(2013-01-18)-APHR-2009-Full-report

Oral Health in Islington

ANNUAL PUBLIC HEALTH REPORT 2009

Having an unhealthy mouth canhave a real impact on health andwellbeing. This is particularlyimportant in Islington as oralproblems are strongly linked todeprivation. However there ismuch we can do to tackle thisimportant public health problem,as oral diseases are almost entirelypreventable.

Our in-depth analysis of the oralhealth of Islington’s residentsshows a stark difference in healthexperience between differentgroups. Patterns in oral diseasefollow the patterns we see in other disease groups with suffererstending to come from less affluentgroups. Local surveys suggest thatyoung children and older peoplehave particularly high levels of oral disease, yet poor access todental treatment.

People with oral diseasesneedlessly suffer from physical and psychological effects includingpain, poor diet, time off work or school and low self-esteem. We need to prevent oral diseasesby tackling their causes, many of which are shared with othercommon chronic diseases. By improving the food people eat, for example, we can reduceoral disease along with obesity and diabetes. By tackling the causesof oral disease across the range ofaction on health inequalities, wewill improve both oral health andgeneral health and wellbeing forour most disadvantaged groups.

We have all heard lots in themedia about the lack of NHSdentists but, like in other Londonboroughs, this is not a problem inIslington. In fact Islington dentistshave the capacity to see people for NHS treatment, but manypeople only visit their local dentistwhen they have an acute need.Unfortunately these tend to bepeople who are at greater risk of suffering from oral disease.

We want to ensure that peoplehave good oral health so that they do not have to experience the many effects of oral diseases in the long term. We also want toensure that NHS dental treatmentis easily accessible for all, particularlythose who need it most.

These are all reasons for focusingin on oral health and laying outthe evidence, gaps and challengesof improving oral health outcomesin Islington. This report looks at the challenges we face inimproving oral health, reducinghealth inequalities and improvingaccess to dental care as well asidentifying the groups that weshould focus on.

Following an introduction that setsout the definitions of oral healthand the impact oral disease has on the quality of our lives, we havea number of chapters that examinedifferent aspects of oral health need.

Chapter 2 focuses on theinequalities in oral disease and the groups in Islington that are

particularly at risk. This includesdata by population group andmakes some recommendations on where we should focus ourattention.

Chapter 3 looks at the underlyingcauses of oral disease, why theoral health of people in Islington is worse than elsewhere and whatwe can do to address these issues.

Chapter 4 sets out the dentalaccess issues in Islington, detailingthe groups that do not access a dentist and how to reduce themany barriers they face.

Chapter 5 considers how oral health can be improvedthrough developing a range of complementary strategies across agencies and sectors.

Chapter 6 discusses how we canimprove the quality of dentalservices so that they promoteaccess and health outcomes, aswell as provide excellent treatment.

Each of the chapters makesrecommendations for action that are summarised in ourconclusion where we also lookback at previous reports and givean update on recommendations that we have made on CVD andmental health. As in previousyears, we have updated our localkey health statistics (Health inIslington – the Facts).

As Directors of Public Health acrossthe country will all say, developingand writing an Annual Public Health

Foreword

In a Borough like Islington, with many health challenges, it mayseem surprising to choose oral health as the focus of our AnnualPublic Health Report this year. However oral health affects all of usin some way from how we look and speak to the food we can eat.

Report is a major task and willusually rely on one key personwithin the public health team to pull things together. This year,our lead has been Jenny Donaghywho has done the majority of the work to bring this report tofruition. Our understanding of oralhealth need in Islington has movedon exponentially in the last yearand this report is the culminationof this work and I would like tothank Jenny for her hard work and leadership. Mandy Murdochhas supported Jenny and overseenthe development process as well as contributing to the content of this report. Thanks also go toRachel Maan for her contributionto the content. We are also verylucky to have excellent relationshipswith our academic colleagues and as usual they have been verysupportive in developing this work,led by Professor Richard Watt.Sarah Dougan has done much of the epidemiological analysis that is so key to strong needsassessment. The communicationsteam, particularly Caroline Rowe,has given their expert input onlayout and design.

We hope you enjoy reading thereport, either as a whole or bydipping into individual chapters,and that it gives you a clear pictureof oral health in Islington.

PUBLIC HEALTH REPORT 1

ContentsIntroduction1. Introduction 22. Inequalities in oral diseases in Islington 63. The causes of inequalities in oral health 194. Inequalities in access to dental services 275. Improving oral health in Islington 386. Improving oral health services in Islington 477. Conclusions and recommendations 59

Glossary 61Progress on promoting mental health in Islington 64Progress on reducing early deaths from cardiovascular disease in Islington 66

Acknowledgements(in addition to thosementioned in the foreword)

Alun LewisBaljinder HeerChrisa TsiarigliDavid Bates Emily CarrGeorge TskakosHelen CameronHuda YusufIan SandfordJennifer MillmoreJonathan O’Sullivan

Julie BillettKate HaleKatie LindsayMartin MachrayPaula CoozeRenu BindraSarah AmbroseSimon LoganVanessa SuchitZoe Burt

Sarah PriceDirector of Public Health

2 INTRODUCTION

The impact of dental disease on the individual and the communityOral diseases place a significantburden on society and theindividual and are among the most commonly found chronicdiseases in the UK. Despiteimprovements in recent years, oral diseases can have seriousconsequences and many adultsand children still suffer from oralpain and discomfort. Oral disease

reduces quality of life by impactingon physical well being, such as theability to eat and speak. In childrenfor example, severe tooth decaycan cause pain, disfigurement,infections, poor dietary intake,sleep deprivation, days off schooland reduced nutritional intake andgrowth. Psychological impacts areless often considered but can alsobe significant, for example theembarrassment of having broken

teeth can have a negative effect onself-esteem and social confidence.The many impacts of oral diseasesare summarised in Figure 1.1.

At a societal level, oral diseases areresponsible for reduced productivityof the workforce and are expensiveto treat. In 2005-06 for example,around £1.5 billion was spent onNHS dentistry in primary care inEngland, £300 million of which wasfunded through patient charges.

Introduction

Figure 1.1. Impacts of oral diseases on society and individualsSource: Department of Health Choosing Better Oral Health. An Oral Health Plan for England. 2005 Available at URL:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123251

1

Impact ofOral Diseases

Sleepless nights

Cost to the NHS

Pain/discomfort

Fear/anxiety

Cost of treatment Self esteem Aesthetics

Time attendingservices

Socialisolation

Socialattractiveness

Time offschool

Time offwork

Functional limitation

Poor educationalperformance

Reduced productivityof workforce

What is oral health?

Oral health is a state that enables individuals to ‘eat, speak, andsocialise without active disease, discomfort or embarrassment’. It contributes to general well being and is integral to general healthand quality of life. Oral health is compromised by oral diseases: a range of conditions that include gum (periodontal) disease, oral cancers and dental decay (caries).

Inequalities in oral health There has been a significantimprovement in oral health overthe past 30 years and manychildren and young adults are now free from dental decay.However this improvement has not been evenly spread across thepopulation as disease experiencevaries by gender, age, social classand ethnic group. The distributionof dental decay has becomeincreasingly polarised and is nowconcentrated in certain populationgroups, particularly the vulnerableand socially disadvantaged.

Socioeconomic inequalities in oral health have been well andconsistently established. Theserelate to both clinical diseases(such as tooth decay, gum disease,tooth loss and oral cancer) andsubjective perceptions of oralhealth and quality of life. A socialgradient in oral health exists,whereby there is better oral healthand quality of life for each higherlevel of socioeconomic position.This is particularly pertinent toIslington as it has a largely deprivedpopulation who are more likely to experience poor oral health.Indeed incidence of dental diseasein Islington is higher than regionaland national averages.

Inequalities in access toservicesHard to reach, socially deprivedgroups are doubly burdened with the poorest oral health and lowest uptake of dental care.NHS dentists in Islington are readilyavailable but are not used by manyresidents, particularly those with thehighest risk of disease. A variety of barriers exist that preventattendance, such as cost and fear. Young children, older people,single people living in socialhousing, prisoners, people withmental illness and those from Black and Minority Ethnic groups are just a selection of those who experience barriers to dental service use.

The causes of inequalities in oral health At the simplest level oral diseasesare primarily caused by riskbehaviours such as frequent sugar consumption, tobacco useand poor oral hygiene practices.However the circumstances inwhich people live and work alsohave a profound effect on theirhealth and well-being. There isstrong evidence to suggest thatthe main causes of oral healthinequalities are social andenvironmental.

Improving oral health To improve oral health and reduceoral health inequalities it is necessaryto tackle the social determinantscommon to a number of chronicdiseases through, for example,creating healthy environments in schools and workplaces andstrengthening communitiesthrough engagement in healthservices. In addition, it is necessaryto provide specific oral healthinterventions and equitable accessto high quality NHS dental treatment.

Dental services are, by necessity,treatment focused and cannoteliminate oral health inequalitiesalone, no matter how accessible or effective they may be. Neithercan they reach those most in need of prevention, as the most at risk groups are also those leastlikely to seek regular treatment.Appropriate treatment servicesmust therefore be supplementedby oral health promotion activity at a community level, as illustratedin figure 1.2 above.

Improving oral healthservices NHS dentistry in Islington has beenfairly stable for a number of years.However with a number ofnational drivers for change thereis now a real need for services to modernise and become moreresponsive to their users. NHSdental services will be increasinglyexpected to do more than treatdisease; they must contributetowards health improvement,access to services and provide highquality, evidence-based treatment.Now that Primary Care Trusts arein control of commissioning dentalservices there is a real opportunityto work with our clinical partnersto continuously improve servicesfor the benefit of the populationwe serve.

Improved oral health

Oral healthpromotion

Preventionfocused

treatmentservices

Additionalsupport tovulnerable

groups

Reducedoral healthinequalities

INTRODUCTION 3

Figure 1.2. A simplified model for improving oral health and reducing oral health inequalities

4 INTRODUCTION

1. Introduction

Oral health as a public health priority for IslingtonOral disease, particularly dentaldecay, is a priority for action inIslington. For a disease to be apublic health problem it mustdisplay a number of key features: it should be widespread, havesevere consequences and costs for the individual or the communityand effective methods to prevent,alleviate or control the diseasemust be available. Dental decay fits comfortably into this definitionand is responsible for much poor oral health and oral healthinequalities locally.

The strong association betweenoral diseases and deprivation, and the fact that oral diseases are largely preventable, makes oral health a particularly importantpublic health issue in Islington. It is vital that we tackle preventabledisease to improve health andreduce oral health inequalitiesamong our ethnically diverse and largely deprived population.

This public health report exploresthe various aspects of oral healthand related inequalities in Islingtonincluding inequalities in oraldiseases, inequalities in access to services and the causes of poor oral health. It makesrecommendations for actionaround improving oral health and improving oral health services.

BIBLIOGRAPHYAcs G, Lodolini G, Kaminski S, Cisneros GI.Effect of nursing caries on body weight in a paediatric population. PaediatricDentistry 1992; 14:302-5.

Astrom AN, Haugejorden O, Skaret E,Trovik TA, Klock KS. Oral impacts on daily performance in Norwegian adults: the influence of age, number of missing teeth, andsociodemographic factors. Eur J Oral Sci 2006; 114:115-121.

Bower E, Gulliford M, Steele J, Newton T.Area deprivation and oral health inScottish adults: a multilevel study.Community Dent Oral Epidemiol 2007;35:118-129.

Cancer Research UK. UK oral cancerincidence statistics. Available at URL:http://info.cancerresearchuk.org/cancerstats/types/oral/incidence/?a=5441.

Cancer Research UK Information ResourceCentre. Open Up to Mouth Cancer.London: Cancer Research UK; 2005.Available at URLhttp://info.cancerresearchuk.org/healthyliving/openuptomouthcancer/healthprofessionals/statistics/.

Corbet E. Public Health Aspects of OralDiseases and Disorders – PeriodontalDiseases. In Pine C, Harris R (eds.).Community Oral Health 2nd edition 2007;Quintessence: Surrey.

Department of Health. Choosing BetterOral Health: An Oral Health Plan forEngland. London: Department of Health;2005. Available at URL www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf.

Do LG, Roberts-Thomson KF. Dental cariesexperience in the Australian adultpopulation. Aust Dent J 2007; 52:249-251.

Donaldson AN, Everitt B, Newton T, SteeleJ, Sherriff M, Bower E. The effects of socialclass and dental attendance on oralhealth. J Dent Res 2008; 87:60-64.

Downer MC. Oral Cancer. In Pine C (Ed.).Community oral health 1997; Wright:Oxford; pp.88-93.

Drury TF, Garcia I, Adesanya M.Socioeconomic disparities in adult oralhealth in the United States. Ann N Y AcadSci 1999; 896:322-324.

Haugejorden O, Klock KS, Astrom AN,Skaret E, Trovik TA. Socio-economicinequality in the self-reported number ofnatural teeth among Norwegian adults –an analytical study. Community Dent OralEpidemiol 2008; 36:269-278.

Hjern A, Grindefjord M, Sundberg H,Rosen M. Social inequality in oral healthand use of dental care in Sweden.Community Dent Oral Epidemiol 2001;29:167-174.

Holst D. Oral health equality during 30 years in Norway. Community Dent OralEpidemiol 2008; 36:326-334.

Locker D. Deprivation and oral health: a review. Community Dent Oral Epidemiol2000; 28:161-169

Lopez R, Fernandez O, Baelum V. Socialgradients in periodontal diseases amongadolescents. Community Dent OralEpidemiol 2006; 34:184-196.

Makhija SK, Gilbert GH, Boykin MJ, LitakerMS, Allman RM, Baker PS, Locher JL,Ritchie CS. The relationship betweensociodemographic factors and oral health-related quality of life in dentate andedentulous community-dwelling olderadults. J Am Geriatr Soc 2006;54:1701-1712.

Morita I, Nakagaki H, Yoshii S, Tsuboi S,Hayashizaki J, Igo J, Mizuno K, Sheiham A.Gradients in periodontal status in Japaneseemployed males. J Clin Periodontol 2007a;34:952-956.

Morita I, Nakagaki H, Yoshii S, Tsuboi S,Hayashizaki J, Mizuno K, Sheiham A.Is there a gradient by job classification indental status in Japanese men? Eur J OralSci 2007b; 115:275-279.

Moynihan PJ. The role of diet and nutritionin the etiology and prevention of oraldiseases. Bulletin of the World HealthOrganization 2005; 83:694-699.

Nuttall N et al. A guide to the UK AdultDental Health Survey 1998. British DentalAssociation; 2001: London.

Office of Public Management. A futures study of dental decay in five and fifteen year olds in England; 2005.Available at URL: http://www.opm.co.uk/resources/papers/children_bhlp/dental_children_reportWEB.pdf.

INTRODUCTION 5

Pavia M et al. Association between fruitand vegetable consumption and oralcancer: a meta-analysis of observationalstudies. Am J Clin Nutr 2006; 83(5):1126-34.

Pine C, Harris R. Community Oral Health.2007; Quintessence Publishing Co. Ltd:London.

Pitts NB, Boyles J, Nugent ZJ, Thomas N,Pine CM. The dental caries experience of 5-year-old children in Great Britain;2005/2006. Surveys co-ordinated by the British Association for the Study of Community Dentistry. Available fromwww.bascd.org.

Reisine ST, Psoter W. Socioeconomic statusand selected behavioral determinants asrisk factors for dental caries. J Dent Educ2001; 65:1009-1016.

Sabbah W, Tsakos G, Chandola T, SheihamA, Watt RG. Social gradients in oral andgeneral health. J Dent Res 2007; 86:992-996.

Sanders AE, Slade GD, Turrell G, SpencerAJ, Marcenes W. The shape of thesocioeconomic-oral health gradient:implications for theoretical explanations.Community Dent Oral Epidemiol 2006;34:310-319.

Sanders AE, Slade GD, John MT, Steele JG,Suominen-Taipale AL, Lahti S, Nuttall NM,Allen PF. A cross-national comparison ofincome gradients in oral health quality oflife in four welfare states: application ofthe Korpi and Palme typology. J EpidemiolCommunity Health 2009; 63(7):569-74.

Seremidi K, Koletsi-Kounari H, KandilorouH. Self-reported and clinically-diagnoseddental needs: determining the factors thataffect subjective assessment. Oral HealthPrev Dent 2009; 7(2):183-90.

Sheiham A. Dental Caries affects bodyweight, growth and quality of life in pre-school children. British Dental Journal2006; 201(10):625-626.

The Information Centre 2008NHS Expenditure for General DentalServices and Personal Dental ServicesEngland, 1997/98 to 2005/06. Available at URL: http://www.ic.nhs.uk/webfiles/publications/dentalexpend/NHS%20Expenditure%20for%20General%20Dental%20Services%20and%20Personal%20Dental%20Services.pdf.

Thomson WM, Poulton R, Milne BJ, Caspi A, Broughton JR, Ayers KM.Socioeconomic inequalities in oral health inchildhood and adulthood in a birth cohort.Community Dent Oral Epidemiol 2004;32:345-353.

Tsakos G, Sheiham A, Iliffe S, Kharicha K,Harari D, Swift CG, Gillman G, Stuck AE.The impact of educational level on oralhealth-related quality of life in older peoplein London. Eur J Oral Sci 2009;117(3):286-92.

Watt RG. From victim blaming to upstreamaction: tackling the social determinants oforal health inequalities. Community Dent Oral Epidemiol 2007; 35:1-11.

Watt RG, Sheiham A. Inequalities in oralhealth: a review of the evidence andrecommendations for action. Br Dent J1999; 187:6-12.

6 INEQUALITIES IN ORAL DISEASES IN ISLINGTON

People from lower socio-economicgroups, who are particularly at risk, carry much of the burden of oral diseases. They tend toexperience more dental decay,periodontal disease, tooth loss and edentulousness. Children andadults from disadvantaged socialgroups also have more unmetneed for treatment than moreadvantaged groups. This meansthat Islington residents, many ofwhom are from deprived socio-economic groups, will experiencemore oral morbidity than thenational average.

Oral diseases follow a social gradientwhereby individuals from thehigher end of the socio-economicscale tend to enjoy better healththan those below them. Healthdeteriorates further as you movedown the social scale. This ‘socialgradient’ in oral health follows thesame pattern to that of generalhealth, with those from sociallydeprived groups tending to havepoorer health and poorer access to health care services. While thisappears to be a recent finding, it is likely that these inequalities in oral health have always existed,even at the high disease levels ofearlier decades.

In addition to the socially deprived,there are a variety of other groups who are at greater risk of developing oral diseases. These tend to be the morevulnerable, difficult to reachgroups such as homeless people,people with mental healthproblems, people with learningdifficulties and prisoners.

Tackling these health inequalitiesand addressing the underlyingcauses of differences in people’shealth is a priority for Islington.This chapter explores the inequalitiesin oral diseases found in theIslington population and howthese inequalities relate to levels of socio-economic deprivation and identified at risk groups.

Oral diseases in children

National trendsThe oral health of children in theUnited Kingdom has substantiallyimproved over the past fourdecades. It is now the best it hasbeen since records began and onaverage, England has the lowesttooth decay among 12-year-oldchildren in Europe. In 5-year-oldchildren, although there have beenimprovements, disease levels havelevelled out.

A key measure in oral health is the average number of teeth that are decayed, missing or filled(dmft). The average number ofdmft in children has decreasedamong all age groups since 1973in the United Kingdom, with aparticularly large improvementamong 12-year-old children(figure 2.1). Among 5-year-oldsimprovements in the decayexperience occurred between1973 and 1983. This is attributedto the widespread use of fluoridetoothpaste. During this period, the average number of dmft perchild halved and the percentage of children without any cariesdoubled. However, there has been limited, if any, improvementin children since 1983. It is apparentthat additional interventions areneeded to further improve oralhealth.

National and regionalcomparisons of dental healthin 5-year-oldsAcross the UK, the most valuablesource of data on oral healthcomes from regular, nationallycoordinated surveys of 5-year-oldsin schools. This group is surveyedmost frequently and, by convention,

Inequalities in oral diseases in Islington

2

Introduction

In the first half of the twentieth century, oral disease had an impact on the health of the majority of the population. Since then there have been substantial reductions in oral diseases,but these improvements have not been evenly spread across the population. Instead, the pattern of oral diseases has changedand they have become concentrated in a small segment of thepopulation. This appears in epidemiological data as marked oral health inequalities.

is used as a proxy for the wholepopulation of a PCT. Surveys show that there are widedisparities in the oral health of 5-year-old children acrossEngland. In 2005/2006, of the 5-year-old children examined, there was an average of 1.46 dmftper child in England. Average dmftin London was higher than theEngland average at 1.66, butlower than SHAs in the north of England (figure 2.2).

Local surveys of oral healthin childrenThe last reported surveys for 5-year-old children were in2003/2004 and 2005/2006. The results from these two surveyshave been used in the analysis of oral health among children inIslington. However the followingpoints should be noted wheninterpreting the results of thesesurveys:

• There may be inter-examiner biases between different PCTswhich will have impacted on the comparability of results.

• In Islington the percentage ofyoung children sampled variedfrom 89% in 2003/2004 to 19%in 2005/2006.

• The minimum sample size is 250 children but where resourceallows, the PCT will sample agreater number, e.g. in 2003/4.

• With a relatively small sample size in the 2005/2006 survey inIslington it is difficult to knowwhether the children examined in 2005/2006 were truly arepresentative sample.

At a local level, therefore, theresults of the 2003/2004 surveyare considered to be more robust.

