Cumbria
Oral Health Strategy
and
Commissioning Plan
2012 – 2015
Summary
(Draft 2/3/12)
INTRODUCTION
The publication of the NHS White Paper, Equity and excellence: Liberating the NHS in June 2010 set
out the Government’s plan for the future of the NHS and has led to significant changes to the ways
in which health services will be commissioned.
Health and Wellbeing Boards (HWBs) have been created to bring a local democratic overview to the
planning for, and delivery of, better health outcomes. They bring together Local Authorities (LA),
Clinical Commissioning Groups (CCGs), the NHS Commissioning Board (NHSCB) and Public Health
England (PHE) to ensure that there is a coordinated approach to priority setting, commissioning and
the delivery of health and social care services.
This Oral Health Strategy is designed to support the Health and Wellbeing Board for Cumbria and has
been developed by the Dental Professional Network (DPN) of the NHS Cumbria Cluster.
It builds on the previous Oral Health Strategy of the Cumbria PCT and seeks to identify the key oral
health needs and inequalities of the population living in the footprint of the wider Cumbria area. It
sets out what is known about the level and impact of oral diseases and identifies best practice and
evidence based interventions to address these. It makes clear recommendations for action under 3
strategic headings.
Actions to improve Oral Health
Actions to improve Oral Health Services
Actions to develop the workforce to support the improvement of oral health and health services
The Strategy is based on a number of principles listed below.
Recommendations developed within the strategy should
• Be based on a recognised need for service or action
• Address equity of provision and access to services across Cumbria
• Be based on evidence, national guidelines or best practice
• Support the QIPP agenda.
• Encourage care in the most appropriate setting
Implementation of the recommendations should
• Involve clinicians, commissioners and others working in networks to design, develop, implement
and review
• Involve regular engagement with the wider dental workforce
• Be supported by appropriate workforce development in association with the North West Deanery
and the Northern Deanery
ORAL HEALTHAND THE CUMBRIA POPULATION
General statistics
Latest figures (2007/8) show that 35% of children in Cumbria have experienced tooth decay in their
baby teeth by the age of 5 years old compared to 31% in England. Each of those children have on
average 4 decayed baby teeth.
Of 12 year olds measured in 2008/9, 39% had on average 2-3 permanent teeth with tooth decay.
Although the results of the Adult Dental Health Survey conducted in 2009 do not provide data at a
Cumbria level, it showed that 93% of all adults in the North West have some natural teeth with an
average of 25.3 teeth. Although this is good news, only 7% of the adults in the North West were
described as having excellent oral health and 30% of all adults with teeth have untreated tooth
decay
Access to NHS dentistry in Cumbria has improved in recent years with 269,000 people now under
the care of an NHS dentist. This is however less than in 2006, when responsibility for access was
devolved to PCTs (291,000). The PCTs is currently underperforming against its planned access
numbers.
These general statistics hide considerable inequalities that exist within sections of the population.
Deprivation and Oral Health
There is a strong link between deprivation and chronic diseases including dental tooth decay.
Studies have consistently shown that the most disadvantaged populations are more likely to have
the highest levels of tooth decay resulting in health and oral health inequalities. It is important that
oral health initiatives focus on these populations and link closely with other general health
improvement initiatives.
Tobacco and Alcohol
Rates of smoking in Cumbria are above the national average with 25% of adults aged 18years and
over smoking. (England average 21.3%). Tobacco use, particularly smoking, is associated with several
chronic diseases. It increases the prevalence and severity of gum disease and is a risk factor for oral
cancer. The North West had one of the highest alcohol-related death rates for adults in England
between 2000 –2009. Alcohol consumption has a synergistic effect on the oral cancer risk. Using
the dental workforce to support existing services such as “stop smoking” teams in this area is vital.
Drug misuse
The association between poor health and drug and substance misuse is well reported. In 2007/8
the number of Cumbrian adults who were participants in drug treatment programmes was 718. Drug
misuse and its consequence can be associated with several complex factors which may result in poor
oral health and the need for access to emergency dental care.
Elderly people
In common with the rest of England, the population of Cumbria is aging. People aged 65 years or
older make up to 19% of the population (compared to the England average of 16%). It is expected
that by 2032 the population in Cumbria aged over 85 years old will increase in size by 147%. Whilst
it is true that adult oral health is steadily improving and more adults keep their teeth for life, some
of the adults aged 65 years and over have no natural teeth. Those with natural teeth require
complex treatment to maintain their aging dentition. There is greater prevalence of illness or
disability within this group and this can have an impact on the oral health and complicate dental
care.
Looked After Children
Cumbria has a large number of residential settings for children, often placed their by Local
Authorities outside Cumbria. Looked after children and young people are often relocated and this
can pose particular challenges for health care provision. In responding to the health needs of these
children it is important to include the provision of dental care and preventive interventions.
