated in Barnhill ward. However, Ruislip and Northwood s overall number is the largest amongst all three localities at 131,252 compared to 109,876 in Uxbridge and 103,087 in Hayes and Harlington. This is a result of the larger number of dental practices that are situated in Ruislip and Northwood compared to the other localities. Figure 5(b) also shows that the majority of the wards within Ruislip and Northwood have access to at least one dental practice with higher UDAs (above 7,000) with the exception of Manor ward. In Uxbridge there is good coverage of larger UDAs in Ickenham, Hillingdon East, Uxbridge North, north of Uxbridge South ward and West Drayton all with at least one practice with more than 8,000 UDAs. In Hayes and Harlington there are three wards with the best coverage in the borough of UDAs in Barnhill, Botwell and Townfield all with one practice above 20,000 UDAs. These practices are also in the most deprived areas and show good access to a larger number of UDAs for more deprived communities. 13

17 Unmet need UDAs Despite the best coverage of UDAs in three wards in Hayes and Harlington there are still wards within this locality and Uxbridge that either have access to a dental practice but with low UDAs or no access at all, which stems from the unequal number of dental practices in the south of the borough compared to the north. The highest unmet need of UDAs is in wards with high deprivation, low registrations to NHS dentists, access to dental practices with low UDAs or no dental practice in the ward. The wards with the highest unmet need are Heathrow Villages, Yiewsley, Yeading and Brunel. However, some of the most deprived areas do have access to high UDAs but with a lower number of dental practices. Waiting Times Table 5: Average Waiting Times (wks) for check-up (Ch-Up) and treatment (T-mnt) appointments for dental practices in each locality in Hillingdon Length of waiting times Hayes and Harlington Uxbridge Ruislip and Northwood Hillingdon PCT Ch-up T-mnt Ch-up T-mnt Ch-up T-mnt Ch-up T-mnt No waiting times 1 (14%) 1 (14%) (5%) 0 2 (5%) 1 (2%) Less than 7 days (18%) 2 (9%) 4 (10%) 2 (5%) 1-2 weeks 1 (14%) 2 (29%) 5 (42%) 4 (33%) 5 (23%) 6 (27%) 10(25%) 12(29%) 3-4 weeks 3 (43%) 3 (43%) 1 (8%) 1 (8%) 8 (36%) 6 (27%) 12(29%) 10(25%) More than (17%) (14%) 2 (5%) 3 (7%) weeks No reply 2 (29%) 1 (14%) 4 (33%) 7 (58%) 4 (18%) 5 (23%) 10(25%) 13(32%) *Proportion of dental practices in brackets These results are based on the questionnaire sent out to practices in October There was quite a poor response to the waiting times question within the questionnaire with 25% and 32% of dental practices not providing information on waiting times for check-up and treatment appointments respectively. The lowest responses came from practices in Uxbridge with over half not providing information on waiting times for treatment. Despite this the results in table 5 and figures 6(a) and (b) show that in Hillingdon overall just over a third of patients wanting an appointment for a check-up (40%) or treatment (36%) can obtain one in less than 2 weeks. However, a third of patients have to wait over 3 weeks for both a check-up (34%) and treatment (32%) appointments. Within the localities more dental practices in both Hayes and Harlington and Ruislip and Northwood have waiting times that are more than 2 weeks for treatment compared to less than 2 weeks. Uxbridge has the shortest waiting times but this may be an inaccurate picture due to the large nonresponse rate from the dental practices. Unmet need waiting times The waiting times are longest in Hayes and Harlington where 43% of practices have a waiting time of more than 2 weeks for a check up and treatment. This could be due to the lower number of dental practices in this densely populated 14