INEQUALITIES IN ORAL DISEASES IN ISLINGTON 7

Figure 2.1. Changes in the average number of decayed, missing and filled teeth(DMFT/dmft*) in children by age group, United Kingdom, 1973-2003 Source: National Children’s Dental Health Surveys 1973 to 2003. Harker R and Morris J (2005). Office for NationalStatistics, London. In Choosing Better Oral Health, Department of Health (2005):http://www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf Available at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123251

Figure 2.2. Dental caries experience (dmft) of 5-year-old children, by Strategic Health Authority, England, 2005/2006Source: BASCD co-ordinated NHS Dental Epidemiology Programme survey 2005/2006

*By convention, DMFT (upper case) is used for permanent teeth (12 and 15 years) while dmft (lower case) indicatesprimary teeth (5 years)

5 Years 12 Years 15 Years

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2. Inequalities in oral diseases in Islington

Local, regional and nationalcomparison of oral health in childrenAlmost half (around 45%) of 5-year-olds in Islington hadexperience of tooth decay in2003/04. This was a significantlyhigher proportion than the London and England average:44.7% (95%CI: 42.3-47.1%)versus 38.4% (95%CI: 37.8-39.0%) and 38.7% (95%CI:38.5-38.9%), respectively. This is illustrated in map 2.1.In the 2005/2006 survey, however, Islington was notsignificantly different to either the London or England averages but this is likely to be because the children who were examined in 2005/2006 were not representative of Islington schoolchildren, as discussed previously.

Map 2.1. Comparison to London average of 5-year-olds with experience ofdental decay across London PCTs, 2003/04 Source: BASCD co-ordinated NHS Dental Epidemiology Programme survey 2003/2004

Figure 2.3. Dental caries experience (dmft) of 5-year-old children by London PCT, 2003-2004 survey*Source: BASCD co-ordinated NHS Dental Epidemiology Programme survey 2003/2004

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Figure 2.4. Comparison of average dmft for 5-year-olds with decay experience versus all 5-year-old children, Islington, London and England, 2003-2004Source: BASCD co-ordinated NHS Dental Epidemiology Programme surveys, 2003/2004

Figure 2.5. Social class inequalities in 5-year-old children’s oral health in Britain,1937-1993Source: National Children’s Dental Health Surveys 1973 to 2003. Harker R and Morris J (2005). Office for NationalStatistics, London. In Choosing Better Oral Health, Department of Health (2005):http://www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf

Dental health of young children in Islington is, along with Camdenand Barnet, among the poorest in North Central London as canalso be seen from the dental caries experience estimates fromthe same survey (figure 2.3).

There appears to have been littlevariation in the severity of dentaldisease experienced by 5-year-oldsin North Central London over thepast few years. In Islington, theaverage dmft among 5-year-oldswith decay experience seems tohave decreased, but again, this is likely to be associated with therepresentativeness of the childrensampled in 2005/2006 resultingin an underestimate of the trueburden of disease.

Dental decay is not shared equallyamong the children of Islingtonand a minority of childrenexperience a high burden ofdisease. The use of a populationaverage does not thereforeaccurately describe the picture ofdental caries in children. In realitymany children have no decay at all, while the remainder will have a substantial amount. This isillustrated in figure 2.4 whichcompares the average number of dmft in 5-year-old children withdecay experience to the averagedmft for all children. This indicateda high disease burden amongchildren with decay in Islingtonwith around 4 and 5 decayed teetheach, on average.

This shows that among the sample of Islington schoolchildrenin 2003/04, those with decayexperience have an averagenumber of 4.37 decayed teethcompared to 1.95 for all children.This represents a considerablehealth inequality for an entirelypreventable disease, with similarpatterns seen at regional andnational levels.

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*Columns for 5 and 8-year-olds indicate primary teeth.Columns for 12 and 15-year-olds indicate permanent teeth

Figure 2.6. Average number of teeth with obvious decay experience by socio-economicstatus of household, United Kingdom, 2003*Source: Lader, D., Chadwick, B., Chestnutt, Harker, R., Morris, J., Nuttall, N., Pitts, N., Steele, J. & White, D.Office forNational Statistics: March 2005. Children’s Dental Health in the United Kingdom, 2003: Summary Report.

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Inequalities and the socialgradient in oral health in childrenOral health in children displays a social gradient whereby thosefrom socially deprived groups tendto have poorest oral health andpoorest access to oral health care services. Despite overallimprovements in the oral health of children in the United Kingdom,health inequalities remain betweenhouseholds in the lowest andhighest social classes, and havepersisted over time (figures 2.5 & 2.6). In 2003, for example, the probability of having obviousdecay experience of the primaryteeth was about 50% higher inthe lowest social group than in the highest social group. A similarpattern is also observed forsecondary (permanent) teeth in teenagers.

This is very relevant for childrenresident in Islington, as more than50% of children in the boroughare estimated to live in families that are income deprived and so are likely to experience pooreroral health.

Differences in levels of deprivationbroadly explain these differences in average dmft by Islington schoolas shown in figure 2.7 above.Assigning an index of multipledeprivation (IMD) score to each of the Islington schools based onlocation within the borough showsa significant association betweendeprivation and the averagenumber of dmft and decayedteeth (dt): schools in moredeprived areas have a higher than average dental decayexperience, as well as untreateddental decay, among their children (figure 2.8).Unsurprisingly, there was nosignificant association betweendeprivation and missing or filledteeth by Islington school as this isan indication of treatment receivedand deprived children are leastlikely to receive treatment. Thesocial gradient in oral health inchildren in Islington can be clearlyseen from the significant variationin average dmft in young childrenby school in Islington in 2003/2004,from 0.31 to 3.67 (figure 2.7).

By considering the differentelements of the dmft indexseparately, it can indicate the level of treatment being carriedout in the surveyed group. The ‘missing’ and ‘filled’ portionsrepresent treatment of disease(assuming that missing teeth have been extracted). The decayedportion represents untreateddisease or unmet need. Figure 2.7displays variations by school in theaverage number of teeth that hadbeen decayed, were missing orwere filled which is indicative ofthe amount of treatment childrenreceive. In fact surveys at local,regional and national levelconsistently show that the majorityof decayed teeth in 5-year-olds isuntreated. This could indicate thatthese children are not accessingcare and/or are accessing care but not receiving treatment.Where the latter is occurring this has important implications for commissioners.

Oral diseases in adultsThe three major oral conditionsaffecting adults in the UK are dental decay, periodontal(gum) disease and oral cancer.Unfortunately, local data on adult oral health are not routinelycollected in Islington or elsewherein England. There are only regionalestimates from the decennialnational surveys. The latest survey (2009) has been delayed,however, and so the most recentdata are from 1998. While thesecan be used to determine somehigh level estimates, they are likely to underestimate diseaselevels in Islington because theborough has higher than averagelevels of deprivation which arestrongly associated with poor oralhealth. In 2007, Islington was theeighth most deprived borough in

Figure 2.7. Dental caries experience (dmft) in 5-year-olds by school, Islington, 2003/2004 Source: BASCD co-ordinated NHS Dental Epidemiology Programme surveys, 2003/2004

0.0

0.5

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Average of dt Average of mt Average of ft

England and the fourth mostdeprived in London.

The dental health of adults in theUnited Kingdom has improveddramatically over the past 50 yearsdue largely to the widespread useof fluoride toothpaste. During thepost-war years, the nation’s oralhealth was poor, dental diseasewas rife and there was littleexpectation that teeth would last a lifetime. This expectation has now changed, with thepercentage of adults in Englandwith no teeth falling from 37% in1968 to 12% in 1998 (figure 2.9).However, compared to some otherEuropean countries, there are still a relatively large number of adultsin England with no natural teeth.

The oral health of adults in theUnited Kingdom is improving inseveral ways as suggested by datafrom national surveys:

• Almost a third of young adults(aged 16-24 years) have nofillings.

• More adults are keeping theirteeth into older age and theproportion of adults with noteeth is expected to drop to 8% by 2008. It is predicted that by 2028, around 96% of the population will have their natural teeth.

• The average number of decayedteeth has dropped substantiallyfrom 1.9 teeth in 1978 to 1.1 teeth in 1998 and theproportion of younger adults,with a sound dentition (i.e.without any dental restorationsor decay) has risen dramaticallyfrom 9% in 1978 to 30% in 1998.


Figure 2.8. Figure 2.8: Deprivation index and decay experience, Islington schools,2003/2004Source: BASCD co-ordinated NHS Dental Epidemiology Programme surveys, 2003/2004; analysis by UCL.

a) Association between the average number of decayed, missing and filled teeth(dmft) and deprivation

b) Association between the average number of decayed teeth (dt) and deprivation

0

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Correlation coefficient: -0.337p= 0.02

Correlation coefficient: -0.338p= 0.02



It is difficult to collect robust data on gum disease; howevernational surveys suggest that theincidence of severe periodontaldisease is declining. Nevertheless,chronic periodontitis still affects a significant proportion of thepopulation. The most recent Adult Dental Health Survey, in1998, found that 54% experiencechronic periodontitis. Prevalenceincreases with age with 14% of 16-24 year olds and 85% of people aged 85 years and over having signs of the disease.Approximately 5% of thepopulation suffer from severedisease and are, therefore, at significant risk of tooth loss(figure 2.10). National figures are likely to underestimate theprevalence in Islington, however,because of the widespreaddeprivation in the borough and the positive association betweendeprivation and poor oral health.

Although oral hygiene is animportant risk factor for gingivitisand the bulk of periodontitis, oral hygiene levels alone are notsufficient to explain the prevalenceof all forms of periodontitis.Tobacco smoking is currently the best example of a true riskfactor for periodontitis. Stress, and less than adequate copingmechanisms to stress, can belinked to risk for periodontitis. It is becoming accepted that the periodontal conditions widelyencountered worldwide, namelyshallow pocketing, dental calculusaccumulation and bleeding gumsare not public health problems as they are unlikely to lead totooth loss.

The incidence of oral cancer hadbeen declining steadily over thepast few decades, but it hasrecently begun to rise in Englandand London. Between 2002 and

Figure 2.9. Percentage of adults with no natural teeth, England, 1968–1998 Source: National Adult Dental Health Surveys, 1968 to 1998. Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E and White D (2000). In Choosing Better Oral Health, Department of Health (2005)http://www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf

0%

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1968

Year

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Figure 2.10. Prevalence of severe periodontal disease (pocketing >5.5mm) in adults, United Kingdom, 1998 Source: Morris AJ, Steele J, White DA. Adult Dental Health Survey (2001). The Oral Cleanliness and PeriodontalHealth of UK Adults in 1998, British Dental Journal ; Vol 191(4): 186-192

0

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Figure 2.11. Percentage of adults with decayed/unsound teeth or periodontal (gum)disease by social class, United Kingdom, 1998Source: Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E, White D. Adult Dental Health Survey. Oral Health in the United Kingdom 1998.

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2006, the age-standardisedincidence of lip and oral cancers in Islington was no different toLondon and England, with anaverage of eight cases per annum(table 2.1). Similarly, relativesurvival of those with lip and oral cancers in Islington does notsignificantly differ from London or England, and neither doesmortality, with on average, threedeaths per year from lip or oralcancers between 2003 and 2007.

Inequalities in oral diseasesin adultsWhile oral health has improvedgenerally, it is not all good news.As for children, population averageshide oral health inequalities and a ‘social gradient’ exists wherebyhigher levels of disease can beseen at each lower level of thesocial hierarchy. Adults from themost deprived areas, in most agegroups, are more likely to haveone or more decayed or unsoundteeth than those from less deprivedareas, and there are also differencesin the prevalence of gum disease(figures 2.10 & 2.11).

Clearly this has implications forIslington because of both the high levels of absolute deprivationand relative deprivation within theborough. It is well established that

absolute deprivation has asignificant impact on health status but the social gradientillustrates the importance ofrelative deprivation. The socio-economic composition of Islington means this is of particular significance locally.

In Islington, as elsewhere, theincidence of lip and oral cancer is significantly higher in men thanwomen. There are no local data by age or deprivation because ofsmall numbers, but generally, theincidence of oral cancer increaseswith age from 50 years and isstrongly related to socioeconomicdeprivation with the highest rates occurring in the mostdisadvantaged groups. Incidence is higher in men, which is likely tobe caused by a greater prevalenceof tobacco chewing (particularlyamong BME groups), excessivealcohol intake and higher smokingprevalence. However the genderdifference is becoming lesspronounced over time.

Population groups inIslington who are atincreased risk of oral diseaseAll of the above suggest thatdespite substantial improvementsin oral health, marked inequalitiesremain between different socialgroups. As we have seen, sociallydeprived groups in society tend to have poorer oral health andpoorer access to oral health careservices. However, there are anumber of other vulnerable, hard to reach groups that facegreater risks and have worse oral health than the average.Groups particularly at risk fromoral diseases include, but are not limited to, the following:

People living in socio-economicdeprivationThere is a well-recognisedassociation between poor oralhealth and socio-economicdeprivation. All Islington wards are deprived compared to the rest of England. However, it ismore useful to compare levels of deprivation within Islington so that relative deprivation can be assessed. The pattern ofdisadvantage in Islington iscomplex, with areas of relativedeprivation lying adjacent to areas of affluence.


Table 2.1. Number and directly standardised rate of incident lip and oral cancer, by area of residence, 2002-2006 Source: Thames Cancer Registry, via NCIS, 2009

Persons Men Women

Area ofresidence

Average no.of cases per year

Standardisedrate per100,000

95% CIAverage no.of cases per year


95% CIAverage no.of cases per year


95% CI

Islington 8 5.8 3.9 – 7.6 6 8.9 5.6 – 12.2 2 2.7 1 – 4.4

NorthLondon* 74 5.2 4.6 – 5.7 46 6.9 6 – 7.8 28 3.4 2.8 – 4

London 387 5.6 5.4 – 5.9 238 7.4 7 – 7.9 149 3.8 3.5 – 4.1

England 3023 5.2 5.1 – 5.3 1836 6.8 6.6 – 6.9 1187 3.6 3.5 – 3.7

*North London Cancer Network: includes PCTs of Barnet, Camden, Enfield, Haringey, Islington & West Essex



Socio-economically deprivedneighbourhoods are oftencharacterised by poor jobprospects, high levels of crime and fear of crime, a poor physicalenvironment and poor access topublic services thus people living in such areas tend to be lesshealthy. Deprivation levels arelinked to numerous healthproblems (chronic illness, lower life expectancy, dental caries) and unhealthy lifestyles (smoking, drug misuse, poor diet), increasingthe need for health resources inthose areas. Additionally, those in more deprived areas are lesslikely to engage with healthservices, including dental services.

People who have a learningdisabilityIndividuals with learning disabilitiesexperience more oral disease andhave fewer teeth than the generalpopulation. They also have greaterunmet dental needs as they havemore difficulty in accessing dentalcare. Access to oral health care is affected by where people withlearning disabilities live: evidencesuggests that adults with learningdisabilities living in the communityhave greater unmet oral healthneeds than their residentialcounterparts and are less likely to have regular contact with dental services.

People with mental illnessEvidence suggests that people withmental illness have a greater risk of experiencing oral disease andhave greater oral treatment needs.There is a complex interrelationshipbetween socio-economic factors,illness, its treatment and oral health.Illness, whether physical or mental,may lead to deterioration in self-care, and oral care may alreadyhave a low priority. Risk factors areinter-related and are often barriersto oral health. It is important to ensure that individuals havesufficient information and supportin order to live independent livesincluding oral self-care and accessto appropriate dental services. In 2006/07 in Islington there wereapproximately 99 admissions per100,000 population to hospital for schizophrenia and delusionaldisorders compared to 78.2 forLondon. In 2006/07 there wereapproximately 115 admissions per100,000 population to hospital forcommon mental health problemscompared to 58 for London.

Older people Around 9% of Islington’spopulation are over the age of 65 which is less than thenational average. However, thenumber of people aged 75 andover is set to double in the nextten years. In older people, theretention of natural teeth into old age makes a major positivecontribution to the maintenance of good oral health related qualityof life and there is a clear andconsistent relationship betweenretention of natural teeth, ahealthy diet and good nutrition.

As the population ages and peopleare increasingly retaining theirteeth into later life, the restorativeproblems experienced by adultshave become more complex.

In addition, the prevalence ofperiodontal disease and root cariesincreases with age, as does themedical complexity of patients. At the same time, older people mayhave a reduced manual dexterity,which renders them less able tomaintain good oral hygiene.

Older people have specific oralhealth needs as oral healthproblems increase with age. In particular, age-related changescan lead to dry mouth (often drugrelated), root caries and recurrentdecay. Systemic problems can also have an effect on oral health;for example, many older peoplesuffer from illnesses associatedwith memory loss (e.g. Parkinson’sdisease and Alzheimer’s disease)that cause difficulties in controllingand retaining dentures andcleaning remaining teeth effectively.

Health services are likely to beincreasingly challenged by theneed to tackle ever more complextreatment in the context ofgrowing expectations arounddental health and demand for high quality treatment among the population. There are anumber of barriers to accessingcare for older people, particularlyfor those in institutional care: poor general health, not knowinghow to access care, patterns ofmobility, physical access to buildings(e.g. stairs) and available modes of transport.

A recent assessment of oral healthneeds of older people living innursing homes in Islington foundaround 40% had a reduced qualityof life due to oral health problemsand 75% had an unmet need fordental treatment.


PrisonersThere are around 1,600 residentsin Islington’s two prisons,Pentonville (men) and Holloway(women). Prison inmates have a standard of oral health that issignificantly worse than that ofthe general population. Prisonerstend to have more decayed teeth,fewer filled teeth and less naturalteeth than the general population,even when social class is takeninto account (adults in socialclasses IV and V have been shown to have fewer decayed or unsound teeth than the prisonpopulation). Evidence suggeststhat there is a substantial amountof unmet need in British prisons.Prisoners tend to have poorerphysical, mental and social healththan the population overall withlifestyles that are more likely to put them at risk of ill health.There is longstanding neglect in general health as well as oralhealth due to increased rates ofsmoking, drug abuse as well as a poor diet against a backgroundof deprivation. They are also lesslikely to access healthcare services.In addition, prisoners find itdifficult to self-care in difficultcircumstances. Furthermore,prisoners had less positiveattitudes to dental health and are less likely to have visited thedentist in the past two years than the general population.

Black and minority ethnicgroupsLevels of oral disease can varybetween ethnic groups andcertain groups are more likely toengage in risk taking behaviours.One quarter of Islington’spopulation are estimated to be non-white with half of thesebeing Black or Black British. Black African, Black Caribbeanand Bangladeshi ethnic groups

constitute the largest non-whiteethnic groups (20%, 17% and11% respectively). Data on theoral health of ethnic minorities arenot routinely collected in the UK.Therefore knowledge of the oralhealth status of different groups is limited. There is no clear patternof oral diseases among BMEgroups as they vary by ethnicity,age, sex, socioeconomic statusand length of stay in the UK.There is a diversity of experienceswithin, as well as across, ethnicgroups, by class, gender, andgenerations. Health inequalitiesare thought to be related to a number of factors includingmigration effects, geneticdifferences, culture, racialharassment, and access to and quality of healthcare.

Published literature suggests that the oral health of the Asiancommunity is poorer than that of their indigenous White peersand that subsequent, British borngenerations tend to have evenhigher caries experience. Carieslevels are high in younger children,while older Asians of Pakistaniorigin tend to suffer fromperiodontal disease. The mainethnic groups likely to havesignificant oral health needs in Islington are Bangladeshi, Black African and Black Caribbean.

There is further evidence tosuggest that, despite high levels of dental need, minority ethnicgroups experience barriers to accessing oral health care.Whilst perceived barriers interactand differ across ethnic groups,the main barriers are language(which affects uptake of bothtreatment and oral healthpromotion services), mistrust of the dentist, cost, anxiety and cultural misunderstandings.

It is important to consider thecultural characteristics of eachsubgroup when designing oralhealth promotion activities fordiverse ethnic groups.

Homeless peopleHomeless people tend to havepoorer health than the rest of the population. The population of homeless people also has ahigh prevalence of mental healthproblems including serious mentalillness, drug and alcohol relatedproblems, personality disordersand chronic stress. Data on theoral health status of homelessindividuals is limited; however,studies consistently report a highclinical and perceived need for oralhealth care within this population.They have a higher dmft (decayed,missing and filled teeth) than the general population and thereis a greater prevalence of dentalpain and gum disease. Homelesspeople tend to have fewerremaining teeth and heavy plaque accumulation. Despitethese high levels of need however,homeless people experiencedifficulty in accessing dentalservices. Around 1,130 Islingtonhouseholds were classified asstatutory homeless in 2004/05,which is 18% of households on the Local Authority housingregister. The average value forEngland is 7.8%. The mostcommon health problemsaffecting homeless people in Islington are drug misuse,mental health, alcohol misuse,dermatology and respiratoryproblems.



SummaryDespite substantial improvements in oral health, markedinequalities remain. Incidence of dental decay in Islington is high in comparison with regional and national averages. A social class and deprivation gradient exists in dental caries,periodontal disease, tooth loss and possibly oral cancer inIslington residents. This means that the Islington residentscarrying the bulk of the oral disease burden come from the most deprived and vulnerable groups.

Improvements in oral health have plateaued in recent yearsand it is clear that a fresh approach to both prevention andtreatment of oral disease is needed. Oral health inequalitiesrepresent a major public health problem for the borough and must be addressed.

Recommendations• Oral disease must be actively prevented by tackling its

causes, particularly in high need groups such as childrenand vulnerable adults.

• The quality of data collection at a local level should beimproved to allow a clearer understanding of oral diseaseexperience in specific target groups, e.g. information on ethnicity and disabilities, and conduct comprehensiveneeds assessments for target groups, e.g. vulnerable adultsand BME groups.

• Oral health promotion must be available to prevent diseasein children and vulnerable adults. This should integratewherever possible with generic health promotion, e.g.through smoking cessation services in dental surgeries.

