On May 5th, 6 months after launch, the Real Junk Tooth Project supported by Dentaid reached its first 100 patients - sufficient to provide relevant insights to the situation.
And here it is.
The UK Homeless face major barriers in accessing dental services, even though they are more likely to experience oral health problems. A study involving 853 people experiencing homelessness identified 98% had experienced dental decay.
According to Cole et al (2011) decayed and missing teeth can psychologically influence and exacerbate depression within the homeless community. Government statistics from 2014 showed; the percentage of rough sleepers across England has risen by 14% from 2013. A study conducted in Eastman Dental hospital in London (2013) identified the difficulty for homeless people accessing dental services. Over 50% reported that NHS dentistry was ‘hard to find’ and ‘accessing it was difficult.’
The Dentaid Dewsbury/Real Junk Tooth Project (RJTP) pilot was set up in response to requests from the The Real Junk Food Project Dewsbury (TRJFPD) to treat those attending who were unable to eat free food because of dental pain.
The intention had originally been to treat those using the TRJFPD who were migrants or unable to officially access NHS dental services.
Very soon, and following on from reading the Healthwatch report into dental access for Dewsbury , The need was identified to treat those unable to access NHS dentistry despite being entitled to this service.
The dental practice involved was volunteered by Nick O Donovan for use by the charity Dentaid and staffed by volunteers mainly from the DFT postgraduate course, both FDs and trainers.
These FDs experienced working with a charity, gained experience of treating a different cohort of patients, emergency dentistry, extractions experience and taking part in this pilot seeing innovation working (HEE QA initiative).
The Dean gave permission for the DFT involvement and they were supported by DFT Trainers, experienced dentists or oral surgeons in order to provide a safe clinical environment. FDs were responsible for contacting and gaining approval from their indemnity society and Dentaid managed and checked DBS certification.
All attendees were asked a series of voluntary questions regarding access as well as the normal dental records mandatory for all patients e.g. medical history and treatment completed; the results for the first 100 patients are available in the audit summary that you can download here.
Download a .pdf version here
1. 49% of those attending were currently smokers; this is in contrast to the 19% of adults in England (4.) who are smokers. Numbers have been dropping following campaigns and advertising cuts, warnings, social pressure. This is actually higher than figures for England in the 1950s and indicates a ‘group or section of society where improvements in health and life expectancy are not keeping pace with the rest of the population’.
2..23% had visited a dentist within the last 5 months but were still experiencing dental problems.
3. 59% had tried to access NHS dental services but were unable to do so. Some had been waiting for years and had resorted to taking painkillers up to 5 times daily. Some patients thought they were on waiting lists for nhs services and were expecting to be told when they reached the top of the list; this generally never happened and they were left waiting with no information.
4. Twice as many male patients attended compared to female patients.
5. Around a quarter of those seen had mental health and/or addiction problems.
6. The general impression was that patients did not disclose all information for fear of not receiving treatment but this is not definitive evidence.
7. The number of patients who had either accessed 111 emergency services and received incomplete advice, or poorly communicated treatment, or tried to access dental treatment at an inappropriate site (A+E, GP) made up nearly a quarter (24%) of all those seen. The cost attached to this, both for the service and the patient, is significant.
Patients accessing 111 services because they couldn’t obtain NHS dental treatment were being treated with a pulp extirpation and dressing (at a cost to the patient of the nhs charge of £51.30 in some cases and £18.80 depending on the site accessed) then being advised to find a dentist to get further treatment. This was poorly communicated to the patient concerning the cost and need for further treatment.
The patients were attending the emergency service because they are unable to access regular dental services at all; the dressing was then lost within days or weeks and the patient was no better off. The cost of the service for 111 plus the patient charges could be better spent paying for considered and patient centred treatment.
8. Some patients on low income were unable to pay the NHS charges some were too frightened of the costs.
9. 6% of those attending were children (none of them migrants and were all entitled to free nhs treatment) who were losing permanent molars in the mixed dentition. The cost for later orthodontic treatment to correct this is not insignificant plus the pain, suffering and loss of educational time associated with dental decay.
10. 98% of patients attending gave details of a GP where they said they were registered. It was noted that some GP addresses were not near the address given for residence. This was due to some patients just working or living in the area temporarily.
11. Distance travelled. 70% of those attending travelled less than 2 miles. Only 5% travelled more than 4 miles. Currently the only emergency dental service accessed through 111 is either in WF1 or HD1 which are both 10 miles from Dewsbury and not easily accessible for this population group as these figures indicate.
12. This pilot has confirmed and has added understanding to the findings of the Healthwatch Kirklees report ‘Why can’t I find an NHS dentist in Kirklees? 2014
Dewsbury West has the lowest number of UDAs commissioned per population in the region and the highest attendance at Dentaid /RJTP . WF13 accounted for 53% of those attending as the pilot was positioned in the most appropriate place where the current access is poor.
