Present version 2013v7
NHS GRAMPIAN
DENTALPLAN
2020
A FRAMEWORK FOR CONTINUED IMPROVEMENT IN ORAL HEALTH AND DEVELOPMENT OF QUALITY ASSURED DENTAL SERVICES IN GRAMPIAN
August
2013
CONTENTS
Introduction and Vision
Part I Improving Oral Health and NHS Dental Services through Health and Service Equity
Priority Targets for Dental Plan 2020
Oral Health
- Where are we now?
- Children’s Oral Health
- Adult Oral Health
- Where do we want to be by 2020?
- Oral Cancer
NHS Dental Registration in Grampian
- Where are we now?
- Where do we want to be by 2020?
- Proposed Targets for NHS Registration
- Infrastructure components of the Dental Plan
PART II Ways of Working - Developing Clinical Networks and Patient Care Pathways
Managed Clinical Network (MCN) for Oral and Dental Health and Services
Quality and Quality Assurance in Oral and Dental Health MCN
- Quality Framework for NHS Grampian Dental Services
- Monitoring of Framework and Quality Standards
Action Plan
- Aim 1 – Continued Improvement in Oral Health of Children and Adults
- Aim 2 – Continued Increase in NHS Dental Care and Services
- Aim 3 – Maintain and Improve the Dental Care Infrastructure in Grampian
- Aim 4 – Structure and Organisation – Clinical Networks Delivering Quality Services for Dental Care
- Aim 5 – Introduce a Revised Quality Framework for all Dental Practices and Services in Grampian
- Aim 6 – Ensuring Good Communication and Feedback on Dental Plan
INTRODUCTION AND VISION
In 2008,NHS Grampian Board approvedan ambitious plan to improve oral health and dental servicesin Grampian. The plan has been implemented resulting in all priority targets being exceeded.
60% of children with no obvious decay in Primary 1 and Primary 7.
Outcome-Target exceeded.
Primary 1 (Deciduous teeth) 2012 - 67.8% no obvious decay.
120,000 additional NHS registrations between June 2007 and March 2012.
Outcome-Target exceeded.
March 2012 - 131,000 additional NHS registrations (based on June 2007)
March 2013 -169,000 additional NHS registrations (based on June 2007)
The plan was supported by a range of infrastructure programmes including workforce and facility development which has resulted in
- an increase of over 80 (2013 - 91) dentists and associated support staff
- Aberdeen Dental School and Hospital
- over 12 new premises to modernise and support NHSGrampian salaried dental services
- a capital grants programme to develop new practices and/or modernise premises of primary care partners offering NHS dental services
Considerable change in both dental services and oral health has occurred over the last 8 years. However, more can be achieved. This plan aims to build on the previous achievements and in particular will focus on quality improvement as a significant theme of the plan.
Vision
All infants and children can develop and shed their baby teeth with no significant intervention from the NHS dental services.
All children can develop their adult dentition with no significant intervention from NHS dental services required for the 2 main dental diseases – dental decay and periodontal (gum) disease.
All adultscan maintain a healthy natural dentition through to later life (over 70 years) with minimal need for artificial replacement (dentures).
To offer90% of NHS dental services to people within their local community i.e. the community in which they live or work. Local Community is defined as nearest town.
To ensure a quality assured efficient NHS dental service delivering an
–affordable
–safe
–effective
–person-centred service to all those who request it
Aims
Through this new plan spanning 2013 to 2020,NHS Grampianaimsto:
- Help and support people to sustain and improve their own oral and dental health
- Enhance and prioritise the support given to disadvantaged individuals and disadvantaged communities.
- Ensure high quality,local NHS dental services are accessible to all who request and need such care
- Ensure that services are delivered through clear patient-focused standards
The core themes of this plan are to:
Improve oral health
Improve oral health through
- informed self care
- informed supported self management of early presenting oral diseases
- preventive anticipatory care
- health promotion
Ensure local services
Provide communities with accessible and affordable local services focused on high quality, effective treatments provided through clearly defined standards
Define and support an intermediate care network dispersed across Grampian to deliver services complementary to secondary care services closer to patients local community
Embed sustainable services in local communities through investment in dental services,dental premises and leading edge technology.
