Dental Health Services and Benefits: Review – June 2015.

JUNE 2015

Review of Dental Health Services  and Benefits  

R.91/2015

Foreword

During 2014 the departments of Health and Social Services and Social Security worked together to commission two expert reviews of the Island's dental provision. The oral health of school children was surveyed by a specialist UK dental examiner and our spending on dental services and benefits was independently examined by a team of external experts. Both reports are presented here in full.

The research offered some good news. The dental disease experience of five-year-old children in Jersey is well below the average experienced in England and lower than the best performing region in England and the South East. But even so, this research shone a spotlight on some significant challenges.

The review of dental spending estimates a States spend in the region of £1 million a year, some of which is targeted towards low income families and pensioners and some of which is a universal provision for children or for people with special needs. But there are gaps in the data and information we collect, and these gaps hamper our attempts to assess how effective we are at meeting demand. In addition, it is not possible to offer reassurance that the current service model can adapt to and absorb the demands of our ageing population.

We have considered these challenges in the departmental report which acts as a preface to the independent studies. Here we set out the background to this research, the key findings and a programme of work that aims to create the foundations on which a coherent and sustainable service may be built. Our action plan begins with the collection of better data and improved governance; with these two foundation stones in place we can be confident that our budgets can be focused on areas of real need and deliver clinically appropriate services.

The review gathered views from a wide range of people. In the course of their discussions, and viewed through the eyes of independent observers, a series of simple and short-term actions have been identified. We have already started to make changes which have the potential to improve the services people experience. We have strengthened leadership and management structures in the dental department; identified ways to improve benefit schemes and ways to increase uptake among eligible people; and we have initiated a new way of collecting data - for the first time, Islanders have been be asked about their experience of dental disease in the Jersey Annual Social Survey. And there are more changes that can be made over the coming year. In particular we are seeking to invest more funding into dental benefits in the 65+ healthcare scheme for pensioners, but this will ultimately be determined by the content of the Medium Term Financial Plan.

The final part of our Action Plan points to the creation of a sustainable and coherent oral health strategy. We use sustainable' in that the strategy must be affordable as our population ages and the needs of islanders change and we use coherent' to mean it is joined up between departments and with other States strategies and priorities. The oral health strategy will be developed using the frameworks provided by our external experts and will be informed by our own data, as it builds. A fundamental requirement is that the strategy sits within the wider Sustainable Primary Care Strategy, adopting common principles and values and reporting into the Ministerial Oversight Group. Delivery against these actions will be launched in September 2015 with the establishment of a Dental Strategy Working Group, formed by officers across States departments.

Our ambition for improvement is high – however, we have to acknowledge that we will be undertaking service re-design during unusually challenging times as the States takes measures to address a significant budgetary deficit.

Finally, we would like to thank the community dentists, consultants and hospital staff who have shared their views, and various organisations, including the Jersey Consumer Council, Jersey Dental Fitness Scheme Board of Management and Jersey Dental Association, for their support with this review. We would also like to thank the Island's Primary schools which worked with us to benchmark children's dental health. Their opinions and the conclusions set out in these reports provide a valuable platform from which we can take the next steps in developing a service fit for our needs and for the future.

Deputy Susie Pinel  Senator Andrew Green MBE

Minister for Social Security  Minister for Health and Social Services

A report from the departments of Health and Social Services and Social Security

Progress and Action Plan: Delivering dental services within a sustainable oral health strategy

Introduction

In November 2013 the Minister for Health and Social Services and the Minister for Social Security gave a joint commitment to undertake a programme of work to review dental benefits and services. The four deliverables identified at that time were:

1. An epidemiological survey recording the dental health of children
2. A review of States spending on dental services and benefits
3. Completion of a business case to deliver dental education
4. An implementation plan to deliver enhanced dental services

This report provides a summary of the work that has been completed and presents an Action Plan for further tasks. The external reports completed in respect of tasks one and two are reproduced in full.

During 2014 a dental examiner (trained to BASCD standards) conducted a survey among 5-year old children. The dental examiner used the same methodology as that applied in the UK, allowing direct comparisons with the UK. Oral Health among the children examined was generally good, exceeding the averages noted in the UK.

A review of States spending was completed during 2014 using a team of independent experts (OCC'). The review took a strategic look at provision across the Island and the respective roles and spend of SSD and HSSD. It identified short term and longer term actions and identified some significant challenges.

As a result of the review, tasks three and four have been reconsidered. The original intention, to write a business case to develop dental education, has been revised and a new action is proposed to develop oral health education within public health messages. This is in line with OCC recommendations. In addition, the OCC review suggested there are some basic but essential pieces of housekeeping which must be completed before we embark on any whole scale change. Our implementation plan has changed focus to become an Action Plan which will develop the foundations on which a coherent and sustainable strategy can then be built.

Key Findings - Epidemiological survey

The epidemiological survey in March 2014, reported that the oral health of the children reviewed was generally good and comparable to regions in England with the highest levels of good oral health. As in previous years there was disparity in the level of dental health between schools. The review of dental services suggested that these data may not be relied on to target interventions at specific schools since the pattern of decay and distribution of poor dental health is not sustained as children grow older; at age 7 epidemiological data would prioritise a different set of Jersey schools from those identified at age 5.

Key findings – Dental services and benefits

The OCC review of spending on dental services and benefits proposed a number of recommendations, scalable from short term tactical actions up to challenges which impact system wide. The review identified three areas of concern which should be addressed as a priority to facilitate the development of oral health care across Jersey.

1. Management information: the review suggested that existing management information was insufficient to be able to fully determine the extent to which the States achieve value for money against an estimated £1 million per annum spend. A key recommendation is to improve our intelligence around demand, capacity, service delivery, quality and care outcomes.
2. Governance: the review identified gaps and inadequacies in governance across all services. The roles played by bodies, departments and stakeholders needed to be clarified and strengthened and it was not possible to easily demonstrate adherence to GDC requirements. Governance surrounding initial and ongoing eligibility for the dental schemes and for reimbursement of dental charges should be strengthened.
3. Strategy: The review identified a lack of strategic direction for oral health services and recommended that a cohesive strategy, involving all stakeholders is developed. Since the field work underpinning the review was undertaken, considerable progress has been made on developing a primary care strategy and an acute services strategy, both in line with the overarching strategy agreed by the States in 2012 (P.82/2012). The future of dental services must be considered in line with these other strategies.

Action Plan

The original intention was to use the external reviews to help to shape an implementation plan to deliver a new system. However the research has identified challenges in our current management information and governance which must be addressed before further development can take place.

Our commitment to deliver an implementation plan' has therefore been superseded by a commitment to develop and commence implementation of an Action Plan which will address the recommendations of the review. The plan contains six elements comprising four enablers (required to take the service forward) and two directionally correct initiatives, (which can be tackled in the short to medium term). The evaluation and learning from these will then influence the content of an Oral Health Strategy.

The elements of the Action Plan are:

Enabler: Strengthen Governance

The OCC review identified gaps in local governance arrangements and highlighted this as a pressing concern. As a result of their observations this Action Plan suggests that the service is offered strong leadership (by the Primary Care Governance Team or a Head of Profession). The aim would be to further the quality of care and monitor adherence with the requirements of the General Dental Council, contributing clinical expertise to the delivery of a sustainable strategy.

The Governance stream of work also calls for greater clarity in the roles and responsibilities of departments, bodies and other stakeholders, these will be agreed and clarified. A new Dentistry (Jersey) Law has recently been developed by HSSD to provide for the local registration of all types of professional involved in providing dental care. The implementation of this new law will be a useful step in the future development of an appropriate governance system.

Enabler: Workforce Development

Workforce development is key to delivering good governance, an efficient and value for money service and to develop a service which is sustainable. The review did not complete a workforce survey but anecdotal reports suggest a sizeable cohort of clinicians are due to reach retirement age within short succession of one another. There is an opportunity to ensure that the most appropriate practitioners are identified, via workforce strategy development, to enable Jersey to attract and develop the right mix of skills for a sustainable service. The Action Plan should also consider mechanisms to invest in the workforce so they may develop the skills to manage dental data and regulatory compliance.

Enabler: Develop a needs assessment

The OCC review recommended that a needs assessment be conducted, offering better intelligence on the demands placed on Jersey's oral health system. While the value of epidemiology surveys was questioned, the review identified opportunities to collect information by recording the oral health of children examined as part of the Community Dental Service school visits. Further opportunities may be found in the school survey conducted by Education among children in years 6, 8 and 10. The opportunity has already been taken to include questions in the 2015 Jersey Annual Social Survey to collect data on the experience of dental disease among adults.

Enabler: Develop management information

The review encountered difficulties in quantifying the service currently offered and identified gaps in management information, particularly in the Dental Department. As a priority the Action Plan should seek to identify opportunities to improve the functionality of the current IT systems as part of the HSSD IT strategy and to integrate this, possibly via future upgrades, to its Patient Management systems.

