ORAL HEALTH DELIVERY PLAN 2013-2018 INITIATED BY: SUPPORTED BY: APPROVED BY: Director of Primary Care, Community & Mental Health Cwm Taf Oral Health Advisory Group Executive Board DATE APPROVED: 18 December 2013 1
CONTENTS Page No. Foreword 3 1. Background and Introduction 4 2. Oral Health Profile of Cwm Taf 5 3. Oral Health Improvement Programmes 12 3.1 Designed to Smile 3.2 Cwm Taf Tooth brushing Programme 3.3 Mouth Care for Adults in Hospital 3.4 Integration of Oral Health into care plans of vulnerable groups 4. Dental Services Delivery 16 4.1 General/Personal Dental Services 4.2 Community Dental Services 4.3 Unscheduled/Urgent Dental Care 4.4 Hospital based Specialist Services 5. Integrated Service Planning, service development and improvement 29 6. Governance, Quality and Patient Safety 35 7. Education, Training, Research and Development 40 8. Prioritised Actions for 2014/15 43 9. Conclusion 47 2
FOREWORD The National Oral Health Plan (NOHP) for Wales outlines a series of actions for improving oral health and reducing oral health inequalities in Wales over the next five years and beyond. The Plan fits in well with the Welsh Government s vision for the NHS in Wales outlined in Together for Health. Cwm Taf Health Board has developed this Local Oral Health Plan (LOHP) to respond to each of the actions identified in the NOHP in order to address the oral health needs of the residents of Merthyr Tydfil and Rhondda Cynon Taf. The skills, experience and dedication of the dental workforce are, and will remain, a vital resource upon which we will need to draw in order to achieve change. Oral health is an intrinsic part of general health and it is the responsibility of everyone involved in delivering health services, to play a role in helping to deliver the oral health improvement we need to see. There remain sharp differences between individuals with the best and worst oral health in Wales and in Cwm Taf and our performance lags behind similar areas in some important aspects. Sustainability lies at the heart of our agenda and good health is vital to the creation of a prosperous, successful and sustainable Wales. We must improve the health of everyone in Cwm Taf and pay particular attention to the young and reduce health inequalities. We must ensure we have modern NHS dental services delivering high quality care. Prevention is at the core of the Plan. Reducing the risk factors that lead to oral disease is only possible if the delivery of dental services and oral health improvement programmes are oriented towards primary health care and prevention. One of our major goals must be to help people take responsibility for ensuring their own good oral health. By working together, we believe we can make a real and sustainable difference to the oral health of our population. DR C D V JONES CHAIRMAN 3
1. BACKGROUND AND INTRODUCTION The Health Board is responsible for improving the oral health of its population and reducing inequalities across Cwm Taf. The Health Board commissions dental services to improve access for routine, urgent and specialist dental services and aims to reduce inequalities and integrate prevention in the delivery of dental services across Cwm Taf. The Health Board has a duty to develop a Local Oral Health Plan to address the oral health needs of its residents, and clearly describe how we will ensure good governance in commissioning and delivery of all dental services (NOHP Action 1). The Health Board is expected also to work with dentists and their teams, and all other relevant stakeholders to develop and support delivery of Local Oral Health Plan (NOHP Action 2). This includes engagement with public and patients to understand their oral health need. This Local Oral Health Plan has been developed in conjunction with the Consultant in Dental Public Health and shared with members of the Cwm Taf Oral Health Advisory Group (OHAG) which has primary and secondary care practitioners amongst its membership together with the Community Dental Services. The OHAG is responsible for strategic advice on improving oral health, developing dental service provision and identifying innovative ways of delivering oral health and dental services within Cwm Taf. Wherever possible, the Health Board will deliver these services in a primary care setting. This Local Oral Health Plan and the associated actions will form the work programme for the OHAG for the next 5 years and progress will be monitored through the quarterly meetings of the Group. The Health Board has robust clinical governance arrangements in place to monitor general dental services via its Dental Quality and Patient Safety Group, which meets on a quarterly basis. The Dental Quality and Patient Safety Group provides professional advice to the Health Board with regard to contract monitoring to ensure practices deliver a high quality, safe, consistent and effective dental care for patients which represents good value for money. Secondary care services are monitored through the Acute Service Clinical Governance Committee and linked to the overarching Health Board Clinical Governance Committee. In addition, the Cwm Taf Healthcare Professionals Forum meets regularly to provide a balanced, independent, multi disciplinary view of healthcare professional issues and to advise the Board on local strategy and delivery. 4
The Local Dental Committee (LDC) representative on the Forum is also a member of the OHAG. Continue to seek professional support and advice from the Oral Health Advisory Group which includes the Consultant in Dental Public Health and a representative of the LDC. Continue to work with the Community Health Council and the Third Sector to improve engagement with patients and the public and use the information to plan and improve services. Continue to link with the Cwm Taf Healthcare Professionals Forum to seek a balanced, independent, multi disciplinary view of dental healthcare professional issues when appropriate. Include issues relating to primary dental care as part of its annual primary care reporting process, and include them in our Annual Quality Statement (NOHP Action 12). The Setting the Direction Assurance Collaborative will continue to review the primary care dental services dashboard. 