Agenda item

Dental Health Services

Minutes:

The Chairman welcomed those present to the meeting.  He noted that this item had arisen from discussions raised at a previous meeting in relation to a review of children’s oral health that had been undertaken by the Council’s Social Services, Housing and Public Health Policy Overview Committee (SSH&PH POC) in 2015. 

 

Dr Andrew Read, Clinical Director Dental Services at Whittington Health NHS Trust (WH), advised that the Trust was an integrated care organisation providing community services across North London and acute services from the Whittington Hospital in Archway.  WH provided community dental services from 22 sites across 10 London boroughs in North Central and North West London, employing over 130 staff.  Hillingdon community dental services had transferred from Central and North West London NHS Foundation Trust (CNWL) to WH in April 2019. 

 

Community dental services provided treatment to patients with complex needs who were unable to be seen in general / high street dental practices.  70% of the services provided were in relation to paediatric dentistry with the remainder being made up of:

·         adult special dentistry – patients with complex disabilities, frail, learning disabilities, etc;

·         sedation and general anaesthesia;

·         domiciliary care – on demand;

·         community oral health promotion (OHP) preventative programmes – seen as one of the most important aspects of community dental services; and

·         epidemiology – surveys undertaken of local dental health, primarily of children.

 

WH had opened new premises at Redford Way on 17 June 2019.  However, community dental services were located on the first floor of the building and the lift construction, which should have been completed at the same time, had been delayed.  WH had written to patients to notify them of the delay and to advise them of alternative arrangements. 

 

Dr Read was advised that queries had been received from residents in relation to the service provided at Redford Way.  He affirmed that all patients had been contacted to advise them of the change in provider and about the new facility opening.  Only the patients who had needed the lift had been disadvantaged; it was anticipated that the lift construction would be completed by 14 November 2019.  In the meantime, Dr Read advised that WH continued to offer patients (who might have an urgent need for dental care and require lift access) treatment at sites in neighbouring boroughs.  He stated that a number of patients had taken up this offer whilst some had decided to wait until the lift in Uxbridge was complete.

 

Dr Read advised that WH provided high quality, community-based specialist dental services for children and adults with complex needs.  He stated that WH was a model provider of evidence-based oral health promotion and preventative programmes in the community which had been recognised by NICE and Public Health England (PHE).  WH had built effective partnerships with NHS England (NHSE), PHE and local authorities to address inequalities in dental health and access to care.

 

Members were advised that the dental services contracts had been changed by NHSE in 2017 so that paediatric patients were referred to community services rather than to hospital.  This had led to challenges with regard to paediatric dental demand versus available capacity.  Other challenges included the oral health of older people in care homes and the funding available for prevention / oral health promotion (which was an issue across London).

 

Research had illustrated the impact of dental disease on older people in care homes and, in June 2019, a CQC report highlighted the need to improve oral care in care homes.  With regard to older people, it was agreed that people who lived in care homes, their families and carers needed to be made more aware of the importance of oral care.  This ambition could be supported by better training in oral care for care home staff and improved guidance for the dental profession on how to treat people in care homes. 

 

It was noted that older people were now keeping their own teeth for longer than they used to but that these teeth were often not in good condition.  This could then be complicated by conditions such as dementia.  Dr Patel advised that his was a training practice where trainee dentists were encouraged to attend local dementia cafes to provide advice and guidance to carers on how to deal with the teeth of someone living with dementia.  He was not aware of a separate care home service. 

 

Dr Read noted that care home residents attended appointments in general dental practices if they were able to.  Those that were unable to attend general practices would have treatment through the community dental service.  He noted that daily oral care in care homes was poor as survey results showed that residents were not having their teeth brushed on a daily basis.  The CQC had identified the need for staff in Hillingdon care homes to receive training on how to care for their residents’ teeth.

 

With regard to Hillingdon, Dr Read noted that:

·         the Borough had the highest decay rate in London for 3 year olds;

·         32½% of 5 year olds had experienced dental decay (compared with 23% in England);

·         more than double the number of 5-9 year olds were admitted to hospital for dental caries than tonsillitis in 2017-18;

·         inequalities in oral health were strongly associated with social deprivation; and

·         there was significant evidence to suggest that oral health had a profound impact on a child’s development.

