For those of you not aware of specialist training in dental public health I’ll give you a little bit of background. There are about 25 DPH SpRs in the UK (none in N. Ireland). We are all dentists by background and for our training we are based in PCTs and academic institutions. Our training is between 3-5 years depending on experience, previous completion of MPH and whether the post is an academic one or not. We can get some reduction in training because of previous experience. I work in 2 PCTs, MK and Northants, which means I work across 2 SHA areas. The project I am going to talk about today is one which I have been working on in Northants. As dentists we have our own language. I will do my best to explain any dental terms I use but if anything is not clear please stop me and ask. The project involves the commissioning of dental services to the residents of care homes. This population has traditionally had poor access to dental services.
Bit of background about care homes residents in Northants Not talking about huge numbers of people SDS did very few dom visits and really only saw those with the very greatest need
From the questionnaire main findings were they wanted access for residents to NHS dental care and training for staff. The needs assessment was carried out in 2007. The assessment included an oral health quality of life assessment and focus group interviews and a clinical examination
DMFT is a measure of dental disease experience (caries and periodontal disease). Stands for decayed, missing (from an extraction) and filled teeth. DMFT of 27 means that on average 27 teeth in each person were either decayed, missing or filled. As a comparison in the adult dental health survey of 1998 13% of the sample were edentulous and the mean DMFT was 16.6 Figures suggest that most of those examined were happy with their oral health, even if the examiner did not agree
For obvious reasons the patients who were unable to consent or who lacked the ability to complete questionnaires did not take part in the qualitative part of the needs assessment. Not sure if examination included those not able to consent but suspect not.
Drew up different possible commissioning options and payment models The rationale behind this was that in the long run it would be much better for the homes if the practice looking after the residents was local. It was felt this would enable relationship building and create a more personal service. Talked to clinical director in Sheffield (scheme described in Steele)
The contracting team wanted to put something in about improving oral health but based on the fact that the residents didn’t think their oral health was an issue and that there is not a huge amount of evidence that shows that dentists improve oral health the DPH team felt that this was unachievable and would set us up to fail when pilot was evaluated.
The residents may not accept/ want an assessment especially if they have their own dentist but they should be offered the opportunity. The assessment will include an examination and will include the following information: Medical and social history Presence or absence of dentures Support necessary for the resident to maintain their oral health Habits Assessment of oral hygiene Assessment of treatment need, where possible Mental capacity of the patient Where treatment is required this will be offered. Having worked in salaried service for many years I anticipated that consent would be an issue so wanted to make it clear that what legislation should be followed. Protection of vulnerable adults included mandatory training. Details of who to contact if there were concerns was also put in the spec. same true about home standards.
Construction/ adjustment of dentures Simple scaling Simple extractions where radiographic assessment is not necessary Simple restorations where excavation only is necessary Application of fluoride varnish
Very aware that improving access would increase referrals but wanted to try and ensure that only those needing specialist skills were referred otherwise might just as well have contracted with SDS to provide the service. Worked with SDS when developing the pathway etc.
The advice and support included information on the use of the higher concentrations of fluoride toothpaste We stressed the need for the training to be evidence based and specifically mentioned DBOH to try and ensure people were giving strange and mixed messages. Training sessions were pro rata for the pilot The emergency drugs has proved a bit of a problem but I’ll come to that later
Specification also made it clear that the care homes had certain responsibilities otherwise the pilot would fail
Wanted to offer service to those with full contracts rather than child only – do everything can to discourage child only contracts Dentist actually doing the work had to be on the performer list Will discuss the training day later Wanted to be able to evaluate the pilot well so needed GDP co-operation No point offering Tx in a surgery if pat can’t get into it. Compliance with decontamination standards etc also highlighted Last point was to ensure that involved patients and carers
Contract arrangements in dentistry are complex and patient charges also have to be taken into account.
Worked with the contracting team
The training was held after the theoretical start of the pilot, though in practice no-one had really done anything. Delay was due to finding an a date acceptable to everyone. Performer is the person actually seeing the patients, contract holder is person who as it says holds the contract for the practice. The day was set up because I felt that the dentists would just not have the knowledge for this type of group of patients. Especially since all those who had entered the NHS post 2006 would have had no doms experience and those who had before needed updating. Contracting team were not keen on making it mandatory and wanted to keep it to ½ day. We wanted mandatory and 2 days! Agreed a compromise. In the end the mandatory nature was a little compromised because on the morning it snowed quite heavily
To try and help the dentists they were given packs with the spec etc in it. SDS also supplied risk asses forms. Had already been sent specs and referral forms etc. Used a variety of speakers including care home staff. DBOH is an evidence based toolkit for prevention. Produced by the department of health and DPH specialist society.