2. ORAL HEALTH PROFILE OF CWM TAF In Wales, people in the most deprived areas have higher levels of mental illness, hearing and sight problems and long-term conditions, particularly chronic respiratory diseases, cardiovascular diseases and arthritis. Oral health is also closely associated with deprivation. Hence, people living in the most deprived communities in Wales have multiple chronic diseases as well as the worst oral health. Tooth decay, although preventable, is the most prevalent chronic disease. 47% of adults (2009), 27% of 12 year olds (2008/09) and 36.5% (2012/13) of 5 year olds in Wales have obvious untreated tooth decay. Tooth decay is a significant public health problem. (a) Tooth decay National dental surveys provide pictures of the dental health of the population in Wales. Overall, the dental health of the Welsh population has been improving over the last four decades. However, the dental health of children in the Cwm Taf area is one of the worst in Wales. DMFT (for adult / permanent teeth) and dmft (for baby / deciduous teeth) are commonly used indicators of dental health. DMFT/dmft is the total number of teeth in a person that are decayed, filled or missing (extracted due to decay). 5
Children There is wide variation in distribution of tooth decay within the Health Board. The majority of tooth decay is present in the deprived communities. The most recent five year olds dental survey carried out in 2011/12 reported that 50.7% of five year olds in Cwm Taf had experienced tooth decay 1, i.e. dmft >0 (51.8% in Merthyr Tydfil and 50.4% in Rhondda Cynon Taf). Average dmft per five year old was 1.9. However, among those with dmft >0, on average 3.7 teeth were affected. When compared to the previous survey in 2007/08, there was no significant change in dental health of five year olds. Average dmft of five year olds in the most deprived communities in 2011/12 was 2.78. This is almost twice the average dmft of five year olds living in the least deprived communities (1.43). The Health Board needs to put additional effort into improving the dental health of 0-5 year olds and aim to reduce dental health inequity. The most recent survey of 12 year olds was carried out in 2012/13. However, the results of this survey are not yet available. In 2008/09, 50.8% of 12 year olds in Cwm Taf had experienced tooth decay, i.e. DMFT > 0, the worst in Wales (42.7% in Merthyr Tydfil and 51.4% in Rhondda Cynon Taf). Average DMFT for Cwm Taf in 2008/09 was 1.2. Average DMFT of 12 year olds in the most deprived communities in the Health Board was 1.38 compared to 0.62 in the least deprived communities. It has been proposed that the National Dental Epidemiology Programme will be carrying out a survey of 3 year olds in 2013/14. Findings of this survey should improve our understanding of development of tooth decay in early years. Support and participate in National dental epidemiology programme including the 3 yr old s survey in 2013/14 - (please see CDS and D2S section for further actions on tooth decay). Adults Adult Dental Health Surveys (ADHS) have been carried out every ten years since 1968. However, results are only available at an all Wales level. ADHS carried out in 2009 found that 47% of dentate adults in Wales had tooth decay with average number of 1.1 decayed teeth per person. 1 A child with experience of tooth decay i.e. dmft > 0 means he/she has at least one tooth which has decay or filling or has been extracted due to decay. 6
Ten percent of adults did not have any of their own teeth. In 2009, 58% of adults aged 75 yrs and over in Wales were dentate, i.e. had one or more of their own teeth, compared to 18% in 1988. Eight percent of adults in Wales reported current dental pain. Over half of dentate adults in Wales (51 per cent) were classified as having a high sugar intake, i.e. they consume cakes, puddings, biscuits, pastries, sweets, chocolate or fizzy drinks six times a week or more. High sugar intake is relevant for both tooth decay, obesity and obesity related diseases. Almost three quarter of adults reported receiving dental hygiene advice from a dental team. However, 77% had visible plaque on average of 7.7 teeth (32% of their teeth). 67% of dentate adults had visible calculus. Although more adults in Wales in 2009 reported receiving dental advice from a member of a dental team compared to 1998, oral hygiene practice and its effectiveness at home seems to have worsened. This finding reconfirms the established knowledge that oral health education and instruction without delivery of fluoride based prevention is unlikely to make impact on oral health of the population. Hence, all oral health programmes and dental service delivery should include delivery of fluoride to the population. Health Board Action Work with partner organisations to promote better oral health and encourage patients to take responsibility for their own health. Patients will be encouraged to attend a dental practice on a regular basis and prevention will be integrated into treatment service delivery wherever possible Vulnerable Groups There is sufficient evidence in the literature that vulnerable groups (vulnerable older people living in care homes or their own homes, patients with mental illness, learning disability, substance misuse, looked after children, homeless etc.) have either a higher level of unmet oral health need or higher level of extraction rate compared to the general population. In Wales, oral health data on vulnerable groups is lacking or insufficient for planning purpose. National dental health survey of care home residents was carried out in 2010/11. Dental health of care home residents in Wales is poor compared to independently living adults in their own home. In 2010/11, 73% percent of dentate care home residents in Wales had tooth decay and 13% reported current oral pain. Older people have higher levels of frailty, dementia and chronic diseases, often in combination with each other. These co-morbidities, presence of dry mouth 7
