NHS GRAMPIAN

Board Meeting 01/12/2016 Open Session Item 8

NHS Grampian Dental Plan 2016-2022 1. Actions Recommended The Board is asked to:    

Note improvements in the oral health of the Grampian population and the considerable work already undertaken to sustain progress; Note the aims of the NHS Grampian Dental Plan 2016-2022 to make further improvements, particularly around health inequalities; Note the resource realignments highlighted in section 3; Endorse and support the Dental Plan.

2. Strategic Context There has been a sustained improvement in the oral health of children and adults in Grampian in the last decade, with record numbers of children now decay free. There has also been significant improvement in numbers of patients accessing NHS dentistry. Despite these improvements, inequalities still exist in oral health status and in access to dental services. The landscape for healthcare has changed considerably since the publication of the most recent NHS Grampian Dental Plan in 2013. The introduction of the integration of health and social care services, with the delegation of General Dental Services (GDS) and the Public Dental Services (PDS) to Integrated Joint Boards (IJBs), provides an opportunity to revisit the Dental Plan. This is with the intention of ensuring that dental services in Grampian continue to meet the needs and expectations of the people they serve and contribute to improving their overall health and quality of life. In addition, the findings of a stakeholder event held in June 2015 to discuss key issues in oral health and dentistry across the North of Scotland, with delegates drawn from service users, providers and managers, also served as a key driver for the revision. Other key strategic policy documents that informed the revised Dental Plan include the:  NHS Grampian Child Health 2020 Strategy  Scottish Government Dentistry Outcomes Framework 2016-17  An Action Plan for improving oral health and modernising NHS dental services in Scotland (2005)  National oral health improvement strategy for priority groups (2012)  Scottish Government’s 2020 Strategic Vision for e-Dentistry  NHS Grampian Clinical Strategy (2016)  Strategic Plans for the three Integrated Joint Boards (IJBs) in Grampian (Aberdeen City, Aberdeenshire & Moray)  The Healthcare Quality Strategy for NHS Scotland (2010) 1

3. Key matters relevant to recommendation The vision for oral health in Grampian is for the best possible oral health for all. This is anchored in the belief that the Grampian population should be able to develop and maintain their dentition and oral health in a good state, with minimal intervention from dental services, throughout their life. There will be a renewed focus and emphasis on tackling inequalities associated with oral health and access to dental care to ensure equitable oral health outcomes. The strategic goal is to create an equitable and responsive oral healthcare system with more focus on prevention, supported self-care and management, and treatment for all in relation to need, with a reduction in unnecessary variation in practice and outcomes. A brief update on the current status of oral health and registration status is outlined below with revised targets for oral health improvement and access to dental services, including the need to reduce health inequalities. Children’s Oral Health Children’s oral health has been improving with the proportion of primary 1 (P1) children (average age 5.6yrs) that are decay free rising from 53% in 1988 to 73% in 2014 (Figure. 1). There has since been a drop in this statistic to 70% following the recent publication of the 2016 inspection results. Similarly, the severity of the disease has been reducing, with the average number of teeth affected by decay (dmft1) falling from 1.86 to 1.00. Despite these improvements in children’s oral health, the prevalence of dental decay is still relatively high with 27% of P1children in Grampian having the disease in 2014. In this group of children with the disease, the average number of teeth with decay experience (dmft) was 3.84.

% with no obvious decay experience

Figure 1

Proportion of P1 Children with no obvious decay experience in Grampian & Scotland (1994-2014) 100 80 60 40 20 0 1988 1990 1992 1994 1996 1998 2000 2003 2004 2006 2008 2010 2012 2014

Year Scotland

Grampian

Source – NDIP, SHBDEP

1

dmft – decayed missing filled teeth

2

Inequalities in dental health still persist among P1 children, with the differences between the SIMD2 quintiles highlighted in Figure 2. There is an absolute gap of 24% between the most deprived children in SIMD1 and the least deprived children in SIMD5 in terms of the proportion of children having no decay experience. We are unable to determine whether this gap is narrowing or widening due to lack of local trend data, but nationally the gap has stayed at around 30% since 2008. In addition, the survey also shows that if you are a child living in the most deprived quintile in Grampian, you are more than twice as likely to start school with tooth decay experience compared to a child from the least deprived quintile. Figure 2

