An Action Plan for Improving Oral Health and Modernising Nhs Dental Services in Scotland
NHS GRAMPIAN DENTALPLAN 2008- 2012
A PLAN FOR IMPROVING ORAL HEALTH AND MODERNISING NHS DENTAL SERVICES IN GRAMPIAN
July
2008
INTRODUCTION
Key principles to underpin the way ahead:
Stakeholder Consultation
TARGETS FOR ORAL HEALTH IMPROVEMENT IN GRAMPIAN
Dental Health ofAdults (over 16 years)
Dental Health of Primary 1 Children - 5year olds
Dental Health of Primary 7 Children-11 year olds
TARGETS FOR NHS DENTAL REGISTRATION IN NHS GRAMPIAN
Child NHS registrations
Adult NHS Registrations
TARGETS FOR THE DENTAL WORKFORCE IN NHS GRAMPIAN
Total NHS Dentists in Grampian and Scotland 1996 - 2007
Independent Dentists Grampian and Scotland and by CHP
NHS GRAMPIAN DENTAL PLAN 2008-2012
Consultations and National Plans
DEVELOPING PATIENT PATHWAYS OF CARE
Way Forward - A Clinical Network for Oral Health
Main Services/ Pathways for Delivery of Dental Care
ORAL HEALTH IMPROVEMENT
Children
Adults
Services to Improve Dental and Oral Health
Effective Programmes of Care
General and Crosscutting Initiatives
Adults and Older People
ENHANCED DENTAL SERVICES
Enhanced services through local contracting
IMPROVING AND MODERNISING DENTAL PREMISES
Dental Premises
IMPROVING INFORMATION AND COMMUNICATION
PATIENT CHARGING POLICY
QUALITY STANDARDS AND CLINICAL EFFECTIVENESS
EDUCATION AND TRAINING TO DEVELOP AND ENHANCE THE WORKFORCE
Workforce Numbers
Dental Education and training plan
Additional issues that could impact on workforce development
MONITORING AND EVALUATION
RESOURCING THE DENTAL PLAN
Financial Consequences of Programme 1 - Capital 1
Summary Revenue Financial Consequences
APPENDICES
Appendix 1 – Summary Report of Public Feedback
INTRODUCTION
Through this plan NHS Grampianaimsto:
- Help and support people to sustain and improve their oral and dental health with clear priority given to disadvantaged individuals and disadvantaged communities.
- Ensure high quality,local NHS dental services are accessible to all who need such care, delivered through clear patient-focused standards.
The core themes of this plan are to:
Improve oral health through preventive anticipatory care and health promotion
Provide high quality patient-focused care with the patient identified as a partner and a clear understanding of the patient’s contribution to self care
Provide communities with accessible services focused on high quality, effective treatments provided through clearly defined standards
Provide,where there is long term and/orhigh intensity care required, support for both the patient and the carer
Embed sustainable services in local communities through investment in dental services,dentalpremises and leading edge technology.
The public should receive clear information on how to achieve and maintain good oral health, what services they can reasonably expect and what responsibilities they have in return.
Learning the essential skills to secure and maintain good oral health in childhood lays the foundations for a healthy mouth for life.
High quality dental services, utilising the skills of the whole dental team are a key part of this process, supporting individuals in maintaining their oral health (self care) and providing additional care and advice when needed.
Professionals who provide dental services need to feel that a career in NHS dentistry meets their aspirations and provides job satisfaction, professional development and a fair reward. If we are to improve oral health and health services, we must both attract and retain the dental workforce which NHS Grampianneeds.
Meeting NHS Grampian objectives can best be achieved by taking steps to improve both oral health and health services. This will require a genuine partnership between a well-informed public, patients, public organisations and committed professionals.
Key principles to underpin the way ahead
- Oral health as an integral part of overall health improvement
- Oral health improvement supported byhealth policies on healthy eating, reducing addictions such as smoking and through consistent information to the public from all health professionals
- Services for children, young people,elderly and disadvantaged groups focused on prevention and aim to meet the oral health needs of those in the most disadvantaged circumstances.
- Patient-focused standards ensuring high quality services with more transparent information for patients
- A strengthened salaried dental service targeted at those in most need.
- Increasing support for practices demonstrating commitment to the NHS through the provision of NHS services.
- Development of local contracts for enhanced services in general dental services
- Support and encouragement for recruitment and retention of all dental team members
- A workforce trained to deliver services in a way which is effective and complements and supports a preventive approach to care
- Services delivered locally throughintegrated care pathways supported by multi- disciplinary staff, and primary and secondary care service providers
- Oral health improvement supported by free dental services for those in most need and free dental examinations for all population groups
- A local education and training plan to deliver an increase in the number of dental professionals and an increase in dental professionals with enhanced skills.