and lack of appropriate preventive oral care puts dependent older people at high risk of dental diseases. Health Board Action Ensure dental service provision for all vulnerable groups, mainly through the Community Dental Service (CDS), and work with partners to include oral health prevention into care plans, starting with care home residents. (b) Gum Disease (Gingivitis and Periodontal disease) Poor oral health, smoking, stress and systemic diseases like diabetes are risk factors for gum disease. Fifty six percent of dentate adults in Wales had bleeding gums and 50% had periodontal pocket of 4mm or more. As increasing numbers of people keep their teeth into their old age, prevalence of periodontal disease is also likely to rise. Only 71 percent of dentate adults in Wales reported brushing their teeth twice a day. 77% of dentate adults had visible plaque on their teeth. Many systemic diseases and their treatment have implications on oral health. Similarly, increasing numbers of researches are exploring the links between gum disease and systemic diseases. Effective oral hygiene at home and smoking cessation are the most important factors in prevention and treatment of gum disease. All smokers who attend a dental practice should be provided with information on effect of smoking on health (including oral health) and offered referral to a local smoking cessation service Work with the Dental Services providers so that they encourage smokers to quit and provide information on local smoking cessation services Make a strong case for inclusion of health promotion especially smoking cessation in the new dental contract being developed by the Welsh Government (c) Oral Cancer Between 1995-2009, the average number of head and neck cancer patients registered in the all Wales database per year was 476 (328 males and 149 females; total number of patients alive 2991, rate of 99.7 per 100000 population). The average age of patients at diagnosis is about 65 years. Approximately 23% of these patients die within the first year of diagnosis (compared to 20% in England) and approximately 45% within five years of diagnosis. 8
Between 1995-2009, there were 285 living head and neck cancer patients in Cwm Taf. Oral cancer is predominantly a disease of males over the age of 50 yrs. However, its incidence in females and younger adults is increasing. Although the rate of oral cancer in the population is low, its impact can be devastating. Incidence of oral cancer is highest in the deprived population in Wales. The most important risk factors are tobacco usage and excess consumption of alcohol. The link between exposure to the sun and lip cancer is well established. There is increasing evidence of the role of Human Papilloma Virus (HPV) in certain oro-pharyngeal cancers. Tobacco smoking, alcohol consumption or a combination of the two cause an estimated 80% of oral cancer cases. Effective tobacco and alcohol control plans will be important to reduce the incidence of oral cancers. Early referral, diagnosis and intervention in oral cancers are important to lessen the burden of disease on the local population and the NHS. Ensure that there are targeted and integrated local actions on raising awareness of oral cancer and its risk factors. Work with the Welsh Government, Public Health Wales and others to ensure national campaigns reach high-risk groups (e.g. Mouth Cancer Awareness and National Smile months (NOHP Action 15). Work with PGMDE to ensure that the dental actions contained within the Tobacco Control Action Plan (TCAP) are taken forward (NOHP Action 10). Health Board will work with the local dental services and other appropriate stakeholders such as Stop Smoking Wales/Public Health Wales, Ash Wales and postgraduate Medical and Dental Education (PGMDE) so that dental services are offered brief intervention training and included in the local plan for tobacco control especially smoking cessation. Work with the PGDME to develop a new programme in smoking cessation training aimed at the primary care dental setting both as an in practice module and centre based. Develop proactive targeted communications materials for local communities to link in with National Smile Month and Oral Cancer Awareness Month, to be issued via local media and Health Board communications channels, including websites, social media and e- publications (Your Healthcare) 9
Continue to promote positive oral health messages in all press releases/communications materials linked to the subject. Recent examples include highlighting the risk factors for mouth cancer and some of the prevention messages in a feature about the introduction of alcohol detox for patients undergoing surgery for head and neck cancer and promoting free NHS dentistry for people, who are not currently registered with a dentist at Ysbyty Cwm Cynon. (Please see other relevant actions under the Hospital based Specialist Services and Integrated Service Planning and Delivery sections). (d) Others Tooth Surface Loss (TSL) Tooth surface loss is an increasing problem mainly due to increasing consumption of acidic drinks. Sixty-seven per cent of dentate adults had wear on their anterior teeth in 1998, compared with 87% in 2009; 2009 ADHS found that 2% of adults have severe tooth surface loss (tooth wear) on their anterior teeth. These patients require prevention and expensive and complex oral rehabilitation. It is important to include oral health message on dental erosion in oral health programmes, diet/nutrition programmes and relevant health services such as the Eating Disorder Service. Health Board Action Explore areas where messages on tooth surface loss especially tooth erosion can be integrated into existing health improvement programmes and services. Oral and Maxillofacial Injuries Head and neck injuries range from simple loosening of teeth and cut in the skin to complex injuries requiring multidisciplinary surgery and care. There is approximately 1 facial injury per 100 people per year and the incidence is rising 2. Many people with oral and maxillofacial trauma attend A&E departments and receive care from maxillofacial departments in secondary care. Fall, violence (mainly alcohol related), road traffic accidents and contact sports cause these injuries. Alcohol plays a major role in violence. Majority of the assault include trauma to face and teeth. Hence, a reduction of assault in the local communities and effective 2 British Association of Oral and Maxillofacial Surgeons http://www.baoms.org.uk/what_is_oral_and_maxillofacial_surgery/sub_specialist_areas/trauma 10