Proportion of P1 children in Grampian with no decay experience by Local SIMD Quintile (2014)

---60% National target for P1 children

73.0%

74.4%

2

3

79.0%

80.1%

4

5 - Least Deprived

56.2%

1 - Most Deprived

Health Board 2012 SIMD Quintile

Source – NDIP, ISD

The oral health of P7 children in Grampian shows a similar pattern of improvement. The proportion of P7 children with no obvious tooth decay experience has increased from 70% in 2011 to 73% in 2015 (Figure 3). There is some local variation at HSCP level, but generally the trend across Grampian is of continued improvement in the oral health of P7 children.

2

SIMD – Scottish Indices of Multiple Deprivation

3

Figure 3

Proportion of P7 children with no obvious decay experience 2011 - 2015

Aberdeen City

Aberdeenshire

Moray

75.3%

72.8%

73.2%

Grampian

69.4%

70.5%

73.7%

2015

76.8%

2013

72.4%

72.2%

73.3%

70.8%

70.0%

71.8%

77.8%

68.9%

2011

Scotland

Source – NDIP, ISD

Adult Oral Health Adult oral health in Grampian is also improving, with 91% of adults over 16 years having some or all of their natural teeth (GADHS3 2010). The 2010 Grampian survey shows that 9% of adults have no teeth remaining, which is an improvement on the 1993 survey findings of 23%. Grampian has now met the Scottish Government target of ‘less than 10% of adults to have no teeth remaining by 2010’.

Targets for Oral Health The actions set out in the Dental Plan are centred on delivering population improvements in oral health and reducing health inequalities. Progress will be monitored through the following indicators: Children’s Oral Health Targets 1. Oral Health Improvement Grampian Primary 1 – (Currently 70% of P1 children have no obvious decay as of 2016) a. 75% of P1 children with no obvious decay by 2018. b. 80% of P1 children with no obvious decay by 2022. Grampian Primary 7 – (Currently 73% of P7 children have no obvious decay as of 2015) a. 75% of P7 children with no obvious decay by 2018. b. 80% of P7 children with no obvious decay by 2022. 2. Oral Health Improvement Equity a. By 2020, at least 60% of P1 and P7 children in each SIMD quintile will have no obvious dental decay in Grampian. (Currently ranges between 80% in the least deprived quintile to 46% in the most deprived quintile). 3

GADHS – Grampian Adult Dental Health Survey

4

b. By 2018 & (2022) in all: i. Health and Social Care Partnerships (HSCPs) - 75% (80%) of P1 and P7 children will have no obvious dental decay. ii. Associated School Groups (ASGs) & Community School Networks (CSNs) - at least 50% (60%) of P1 and P7 children will have no obvious sign of dental disease. Adult Oral Health Target Less than 5% of adults in Grampian should have no teeth remaining by 2022. Oral Cancer Target To reverse the rising incidence of oral cancer in Grampian by 2022.

Dental Registrations Historically, Grampian has had low levels of NHS dental registration; due in the main to a lack of NHS committed dental practices. However, as a result of a number of initiatives to improve access, including the recruitment of salaried General Dental Practitioners (sGDPs) and the Scottish Dental Access Initiative (SDAI) scheme, registration rates have been rising since 2007. The latest ISD statistics show that just over 7 out of 10 people in Grampian are now registered with a NHS dentist as at September 2015 (73.6%; 431,268). The proportion of the Grampian population registered with an NHS dentist increased from 35.2% to 73.6% between March 2007 and September 2015 (Figure 4). Despite this huge improvement in registration, NHS Grampian still has the lowest registration rates in Scotland, particularly amongst adults. This may be explained by the historical low levels of registration and the relatively higher use of private dentistry in Grampian. Figure 4