• Barriers to uptake of dental treatment for children andother vulnerable groups must be tackled.

Drug misusersIntravenous drug use is associatedwith poor oral health, in particulardental decay and gum disease.This is thought to be due to acomplex relationship between anumber of factors, which includepoverty, self-neglect, consumptionof high sugar foodstuffs, poor oral hygiene and the intake ofmethadone syrup. Prolonged drug use is often associated with self-neglect and a cariogenic(decay promoting) diet. There are indications that drug addictsexperience severe dental andperiodontal tissue destruction.

In comparison with the generalpopulation, drug users tend tohave poorer oral health and displaylower utilisation of dental services.In 2006/07, there were 1,793Islington residents in drugtreatment compared to 1,540 in 2005/06. The rate for drugmisuse for Islington is 35 per 1,00015-64 year olds. It is the highestdrug misuse prevalence nationally(average for England is 10 per1,000). This group has specialdental needs and require greateraccess to dental care than most.


BibliographyCancer Research UK. UK oral cancerincidence statistics. Available at URL:http://info.cancerresearchuk.org/cancerstats/types/oral/incidence/?a=5441

Chiappelli F, Bauer J, Spackman S, Prolo P,Edgerton M, Armenian C, Dickmeyer J,Harper S. Dental needs of the elderly in the 21st century. Gen Dent 2002 July-Aug; 50(4):358-63.

Conte M, Broder HL, Jenkinds, G, Reed R,Janal MN. Oral health, related behavioursand oral health impacts among homelessadults. J Public Health Dent 2006 Fall;66(4):276-8.

Daly B et al. Essential dental public health.2003; Oxford University Press: Oxford.

De Palma P, Frithiof L, Persson L, Klinge B,Halldin J, Beijer U. Oral health of homelessadults in Stockholm, Sweden. ActaOdontol Scand 2005 Feb; 63(1):50-55.

Department for Communities and LocalGovernment (DCLG), Income DeprivationAffecting Children Index (IDACI), 2007.

Department of Health. An Oral HealthStrategy for England. 1994; Departmentof Health: London.

Department of Health. Choosing BetterOral Health. An Oral Health Plan forEngland. London: Department of Health;2005. Available at URL: www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf.

Downer M. Public Health Aspects of OralDiseases and Disorders – Oral Cancer. InPine C, Harris R (eds.). Community OralHealth 2nd edition. 2007; Quintessence:Surrey.

Fiske J, Gelbier S, Watson RM. Barriers to dental care in an elderly populationresident in an inner city area. J Dent 1990;18:236-42.

Gerodontology 2005; 22(Supplement 1):2-48.

Glassman P, Miller CE. Preventing dentaldisease for people with special needs: the need for practical preventive protocolsfor use in community settings. Spec CareDentist 2003 Sep-Oct; 23(5):165-7.

Godson JH, Williams SA.Oral health and health related behavioursamong three-year-old children born tofirst and second generation Pakistanimothers in Bradford, UK. CommunityDental Health 1996 Mar; 13(1):27-33.

Griffiths, J. et al. Oral Health Care forPeople with Mental Health ProblemsGuidelines and Recommendations. BritishSociety for Disability and Oral Health 2000.

Harker R, Morris J. (2005). NationalChildren’s Dental Health Surveys 1973 to 2003. Office for National Statistics,London. In Choosing Better Oral Health,Department of Health (2005). Available at URL http://www.dh. gov.uk/assetRoot/04/12/32/53/04123253.pdf

Islington PCT. Health in Islington: The Facts Update 2008. Available at URL:http://www.islington.nhs.uk/Publications/Health%20in%20Islington%20the%20facts%20-%202008.pdf

Jones CM, McCann M, Nugent Z. Scottish Prisons Dental Health Survey2002. Scottish Executive: Edinburgh.2004. Available at URL:http://www.scotland.gov.uk/Resource/Doc/47210/0013527.pdf

Jones CM, Woods K, Neville J, Whittle JG.Dental health of prisoners in the northwest of England in 2000: literaturereview and dental health survey results.Community Dent Health 2005 Jun;22(2):113-7.

King TB, Gibson G. Oral health needs andaccess to dental care of homeless adults in the United States: a review. Spec CareDentist 2003 Jul-Aug; 23(4):143-7.

Luo Y, McGrath C. Oral health status of homeless people in Hong Kong. SpecCare Dentist 2006 Jul-Aug; 26(4):150-4.

Mattin D, Smith JM. The oral healthstatus, dental needs and factors affectingutilisation of dental services in Asians aged 55 years and over, resident inSouthampton. Br Dent J 1991 May 25;170(10):369-72.

Newton JT, Thorogood N, Bhavnani V, Pitt J, Gibbons DE, Gelbier S. Barriers tothe use of dental services by individualsfrom minority ethnic communities living inthe United Kingdom: findings from focusgroups. Prim Dent Care 2001 Oct;8(4):157-61.

NHS Dental Epidemiology Programme.Oral Health Survey of 12 year old childrenin England 2008/9. National Protocolmodified 17/09/08. Available at URL:http://www.bascd.org.

NHS information centre. March 2009.Available at URL http:// www.ic.nhs.uk/news-and-events/ news/nhs-information-centre-award-adult-dental-health-survey-2009-contract-to-ons-led-consortium

Nuttall N et al. A guide to the UK AdultDental Health Survey 1998. British DentalAssociation; 2001: London.

Office for National StatisticsAdult Dental Health Survey 1998,accessed November 2005. Available atURL: www.statistics. gov.uk/downloads/theme_health/AdltDentlHlth98_v3.pdf.

Petersen PE. Inequalities in Oral Health:the Social Context for Oral Health inCommunity Oral Health.

Pilinova A, Krutina M, Salandova M, Pilin A. Oral health status of drug addictsin the Czech Republic. J ForensicOdontostomatol 2003 Dec; 21(2):36-9.

Robinson PG, Acquah S, Gibson B. Drugusers: oral health-related attitudes andbehaviours. British Dental Journal 2005Feb 26; 198(4):219-24.

Sainsbury D. Drug addiction and dentalcare. New Zeal Dent J 1999; 95: 58-61.

Sheiham A. Oral health, general healthand quality of life. Bull World HealthOrgan website 2005; 83(9):644. Availableat URL www.who.int/bulletin/volumes/83/9/644.pdf

Sheridan J, Aggleton M, Carson T. Dentalhealth and access to dental treatment: a comparison of drug users and non-drugusers attending community pharmacies. Br Dent J 2001; 191:453-457.



Thames Cancer Registry, Cancer Statisticson Incidence, Survival and Mortality,provided to NHS Islington, 2009.

Tiller S, Wilson KI, Gallagher JE. Oralhealth status and dental service use of adults with learning disabilities living in residential institutions and in thecommunity. Community Dent Health 2001 Sep; 18(3):167-71.

Titsas A, Ferguson MM. Impact of opioiduse on dentistry. Australian Dental Journal47:94-8, cited in Jones CM, McCann M,Nugent Z. Scottish Prisons Dental HealthSurvey 2002. Scottish Executive:Edinburgh. 2004. Available at URL:http://www.scotland.gov.uk/ Resource/Doc/47210/0013527.pdf.

Tsakos G, Yusuf H, Sabbah W, Watt R.The oral health needs of Islington olderpeople living in Islington nursing homes.Dept. of Epidemiology and Public HealthUCL 2009 May.

Waldman HG, Perlman SP. Dental care forindividuals with developmental disabilitiesis expensive, but needed. J Calif DentAssoc 2002 Jun; 30(6):427-32.

Watt R & Sheiham A. Inequalities in oral health: a review of the evidence and recommendations for action. BritishDental Journal1999; 187(1):6-12.

Watt RG. From victim blaming to upstreamaction: tackling the social determinants oforal health inequalities. Community DentOral Epidemiol 2007; 35:1-11.

Whittle G, Woods K, Jones C, and Terrell J.Dental Health of Prisoners in the NorthWest of England. 2000.

Wright D, Allen C, Gibson B. A study ofthe perceived oral health and treatmentneeds of prisoners. 2001. Unpublished.

Zador D, Lyons Wall PM, Webster I. Highsugar intake in a group of women onmethadone maintenance in south westernSydney, Australia. Addiction 1996;91(7):1053-61.

THE CAUSES OF INEQUALITIES IN ORAL HEALTH 19

The causes of inequalities in oral health

3

The traditional view of oralepidemiology is that oral diseasesare caused by ‘downstream’individual lifestyle and biologicalrisk factors. Indeed there is littledoubt that risk of experiencing oral disease varies with age,gender and genetic predispositionand is increased by certainbehaviours, such as frequent sugar consumption. However,the importance of these factors at a population level is limited; a persuasive body of public healthevidence has emerged to suggestthat the main causes of oral health inequalities are social and environmental.

The circumstances in which people live and work have aprofound effect on their healthand well-being. It is essential when assessing the causes of oral disease to recognise theunderlying importance of social,economic and environmentalfactors. These broaderdeterminants are often the true causes of ill health and have a substantial impact onhealth inequalities, as illustrated in Figure 3.1. This chapter willdescribe the main factors that lead to oral health inequalities and therefore contribute towardsthe social gradient.

Introduction

The social gradient in oral health is a major public healthchallenge. Oral health has improved significantly since the1970s, yet the social gradient in oral health has remainedrelatively constant. In order to reduce these inequalitiesthe causes of this gradient must be understood.

Figure 3.1. The underlying causes of oral healthSource: Modified from Watt (2005) in Choosing Better Oral Health: An Oral Health Plan for England

Oral Health

BiologicalFactors

Oral HealthBehaviours

Social Environment

Political, Economic& Policy Context

20 THE CAUSES OF INEQUALITIES IN ORAL HEALTH

Behavioural causes of oralhealth inequalitiesUnfavourable health-relatedbehaviours tend to cluster togetherin the same individuals and aremore prevalent in those at thelower end of the social hierarchy. It has therefore been postulatedthat a culture of more healthdamaging behaviours hasdeveloped in deprived socialgroups leading to oral healthinequalities. However, there is little evidence to suggest that the poor oral health of less affluent people is explained solely by self-neglect or harmfulbehaviour.

Health related choices are made in response to complex social and environmental conditions and so are only partially controlledby personal choice. Family, social and community factors, as well aspolitical and economical measuresall have an influence. For example,the amount of sugar a teenagereats might be influenced by arange of interconnecting factors,from immediate influences such as family and friends, culturalnorms and social eating trends, to macro level influences such as cost, access, transport andavailability of food choices.

Certain health damagingbehaviours will increase risk of oral disease; particularly poordietary choices, using tobacco and alcohol, poor oral hygiene and low use of dental services.These health-damaging behaviourswill affect health at an individuallevel but are likely to have only a minor impact on oral healthinequalities. Health promotioninterventions must consider social context and be achievablewithin the social environmentalconstraints operating for thatindividual.

Local significanceDietAn unhealthy diet is a risk factorfor oral cancer and dental decay as well as systemic diseases likeobesity and diabetes. Frequentsugar consumption is a key riskfactor for dental caries and is moreprevalent in low-income groups.Non-milk extrinsic sugars (NMES)are ‘free sugars’ includingmonosaccharides and disaccharidesas well as those sugars naturallypresent in honey, fruit juices andsyrup. Soft drinks are now thelargest source of NMES in theaverage child’s diet. This is likely to contribute toward obesity andalmost a quarter of ten year olds in Islington are obese. Similarly anestimated 10-15% of oral cancersmay be caused by unhealthy diets,yet approximately three quarters ofadults in Islington do not consumethe recommended portions of fiveor more fruit and vegetables a day.

Tobacco useSmoking or chewing tobacco arerisk factors for oral cancers andperiodontal disease and smokerstend to self-rate their oral health lower than non-smokers. In Islington, smoking prevalence is around 27%. However, in areaswhere residents are predominantlyfrom lower socio-economicgroups, smoking prevalence is expected to be higher. Otherpopulations with high smokingrates are Bangladeshi, Irish andBlack Caribbean communities.While we do not have Islingtonspecific figures, national dataindicate that there are likely to be significant numbers of the Bangladeshi population,especially women, who are users of chewing tobacco.

AlcoholThere is a well-recognisedrelationship between alcoholmisuse and oral disease. An estimated 15% of adults in Islington are binge drinkers.Research suggests that patientssuffering from alcohol usedisorders experience poor oralhealth. This includes significantlevels of dental caries, gingivalinflammation, soft tissueabnormalities, tooth erosion andan increased risk of developinggum disease. In addition, excessivealcohol use is also a significant risk factor for oral cancer. Of particular concern is thesynergistic action of excessivealcohol consumption with tobacco (smoked and chewed),which when used together, willsubstantially increase the risk ofdeveloping oral cancer.

Oral hygieneInfrequent tooth brushing isassociated with socioeconomicdisadvantage and higher levels of tooth loss, severe impact onquality of life and low self-ratedoral health. Belonging to a highsocial class has been associatedwith cleaning the teeth moreeffectively and frequently and with using more oral hygiene aids than those of low social class.The high levels of deprivation inIslington mean that poor oralhygiene is likely to be widespread.

Health-related behaviours are largely determined andconditioned by the socialenvironments in which individualslive and work. For example,smokers who experience moreundesirable life events and dailystress may cope with these bysmoking more. Tobacco use isgreater in communities whereit is culturally associated with

3. The causes of inequalities in oral health


relaxation and attractiveness. It istherefore over-simplistic to assumethat individuals can change theirbehaviour easily once they havereceived information through a‘lifestyle’ intervention.

Concentration on lifestyle candistract from examination of thebroader determinants of healthand can lead to ‘victim-blaming’.Understanding how unhealthybehaviours lead to oral diseases is not enough; we need tounderstand why people choose to engage in these activities. To reduce oral health inequalitieswe must tackle the underlyingsocial conditions that determinebehavioural patterns. The relativeineffectiveness of behaviourchange interventions stems from a failure to take peoples’psychological and emotionalresponses to their socialcircumstances into account.

Psychosocial causes of oral health inequalitiesPsychosocial factors are subjectiveexperiences and emotions thatproduce acute and chronic stresswhich, in turn, affects biology and leads to physical and mentalillnesses. The psychosocial factorswith the strongest evidence of contributing towards healthinequalities are control, socialparticipation, negative emotionsand coping abilities. Psychosocialfactors are more commonlyexperienced by people in lowersocioeconomic groups, particularlythose living in relative deprivationand therefore contribute to health inequalities.

Psychosocial factors can affecthealth status in a number of ways ranging from a lower lifeexpectancy to poor oral health.The mechanism through whichpsychosocial factors exert effects

on health can be either direct or indirect. Direct effects involvebiological pathways leading to ill health, for example, anxiety anddepression changes salivary flowrates, which increases susceptibilityto tooth decay. Indirect effectsoccur when psychosocialresponses stimulate healthdamaging behavioural changes;for example, stress can lead toincreased tobacco use, poor oralhygiene, and poor compliancewith dental care.

The direct and indirect effects of psychosocial factors can occursimultaneously, for example, stress increases severity of gumdisease through direct pathwaysbut can also indirectly increase risk of periodontal disease throughstimulating behaviour change (e.g. reduced nutrition, oralhygiene and increased smoking).

Evidence suggests thatdisadvantaged groups may be less likely to engage in oraldisease prevention (e.g. oralhygiene and preventive use of dental services) because theirresources are focused on moreurgent survival needs. The negativeeffects of psychosocial factors on health can be buffered by social support. However, theopportunities for this to developare reduced in more deprivedgroups. Provision of instrumentalsupport and information has beenshown to have a positive effect on oral health.

Local significancePsychosocial factors are aggravatedin societies where unequaldistribution of wealth is apparent(known as relative deprivation).This is particularly relevant to Islington where there is no clear geographical demarcationbetween deprived and more

affluent areas. The result is aborough where impoverishedgroups, with associated long-term benefit dependency,unemployment, high levels ofchronic health and prematuremortality, live virtually side-by-sidewith the wealthy.

Family environment has beenshown to be associated with oral health. Children’s dentalcaries, periodontal status andpattern of dental attendance havebeen shown to be influenced bytheir mothers’ ‘sense of coherence’(SOC). The SOC components seem to be close to concepts likeoptimism, will to live, self-efficacy,learned resourcefulness, andhardiness. Individuals with astronger SOC are more adequatelyable to cope with stressors andthus maintain health. Almost afifth of households in Islington are lone parent – four fifths ofwhich are unemployed. Islingtonhas the second highest level of child poverty in London andtherefore low levels of SOC arelikely to influence the oral healthstatus of children in the borough.

In addition, around three-quartersof the Islington population are of working age and job strain has been shown to affectwellbeing and a wide range of health outcomes, including oral health. The promotion of more flexible and healthyworkplaces can therefore play arole in improving the oral healthstatus of the adult population.

To reduce health inequalities inIslington, measures need to betaken to improve psychosocialfactors such as personal control,psychological stress and socialsupport. Dental decay (as measuredby decayed, missing and filled teeth)is significantly lower in areas with

higher levels of communityempowerment. Efforts to developsocial support must therefore be made through, for example,involvement in local health issues,which can stimulate a sense ofbelonging and increase socialsupport within a community.However, while psychosocial stresshas been shown to partly influencethe socioeconomic inequalities inoral and general health, addressingpsychosocial factors does not resultin eliminating inequalities.

Environmental factorsThe environmental factors that contribute to oral healthinequalities are many and includepoverty, poor housing andstandards of water, low levels of education, unemployment and sanitation. This materialdeprivation leads to healthinequalities directly throughexposure to an unhealthyenvironment and indirectly through restriction of behaviourand thus the limited ability tomake healthy lifestyle choices. For example, adults with lowerlevels of income and educationalattainment have been shown to suffer greater tooth loss andworse subjective oral health. The odds of being edentate(toothless) have been found to be almost nine times higher for adults with no qualifications.Environmental factors tend tocluster in deprived groups andtheir effects accumulate over timeleading to increased risk of chronicoral and systemic conditions.

There are thought to be criticalperiods in development duringwhich the interaction betweenpeople and their environments is particularly important.Experience of disadvantage during these periods is likely to

have profound long-term effectson health. These include early life,school examinations, the transitionfrom primary to secondary school,entry into the labour market, job insecurity, and change or loss, among others. For example, adult oral health can be predictedby childhood socioeconomicdisadvantage and oral health in childhood.

Creating supportive environmentswhere people have access tohealthy food choices is vital for oral health. Lower socio-economicgroups tend to be less responsiveto healthy eating messages owingto income and other constraints.Being on a low income means youmust spend relatively more of yourdisposable income on food andpurchasing healthier options canprove expensive. This can be madeworse if there is limited availabilityof healthy food options, which issometimes the case in less affluentareas. Such areas are sometimestermed ‘food deserts’ wherepeople have no access to healthyfood within a reasonable walkingdistance.

Local significanceIn Islington childrens attainment at GCSE level is shown below.Levels of attainment are improvingbut are still below the nationalaverages suggesting that Islingtonresidents may be more likely toincur poorer oral health.

Islington has the second highestlevels of child poverty in London,with 52% of children living inpoverty. Early life circumstanceshave a particular impact on oralhealth, with children from deprivedor lower income backgroundsmore likely to experience pooreroral health at later stages. Thissuggests that a higher proportionof Islington children are likely toexperience oral diseases as theyprogress through life.

There has been no formalmapping of food deserts inIslington, but there is someevidence of pockets of ‘less’availability. An example is EC1where parts of the area (closer to the business district), are wellserved by stores selling fresh fruitand vegetables. However these

Table 3.1. Percentage of pupils attaining 5 or more A*-C grades includingEnglish and Maths at Key Stage 4 (GCSE & equivalent)



2005 2007 2008

Islington 44.2% 48.8% 56.4%

National 55.0% 60.8% 64.8%

Key Stage 4 5 or more A*– C GCSEs or equivalent

stores tend to be supermarketchains designed for peoplewishing to buy ready-made meals,salad packs and ready choppedvegetables. Much of this is notaffordable to many of the localresidents. The rest of EC1 has few dedicated fruit and vegetableretailers and only one streetmarket, with a single fruit andvegetable seller. Efforts must betaken to improve the eating habitsof the local population, as poordiet is a common risk factor forboth oral diseases and otherhealth conditions such as diabetesand obesity. Food strategies needto address cost and access issuesin relation to food, and influencekey groups including foodproducers, manufacturers andgovernment departments.

Political factors There are a number of political orstructural factors that have a largeimpact on oral health. As thesetend to operate at a national or

international level, there is littlelocal control over how they impacton the population. Such factorsinclude policy making, advertisingcontrol, effective labelling, legalobligations and governmentlegislation. For example,agricultural policy influences the type of food that is grown and at what price; and directlyinfluences what we eat. Dietaryrecommendations in relation to the consumption of sugar can only be achieved with actionacross the whole food chain, from production to consumption.

Appropriate control overadvertising can help decreasedemand for products high in sugar and increase consumptionof healthier alternatives. However,despite regulations within theadvertising industry, expenditureon advertising of high sugar and fat foods is far greater thanexpenditure on fresh fruit andvegetables.

Government policy to promote a smoke free England, notablywith the introduction of thesmoking ban in 2007, has positive implications for oralhealth. Similarly, the influence of government legislation can be seen in the introduction ofstandards for school meals. School meals are important bothfor nutritional and educationalreasons.

Provision of school meals is nowcompulsory and the governmenthas set out statutory nutritionalstandards to support availability of healthier food choices. The national Healthy SchoolsProgramme is aimed at promotinghealth and well being in schoolsand equipping children to makeinformed health and life choices.Much of the work is focusedaround healthy eating. In Islington97% of schools have achievedHealthy Schools status.