Stakeholder consultation inthe development of the NHS Grampian Dental Plan 2008-2012
Public and professional stakeholder groups were consulted on the draft Dental Plan. Their views and comments have been incorporated into this amended plan and are summarised in Appendix 1.
Staff and professional groups consultation
Consultation with these stakeholders took place between June 2007 and June 2008.
Last summer members of our Oral Health and Dental Services team held evening meetings across Grampian, attracting over 70 dental professionals who were invited to comment on the future of Oral/Dental Health Services in Grampian. A further series of professional meetings were held with the staff groups based in each Community Health Partnership (total 120 staff).
Feedback
Consistent themes from staff were
- Supportive of direction although targets were extremely challenging
- Welcomed training and education for all members of the team
- Need to prioritise disadvantaged individuals and communities
Public engagement and consultation
Consultation with public and community groups took place during April to June 2008. A user-friendly version of the consultation paper summarising the key targets and actions as set out in the full plan was produced along with a response form.
Feedback from the public consultation
50 people attended the Community Forum meeting on 27th May 2008 and their views and questions were captured in a meeting report. By the close of the consultation over 40 written responses had been received. All responses were collated and analysed according to themes which emerged. A detailed report of the public feedback was produced.
Key points which emerged
Through the public consultation, it is clear that the targets and recommendations as set out in the plan are broadly welcomed and supported by the public, but there were many views expressing some scepticism about the deliverability and affordability of the plan.
People are confused by the current range of dental services available and do not understand the difference between an NHS dentist, salaried dentists and private providers. A campaign to raise understanding of dental service provision using methods like website pages, brochures, posters, newspaper articles, etc has been suggested.
There is a consensus on the need for a consistently appliedfair and transparent system of patient charging.
There is strong support emerging for the actions around oral health improvement as the way to tackle dental disease in the longer term. Prevention is seen as the key with strong support for the actions around health improvement and self-care and improving oral health of children through early interventions and education.
TARGETS for ORAL HEALTH IMPROVEMENT in GRAMPIAN
Dental Health of Adults (over 16 years)
Target 1 AdultsBy 2010 - less than 10% of adults(over16 years) with no teeth
Dental health has improved steadily for Scottish adults although there is little information available on the dental health of adults in Grampian with only one survey published in 1993. Projected trends identified in UK and Scottishdental health data,would suggest that by 2010 less than 10% of Grampian /Scottish adults would have no teeth.
Adult Dental Health in Grampian and Scotland
(Data -Adult Dental Health UK Surveys 1972-1998)
(Data -Scottish Adult Dental Health Survey 1993)
Dental Health of Primary 1 Children –5 year olds
Target 2 Primary 1By 2010 - 60% children with no obvious dental decay
Progress of dental health of children in Grampian has been relatively staticsince 1988. Preschool children in Grampian and Scotland have some of the worst oral health recorded in Europe. In the latest 2006 survey of Primary 1 (5 year old) children starting school, 55.5% of children in Grampian (Scotland54%)recorded no signs of dental decay.
In Grampian there has been little change from 1988 when the recorded level was 53.2%.Scotland in contrast has recorded a consistent trend in oral health improvement over the last 10 years.
The graph below also illustrates the potential benefits ofthe introduction of the recommended oral health improvement programmes outlined later in this plan. Clinical effectiveness reviews confirm that supervised nursery and school toothbrushing programmes and fluoride varnish applications (Childsmile) can lead to significant improvements in dental health.
Percentage of pupils in Primary 1 with no obvious dental decay 1988-2006
(Data from National Dental Inspection Programme –NDIP 1988-2006)
Dental Health of Primary 7 Children-11 year olds
Target 3 Primary 7By 2010 - 60% children with no obvious dental decay
Primary 7 children in Grampian were 10th in a list ranked by dental disease of Scottish health boards. Grampian was below the Scottish average and grouped with health boards in the West of Scotland. These latter health boards record amongst the worst level of dental decay in Europe. Whilst some of this disease can be linked to deprivationa considerable proportion may be linked to lowmotivation, self careand related to poor services.
Data -Selected statistics from the 2005 and 2006 National and Local NDIP
National Dental Inspection Programme - targetingservices
The National Dental Inspection Programme (NDIP) collects data for national statisticsbut also identifies local disease levels. Health Boards use the data to identify areas of high dental need and can use the data to identify areas for preventive services for children.