13. Accuracy of given information: The postcodes for patients was discussed with one attendee at RJFP. In the case of the homeless, this was usually a friends postcode of the flat where they lived in the stairwell, or the postcode used for claiming benefits but they didn’t actually live there. The postcode was however considered to be close enough to be an indication of the distance travelled. It was also noted that the medical history declared was probably not complete possibly due to fear of not receiving treatment.
14. Access to this patient group has traditionally been difficult but running this clinic in association with the The Real Junk Food Project Dewsbury has targeted this group effectively.
15. The Real Junk Food Project Dewsbury also makes healthy food accessible which works in collaboration with dental health and medical health. Over 3 months in Dewsbury TRJFPD have intercepted 10 tonnes of food, fed 6820 people, provided 14000 meals. Multiprofessional working has shown to be very effective in this respect. Partnership working with TRJFPD alongside Connect Housing, Lifeline, ‘On Track’, churches and other groups has been the key to effective targeting and treatment of high need patients.
16. General Dental Practitioners working in an area with very low UDA commissioning will not select these patient types due to the lack of profitability for their business when they have such a choice of patient demand. Practices which are overloaded with high needs patients worry they may run the risk of bankruptcy or resorting to inappropriate activity.
17. Discussions with Healthwatch and the Health and Wellbeing Board show that access is an issue which has not been addressed despite evidence over several years by Healthwatch.
18. This pilot has gained further understanding of patient experience and has developed a model to provide care which is appropriate.
19. To date this project has received no support from the NHS for provision of these services.
The results of this pilot show a link between the data collected for poor access and the Index of Deprivation. The UDAs commissioned in the region are worst in the areas of maximum deprivation when it should ideally be the opposite if the NHS Constitution is to be upheld.
The population for Dewsbury West is slightly higher than Dewsbury East yet the UDAs commissioned are 6500 UDAs for Dewsbury West compared to 41,453 UDAs for Dewsbury East (over 6 times more).
The NHS aims to provide a comprehensive service, available to all (Department of Health NHS Constitution for England updated Oct 2015).
Highlighted are extracts from the constitution showing the areas where the charity Dentaid/RJTP is able to work alongside NHS England in developing appropriate access for this group of patients that currently are ‘falling through the cracks’ of NHS dental provision in Kirklees :-
Key to this project is the extensive links between charities and other organisations who have access to the population that find it difficult to reach dental care. Linking together and having a charity providing the treatment has broken down barriers for this population; concerns regarding costs of treatment or language difficulties or judgments of situation have been removed.
The provision of emergency treatment for 100 patients at 1.2 UDAs (suggested rate £30/UDA for a high need population) over 22 weeks equates to £ 136 per 2hr session. Many emergency services are historically allocated band 2 for pulp extirpation and extractions which would put the cost per session at only £346 per 2hr session.
A suitably funded model of working that links The Real Junk Food Project Dewsbury (or similar feeding programme) with Dentaid and postgraduate teaching and training has been shown to work with regard to access for the target patient base and provision of appropriate treatments in a cost effective way using the finite resources which are available.
The NHS working with, and funding this model, would move dentistry nearer to the NHS constitution recommendations.
Healthwatch Kirklees . ‘Why can’t I find an NHS dentist in Kirklees? 2014’
Department of Health NHS Constitution for England updated Oct 2015
ASH Nov 2015 Facts at a Glance
Dept Health statistics on smoking http://www.hscic.gov.uk/catalogue/PUB17526/stat-smok-eng-2015-rep.pdf
Freeman , R. Beaton , L. Rodriguez , A. (2015). Scottish Oral Health Improvement Homelessness Programme: Smile4life. University of Dundee. Accessed October 2015: http://dentistry.dundee.ac.uk/scottish-oral-health-improvement-homelessness-programme-smile4life
Coles, E., Chan, K., Collins, J., Humphris, G.M., Richards, D., & Williams, B., Freeman, R. (2011). Decayed and missing teeth and oral health-related factors: predicting depression in homeless people. Journal of Psychosomatic Research, 71: 108-112. Accessed October 2015: http://www.sciencedirect.com/science/article/pii/S0022399911000067
Howard D. (2014). Rough Sleeping Statistics England - autumn 2014 Official Statistics. Department for Communities and Local Government, 3. Accessed October 2015: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/407030/Rough_Sleeping_Statistics_England_-_Autumn_2014.pdf
University College London. (2013). New study discovers homeless dental problems. University college London hospitals. Accessed October 2015: http://www.uclh.nhs.uk/News/Pages/Newstudydiscovershomelessdental problems.aspx
Thank you to everyone who has worked hard to make this project happen.
Paul Burr from The Real Junk Food Project Dewsbury; Sue Baker HEEYH; Linzi Maybin LDFTyr2 for the rota organisation; Andy Evans and Jill Harding at Dentaid; Bruce Bird VIPromotions; Nick O Donovan for the use of his surgery, equipment and materials free of charge; Ian Wilson for support and encouragement; dentists, foundation dentists, nurses and receptionists from Yorkshire and Humber for your dedication to patient care; our works experience volunteers; Linda Holmes manager at Sensory World for giving us a base from which to operate.