Initiatives: Public Health Education

In 2013, the Ministers for Health and Social Services and Social Security gave a commitment to develop a business case for dental education. Independent of this commitment the OCC review recommended the introduction of an education programme. The review stressed, however, that this programme should not be isolated and badged as Dental' or Oral Health' but that it be fully integrated into the Public Health agenda, arguing that common determinants of disease cut across issues such as obesity, diabetes, alcohol misuse. The education plan should also recognise a life course approach and initiate interventions and messages appropriate to specific life stage.

Initiatives: Improve existing delivery systems

The OCC review suggested the island will struggle to move forward with our provision of dental services and benefits without putting in place improved management information and

governance. However it is possible to identify some short and medium term activities which are directionally correct. These activities will be identified and championed by a working group and are likely to include a rationalisation of administration cost (creating savings which might be diverted to revise existing services), prioritisation of dental hospital services and changes to the process for identifying and supporting people wishing to receive benefit.

Some activities have already been completed. The Jersey Dental Fitness Board of Management has looked at how its scheme is advertised, and has financially supported direct mailing to eligible school children and attended open evenings where packs promoting the scheme were distributed directly to parents. Over a thousand information packs have been distributed to children and their parents during 2014. Social Security has also increased communications with pensioners. Each August a leaflet has been sent to pensioners informing them of the benefit schemes they may be entitled to. A second leaflet was sent in January, these communications are being redesigned and will become part of the regular programme of communications.

Social Security has also surveyed pensioners who are members of the 65+ healthcare scheme but have not made any claims for benefit. Contact was made with 20% of non-claimers and half of those interviewed said they had not made a claim because they'd forgotten they were entitled. This is being taken forward in discussion with the company who administer the scheme.

These actions are in line with the agreement in the 2013 debate "to undertake a publicity campaign to promote dental health services provided in Jersey." The other action agreed at that time was to examine "the potential for expanding the range of those eligible to partake in the Jersey Dental Fitness Scheme." The future development of that scheme will be considered, alongside the 65+ Healthcare scheme and other dental spend, as part of the Action Plan and in conjunction with the development of the primary care strategy.

Outcome: Development of a Sustainable and Coherent Oral Health Strategy

The OCC review recommends that Jersey develop an oral health strategy. In order for this to integrate with the strategic direction and development of other services, this strategy should be formed mindful of wider developments across the Island's healthcare. For example oral health should feature in the Public Health Strategy, acute dental care should be encompassed in the Acute Service Strategy and all other dental services within the Primary Care Strategy. In particular, the Acute Service Strategy has identified the requirements and clinical model for the complex dental services requiring hospital facilities and/or expertise. The Acute Service Strategy does not currently envisage making provision for any other dental services as, in line with the strategic principles agreed by the States, these should be located and managed within Primary Care.

It is proposed that an oral health service model is developed by a cross department/multi- discipline working group informed by a series of lower level tactical and information gathering projects. The group will work with the authors of the public health, acute services and primary care strategies and identify, prioritise, initiate and monitor projects that support an oral health service plan for the island.

Outcome: Future delivery system

The OCC review, drawing on models of dental care in other jurisdictions, suggested that our future delivery system consider contracting out services from the existing Community Dental Service and that these contracts are based on a reduction of treatment need, with payment through capitation schemes or insurance schemes. State funded support based on need will be an important principle, as will interventions to tackle the determinants of disease.

Next steps

All Departments are facing significant funding challenges at present and any new initiatives must be carefully prioritised against a range of competing demands. Whereas actions have been identified in this report, it has not been possible to allocate a clear timetable to their completion. Both departments will use their best endeavours to address these actions as resources allow, and to ensure that the ongoing development of other areas of health strategy fully reflect the need for the introduction of a sustainable and coherent oral health strategy.

10

The Oral Health of five–year-old school children in Jersey

A report on an epidemiological survey carried out in March 2014 to measure the prevalence and severity of decay in five-year-old school children.

Report commissioned by the States of Jersey Health and Social Services Department and Social Security Department

Fieldwork and Report written by: Kate Cullotty BDS FDS RCPS

CONTENTS  page 2 Executive Summary  page 3

1. Introduction page 4
2. Background page 4
3. Current survey page 4
4. Method page 5
5. Examination and data collection page 5
6. Results
   1. Participation in the survey  page 6
   2. Prevalence of decay experience  page 7
   3. Proportion of children with decay experience  page 8
   4. Untreated dentinal decay  page 9
   5. Missing and filled teeth  page 11
   6. General observations  page 12

8. Discussion

1. UK data  page 13
2. Jersey data  page 14
3. Implication of results  page 14
   4. Impact for Jersey  page 15

8. Conclusion page 16
9. References page 17 10 Data tables  page 18

EXECUTIVE SUMMARY

This report presents results from a dental epidemiological survey in Jersey, on dental disease prevalence in five year old school children, undertaken in March 2014. It was undertaken using the standard arrangements for dental epidemiology introduced in England in 2007. Since 2007/08 positive consent is required from parents and as this is a change in protocol and methodology, results of surveys carried out after 2008 cannot be compared directly with surveys prior to 2008 where negative consent was used. Positive consent has been used in England in the 2007- 2008 and 2011- 2012 five year old surveys.

Likewise the results for the Jersey survey in 2008, where negative consent was used, cannot be compared directly to this survey where used positive consent was used.

Twenty-nine schools and a total of 659 children took part. All state schools participated, and parental consent ranged from 100% to 39.2%. The overall consent rate for Jersey was 70.4%.

The standard measurement of decay/dental disease used for the BASCD surveys is visual decay at the dentinal level. This decay experience is measured by an index represented as dmft for primary teeth. This is a measure of the number of decayed (dt), missing (mt), and filled (ft) primary teeth as a result of dentinal decay

A low dmft is an indicator of low disease experience and conversely a high dmft indicates greater disease experience.

The survey carried out in 2008 reported a decay experience (mean dmft) of 0.76 comprising a dt component of 0.5, mt component of 0.17, and ft component of 0.09. The 2014 survey components are a mean dmft of 0.57, a dt of 0.37, a mt of 0.06, and a ft 0.14.

Whilst the dmft appears to have decreased and dental health may be improving, as this is the first survey using positive consent, real comparisons cannot be made at this time and ongoing surveys are recommended

Valuable data can be obtained by the use of standardised surveys, the limitation at this point is the impact of positive consent and the unknown prevalence of decay in the non response group. The dental decay experience of those surveyed in Jersey, is lower than the average for England and lower than the lowest region in England the South East (dmft 0.67).

174 of those surveyed in Jersey already have decay experience at five years old and work with families earlier for example, preschool, may be beneficial.

It is recommended that there is pro active work to improve response rates and further surveys are undertaken to enable comparisons. The use of other indicators such as ethnicity and measures of deprivation in future surveys are also recommended.

Dental Survey of Five year old schoolchildren, March 2014

1. Introduction

This report presents the summarised results of a commissioned dental epidemiological survey of the dental health of five year old schoolchildren in Jersey surveyed in March 2014.

2. Background

Jersey first undertook an epidemiological survey in 1987 and participated in a programme of surveys between 1998 and 2008. These surveys employed the British Association for the Study of Community Dentistry BASCD' methodology and allowed for direct comparison between Jersey and UK data. The States of Jersey wished to conduct a repeat of these surveys, focussing on children aged 5. The States of Jersey commissioned an independent, BASCD trained, freelance examiner to complete the fieldwork, analyse the data and to produce a report. The intention was that the resulting data should allow, where possible, comparisons between Jersey and other jurisdictions and comparisons across time with previous local surveys. As data from dental surveys can be used to plan and evaluate local services and plan programmes for dental health improvement, this survey will be used to inform policy development and will provide a benchmark of dental health.  

3. Current survey

In the UK nationally co-ordinated dental epidemiological surveys of specific age groups have been run since 1987 using standards set by BASCD for sampling, examination, disease recording and reporting. In England these surveys are now part of the dental public health programme within Public Health England (PHE).

This survey in Jersey was undertaken using the standard arrangements for dental epidemiology introduced in England in 2007. Prior to 2007/08 dental surveys were carried out using the principle of negative consent i.e. parents were informed about the planned survey but had to proactively opt out. Directions from the Department of Health for England (2007) required that the method of consent should change. Since 2007/08 positive consent is required from parents and this change in protocol and methodology means the results of surveys carried out after 2008 cannot be compared with previous surveys where negative consent was used.

The survey carried out in Jersey in March 2014 therefore needs to be viewed as a baseline survey for Jersey. The methodology used is the same as that used for the survey of five year old children in England in 2007/2008 and 2011/12 and therefore comparisons can be made with England. As part of the National Dental Epidemiology programme the next survey of five year old school children is due to take place in England in the academic year 2014/15.

4. Method

All State and private schools were approached to participate as well as Mont a L'Abbe special school; this is a variation from the surveys in England where only children attending mainstream schools were sampled.

A letter was sent to the head teacher of each school explaining the purpose of the survey and requesting the schools involvement. Participating schools were contacted and a date for the survey agreed. Class lists were obtained with dates of birth to determine which children would be five on that day.

 All children who were five on the day of examination could be included in the survey and a letter was sent via schools to the parents of these children asking for written, positive consent for their children to take part. No child was examined if positive written consent had not been obtained.