18 area (8 practices) and despite larger practices on average there is a large shortfall of dentists in Hayes and Harlington (see table 3) which all contribute to longer waiting times. The wards with the greatest unmet need are all those with longer waiting times, low UDAs, little or no access to dental services and higher deprivation. These are Yeading, Yiewsley, West Drayton, Harefield and Heathrow Villages. Access to services is also influenced by travelling distance, opening hours and out of hours provision of the service (under the new contract this service is now provided by the PCT on a sector basis). The following sections look at the influences these factors have in Hillingdon. Travelling distance Figure 7 shows the population density of Hillingdon, the location of dental practices offering NHS services (excluding four solely orthodontic practices) and a one mile radius around each dental practice to show access to each. The majority of dental practices are situated in the more densely populated areas of their ward; however access is varied across the borough. In Ruislip and Northwood the majority of the residents in each ward has access (within one mile) to more than one dental practice offering NHS services. The north of the borough has a larger elderly population and this shows a good level of access to services in the north of the borough in terms of travelling distance. However the picture changes when looking at the southern area of the borough. In this area (south of Uxbridge locality and Hayes and Harlington locality) there are residents in some wards that live within one mile of a dental practice, which in mostly only one dental practice. However, there are also large gaps in access where residents in densely populated areas (mainly in Uxbridge South, Brunel, Yiewsley, Botwell and Charville wards) have to travel over a mile to access any NHS dental practices. Figure 2 shows that this area has some of the more deprived populations in the borough and the 2001 Census shows a lower access to a car or van than in the north of the borough. Residents in these areas may have to rely on public transport to access the dental services as they are not within easy walking distance and may result in a lower uptake of service. Opening Hours Table 6: Opening hours of dental practices per week in Hillingdon PCT Locality Number of Dental Practices Open less than 5 days a week Open on sat Open Late nights per wk (7pm onwards) Average no. of hours open per week Hayes and 1 1 (open (total of Harlington hours) nights) Uxbridge* 0 5 (avg. open 4 2 (total of hours) nights) Ruislip and 3 3 (avg. open 4 3 (total of 5 40 Northwood* hours) nights) Hillingdon 4 9 (avg. open 4 hours) 7 (total of 11 nights) 41 * For one dental practice in Ruislip and Northwood and one in Uxbridge no information was found on opening hours 15

19 Table 6 shows that Uxbridge locality has the best access to dental practices out of the normal core hours (Monday to Friday 8-6pm); however these are highly concentrated in Uxbridge town centre. Hayes and Harlington has the worst access to out of core hours service with only 1 dental practice open on Saturday and 2 offering late night opening Current unmet need Access overall Registrations to NHS dentists are higher in the north of the borough compared to the south. The south of the borough is also the most deprived area. Deprivation has been linked to poor oral health which shows an increased need in these deprived areas but a lower uptake of service compared to more affluent areas, in large due to the lack of dental practices in the area and a possible poor awareness of maintaining good oral health and hygiene. Travelling distance is longer in the south and waiting times for check-up and treatment are on average longer in practices in Hayes and Harlington. This all shows an unmet need in terms of access to dental services in many wards in the south. The wards with the highest unmet need in terms of access are those areas where there is high deprivation, low registrations to NHS dentists, low provision of NHS service within practices, low UDAs, longer waiting times, no dental practices within a mile and no practice offering longer opening hours. These areas are all situated in the south of the borough and include the wards of Yiewsley, Heathrow Villages, Yeading and Brunel with the highest unmet need Current services and need Current services offered by dental practices All General Dental Practitioners with a GDS contract after April 2006 provide mandatory services which are services generally undertaken by a dentist. Specialist and additional services are those that fall outside the mandatory and include orthodontics, sedation and domicilliary. These are usually provided under a Personal Dental Services (PDS) agreement. PDS were established in England in 1998 as an alternative method of delivering NHS dental services, based on local contracting arrangements. One of the main uses for the PDS scheme was to develop the provision of specialised treatment in a primary care setting, and to help improve access to dental services for adults and children that find it hard to access GDS. There were no PDS pilot sites in Hillingdon. Where a dentist provides solely a specialist service then a PDS agreement is set up with the dentist. There are only a small number of these in Hillingdon, mainly those providing solely orthodontic and domiciliary services. The local survey carried out in October 2005 asked the Hillingdon dental practices about the services they provided and were mainly GDS practices offering some specialised and additional services. The service provision of GDS practices in Hillingdon is shown in the table below. As this information is based on the local survey in 2005 the information was asked on the old system and not 16