Prioritise care and oral health improvement to those with highest need
Target anticipatory care, prevention and dental services at groups and localities with the highest need
Provide, where there is long term and/or high intensity care required, support for both the patient and the carer
Set clear quality standards for dental services
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
Put in place a quality assurance system to maintain high standards of dental care
Consider how local commissioning or local dental contracting can contribute to continued improvements in oral health and dental services
Develop with local and national partners potential frameworks for commissioning NHS dental care and servicesacross the North of Scotland.
PART1 IMPROVING ORAL HEALTH AND NHS DENTAL CARETHROUGH HEALTH AND SERVICE EQUITY
PRIORITY TARGETS FOR DENTAL PLAN 2020
Where are we now and where do we want to be?
The 2008-12 Dental Plan set out a wide ranging infrastructure programme to modernise dental services in Grampian.
This new plan will prioritiseonly 2 keyissues for targets and set 2016 / 20 targets for these i.e. oral health and NHS registrations.
The remainder of the plan will focus through an operational actionplan on structure and function to support continuous quality improvement.
ORAL HEALTH
Where are we now?
Children’s Oral Health. NHS Grampian has seen a trend of oral health improvement of children and adults over the last 20 years with continuing sustained improvement most obvious in the last 8 years.
The graphs below indicate that NHS Grampian hasconsiderably exceeded the national targets set for 2010 for children in Primary 1 and Primary 7 i.e.60%with no obvious dental disease starting and leaving primary school. The impact of a range of interventions has resulted in dental health in both Grampian and across Scotland reaching levels never previously recorded.
This planidentifies new targetsfor 2016 and 2020aiming for a continued improvement in dental health of children.
Oral Healthof Children in Primary 1 (Deciduous teeth) 1995 -2012
Average number of teeth per child affected by dental decay in Primary 1 in Grampian and Scotland 1991-2012
In the late 1980s NHS Grampian consulted on fluoridation of the water supplies in order to reduce dental disease. The level of dental decay in children has now reduced to a level less than that predicted when Grampian considered widespread fluoridation of the water supplies.
Anticipated outcome of water fluoridation in 1990if implemented - 1.25 teeth (dmf) for 5 yr old children
Actual achieved in Grampian in 2012 1.17 teeth (dmf)
dmf is a dental index of disease defined as the average number of teeth affected by dental disease i.e. average number of decayed, missing or filled teeth for each child, in this case a child of 5 years of age.
This health improvement has resulted in a considerable reduction in preventable pain and suffering for children. The fall in dental disease has resulted in a considerable reduction in dental fillings and extractions. One measurable treatment reduction is the fall, by over 50%,of the numbers of day case admissions for children forgeneral anaesthesia to have teeth extracted in Grampian. An expensive procedure involving hospitaland dental staff at an average cost per case of between £800 and £1000 per child.
Addressing Oral Health inequalities within Grampian
There are considerable dental healthinequalities within Grampian. Dental services monitor these inequalities through the annual national schooldental inspectionprogramme. Data from this annual inspection iscollated by primary school groups or clusters linked to High schoolsin each geographic area.
Results for the Associated School Groups (ASG) are illustrated below toillustrate the inequity of disease / health in Primary 1 children.
If a child is in school group T below he or she is twice as likely to start school with dental disease compared with a child in school group T1. When the data is analysed by the individual schools within these clusters the variation in disease or health inequalities become even wider.
The most challenging cases are when children present with gross dental decay which has already resulted in dental abscesses. In school group D this would be a rare occurrence whilst in school group F over 1 child in every 4 already has gross decay and /or abscesses.
School inspection resultsby ASG – Primary 1 data outlined below 2009/10
Range of results ASGs - no obvious dental disease starting school
School group T-41% Primary 1pupils
School group T1 -85% Primary 1 pupils
Range of ASG – Gross disease starting primary school (abscesses/extractions/missing teeth)
School group D- 0% Primary 1 pupils with abscesses or extractions.
School group F-28% primary 1 pupils with abscesses and or extractions
There are clear indications that much of this disease is linked to deprivation although often it is more difficult to link deprivation directly to disease in our more rural communities of Aberdeenshire and Moray where we see equal numbers of children withpoor oral health,but in less clearly defined areas of deprivation.
Adult Oral HealthAdult oral health has improved over the last 20 years since it was last assessed in Grampian. In 2009-10 Grampian was the only Health Board in Scotland to confirm that it exceeded the national targetset for 2010 i.e.less than 10% of adults with no teeth.