Lack of emerg drugs came as a surprise. Solution was use risk assess and if high risk of medical problem would be seen in surgery Form 4 was ordered and distributed by PCT No insurance nec for clinical waste Evaluation was also interesting from my point of view – some lessons learned: hear speakers first, share slides to avoid duplication, really re-iterate brief and see slides in advance so can ensure are sticking to it.
68 homes did not want to participate – part of the evaluation will be to find out why Contracting team did set a maximum of 10/ provider but limit was naturally set by the providers anyway.
Had 3 homes, 1 has been reallocated and others have been supported by SDS Form needs revision as difficult to complete may explain why info is not always being submitted on time DF had 3 or so participants and was sometimes used to moan Collection of money is issue – those with SDS experience could have told them that – think they are beginning to appreciate the things that SDS deal with PCT has agreed 3 month extension for completion of treatment as at present mainly only been assessments that have been completed. PCT now not sure a unified rate was the correct way to go – considering whether should have used practices own UDA rate.
Following the evaluation the intention is to role this out across the county in some form or another.
Provision of dental services to care homes
A pilot to provide NHS dental services to care homes in Northamptonshire Anna Ireland Specialist Registrar, Dental Public Health NHS Northamptonshire, NHS Milton Keynes
Northamptonshire Demographics <ul><li>People aged 65 and over are 14.1% of population </li></ul><ul><li>1% are non-white ethnic origin </li></ul><ul><li>2,306 people aged over 65 in care homes (2007) </li></ul><ul><li>115 care homes in the county </li></ul><ul><li>Prior to pilot SDS carried out a limited number of domiciliary visits </li></ul>
Background <ul><li>PCT Local delivery Plan highlights need to improve access to NHS dentistry for vulnerable groups </li></ul><ul><li>Questionnaire sent to Care Homes in 2006 </li></ul><ul><li>Needs assessment carried out by previous SpR </li></ul><ul><li>Focussed on dependant elderly institutionalised population </li></ul>
Needs Assessment 1 <ul><li>91 residents had a clinical examination </li></ul><ul><li>Mean DMFT was 27.24 (22.93MT) </li></ul><ul><li>38% of sample were edentulous </li></ul><ul><li>Only 43% of dentate patients with dentures were wearing them </li></ul><ul><li>30% said their oral health was very good, 55% said good and 15% said fair – no-one said very poor </li></ul>
Needs Assessment 2 <ul><li>Focus group – 2 residents, 2 carers </li></ul><ul><li>Themes included: </li></ul><ul><li>Training and support for staff </li></ul><ul><li>Access to basic NHS dental care, including domiciliary </li></ul><ul><li>Results were for the most “mentally able” residents </li></ul>
Pilot project <ul><li>Decision was made to involve local practices rather than commissioning a single service or contracting with the SDS. </li></ul>
Pilot service specification <ul><li>The aim of the service is to improve the access to NHS dental care, oral health advice and offer support to the staff and residents of care homes in Northamptonshire. </li></ul>
Pilot service specification <ul><li>All residents would be offered an oral health assessment </li></ul><ul><li>Clearly defined what an assessment included </li></ul><ul><li>Where treatment is required this will be offered </li></ul><ul><li>Requirements of the 2005 mental capacity Act were stressed </li></ul><ul><li>Need for a dental nurse and reference to the protection of vulnerable adults was also made. </li></ul>
Pilot service specification <ul><li>If the assessment suggests treatment may be needed the patient is offered an appointment for a comprehensive oral health review (full clinical examination) </li></ul><ul><li>If patient can travel then review and Tx will be done in providers surgery </li></ul><ul><li>Tx that is appropriate for a dom setting was clearly described. </li></ul><ul><li>In-hours urgent care included </li></ul>