20 under the new contract. Hillingdon PCT is hoping to replicate this survey under the new contract asking more detailed questions about the services that each dental practice offers and hope to be able to update the data below when this information is collated. Table 7: Current specialist and additional services offered by dental practices in Hillingdon PCT Type of service Number and Proportion* (%) of total dental practices for each locality offering each service Specialist services Hillingdon Hayes and Harlington Uxbridge Ruislip and Northwood Orthodontics 7 (20%) 1 (14%) 1 (11%) 5 (26%) Sedation** 5 (14%) 3 (43%) 0 2 (11%) Domicilliary 12 (34%) 2 (29%) 1 (11%) 9 (47%) Additional services Hillingdon Hayes and Harlington Uxbridge Ruislip and Northwood Special Needs 12 (34%) 3 (43%) 2 (22%) 7 (37%) Smoking 10 (29%) 1 (14%) 2 (22%) 7 (37%) Cessation Healthy 10 (29%) 2 (29%) 1 (11%) 7 (37%) Lifestyle Mouth Cancer Awareness 17 (49%) 3 (43%) 4 (44%) 10 (53%) Oral Education for teenagers No Response to survey 17 (49%) 4 (57%) 4 (44%) 9 (47%) 7 (17%) 1 (13%) 3 (25%) 3 (14%) * Proportions are of the total no. of dental practices that responded to the survey; not the absolute number of dental practices in that area. **All sedation services (inhalation and IV) Table 1 shows that the majority of dental practices are situated in Ruislip and Northwood locality and therefore the majority of services offered will also be situated in this area (table 7). This makes the three localities difficult to compare; the following sections should help to highlight the unmet need in each area. This information is based on the survey sent out in October 2005 by the dental team in the PCT. There is no information on services on 7 out of the 42 dental practices either due to them not responding to the survey or they were set up after the questionnaire had been sent out. Therefore the proportions for each area are based on the 35 dental practices that responded rather than the total number of dental practices. Looking at the proportion of dental practices that responded to the survey for each area shows overall for Hillingdon the most common specialist service offered in practices is Domicilliary (34% of dental practices) and the most common additional services offered are Mouth Cancer Awareness and Oral Education for Teenagers (49%). The lowest service provision in all practices is Sedation (14%). 17

21 Within the three localities the proportion of services differs. Despite numbers being vastly different (much higher in the north) looking at the proportion of services within each locality shows that Ruislip and Northwood have a higher proportion of their dental practices offering Orthodontics (26% of their dental practices). There is also a much higher proportion offering domiciliary services which reflects their larger elderly population. Hayes and Harlington have the highest number overall and proportion of their dental practices offering sedation services (43%). They also have a higher proportion of their practices offering Special Needs and Oral Education for Teenagers; however the numbers of practices are much smaller than Ruislip and Northwood. Uxbridge offers the least specialist and additional services out of the three localities. The following information should help to determine where there are gaps in services and the areas where further commissioning of services may be needed Vulnerable/ at risk groups to poor oral health Although there has been a general improvement in oral health overall in England there still remain large inequalities in oral health. People who live in areas of material and social deprivation have much higher levels of tooth decay. They are also more likely to have high sugary content to their diet and brush their teeth less often. There are also vulnerable groups in society who have poorer oral health and less access to services. These include children and adults with a learning disability and people with a mental illness who have less teeth, more untreated tooth decay and periodontal disease than the general population. Other groups at risk of poor oral health include those who have been in long-term institutional care and some ethnic minority groups as they are more likely to live in disadvantaged areas. 19 This section will look at some of the main vulnerable groups and whether current service provision is meeting their oral health needs Children and Young Adults Oral Health Needs Poor oral health is linked to deprivation and social exclusion. The 2003 National Child Dental Health Survey 20 showed that 12 year old children in England have the best oral health in Europe. However oral health inequalities still exist for this age group between the more deprived and affluent areas. Also the improvement in oral health does not extend to young children (5 year olds) which have shown no real progress in last few years. 19 Choosing Better Oral Health: An Oral Health Plan for England, DoH Nov National Child Dental Health Survey