PRO PO RTIO N O F G RAMPI A N PO PUL ATI O N REG ISTER ED WITH A NH S D ENTIS T 2 0 0 7 - 2 0 1 5 Children %

Adults %

All Ages %

100 90 80 70 60 50 40 30 20 10 0

2007

2008

2009

2010

2011

2012

2013

2014

2015

Children %

58.3

63.2

66.7

69.5

72.6

78.5

82.8

85.2

87.4

Adults %

29.2

33.1

38.4

43.2

47.7

54.5

60.7

65.8

70.6

35

39

44

48.3

52.5

59.1

64.9

69.5

73.8

All Ages %

Source – ISD

5

Dental Registration Targets 1. All Children (0-17 years) a. 90% of all children registered with a NHS dentist by end of 2018. (Currently 87% of all children are registered as of September 2015). b. 93% by end of 2020. c. 95% by end of 2022. 2. All Adults (18+) 2016 - 2022 a. 73% of adults registered with a NHS dentist by end of 2018. (Currently 70% of adults registered as of September 2015) b. 75% by end of 2020. c. 78% by end of 2022. The action plan which has been developed to facilitate achievement of the above targets will be managed and monitored by the Oral and Dental Health Managed Clinical Network (MCN). The full action plan is available on request, with a selection of key actions listed below, highlighting resource implications where applicable. Aim 1 – Continuous improvements in the oral health of the Grampian population. 1. Maintain the current emphasis on the two main oral health improvement programmes: a. Childsmile - Childsmile is a national programme designed to improve the oral health of children in Scotland and reduce inequalities both in dental health and access to dental services. b. Dental Priority Groups – Caring for Smiles (Older people), Smile4Life (Homeless) and Mouth Matters (Prison). 2. Seek improvements in the delivery and quality of the programmes with a focus on improving oral health in deprived and vulnerable populations in an effort to close the inequalities gap. 3. Work with key stakeholders to implement an oral (mouth) cancer awareness campaign annually on the causes and symptoms of the disease. 4. Work with acute sector partners (Head & Neck cancer services and Aberdeen Dental Hospital) to embed preventive initiatives such as smoking cessation and alcohol brief interventions in their clinical pathways. Aim 2 - Improve access to high quality NHS Dental services for all those who request and need routine and unscheduled dental care. 1. Undertake evidence-led registration campaigns to further improve NHS dental registration and participation rates in Grampian. Particular emphasis will be placed on trying to encourage the registration and participation of very young children, the elderly and the vulnerable population. 2. Ensure the ‘rebalancing’ of the PDS creates increased opportunities for access to NHS dental care and oral health improvement for vulnerable groups. ‘Rebalancing’ is the realignment of dental services in line with the Scottish Government policy that wherever possible the independent general dental practice is the preferred provider of primary care dental services. The PDS is required to refocus on its key remit of providing dental services for the vulnerable 6

population including those with special care needs and difficulties accessing the ‘high street’ dentists. 3. Implement the recommendations of the Special Care Dentistry Needs Assessment to improve the special care dentistry service provided by the PDS. The Needs Assessment recommends increasing capacity for specialist roles in this field from 2 wte to 4 wte in order to best meet the needs of this population. This has resource implications for the three Public Dental Services in Grampian which could be met from realignment of existing resources within the services.

Aim 3 - Enhance and strengthen the role of the Oral and Dental Health Managed Clinical Network (MCN) as a platform for delivering the vision of best possible oral health for all. 1. Undertake a review of the Grampian Dental Emergency Services (GDENS) to ensure it continues to meet the changing demand for unscheduled dental care. 2. Explore opportunities to strengthen engagement with General Dental Practitioners (GDPs) to increase participation in decision making, care pathway and policy development, and implementation of evidence-based practice. 3. Work with the North of Scotland Planning Group, Aberdeen Dental School & Hospital, NHS Grampian Acute Sector and other stakeholders to develop solutions to address the shortage of paediatric dentistry specialist skills across the North of Scotland. Aim 4 - Help and support people to maintain and improve their oral health by emphasising prevention and supported self care and management of oral diseases. 1. Update the Teeth TLC website to provide information on oral health for the Grampian population to support prevention, self care and management. 2. Continue to develop the Teen TLC website with partners to provide an online platform for health and wellbeing information targeted at teenagers. 3. Develop an oral health care management resource for the self management of long term conditions, such as diabetes. Aim 5 – Strengthen and improve the effectiveness and efficiency of the dental quality improvement and assurance framework. 1. Ensure the introduction of appropriate quality standards for primary care dental services as currently being piloted by the Scottish Government. 2. Recruit to a dental clinical effectiveness role to support audit, standards and performance management in Dental Services – this has resource implications, but is key to ensuring robust quality improvement. 3. Work with Scottish Government, IJBs/HSCPs and the local dental workforce to achieve the objectives of the Strategic Vision for e-Dentistry particularly the management of the increased requirement for timely good quality data and analysis to target health care improvement and meeting the clinical, governance and business support requirements of primary care dentists. This action plan, along with the full NHS Grampian Dental Plan 2016-2022, was circulated from July – September as part of a consultation exercise to the following 7