5. Examination and data collection

The examination process and diagnostic criteria used were those defined by BASCD (Pine et al 1997; Pitts et al 1997). This involves a visual examination using a plain mouth mirror and a standard light source, (Daray lamp). Dental recording is only of the primary dentition. Teeth are examined for decay (dt) at the dentine level, missing teeth (mt) and filled teeth (ft). Children were also examined for the presence or absence of dental plaque and dental sepsis (visual dental abscess). It is acknowledged in literature that this level of examination is an under estimate of the true level of disease as it is a visual examination only and the decay has to involve dentine, i.e. to have breached the hard outer surface of the tooth, the enamel. It is however a standardised, calibrated, method of recording to allow comparison.

All examinations were carried out by a BASCD trained examiner who is also a regional trainer. This was a different examiner to that used in the surveys in Jersey up to 2008.

The examiner used had also been involved in the fieldwork for the decennial Child Dental Health survey from November 2013 to January 2014. The data recording in the dicennial survey involves similar coding, but also involves decay detection at the enamel level. As part of the fieldwork the examiner also noted enamel decay. As this is not part of the standard BASCD reporting the results presented do not reflect this coding but the clinical findings of the examiner are used in the discussion/recommendations.

Data was recorded at the schools on to paper by trained recorders and the data was later entered into the Dental Survey Plus 2 computer programme specifically designed for survey analysis.

6. Results

6.1. Participation in the survey

All State and private schools were invited to participate in the survey. One private school declined and another has been excluded from the analysis due to a misunderstanding of the sample required and a resulting inability to revisit the school in the time scales available for fieldwork.

All state schools participated, and there was a range of consent from parents from 100% to 39.2% across all schools, State and private. The overall consent rate for Jersey was 70.4%

A total of 29 schools were visited, although the data from St Georges, (a private school), has been excluded due to a misunderstanding of the survey requirements.

A total, therefore, of 659 children were examined which represents 68% of the five year children sampled. Twenty children whose parents had consented were absent on the day of the survey (3%) and although no consent was received from 285 parents (29.6%), only two parents actually refused permission for their child's participation. Only one child refused to participate on the day (table 1, section 10).

The percentage of eligible children examined, at 68%, compares favourably with the percentage of 65.2% children examined in the 2011/12 survey in England and 66.8% in the 2007-08 survey.

The number and percentage of consent response rates for each school is shown in figure 1 below. The data for this table is represented in table 1, section 10, at the end of this report.

Figure 1

positive consent by school

100 90 80 70 60 50 40 30 20 10 0

Positive consent %

FCJ JCG

Trinity

SpringfieBldeaulieSuamDe ereLsa Salle St Saviour Grand Vaux Les Landes D'AuvergnJaenvarin First TowerSt Lawrence Mont NecoSt Cllleements Plat Douet

Bel Royal St Johns St LukeLsa MoGryeouville Helvetia St Martins St PeteSrst Marys

Rouge Bouillon Mont a L'Abbe

school

It is worth noting that at the school with the lowest response rate, Springfield, (39.2%) a standard school screening was also being carried out on the same day. There was a higher response rate for this screening and it may be that parents were unaware of the difference in the two processes and didn't understand the need to complete two consent forms. Another point to note is that at Rouge Bouillon there was one class where no consent forms were returned.

2. Prevalence of decay experience in five year old school children (dmft)

The standard measurement of decay/dental disease for the BASCD surveys is visual decay at the dentinal level. This decay experience is measured by an index represented as dmft for primary teeth. This is a measure of the number of decayed (dt), missing (mt), and filled (ft) primary teeth as a result of dentinal decay.

26.3% of five year old children in Jersey whose parents gave consent, had experienced dental dentinal decay, evidenced by untreated decay, extracted/missing teeth, or fillings due to decay (dmft). The comparison percentage for England in 2012 was 27.9%.

The mean dmft for Jersey of 0.57 compares favourably to England at 0.94 and that of the region with the lowest level in England the South East whose dmft was 0.67. Data again is from the 2011/12 five year old survey in England.

Figure 2 shows the individual Jersey schools ranked by mean dmft, the data for this chart is in the data tables in section 10.

mean dmft by school

1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0

dmft

John JCG FCJ lukes St Helvetia Trinity Janvarin La moye Jersey Sameres St

Mont L'Abbe St Lawrence St PeStet clemrs ents De La Salle D'Auvergne Bel RoyaBleeaLuelies Lu andeGrsouville Mont Necole grand Vaux SpringFfieirlst d TowSet rMartinSst maSryst Saviour

Plat Douet

Rouge boullion

school

A low dmft indicates low disease experience or good dental health. The higher the dmft the greater the disease experience in the surveyed population. The mean dmft ranges from 0 at Mont L'Abbe to 1.63 at St Lukes across the total population of five year olds surveyed in each school.

3. Proportion of children with decay experience

The mean dmft for Jersey is 0.57 which is calculated across all the children surveyed. The majority of children however have no decay experience and to examine the data more closely the number and proportion of children with dmft>0 is used.

Across all Jersey schools 174 children were identified as having decay experience (dmft >0,) this represents 26.3% of those surveyed, with a mean dmft for this group of 2.15.

Figure 3 demonstrates the proportion of children with dmft >0 by school and also shows the mean dmft for these children.

The proportion of those surveyed with decay experience (dmft > 0), ranges from 0% at Mont a L'Abbe to 50% at Grand Vaux and St Saviour.

% of children in each school with dmft >0 ranked by %

60 50 40 30 20 10 0

number %

av dmft

FCJ JCG

Trinity

HelvetiaSt John JanvarinLa moSyet Peters St marys St lukeBseaulieGruouvilSleameres

Mont L'ASbbperingSft ieLladwrence Mont Necole Bel RoyaDe leLa Salle St clemD'enAtsuvergne Plat DouFirest tToLwes Ler andSet sMartins grand VaSut xSaviour

Rouge boullion

school

The data tables in section 10, table 3, shows the values of the mean dmft for each school which ranges from 1 tooth in St Johns to 9 teeth at Springfield. This table also indicates the number of children in each school making up the mean school dmft. It has to be recognised that a small number of children make up these averages, 3 children in St Johns and 1 child at Springfield and caution should be used in extrapolating this data.

4. Untreated dentinal decay

The mean dt component is dental decay that is untreated at the time of the survey. As with mean dmft, to identify the numbers contributing to this component the proportion and number of those with d>0 is used. Across the five year old children surveyed in Jersey as a whole this represents 126 children with a Jersey mean of 1.94 teeth having untreated dentinal decay.

Figure 4 demonstrates the number and percentage of children with d>0. Within the figure the data is ranked by the mean decayed teeth, (dt), of these children. This ranges from 0 teeth at Mont a L'Abbe and Springfield to 5.67 teeth at St Marys.

ranked mean d of children with d>0 by school

40 35 30 25 20 15 10 5 0

number %

av d

JCG FCJ lukes

St John Trinity t

Helvetia St Peters BeaulieGru ouvillSeameres Janvarin La moye S St marys Mont L'AbSbperingfield grand Vaux St clemD'enAtsuvergne Les LanDe deLsa SaSllt eMartins St Lawrence Mont NecoPlleat DouBeel Royat Firlest TowSet rSaviour

Rouge boullion

school

Figure 5 uses the same data, (table 4, section 10), as figure 4 but demonstrates the number of children with d >0 and the % this is of those surveyed by school, ranked by %.

Figure 5 (table 4, section 10)

ranked % d>0 by school

40 35 30 25 20 15

number %

10 5 0

John FCJ JCG lukes Vaux

Mont L'AbbeSt HelSvt etiLaawrence Mont Necole JanvariLan moye St marys St PeterBseaulSieut MarFtiinsrst Towergrand St SaviouSrameres Grouville

Trinity t

S

Springfield De La SLealsle Landes Plat DoueBelt Royale D'AuvergneSt clements

Rouge boullion

school

The proportion of children with d>0 for Jersey is 19.06. There is variation in the proportion of children with untreated decay across the schools and ranges from 0% at Springfield and Mont L'Abbe to 37.84% at Grouville .

5. Missing and filled teeth

Analysis of the other components of the dmft index of the174 five year children surveyed who had a mean dmft >0 is shown in figure 6. It can be seen that nearly three fifths of these children (59%) had untreated decay only. Over one fifth (23%) had evidence of fillings and no decay which would indicate these children have accessed dental services. Seven children (4%) had evidence of missing teeth and no active decay or fillings.

The proportion for missing teeth in the 2012 survey in England was 3.1% although this varied across local authorities and regions.

It cannot be stated that those children with untreated decay are not attending dental services as there are different treatment views for deciduous decay with not all cavities in deciduous teeth being restored.

Figure 6

number of children

200 180 160 140

120 100 80 60 40 20 0

number

dmft>0 decay only missing teeth only filled teeth only decay and missing decay and filled missing and filled

6. General observations

A further observation made, the data for which is not analysed and presented in BASCD data, was the number of stainless steel crowns that had been placed. A total of 18 children had stainless steel crowns placed on 28 teeth. A stainless steel crown is not only placed as a result of the decay process it may for example, be placed to protect a structurally weakened tooth (hypoplastic) tooth. As a result these crowns are not currently part of the dmft index. Their presence demonstrates dental care but no judgement can be made on whether a decay process was involved.