Grampian 9.1% adults no teeth in 2009/10
The main reasons for this improvement reflects
- better child dental health working through into young adults
- better self care and better preventive behavioursi.e. brushing, flossing
- better informed choice of treatmentsby patientsi.e. patients choosing to have a filling rather than have a tooth extraction
- better restorative services offered to patients i.e. dentists offering or patients requesting,restorative care such as root canal treatment instead of extracting teeth when affected by decay
NHSGrampian Adult Dental Health Survey postal questionnaire to a random sample of the adult population was completed in 2009/10 with 3353 respondents - a 58.5% participation rate.
The results confirmed that only 9.1% of the Grampian population have no teeth in 2009. This has reduced from 44% of adults in 1972 (national data) and 22.9% of adults in 1993 (Grampian data),each assessment period saw a reduction by over 50% in disease levels.
The graph below shows how these changes affected different age groups, with the largest changes seen in the 55-64 year age group.
Where do we want to be?
Children The targets set for children are based on a positive health outcome i.e. no obvious disease/disease free.Child targets therefore will be based on expected further improvements from the continued expansion and development of the Childsmile programme especially the component that targetshealth inequalities. The expected outcome from this programme should deliver improvement at a rate of 1% to 2 % a year. Targeting children with the highest need through anticipatory care programmes in schools combined with preventive care through their own dental service provider will deliver such improvements.
The recommended targets for children are highlighted below
Adults
In 1972 over 46% of Scottish adults aged over 16 years had no teeth. The level of disease and the subsequent total tooth loss by almost half of Scottish and UK adult population became the primary indicator of dental health in the UK over the last 40 years i.e. % of adults with no teeth remaining (normally replaced with plastic upper and lower dentures.
As Grampian and Scotland move towards over 95% of adults with some teeth, new oral health targets are needed which reflect a more positive oral health outcome.
It is recommended that a single age group will be used to monitor and report on adult oral health i.e. 55-64 yr olds.
Targets recommended for NHS Grampian for the 55-64 yr old age group as a key indicator for the whole population by 2020are:
Oral Cancer
Oral cancer continues to increase, in part due to increasing number of older people in the general population. The main cause of this cancer is linked directly to smoking and alcohol.
A full review of oral cancer incidence and quality of care will be undertaken with a view to developing an appropriate target for NHS Grampian.
TARGETS FOR NHS DENTAL REGISTRATION IN GRAMPIAN
NHS dental registrations are an indicator of uptake of dental services and are a key stage in the pathway of care. Dental registration gives a patient a right of access to dental services both within normal hours and outwith normal hours. Dental examination,the next stage in the care pathway allows early detection of disease and preventive clinical interventions.
Where are we now?
NHS Grampian and parts of the North of Scotland still have some of the lowest levels of NHS dental care in Scotland. It is our aim in Grampian to offer quality NHS services to all who wish to access affordable NHS dental care.
In the last dental plan (2008-2012) a target of 120,000 additional registrations by March 2012 (baseline June 2007) was agreed. The plan contributed to over 131,000NHS Registrations by the target date of March 2012. The improvements have continued into 2013 with 169,000additional NHS registrations achieved between June 2007 (lowest recorded) and March 2013. It is expected that registrations will continue to increase as NHS dental services continue to expand to 2020.
The waiting list for primary dental care exceeded 32,000 in June 2009 and is presently below 1500 and still falling.
Thetable below illustratesthe trend over the last 12 years, andthe most recent statistics in March 2013. The statistics for March 2013 are presented by the smallest area statistics available -Scottish Parliamentary Constituency. They are presented to identify where additional action is required and estimate the future levels of service to be targeted for NHS registration by 2016.
Number of NHS Registrations in Grampian March 2002 -2016March of Year / Adults / Children / Total
2002 / 188,143 / 72,292 / 260,435
2003 / 175,314 / 69,915 / 245,229
2005 / 154,673 / 66,150 / 220,823
2007 / 124,194 / 62,492 / 186,686
2009 / 150,404 / 71,869 / 222,273
2011 / 202,899 / 76,983 / 279,882
2013 / 264,622 / 86,636 / 351,258
2016* / 333,000 / 100,000 / 433,000
* Projected estimate
Where do we want to be by 2020?
Children
It is essential for the overall strategy that we aim for full registration of all children. This will allow our community based programmes to be complemented by individually targeted prevention in the clinical services. Early detection of disease and appropriate intensity of response by clinical services can only be undertaken at the clinical service interface.