 

Dr Read advised that evidence suggested that the following interventions worked best in reducing tooth decay in children (with the first two being most impactful for children in early years but not currently taking place in Hillingdon):

1.    supervised tooth brushing in early years settings (STP);

2.    fluoride varnish schemes in early years settings (FVP) – it was queried why NHSE could not be encouraged to pay for this intervention (and STP) given the current levels of caries in the Borough;

3.    provision of toothbrushes and paste by heath visitors / Brushing for Life (B4L);

4.    train the trainer model (TTT); and

5.    multi-component community promotion / oral health promotion (OHP) / making every contact count (MECC).

 

It was noted that Bexley had less than half the number of five year old children with decay experience that Hillingdon had.  Members asked what it was that Bexley was doing that Hillingdon wasn’t.  Dr Read advised that he was unaware of the demographics in Bexley but noted that there was a significant dental decay issue in North London.  He also noted that dental activity needed to shifted from being reactive (in dealing with disease) to preventative (in stopping disease from happening in the first place).

 

Ten years ago, Camden and Islington had had high levels of decay in 5 year olds.  The introduction of STP and FVP in these Boroughs had contributed to these levels starting to decrease.  STP and FVP were not commissioned in Hillingdon. 

 

Concern was expressed that parents were not taking their children to a dentist with early symptoms of decay as dental treatment for those under 18 was completely free.  Dr Read noted that children with the highest risk of tooth decay came from families that had the lowest use of dentists.  Pan-London campaigns had been undertaken to encourage parents to take their children to the dentist when their first tooth came through but only 7% of 2 year old children in Hillingdon had been registered with a dentist this year. 

 

It appeared that it might not have been made clear enough that NHS dental care for children was completely free and that they should have their first appointment as soon as their teeth started to come through.  Dr Read noted that attendance could usually be improved by piggybacking communication onto other community programmes. 

 

Without a preventative programme in place, there would be a lack of knowledge amongst parents about the importance of dental care.  Ms Ayesha Masood, WH Lead for Oral Health Promotion Programmes, advised that there had been no history of a preventative programme in Hillingdon which had resulted in high levels of decay.  Although Ms Masood suggested that Hillingdon had a very transient population for whom oral health would be a low priority, Members believed that community turnover was not significant enough to lead to the levels of decay that were being reported.  Ms Masood advised that Bexley’s needs would be different to those in Hillingdon and that a tailored programme would be needed that included a comprehensive preventative programme. 

 

Ms Alison Braithwaite, Head of Children’s Health at CNWL, advised that there had been oral health promotion in Hillingdon during CNWL’s contract and progress had been made.  She noted that a lot of work had been undertaken with children but that the community turnover meant that messages needed to be sent out continuously. 

 

Ms Claire Fry, the Council’s Head of Service - Child and Family Development, advised that the authority ran the B4L programme (where parents were gifted an age appropriate toothbrush and paste pack) and Bottle to Cup programme  (where parents were gifted a Doidy or free flow cup) from Children’s Centres in the Borough.  All Children’s Centre staff had been trained by community dental health practitioners on brushing and a range of training opportunities had been made available to parents.  Whilst it was acknowledged that not all parents would attend a Children’s Centre, all parents should be seen by a health visitor.

 

Members were advised that NHSE was responsible for commissioning all NHS dental services, including those carried out in hospitals and high street dental practices, and was required to commission services to meet the needs of the local population, for both urgent and routine dental care.  Public health responsibilities used to be part of the NHS but passed back to local authorities in 2012 and included the need to improve the oral health of their populations.  It was clear that the commissioning arrangements around dental health were not straightforward and partners were therefore asked to provide Members with a representative map for Hillingdon of providers and commissioners. 

 

Ms Shikha Sharma, Consultant in Public Health for the Council, advised that rates of dental decay in the Borough had improved since the 50-55% levels of 2009.  Following the SSH&PH POC review in 2015, FVP had been undertaken in Hillingdon with schools that had been identified as having the highest levels of deprivation.  Promotional work was also undertaken in the Chimes shopping centre in Uxbridge and the Council had worked with NHSE to provide two new dental practices in the Borough (one in Harefield and the other in Yiewsley).  Members were advised that NHSE had also recently agreed to fund STP in Hillingdon. 

 

It was noted that no information was available regarding the FVP undertaken in Hillingdon schools as the team no longer existed and its oversight had fallen through the cracks.  Although the FVP take up was thought to have been good, there had been no monitoring undertaken and, therefore, no way to tell how effective the intervention had been and whether it was worth repeating. 

