City of York Council (Logo)

Meeting:

Health, Housing and Adult Social Care Scrutiny Committee

Meeting date:

13 December 2023

Report of:

Philippa Press

Portfolio of:

Health, Wellbeing and Adult Social Care


Scrutiny Report: Oral Health (Including work in schools, and oral health promotion programmes)


Summary

Good Oral Health starts from the eruption of the first tooth and carries on throughout the life course. Tooth decay is the most common oral disease affecting children and young people and yet it is largely preventable.  Whilst children’s oral health has improved over the last 20 years, dental decay is the top cause of children’s hospital admissions for 5- to 9-year-olds and the most common reason for this age group to experience a general anaesthetic.

 

Significant inequalities exist in oral health with those living in more deprived communities, parents with lower levels of education, living in poverty and those with disabilities experiencing poorer oral health than their more affluent counterparts. Good oral health contributes to school readiness and prevention of school absence.

 

Although dentistry is one of the four pillars of Primary Care, there is no national registration system in dentistry as there is in general practice. People should be able to access any dental practice that holds an NHS contract without geographical or boundary restrictions, however the reality is far from this, with a severe shortage of NHS dentists and long waiting lists.

 

Policy Basis

Under the terms of the Health and Social Care Act (2012) upper tier and unitary authorities became responsible for improving the health, including the oral health, of their population since 2013. Local Authorities have a statutory responsibility.

 

From 1 October 2015 commissioning responsibility for the Healthy Child Programme for zero to five-year-olds transferred from NHS England to local government. This included the commissioning of health visitors, who lead and support delivery of preventive programmes for infants and children, including providing advice on oral health and on breastfeeding reducing the risk of tooth decay.

 

Local authorities are also required to provide or commission oral health surveys and have responsibility for oral health promotion and the prevention of dental decay. Dental decay is the largest non-communicable disease and it largely preventable by:

 

·        Cutting down on sugar consumed and how often you consume it

·        Brushing teeth twice a day – last thing at night and at one other time during the day

·        Choosing a fluoride toothpaste and increasing exposure to fluoride by not rinsing after brushing (Spit, don’t rinse).

·        By regularly visiting a dentist.

 

The City of York Council’s Council Plan (2023-2027) sets strong and ambitious plan to increase opportunities for everyone living in York to live healthy and fulfilling lives. One of the key priorities is Health and Wellbeing which aims to reduce inequalities and achieve better outcomes by targeting areas of deprivation.

 

Since April 2023 dental commissioning and policy is the responsibility of the NHS via the Integrated Care Board. A separate paper to be tabled at this meeting, from the ICB, will outline the dental commissioning and contracting arrangements locally.

 

Recommendation and Reasons

·        To note the report.

·        Work with the ICB and partners to increase the access to dental services where possible.

·        Support work to prevent dental decay and improve the oral health of our population.

 

 

 

Background

 

From April 2023 Integrated Care Boards (ICB’s) took over commissioning for primary, secondary and community dental services. In York the ICB along with Rachael Maskell (MP for York Central) held an initial meeting in August 2023 to discuss the challenges and listen to colleagues working within dental services in York. Acknowledging the limits and the restrictive nature of the national dental contract, which is unlikely to change in the next few years, the meeting discussed access to dentistry in York comprehensively, including recruitment and retention, data and working collaboratively. A further meeting is planned for January 2024.

 

Community Dental Services, in York this is commissioned from Harrogate and District NHS Foundation Trust, by the ICB and provides dental care for adults and children with more specialist needs, e.g. those with learning disabilities, medical conditions, housebound or experiencing homelessness.

 

Through their Public Health Teams, local authorities also have a statutory responsibility to provide or commission oral health improvement programmes to improve the health of the local population, to the extent that they consider appropriate in their areas.

 

     I.        Oral Health Promotion Service. A three-year service funding via public health, commissioned from Harrogate and District NHS Hospitals Trust this service aims to reduce inequalities in oral health by targeting health promotion programmes.

 

There are two main elements to this service:

·        Delivery of a supervised toothbrushing (STB) programme in targeted early years and primary schools settings. Those chosen to take part were based on data that included: number of funded 2-year-old places, those with high numbers of free school meals, and those in areas of known inequalities. In the first year (November 2022 to November 2023) 6 settings were chosen to take part plus the two special schools (Hob Moor Oaks and Applefields).

·        Workforce Development. Delivery of evidenced based oral health interventions that professionals and volunteers can use within their roles, including, Health and Social Care workers, to Health Child Service, school staff and early years staff.  This includes those settings not included in the targeted STB programme.

 

   II.        Best Start in life.  A universal offer to all children born in York at the 6-9 month visit by the Healthy Child Service. A toothbrushing kit is given which contains: a toothbrush, toothpaste, a doidy cup and oral health information. Doidy cups encourage drinking from cups rather than bottles. All Health Visitors are trained to offer appropriate oral health advice on toothbrushing, weaning, healthy foods and prevention of dental decay.