SummaryOral health inequalities are not inevitable and cannot beaccounted for by biological variation or lifestyle choices. While individual behaviours have some effect, there is apersuasive body of evidence to suggest that social structureis the true cause of oral disease and oral health inequalities. It is therefore vital that the social context of oral health andillness be understood, and there is a clear need to tackle thepsychosocial, environmental and political causes of the causesof health inequalities in order to achieve real improvements.The most beneficial interventions will invest resources early in the life course to minimise inequality in conditions andconsequently in oral health outcomes.



Recommendations• Improve oral health through the common risk factor approach, including:

– Tackle poor diet and soft drink consumption and increase access to healthyfood options through multisectoral food strategy, e.g. increasing availabilityof fruit and vegetables in deprived areas, 5-a-day, education on shopping,labelling and cooking, Change4life and healthy eating policies in schools and workplaces.

– Customise our stop smoking service to provide high levels of support togroups with a high prevalence of smokers, particularly routine and manualgroups and BME communities.

– Dentists and other staff who come into contact with residents with alcoholmisuse problems to deliver ‘brief advice’ interventions to reduce harmful or hazardous drinking.

• Continue to strengthen partnership working to develop opportunities to promote better mental and physical health in the community and other settings.

• Work with the Local Authority to improve the social and environmentalconditions of the local community which will have an impact on the health of residents, e.g. through regeneration projects.

• Explore opportunities for supporting development of strong local communities.

• Create opportunities for involving local communities, particularly from sociallydeprived areas, in the planning, development and management of services, and activities which aim to improve health or reduce health inequalities.

• Support the development of, and work in partnership with, programmes withinthe Personal, Social and Health Education (PSHE) curriculum which enhancechildren’s decision making skills and assertiveness around diet and cooking.

• Develop oral health promotion programmes for schools where oral health need is identified by the needs assessment as part of the enhancement modelfor healthy schools.

• Increase people’s capacity for positive behaviour change by supporting thedevelopment of positive wellbeing programmes.

• Strengthen partnership working to ensure effective interventions are developedto support families with young children, especially those from more sociallydeprived groups, e.g. education in effective parenting and the development of effective family behaviours.

• Develop strategy to integrate oral health promotion into the work which isalready being done around healthy schools and workplaces, as well as othersettings such as colleges and places of worship.

• Target oral health promotion support to deprived areas and groups in the form of community-based fluoride delivery strategies, support and informationand oral hygiene instruction.


BibliographyAdler NE, Snibbe AC. The role ofpsychosocial processes in explaining thegradient between socioeconomic statusand health. Curr Dir Psychol Sci 2003;12:119-123.

Akhter R, Hannan MA, Okhubo R, MoritaM. Relationship between stress factorsand periodontal disease in a rural areapopulation in Japan. Eur J Med Res 2005;10: 352-7.

Aleksejuniene J, Holst D, Eriksen H,Gjermo P. Psychosocial stress, lifestyle and periodontal health. A hypothesisedstructural equation model. J ClinPeriodontol 2002; 29: 326-35.

Araujo MW, Dermen K, Connors G,Ciancio S. Oral and dental health amonginpatients in treatment for alcohol usedisorders: a pilot study. J Int AcadPeriodontology 2004 Oct; 6(4):125-30.

Camden Primary Care Trust Annual Public Health Report 2006/07: Ashes to Ashes. Available at URL: http://www.documentstore.candinet.nhs.uk/store/camden/Annual%20Public%20HealthA%20Report%202006-07.pdf

Department for Environment, Food andRural Affairs. National Statistics: FoodStatistics Pocketbook 2008.

Dolic M, Bailer J, Staehle HJ, Eickholz P.Psychosocial factors as risk indicators ofperiodontitis. J Clin Periodontol 2005;32:1134-1140.

Islington PCT. Health in Islington: TheFacts Update 2008. Available at URL:http://www.islington.nhs. uk/Publications/Health%20in%20Islington%20the%20thefacts%20-%202008.pdf

Gelbier S, Harris C. Oral and dental healthin the alcohol misuser. Addictive Biology1996; 1(2):165-9.

Gift HC. Social factors in oral healthpromotion. In Schou L, Blinkhorn AS(Eds.). Oral Health Promotion 1993.Oxford University Press: Oxford.

Kristenson M, Eriksen HR, Sluiter JK,Starke D, Ursin H. Psychobiologicalmechanisms of socioeconomic differences in health. Soc Sci Med 2004; 58:1511-1522.

Freire M, Hardy R, Sheiham A. Mothers’sense of coherence and their adolescentchildren’s oral health status andbehaviours. Community Dent Health2002; 19:24-31.

Freire MCM, Sheiham A, Hardy R.Adolescents’ sense of coherence, oralhealth status, and oral health-relatedbehaviours. Community Dent OralEpidemiol 2001; 29:204-12.

Health in Islington: The Facts Update2008. Available at URL:http://www.islington.nhs.uk/Publications/Health%20in%20Islington%20the%20facts%20-%202008.pdf?sksearchtext=health%20facts

Marcenes W, Sheiham A. The relationshipbetween work stress and oral healthstatus. Soc Sci Med 1992; 35:1511-20.

Marmot M, Wilkinson RG. Psychosocialand material pathways in the relationbetween income and health: a responseto Lynch et al. BMJ 2001; 322:1233-1236.

Newton JT, Bower EJ. The socialdeterminants of oral health: newapproaches to conceptualizing andresearching complex causal networks.Community Dent Oral Epidemiol 2005Feb; 33(1):25-34.

Nicolau B, Marcenes W, Bartley M,Sheiham A. Associations between socio-economic circumstances at two stages of life and adolescents’ oral health status.Journal of Public Health Dentistry 2005;65(1):14-20.

Nicolau B, Marcenes W, Bartley M,Sheiham A. A life course approach toassessing causes of dental cariesexperience: the relationship betweenbiological, behavioural, socio-economicand psychological conditions and caries inadolescents. Caries Research 2003; 37:319-326.

Nicolau B, Thomson WM, Steele JG,Allison PJ. Life course epidemiology:concepts and theoretical models and its relevance to chronic oral conditions.Community Dent Oral Epidemiol 2007Aug; 35(4):241-9.

Nuttall N et al. A guide to the UK AdultDental Health Survey 1998. London:British Dental Association; 2001.

Pattussi MP, Hardy R, Sheiham A.The potential impact of neighborhoodempowerment on dental caries amongadolescents. Community Dentistry andOral Epidemiology 2006; 34:344-350.

Peres MA, Latorre MRDO, Sheiham A,Peres K, Barros FC, Hernandez PG, MaasAMN, Romano AR, Victoria CG. Socialand biological early life influences onseverity of dental caries in children aged 6 years. Community Dentistry and OralEpidemiology 2005; 33:53-63.

Petersen PE. Inequalities in Oral Health:the Social Context for Oral Health inCommunity Oral Health.

Rose G. Strategy of preventive medicine.1992. Oxford University Press: Oxford.

Sabbah W, Tsakos G, Sheiham A, WattRG. The role of health-related behavioursin the socioeconomic disparities in oralhealth. Social Science & Medicine 2009;68:298-303.

Sabbah W, Watt RG, Sheiham A, TsakosG. Effects of allostatic load on the socialgradient in ischaemic heart disease andperiodontal disease: evidence from the Third National Health and NutritionExamination Survey. J EpidemiolCommunity Health 2008; 62:415-420.

Sanders AE. Social determinants of Oral Health: conditions linked tosocioeconomic inequalities in oral healthin the Australian population. AIHW cat.No. POH 7. 2007: Australian Institute of Health and Welfare (Population OralHealth Series No. 7): Canberra.

Sheiham A, Nicolau B. Evaluation of socialand psychological factors in periodontaldisease. Periodontology 2000 2005;39:118-131.

Sheiham A, Watt RG. The Common Risk Factor Approach: a rational basis for promoting oral health. CommunityDent Oral Epidemiol 2000; 28:399-406.



Siegrist J, Marmot M. Health inequalitiesand the psychosocial environment-twoscientific challenges. Soc Sci Med 2004;58:1463-1473.

Spencer AE, Spencer AJ, Slade GD.Evaluating the role of dental behaviour in oral health inequalities. CommunityDentistry and Epidemiology 2006;34(1):71-79.

Taylor SE, Seeman TE. Psychosocialresources and the SES-health relationship.Ann N Y Acad Sci 1999; 896:210-225.

Thompson WM, Poulton R, Milne BJ, Casi A,Broughton JR, Ayers KMS. Socioeconomicinequalities in oral health in childhood andadulthood in a birth cohort. CommunityDent Oral Epidemiol 2004; 32:345-53.

Treasure E, Kelly M, Nuttall N, Nunn J,Bradnock G, White D. Factors associatedwith oral health: a multivariate analysis of results from 1998 adult dental healthsurvey. British Dental Journal 2001; 190(2).

Watt RG. Emerging theories into the socialdeterminants of health: implications fororal health promotion. Community DentOral Epidemiol 2002; 30:241-7.

Watt RG. From victim blaming to upstream action: tackling the socialdeterminants of oral health inequalities.Community Dent Oral Epidemiol 2007;35:1-11.

Watt R, Sheiham A. Inequalities in oral health: a review of the evidenceand recommendations for action. BritishDental Journal 1999; 187(1):6-12.

Watt R. Strategies and approaches in oraldisease prevention and health promotion.Bulletin of the World Health OrganizationSeptember 2005; 83(9):711-718.

Wilkinson RG. The epidemiologicaltransition: from material scarcity to social disadvantage? Daedalus 1994;123:61-77.

INEQUALITIES IN ACCESS TO DENTAL SERVICES 27

Inequalities in access to dental services

4

Primary Care Trusts (PCTs) have a duty to develop services thatprovide effective and equitablecare according to the needs oftheir local population. However,achieving high levels of service usein high need groups is challengingand requires that local barriers to uptake are reduced. Servicesshould be designed to fit closelywith the needs of users in order to maximise the chances ofresidents with the greatest needreceiving appropriate dental care.In Islington’s multicultural urbansociety the ‘one size fits all’approach to dental services is unlikely to be effective. It is likely that a range of differentservice models will be requiredbefore all groups can have theiroral health needs met.

Dental access as a nationaland local NHS priorityImproving dental access hasbecome a national and regionalpriority for the NHS due to adecrease in NHS dentists since the early 1990s. Dissatisfactionwith the ‘new’ NHS dentalcontracts in 1990 and 2006caused many dentists to transfer to the private sector. Since thenthere has been much media

rhetoric about the lack of NHSdentists, which appears to havepervaded the public consciousness.However, this does not truly reflect the current picture. The NHS has invested substantialsums in NHS dentistry in recentyears and service availability is by no means uniformly poor.Pockets of the UK do remainwhere dentists are in short supply,but this is not the case in London.

The NHS Operating Framework2009/10 requires PCTs to achieveyear-on-year improvements in the number of patients accessingNHS dental services and hascommitted growth funding tosupport this. National guidance on dental commissioning hasemphasised that PCTs need toconsider the following whencommissioning services to increase access:

• Improving primary care forsocially excluded groups bylevelling up access, improvingchoice for groups that cannoteasily access services andproviding services that aresensitive to their needs.

• Commissioning preventiveservices.

• Ensuring there is effectivemarketing and communityengagement to promoteawareness of how to accessservices.

What is meant by ‘dentalaccess’?The NHS definition of dentalaccess is the number of individualpatients seen by a NHS dentist, at least once in the most recent24-month period. Access to dentalcare is a complex issue of whichthe availability of services is onlyone aspect. It has been morecomprehensively described as ‘the level of fit between theexpectations of people who mightuse services, and what providersoffer to meet those expectations’.

A range of factors is known to influence access to care,including geographic, financial,socioeconomic, educational andcultural factors. Access can bebroadly divided into five themes:

1. Availability of servicesThis refers to how well servicesare distributed, e.g. ratio ofdentists to population.

Introduction

Access to NHS dental services is both a local and a national priority.In some parts of the UK services are in short supply. However, inIslington dentists are plentiful and NHS dentistry is readily available.The local challenge is therefore to increase access to services forthose who need it most, e.g. people living in social deprivation and older people, and in so doing reduce oral health inequalities.However, health services play a limited role in improving oral health.

28 INEQUALITIES IN ACCESS TO DENTAL SERVICES

2.Accessibility of servicesThis refers to location, e.g.travelling distance as well asphysical accessibility within thepractice itself, e.g. for disabledaccess.

3. Affordability of servicesThis includes both direct costs of dental treatment and indirectcosts, e.g. travel costs, time offwork, child-care. All of thesecosts tend to be more significantfor those on a low income.

4. Acceptability This relates to public expectationsabout how services should look.This can vary substantially fordifferent population groups, e.g. a study of homeless peoplein London found that theyprefer older, shabbier clinics asthey perceive them to be moreaccepting of their appearanceand circumstances.

5. AccommodationThis relates to how care isprovided, e.g. opening hours,emergency care, waiting times, ease of booking anappointment. Again this mayvary across different population

groups. While some peopleappreciate seeing the samedentist at regular intervals, thoseliving in the most deprived areastend to be irregular attenders.They may therefore fit poorlywith the traditional high streetdental practice model.

The ultimate aim of the dentalaccess programme is to removebarriers to uptake and thereforeimprove the fit between the userand the service provided.

Access to dental services inIslington Access to general dental careservices is measured through theVital Signs metric ‘percentage ofthe total population seen by a NHS dentist in the past 24 months’.These data are routinely collectedand form part of the performancemanagement of the PCT.

The proportion of the populationof Islington seen by a NHS dentisthas remained fairly steady sinceMarch 2006, at around 50%, asshown in figure 4.1. In September2008, the proportion of the

Islington population seen by a NHS dentist in Islington washigher than the London average,but lower than the national average.

However, the most recent figuresto March 2009 show that IslingtonPCT bucks the national andLondon SHA trend and hasincreased the level of access forpatients since the baseline periodof 31 March 2006. While this is apparently good news, it does not necessarily help the PCT achieve its objective ofreducing oral health inequalities.This cannot be deduced from thecurrent access measure, which hasa number of limitations, including:

1. It has no inequalities element.Each patient is given equalweight, which does not allow assessment of whether it is having a positive or negative impact on oral health inequalities.

2. It does not incorporate a qualitymeasure. This is particularlyrelevant in this context, as thedentist will be monitored on the

4. Inequalities in access to dental services

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31 Mar2006

England London SHA Islington PCT

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Figure 4.1. Total patients seen as a percentage of the population in the previous 24 months as at quarterly intervals,March 2006 and September 2008 Source: NHS Dental Statistics for England: Quarter 2: 30 September 2008. Annex 2a: Primary Care Trust (PCT) Factsheet. The Health and Social Care InformationCentre, Dental Statistics. Available at URL: http://www.ic.nhs.uk/webfiles/publications/Dental0809q2/


number of new patients theysee so there is a risk they willspend less time treating existingpatients.

The limitations of this measure ofaccess are becoming more widelyrecognized and the Department of Health is currently reviewing this metric.

There are a number of local factorsto consider:• The population mobility

in Islington is higher than the England average. It ischaracterized as being young,highly mobile and ethnicallydiverse with approximately 25% identifying themselves as members of an ethnicminority group.

• In contrast to GP registration,under the current dentalcontract, patients who wish to visit a dentist do not need to ‘register’ with that dentist.People are free to use anydentist in the country resulting in considerable cross borderflows between boroughs,especially in London. As a result,many dentists in Islington will be treating people who are not residents of the borough.The numbers of non-residentstreated are also likely to behigher due to the large numberof people who commute intoIslington for work. Approximately55% of the patients treated byIslington dentists are notresidents of the borough but, asubstantial number of Islington’sresidents do access treatment in other PCTs, particularlyneighbouring boroughs.However, the patients accessingthese dental services regularlyare unlikely to be those with thegreatest need. Ideally we wantlocal services for local people.

The impact of access todental care on oral healthProvision of access to high qualitydental services is only one aspectof the public health action neededto reduce oral health inequalities.Dental services are, by necessity,treatment focussed and cannoteliminate oral health inequalitiesalone, no matter how accessible or effective they may be.

There is an assumption that regular attendance for dental care leads to improved oral health.There is some evidence to suggestthat regular attendees suffersignificantly less severe oral disease as well as fewer social and psychological impacts of poor oral health. However, regularattendees also have higher DMFTscores and the impact of dentalcare on the incidence of dentalcaries on adults and children issmall. It is therefore important to be aware of the limited benefits to oral health that can be achieved by increasingaccess to dental services.

There is no evidence thatincreasing the provision of caredecreases inequity in oral health.The decline in caries over recentdecades has been steady andsustained and has affected allsocial groups including regular and irregular dental attendees. It is therefore unlikely that clinicaltreatment has made a majorimpact in improving oral health. It is more likely that the overallimprovement in oral health is dueto improvements in self-care, diet,education, standards of living andeconomic growth.

It is important to tackle the causesof poor oral health through oralhealth promotion, as well astreating disease. This means that in addition to improving access to

NHS dental treatment and tacklingthe broader determinants ofdisease, key areas for oral healthaction include increasing the use of fluoride, improving diet, reducing sugar intake and reducing tobacco use. Tackling the underlying causes of oral disease will have a muchgreater impact on oral diseasesthan treatment services ever could.

Inequalities in access todental services and keygroupsInequalities in oral health arecompounded by inequalities in access to dental services. There are inequalities in access to dental care by geographicalarea, ethnic group and socio-economic group:

1. Inequalities by geographicareaThe operation of Tudor Hart’sinverse care law is well recognised,whereby the availability of healthcare is inversely related to the need of the population served.Independent contractors workingin the ‘General Dental Service’provide the vast majority of dentalservices. Historically, these dentistshave been free to choose where to provide services and an inversecare law has been the result. PCTs now have control overfunding, allowing them to match services to the needs of the local population.

Characteristics and location of non-attending IslingtonresidentsIn the two years from June 2007to June 2009, an estimated 42%of children and 67% of adultsresident in Islington did not access NHS dental services in theborough.



Mosaic™ analysis suggests thatthe largest number of both adultand child non-attendees are fromthe following Mosaic™ types, asshown in Figure 4.2 below:

• Living in high density socialhousing (F36)

• Living in neighbourhoods withtransient singles (E28)

There were also several thousandnon-attending adults described as economically successful singles(E29) and financially successfulpeople (A01).

Mosaic™ profiling allows us toidentify areas of residence wherewe can focus our access initiatives.See maps 4.1 and 4.2. Residentsliving in the high deprivation areasof Finsbury Park, Canonbury,

St. Mary’s, Bunhill and Caledonianwere less likely to have attended aNHS dentist in the past two years.

It is important to note that not allof the groups who fail to accessNHS care are deprived. Both mosaicanalysis and local research suggestthat a substantial number ofaffluent Islington residents are not accessing NHS dental services.Areas with pockets of relativelylow deprivation that have lowuptake of services include Hillrise,Mildmay, St. Mary’s, St. Peters and Barnsbury. Residents fromthese wards are characteristicallymore likely to use private, ratherthan NHS, healthcare facilities. By targeting these wealthiergroups with access initiatives there is the risk of increasinghealth inequalities.

2. Inequalities by socio-economic group Socially deprived and/or vulnerablegroups in society tend to beparticularly at risk of having poorer oral health and pooreraccess to oral health care services.The prevalence of oral disease is universally highest in areas of social deprivation, with adultsfrom the most deprived areasmore likely to have decayed orunsound teeth than people fromless deprived areas. Despite thehigher level of need in adults fromdeprived areas, they are less likelyto receive dental treatment and are more likely to attend irregularlyand only when they have aproblem. This situation isexacerbated by the characteristicsof the new dental contract: under

Figure 4.2. Estimated number of children and adults who have not attended dental services in Islington by Mosaic™ public sector type, June 2007 to June 2009Source: Dental Services Data, 2009; Experian Mosaic™, 2007

A01 Financially successful people; A02 Highly educated senior professionals; B08 Families and singles living in developments built since 2001; D27 Multi-cultural inner city terraces; E28 Neighbourhoods with transient singles; E29 Economically successful singles; E30 Young professionals and their families who have gentrified terraces in pre 1914 suburbs; E33 Older neighbourhoods increasingly taken over by short term student renters; F36 High density social housing; F38 Singles, childless couples and older people living in high risesocial housing; F39 Older people living in crowded apartments; Other includes all other Mosaic™ types in Islington that have not been previously listed.

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

A01

A02

B08

D27

E28

E29

E30

E33

F36

F38

F39

Oth

er

Mosaic public sector type

Nu

mb

ero

fn

on

-att

end

ers

Children Adults

the new arrangements dentists are paid the same for 10 fillings as for 1, and there are noincentives in the new dentalcontract to take on patients with high levels of treatmentneed. Deprived population groupsshould therefore be considered to have a higher need for targetedinterventions or readier access to health care.

Barriers to service uptake in deprived socio-economicgroupsThere are a number of reportedbarriers to dental care amongirregular users of dentistry. Thetwo main barriers are cost andanxiety. Other factors includeperception of need, time and cost of the journey to the dentist,reception and waiting procedures,treatment, image of the dentistand attendance at different stages in life. For example, dental attendance pattern may be broken once a child leaves school. Uptake of dentalservices is affected by age (thevery young and the very old rarelyuse dental services), sex (women use services more frequently),socioeconomic status (socialgradient in health status andhealth services use), perceivedneed and ethnicity.

Findings of a local survey reportedlack of access to a NHS dentist as a common reason for non-attendance. However, there is a misconception amongst non-attendees that NHS dental servicesare unavailable locally, as 67% of respondents to NHS Islington’srecent local survey who tried tomake an appointment were ableto get one easily. Some peoplethink that they do not qualify for NHS treatment because theywork. A further misconceptionpeople have is that they are


Map 4.1. Residence of Islington non-attendees of NHS dental services (adults belonging to Mosaic groups E28 and F36) Source: Dental Services Data, 2009; Experian Mosaic™, 2007


required to ‘register’ with a dentistin order to receive treatment.