The following are examples of the targeting process which will define those areas where programmes should be delivered as a first priority due to high need.
CHP / Towns /areas with high dental needMoray / Buckie,South and East Elgin,Dufftown and rural areas to the south of Moray
Aberdeenshire / Banff, Macduff,Fraserburgh,Peterhead,rural areas around Huntly and Oldmeldrum and small coastal villages below Stonehaven
AberdeenCity / Mastrick, Northfield, Torry, Tillydrone, Middlefield
Oral Cancer
Oral cancer trends are not identified by individual health boards in Scotland. Analysis and review of oral cancer incidence and 5year survival needs to be identified for Grampian with appropriate targets set for bothincidence and survival.
TARGETS forNHS DENTAL REGISTRATION in GRAMPIAN
NHSdental registrations in Grampian 1998-2007
In Grampian only 29.5% of adults are registered with the NHS for dental care (Scotland49%). Patients in Moray have one of the lowest registration levels in Scotland with only 15%of adults registered.
Child registration levels are equally poor, with only 57%children registered with the NHSin Grampian, well below the Scottish level -66% of children in Scotland.Moray again records a low level with only 51% of children registered with the NHS.
Additional numbers of children and adults access primary care dental services through the Community Dental Service estimated at over 12,000 per year.There are no recorded statistics for the number of children and adults who access care under private arrangements.
Data ISD Scotland 1998-2006
The above statistics show a concerning fall in NHS registrations over the last 8 years(1998-2006).
Children 73,248 down to 64,715 (- 8533)
Adults 208,765 down to 136,513 (-72,252)
In 2007 the 10 year trend of decrease in registrations stopped and following a low point in September 2007 registration levels have started to rise over the last two consecutive quarters.
Child NHS registrations
Registrations act as an indicator of NHS dental care. Presently NHS Grampian has one of the lowest mainland health board registration levels and compares poorly with health boards such as Glasgow (Glasgow73% children registered).
Anecdotal evidence suggests that for children there is little private dental care.
The Scottish Government has set targets for registration levelsof 80% for 3-5 year olds (HEAT Target).
In order to predict and set targets, the scenario below is presented which would meet the targets set out in the Scottish Dental Action Plan.
Presently child registrations in Grampian stand at 57%, with Moray the lowest level at 51%.The scenario below would suggest that in order to achieve the present Scottish average rate of registration for children (present Scottish average 67%) NHS Grampian would have to increase registrations by over 11,000but to achieve the 2010 ScottishDental Action Plan TargetsNHS Grampian would have to register an additional 25,000 children.
Predicted target setting scenarios for Grampianchildren
0-2 / 3-5 / 6-12 / 13-17 / ChildrenGrampian number / 4,080 / 9,436 / 27,791 / 21,185 / 62,492
Grampian% / 24.6 / 59.0 / 65.8 / 63.3 / 57.7%
Scottish action plan target by 2010 / 55% / 85% / 90%
Target% / 55.0% / 85.0% / 90.0% / 80.0% / 80.8%
Number / 9121 / 13,594 / 38007 / 26,773 / 87,500
Increase / 5041 / 4152 / 10,216 / 5588 / 25,000
Data ISD Scotland 2007
Target 4 Child RegistrationsBy 2010- 80 % of 3-5 year olds registered (HEAT Target)
Adult NHS registrations
NHS registrations act as an indicator of NHS care for adults. Feedback from consultation would suggest that there is limited private dental care for some adult groups such as the elderly (75+).
In order to predict and set targets the scenario below is presented which would meet the targets set out in the Scottish Dental Action Plan.
Predicted target setting scenarios for adults
2006-2007 adults / 18-24 / 25-34 / 35-44 / 45-54 / 55-64 / 65-74 / 75+ / Adults totalGrampian number / 17,349 / 18,791 / 27,211 / 24,819 / 19,214 / 11,000 / 5,810 / 124,194
Grampian % / 36.9 / 29.2 / 32.7 / 32.2 / 29.1 / 24.2 / 15.0 / 29.5
Scotland Targets / 60 / 40
Target % / 60 / 60 / 50 / 50 / 50 / 60 / 40 / 53
Number / 28,199 / 38,603 / 41,608 / 38,506 / 33,025 / 27,772 / 15,459 / 223,128
Increase / 10,850 / 19,812 / 14,397 / 13,687 / 13,811 / 16,686 / 9,649 / 99,000
Data ISD Scotland 2007
NHS Registration Targets
In order to meet the necessary registration targets set in the Scottish Dental Action Plan for children by 2010 and to achieve a level of NHS registration for adults similar to that achieved in Grampian in 1998,the following registration increases are presented as targets.