Oral cleanliness and dental sepsis were examined and the general finding was that the oral cleanliness was very good with only 3% having visible plaque on the index teeth.

There were only 3 children (0.45%) who had evidence of dental sepsis,(visible dental abscess) at the time of the survey. Whilst any child with dental sepsis is not positive this figure is lower than the 1.7% level in England overall; with the lowest level in England being 1% in the South East.

In addition 17 children were identified with enamel caries, a National Child Dental Health survey measure not BASCD measure. This is not a standardised measure for BASCD surveys and is a small number spread across 16 schools. This cannot currently be compared to levels in England therefore no significant analysis can be made.

7 Discussion

1. UK data

The methodology used for these surveys has changed since 2008 and comparisons cannot be made with previous surveys. Within the National Epidemiology programme for England's report on prevalence and severity of dental decay in 2012, it is stated that:

 this change (positive consent) has introduced an unquantifiable response bias and means that direct comparison should not be made between this survey and the surveys conducted between 1992 and 2006 (in England)'.

The report also comments however on general trends over time that is there has been a slight drop in decay severity and prevalence from 1991 – 2006, but a much greater drop in 2007-08 and a further drop in 2011-2012. This change has been across all regions in England with the exception of London. The National picture is shown in the copy of

the figure below, taken from the same report.

The observation that decay levels have apparently reduced significantly between 2006 and 2008 cannot be stated as an actual change in disease levels due the changed methodology.

2. Jersey data

Looking at results for Jersey the last survey in 2008 used negative consent and this current 2014 survey has used positive consent. The survey carried out in 2008 reported results for mean dmft of 0.76 comprising a dt component of 0.5, a mt component of 0.17, and a ft component of 0.09. The 2014 survey components are mean dmft 0.57, dt 0.37, mt 0.06, and ft 0.14

Figure 7 demonstrates the difference with 2008 and the 2014 results, (new methodology).

Figure 7

Jersey dmft 2008 and 2014

0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

dmft dt mt ft

2008 (negative consent) 2014 (positive consent)

In 2008 the percentage of children with decay experience (dmft > 0), was 24% and the percentage of untreated decay (dt >0) was 19% compared to a dmft > 0 of 26% and a dt>0 of 19% in 2014.

Whilst the dmft appears to have decreased and dental health may be improving, (potentially due to measures such as increased levels of fluoride in toothpaste since 2007 as recommended by Delivering better Oral health, an evidence based toolkit for prevention), as this is the first survey using positive consent real comparisons cannot be made at this time and ongoing surveys are recommended.

3. Implications of results

Davies et al, key personnel involved in dental epidemiology at Public Health England recently published a paper in the Community Dental Health journal (March 14, vol 31 p21-26) titled; Investigation of bias to non return of consent for dental epidemiological survey of caries among five-year olds. The aim being to try and establish the effect of non return of parental consent, including the role of deprivation.

Some key findings of this paper were;

• It was recognised that there is a lack of information on non responders, although they did have the home postcode information hence could use this to investigate potential influence of deprivation, they found there was an association between deprivation and consent return and deprivation and caries severity but was not able to show a link between disease levels and consent returns.
• There was recognition of the scientific causes of decay and that lifestyle factors cause decay to progress, not deprivation itself.
• The reduction in decay was greatest where consent returns were lowest but this was only a part effect so other factors must also be involved.

The study concluded that the relationship between consent and disease levels is complex and the magnitude is unknown which is why comparison cannot be made with previous surveys.

7.4. Impact for Jersey

The same principles could be applied to the 2014 survey in Jersey. There was a 29.6% non response rate and the dental health of this group is therefore unknown and may change the overall disease prevalence picture for the island. Consequently it would be useful to know more about non responders.

Davies et al proposed reasons for non return of consent forms such as;

• Difficulty in understanding the form or reduced literacy skills
• Lack of motivation/interest or organisation
• Possibility that parents know their children have poor oral health and might have wanted to conceal the fact

These could be applicable in Jersey and measures to improve consent response rate should be considered in the planning stages of any further surveys. The influence of school staff and culture is also important and was demonstrated particularly in one school in Jersey where the dental department have already been working with the school. At this school, there was obvious pride and commitment that they had managed

to get 100% of consent forms returned. Other good proactive examples were notice boards in the school entrance informing parents that the survey was taken place that day and it would appear there is a good relationship basis already which could be potentially developed to target/work with non responders.

Ethnicity was not recorded for this survey which may wish to be considered in the future. The 2001 census for Jersey reported 46% of respondents considered their ethnicity to be Jersey, 33% British, 8% Portuguese or Madeiran, 3% Polish. It may be that different methods are needed to target different populations. However as stated already knowledge is needed about the non responders before targeted action can be taken.

8. Conclusion

Valuable data can be obtained by the use of standardised surveys, the limitation at this point is the impact of positive consent and the unknown prevalence of decay in the non response group. The dental disease experience of those surveyed in Jersey, is lower than the average for England and lower than the lowest region in England the South East (dmft 0.67).

174 of those surveyed in Jersey have decay experience at age five and work with families earlier, for example preschool, may be beneficial. In England 3 year old children were surveyed under BASCD standards in 2012/13 but the prevalence data is not yet available for comparison or service planning.

It is recommended that there is pro active work to improve response rates and further surveys are undertaken to enable comparisons. The use of other indicators such as ethnicity and measures of deprivation are also recommended.

9. References

Davies, G.M, et al Investigation of Bias related non-return of consent for a dental epidemiological survey among five- year-olds, Community Dental Health (2014) 31, 21- 26

Department of Health (2007: Dental screening (Inspection) in schools and Consent for Undertaking Screening and Epidemiological Surveys. Gateway Reference 7698.

Department of Health and the British Association for the Study of Community Dentistry (2007) Delivering Better Oral Health: An evidence based toolkit

National Dental Epidemiology Programme for England: oral health survey of five year old children 2012, A report of the prevalence and severity of dental decay Public Health England September 2013.

Pitts, N.B, Evans DJ and Pine, CM (1997) British Association for the Study of Community Dentistry (BASCD) diagnostic criteria for caries prevalence surveys, Community Dental Health

10: DataTables

Table 1:  Consent response rates

Consent

Number

of 5yr School  olds Springfield  28 Beaulieu  28 Sameres  41 De La Salle  51 Rouge

Bouillon  43 St Saviour  32 FCJ  47 Trinity  28 Bel Royal  28 Grand Vaux  26 St Johns  27 Les Landes  24 St Lukes  24 La Moye  49 Grouville  54 D'Auvergne  40 Janvarin  44 JCG  61 Helvetia  19 First Tower  56 St Martins  29 St Lawrence  30 St Peters  30 St Marys  19 Mont

Necolle  33 St Clements  29 Mont a

L'Abbe  2 Plat Douet  42

Jersey  964

Positive consent  %

11  39.2 13  46.4 20  48.7 25  49

24  56 19  59.4 29  59.6 17  60.7 17  60.7 16  61.5 18  66.7 16  66.7 16  66.7 36  73.4 40  74 30  75 33  75 46  75.4 15  79 47  83.9 25  86.2 25  86.3 26  86.7 17  89.5

30  91 28  96.5

2  100 42  100

679  70.4

Number  Number  Refusal  Refusal Seen  %  absent  (Parent)  (child)

11  39.2  0  0  0 13  46.4  0  0  0 19  46.3  1  0  0 25  49  0  0  0

22  51  2  0  0 18  56.25  0  0  0 27  57.4  1  0  0 16  57.1  1  0  0 17  60.7  0  0  0 16  61.5  0  0  0 17  52.9  1  0  0 16  66.7  0  0  0 15  62.5  1  0  0 35  71.4  1  0  0 37  68.5  3  0  0 330  75  0  0  0 33  75  0  0  0 46  75.4  0  0  0 13  68  1  1  1 45  80.4  2  0  0 24  32.7  1  0  0 25  83.3  0  0  0 26  86.7  0  0  0 16  66.7  0  0  0