alcohol control actions should also reduce burden of oral and maxillofacial injuries. Health Board Action Carry out work to understand more about the local burden of oral and maxillofacial trauma and work with partners to reduce the burden of oral and maxillofacial trauma. (e) Implications of changing demographic The Cwm Taf population increased by 1.7% between the two censuses in 2001 and 2011. There were 293,229 people living in the Health Board in 2011 (234,343 in Rhondda Cynon Taf and 58,851 in Merthyr Tydfil). Population of 65 yrs and over increased by around 6.6% between 2001 and 2011 (around 46,866 in 2001 to 50,170 in 2011). During the same period population of 80 yrs and older increased by 11.8%. Hence, the local population is increasing but most of the increase is because of the increase in older people. This trend is similar to the national trend seen in Wales. Decennial Adult Dental Health Surveys show that the dental health of adults has improved over the last four decades. Increasing numbers of older people are retaining their own teeth into older age compared to their predecessors. Many teeth of older people have fillings, including complex restorations. In terms of need for dental services, adults aged 45 yrs and over pose the greatest challenge in the future for the Health Board. They will retain most of their own teeth, many with dental fillings including crowns, into old age. With presence of chronic diseases, dementia and cancers, complexity of care required by older people in future will increase. Hence, it is important that this cohort of adults are exposed to regular dental prevention throughout their life course so that they are able to enjoy good oral health into their old age and future demand for complex dental care is reduced. Monitor and aim to improve delivery of oral health promotion and prevention to older people through dental services and other relevant services. Assess areas where oral health assessment, promotion and prevention could be incorporated into appropriate public health programmes, chronic disease management and care planning of patients with mental illness, dementia, cancer, learning disability etc. 11
(Please also see sections on the Welsh Dental Contract Pilot and integration of oral health into care plans) 3. ORAL HEALTH IMPROVEMENT PROGRAMMES 3.1 Designed to Smile (D2S) The D2S team continues to work closely with special care schools, primary schools and pre school settings to provide the core elements of the D2S programme, supervised tooth brushing and fluoride varnish application. In RCT 92% of primary schools (includes special care) participate in the tooth brushing programme with 78% participating in the fluoride varnish element. 95% of the pre school settings participate in the tooth brushing; this group are not targeted for the fluoride varnish application. During the previous financial year, 4 members of staff attended the OCN Community Nutrition course update; all staff have previously attended the training and obtained a certificate in this course. The D2S team continues to work closely with the Healthy Schools team to provide consistent health messages for parents, pupils and teaching staff. The team also works with Flying Start and Sure Start, alongside the Health Visitors, to provide support and advice at weaning groups and breastfeeding support groups. A member of the D2S Team provides expert advice at steering groups across RCT and Merthyr Tydfil, including healthy schools, healthy and sustainable pre schools, Core Aim One, OHAG. The teams take every opportunity to engage in health and community events and this enables contact with parents, families and children and helps to raise the profile of the Designed to Smile programme. Ensure the continued participation in evidence based community oral health promotion programme- Designed to Smile (NOHP Action 3). Ensure that relevant staff working in the primary and community setting, e.g. health visitors in Flying Start, school nurses, nursery nurses etc, continue to provide oral health promotion to young children and encourage attendance at a dental practice, especially to improve attendance rates of 0-5 year olds in the most deprived communities. Continue to work with C&V UHB CDS to support and deliver the D2S programme, including collection and reporting of activities, as per the Welsh Government requirements. 12
Monitor local delivery of D2S programme via multi-professional local D2S Steering Group and ultimately the Executive Board. Ensure that the D2S programme is delivered in partnership with the Healthy Schools Network and other health and social care programmes targeted at early years and families in the deprived communities e.g. Flying Start. Ensure that the D2S staff are trained in nutrition and deliver oral health training to relevant staff working in primary and community setting e.g. health visitors in Flying Start, school nurses, nursery nurses etc. Work with the Local Authorities and schools to encourage targeted participation in the tooth-brushing programme and to promote oral health education for the whole school. 3.2 Cwm Taf Tooth Brushing Programme In addition to the Designed to Smile programme the Health Board funds its own tooth-brushing programme for those schools outside the Community First areas. The Health Board employs two oral health educators who have introduced the programme to 38 schools not included in the Designed to Smile programme. Within Cwm Taf there are now only 15 primary schools not participating in a tooth-brushing programme (i.e. 3 schools not participating in the Designed to Smile programme and 12 schools not participating in the Health Board programme). Currently the programme includes tooth-brushing for children in nursery, reception and year 1 classes. In order to promote tooth-brushing at home, children are also given one home pack per year but this will increase to two home packs in 2013/14. The Oral Health Educators also provide oral health education to the remainder of the year groups, if requested. Continue to deliver this local initiative and ensure it is monitored and linked to the wider D2S programme. Increase the number of tooth brushing programme take home packs for children from 2013-14 onwards. 3.3 Mouth Care for Adults in Hospitals 13