Access, however, is limited bymore than service availability. In a recent survey of Londoners(Figure 4.3), availability of serviceswas only one reason for lack ofdental service uptake, across allsocial classes.

For most social groups the“other”category was the most commonlyselected reason for non-attendance.This indicates that the reasons for non-attendance are complex.There are a number of otherrecognised barriers to uptake of services; fear and cost oftreatment are common, andothers include reception andwaiting room procedures, traveltime and time off work.

The reasons most frequentlyreported by Islington residentswho had not attended a dentist in the last year were: haven’tneeded to (no problems/pain),haven’t got around to it, or it’s too expensive. Residents whonever go to the dentist mostfrequently reported fear (oftencaused by childhood trauma),mistrust of dentists, and thefeeling that treatment was notrequired as the main barriers.

3. Ethnic group There is evidence to suggest thatsome minority ethnic groups maybe more at risk than others ofpoor oral health. They are morelikely to live in deprived areas and in some cases are more likelyto engage in health damagingbehaviour, e.g. South Asian peopleare more likely to use chewingtobacco. They may also encounterlanguage and cultural barriers to accessing care and advice. Men and women from all minorityethnic groups are significantly


Map 4.2. Residence of Islington non-attendees of NHS dental services (children belonging to Mosaic groups E28 and F36) Source: Dental Services Data, 2009; Experian Mosaic™, 2007

less likely than the generalpopulation to visit a dentistregularly.

Barriers to service uptake inBME groupsPeople from all minority ethnicgroups are significantly less likely than the general populationto visit a dentist for a regularcheck up and more likely to be symptomatic attendees. It is therefore important toconsider cultural and languagerequirements when planningservices.

Individuals from minority ethniccommunities living in the UK have reported the followingcommon barriers to serviceuptake: language barriers, fear,cost and the perception thatpreventive check-ups were of low priority.


Table 4.2. Summary of types of people attending and not attending a dentist in IslingtonSource: NHSI social marketing research, 2008/09

Figure 4.3. Reasons why respondents went without or delayed treatment bysocial classSource: A survey on NHS Dental Services in London. August 2007. Charts appeared in the London Assembly report ‘Teething Problems’. Available at URL: http://www.london.gov.uk/assembly/reports/health/dentistry.pdf

Types of people more likelyto attend a dentist routinely

Types of people less likelyto attend a dentist routinely

30 – 59 year olds 16 – 29 year olds

Those with children 60+ year olds

Women Those without children

Home owners In rented accommodation

In full time employment Unemployed

Employed part-time

0%

10%

20%

30%

40%

50%

45%

35%

25%

15%

5%

AB

Social class

Cost

Perc

enta

ge

DEC2C1

OtherProblems finding an NHS dentist


4. Other at risk groups A number of other groups, areknown to be particularly at riskfrom oral diseases, while sufferingadditional barriers to access. These include as a minimum:

• Children, particularly preschool children

• Older people

• People who have a learning disability

• People with mental illness

• People in long term institutionalcare (including prisons)

• Looked after children

• Homeless people

• Some refugee and asylum seeker groups

• Some migrant groups

• People requiring palliative care

• People with serious medicalconditions, e.g. undergoingchemotherapy.

• Housebound people

These population groups may be considered to have a higherneed for targeted interventions or easier access to health care. At present there is limitedknowledge on barriersexperienced by many of these groups and more work is required to gain a fullerunderstanding of their needs.However, NHS Islington hascollected information on theaccess barriers experienced by children and older people,which are outlined below.

Older people Older people living in the mostdeprived 20% of neighbourhoodsare much more likely to use dentalservices only when symptomatic,rather than going for regular oroccasional check-ups. Oral healthproblems in older age include gumdisease, dental caries, dry mouth,defective dentures and oral cancer.These can lead to poor levels ofnutrition and affect self-esteemand well-being. However there are a number of barriers to access including mobility difficulties,poor general health, cost and fear.Access to dental services is also acommon problem for older peopleliving in nursing homes in Islingtonand a significant proportion reportan oral health impact on theirquality of life.

Evidence suggests that of all socialgroups, older people in particularwould benefit from a significantlyimproved quality of life if theyreceived more dental care. Actionis needed to ensure older peoplein deprived communities accessappropriate and comprehensivedental services.

Children Children in Islington have some of the worst teeth in London with around 45% of five-year-oldshaving an average of 4 – 5 decayedteeth each. Children from sociallydisadvantaged groups are morelikely to experience decay thanthose from non-manual classesand experience disproportionatelyhigh levels of dental disease.Despite this, the majority of dental decay in young children is currently going untreated andthere is evidence of a substantialincrease in the number of localchildren having extractions undergeneral anaesthetic. This may bebecause children living in deprived

wards access general dentalpractices less than those living inwealthier wards. It is also possiblethat some of the children who do access care are not going on to receive definitive treatment.

The barriers preventing childrenfrom attending the dentist differedfrom the barriers experienced byadults. Local research found thatthere is some confusion aroundwhen to first take children to the dentist. The majority ofparents questioned held themisconception that a child’s first visit to the dentist should be when they are 3 years old. This appears to be reflected inreported behaviour with youngerchildren less likely to go to thedentist regularly than older children,and most children between 0 – 2years never attending the dentist.

Parental anxiety, driven by parents’experience of and attitude towardsthe dentist, was identified as the key barrier to taking children to the dentist regularly. Mothersfrom low socio-economic groups,who were infrequent visitorsthemselves, tended to have apassive approach to preventivedentistry and did not see theimportance of healthy milk teethas a basis for healthy adult teeth.

Mothers tend not to take theirchildren to the dentist if they do not want to go themselves and assume that their children will also find the environmentscary. The rationale for this is lackof perceived need, e.g. if theyhave no pain, then there cannot be a problem. However, the mostfrequently performed dentalinpatient procedure for Islingtonresidents is extraction of multipleteeth under general anaesthetic in children aged 3 to 5 years,suggesting that children in



Islington need to attend thedentist from a younger age. An increase in hospital care for an essentially preventablecondition such as dental cariesconstitutes a major public health issue.

Public view on how toincrease uptake of NHSdental services locallyIt is important that the specificbarriers experienced locally areunderstood and broken down if inequalities in access are to bereduced. To this end, NHS Islingtoncommissioned research to identifyhow Islington residents could

be encouraged to attend an NHSdentist regularly. The most popularoptions that would encourageattendance were:

1.Making it cheaper

2.Provision of walk-in urgent orroutine services

3.Provision of extended openinghours (which could also reducecost by minimising time offwork)

4. Being able to find a NHS dentist.

Educating mothers on theimportance of looking after theirchildren’s teeth and introducingmore child-friendly dental practices

have been suggested by residentsas ways to encourage parents totake their children to the dentistmore regularly.

Residents reported that oral health is not given a high profile in NHS communication campaignsunlike other subjects, for examplesmoking or Change4Life. The low profile of oral health ledrespondents to believe that oralhealth is not an important issue.

SummaryHard to reach, socially deprived andvulnerable groups are doubly burdened with the poorest oral health and the poorestaccess to oral health care. In a deprivedborough like Islington, it is important tominimise these inequities in access in order to reduce inequalities in health.

Access is a term seen to be synonymous withcapacity, however it is a much more complexissue. Access is influenced by a number ofelements that must be considered whendesigning services including acceptability,accessibility, affordability and accommodation.Services may be readily available, but this isonly the first step and will be insufficient toreduce barriers to uptake.

In Islington, deprived groups with pooruptake of dental services tend to be transient singles living in multiply occupiedaccommodation and those living in high-density social housing. Groups less likely to attend regularly are pre-school children,older people, people from ethnic minorities and other at risk groups such as people with a learning disability, homeless people,housebound people and prisoners.

There may be a temptation to achieve thedental access target through increasingcapacity to achieve ‘quick wins’. However this is likely to increase oral health inequalitiesand should be avoided. To truly improveaccess it is necessary to address the complexbarriers to care affecting those with greatestneed. Improving access to oral health servicesis discussed further in chapter 6.

However, while promoting access to oralhealth services is an important element ofNHS dental services, there is no evidence that increasing the provision of care decreasesinequity in oral health. Tackling the underlyingcauses of oral disease will have a muchgreater impact on oral diseases than treatmentservices ever could.



Recommendations• Explore ways to increase the use of

local services for local people throughcommunity engagement and take publicpreferences, identified through socialmarketing research, into account whendesigning local access initiatives.

• Consider all elements of access whencommissioning/designing services; theymust be acceptable, accessible, affordableand accommodating as well as available.Perceptions of these elements will varybetween population groups.

• Explore ways to reduce the impact ofdisincentives in the new dental contract to treating new, high need patients

• Commission services which match theneeds of high need groups with pooruptake, e.g. transient singles and thoseliving in social housing, and strive tominimise barriers to accessing careexperienced by these groups, e.g. freecheck ups, extended opening hours andwalk-in clinics.

• Investigate local barriers to access for highneed groups, e.g. people with learningdifficulties, homeless people, and migrantgroups.

• Develop dedicated dental services for highneed groups with low service uptake inparticular preschool children, prisoners andolder people.

• Develop a communications strategy to raisethe profile of the importance of oral health,increase understanding of how to accessservices, as well as targeted messages forkey groups, e.g. inform mothers of youngchildren of the need to see a dentist so thatdisease can be identified at an early stage.

BibliographyAtkinson M, Clark M, Clay D, Johnson M,Owen D, Szczepura R. A SystematicReview of Ethnicity and Health ServiceAccess for London. 2001. LondonRegional Office, Coventry: Centre forHealth Services Studies, with MSRC andCRER, NHS Executive.

BASCD surveys of 5 year-olds in GreatBritain. Available at www.bascd.org

Daly B, Watt R, Batchelor P, Treasure E.Essential Dental Public Health. 2002;Oxford University Press: Oxford.

Department of Health. Choosing BetterOral Health. An Oral Health Plan forEngland. 2005 London: Department ofHealth. Available at URL:http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4123253.pdf.

Department of Health Commissioning NHS primary care dental services: meetingthe NHS operating framework objectives.Gateway ref: 8903 January 2008 Availableat URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082104

Department of Health 2009 Improvingdental access, quality and oral healthAvailable at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093831

Department of Health. NHS Dentistry:Delivering Change. Report by the ChiefDental Officer(England) July 2004.London: Department of Health: 2004.Available at URL www.dh.gov.uk/assetRoot/04/08/59/75/04085975.pdf.

Erens B, Primatesta P, Prior G. HealthSurvey for England 1999: The Health of Minority Ethnic Groups. 2001;The Stationary Office: London.

Finch H, Keegan J, Ward K. Barriers to the receipt of dental care – a qualitativeresearch study. 1988; Social andCommunity Planning Research: London.

Fiske J, Gelbier S, Watson RM. Barriers to dental care in an elderly populationresident in an inner city area. J Dent 1990;18:236-42.

Gulliford M, Morgan M. Access to HealthCare. 2003; Routeledge: London.

Harris R, Burnside G. Survey of users of a dental access centre situated in an areaof mixed socioeconomic affluence anddeprivation. Primary Dental Care 2007;14(4) 157-162.

Lang IA, Gibbs SJ, Steel N, Melzer D.Neighbourhood deprivation and dentalservice use: a cross-sectional analysis ofolder people in England. J Public Health(Oxf) 2008 Jun 27.

London Assembly. A survey on NHS DentalServices in London. August 2007.Available at URL:http://www.london.gov.uk/assembly/reports/health/ dentistry.pdf

Maunder P, Landes DP, Steen N. The equityof access to primary dental care forchildren in the North East of England.Community Dent Health 2006 Jun; 23(2):116-9.

Murray J. Attendance patterns and OralHealth. Br Dent J 1996; 181:339-42.

Newton JT, Thorogood N, Bhavnani, V, Pitt J, Gibbons DE, Gelbier S. Barriers tothe Use of Dental Services by Individualsfrom Minority Ethnic Communities Livingin the United Kingdom: Findings fromFocus Groups. Behavioural Psychology andPrimary Dental Care 2001; 8(4):157-161.

NHS Islington Oral health needsassessment, 2009

NHS Islington social marketing research,2008/09

Office for National Statistics. Adult DentalHealth Survey: Oral Health in the UnitedKingdom 1998. ONS website, accessedSeptember 2007. Available at URL http://www.statistics.gov.uk/downloads/theme_health/AdltDentlHlth98_ v3.pdf

Office for National Statistics.2003 Children’s Dental Health Survey.London: ONS; 2004. Available at URL www.statistics.gov.uk/children/dentalhealth/.

Patient Survey Report 2008: NationalSurvey of local health services 2008 –Islington PCT. Healthcare Commission.Available at URL: http://www.healthcarecommission.org.uk/_db/_documents/Islington_PCT_5K8.pdf

Penchansky R, Thomas J. The concept of access: definition and relationship toconsumer satisfaction. Medical care 1981;1:127-40.

Richards W, Ameen J. The impact ofattendance patterns on oral health in a general dental practice. Br Dent J 202;193:69-702.

Sabbah W, Tsakos G, Sheiham A, WattRG. The role of health-related behavioursin the socioeconomic disparities in oralhealth. Social Science & Medicine 2009;68:298-303.

Sheiham A. The impact of dentaltreatment on the incidence of dentalcaries in children and adults. CommunityDentistry and Oral Epidemiology 1997;25:104-112.

Smith M. Divided by a common tongue –‘Access’. Br Dent J 206; 4:185.

Todd J, Lader D. Adult Dental Health 1988United Kingdom. London: HMSO; 1991.

Tsakos G, Yusuf H, Sabbah W, Watt RG.The Oral Health Needs of Older PeopleLiving in Islington Nursing Homes.UCL/NHS Islington. Unpublished report.

Watt R & Sheiham A. Inequalities in oral health: a review of the evidence and recommendations for action. British Dental Journal 1999; 187(1):6-12.

Wright J, Williams R, Wilkinson JR.Development and importance of healthneeds assessment. British Medical Journal1998; 316:1310-1313.


38 IMPROVING ORAL HEALTH IN ISLINGTON

The need for oral diseaseprevention in Islington has recentlybeen brought to the fore. At anational level, the publication ofthe oral health plan for EnglandChoosing Better Oral Healthemphasised the need to “reduceboth the prevalence of oral diseaseand oral health inequalities acrossall age groups in England”. At alocal level the recent Oral HealthNeeds Assessment for NHSIslington and the 2007 IslingtonScrutiny Review of Oral Healthhighlighted the need for activedisease prevention and integrationof oral health promotion withingeneric health promotion workstreams.

What is oral healthpromotion?Oral health promotion isconcerned with prevention ofdisease, in particular oral diseases.In the past, oral health promotionwas seen to be synonymous withdental health education but inreality it is much broader. Effectivedisease prevention, or oral healthpromotion, should be evidencebased and have both generic and

specific elements (see figure 5.1below).

Generic oral health promotionactivities should integrate oral andgeneral health promotion throughthe Common Risk FactorApproach. In this way theunderlying social determinants oforal health can be addressed andthe social gradient in oral healthcan be reduced. Specific oralhealth promotion elements focus

largely on prevention of decaythrough fluoride delivery and areboth community and practicebased. However, there is muchoverlap between these twoelements.

There are three main preventionstrategies; the ‘high-risk’ approach,the ‘population’ approach and the‘targeted’ or ‘directed’ populationapproach. These are summarised infigure 5.2 overleaf:

Improving oral health in Islington

5

Introduction

Effective action is urgently required to tackle oral health inequalitiesand prevent oral diseases in Islington. For a number of years oralhealth work has focused on local treatment services rather thanprevention of disease. However treatment services have little impacton population oral health and cannot address the underlying causeof oral diseases. Improvements in oral health over the past 30 yearshave been due to social, economic and environmental factors aswell as the widespread use of fluoride toothpaste. It is importantthat we apply this evidence locally for the benefit of our population.

Waterfluoridation

Partnershipworking

Community oralhealth promotion

initiatives

Whole populationstrategies

Common riskfactor approach

Targetedpopulationstrategies

Generic healthpromotionactivites

Specific oral health promotion

activites

Oral healthpromotion

Figure 5.1. A summary of evidence-based oral health promotion

IMPROVING ORAL HEALTH IN ISLINGTON 39

In the past, oral health promotionhas been dominated by the highrisk approach which focused on individuals who have beenidentified as high risk through a screening test. However,population health is moreeffectively improved through thepopulation approach which hasthe potential to reduce diseaseacross the whole population.Where this is not practical thisapproach can be ‘directed’towards high risk groups.

Limitations of the individuallifestyle approach to oralhealth promotionOral health promotion hastraditionally focused on achievingbehaviour change in individualsthrough oral health education. The theory is that behaviourchange will occur once oral health knowledge has beenacquired. However this approach is fundamentally flawed, as it failsto acknowledge the complexitiesof human behaviour and its

broader social, economic andenvironmental influences.

Lifestyle interventions have failed to produce sustainedimprovements in oral health orreduce oral health inequalities. This is unsurprising as they lack astrong evidence base. Systematicreviews of oral health educationhave found the following evidenceof effectiveness:

• Information can improve oralhealth knowledge for shortperiods but effects on behaviourare very limited

• Interventions at individual levelwill only improve oral hygiene in the short term

• School based toothbrushingcampaigns are largely ineffectiveat improving oral hygiene

• Mass media campaigns arelargely ineffective at promotingknowledge or behaviour change.

In fact it is likely that lifestyleinterventions may widen oral

health inequalities by benefittingmiddle class families most. Theyare also relatively costly to provide,as they are delivered by clinicalpersonnel. It is clear that theindividual behavioural focus isinadequate and a fresh approach is needed to improve oral healthand reduce oral health inequalities.

Generic oral healthpromotion: socialdeterminants and theCommon Risk FactorApproachInternational comparisons haveshown that the social gradient inhealth and oral health is avoidable.The focus of health promotionshould therefore be to remove this gradient. Marmot’s work has shown that if the majordeterminants of health are social,so must be the remedies. Clearlythen, a multisectoral approach is needed involving economic,environmental and social changes.

A useful framework formultisectoral health promotion isprovided by the Ottawa charter,which advocates the following keyactions to promote health:

1. Healthy public policyA review of social policies thatwould reduce health inequalitiesidentified the following: taxationand tax credits, old age pensions,sickness and rehabilitation benefits,unemployment benefits, housingpolicies, labour market, socialinclusion and care facilities.

2. Creating supportiveenvironments

To minimise the unhealthy impactof the environment and worktowards healthier choices beingeasier choices, for example havingeasy access to affordable healthyfood choices.

Figure 5.2. Approaches to prevention

The ‘high risk’approach

• Involves targeting preventive strategies towards at-riskindividuals for example, people living in areas of materialand social deprivation, people who have a learning disabilityand people in long term institutional care.

• Strategies limited to individuals ‘at risk’ would fail to dealwith the majority of new lesions.

• Fails to target the underlying cause of disease thereforeallowing new high-risk individuals to continue to emerge.

The ‘population’approach

• Reduces the level of risk in the whole population

• Dental caries occurs throughout populations (although it is most severe in certain groups) and is not confined to subgroups.

• More likely to be effective and cost-effective and, wherepossible, should form the basis of any preventive strategy.Can be combined with a targeted approach with success.

The ‘targeted’ or ‘directedpopulation’approach

• Focuses action on higher risk subgroups.

• Subgroups identified through sociodemographic andepidemiological data.


5. Improving oral health in Islington

3. Strengthening communityaction Active involvement in local healthissues can increase the socialcapital in a community, which willhave a positive impact on health.One example is community linkworkers to facilitate improvementsin oral health among sociallydeprived groups. Another exampleis increasing the food choicesavailable to communities withindeprived neighbourhoods, whichlack access to cheap and appealinghealthy food, by establishing foodcooperatives.

4. Developing personal skills This will encourage people to take action to promote their own health, for example through inclusion of training in assertiveness, cooking anddecision-making in schoolcurricula.

5. Reorienting health servicestowards prevention rather than treatment Dental services have traditionallybeen funded on the basis oftreatment provided. In recentyears, policy makers have madeefforts to increase the importanceof, and capacity for, diseaseprevention in NHS dentistrythrough the new dental contractand publication of guidance onprevention in practice.

It is clear that to improve health an upstream approach involving a wide range of partners andsettings is necessary. An ‘upstream’approach to public healthstrategies recognises theimportance of addressing theunderlying social, economic and environmental determinants of health. It is necessary forinterventions to focus on creatingenvironments that supportbehaviour change and which

will have a positive impact on oralhealth. Healthy public policiesshould be implemented at a local level. Oral health promotionmust link in to local projects that are already in existence, for example, children’s centres,healthy schools and infant feedingprogrammes. An example of amore upstream approach topromotion of oral health isillustrated in figure 5.3.

Settings such as children’s centres,schools, older people’s nursinghomes and prisons, should adopt policies which promote the development and adoption of nutrition and healthy eatingguidelines. The consistency of all dietary messages should be improved, and in particular the importance of reducing thefrequency of sugary drinks andfoods should be stressed. We alsoneed to ensure that oral healthinput influences community basedwork such as infant feeding peer

support programmes. Practiceswhich improve oral health such as breastfeeding and followingrecommended weaning practicesshould continue to be promoted.In particular, the addition of sugarsto children’s diets should bediscouraged.

An oral health strategy documentChoosing Better Oral Health: anoral health plan for England waspublished in 2005 to complementthe white paper Choosing Health:making healthier choices easier.It provides a good practiceframework for tackling oral healthinequalities and emphasises theneed to reorient oral diseaseprevention to the main socialdeterminants. It identifies the roles and responsibilities of keystakeholders across a range ofcomplementary activities, e.g.improving diet, improving oralhygiene, tobacco control andsensible alcohol use.