27  82  3  0  0 28  96.5  0  1  0

2  100  0  0  0 40  95  2  0  0

659  68  20  2  1

Table 2:  Dental disease experience (dmft) by school

School

Mont a L'Abbe St Johns

St Lawrence Helvetia

Trinity

JCG

FCJ

St Peters

St Clements Rouge Bouillon De La Salle Janvarin D'Auvergne

La Moye

Bel Royal Beaulieu

Les Landes Grouville

Mont Necolle Plat Douet Grand Vaux Sameres Springfield First Tower

St Martins

St Marys

St Saviours

St Lukes

Jersey

Mean dt  Mean mt 0  0 0.06  0 0.16  0.04 0.08  0 0.25  0 0.28  0 0.14  0 0.27  0

0.3  0

0.25  0

2. 0
3. 0.13

0.27  0

0.34  0

0.47  0

0.31  0.08

0.19  0.38

0.54  0

0.33  0

0.45  0

0.38  0

0.53  0 0  0.82

0.7  0

0.42  0.21 1  0

1.11  0

0.38  0.75

0.37  0.06

Mean ft  Mean dmft 0  0

0.12  0.18 0  0.2

0.15  0.23 0  0.25 0  0.28

0.14  0.29

0.04  0.31

0.07  0.37

0.13  0.38

0.2  0.4 0  0.43

0.17  0.43

0.11  0.46

0.06  0.53

0.15  0.54 0  0.56

0.03  0.57

0.26  0.59

0.15  0.6

0.38  0.75

0.26  0.79 0  0.82

0.22  0.91

0.42  1.04

0.12  1.12

0.28  1.39

0.5  1.63

0.14  0.57

Table 3 : Number and proportion of children with dmft >0 by school

dmft>0

Number of

School  children  %  mean dmft Mont a L'Abbe  0  0  0 Springfield  1  9.09  9 St Lawrence  3  12  1.67 FCJ  4  14.29  2 JCG  7  15.22  1.86 Helvetia  2  15.38  1.5 St Johns  3  17.65  1 Mont Necolle  5  18.52  3.2 Trinity  3  18.75  1.33 Janvarin  6  20  2.17 La Moye  7  20  2.29 St Peters  6  23.08  1.33 Bel Royal  4  23.53  2.25 De La Salle  6  24  1.67 Rouge Bouillon  6  25  1.5 St Clements  7  26  1.43 D'Auvergne  8  26.67  1.63 St Marys  5  29.41  3.8 Plat Douet  12  30  2 First Tower  14  30.43  3 Les Landes  5  31.25  1.8 St Martins  8  33.33  3.13 St Lukes  6  37.5  4.33 Beaulieu  5  38.46  1.4 Grouville  15  40.54  1.4 Sameres  9  47.37  1.67 Grand Vaux  8  50  1.5 St Saviour  9  50  2.78

Jersey  174  26.32  2.15

Table 4: Number and proportion of children with dt>0 by school

  d>0

School  number Mont a L'Abbe  0 Springfield  0 Helvetia  1 St Johns  1 St Peters  6 Grand Vaux  5 Trinity  3 St Clements  6 D'Auvergne  6 Beaulieu  3 Grouville  14 Sameres  7 Les Landes  2 De La Salle  3 St Martins  6 Janvarin  5 JCG  7 St Lawrence  2 FCJ  2 La Moye  6 Rouge Bouillon  3 St Lukes  3 Mont Necolle  4 Plat Douet  7 Bel Royal  3 First Tower  12 St Saviour  6 St Marys  3

Jersey  126

% mean d 0  0 0  0

7.69  1

5.88  1

23.08  1.17

31.25  1.2

18.75  1.33

22.2  1.33 20  1.33

23.08  1.33

37.84  1.43

36.84  1.43

12.5  1.5 12  1.67 25  1.67

16.67  1.8

15.22  1.86 8  2

7.14  2

17.14  2

12.5  2

18.75  2

14.81  2.25

17.5  2.57

17.65  2.67

26.09  2.67

33.33  3.33

17.65  5.67

19.06  1.94

Acknowledgements

It would not have been possible to carry out this survey without the help and support of all the participating schools and I would like to thank them all, the staff and the pupils for their help and contribution in making the fieldwork run smoothly and making the school visits enjoyable. I also wish to thank the States of Jersey, Health and Social Services Department, Social Security Department and Mr Mike Cassidy, Consultant in Restorative Dentistry and Head of Community Dental services for allowing me to undertake this survey. I especially would like to thank the Dental department for welcoming me and looking after me so well. The nursing support was excellent and ensured smooth school visits and the administrative organisation by Catherina Marcroft and Caroline Carpenter enabled an effective timetable of school visits.

Review of States spending on Dental Health and Benefits and the services provided

ORAL CARE CONSULTING SEPTEMBER 2014

CONTENTS

Acknowledgements  4 Executive Summary  5 Introduction  10 The oral health status and dental care delivery arrangements of the States of Jersey  11

Overview  11 The oral health status of the population of the States of Jersey  11 Surveys of 5 year olds   11

Oral Health Survey of over 65s   15 The dental care delivery arrangements within the States of Jersey  16

The Department of Health and Social Care funded and managed dental services   17 The Hospital Dental Department  17

Community Dental Service  19 Hospital Consultant-led Orthodontic Service  20

Hospital Consultant-led Oral Surgery service  21 The Department of Social Security funded dental schemes  22

The Jersey Dental Fitness Scheme  22 The Jersey Special Payments under Income Support Scheme (ISSP)  23

The 65+ Healthcare Scheme  24 Summary of the delivery arrangements   24

The financing of State funded dental care within the States of Jersey  25 Governance arrangements of State funded dental care within the States of Jersey   29 Overall comments on the delivery, finance and governance arrangements  30

Our analysis of the existing arrangements  31 Overview  31

A framework for evaluating the dental care system's performance  31 The Governance Process  34

The public's views on the current Primary Dental Care delivery arrangements  36 Issues arising from the analyses  37 Overview  37 Defining a well functioning health care system   38 Developing a patient centred healthcare system   38

Health promotion  39 Summary  39

The principles underpinning the development of state funded dental care arrangements  40 Overview  40

General Comments  42 Management Arrangements  44 Strengthening governance arrangements  45 System sustainability  46 Options  46

Option 1: The status quo (+)  46 Option 2: A merged state priority system  47

Option 3: An external (outsource) arrangement   47 Options for policy implementation of dental care arrangements   49 Short Term Development Options  49

Long Term Development Options  50 Benefits and Risks of the above approaches  52

References  53

Acknowledgements

We would like to acknowledge the enormous support and help from all those individuals who gave of their time in this project. In particular throughout this work, Samantha Woods organised meetings and the timetable for the visits as well as providing information when requested. It would not have possible to complete this work without her assistance.

We would also like to acknowledge the level of engagement and time that the dental profession, in particular Dr Kiran Kumar Chair of the Jersey Dental association, took to work with us during our visits and Kiera Milner. They were without exception positive in their views and gave freely of their time. Within the Dental Department we would especially like to thank: Michael Cassidy, Manger of Community Dental Services and Consultant in Restorative Dentistry; Michael Belligoi, Consultant Oral Surgeon; Bruce Skinner, Consultant Orthodontist; Jayaraman Chandrasekhar, Associate Specialist; Victor Fagence, Dental Officer; Justine Kuijpers, Dental Officer and Sarah Pollard, Dental Officer.

In addition, numerous dental staff also gave of them time and included: Caroline Carpenter, Dental Nursing  and  Administration  Manager;  Judith  Gindell,  Division  Lead/Head  of  Nursing;  Catherina Marcroft,  Dental  Nursing  and  Administration  Manager;  Sarah  Boyes-Varley,  Sister;  Natalia  Miller,

Orthodontic Nurse; Anne Robertson, pre-admission nurse; Kerrie Le Cron, Dental Nurse, and Kathy Berry, Dental Nurse.

The existing management team and staff involved in the hospital sector and dental team also fully engaged with us and provided excellent advice. From the hospital team we would like to acknowledge the help of: Helen O'Shea, Hospital Director; Michelle West, Director of Operations; Jackie Tardival, Divisional Lead /Head of Nursing Ambulatory Care and Chris Sanderson, Deputy Director of Operations.

Within the Health promotion team we would like to acknowledge the work of Andrew Heaven, Director of Commissioning Health Promotion.

We are also grateful for the time with the Jersey Consumer Council, in particular Anne King, who provided us with the opportunity to discuss the findings of their work with respect to the health care sector.

Additional members besides Sam Woods who gave of their time from the Division of Social Security included: Francis Du H Le Gresley, Minister for Social Security; Sue Duhamel, Policy and Strategy Director and Will Lakeman, Policy Principal. All were open with us in our discussions.

Finally,  we  would  like  to  thank  Clare  Fitton,  Primary  Care  Manager  based  in  the  Primary  Care Governance  Team  for  her  insight  into  the  work  of  the  team  and  its  progress  to  date.

EXECUTIVE SUMMARY

Oral Care Consulting (OCC) was awarded a contract to undertake a review of the States of Jersey spending on dental health and benefits and the services provided. The agreed proposal had as its aims:

• To work with the States of Jersey to collate the available data on the status of publically funded non specialist oral health care provision.
• To  review  this  information  and  make  reference  to  recognised  good  practice,  nationally  and internationally, as applicable.
• To  make  recommendations  on  how  services  can  be  improved  within  existing  budgets  and prioritise these recommendations.
• To provide a framework for the management of recommended systems to allow performance to be assessed against good practice.

To achieve the above, the agreed framework for the work was to provide the following:

• A series of options for the development of non specialised, state funded dental care arrangements based on data made available to the consultants and discussions with stakeholders.
• For the options provided, an analysis of associated risk and prioritisation based on discussions with the Health and Social Services Department and the Social Security Department.
• The options will be based on a framework that would allow comparisons between differing care arrangements and the prioritised options for Jersey and other comparable systems.
• The options will be based on the key themes of finance, delivery and governance, highlighting key findings and recommendations.
• A presentation of results to a senior management audience.