Cwm Taf Health Board was one of the initial pilot sites which participated in implementation of an Oral Health Assessment Toolkit for adult inpatients in hospitals. Local piloting was useful for modification of original toolkit and development of an All Wales oral health assessment toolkit currently in use. This has delivered a consistent approach to patient assessment and care planning and showed improvement in overall oral care standards as outlined in the Fundamentals of Care. The Practice Development Nurse has led on improving oral care for inpatients and has already co-ordinated efforts with pharmacy and procurement, to ensure the physical tools are available to clinical areas to meet the requirements of the new (2013) Mouth Care Risk Assessment Tool and the 3- level prescribed action plan. Cwm Taf Health Board has been reviewing priorities for engagement with the 1000 Lives Plus work streams and oral care has been identified within those priorities. Since June 2013: The Practice Development Nurse has attended the 1000 Lives Plus oral care national learning events. A Cwm Taf oral care mini-collaborative has been established, through which the national work can be progressed. Test wards have been identified Staff training has started with support from Community Dental Services. Process measures have been agreed and data collection is progressing. The All Wales toolkit will be used as a minimum dataset when documentation is being designed to comply with the format used by Cwm Taf Health Board wards. The Community Dental Service will continue to roll out and provide the necessary training to ensure that the general nursing teams have the necessary skills promote good oral health, carryout oral hygiene. This aims to prevent oral discomfort and inadequate nutrition, and improve quality of care. It is hoped that with active participation in the 1000 Lives Plus programme further improvements in oral care will be incorporated into practice to support better outcomes for patients. It will also contribute to more confidence for staff who know that they are observing best practice and measuring their performance outcomes. Continue to participate in the 1000 Lives Plus programme to ensure that further improvements in oral care are incorporated into nursing practice to support better outcomes for hospital inpatients. 14
3.4 Integration of Oral Health into care plans of vulnerable groups and others Sustainable improvement of oral health of individual patients and the whole population will require integration of oral health into wider general health and social care. Integration of oral health into integrated care planning (for e.g. care planning of frail and vulnerable older people and people with complex medical and social care needs) will improve quality of care and improve individual s quality of life. The National Oral Health Plan expects that health boards, in partnership with other agencies, will play a major role in integrating oral health into wider health and social care assessments, care plans, and pathways The Health Board has requested representation from the local authorities to join the OHAG to ensure that issues that there is an integrated approach to patients with complex medical and social needs and their oral health. As part of the work the Health Board is undertaking to look at the health and social care needs of people in nursing or residential care. Oral health needs will be included in the assessment of these patients. People with substance misuse issues, including both drug and alcohol users, have poor oral health. Individuals with substance misuse issues are more likely to exhibit other risk factors for oral cancer such as alcohol use and poor diets. In addition, dental trauma is associated with high alcohol consumption and dental trauma / facial injuries may result from alcohol related falls, assaults or fights. Homeless individuals represent a particular at risk group, particularly due to concurrent tobacco and substance (alcohol and drug) misuse. Findings from homeless populations, both street and hostel based, indicated that they have high dental need and anxiety/phobia about dental treatment. A number of dental impacts were commonly reported including toothache, difficulty eating, feeling selfconscious or ashamed of their teeth. Harm reduction does not solely lie with drug and alcohol agencies but spans a variety of services such as criminal justice, housing and health. As such, the Cwm Taf Area Planning Board, which is made up of responsible authorities is responsible for commissioning good quality substance misuse services that responds to local need and improves the health, well being and safety of those directly or indirectly affected by substance misuse. Invite representation from Local Authorities to join the OHAG. Work with relevant stakeholders to include oral health assessment in the Care Needs Assessments of frail and dependent older people (including care home residents). 15
Work with the GPs and other services to integrate oral health into care planning of patients e.g. Learning Disability, Mental Health problems, patients with diabetes. Work with Cwm Taf Area Planning Board, Community Drug & Alcohol Team, GPs and other commissioned substance misuse providers to ensure oral health assessment is included as a part of Health Needs Assessments of People with Substance misuse and make provision for preventive and treatment services as outlined in the Substance Misuse Treatment Framework Health and Wellbeing Compendium published by the Welsh Government in October 2013. 4. DENTAL SERVICES PROVISION WITHIN CWM TAF Dental service provision within Cwm Taf is based on historical provision. General/Personal Dental (GDS/PDS) services provide majority of the dental services to the local population. This service is complemented by the dental services for vulnerable groups via Community Dental Services (CDS) and specialist services based in the hospital. Many patients access specialist services outside the health board boundary. The Health Board engages with the relevant stakeholders in planning and delivery of dental services. It is important that professional advice and public views are considered in dental services planning and there is clinical leadership in re-orientation of dental services especially to integrate prevention and develop intermediate services in primary/community setting. Continue to engage with the Local Dental Committee, OHAG, Community Health Council and directly with patients and public where appropriate in the planning and delivery of dental services and wherever possible move services to a primary care setting. The residents of Cwm Taf can access NHS dental treatment from the following services. 4.1 General/Personal Dental Services (GDS/PDS) GDS/PDS services are provided by independent dental contractors who have contracts with the Health Board to provide the full range of mandatory general dental services. There are currently 37 GDS/PDS practices in Cwm Taf as set out below: - Locality Locality population No. of practices No. of UDAs Ratio of UDAs per patient 16