Figure 5.3. Examples of upstream and downstream options that contributetowards oral disease prevention

Healthy public policyUpstream

Downstream

Smoke-free environments

Healthy environment

Health promoting schools, children’s centres, workplaces

Community development

Community link workers to increase uptake of services

Developing personal skills

Dental health education included in national curriculum

Reorienting health services towards prevention

Prevention in practice through Delivering Better Oral Health

Adapted from Watt RG. From victim blaming to upstream action: tackling the socialdeterminants of oral health inequalities. Community Dent Oral Epidemiol 2007; 35:1-11.

Reorienting dental public healthpractice to the social determinantsmodel is challenging. However theCommon Risk Factor Approach(figure 5.4) provides a rationalbasis for this. The Common Risk Factor Approach involvespartnership working between oral and generic health promotersto address risk factors shared bycommon chronic diseases, such astobacco smoking, poor diet, highalcohol consumption, injuries anda sedentary lifestyle.

Targeting these risk factors would simultaneously reduce the incidence of conditions suchas obesity, heart disease, stroke,cancers, diabetes and mentalillness as well as oral diseases.These risk factors should betargeted through a mixture of upstream and downstreamactions as illustrated in figure 5.3.It is critical however thatimprovements in oral health aresustainable and must ultimately

be able to be maintained bycommunities and individuals.

Risk factors cluster in certaingroups, particularly lowersocioeconomic groups. Changingone of the factors may influencethe others, e.g. smokers are morelikely to eat a high fat and sugardiet, take less exercise and drinkmore alcohol than non-smokers. It is logical therefore to directefforts at clusters of risk factorscommon to a number of diseasesand the social structures thatinfluence these factors.

Good practice examples of thecommon risk factor approachinclude:

• Oral health promoters educatingother health professionals andlocal authority staff in oralhealth promotion, such as GPs, teachers, pharmacists,community nurses, dieticiansand social workers. They canthen include oral health in their

health promotion activities,deliver consistent and effectiveoral health messages, prescribesugar free medicines, andsignpost vulnerable people for dental treatment.

• Nutritional guidelines used by institutions like nurseries,schools, hospitals andworkplaces should incorporateoral health.

• The range of settings for oralhealth interventions should beextended beyond schools andchildren’s centres to includeyouth centres, colleges,workplaces, places of worship,residential homes andcommunity centres.

• Action should be targeted atdecision-makers and influentialindividuals in the localcommunity, e.g. head teachers,local politicians or communityrepresentatives.


Figure 5.4. The Common Risk Factor Approach Source: Watt RG. Public Health Reviews. Strategies and approaches in oral disease prevention and health promotion. Bull World Health Organ website 2005;83(9):711-718. Available at URL www.who.int/bulletin/volumes/83/9/711.pdf.

Diseases

Risk conditions

Workplace

Housing

School

Policy

Politicalenvironment

Physicalenvironment

Socialenvironment

Obesity

Cancers

Heart disease

Respiratory disease

Dental caries

Periodontal diseases

Trauma

Risk factors

Tobacco

Alcohol

Exercise

Injuries

Risk factors

Diet

Stress

Control

Hygiene


• Engaging dental teams ingeneric health promotion, e.g. referring patients to obesitycare pathways and becominginvolved in smoking cessationand alcohol reduction.

The Common Risk FactorApproach reduces healthinequalities by focusing onimproving health conditions forthe whole population and forgroups at high risk. It ensures thatconsistent messages are given tothe public by health professionalsand is the most effective andefficient method of promoting oral health.

Specific oral healthpromotion Evidence-based specific oral healthpromotion focuses on key areasfor action that are necessary toachieve sustainable improvementsin oral health. As well asintegrating oral healthimprovement with generic healthimprovement these are:

• Increasing use of fluoride

• Increasing detection of mouthcancer

• Ensuring that dental serviceshave an evidence-based,preventive focus

These areas for action should betackled through both communityand practice based oral healthpromotion.

1. Community based oralhealth promotionCommunity based oral healthpromotion incorporates many ofthe key actions described above.However it is most effective whentargeting dental decay throughdelivery of fluoride. There are anumber of community-basedfluoride delivery interventions, but they are not equally effective.

Their evidence base is summarisedin figure 5.5 above.

The fluoride interventions that arelocal priorities for action at acommunity level are fluoridetoothpaste and fluoride varnish:

• Community based fluoridetoothpaste is commonlydelivered through the Brushingfor Life programme in children’scentres. This is a nationalprogramme focusing upon thedistribution of toothbrushes andfluoride toothpaste packs topreschool children to reduceinequalities in children’s oralhealth, along with oral hygieneinstruction and dietary advice.Brushing for Life has shownsome encouraging indicationsfor potential benefit. Childrenwho start brushing with fluoridetoothpastes in infancy are lesslikely to experience tooth decaythan those who start brushinglater. It also stimulates healthy

dental behaviour from a youngage.

• Community based fluoridevarnish application is a relativelynew intervention, despite theavailability of high qualityevidence of the caries preventiveeffectiveness of fluoride varnishin both permanent and primarydentitions. Fluoride varnish foruse as a topical treatment has anumber of practical advantages;it is well accepted andconsidered to be safe, theapplication of fluoride varnish is simple, and requires relativelylittle training. It can be deliveredin a variety of communitysettings, including children’scentres, nurseries and schools.The varnish can be applied byan enhanced duty dental nurseor other members of the dentalteam, including hygienists,therapists or dentists.


Figure 5.5. Summary of specific oral health promotion activities

InterventionLevel ofevidence ofeffectiveness

CommentPriorities for action

Fluoridetoothpaste

I Effective at community level

Fluoride varnish

IOnly twice yearly applicationNo dentist required

Pit and fissuresealants

I No benefit for primary teeth

Fluoridemouth rinse

ILong term compliance is an issue

Water fluoridation

IIITechnical, ethical, politicaldifficulties

Oral healtheducation

IIILittle evidence of effectivenessat a population level

Milkfluoridation

IIIUptake variableEquivocal evidence of effect

Saltfluoridation

IIIFits poorly with Common RiskFactor Approach

Oral health promotion inIslingtonNHS Islington has recentlydeveloped an oral healthpromotion team made up of two oral health promoters.They are working hard to deliverthese priorities and begin tointegrate oral health with generichealth promotion. However theyare starting from a low base aslittle oral health promotion hasbeen carried out in recent years.Consequently prioritisation hasbeen necessary and at the currenttime efforts are focused onchildren and older people (whowere identified as high needgroups in recent oral health needsassessments). It has been possibleto deliver the Brushing for Lifeprogramme to young children.However, fluoride varnish is notyet being delivered at acommunity level due to limitedcapacity in the oral healthpromotion team.

2.Practice based oral healthpromotionPrimary care general dentalservices have historically beentreatment focused and have failedto maximize the potential benefitsof a more evidence-based,preventive approach. For example,taking a more preventive approachin practice would improve the oralhealth of existing patients. In time,this would reduce the need tospend time treating these patientsand so free up capacity andimprove access.

The new contract was designed toallow all primary care dentists towork in line with evidence-basedpractice by focusing on preventionand health promotion andcarrying out fewer interventions.However, while it has removed theincentive for over-treatment

inherent in the old fee-per-itemsystem, there is still limitedincentive for the general dentist totake a more preventive approach,particularly in a practice that doesnot take advantage of the widerdental team, e.g. dental therapistsand hygienists.

Preventive activity undertakenwithin general dental servicestends to be limited, largelyundocumented and based on oral health education (which has a weak evidence base).Anecdotal evidence suggests that this education is mainlyaround oral hygiene with limitedadvice on broader risk factors such as dietary choices, tobaccouse or alcohol misuse.

There is strong evidence tosuggest that oral healthpromotion in dental practices must include interventions basedon fluoride delivery. The evidenceof effectiveness of fluoride in reducing dental decay ispersuasive and long establishedand interventions like fluoridevarnish are simple and cheap todeliver. The good practice guideDelivering Better Oral Healthwas published by DH in 2007 tosupport PCTs in the commissioningof preventive dental services. This document takes a populationapproach to prevention (seefigure 5.2), endeavouring totackle oral health inequalities byreducing levels of oral disease inall age groups.

Delivering Better Oral Health is areference guide on evidence-basedprevention, designed to be usedby the entire primary care dentalteam to deliver a more preventiveapproach and to give oral healthmessages that are in line withgeneric health promotion. Subjectareas include: increasing fluoride

availability, healthy eating advice,identifying sugar-free medicinesand stop-smoking guidance.However, following this guidancecan only lead to improved healthoutcomes in those who attend adentist regularly. It must thereforebe supplemented with communitybased oral health promotion toavoid an increase in oral healthinequalities.

Dental practices should alsoengage with generic healthpromotion work. Smokefree andSmiling: helping dental patients toquit tobacco was published by theDepartment of Health in 2007 aspart of their ongoing campaign toinvolve dental teams in supportingpeople to stop using tobacco.Dental teams are well positionedto influence people who aretobacco users, particularly sincetheir patients are often differentfrom those that visit GP surgeries.They therefore have a veryimportant role to play in increasingand supporting the number ofpeople wishing to quit usingtobacco. A pilot scheme iscurrently underway to assess thefeasibility of the use of generaldental practices as providers oflevel 1 and level 2 smokingcessation interventions in Islington.




SummaryEffective action is urgently needed to tackleoral health inequalities and prevent oraldisease in Islington. The traditional lifestyleapproach to health improvement is flawedand outdated. Interventions should beevidence-based and tackle general as well as oral health wherever possible.

The most effective interventions focus onbroader determinants of health throughupstream actions such as creating healthypublic policies and supportive environments.These will improve health and reduce healthinequalities in a sustained and evidence-based manner.

Oral health promotion should happen in bothcommunity and practice settings. The mosteffective and efficient model for promotingoral health in the community is through theCommon Risk Factor Approach. This methodinvolves partnership working to address therisk factors shared by common chronic

diseases. This is a significant step forwardfrom the traditional health services approach,which separates the mouth from the rest of the body leading to duplication of effort,wastage of limited resources and contradictoryinformation being given to the public.

The Common Risk Factor Approach shouldbe complemented with maximising fluoridedelivery in community settings. However, the community-based oral health promotionteam in Islington is small and has limitedcapacity. This means it is unable to providethe full range of oral health promotionactivity required for Islington’s high needpopulation.

Practice-based oral health promotion shouldfocus on implementing Delivering Better OralHealth, which emphasises fluoride deliveryand integration with the wider healthpromotion agenda.


Recommendations1. Tackle broader determinants of health

through:

• Ensuring oral health priorities areappropriately integrated with all PCTstrategy documents and general health policies.

• Use community engagement strategies in target populations to facilitateimprovements in oral health and increaseactive involvement in local health issues.

• Health promoting schools should developpolicies which support the prevention of oral injuries and the development of life skills.

2. Implement the Common Risk FactorApproach:

• Develop food policies for schools,nurseries, looked-after children, olderpeople in care and nursing homes,prison, colleges and workplaces.

• Encourage GPs and pharmacists toprescribe sugar-free medicines,particularly for chronically ill children.Computerised prescribing systems should be adapted to make it easier for GPs to prescribe sugar-free options.GPs and pharmacists should educatepatients on the importance of usingsugar-free medicines.

3. Community-based oral health promotion

• Oral health promoters should train otherprimary health care workers (includingdental teams) and care workers outside the health services, to include oral health in their health promotion activities andsignpost vulnerable people for dentaltreatment.

• Oral health promoters should work withlocal schools to increase cooperationaround specific oral health interventions,screening and epidemiological surveysconducted in this setting and to promotesignposting to dental services.

• Fluoride delivery should be maximised at a community level through distributionof fluoride toothpaste and application offluoride varnish.

4. Practice based oral health promotion

• Oral health promotion in dental practicesshould include interventions basedaround fluoride delivery as well asgeneric health promotion work, e.g.smoking cessation and advice on dietand alcohol misuse.



BibliographyBatchelor P, Sheiham A. The limitations ofa ‘high-risk’ approach for the preventionof dental caries. Community Dent OralEpidemiol 2002 Aug; 30(4):302-12.

Crombie IK, Irvine L, Elliott L, Wallace H.Closing the health inequalities gap: aninternational perspective. 2004; NHSHealth Scotland and University of Dundee:Dundee.

Department of Health. Delivering BetterOral Health: An evidence-based toolkit forprevention 2007 London: Department ofHealth. Available at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742.

Department of Health. Choosing BetterOral Health. An Oral Health Plan forEngland. 2005 London: Department of Health.Available at URL: http://www.dh.gov.uk/prod _consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4123253.pdf.

Fejerskov O. Strategies in the design ofpreventive programs. Adv Dent Res 1995Jul; 9(2):82-8.

Marinho VCC. Fluoride varnishes forpreventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, 2002; (3): CD002279.

Marinho VCC, Higgins JPT, Logan S,Sheiham A. Fluoride toothpastes forpreventing dental caries in children andadolescents. Cochrane Database ofSystematic Reviews 2003, (1). CD002278.

Marmot M. Social determinants of healthinequalities. Lancet 2005; 365:1099-104.

Milio N. Promoting Health Through PublicPolicy. 1986; Canadian Public HealthAssociation: Ottawa.

Sheiham A, Watt RG. Oral healthpromotion and policy. In Murray JJ, NunnJH, Steele JG (eds.). Prevention of oraldisease 2003, 241-258; Oxford UniversityPress: Oxford.

Sheiham A, Watt RG. The common riskfactor approach: a rational basis forpromoting oral health. Community DentOral Epidemiol 2000 Dec; 28(6):399-406.

Shou L, Wight C. Does dental healtheducation affect inequalities in dentalhealth? Community Dent Health 1994;11:97-100.

The relative contribution of dental servicesto the changes and geographical variationsin caries status of 5 and 12 year old childrenin England and Wales in the 1980s. CommDent Health 1994; 11:215-223

Watt R, Sheiham A. Inequalities in oralhealth: a review of the evidence andrecommendations for action. British DentalJournal 1999; 187(1):6-12.

Watt RG. Emerging theories into the socialdeterminants of health: implications fororal health promotion. Community DentOral Epidemiol 2002; 30:241-7.

Watt RG. From victim blaming to upstreamaction: tackling the social determinants oforal health inequalities. Community DentOral Epidemiol 2007; 35:1-11.

Watt RG. Public Health Reviews. Strategiesand approaches in oral disease preventionand health promotion. Bull World HealthOrgan website 2005; 83(9): 711-718.Available at URL: www.who.int/bulletin/volumes/83/9/711.pdf.

World Health Organisation.The Ottawa Charter for Health Promotion.Health Promotion 1981; 1:iii-v; WorldHealth Organisation, Geneva.

IMPROVING ORAL HEALTH SERVICES IN ISLINGTON 47

Improving oral health services in Islington

6

Oral health and related serviceshave been rising up the nationalNHS agenda for a number of years. The NHS operatingframework for 2009/10 describesdentistry as a priority area and the Department of Health expectsto see ‘real improvements forpatients’ over the coming year in terms of access to dentistry,quality of care and oral health in the community.

National policy developmentsaimed at improving general healthand health services in recent yearshave been reflected in a wealth ofguidance on improving oral healthand related services. An oral healthplan for England Choosing BetterOral Health was published tocomplement the public healthwhite paper Choosing Health:making healthier choices easierand provides a good practiceframework for tackling oral healthinequalities within the newcontractual arrangements for NHSDentistry. The strategic directionset out in the Darzi NHS review

High Quality Care for All and Ourvision for primary and communitycare has been applied to primarycare dental services in a guide for world class commissioning of primary care services and an independent review of NHSdentistry has just been completed.

The Steele review of NHS dentistryNHS dental services in Englanddraws together many of the keythemes raised in these earlierpublications and makes a numberof recommendations for action.These themes are fundamental to achieving sustainableimprovements in oral health,quality of and access to dentalservices and will be explored in this chapter in the context of Islington.

Dental services in IslingtonThe vast majority of NHS dentalcare in Islington is provided inprimary care by independentcontractors known as generaldental practitioners (GDPs). Thecommunity, or salaried, dentalservice (CDS) provides dentaltreatment for special needs groupsin primary care. The geographicaldistribution of these services isfairly evenly spread, as illustrated in figure 6.1 although there arefew practices in the centre of theborough. Most of the specialist orsecondary dental care for Islingtonresidents is provided by theEastman Dental Hospital, part of University College LondonHospital, just across the border in Camden.

Introduction

NHS dentistry has experienced a major cultural shift in recent years.Policy makers have acknowledged the need to improve oral healthby increasing disease prevention, improving access to dentistry and developing service quality. The 2006 ‘new’ dental contract was designed to allow dentists to focus on promoting health, placingless emphasis on treatment provision. This began a fundamentaloverhaul of NHS dental services, involving a move to localcommissioning and a reform of the remuneration and patientcharge systems. Since then developments have continued apacewith the need to modernise services and improve health outcomesbecoming ever more evident.

48 IMPROVING ORAL HEALTH SERVICES IN ISLINGTON

The bulk of NHS dentistry inIslington is delivered by theGeneral Dental Service (GDS). The GDS is administered byindependent practitioners, whocontract with the PCT to provideroutine, ‘high street’ NHS dentalservices. This service provides alltreatments required to achieve a reasonable level of oral healthfor the majority of people: fromsimple fillings and extractions to more complex crown andbridgework. Most combine theirNHS service with an element ofprivate practice, to a greater orlesser extent.

There is limited use of the dentalteam in Islington with only 3practices routinely using DentalCare Professionals (e.g. hygienists).This may be related to the limitedsurgery space available, asdisplayed in figure 6.2.

The Community or Salaried DentalService is an element of the PCTprovider arm. It provides treatmenton referral in a community settingand its primary aim is to treatpatients who are unable to access GDS care, e.g. people withphysical or learning disabilities thatrequire specialist care. Community-based specialist services providedby the CDS are:

• Special care dentistry

For people who have a physical,sensory, intellectual, mental,medical, emotional or socialimpairment or disability or, moreoften, a combination of a numberof these factors, e.g. adults withlearning disabilities and mentalhealth problems, adults who are socially-excluded, drug users or medically-compromised and frail older people including thehousebound and those in carehomes.

Figure 6.1. Geographical distribution of primary care dental services in Islington against deprivation

6. Improving oral health services in Islington

Salaried Dental Practices

1 Goodings Health Centre2 Highbury Grange Health Centre3 Hornsey Rise Health Centre4 Finsbury Health Centre

General Dental Practices

1 Angel Dental & Cosmetic Centre2 Berlin Angel Orthodontist Clinic3 Blackstock Dental Care4 City Dental Clinic5 Dentalmark6 Family Dental Care7 HM Prison Holloway8 HM Prison Pentonville9 H S Dhamu10 Highbury Dental Practice11 Holloway Dental Centre12 Hornsey Dental Centre13 Kindandental Surgery14 Kings Cross Dental Practice15 Landau Dental Surgery16 N1 Dental Surgery17 N7 Dental Practice18 Old Street Dental Clinic19 Pickerings Dental Surgery20 Ruparelia Dental Surgery21 Shah M A Dental Surgery22 Smilecare Dental Surgery23 The Dental Practice24 The Dental Surgery25 Torrance Dental Surgery


• Paediatric dentistry

Specialist paediatric dentistry isrequired when a child’s needscannot be managed in the GDS,e.g. because they are dentallyphobic, have many decayed teethor require complex restorativetreatment.

• Public health and oral healthpromotion

The CDS also performs a publichealth role and is involved inepidemiology, needs assessmentsand screening. It also hostsIslington’s oral health promotionservices. The oral health promotionteam consists of two oral healthpromoters who work in thecommunity with a number of partners, such as children’scentres, older people’s residentialhomes and health visiting teams.At present there is no overlapbetween this team and the GDS.

From dental contracting tocommissioning for oralhealthThe move to local commissioningempowered PCTs to be moreresponsive to their population’sneeds. However, dentalcommissioning is a relatively newfield and the introduction of thecontract has been challenging for all concerned. Consequentlyinnovative commissioning hasbeen slow to emerge andcontracting has been the norm.

Commissioning teams have tendedto use nationally developed modelcontracts that focus on units ofdental activity (UDA) performancerather than adapt the dentalcontract locally. However the Steelereview found that contracting onthe basis of numbers of treatmentsencourages delivery of thosetreatments at the expense ofquality and prevention. Howeverthis is beginning to change nowthat the ‘new’ contract has hadtime to embed.

Some PCTs have begun to use thecontract flexibly and there is anincreasing acknowledgement thattreatment services and oral healthpromotion services should beoverlapping and interrelated. It is important that dentalcommissioners are not restricted to commissioning treatmentservices: the Steele reviewrecommends that ‘oral healthstrategies and commissioning plans should include elements of public health activity that lieoutside those treatments which are provided to patients in thedental surgery’. This will require a significant culture shift as dentalservices have traditionally beenfocused on treatment rather than prevention. On the basis of Steele’s recommendations, it is likely that contracting forms and incentives to rewardcontinuing care, activity and quality will be developed centrally,piloted and evaluated.

Figure 6.2. Number of dental chairs per dental practice in Islington

0

1

2

3

4

5

6

7

1 2 3 4 5 6 7 8 9 10

No

.of

pra

ctic

es

No. of dental chairs per practice



Health improving oral health services Helping people stay healthy andimproving the health of thosemost in need is a key priority forthe NHS. The Darzi review statesthat every PCT is to commissioncomprehensive wellbeing andprevention services that meet the specific needs of their localpopulations. However oral health and related services havetraditionally been separate fromgeneric health and related services.This distinction is artificial andoutdated as there is strongevidence to suggest that oralhealth is integral to general health.In order to improve oral health,programmes should be developedin line with the local oral healthneeds assessment that have aprevention focus, address areas of poor health and are sensitive to the needs of vulnerable groups.