OCC was provided with previous reports and data. It also undertook a number of visits to establish details of the existing arrangements and the issues as seen by the various parties.

There  are  a  range  of  State  sponsored  schemes  in  operation  that  provide  care  through  differing arrangements  to  differing  sub-groups  of  the  population.  Each  of  the  schemes  has  administration arrangements in which either clinical or non-clinical assessments are made to determine the entitlements and interventions that determine the States contribution to the identified care. The degree and complexity of administrative arrangements (and costs) varies considerably between schemes. There is also a blurring of the roles of the two Departments, Health and Social Services (HSSD) and Social Security (SSD) in determining patient entitlements.

Overall, data availability is poor, that which are available is of limited value in helping inform the development of services. Addressing this shortfall would make a major contribution to identifying the appropriateness of any options for service development and is central to any future work. Governance arrangements are weak in all aspects of the current system. Addressing this aspect will strengthen the basis for and the qualities of existing and any future delivery arrangements. Furthermore, although it is not  covered  by  our  present  remit,  possible  developments  in  governance  arrangements  may  provide considerable benefits for the health system as a whole. Given the current work around primary health care

we recommend that the suggestions for improving dental governance are raised with the Sustainable Primary Healthcare working group.

To help examine the impact of these issues, this report is divided into five further sections. These are: an overview of the current States' sponsored primary dental care schemes (some of which are delivered in secondary settings); an analysis of the existing arrangements; issues arising from the analyses; principles underpinning service development, and; options for service development

We would suggest the major challenges are:

• The roles of the two Departments. We would argue that the role of the Department of Social Security should be limited to identifying individuals who are entitled to access the benefits of whatever dental schemes the States of Jersey decide to develop. All other roles within the dental care delivery system should be the responsibility of the Department of Health and Social Services, in particular clinical decision making. The arrangements will need to acknowledge the findings of the Sustainable Primary Healthcare Review and the proposed developments,

• The governance arrangements in all aspects of the current delivery system. We would wish to see a strengthening  of  the  management  and  information  systems  within  the  sector  as  a  whole.  The information requirements would include patient management details and provide the opportunity to assess the qualities of care. The work would also include working with the relevant regulatory bodies to ensure that public and patients can have improved confidence in the system, and

• The development of a structure, or introduction of a head of profession, to facilitate a sustainable arrangement that provides continuity of clinical service delivery by the State at an appropriate level into the future. This includes training and development programmes, in both clinical and non-clinical fields, to help contribute to the culture and expertise necessary to ensure services develop in line with the evolving needs of the population.

We have explored three models, although all are predicated on addressing the shortcomings highlighted above. These options are:

Maintaining the status quo

This  would  see  a  continuation  of  the  variety  of  schemes  that  treat  differing  sub  groups  of  the population.  Improved  governance  and  management  could  lead  to  increased  efficiencies  and effectiveness  and  provide  clinical  gains.  However,  this  would  still  be a  relatively  inefficient  and

incoherent arrangement. It is likely that continual tension between the various schemes would arise from priority setting. The fragmentation is likely to impact on the confidence that the public has with the dental system;

Merging State provision into a single prioritised system.

This would see the bringing together of existing schemes under a single umbrella. The major advantage of this arrangement is the relative reduction in administration arrangements and the ability of the service to develop as the changing needs and social circumstances of the population evolve. We would wish to see closer working relations with the other health sectors that have a bearing on health especially the health promotion team to ensure a chronic disease management programme that is public and patient centred.

• An external (outsource) arrangement

In this model, the majority of the current arrangements are contracted out to independent contractors, for example as currently happens with the Jersey Dental Fitness Scheme. This option raises contractual issues, including service definition and delivery, governance and so on, the complexities of which should not be underestimated. All aspects of the system could be outsourced to varying degrees and may help address some of the sustainability issues raised.

In terms of priorities, we recommend that in the short term:

Short term development options

1. The Departments of Health and Social Services and Social Security establish a working party to agree arrangements for dental entitlements funded by the States of Jersey in which the former is responsible for all aspects of care treatment provision and the latter, for establishing which individuals are entitled to the defined benefits.
2. The Department of Health and Social Services seek to engage with the dental profession on developing standards of care through their involvement in the Primary Care Governance Team. The development of more transparent arrangements surrounding costs of care and the use of patient satisfaction measures would be key. In addition, we would recommend that the States utilises the need for adherence to the General Dental Council guidance on the provision of care plans and costings prior to the commencement of treatment.

3. The Department of Health and Social Services explore ways to improve current information systems for the States provided dental services. The information system should provide, at minimum,  an  ability  to record  the  booking  of  appointments,  patient  records  and  clinical activity. We would strongly urge the Hospital Service to explore the options available in dental management systems and their integration with the current hospital IT arrangements.
4. The value of the current epidemiology work is questionable. There is a need to develop a more coherent approach to oral health needs assessment that may include a clinical component. International experiences have highlighted a number of possible instruments that could be used. Given current resource expenditure, the improvements could be achieved on a cost neutral basis.
5. The Department of Health and Social Services work with the dental profession to explore options for the provision of dental care for individuals under the age of 16. There could be considerable efficiency savings and patient benefits if the more routine care of children was undertaken by existing primary care practitioners through an agreed contractual arrangement with the current hospital services undertaking a more specialised role. This would require better integration over the present arrangements and not least, leadership and management training. We would also suggest that the States explore the idea of introducing a capitation centred scheme for children using existing resources.
6. Governance  arrangements  for  assessing  the  qualities  of  treatment  provided  under  all arrangements  funded  by  the  States  of  Jersey  should  be  improved.  The  value  of  current arrangements to assess the qualities of care must be questioned and these resources could be allocated to provide a more efficient solution.

The following long term actions may be considered:

Longer term development options

7. There is lack of any coherent vision for the provision of oral care services across the States and itis strongly recommended that the Department of Health and Social Services work with the public and the dental profession on the development of an oral health strategy which addresses key areas: the determinants of disease; service provision; training, and; sustainable funding arrangements based on need. One part of the work should explore the extent to which current hospital based activity could be transferred to primary care settings and the sustainability of the current Consultant led hospital service.
8. The future oral health needs of the population of Jersey are unknown but are likely to see a substantial increase in demands for more complex care in particular, in the elderly age groups. The States need to give considerable thought to how the needs of this growing sector of the population could be managed. We would suggest that planning should centre on an integrated approach  involving  other  care  workers  as  well  as  ensuring  the  capability  of  the  dental professions to meet identified needs.

9. The  States  explore  with  third  party  health  insurance  schemes  options  for  dental  benefits packages for adults. The arrangements would need to take into account the context of current care provision within the States of Jersey and the present weak governance structures.
10. The Department of Social Security will need to develop monitoring arrangements on dental benefits  expenditure  to allow  for  budgetary  challenges  that  may  arise  as  economic circumstances  alter.   Should  the  number  of  individuals  entitled  to benefits  increase, commensurate service resource implications would arise.

INTRODUCTION

This report provides a summary of the work undertaken by Oral Care Consulting (OCC), the findings and recommendations to meet the project brief to review of the States of Jersey spending on dental health and benefits and the services provided.

Working with both the Departments of Health and Social Services and the Department of Social Security, the work undertaken covered four aims:

• To work with the States of Jersey to collate the available data on the status of publically funded non specialist oral health care provision.
• To  review  this  information  and  make  reference  to  recognised  good  practice,  nationally  and internationally, as applicable.
• To  make  recommendations  on  how  services  can  be  improved  within  existing  budgets  and prioritise these recommendations.
• To provide a framework for the management of recommended systems to allow performance to be assessed against good practice.

To achieve the above, OCC agreed a framework with the States of Jersey for the work. The structure is as follows:

• A series of options for the development of state funded dental care arrangements based on data made available to the consultants and discussions with stakeholders.
• For the options provided, an analysis of associated risk and prioritisation based on discussions with the Health and Social Services Department and the Social Security Department.
• The options will be based on a framework that would allow comparisons between differing care arrangements and the prioritised options for Jersey and other comparable systems.
• The options will be based on the key themes of finance, delivery and governance, highlighting key findings and recommendations.
• A presentation of results to a senior management audience.

OCC were provided with previous reports and data to help with their work and undertook a number of visits to establish the nature of the existing arrangements and the issues as seen by the various parties involved.

THE ORAL HEALTH STATUS OF AND DENTAL CARE DELIVERY SYSTEM OF THE STATES OF JERSEY

Overview

This section of the report provides an overview of the available data on the oral health status and existing arrangements for the delivery of oral health care to address the needs of the population of the States of Jersey. The section is subdivided into two main sections covering, first, the oral health status and secondly, the actual delivery system.

For the oral health status we have reported on the surveys commissioned by the States, the emphasis of which to date has been on the child population. For the delivery system we have provided an overview of the total system and subsequently a more detailed description of the elements in which the States of Jersey is currently allocating resources.

We have broken down the elements of the system into their financing, delivery, and governance. These issues will be explored in more detail in subsequent sections.