Merthyr Tydfil 58,800 9 77,725 1.32 Cynon Valley 63,588 8 100,398 1.58 Rhondda 97,945 7 176,670 1.80 Taff Ely 72,867 13 153,376 2.10 Total 293,200 37 508,169 - The Health Board recognises that there are inequities in the distribution of dental services within Cwm Taf. These practices were all established prior to the new dental contract introduced in April 2006 and before the Health Board had responsibility to commission services to address local dental health needs. The Health Board needs to ensure that future commissioning is based on dental need and not demand. There may be opportunities for the Health Board to influence the distribution of GDS/PDS services when Welsh Government implements new dental contract. There are currently dental practices accepting new NHS patients in each of the four localities and Cwm Taf does not seem to have a problem with access to primary care dental services. However there are areas within each locality where access is limited. Hence, the Health Board needs to engage with dental service providers to improve access further. This can be partly achieved by ensuring practices comply with the National Institute of Health and Clinical Excellence (NICE) guidelines on dental recall intervals and robust management of GDS / PDS contracts. The Health Board will ensure that available funding is aimed at areas of highest dental need (see map 1 & 2 below). More than half of the practices in Cwm Taf are currently accepting adults and child patients. A recently produced report Primary Dental Care Service Use and Provision in Relation to Need 2012/13 by the Dental Services, NHSBSA, highlighted that: - In the 24 months preceding 31 March 2013, 61.5% of the resident population of Cwm Taf attended an NHS dentist at least once compared to the average of 58% across the whole of Wales. The number of patients accessing dental services was highest in the least deprived area (68%) with lower levels in the most deprived areas (58.4%). (Inverse Care Law) Attendance rates are related to levels of deprivation as children in the least deprived areas attended an NHS dentist at a higher rate as compared to those in the most deprived areas, (however this data excludes children treated in the Community Dental Service). This pattern is reversed in rates for young adults with higher rates in the most deprived areas - see chart 1 below. 17
The most common re-attendance interval for adult patients was between 6 to 8 months which suggests that a significant number of patients and their dentists are continuing with the long established pattern of twice yearly dental attendance - see chart 2 below. A shorter re-attendance interval, within 3 months, accounts for a higher proportion in the most deprived areas, which is partly due to a greater dental need. * It should be noted that this data does not give the complete picture of dental access in Cwm Taf as it does not include data on the number of patients accessing dental treatment from the Community Dental Service (CDS). Chart 1 shows extremely low attendance rates for children in the most deprived areas as compared to the least deprived areas but the CDS clinics are based in the most deprived areas of Cwm Taf. Chart 1: Access Rates by Age Group for Most/Least Deprived Areas Map 1 below shows the Welsh Index of Multiple Deprivation (WIMD) 2011 score relative to the Health Board area only, i.e. ranking only Lower Super Output Areas (LSOAs) in the Health Board. Those areas shaded yellow are the most deprived relative to the LHB area. Main towns or cities are shown for geographical reference. LSOAs are stable statistical areas with population of 1000 3000 and there are 1896 LSOAs in Wales. Map 2 shows LSOAs in the area which fall into national WIMD 2011 quartiles; i.e. the 25% most deprived to 25% least deprived nationally. Main towns are shown for geographical reference. 18
Map 1: WIMD Score Relative to LHB Area Map 2: WIMD Score National Quartiles Map 3 below shows the number of Cwm Taf patients accessing dental services by LSOA, and shows those areas where access is lowest relative to the area as a whole. Those areas shaded red, (i.e. Merthyr locality) have the lowest levels of patient s accessing dental services and those blue the highest. (Main towns are shown for geographical reference). Map 3 - Access Rate (% of population attending a NHS dentist in 24 month period) for All Patient Ages 19
Work with the GDS/PDS providers to increase delivery of fluoride based prevention and fissure sealant to patients attending dental practices. Continue to monitor general level of GDS/PDS and CDS access and work towards improving inequity in provision/commissioning and utilisation of services. This will include increasing the dental provision in the Merthyr Tydfil locality by agreeing additional Units of Dental Activity to the existing practices. Any available funding will be targeted to the areas of highest dental need and where there is currently least dental provision. Ensure full and appropriate use of the ring-fenced dental budget allocation on primary care dentistry. Review dental attendance rate of 0-5 year olds and improve dental attendance of 0-5 year olds living in the most deprived communities. Encourage and support GDS/PDS providers to work with other primary health care professionals e.g. GPs, health visitors, for delivery of coordinated care. PDS Orthodontic Service Three PDS non-specialist orthodontic providers in Cwm Taf work closely with a consultant in Orthodontics to deliver orthodontic treatment in primary care setting. Cwm Taf patients access primary care based specialist orthodontic services from three specialist orthodontic practices 20