Pilot service specification <ul><li>Patients requiring specialist care referred to SDS </li></ul><ul><li>Pathway drawn up </li></ul><ul><li>Evidence-based referral criteria developed </li></ul><ul><li>Referral form </li></ul><ul><li>Assessment of ability to co-operate </li></ul><ul><li>Monitoring of referrals </li></ul>
Pilot service specification (Non-clinical) <ul><li>Dental advice to care home staff </li></ul><ul><li>2x annual training sessions for care home staff (evidence-based) </li></ul><ul><li>Practice information leaflet </li></ul><ul><li>Ensure access to emergency drugs </li></ul><ul><li>Operate during own normal working hours </li></ul>
Care Home responsibilities <ul><li>Engage with practice </li></ul><ul><li>Encourage residents and carers </li></ul><ul><li>Pass on information about patients (e.g. who can travel) </li></ul><ul><li>Facilitate travel </li></ul><ul><li>Make staff available for training </li></ul><ul><li>Provide suitable rooms </li></ul><ul><li>Look after the oral health of residents </li></ul>
Conditions of participation <ul><li>Full existing NHS contract </li></ul><ul><li>On performer list </li></ul><ul><li>Attendance at training day </li></ul><ul><li>Participation in evaluation </li></ul><ul><li>DDA compliant premises </li></ul><ul><li>Awareness of “person centred planning” </li></ul><ul><li>Completion of monthly activity form </li></ul>
Financial arrangements <ul><li>Provider collects (and keeps) patient charges </li></ul><ul><li>£50.00 per resident participating in pilot </li></ul><ul><li>unified UDA rate </li></ul><ul><li>Payments made through BSA </li></ul><ul><li>Separate contract numbers </li></ul>
Setting up the pilot <ul><li>As a pilot a full tender process was not necessary </li></ul><ul><li>Specification sent out to providers </li></ul><ul><li>Asked for expressions of interest </li></ul><ul><li>Pilot to run from 1 st February to 31 st July </li></ul><ul><li>Training day organised </li></ul>
Training Day <ul><li>Held on 22 nd February </li></ul><ul><li>Mandatory for the performer who would be participating in the pilot </li></ul><ul><li>Nurses and contract holders also attended </li></ul><ul><li>6 hours 15 mins CPD (1 hr 45 mins core topics) </li></ul>
Training day Programme <ul><li>Guide to care homes </li></ul><ul><li>Medical problems in the elderly </li></ul><ul><li>Alzheimer’s and dementia </li></ul><ul><li>Delivering Better Oral Health </li></ul><ul><li>Protection of vulnerable adults </li></ul><ul><li>Consent </li></ul><ul><li>Risk assessment </li></ul><ul><li>Infection control </li></ul><ul><li>Data collection </li></ul>
Issues arising from training day <ul><li>Care homes do not have emergency drugs (including oxygen) </li></ul><ul><li>Cost of portable sharps containers </li></ul><ul><li>Cost of business insurance </li></ul><ul><li>Access to consent form 4 </li></ul><ul><li>Insurance for clinical waste carriage </li></ul><ul><li>Development of a discussion forum </li></ul><ul><li>What is the best way to carry out the service if you do not have a car? </li></ul>
Pilot <ul><li>47 care homes participating </li></ul><ul><li>9 providers </li></ul><ul><li>Homes matched to providers, where could by locality </li></ul><ul><li>Providers have between 1-10 homes each </li></ul><ul><li>External evaluation </li></ul>
Issues so far <ul><li>1 provider has dropped out (one without a car!) </li></ul><ul><li>Data collection form is complex and not always completed well </li></ul><ul><li>Data submission is variable </li></ul><ul><li>Discussion forum is not used effectively </li></ul><ul><li>Consent and collection of charges difficult </li></ul><ul><li>Everything taking longer than expected (pilot extended by 3 months) </li></ul><ul><li>UDA rate needs further thought </li></ul><ul><li>Incorrect submission of data (wrong contract number used) </li></ul><ul><li>Incorrect charging of patients </li></ul><ul><li>Co-operation from care homes is variable </li></ul>
BUT <ul><li>Most dentists are really enjoying the challenge and the break in routine. </li></ul><ul><li>There is renewed respect for the staff working in care homes. </li></ul>
Evaluation <ul><li>Started this month </li></ul><ul><li>Will use interviews and focus groups as well as data </li></ul><ul><li>Will look at why homes and practices did not want to participate </li></ul><ul><li>Will help determine future commissioning plans </li></ul>