The oral health status of the population of the States of Jersey

The most  systematic  collection of  information about  oral  health need is derived  from occasional examination of children in Jersey Schools, carried out by a trained and calibrated epidemiologist. A single adult dental epidemiological survey of the over 65s was carried out in 2001.

Since 2000 eight surveys of the oral health status of children's teeth have been carried out. These were:

5 year olds (2000); 12 year olds (2001); 5 & 7 year olds (2002); 14 year olds (2003), and; 5 year- olds (2004, 2007, 2008, and 2014).

Surveys of 5 year-olds

On each occasion there was an attempt to examine the 5 year-old children in all state schools on the island,  and  until  the  most  recent  survey,  a  high  proportion  of  such  children  in each  school  was examined. The surveys have also included some, but not all private schools although all were invited to take part. This is important as the population frame from which the sample is drawn is likely to have influence on the subsequent data. If a section of the population is omitted from the sample, then the statistical reporting could be very different to the true situation depending on the nature of the factor or factors and their impact on the relationship to the missing section of the population. This issue may also arise through other methodological changes in the survey when drawing the sample, for example changes in the consent arrangements.

The surveys  undertaken in Jersey are comparable with those undertaken in Britain thus allowing comparisons. The surveys are designed to measure experience of dental decay through a count of the number of decayed and unrestored teeth ('d'), teeth missing, presumed extracted (m'), and teeth with fillings, making the assumption that they were decayed (f'). The total, dmf' is calculated for each child.

Figure 1: An overview of the States of Jersey 5 year-old population surveys undertaken since 2000.

2000 681 n/a  0.56 0.09 0.16 0.81 72% 77% 2002 766 96%  0.48 0.17 0.09 0.74 77% 82% 2004 821 n/a  0.68 0.14 0.28 1.10 68% 75% 2007 659 n/a  0.62 0.13 0.13 0.88 73% 78% 2008 681 93%  0.50 0.17 0.17 0.76 76% 81% 2014 659 70%  0.37 0.06 0.14 0.57 74% 81%

The 2014 survey was carried out with a changed protocol which echoed that of the UK epidemiological survey programme. In 2014 parents were required to provide written positive consent for their child to take part in the survey. The return rate for positive consent forms ranged between 39% and 100% across the schools. Very few parents returned consent forms actually refusing the examination. The majority of children not examined had not returned the form at all.

For 5 year-olds, the reports would suggest that the decay experience (dmf), that had been improving since the first survey was carried out in 1987, fluctuated only slightly during the 2000s (Figure 1). Most, between two thirds and three quarters, of Jersey children were found to have no visible decay experience (dmf=0) when examined at the time of each of the surveys. The picture is one of good overall dental health, which compares very favourably with the areas of England with the lowest levels of decay experience. What little change in the levels of dental decay experience that has been observed over the past 14 years could be explained by variation in the conduct of the examination or sampling biases.

The epidemiological data of 5 year-olds from individual schools have in the past been used to construct a  ranked  table  of  schools;  those  with  the  highest  levels  of  decay  experience  being  targeted  for interventions. The interventions have comprised health promotion/health improvement initiatives delivered by dental nurses providing health education teaching in the classrooms. These have been linked to the children and young peoples' initiatives run and commissioned by the Health Promotion Unit. We are also aware of a dentist-led initiative that has begun recently to distribute toothbrushes and toothpaste to support school-based brushing programmes, initially in schools with higher levels of dental decay experience.

The use of an epidemiology survey to target health education pose some risk in that a snapshot of oral health for one age group cannot reliably capture the shifting pattern of dental decay at different ages. Evidence for this comes from the Jersey school surveys carried out in 2001 (Figure 2). In this year, two age groups (5 year-olds and 7 year-olds) were examined at the same time, by the same epidemiology team, producing consistent data quality. In addition, a very high proportion of children of both ages were examined in every school, minimising the negative effect of selection bias on data quality.

Figure 2: Comparison of the percentage of 5 and 7 year-olds children with decay experience ranked by school in 2002

80

5 year-olds

7 year-olds 60

40

20

0

school Average = Mean

Results of the survey demonstrated that if schools are ranked by the proportion of their pupils with decay experience at age 5 there is a very weak correlation with decay prevalence at aged 7 in the same schools at the same time (correlation coefficient r2 = 0.375) (Figure 3). In addition the quality of any data collected from such surveys, now that prior written consent is needed, is diminished due to selection biases, particular in schools with small rolls. This suggests the need for great caution when using these epidemiological surveys as a tool for targeted school-based oral health interventions. A further consideration is that such surveys are costly and divert staff from clinical work.

Figure 3: Correlation of the same school according to the percentage of 5 and 7 year-olds children with decay experience.

We suggest that the use of epidemiological surveys of dental decay at age 5 as the sole (or main) basis for planning targeted preventive interventions or service prioritisation is not continued. Indeed, at a cost of £14,000 options for other data capture arrangements that could be used for planning improvements may provide a better use of resources including addressing the lack of needs data on the elderly population identified below (see also section Options for service development').

The Community Dental Service currently undertakes school-based screening (case–finding) to identify pupils with unmet treatment need. This screening activity, if it continues, might be used to provide direct clinical observations to underpin service planning and delivery.

Oral Health Survey of over 65s

A survey of 400 randomly-sampled people aged 65 and over living at home was undertaken in 2001. The survey involved both a dental examination and interview but has not been repeated. Unfortunately, the data are probably now too out of date to be of value. At the time, the research concluded that the uptake of dental services declined with age and discussed potential barriers to accessing treatment. These included cost, practical difficulties of access (including mobility), a lack of awareness that treatment was required and social isolation or helplessness'.

The dental care delivery arrangements within the States of Jersey

While the make-up of a dental care delivery system varies between any country, in the vast majority of countries the system consists of two elements: that in which the Government plays no part in the financing (normally referred to as the private' sector) and that in which the Government has taken an

active decision to take public funds and allocate them for a specific purpose, in this case the provision of dental care, (the state' system).

Irrespective of the source and subsequent distribution of funds, other necessary elements of a system include the regulatory framework for the delivery of care and the contractual agreement between the parties involved. Regulatory elements would include definitions of who is legally able to provide care, the nature of the care and the arrangements for its provision. Contractual agreements could be between an individual and the care provider alone, or between the States of Jersey and the contractor. An example of the latter would include care provided through the Jersey Dental Fitness Scheme.

Dentists who wish to practice in Jersey are required, by the Dentists (Registration) (Jersey) Law 1961 to register with the Royal Court. Acceptance on this register is determined by the dentist being registered under UK law (Dentists Act 1984 of the United Kingdom). The Royal Court may arrange to remove a dentist from the register if they are no longer maintained on the UK list, if convicted of a criminal offence or misdemeanor or for infamous or disgraceful conduct in a professional respect'. No local governance arrangements are in place, the regulatory body overseeing the provision of care and by default, helping ensure the public are protected, is the General Dental Council in the UK.

Jersey has a large non-state sector of approximately 70 dentists. These independent dental practitioners are responsible for the premises in which they operate and the staff they employ. Practitioners are free to set their own level of fees for their activities. Although outside of the direct management of the Government,  the  pricing  arrangements  and  standards  of  care  achieved  can  impact  on  how  the population view Government and any issues may have an impact on the demands placed on either, or both, the dental or medical state sector.

The remainder of this section provides an overview of provision of dental care that is under the direct responsibility of the States of Jersey. We have divided the dental care system into three components: the element of the primary dental sector formed by the independent contractors in which the States of Jersey has contracted; the hospital primary care sector (Community Dental service), and the hospital secondary care sector.

Figure 4: Primary Dental Care Arrangements in which the States of Jersey make financial contributions.

Figure 4 shows the four primary dental care arrangements that the States of Jersey have financial commitments to and that contribute towards care provision for eligible residents. The four primary care schemes are:

• the Community Dental Service, (CDS, treatment based in the General Hospital Dental Department)

• the Jersey Dental Fitness Scheme (JDFS)

• Income Support Special Payments (ISSP)

• the 65+ Healthcare scheme (also commonly referred to as the Westfield scheme) .

In addition to these primary dental care arrangements, there is a secondary (hospital) based arrangement providing orthodontic care, oral surgery and special needs care on referral only.

The Department of Health and Social Services funded and managed dental services

The Hospital Dental Department

All States' dental services are based in the General Hospital Dental Department, a multi surgery clinic in Newgate Street, adjacent to the main Jersey General Hospital buildings. Three physically distinct services are provided; oral surgery, orthodontics and the primary care Community Dental Service (CDS)

These three services share arrangements for support staff including;

• a dental nursing and administration manager (job share)

• dental nurses

• dental receptionists, and

• medical secretaries

There are 10.2 substantively contracted support staff currently in post from a total establishment of 10.7. Bank staff are used when circumstances dictate but flexible working or part-time staff is required as a condition of recent contracts.

Nursing is generally provided as dedicated support to each of the three services, rather than managed as a common pool' approach. There are barriers to achieving rotation across the services and plans that these might be addressed. Dental nurses are required to cover absent colleagues on an ad-hoc basis but there is no structured approach to ensuring they develop and retain skills to provide nursing support across the range of dental services provided.