Travellers
There are significant pockets of traveller communities in parts of Cumbria and certain annual
traditions which increase these numbers.. The families and carers within this group have particular
needs relating to access to health services including dental health services and basic preventive
interventions. Addressing the oral health needs of this group requires specific consideration.
ACTIONS TO IMPROVE ORAL HEALTH
Most preventive activities to promote good oral health depend on individuals taking on the
responsibility for their own oral health on a daily basis and less so on what the dentist does on visits
to the dentist. There is currently variation in the availability of resources and the range of activities
delivered across Cumbria to promote oral health. Resources need to be focused on the delivery of
consistent and evidenced based activities. Smile4Life is a community intervention program which is
being delivered jointly by the NHS and Cumbria County Council for this purpose. The program is
currently being implemented in Children’s Centres in Cumbria. It ensures that Children’s Centres
adopt healthy practices and are a source of support and advice on achieving good oral health. The
Centres are being linked with local dental practices to ensure good access to dental services for
children and their families. The programme focusses on 4 key elements and is embedded in the
specification for the Children’s Centres in Cumbria.
Although individuals and families need to adopt healthy behaviours every day, general dental
practices have a key role to play in promoting oral health for individual patients using national
published guidelines (“Delivering Better Oral Health”) and the local Smile4Life programme.
An increased focus on prevention in practice through the Smile4Life program has implications for
the dental workforce. Much of the prevention work can be done by members of the dental team
other than dentists and the General Dental Council (GDC) allows this but requires registrants to
demonstrate appropriate training. A training programme has successfully been run and the NHS and
Deaneries should continue to commission and deliver this.
In 2 areas of West Cumbria water is fluoridated as a public health measure. These schemes are the
responsibility of the North West Strategic Health Authority and are currently being refurbished.
Recommendation:
Use Smile4Life as the vehicle for oral health improvement activities across Cumbria
Continue the Smile4Life program for prisons currently being piloted
Introduce the Smile 4 Life program for vulnerable adults
Ensure that routine care includes preventive elements outlined in “Delivering Better Oral Health”
Ensure that relevant clinical networks include a preventive approach in their care pathway design
Support the reestablishment of the Water Fluoridation Schemes in Cumbria
Develop the health, social care and educational workforce to deliver the preventive agenda
Deliver the Cumbria Oral Health improvement action plan
ACTIONS TO IMPROVE SERVICES
Unscheduled Care
Unscheduled dental care, both in and out of hours, is provided by the Partnership Trust Dental Care
Service and other local providers. It is important that whoever is the provider, patients receive
equitable quality services with an agreed consistent pathway. A review should be undertaken across
Cumbria using the expertise of these groups with the aim of ensuring a high quality coordinated
service for the whole of Cumbria.
Recommendation:
Review the provision of unscheduled dental care services across Cumbria.
Agree a consistent pathway to ensure quality of delivery for patients
Make any appropriate changes in commissioning to reflect the agreed pathway
Routine Care
PCTs currently have, and in the future the NHS Commissioning Board will have, a responsibility to
ensure their populations have access to routine dental care. Although access to an NHS dentist has
improved in Cumbria, the PCT is not achieving their planned access levels.
The PCT currently runs an allocation system matching patients to NHS places. Additional access
money has been secured from the Department of Health in order to create additional access with
the aim of closing the dental database and allowing greater patient choice.
The NHS North West Dental QIIP programme has produced an analysis tool and best practice
guidance to assist PCTs in the commissioning and management of services to deliver routine dental
care.
Work is underway on a national approach to quality assurance dashboards for primary dental care
and this will have an implication for professional advice within the Dental professional network of
the NHS Commissioning Board.
Recommendation:
Commission services to address the inequity in access across Cumbria
Work towards closedown of the dental allocation system and introduce more patient choice
Develop a streamlined approach to the management of existing contracts using the NHS North West
Dental QIPP programme.
Review the approach to quality assurance of routine dental services
Oral and Maxillofacial Surgery
There has been an increase in oral surgery referrals from primary dental services into secondary
care, the setting where traditionally Oral and Maxillofacial Surgery services have been delivered.
A redesigned the oral surgery pathway which introduced new services in a primary care setting was
implemented in April 2009 to manage the flow of patients more appropriately to specialist services
in primary and secondary care. This pathway is governed by the Cumbria Oral Surgery network and
involves clinicians and commissioners who monitor its impact and seek to continuously improve the
operation of the pathway.
The Cumbria Oral Surgery Clinical Network should continue to be supported in transition into the
NHS Commissioning Board.