Target 5 Child RegistrationsBy 2010 - an additional 25,000 child registrations which include an estimated 3800 registrations for children aged 3-5 years (HEAT )
Target 6 Adult NHS Registrations
By 2012 - an additional 99,000 adult registrations
In total this would require a total of 124,000additional NHS dental registrations in NHS Grampian by 2012.
In order to achieve this number of new registrations anestimated 70 dentistsare needed (average 1750 registrations per dentist)as a minimum over and above the present number in Grampian.The new dentists recruited would need to spend the majority of their time offering NHS dental services to achieve these registration numbers.
TARGETS for DENTAL WORKFORCE in GRAMPIAN
Total NHS Dentists in Grampian and Scotland 1996 - 2007
Data from Information and Statistics Division (ISD), Scotland, indicate that, at September 2007, there were a total of 270dentists working in Grampian. This statistic identified the number of dentists (headcount)and includessalaried and non-salaried principals, assistants, vocational trainees and hospital and community dentists.The equivalent figure for Scotland was 2919.
There were 192independent general dental practitioners in Grampian (2261in Scotland). The table below illustrates the increase in dentist numbers over the last 10 years.
Dentists(Headcount ) / 1996 / 1998 / 2000 / 2002 / 2003 / 2004 / 2005 / 2006 / 2007
Scotland
All dentists / 2323 / 2411 / 2465 / 2550 / 2583 / 2617 / 2669 / 2842 / 2919
NHS G
All dentists / 208 / 211 / 207 / 208 / 215 / 227 / 232 / 261 / 270
NHS G Independent dentists (GDP) / 172 / 174 / 168 / 165 / 170 / 177 / 177 / 193 / 192
Data ISD Scotland 1996-2007
It is estimated that independent general dental practitioners deliver over 90% of the primary care services. The number of independent practitioners is closely correlated to registration levels.
However these practitioners also deliver a considerable amount of private care but there is no exact estimate of their total private activity or the number of patientsin private care by each independent dental practitioner.
A health survey/questionnaire is recommended in Recommendation 2 based on eachCommunity Health Partnershipto establish a clearer estimate of dental careservice provision in the general population in Grampian.
Year / 1996 / 1999 / 2002 / 2006 / Target2010 / Target
2012
Grampian / 208 / 219 / 208 / 261 / 300 / 350
Grampian Rate:100,000 / 39.7 / 49.9 / 57 / 67
Scotland / 2323 / 2462 / 2550 / 2842 / 3050 / 3417
Scotland
Rate: 100,000 / 45.8 / 56.1 / 60.25 / 67.5
Best in Scotland / Tayside 76.6: 100,000
Data ISD Scotland 1996-2006
The tables show that the trend of increased dentist numbers over the last 10 years in Grampian is similar to Scotland. However the number of dentists to population ratio in Grampian has always been significantly below the Scottish dentist to population ratio. The targets below are based on the need to recruit an additional 90 dentists to Grampian between September 2006 and September 2012.It would be expected that whilst initial recruitment will be slow it would rise by 2009 to a target whereby NHS Grampian should aim to recruit an additional 20 new dentists annually.
In 2006(ISD) statistics illustrate the low level of dentists in Grampian when compared with Scotland and Tayside
Grampian- 49.9 dentists per 100,000population
Scotland - 56.1dentistsper 100,000 population
Tayside -76.6 dentists per 100,000.population
Data ISD Scotland 2006
Target 7 Total number of dentistsBy 2010 - to increase the total number of dentists working in
Grampian to 300
(Base - 270 Sept 2007)
Target 8 Total number of dentists
By 2012 - to increase the total number of dentists working in
Grampian to 350
(Base - 270 Sept 2007)
Independent Dentists in Grampian and Scotland and by Community Health Partnership (CHP)
When comparing only independent general dental practitioner numbers by CHP,NHS Grampian records the twolowestlevels of dentist to population ratios in Scotland (Information Statistics Division 2006).
The following ratios are calculated:-
Moray 1 dentist: 3144 pop.
Aberdeenshire 1 dentist: 3095 pop.
Scotland and AberdeenCity1 dentist: 2021pop.
DundeeCity1 dentist: 1360 pop.
Scottish Target 1 dentist: 1750 pop.
Data ISD Scotland 1996-2006
To achieve the Scottish Dental Action Plan Target for primary care dentists of - 1dentist: 1750 population, NHS Grampian would need to recruit 77 primary care practitioners between September 2007 and September 2012