in Cardiff. All PDS orthodontic performers in Cwm Taf are recognised Dentists with Enhanced Skills (DES) in orthodontics. Ensure that management of the current GDS contract considers the requirement to work to the Interim Guidance of NHS Orthodontics in Primary Care, include this requirement in the contract during contract renewal (NOHP Action 17). Work with the MCN & Postgraduate Department to provide training to general dental practitioners regarding referral for orthodontic treatment Welsh Dental Contract Pilot The current dental contract introduced in April 2006 does not have separate payments for quality or prevention. Dentists are paid for reaching an annual target, commonly known as Units of Dental Activity (UDA) target, which takes account of number and types of courses of treatment. The dental contract based on UDA has failed to deliver on prevention and thus unlikely to contribute towards oral health improvement of the population. The Welsh Government is currently piloting various aspects of general dental services delivery to develop a new dental contract that addresses issues of access, quality and prevention. It also aims to remove UDA as a currency for calculating service delivery and payment. At patient level, the main aim is to introduce individualised risk assessment and improve patients oral health over the longer term through prevention rather than simply treating the disease present in the mouth. There are currently 6 pilot practices in Wales with 1 of these practices being based in the Cwm Taf area (i.e. Aberdare). Engage with the Welsh Government in development of new dental contract that delivers on health gain, promotion, prevention and Quality e.g. delivery of evidence based prevention, smoking cessation, participation in relevant national and local health initiatives etc. Continue to work with the Welsh Government and the practice involved in the Welsh Dental Pilot Project to test the new way of working in order to introduce dental contract reform. Engage with the Welsh Government so that Dental Contract reform addresses issues on dental service inequity (Inverse Care Law). 21
4.2 Community Dental Service (CDS) There are six Community Dental Services in Wales. CT UHB does not have its own CDS. The Health Board has a Service Level Agreement (SLA) with Cardiff & Vale University Health Board (C&V UHB) to provide CDS services which include routine and specialist dental services for children (including orthodontics and treatment under conscious sedation, general anaesthesia), domiciliary dental care and Special Care Dentistry for patients with complex needs. CDS also delivers national oral health improvement programme, Designed to Smile, in Cwm Taf and support 1000 Lives Plus Campaign for Mouth Care for Adults in Hospital. The services are provided from locality-based clinics as set out below: Cynon Valley Merthyr Tydfil Rhondda Taff Ely Aberdare Abercynon Kier Hardie Treharris Tonypandy Ynyswen Gilfach Goch Ferndale Pontypridd Talbot Green The Welsh Government collects CDS data on an annual basis and produces a report. Current system of CDS data collection, analysis and reporting does not provide details of CDS services provided in Cwm Taf. Health Board recognises that the accurate detailed CDS data is vital for integrated local service planning. Review and renew SLA and Service Specification with the Cardiff & Vale UHB for the Community Dental Service Work with Cardiff & Vale UHB to improve patient data information system within the CDS so that the Health Board receives regular activity and performance reports that provide an accurate picture of the number of patients accessing the dental services. 22
Work with the Welsh Government so that annual CDS service reports are useful for local service planning and include details about services delivered in Cwm Taf. Work with the Local Authorities and other stakeholders to ensure Looked After Children and other vulnerable children are receiving appropriate dental prevention and continuing dental care. Keep up to date information on waiting lists for vulnerable patients ensuring that patients do not wait longer than the Welsh Government guidelines. Review patient failed to attend rates and implement an action plan to improve DNA rates across all clinics. 4.2.1 Special Care Dentistry Special Care Dentistry (SCD) is concerned with the improvement of the oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of these factors. It pertains to adolescents and adults. It is relatively new speciality within Dentistry. CDS delivers Special Care Dentistry service in Cwm Taf. Continuous development and improvement of care pathways is conducted via the Managed Clinical Network (MCN) where the agenda primarily covers primary, secondary, tertiary care in special care dentistry, domiciliary care, core special care dentistry referral pathway and the sedation/ga pathway. Collaborative working will continue between GDS (General Dental Service), CDS (Community Dental service) and HDS (Hospital Dental Service) via the Oral Health Advisory Group and the joint primary care and CDS bi-monthly meetings to address gaps in the service and where these gaps can be met. The Health Board is represented on the Special Care Dentistry Managed Clinical Network and is working with the CDS and the other secondary care organisations to ensure that the recommendations from the Special Care Dentistry Implementation Plan are implemented to meet the oral health needs of all vulnerable groups. The specific information, referral guidance and referral forms will be distributed throughout the health board, general practice (dental and medical) and the third sector to ensure that all vulnerable groups are targeted with the appropriate information. Historically vulnerable people who required dental treatment under GA have been referred and treated by the consultant led restorative dentistry 23