Recommendation:
The Cumbria Oral Surgery Clinical Network should continue to be supported in transition into the NHS
Commissioning Board.
The network should -review capacity and demand
-tackle inappropriate referrals via robust monitoring
-publish waiting time data for all providers
Orthodontics
The 2008/09 dental health survey of children living in Cumbria found that between 29.8% (East
Cumbria) and 40.9% (North Cumbria) of 12 year olds were classified as having a biological or
aesthetic need for orthodontic intervention as compared to 31.6% in the North West and 31.6% in
England. Since then service redesign and development has taken place under the guidance of 2
established orthodontic clinical networks across Cumbria. These networks review and monitor issues
pertaining to orthodontics and they have designed and established local patient pathways to
improve orthodontic services. To facilitate a consistent approach and improve quality of services
further across Cumbria, the existing orthodontic managed clinical networks should be consolidated
to cover the whole area.
Recommendation:
Consolidate the existing orthodontic clinical networks across Cumbria
Develop a common orthodontic pathway for use throughout Cumbria
Publish waiting time data for all providers
Special care dentistry (children and adults)
The circumstances of children and adults with learning disabilities and/or additional needs make
them more susceptible to oral health problems. People with learning disabilities or mental health
problems have less of their dental disease treated compared to the general population, and when it
has been treated they have more extractions and fewer fillings than in the general population.
Historically, this service has been provided by PCT Community Dental Services as some patients with
complex needs require specialist care. A philosophy of shared care between specialists and primary
care practitioners should underpin the future development of these services.
There is an existing Special Care and Paediatric Dentistry Clinical Network, which has developed a
patient pathway including referral criteria and a model for delivery. The network should continue
its work across Cumbria to develop the specification prior to commissioning from the most
appropriate providers.
There is currently no clear pathway to ensure access to dental care for patients who have received
treatment for head and neck cancer. This is important as good oral health is essential to prevent
complications following radiotherapy, such as poor bone healing. An integrated primary and
secondary care pathway to safeguard the quality of care for these patients should be developed.
Recommendation:
Continue to use the Cumbria and Cumbria Special Care and Paediatric Dentistry Clinical Network to
develop clear pathways and a model for delivery of special care dentistry across Cumbria
Review access to Acute services for General Anaesthetic support
Develop and implement an integrated primary, secondary and tertiary care pathway for head and
neck cancer and commission accordingly
Publish waiting time data for all providers
Restorative dentistry
Whilst people are living longer and keeping their teeth for longer, the restoration and repair of these
teeth is becoming increasingly complex.
The 2009 Adult Dental Health Survey showed that as
dentitions age, the need for complex dental treatment increase. Thus older members of the
population are the most likely to have the most filled tooth surfaces, the most active tooth decay,
the highest number of crowns and bridges, implants and dentures. They are also more likely to have
the most severe gum disease
Restorative dentistry expertise , especially in endodontics (root fillings) and periodontics (gum
disease), is required to support general dental practitioners in caring for patients and maintaining
their dentitions following a life time of dental treatment. The development of restorative services
in the primary care setting optimally positioned to support general dental services and serve the
needs of the residents of Cumbria is required.
A restorative network governing an endodontic service currently exists in South Cumbria and
supports primary care dentists. This network should be built on to cover the whole of Cumbria and
should also look at developing periodontal support services.
Recommendation:
Develop the current restorative clinical network to cover all of Cumbria
Expand the current endodontic services using dentists with special interest to support GDPs
To develop and commission optimally positioned periodontics services using dentists with special
interest to support GDPs
Develop the workforce to deliver complex restorative care
INFORMATION, RESEARCH AND EVALUATION
It is important that in developing high quality services, we assess needs, and subsequently measure
and evaluate the impact and the outcomes that our services and interventions achieve.
The ultimate outcome of our work is measured by the oral health status of the population and
throughout this document data has been referenced to support needs or show outcomes to date.
Levels of dental disease in children are currently part of the Public Health Outcomes monitoring
framework. It is therefore recommended that there is a continued support for the local
commissioning of epidemiology in line with the National Dental Epidemiology Programme (NDEP).
Where we are trying new interventions where there may not be an existing evidence or research
base, we should take the opportunity to work with experienced research partners to design robust
methodologies with appropriate research governance which are capable of contributing to the
evidence base.
Recommendation
Continued support for local commissioning of dental epidemiology in line with the National
Programme (NDEP)
Build outcome and process evaluation into all actions in the strategy
Work with established research partners to design robust research around new interventions
ACTIONS TO DEVELOP THE WORKFORCE
We are working with the Workforce group to identify the key priorities as follows
Prevention in Practice and Fluoride Varnish Application Course
Dental Nurse Cadet scheme
Seek to provide CPR First Aid, Fire training locally