 

Members were sympathetic to the current pressures faced by health partners but they had not expected Hillingdon’s performance to have been quite so poor.  It appeared that communication between partners (including PHE and NHSE) was insufficient and, at times, disjointed.  A shift in focus (and funding) was needed towards preventative action which would be vastly more effective, and could be undertaken at a fraction of the cost, than treatment for decay.  Preventing tooth decay in the first place would stop very small children from having to endure the pain and trauma of caries and extractions. 

 

Ms Sharma noted that there had been reports from parents that their children had been turned away when they had asked for an NHS dentist appointment as there were none available.  A log of these practices was being kept. 

 

Dr Lalit Patel had been appointed as Chair of Hillingdon Local Dental Committee (HLDC) in April 2019.  He advised that, since 2006, the NHSE contract provided dental practices with a budget to achieve a specific target.  If that target was not met, funding could be taken away but was not then reinvested in dental services in the area.  Practices were also monitored by NHSE on fluoride applications and prevention work undertaken with children.  Although most dentists were doing what they could, messages needed to be sent out to raise awareness amongst parents. 

 

Dr Patel advised that NHS capacity depended on the funding available to each dental practice which ran from 1 April to 31 March each year.  If a practice had used up all of its NHS funding and had met its targets by December, for example, it would likely not have any further NHS appointments available until April.  Dr Patel suggested that he could provide the list of NHS dentists which could be publicised, along with the message that appointments for children under the age of 18 were completely free.  Ms Sharma noted that an app was available providing dentists’ details and further information was available online.  It was noted that this sort of information should be included in the information hub that had recently been discussed during the GP Pressures Select Panel review. 

 

Dr Read advised that WH undertook surveys of 5 year olds every 2-3 years.  These surveys could provide ward level and/or school level data which could then help to identify those children that were most at risk of poor oral health.  Interventions were often then targeted at those schools with the highest proportion of children in receipt of free school meals.  Members requested that, if possible, they receive ward and/or school level data for Hillingdon.

 

It was agreed that it was not good enough to say that Hillingdon was just as bad as some other London boroughs or to just accept that poor dental health was an issue in North London.  Sustainable preventative action needed to be undertaken.  The Committee was minded that dental health be the subject of its next in-depth Select Panel scrutiny review. 

 

Mr Turkay Mahmoud, Interim Chief Executive Officer at Healthwatch Hillingdon (HH), advised that he would organise a meeting between HH, Council officers and Dr Patel.  HH received approximately 3,000 visitors to its shop each year and would be able to help by promoting oral health messages. 

 

Dr Claire Robertson, Consultant in Dental Public Health at Public Health England, had been unable to attend the meeting but had provided Members with a PowerPoint presentation which was delivered by Ms Sharma.  On average, one in four 5 year olds in London had tooth decay (this was 32½% in Hillingdon and actually ranged from 14% to 40% in London) with, on average, four teeth affected.  Tooth decay was the top cause for non-emergency hospital admission amongst 5-9 year olds in London with around 7,000 children under the age of 10 having one or more teeth extracted because of tooth decay (548 of these children were from Hillingdon making the Borough the second worst performing area in London). 

 

With regard to dental uptake rates in Hillingdon, 65.4% of children had attended a dental appointment in the 12 months to 31 January 2019.  However, only 37.9% of those aged 0-5 had attended an appointment.

 

Smile London was a multi-stranded programme that targeted children aged 0-5 years and involved health, education and social care to deliver the best outcomes for children and their families.  Dr Robertson was leading on the Smile London Programme for PHE and the programme itself was being led by the North West London Sustainability and Transformation Partnership (NWL STP).  Although it was not yet up and running as funding was still being explored, it was anticipated that Smile would: provide training on dental health for front line staff; increase the availability of fluorides; integrate health within Healthy Schools, Healthy Early Years programmes and sugar smart initiatives; and signpost children and families to local NHS dental services. 

 

The Smile London Programme was a pan-London programme with a multi-stranded approach to combining health, education and social care.  It adopted a common risk factor approach which integrated oral health within general child health and wellbeing aligned with Health Early Years London.  It was based on similar programmes in Scotland and Wales but would include a diet element.

 

It was noted that Smile would not be introducing new concepts and that STP was being undertaken in Hillingdon already.  It was suggested that more work be undertaken with schools so that children transferred the good practice to their homes.  Members asked that Ms Sharma establish the anticipated implementation date for Smile in Hillingdon and report back to the Committee. 

 

RESOLVED:  That the presentations be noted.

 

COUNCILLOR VANESSA HURHANGEE LEFT THE MEETING

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