 

Promotion of breastfeeding is an important preventative intervention for oral health, to support this a breastfeeding coordinator for York has been appointed. Evidence based messages regarding the link between oral health and breastfeeding includes:

 

·        Exclusive breastfeeding is recommended by the World Health Organisation and UNICEF for the first 6 months of life, with complementary foods introduced from around 6 months of age alongside continued breastfeeding.

·        Evidence has shown that infants that are breastfed up to 12 months of age have a decreased risk of tooth decay.

·        There is extensive evidence which shows that breastfeeding promotes health, prevents disease, and provides long-lasting protective factors for both mother and baby; however, breastfeeding is no longer the cultural norm.

 

 III.        National Dental Epidemiology Programme for England. The National Epidemiology survey for 5-year-olds takes place every other year and it is a standardised survey which takes place across England. The results result in robust, comparable data for use by national and local government to inform oral health needs assessments and the prevalence of decayed, missing and filled teeth within the population.

 

Unfortunately for the past few years, despite going out to tender this work, the Public Health Team have been unable to find a suitable provider to undertake this work. This is not only an issue faced by York Public Health Team, but similar issues have been faced both nationally and regionally. This is being addressed locally via the regional Dental Public Health Consultants who have established a working group, and a wide variety of options are being considered including the commissioning of the survey on a wider, possibly regional, footprint.  It is hoped that a solution maybe found in time to take part in the 2026 survey.

 

 IV.        Healthy Schools. Schools must now teach about dental health and the benefits of good oral hygiene as part of the statutory Relationships, Sex and Health Education (RSHE) requirements. The York Healthy Schools Award Programme, which is being funded by City of York Council Public Health, provides schools with a framework based on evidence of good practice to support them to implement effective health and wellbeing provision, which includes the statutory RSHE requirements. Oral Health Promotion training is promoted to schools across the city via the Healthy Schools PSHE Network and termly newsletters.

 

  V.        Oral Health Advisory Group (OHAG). The main purpose of the Oral Health Advisory group is to enable City of York Council (CYC) and North Yorkshire Council (NYC) to fulfil their statutory duties with regards to oral health improvement and addressing oral health inequalities. The group meets quarterly and has a strong membership which includes NHSE, ICB, Local Dental Network and Local Dental Committee, Health watch and dental training providers.

The group supports and co-ordinates implementation of both national and local strategies and agreed work plans.

 

 VI.        Flexible Commissioning referral protocol. The Referral Protocol facilitates CYC Healthy Child Service and Children’s Social Care Services to refer 0-19s (up to 25 with SEND and Care Leavers) who are not under the care of a regular dentist AND are in need of dental care (criteria applies) to a dentist who is registered as a flexible commissioning practice for regular dental care. This includes all children and young people cared for by the Local Authority and care leavers.

 

Whilst this has proved a very useful the number of flexible commissioning practices in York is very low and the demand outstrips the supply. Therefore, only the most vulnerable or the most in need may be referred.

 

Regionally and nationally work to increase the number of flexible commissioning practices is on-going with the Yorkshire and Humber Deanery and NHS England developing a regional protocol to roll out across the region and a working group has been established.

 

VII.        Dental Prevention Steering Group. Established by the Humber and North Yorkshire Integrated Care System (HNY ICS) in September 2023 the groups’ purpose is to enhance existing oral health initiatives – particularly supervised toothbrushing schemes to reduce/prevent tooth decay in children and young people via a targeted approach, focusing on those experiencing the greatest health inequalities. The group will also test and evaluate the flexible commissioning arrangements across the HNY footprint.

 

Concern has been expressed that this duplicates the work commissioned by Public Health Teams, including CYC, and the work of the Oral Health Promotion Service and may even increase inequalities as this service will be able to offer ‘fluoride varnish’ treatment and access to dental services, which local authority commissioned services cannot.

 

Initially work is being targeted at East Yorkshire and Hull, with CYC and NYC unlikely to see any activity within the current financial year. Public Health specialists will work with the HNY ICS to ensure that duplication is minimised and that this offer enhances the Oral Health Promotion Service offer currently commissioned by local authorities.

 

Risks and Mitigations

Oral health promotion and prevention of dental decay is not substantially funded through the Public Health Grant but is funded via reserves. Reserves are at risk of being depleted due to the financial issues faced by local authorities.


Wards Impacted

All wards are affected by poor oral health, but the most deprived wards are disproportionally affected, and this increases health inequalities across the city.

 

Contact details.

 

For further information please contact the author of this Report.

 

 

 

 

 

Author

 

Name:

Philippa Press

Job Title:

Public Health Specialist

Service Area:

Public Health

Telephone:

01904 555756

Report approved:

Yes

Date:

27.11.2023


Annex A – Abbreviations and glossary of terms

 

Annex B – Feedback from colleagues and consumers of oral health promotion services commissioned through Public Health.

 

Annex C – Humber and North Yorkshire Integrated Care System

York Dentistry – Commissioning Overview

 

Other reports to note:

Filled to Capacity: NHS dentistry in York. March 2018, Healthwatch York

NHS Dentistry – a service in decay? July 2021, HealthWatch York