for onward dissemination:              

Oral & Dental Health MCN members Aberdeen Dental School & Hospital North of Scotland Oral & Dental Health Group Public Dental Service teams in Aberdeen City, Aberdeenshire and Moray General Dental Practitioners via Primary Care Contracts Public Health Directorate Oral & Maxillofacial Services department Royal Aberdeen Children’s Hospital (RACH) Primary Care Integrated Management Group (PCIMG) Health and Social Care Partnerships in Aberdeen City, Aberdeenshire and Moray Local authority Education Departments in Aberdeen City, Aberdeenshire and Moray Care Homes across Grampian All NHS Grampian staff via Global Email and Intranet Wider general public via Press & Journal article and NHS Grampian Involving You website

Valuable and constructive feedback was received from a variety of sources, including a number of NHS Grampian Public Health colleagues, General Dental Practitioners, all three PDS teams, Aberdeen City Alcohol & Drugs Partnership (ADP), Aberdeen City and Aberdeenshire HSCPs, a Care Home and PAMIS. The feedback was positive on the whole, which is encouraging, with respondents generally agreeing with the overall vision and direction of travel. Responses also highlighted a number of relationships with other services and organisations that can support implementation of the aims of the Dental Plan, as its success depends on partnership working. Work to strengthen these links and relationships will be part of the MCN workplan with examples including:  Linking with Health Promoting Health Service (HPHS) to facilitate oral health being included as an important factor of health and wellbeing and to ensure oral and dental health services refer to other relevant services, e.g. smoking cessation, alcohol brief interventions, etc.  Promoting Keep Well and Making Every Opportunity Count (MEOC) to oral and dental health services to ensure a holistic approach.  Working with relevant third sector organisation to utilise their knowledge and expertise and to engage with their client groups to inform service redesign.

4. Risk Mitigation Risk 586 – Partnership working with local authorities, third sector, independent contractors and community 90% of dental care provision is delivered by General Dental Practitioners (GDPs) who are independent contractors and therefore, in order to implement our vision for oral health fully, engagement with that group is crucial. Due to the nature of the contract, engagement is currently challenging, however the direction indicated by the consultation draft of Scotland’s Oral Health Plan suggests that there may be more opportunities in the future to work closer together. Therefore, NHS Grampian has to 8

be in a position to capitalise on those opportunities and will do so with the MCN at the forefront of that engagement. Risk 851 – Delivery Strategies to meet the future health of the population The Dental Plan takes into consideration the changing demographics and health needs of the Grampian population and re-focuses services to encompass these changes. Health and Social Care Integration is providing the opportunity to revisit the challenges that dental services face with a new perspective. Dental services need to work closer with other multi-disciplinary colleagues to target hard to reach groups with a more holistic approach, rather than working within individual silos. Risk 1134 – Sustainable Workforce There is a requirement to review specialist services on a North of Scotland basis in order to ensure sustainability, as many of these roles can be challenging to recruit to. In addition, education, training and development are key to a sustainable workforce and sharing resources with our colleagues, partners and neighbours is vital.

5. Responsible Executive Director and contact for further information If you require any further information in advance of the Board meeting please contact: Responsible Executive Director Susan Webb Director of Public Health [email protected]

Contact for further information Jonathan Iloya Consultant in Dental Public Health [email protected]

11th November 2016 Additional supporting information The full NHS Grampian Dental Plan 2016-2022, including the action plan, is available on request. A draft workplan for 2016-2018 is currently in development by the Oral & Dental Health Managed Clinical Network (MCN).

9