service within the hospital. Activities are recorded on the Patient Administration System (PAS) which includes the waiting times. This data collection system will continue and the Health Board will make every attempt to ensure that no patients wait longer than the Welsh Government guidelines. Health Board is currently working with the Community Dental Services and the Regional Managed Clinical Network to ensure Special Care Dentistry patients requiring treatment under GA receive appropriate dental care. Use the recommendations from the Special Care Dentistry Implementation Plan to ensure that the needs of all vulnerable groups are addressed (NOHP Action 5). Continue to work with the MCN in SCD and CDS to deliver dental care to SCD patients. Keep up to date information on waiting lists for vulnerable people who require dental treatment under GA, and ensure that patients do not wait longer than Welsh Government guidelines (NOHP Action 7). Develop a hospital based Special Care Dentistry GA services under the CDS for the provision of a GA service for adults with special needs. This service will be linked with the regional Managed Clinical Network (MCN) in Special Care Dentistry and delivered in partnership between the CDS and Oral and Maxillofacial surgery. Ensure that the information related to SCD is subject to regular review and discussion at the OHAG meetings and included as part of the regional MCN discussions on a regular basis. Carry out an estates survey to find out which practices in the GDS/PDS and CDS have accessible dental premises. 4.2.2 General Anaesthesia and Conscious Sedation Services for children The poor dental health of children results in a high need for extractions under general anaesthesia. There is an impact on the child s general wellbeing, disruption of schooling, and for parents having to cope with a young child in pain. Patients with severe learning disabilities or physical impairment may require general anaesthesia as they are unable to cope with dental treatment in a practice. It is unacceptable for children and patients with special needs to wait long periods for treatment, particularly when they are in pain. 24
The provision of general anaesthesia (GA) in general dental practices ceased in 2001 and the service is delivered through hospital setting. The Health Board commissions a GA service from the Community Dental Service to treat children who require dental treatment under GA. These sessions are held twice weekly in the Royal Glamorgan Hospital for children following a triage clinic held in Pontypridd Health Centre. During 2012/13, the Community Dental Service assessed 1,284 children referred by general dental practitioners for a general anaesthetic. These patients were initially triaged in the GA triage clinic and 605 patients then underwent a general anaesthetic for tooth extraction. The introduction of the triage clinic has seen a significant reduction in the number of GAs given to children for the purpose of dental extraction. Provision of appropriate conscious sedation services and effective prevention should reduce the requirement for GAs for dental extractions. All families attending with a child for preoperative assessments prior to attending for a GA at the Royal Glamorgan Hospital receive individualised oral health promotion. Centralised assessment, treatment planning of children referred for dental treatment under GA has resulted in many children being treated using conscious sedation and behaviour management techniques. Collect annual data on the number of children who receive dental treatment, mainly dental extractions under GA (NOHP Action 6) (including children receiving dental extractions through the Oral and Maxillofacial department). Continue to work with the CDS to ensure robust referral criteria and care pathways are in place for children referred for treatment under GA. This includes provision of prevention with aim of reducing repeat GA within same family and provision of sufficient conscious sedation services for children. Continue to monitor the waiting time and annual number of paediatric dental GA and provide information to the Health Board s OHAG, Welsh Government and others as appropriate. 4.2.3 Specialist Paediatric Dentistry Services Community Dental Services deliver Specialist Paediatric Dental Services in Cwm Taf. Many dentists working within CDS has enhanced skills in Paediatric Dentistry. Children requiring specialist or DES in paediatric dentistry services have access to these services via referral from their regular dentist. 25
Ensure provision of specialist Paediatric Dental Service is sufficient to meet the need of the population. Ensure specialist Paediatric Dental service is linked in with the GA and Conscious sedation services and orthodontic services. 4.3 Unscheduled/Urgent Dental Service Patients who regularly attend a dental practice should contact their own dental practice when in pain during weekdays. Health Board expects that the GDS/PDS providers will provide urgent dental care to their patients during surgery opening hours. Patients who do not receive regular care from a dental practice can access urgent in hours dental treatment on weekdays. Sessions are held daily (Mon to Fri) in the Health Board s Dental Teaching Unit (DTU) plus an additional 2 sessions are commissioned from the Community Dental Service. In total 7 access sessions are provided during weekdays for patients who are in pain but do not have a regular dentist. In addition dental sessions are held in Pontypridd Health Centre on weekends and bank holidays for all Cwm Taf patients and visitors who are in pain. Out of Hours unscheduled care is accessed via telephone triage during evenings, weekends and bank holidays. Patients are given advice and when appropriate offered an appointment at a clinic providing urgent dental care. During 2012/13, 5,805 patients accessed urgent dental care from either the weekday or the weekend service. Continue to monitor provision of Urgent Dental Care in the Health Board and ensure everyone living in Cwm Taf has access to Urgent Dental Care. Continue providing the weekday urgent dental sessions and work with the Out of Hours service to review the number of patients not being able to access Urgent dental treatment within 24 hours of contacting the service. If necessary increase dental capacity for urgent dental care. Continue to monitor antibiotics only courses of treatment and ensure antibiotic prescriptions are appropriate. 4.4 Hospital Based Specialist Services 26