This is reinforced by the Steelereview, which describes thepriorities for public investment in oral health, as illustrated in figure 6.3. The reportrecommends that public healthmeasures be given the highestpriority for investment, followed by urgent care and practice-basedprevention. Routine treatment ofdisease, where the bulk of fundinghas historically been spent, comesfourth on the list.

The Steele review states that ‘toprevent oral disease’ is the first aim of an NHS oral health service.This requires an evidence-based,preventive focus with prioritisationof the following areas:

• Optimise exposure to fluoride atindividual and community level

• Promote healthy diet andreduced sugar intake

• Support tobacco cessation

• Increase detection of mouthcancer

• Reduce dental injuries

• Promote use of sugar freemedicines

• Promote breast-feeding

• Encourage and advise on selfcare practices, e.g. oral hygiene

• Encourage sensible patterns ofalcohol consumption

• Develop the dental team and their health promotingknowledge and skills

• Develop personalised preventionplans for individual patients

• Incorporate oral health into the training of other healthprofessionals

• Develop oral health links with other areas of healthimprovement

• High risk groups includingchildren and hard to reach or vulnerable adults, such asprisoners, people with learningdifficulties, mental healthproblems, drug misusers.

Clearly these issues cannot betackled solely in the dental surgery.Partnership working in a communitysetting is vital. Just as there has been an artificial distinctionbetween oral and general health,there has been a division betweendental treatment services and oral health promotion. This is no longer appropriate; a modernNHS dental service should worktowards integrating healthpromotion and dental treatmentservices where possible.

It is clear that public health shouldnow form a key element of theoral health agenda and vice versa.Specifically, the common risk factorapproach should be adopted as aframework for the integration of

Figure 6.3. Priorities for public investment in oral healthSource: Department of Health NHS dental services in England. An independent review lead byProfessor Jimmy Steele. 2009 Available at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_101137

Reducingpriority for

publicinvestment

Advancedand complex

care

High-quality, routinetreatment ofdental disease

Personalised disease prevention

Urgent care and pain relief

Public health

Continuing care

oral health and general healthpromotion. For example, dentistry should mainstream diet improvement and smokingcessation. Oral health risks shouldbe addressed by wider publichealth initiatives such as healthyworkplace campaigns and healthy schools programmes.

Examples of good practice are as follows:

I. ChildsmileThe Scottish Childsmileprogramme is amultiprofessional approach to oral health promotion that combines prevention inschools, nurseries, communitiesand practices, with a focus onareas of greatest need. This iscomplemented by treatmentservices which provide localcommunity based treatment or care from mobile units.

II. Health promoting practiceschemesA number of dental practicesacross the country haveintegrated practice andcommunity based healthpromotion. Oral healthpromoters work with practiceteams to train and supportthem in delivering evidence-based oral health promotion.Practices receive healthpromotion resources, formnetworks and use the teamapproach to prevention.

III. Happy TeethThis is a project developed in Tower Hamlets to activelyprevent disease and promoteaccess to dental services. It isbased on building a strongrelationship between schoolsand dental services andtackling barriers for the most excluded groups.

High quality dental services In his Next Stage Review LordDarzi described a vision for anNHS built around quality of care as a necessity. The three aspects of quality were described aspatient safety, patient experienceand effectiveness of care. These elements should driveimprovement in quality of dentalcare but all need to be measurableand measured in a dental context.Achieving a high quality dentalservice requires consideration of a broad range of complementaryelements:

1. Blended contractsDentists should be rewarded forproviding a high quality serviceand for improving the oral healthof their patients. It will be necessaryto employ the inherent flexibility in the dental contract to create‘blended’ contract currencies.These should include more explicit incentives and levers forprevention and quality in additionto UDA performance targets.

2. Measurement of quality Improved collection and use ofinformation is needed to monitorand develop the quality andeffectiveness of the care patientsreceive. Balanced scorecards canbe used as a tool to measurequality improvement and monitorproviders that are not achievingquality standards. Clinical‘dashboards’ are being developednationally that will presentselected national and locallydeveloped measures as a tool to drive quality improvement and raise standards. Examples of quality measures include:

• Rate of new patientsprogressing to continuing care

• Proportion of new patients or ofreturning patients whose risk is

lowered (as demonstrated bymove to longer recall intervals)

• Increase or decrease in the rateof restoration, across a sampleof patients, year on year

• The proportion of continuingcare patients seen in out ofhours emergency services

• Rate of antibiotic prescription.

3. Clinical leadership andengagementClinical engagement is a key element of world classcommissioning of high qualityclinical services. It is broadlyaccepted that this is a vital part of each stage of a successfulservice redesign. As well asproviding expert clinical advice, it is necessary to understand theincentives and motives that driveclinicians and to instill a sense ofownership among them. There iscurrently little communication oroverlap between dental cliniciansin the various services and this is a barrier to service qualityimprovement.

4. Patient choice and engagementin shaping servicesMore information and choice isneeded for patients to make oralhealth services more responsive to their personal needs. Annualpatient satisfaction surveys shouldbe conducted in general dentalpractices.

5. Measure success in terms ofgood oral healthOral health services are somewhatbehind the rest of the NHS infocusing on health as an outcome.The national Clinical Effectivenessand Outcomes Group is establishingkey performance indicators thatcould be used to measure qualityimprovement in primary caredental practices, as part of the



implementation of the Next Stage Review, Measuring forQuality Improvement. The group is establishing quality indicators that can be used to supplementcommissioning, practice and other aspects of provision. This will include production of a list of measures that act as outcome indicators, as well as indicators relating to access,compliance with Delivering BetterOral Health and dental recallguidance. These indicators areexpected to be released by theend of 2009 for piloting. Oncompletion of this process, theseindicators will be available on theInformation Centre website as partof the Assured Menu of indicators.

6. Modern primary care premisesThe environment must be createdin which quality can be achieved.This will require a number ofelements:

i. The Steele review recommendsthat NHS dental practices becomputerised by the end of2011 in such a way that allowsdata transfer from chair side toNHS BSA and PCTs.

ii. Decontamination facilities must be in line with essentialquality standards in TechnicalMemorandum HTM 01-05:Decontamination in primarycare dental practices by April2010 and practices should beworking towards best practicerequirements.

iii. Work towards developinglarger and therefore moreefficient providers and servicesfacilities. This would alsofacilitate greater use of skill mix, delivery of healthpromotion interventions in practice, improveddecontamination and improvedclinical governance.

iv. All dental practices mustregister with the Care QualityCommission by April 2011,regardless of whether NHS,private or mixed practices. This will help improve patient safety and help PCTs to performance manageunacceptable or unsafe practice.

7. Development of a clearer‘staged’ patient pathway fordentistryThe staged patient pathwayreflects the second and third aimsof the Steele review, which are to‘minimise impact of oral diseaseon health, when it occurs’ then to ‘maintain and restore quality of life when this is affected by the condition of your mouth’. The staged patient pathway isdesigned to deliver oral health as an outcome and is summarisedin figure 6.4.

This patient pathway aims to:

• Improve access by makingurgent care available to all and creating a route for irregular attendees to enter into continuing care.

• Prioritise prevention of diseasethrough regular monitoring andpersonalised prevention for allpatients in a continuing carearrangement.

• Facilitate the creation of apersonalised long-term care planfor each patient that includes hisor her prevention and treatmentneeds. This will be informed by a standardised oral healthassessment to evaluate risk oforal disease.

• Provide complex restorative care: provision of advancedrestorations, e.g. crown andbridgework, only for patients in a continuing care relationshipwhose oral health has become

stable and whose risk of furtheroral disease is low.

The possibility of supporting thispathway through payments forcontinuing care responsibilities iscurrently being considered centrally.

8. High quality dental workforceIncreasing prevention in dentalpractice and adopting the patient care pathway above hasimplications for the entire dentalworkforce. With the GeneralDental Council registration ofDental Care Professionals (DCPs)including hygienists, therapists,and clinical dental technicians,there are now fewer restrictionson who can provide patient care.

It is well recognised that deliveringcare through skill mix and a teamapproach is a more efficient andcost-effective way of working. It enables simpler tasks to becarried out by DCPs leaving thedentist to lead the team and focuson tasks that need a high level of expertise. However this has notbeen widely adopted in GeneralDental Services suggesting thatfacilitation from PCT commissionersis required. It may also be asymptom of the size of practice as skill mix works best in largerpractices.

Improving access to oralhealth services Improving access to oral healthservices is currently high on the NHS agenda. There is awidespread perception among the public that it is difficult to finda NHS dentist and increasingaccess to NHS dentistry appears as one of the NHS OperatingFramework’s ‘Vital Signs’. PCTs are required to ‘provide access to anyone who seeks help in accessing services’ as well as achieve ‘year-on-year


improvements in the number of patients accessing NHS dentalservices’ locally.

Historically dentists have been free to choose where to provideservices and an inverse care law(whereby those most in need ofservices are least likely to receivethem) has been the result.However, the move to localcommissioning in 2006 hasallowed PCTs to be increasinglyable to stipulate the location,quantity, cost or client groups ofthe General Dental Services, e.g.locating services in deprived areaswhere there is greatest need.

The challenge for PCTs is to takefull advantage of this opportunityso as to maximise health gainfrom any access programme.

Increasing access must contributetowards reducing oral healthinequalities and it is thereforeinsufficient to simply increaseservice capacity. An accessprogramme must target groupswith high need and poor levels ofservice uptake. This is reinforced in the Darzi NHS review thatemphasised the importance ofproviding personalised care for allthose who need it, not just thosewho make the loudest demands.This should include those who aretraditionally less likely to seek helpor those who are discriminatedagainst. We need to think morebroadly about ‘access’ to ensurethat it delivers access to treatmentservices as well as access toprevention and health promotion.

Local priorities for the accessagenda include:

• Levelling up access andimproving choice for groups that cannot easily accessservices. Hard to reach groupsmust be the focus of accessinitiatives and require additionaland specific measures, e.g. pre-school children, sociallyexcluded adults, older people.

• Providing primary dental care for children to reduce the highnumbers being referred fordental extractions under generalanaesthetic (GA).

• Tackling high GAs for children – we need to provide increaseduptake of services in children andincreased provision of primarycare treatment for children.

Improving access to dental serviceslocally requires a number ofapproaches:

1. The geographical location of new practices should befocused on areas of high need and low uptake.

2. Availability of a range ofmodels of dental care The ‘one size fits all’ approachto commissioning services isunlikely to be effective in thismulticultural urban society. It islikely that a range of differentservice models are needed if all groups are to have theirneeds met. The traditionalhigh street model dominatesdental services in Islington.People who do not fitcomfortably into the structureand ethos of high streetpractices are unlikely to begetting their needs met. Thiswould include a wide range ofspecial care groups and peoplewith cultural barriers to access.


Figure 6.4. Patient pathway proposed in Steele reviewSource: Department of Health NHS dental services in England. An independent review lead byProfessor Jimmy Steele. 2009 Available at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_101137

Routine care

Accept

Decline

Assessment oforal health

Recommend assessment of

oral health

Disease preventionand management

Continuity of careand routine

management

Advanced care

New patient visits dentist

Urgent care

Definitivepain relief


3. Appropriate provision for thosewho choose not to attendregularlyThere should be a high qualityurgent care dental facility thatis easily accessible.This shouldbe co-located with otherurgent care services wherepossible. It should haveestablished quality measures,including low levels ofantibiotic prescription.

4. Develop systems to supportasymptomatic attendance insymptomatic attendees Symptomatic attendance, e.g. at an urgent care service,presents an opportunity toimprove the health of anindividual who is likely to have poor oral health. Theindividual should be offeredstructured incremental dentalcare to allow confidence andmotivation to grow over thelong term, using the structuredpatient pathway.

5. Partnership working withhealth and non-healthprofessionalsThis should include raising the profile of oral health withother health professionals,social services and the voluntarysector to maximise signpostingto dental services. Wherepossible, dental services shouldbe co-located with othercommunity-based healthservices, e.g. in GP-led healthcentres or polysystems.

6. Provide a greater range of specialist services incommunity settingsThis will lead to improvedhealth outcomes andimproved access for patients.Advanced care should beprovided to those who need

it most and by practitionerswho are appropriately skilled.It includes services for patientswith specific managementneeds (such as those requiringdomiciliary care, sedationservices for anxious patients,urgent services out of hours and for casual patients, prisondentistry) and those requiringadvanced/high-skill treatments(such as multiple crowns,bridges and occlusalrehabilitation, completedentures, molar endodontics,minor oral surgery, treatmentof aggressive or advancedperiodontal conditions andorthodontics).

7. Widespread routine adoptionof NICE guidance for dentalrecallAll dentists should befollowing the NICE guidelinesfor dental recall intervals. The recall interval should bedetermined for each individualpatient according to anassessment of his or her risk of future disease. Recallintervals may vary from 3 months for high needpatients to two years for thosewith low risk. Observance ofthese guidelines should free up capacity to improve accessto NHS dentistry.

8. Incentives for dentists andpatientsIt may be necessary to activelyreduce the effect ofdisincentives in the newcontract to treat high needpatients. It may also be usefulto remove barriers throughprovision of financial incentiveslike free check ups/courses oftreatment.

9. Community engagementActive and ongoing communityengagement is needed toensure that services meet the needs of the population,particularly those groups withthe greatest need. Usersshould be actively involved in the planning and design of services.

Islington residents’ preferencesfor service developments aredetailed in Chapter 4. Theseshould be taken into accountwhen planning services toimprove access. However this information is limited aswe do not yet have a goodunderstanding of the specificpreferences of sociallyexcluded groups. Further workis needed to gather data onthese high need groups, e.g.homeless people and peoplewith learning difficulties.

It may be useful to recruitcommunity link workers. These have been used in Tower Hamlets to increasecommunity engagement andincrease access through serviceredesign. Where possiblecommunity link workersshould be recruited from thetarget community.

10. Social marketing andcommunications campaignA social marketing campaign isneeded to promote awarenessof how to access services andstimulate demand. This shouldinclude universal messages as well as targeted messagesfor high risk, low uptakegroups. However success will be dependent on clinicalengagement and well runpatient information services.


11. Clear information for all There must be easy access toinformation to support anyaccess programme and socialmarketing campaign. TheSteele review includes goodpractice guidance for dentalinformation that should beadopted where possible, e.g. helplines must give broadadvice, including disabledaccess, interpretation services,and transport links. However it is important that we do notrely only on PCT helplines. The Steele review commentsthat ‘the route with the mostaccurate information (forpeople looking for a newdentist) is usually to call thelocal PCT’s dental helpline.However, many people havenever heard of the PCT, letalone know where to find it,what it does or that it has ahelpline’. Information shouldbe provided through a routethat is relevant to users andhelplines promoted morewidely, e.g. in telephonedirectories and GP surgeries.

Patients may need to bereferred by their usual dentistfor advanced care, ideally to a primary care facility.This service could be providedby either dental specialists orDentists with a Special Interest(DWSI) and has been pilotedsuccessfully elsewhere with the support of local clinicalnetworks. PCTs may need to combine commissioningresources and expertise forsome advanced services.

In Islington there is a clearneed for expertise in the careof pre-school children andprisoners. For example, accessto treatment for children could be improved through

a specialist-led, skill mix basedservice. Service uptake couldbe maximized through using a mobile surgery.

12. Widespread adoption of NHSidentity for practicesThis will assist the public in identifying NHS dentalpractices and attract new,irregular and exempt patientsand passers by. It has beenshown to help dentists to beseen as more caring andtrustworthy by patients andreassure patients that theywould not be overcharged for their treatment. It alsocomplements the widerstrategy to introduce the NHSidentity at all levels of primarycare to increase visibility of,and to improve access to, thefull range of NHS services.

Examples of good practice:i. Dental access centre (DAC)

Evidence suggests DACpatients are more likely to beyounger, more disadvantaged,have a preference forsymptomatic attendance,exempt from patient charges,anxious about treatment, havepoorer oral health (frequentexperience of pain, higherlevels of decay and poorer oral hygiene), and be smokers – compared to patients whoattend general dental practices.

ii. Oldham and Salford model This practice model uses the team approach to buildhigh quality care around adental pathway. It providesincremental treatment andevidence-based preventionaccording to patient need and oral disease stability.Anecdotal evidence suggeststhat this model motivatespatients to increase their own

health promoting behaviour.Key performance indicators are not based on activity but are related to quality ofservice and access, preventiveprotocols from DeliveringBetter Oral Health, availabilityand use of information andappropriate recall intervals.

iii. Mobile dental service A mobile dental service hasbeen used with success inTower Hamlets followingcommunity engagement with high need communities.It proved popular with thecommunity and has beenshown to improve access for those not currently using services.




SummaryProviding a modern range of dental servicesthat improve oral health, quality and access is a real challenge for PCTs. A flexible andforward-thinking approach is needed toachieve an ongoing cycle of improvement if the diverse needs of Islington’s populationare to be met. A multi-stranded approach is needed, as summarised in figure 6.5.

Dental commissioners should engage withclinicians and communities and employblended dental contracts to prioritiseprevention, improve health outcomes, and increase access for vulnerable groups.Commissioning of population oral healthimprovement should be integrated withcommissioning of dental services. Dentalservices in turn should be more integrated

with each other, with the rest of primarycare, with the needs of users and the broaderpublic health agenda.

Services should be designed around theneeds and preferences of local users and a range of dental service models is requiredto reflect patterns of service use. Servicesshould be delivered from primary carepremises that support teamwork andcontemporary infection control standards and are co-located with other primary care services where possible. Above all, theemphasis should be on delivering improvedoral health, quality services and access tothose who need it most in order to deliver a local service that can reduce oral healthinequalities for local people.

Figure 6.5. A summary of key actions needed to improve oral health, quality and access through oral health services

Blendedcontracts

Health promotingpractices

Promote access

Promote quality

Oral health needs assessment

World classcommissioning of

dental services

Modern practices

Use ofdental team

User engagement

Prevent generaland oral disease

Staged patientpathway

Close fit withneeds of

vulnerable groups

Multiple modelsof care

Engagement withcommunities


Recommendations1. Improving oral health

• Any procurement should incorporateprovision of treatment, health promotioninterventions and promotion of healthybehaviours.

• Dental services should be integrated intoPCT strategy documents, e.g. urgent carestrategy and primary care strategy.

• Commissioning strategies should prioritisehigh need population groups to reduceinequalities in oral health.

• Prevention of disease is key and requires a combination of practice and communitybased prevention.

• Commissioning of health promotion andtreatment services should be integrated.

2. Commissioning high quality oral health services

• Make use of blended contracts toincentivise improved health outcomes,improved access and greater quality of care.

• Improve dental urgent care services.

• Develop a premises strategy to facilitate:

– Equitable distribution of practices

– Health promoting practices

– Access for disabled people

– Greater use of the dental team

– Compliance with contemporary infectioncontrol standards

– Improved IT systems

• Establish mechanisms to support clinicalleadership and engagement.

• Establish mechanisms to support patientchoice and engagement, particularly withunderserved communities.

• Support practices to make best and mostcost-effective use of the available dentalworkforce.

3. Improving access to oral health services

• Develop an access programme that clearlytargets high need groups with low serviceuptake.

• Provide a range of models of care to meetthe needs of diverse population groups,e.g. walk in services, mobile services.

• Co-locate dental services with otherprimary care services where possible.

• Link with other health and social careservices to ensure that vulnerable peopleare signposted to dental services at everyopportunity.

• Extend opening hours of dental practices.

• Stimulate demand in groups not currentlyusing services through a social marketingcampaign and partnership working.

• Develop a greater range of specialist orspecial interest services in communitysettings, according to population oralhealth needs, e.g. prison dentistry,paediatric dentistry.

• Ensure dental helpline meets with goodpractice guidance.

• Facilitate training for dental teams todevelop communication skills, customerservices skills and creation of a welcomingenvironment.



BibliographyDepartment of Health. Choosing BetterOral Health: An Oral Health Plan forEngland. London: Department of Health;2005. Available at URL www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf

Department of Health. Dear Colleagueletter. Independent review of NHS dentistryin England June 2009. Gateway: 12087Available at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_101248

Department of Health NHS dental services in England. An independentreview lead by Professor Jimmy Steele.2009 Available at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_101137

Department of Health 2009 HTM 01-05:Decontamination in primary care dentalpractices. Available at URL http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_097690

Department of Health 2009 Improvingdental access, quality and oral healthAvailable at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093831

Milsom KM, Jones C, Kearney-Mitchell P,Tickle M. A comparative needs assessmentof the dental health of adults attendingdental access centres and general dentalpractices in Halton & St Helens andWarrington PCTs 2007. 2009 British Dental Journal 206;257-261.

NHS Islington Oral health needsassessment 2009.

NICE Dental Recall – Recall intervalbetween routine dental examinations.2004 London: NICE Available at URL:http://www.nice. org.uk/Guidance/CG19

Primary Care Contracting Dentists withSpecial Interests (DwSIs). A step by stepguide to setting up a DwSI service.Available at URL http://www.pcc.nhs.uk/uploads/Dentistry/april_2006_uploads/step_by_step_guidance__dwsis.pdf

Professor the Lord Darzi of Denham KBE2008 High Quality Care For All: NHS NextStage Review Final Report. www.dh.gov.uk/en/Publicationsandstatistics/PublicationsPolicyAnd Guidance/DH_085825

Public Accounts Committee ReducingAlcohol Harm: health services in Englandfor alcohol misuse. Forty-seventh Report ofSession 2008-09 Report. HC 925(Incorporating HC 1197-i, Session 2007-08) Published on 30 July 2009 by authorityof the House of Commons London: TheStationery Office Limited.