There has been some discussion with private providers to identify the number of children in private regular care but at present NHS Grampian has no information to base its targets on except NHS registrations in Grampian and throughout Scotland.
Present (2013) NHS registration levels in Grampian by Parliamentary constituency with Scottish averages by age group for children
Percentage registered / Age groups / Mar-13Scottish Parliamentary Constituency / 0-2 / 3-5 / 6-12 / 13-17 / All Children
Scotland / 45.5 / 90.7 / 102.0 / 99.1 / 89.5
Aberdeen Central / 25.7 / 72.6 / 73.5 / 70.4 / 61.0
Aberdeen North / 38.9 / 80.5 / 88.0 / 83.8 / 76.8
Aberdeen South / 35.6 / 75.6 / 87.9 / 88.5 / 76.3
Banff and Buchan / 37.1 / 84.9 / 97.5 / 92.7 / 83.5
Gordon / 38.5 / 86.4 / 95.0 / 93.6 / 83.0
West Aberdeenshire and Kincardine / 36.3 / 83.0 / 92.3 / 95.6 / 83.3
Moray / 37.1 / 82.8 / 95.4 / 88.5 / 81.3
The new target for child NHS registration is based on achieving the present (2013) Scottish average highlighted below by 2016.
Present NHS Grampian level March 201379% of all children
Present Scottish Average March 2013 89.5% of all children
Recommended Grampian Target by 2016 90% of all children
Recommended Grampian Target by 2020 93% of all children
Adults
The new target for adults needs to reflect the present trends in attendance of adults. In Grampian there seems to be a higher level of private care than seen anywhere else in Scotland.
Present (2013) NHS registration levels in Grampian by parliamentary constituency with Scottish Averages by age group for adults
Percentage registered / Age groups / Mar-13Scottish Parliamentary Constituency / 18-24 / 25-34 / 35-44 / 45-54 / 55-64 / 65-74 / 75+ / All Adults
Scotland / 87.9 / 90.1 / 84.8 / 82.0 / 73.1 / 72.5 / 60.6 / 79.9
Aberdeen Central / 43.6 / 60.5 / 62.2 / 52.0 / 47.3 / 45.9 / 31.2 / 51.8
Aberdeen North / 97.3 / 86.3 / 71.2 / 65.4 / 56.5 / 56.8 / 35.2 / 67.6
Aberdeen South / 78.6 / 67.1 / 58.5 / 51.4 / 48.0 / 50.7 / 41.6 / 56.8
Banff and Buchan / 93.2 / 85.1 / 72.4 / 73.4 / 61.6 / 63.3 / 42.5 / 70.3
Gordon / 91.1 / 67.9 / 58.3 / 55.8 / 51.0 / 49.4 / 32.8 / 57.5
West Aberdeenshire and Kincardine / 102.4 / 78.2 / 60.3 / 57.0 / 54.6 / 60.8 / 44.6 / 63.2
Moray / 81.1 / 64.1 / 50.4 / 47.1 / 42.0 / 41.7 / 32.3 / 50.1
In general, private care seems to attract mainly affluent or working age adults – primarily in the age group 24 - 64 years.
The waiting list in 2009(i.e. 32,000 adults) consisted of a concerning number of elderly adults who were offered priority access.
A2009 survey 37% of adults recorded thatthey received regular dental care in the private sector the highest level recorded anywhere in Scotland. A large percentage of residents highlighted that they did not access such care out of free choice and complained about the expensive costs of such services.
Present level of NHS registration for the adult population in Grampian March 2013 is 59.5%.
The equivalent Scottish Average NHS registration for adults in March 2013 is 79.9%.
Private Dental Services
Patients must have free choice of care. In Grampian many patients have contacted the Health Board over the last 5 years to record that theirprivate dentist will not offer them NHS care. The private dentist has informed them that they will have to remain private if they wish to stay with the practice. This presents challenges to the NHS and to the private practitioner.
Presently NHS Grampian estimates that up to25% of the adult population in Grampian may be content with their dental care being undertaken privately.
NHS registration targets should therefore be set at trying to achieve full registration for the remaining 75% of the adult population.
There are presently thousands of NHS registration opportunities available across Grampian.
It is therefore recommended that a target of a minimum of 70% of the adult population should have NHS dental registration by 2016 and that a target of 75% of the adult population would be NHS registered with dental services by 2020.