The NHS in England: The OperatingFramework for 2009/10. Department of Health. Available at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091445

At a glance, the problem of oraldiseases seems straightforwardand simple to solve. The causes of oral diseases are understood,they are almost entirely preventableand many people now experiencegood oral health. Yet oral diseasescontinue to place a significantburden on society and the NHS and have multiple impacts onindividuals.

A social gradient exists in oralhealth whereby people at eachhigher level of socioeconomicposition experience better oral health and quality of life. This means that vulnerable,disadvantaged and sociallyexcluded people carry the burden of chronic oral diseases.These oral health inequalities areof particular concern in Islingtonwhere so many residentsexperience socio-economicdeprivation.

The risk of experiencing oral diseases varies with age,gender and genetic predispositionand is increased by certainbehaviours, such as frequent sugar consumption. However thecauses of population inequalities in oral health are primarily social.The circumstances in which peoplelive and work have a profoundeffect on their health and wellbeing. Broader determinants, such as educational and livingconditions, have been shown to have multiple effects on oralhealth. These ‘causes of thecauses’ of oral health inequalitiesmust be tackled to achieve realimprovements in oral health and to

improve the quality of life of thosein greatest need.

It has become clear thatimprovement of oral health at a population level is much morechallenging than it might initiallyappear. The traditional approach to oral health promotion, based on oral health education andtaking personal responsibility for healthy behaviours, has notbenefited the sections of societywho need it most. A sophisticatedapproach is needed that supportsand encourages good oral healththrough sustained, multisectoralaction.

The focus of oral healthimprovement should be oncreating healthy public policies,supportive environments,strengthening community action,developing personal skills andreorienting health services towardsprevention. These ‘upstream’actions should be complementedby specific interventions thateffectively prevent oral disease,such as widespread delivery offluoride. Oral health promotionshould be delivered in bothcommunity and health caresettings and should integrate with generic health promotionactivities wherever possible, e.g. to improve healthy eating orreduce tobacco use.

In addition to preventing disease, it is vital that Islington residentshave equitable access to highquality, modern dental services.With the move to localcommissioning in 2006, PCTsgained influence over the location

and design of NHS dental servicesfor the first time. The initial focushas been on contracting for activity.However the challenge now is tomove towards commissioning forhealth outcomes, high quality andincreased access. An ongoing cycleof improvement will be needed tomeet the diverse needs ofIslington’s population.

At present there are unacceptableinequalities in access to treatmentwith people from socioeconomicallydeprived and socially excludedgroups receiving the least care. It is important to work withcommunities to understand thevarious barriers experienced byIslington residents. This knowledgemust inform dental commissioningto ensure that services fit closelywith the needs and preferences of our population.

This report has summarised the inequalities experienced byIslington’s population in terms of experience of oral diseases and access to services. It has givenan overview of the action neededto improve oral health, access tooral health services and quality ofthese services. It is vital that theserecommendations are adopted so that the unacceptable burdenof preventable oral diseases onIslington residents can be reduced.

Conclusions and recommendations

7

Conclusions

CONCLUSIONS AND RECOMMENDATIONS 59

60 CONCLUSIONS AND RECOMMENDATIONS

Summarised recommendations

Priority area Recommendation

Tackle the socialdeterminants of oral disease

• Continue to strengthen partnership working to develop opportunities to promote better mental and physical health in the community and other settings. To include:– Community development and engagement with health services– Development of personal skills in children and adults– Integrated health promotion in schools and workplaces– Support for families with young children from deprived social groups

Implement the common risk factor approach

• Mainstream involvement of dental teams in generic health promotion, e.g. smoking cessation, alcohol reduction

• Increase healthy eating and reduced sugar consumption through multisectoral food strategy

• Consider oral health in all health promotion activities and healthy eatingpolicies in health and non-health care, e.g. nursing homes, prisons

• Oral health priorities should be integrated appropriately into all PCT strategy documents and general health policies

Actively prevent oraldisease through communityand practice-basedprevention

• Disease should be actively prevented in children and vulnerable adults through delivery of fluoride toothpaste and fluoride varnish at a community level.

• GPs and pharmacists should prescribe sugar-free medicines, especially for chronically ill children

• Dental practices should routinely implement the prevention toolkit DeliveringBetter Oral Health.

Improve access to dental services, particularlyfor vulnerable groups

• Explore ways to increase the use of local services for local people throughcommunity engagement and take public preferences identified through socialmarketing research into account when designing local access initiatives.

• Explore ways to reduce the impact of disincentives in the new dental contractto treating new, high need patients.

• Develop an access programme that reduces barriers for high need groups withlow service uptake.

• Provide a range of models of care to meet the needs of diverse populationgroups, e.g. walk in services, mobile services, and extended opening hours.

• Co-locate dental services with other primary care services where possible.• Link with other health and social care services to ensure that vulnerable people

are signposted to dental services at every opportunity. • Improve patient information and stimulate demand in groups not currently

using services through a social marketing campaign.• Develop a greater range of specialist or special interest services in community

settings, according to population oral health needs, e.g. prison dentistry,paediatric dentistry.

• Facilitate training for dental teams to develop communication skills; customerservices skills and creation of a welcoming environment.

Improve the quality of oral health services

• Commissioning strategies should prioritise high need population groups toreduce inequalities in oral health.

• Dental commissioning of health promotion and treatment services should beintegrated. All procurements should incorporate provision of treatment, healthpromotion interventions and promotion of healthy behaviours.

• Improve dental urgent care services.• Develop a premises strategy to support equitable access, modernisation of

practices and team working.• Establish mechanisms to support clinical leadership and engagement.• Establish mechanisms to support patient choice and engagement, particularly

with underserved communities.

GLOSSARY 61

Age standardization: A processfor adjusting rates, e.g. deathrates, designed to minimise theeffects of differences in agecomposition when comparingrates for different populations.

BME: Black and minority ethnic.

Calculus: A form of hardeneddental plaque synonymous with tartar.

Chronic: Referring to a health-related state, lasting a long time.

Commissioning: The processeslocal authorities and primary caretrusts undertake to ensure thatservices funded by them meet the needs of their client group and offer best value for money.

Common risk factor approach(CRFA): An approach topromoting general health bycontrolling a small number of risk factors which can have a major impact on a large number of diseases. This is a cost-effectivealternative to disease-specificapproaches.

Community: Group of people living or working in a geographically defined area(geographical community) or who have a characteristic, cause,need or experience in common(community of interest).

Community dental service(CDS): Salaried services providedby practitioners who are directlyemployed by PCTs.

Dental care professionals (DCPs):This term commonly refers tomembers of the wider dentalteam, such as dental therapists,hygienists and dental nurses.

Dental caries: The materialremaining after tooth substance hasbeen destroyed as a result of attack

by acid produced by plaque bacteriafrom sugars in the diet. Commonlyreferred to as tooth decay.

Dental disease: Disease whichaffects the teeth or gums. Some of the most prevalent types ofdental disease include dental caries and gum disease.

Dental trauma: Tooth loss ordamage caused by physical injury.

Dentate: Having natural teeth.

Determinant: Any factor, whetherevent, characteristic, or otherdefinable entity, that brings aboutchange in a health condition orother defined characteristic.

DMFT/dmft: An indicator of the level of dental decay obtainedby calculating the number ofdecayed, missing and filled teeth(dmft score).

Edentulousness: Having nonatural teeth.

Emergency: Patients admittedwithout having planned for theadmission ahead of time, generallyvia A&E.

Empowerment: A processthrough which individuals and/orgroups are able to express theirneeds, present their concerns,devise strategies for involvement in decision-making, and achievepolitical, social and cultural actionto meet those needs.

Epidemiology: The study of the distribution and determinantsof health-related states or events in specified populations, and theapplication of this study to controlof health problems.

Erosion: Chemical dissolution of teeth.

Ethnic group: A social groupcharacterized by a distinctive social

and cultural tradition, maintainedwithin the group from generationto generation, a common historyand origin; and a sense ofidentification with the group.Members of the group havedistinctive features in their way oflife, shared experiences, and oftena common genetic heritage. Thesefeatures may be reflected in theirhealth and disease experience.

Fluoride: A chemical compoundthat helps to prevent dental caries.

General dental services (GDS):The GDS are administered byindependent practitioners, knownas general dental practitioners(GDPs). They contract with PCTs to provide NHS services and manycombine this with private practice.

Gingivitis: An infection of thegums which causes swelling, pain,and sometimes bleeding.

Health behaviour: Thecombination of knowledge,practices, and attitudes thattogether contribute to motivatethe actions we take regardinghealth. Health behaviour maypromote and preserve goodhealth, or if the behaviour isharmful, e.g. tobacco smoking,may be a determinant of disease.

Health promotion: The processof enabling people to increasecontrol over and improve theirhealth. It involves the populationas a whole in the context of their everyday lives, rather thanfocussing on people at risk forspecific diseases, and is directedtoward action on the determinantsor causes of health.

Incidence: The number of newevents, e.g. new cases of a diseasein a defined population, within aspecified period of time.

Glossary

62 GLOSSARY

Inequalities in health: Thevirtually universal phenomenon of variation in health indicators(infant and maternal mortality rates,mortality and incidence rates ofmany diseases, etc.) especiallythose associated withsocioeconomic status and ethnicity.

Lifestyle: The set of habits and customs that is influenced,modified, encouraged, orconstrained by the lifelong processof socialization. These habits andcustoms include use of substancessuch as alcohol, tobacco, tea,coffee; dietary habits; exercise; etc.which have important implicationsfor health and are often the subjectof epidemiologic investigations.

Mental health: A state ofwellbeing in which the individualrealises his or her own abilities, can cope with the normal stressesof life, can work productively and fruitfully, and is able to make a contribution to his or her community.

Morbidity: Any departure,subjective or objective, from a state of physiological orpsychological well-being.

Mortality: Death.

Non-milk extrinsic sugars(NMES): ‘Free sugars’ includingmonosaccharides and disaccharidesas well as those sugars naturallypresent in honey, fruit juices andsyrup.

Oral cancer: Malignant tumour of the mouth.

Oral health: A standard of healthof the oral and related tissueswhich enables an individual to eat, speak and socialise withoutactive disease, discomfort orembarrassment and whichcontributes to general well-being(DoH, 1994).

Oral hygiene: The practice ofkeeping the mouth clean in order

to prevent cavities (dental caries),gingivitis, periodontitis, bad breath(halitosis), and other dentaldisorders.

Oral mucosa: The mucousmembrane lining in the mouth.

Partnership: A partnership (forhealth) is a voluntary agreementbetween two or more partners to work cooperatively towards a set of shared health outcomes.

Periodontal disease: Disease of the gums and supportingstructures of the teeth. Commonlyreferred to as gum disease.

Prevalence: The number of events,e.g. instances of a given disease or other condition, in a givenpopulation at a designated time.

Prevention: Actions aimed at eradicating, eliminating, orminimising the impact of diseaseand disability, or if none of these is feasible, retarding the progressof disease and disability.

Primary care: The collective termfor all services which are people’sfirst point of contact with the NHS.

Private practice: This service isfully independent of the NHS andprovides general dentistry as wellas treatments that are not availableunder the NHS, in particularcosmetic dentistry. Dentists chargefees for item of treatment or fortime spent. Patients fund theirown treatment directly or throughinsurance schemes.

Public health: The science and artof preventing disease, prolonginglife, and promoting health throughorganised efforts of society.

Psychosocial: Involving aspects of both psychological and socialbehaviour.

Quality of life: The degree towhich persons perceive themselvesable to function physically,emotionally, and socially.

Risk factor: An aspect of personal behaviour or lifestyle, an environmental exposure, or an inborn or inheritedcharacteristic, that on the basis ofepidemiologic evidence, is knownto be associated with health-related condition(s) consideredimportant to prevent.

Sample: A selected subset of apopulation.

Secondary care: Refers tospecialised medical services andhospital care.

Sense of coherence (SOC): A view that recognises the worldas meaningful and predictable.

Socioeconomic status (SES):Descriptive term for a person’sposition in society, which may be expressed on an ordinal scaleusing such criteria as income,educational level attained,occupation, value of dwellingplace, etc.

Social marketing: The use ofmarketing theory, skills, andpractice to achieve social change,e.g. in health promotion.

Survey: An investigation in which information is systematicallycollected but in which theexperimental method is not used.

Main sources:

Last JM (2001). A dictionary ofepidemiology – 4th edition.Oxford University Press: Oxford.

Islington Primary Care Trust.Public Health Report 2007.

The Free Dictionary by Farlex.http://encyclopedia.thefreedictionary.com

Public Health Electronic LibraryGlossary

World Health Organisation

Cambridge Dictionaries Online.http://dictionary.cambridge.org


64 PUBLIC HEALTH REPORT

The report found that manyaspects of local services werestrong, but that investment was generally concentrated onmanaging serious mental illnessrather than on earlier intervention.In part this reflected a relativelyhigher level of serious mentalillness in the borough, but it meant that areas such as mentalhealth promotion and talkingtherapies, which had the potentialto improve population outcomesand help to prevent more serious illness developing, werecomparatively under-developed.The report also found evidence of strong links between mentaland physical health in the borough,a finding reinforced in 2007’sannual public health report onearly deaths from heart disease in Islington.

The local mental health promotionstrategy set out a phased approachto improving the determinants of mental health under 5 key objectives, supported by NHS Islington’s Business Case for Prevention and Islington’s Local Area Agreement.

The strategy placed a strongemphasis on building capacity and changing the way we thinkabout and respond to mentalhealth needs, working with peoplewho have first hand experience ofliving with mental health problems.

NHS Islington invested significantlyin additional talking therapiesservices in 2008/9 to help boostearlier intervention and treatmentfor people with depression andanxiety. Islington subsequentlysuccessfully bid for additionalnational funding for ImprovingAccess to Psychological Therapies(IAPT) services. With the nationalfunded posts in place, Islington’sPsychological Wellbeing Service will have a full service of 44.2whole time equivalent high and

low intensity specialist workers by January 2010. The service willspecifically promote self referral to enhance access to groupspreviously under-represented in services, including BMEcommunities.

Two anti-stigma campaigns, basedon social marketing research anddeveloped in collaboration withservice users, have been run in avariety of locations across Islington.A further major campaign isplanned to coincide with thelaunch of the full IAPT service in early 2010.

Update on recommendations from the Annual Public Health Report 2006

Progress on promoting mental health in Islington

Promoting mental health in Islington (2006) identified Islington as having one of the highest set of mental health needs in the country. Many protective factors for good mental health at community, environmental and individual levels were relativelyweak in Islington, whereas risk factors for poorer mental healthwere generally worse than national comparators.

Objective 1. Build good mental health in Islington throughcommunity partnerships.

Objective 2. Raise awareness about mental health.

Objective 3. Decrease stigma and discrimination and promote social inclusion.

Objective 4. Encourage people and services to recognise and respond to problems early.

Objective 5. Prevent suicide.


Over 470 people have beentrained in Mental Health First Aid since NHS Islington startedpiloting the innovative course in April 2008. The course is nowcommissioned from IslingtonMIND, with annual targets to train a minimum of 400 local staff and residents annually.15 local facilitators have beentrained up, including service users,to provide the training. ContactIslington MIND if you would like to know more or would like tobook a place: Anne Thomas,Islington Mind, 8 Manor Gardens,London N7 6LA Tel: 020 75615289 Email: [email protected]

The 2006 Annual Public HealthReport identified the Irishcommunity as being at particularrisk of suicide and mental healthadmission. ICAP, a community and voluntary organisation basedin Finsbury Park with over 10 yearsof experience working with theIrish community locally, have been commissioned to deliver a programme of communitydevelopment work with the Irish community to address socialisolation, raise awareness and buildpractical skills in addressing mentalhealth and suicide risk and linkinginto services and support networks.

Islington’s Healthy Children’sCentre initiative and refresh of the Healthy Schools Programme is promoting evidence-basedinterventions in positive emotionaland mental health for children andyoung people and their families.

A local target on mental health in the Local Area Agreement isassisting in promoting access andbuilding capacity in mental health.


Influencing partnershipworkingStrengthening primary preventionwas identified as key to improvingcardiovascular health in Islington.In particular, smoking, unhealthyeating, physical inactivity anddeprivation were identified asmajor contributing risk factors that need to be tackled. Given that no single organisation oragency is capable of addressingthese risk factors alone, there has been a focus on developingstrong partnerships to jointly tacklepopulation risk factors and onembedding prevention in both ourown organisational priorities andthose of our partners, includingthe Local Area Agreement.

In the areas of smoking, unhealthyeating and physical inactivity,specific partnerships have beenestablished and joint strategieshave been, or are being, developed.Proactive Islington is a long-standing partnership which brings together partners from the statutory, voluntary andcommercial sectors with theultimate aim of increasing levels of physical activity in the borough.A wide range of programmes andinitiatives have been successfullydeveloped under the auspices ofthe Proactive Strategy, including

Work-Fit, Islington Health Walks,and expanded participation inafter-schools activities, to namejust a few. The Proactive Strategyfor Islington is currently beingrefreshed.

A similar approach has beendeveloped for healthy eating and food, with the establishmentof a Food Strategy Partnership in 2008. The Partnership hasdeveloped a Food Strategy forIslington, focusing on food inrelation to health, sustainabilityand poverty. Following a period of consultation and sign off by key partners, the launch of theFood Strategy is planned forDecember 2009.

In the area of tobacco control,Islington Smokefree Alliance serves as a multi-agencypartnership focused on reducingrates of smoking in the boroughand promoting smokefreelifestyles. NHS Islington, IslingtonCouncil, London Fire Brigade,Metropolitan Police and localeducational establishments and business are all represented.The Alliance is overseeing thedevelopment and implementationof a Tobacco Control Strategy and action plan (2009-2012) for Islington.

Influencing primary careIn 2008/09 NHS Islington launcheda Local Incentive Scheme (LIS) forGPs to improve case finding ofpeople with established CVD, toensure optimal management ofpatients on CVD disease registersand to promote the identificationand management of people at high risk of developing CVD. All 38 Islington practices took part in the scheme. Some of thekey achievements of the LIS aresummarised below:-

• Over 90.5% of Islington patientsaged 45 years and above havehad their blood pressure (BP)recorded in the previous 5 years(exceeding the national target of 80% and the previous year’sachievement of 89%)

• 2594 patients with a clinicalrecord of high blood pressure(>150/90mmHg) in the previousten years were recalled andreviewed in practice

• 212 patients were identified as having established CVD and added to relevant diseaseregisters, following a search of clinical records to identifypatients on particular CVD drugs

• A further 22 patients wereadded to disease registers as a result of CVD event audit

Update on recommendations from the Annual Public Health Report 2007

Progress on reducing early deaths from cardiovascular disease in Islington

The 2007 Annual Public Health Report highlighted the high rates of premature mortality from cardiovascular disease (CVD) in Islingtonand set out a number of recommendations for reducing rates ofearly CVD death in the borough.

• Records of 136 patients whodied prematurely from CVD were reviewed and key lessonsfor improving primary and/orsecondary prevention andpractice processes were identified.

A revised incentive scheme has been launched in 2009/10.Whilst retaining a strong focus on case finding and optimisingmanagement of key risk factors(BP and cholesterol), this year’sscheme also promotes the deliveryof NHS Health Checks. By 2012/13everyone aged 40-74 should beoffered a check on their vascularhealth once every five years. InIslington, NHS Health Checks willinitially be offered to people whoare at high risk of developing CVD.GPs will be inviting these patientsto attend a full assessment of theirvascular health (including diabetesand kidney disease), and offeringappropriate lifestyle advice anddrug therapy.

In 2008, NHS Islington ran a pilotproject delivering opportunisticcardiovascular health checks in 11 local pharmacies. 1500 peoplecompleted the initial “screening”questionnaire, and of those, 900went on to have a fuller checkincluding BP and blood glucosemeasurement. Taking on board the lessons from this pilot and therequirements of the NHS HealthChecks programme, Islingtonpharmacies will be commissionedto deliver NHS Health Checks fromAutumn 2009.

Influencing commissioningImproving access to and uptake of cardiac rehabilitation has been a key concern for commissioningsince publication of the 2007Annual Public Health Report.Cardiac rehabilitation is anintervention of established clinicaland cost-effectiveness, yet notevery patient suitable for cardiacrehabilitation in Islington benefitsfrom this intervention. A localenhanced service was launched inJune 2009 to encourage generalpractitioners to identify and refersuitable patients to local cardiacrehabilitation services, and ahome-based rehabilitation servicehas been commissioned fromClinicenta to increase capacity in phase III cardiac rehabilitationand to extend patient choice.

NHS Islington is also working with one of its main secondarycare providers, The WhittingtonHospital, to develop its role indisease prevention and smokingcessation in particular. A full-timestop smoking advisor is now basedat The Whittington Hospital, and a programme of work to embedreferral to cessation services insurgical, antenatal and other carepathways is being developed.

Improving healthinformationThe 2007 Annual Public HealthReport presented a preliminaryanalysis of programme budgetingdata for CVD. This analysisidentified Islington as an areaachieving poorer CVD outcomesfor lower per capita spend onCVD, when compared to otherLondon and spearhead PCTs. In July 2009, NHS Islingtonembarked on a significantProgramme Budgeting MarginalAnalysis project to take a moredetailed look at need, activity,expenditure and outcomes in CVD, benchmarked againstsimilar populations. The aim of this project is to make better use of resources within the CVDprogramme, to improve outcomesand reduce health inequalities.



Notes

ANNUAL REPORT 2008-09 5.

Annual Public Health Report produced by:

NHS Islington338-346 Goswell RoadLondon EC1V 7LQ

Tel: 020 7527 1000Web: www.islington.nhs.uk

NHS Islington is the operating name of Islington Primary Care Trust.Des

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