Clinical records are kept in the paper-based patient notes, an arrangement common to all departments within the hospital. As a result of this system, there are occasional problems where the notes are not available with the patient when needed. Patient registration and appointments are made through the Healthcare Information System software used throughout the hospital, InterSystems TrakCare. This software is not ideal in this situation and in particular has severe limitations (as currently configured) in terms of the utility of management reports currently produced.

The reception area, though busy, is welcoming and has low counters to allow communication with patients in wheelchairs. There are two entirely separate comfortable waiting areas, one mainly for children and their parents. The other area allows oral surgery patients (some of whom may have facial trauma or disfigurement) to wait without mixing with child patients.

There are six broadly similar dental surgeries, which in principle are able to be used for treating any category of patient. Pragmatically though, because of the need for distinctive equipment associated with each branch of the service, two surgeries are dedicated to each. One room, Surgery 3, is larger than the

others and is used by the CDS as it allows for easier access for wheelchairs and additional space for carers. The chair is suitable for a wide range of patients and treatment; the purchase of a device to allow patients to be treated comfortably without leaving their wheelchair is under consideration.

There are scheduled Departmental team meetings but universal attendance is not routinely achieved. The meetings cover clinical matters although there is no clear multidisciplinary clinical focus covering the three strands of the service. Some audit of outcomes has been undertaken (for example through orthodontic Peer Assessment Rating rating) but there is no agreed programme for audit or peer review to influence adoption of improved clinical protocols and good practice guidance.

Within the Hospital management structure, the Dental Department sits within the Ambulatory Care Division. There are monthly Dental Executive Committee meetings to oversee the work of the Dental Department; proposals for developments requiring additional funding are dealt with through submitting a  business  case  to  a  competitive  funding  process  at  autumn  and  spring  reviews.  The  Hospital commissioned a review of the work of the Dental Department which was undertaken by the Divisional Lead for Support Services and the Lead for Theatres and Anaesthetics. Produced last year, the main conclusion was a lack of strategic direction and that the did not attend' (DNA) rate was high, in part due to the timings of clinics. To date, recommendations have been partially actioned

There is no routinely collected data from the TrakCare system to provide information about the number of patients seen in the dental department as outpatients or the treatments they received. A wide range of clinical problems associated with the head, neck and mouth is seen, some involving multidisciplinary management involving the orthodontic and other hospital consultants. The data which are available suggests that in 2013 – across all disciplines some 18,000 consultations were held, of these 56% were in community dental, 24% in Orthodontics, 20% in Oral surgery. Due to challenges in data quality, these proportions should be treated with caution.

Community Dental Service

The role of the Community Dental Service (CDS) is to provide care for pre-school and primary school children, people with special needs and restorative dentistry problems referred from other hospital departments  and  primary  care  practitioners.   The  department  is  also  required  to  undertake responsibilities  for  oral  health  promotion,  regular  screening  programmes  for  school  children, epidemiological surveys and participation in the Jersey Dental Fitness Scheme. These are set out in the role specification of the lead clinician.

In addition to the lead clinician, the CDS houses two established Dental Officer posts. Three Dental Officers are employed; one full-time, the other job share between two part-time Dental Officers. These Dental officers are employed on a States civil service contract which varies from that used to employ Consultants. Differing terms are noted in key areas including entitlement to study leave; the States civil service contract does not compare favorably with contracts applied in the UK. These differences could impact on succession and retention and should therefore be considered in the review of civil service terms and conditions (work force modernization) which is currently underway.

Clinical sessions are provided throughout the week. Most patients are able to accept care in the dental chair with local analgesia, although a small number do require a general anaesthetic to complete treatment (most commonly as a day-case procedure). There are scheduled CDS theatre sessions in the hospital for this work, although recently the number of CDS sessions was reduced in an attempt to improve utilisation as some were not being filled. There may sometimes be a delay for urgent treatment being provided on a routine scheduled session. Domiciliary work is being undertaken with visits to people in care homes and wards in outlying hospitals such as St Saviours' Hospital (adult mental health & learning difficulties and old age psychiatry) and Overdale (rehabilitation). Very few visits were recorded suggesting that the actual data are unreliable.

There are significant waits for both initial assessments and follow up treatments, which can be in the order of 6 months. At the time of researching this report, about 500 people were waiting for their first outpatient appointments. There are no agreed departmental protocols or algorithms in place to be applied for prioritisation of available appointments, these decisions being made by either clinicians or reception staff on an individual basis.

School based activity is restricted to primary schools and comprises screening examinations and support for  epidemiological  surveys.  During  screening  children  in  schools  are  examined  and  those  who probably have disease or problems requiring treatment are given a letter to take home suggesting they make  an  appointment  for  a  full  clinical  examination.  There  is,  however  currently  no  systematic approach in place to follow up these children and determine if a visit to the dentist takes place and the oral health of children is not recorded to provide any insights to the level of disease.

The remaining services provided by Health from the Dental department of the General Hospital fall outside the main focus of this review but are described below to provide context.

Hospital Consultant-led Orthodontic Service

The service has been in place for over 25 years. A Consultant delivers 9 sessions per week. As with other parts of the hospital-managed dental service, recruitment of suitably trained staff has been an ongoing problem. Over the past three years an orthodontic post has been occupied by an off-island Consultant who works 2 days (4 sessions) per week, subject to her availability. Between 6th January and 20th May 2014, 50 days were worked on this basis. In addition, a single weekly clinical session is provided by a general dental practitioner with experience but no registerable specialist orthodontic qualifications.

There are normally 7 weekly assessment and treatment clinics including evening and Saturday sessions.

To increase capacity the Dental Department is currently training a member of staff to become a General Dental Council (GDC) registered Orthodontic Therapist. Successful completion would permit her to carry out some of the clinical procedures previously only able to be carried out by orthodontists – subject to the further necessary approval of the States of Jersey for a category of local registration to carry out these additional duties.

Orthodontics patients are seen only on referral from their general dental practitioner, general medical practitioner or other hospital Consultants. All children and young people up the age of 16 can be seen for an assessment and Consultant opinion. Active treatment is only offered to those with a great' or very great' treatment need. This is determined by application of the Index of Treatment Need Dental Health Component (IOTN DHC), which is a validated index and provides a widely-used threshold for intervention internationally. There is no means testing of families of patients accepted for active treatment (braces) in the department.

Definitive orthodontic treatment is generally carried out in adolescence. The population of 12 year-olds at the time of the 2011 census was 1094. Typically about a third of the population will fall into the great' or very great' treatment need category of (IOTN DHC). This suggests that approximately 370 cases per year would meet the threshold for treatment on the Island. This is a theoretical maximum; not all of those will want to have orthodontic treatment and some who do will have treatment provided privately elsewhere.

Currently there are lengthy waiting times both for initial assessment appointments and to start treatment (where indicated). About 350 referrals are waiting to be seen. No orthodontic patients are treated privately at the Hospital.

Hospital Consultant-led Oral Surgery service

This is another well-established service and is currently led by a GDC-registered specialist in Oral Surgery, supported by an Associate Specialist with extensive experience in oral surgery. The majority of patients are seen through state funded arrangements although some private work is undertaken. There

are no other facilities on the island where hospital (inpatient) oral surgery is undertaken. Some primary care dental practices will carry out quite advanced oral surgery as part of the general care they provide for their (fee-paying) patients whereas other practices appear to refer in very straightforward cases that should be within the scope of an experienced dentist.

Oral surgery patients are seen for assessment, review and some minor surgical procedures under local anaesthesia in the Dental Department. Patients requiring more major surgery and/or requiring general anaesthesia or sedation for treatment are seen in the hospital theatres. The majority of these procedures are undertaken on a day-case basis. In 2013, 518 state-funded cases were seen in theatre; 393 were managed as day case procedures and 125 were admitted for treatment.

At  the  time  of  researching  this  report  400  patients  were  currently  awaiting  first  assessment appointments. There is a regular Monday morning operating session. This is helpful as patients are usually  discharged  by  midweek  although  trauma  cases  occurring  over  the  weekend  can  generate pressure on the planned Monday afternoon clinic. Also, planned patient admissions for the Monday list which have not had pre-assessment may require staff to address unexpected complications immediately prior to surgery. Limited staff means there is a burdensome 1 in 2 on-call commitment.

In 2013 there were 133 privately funded procedures undertaken in theatres - 113 were carried out as day cases and 20 were inpatients.

The Department of Social Security funded dental schemes The Jersey Dental Fitness Scheme

The Jersey Dental Fitness Scheme (JDFS) was established via a States Act in 1991. It is overseen by a Board of Management and aims to support lower income families in maintaining the dental health of their children by creating a monthly payment scheme that covers all routine treatment. Children must be dentally fit to join the scheme. They are examined by an independent dentist who sets a monthly fee for which all future routine dental care will be undertaken. The States, from Social Security Department funding, pay £6.00 per month towards this fee. The remaining cost is met by the parent.

As of June 2014 1,134 children were registered on the scheme attended to by 46 primary care dentists working in private practice.

On average dentists charge £13.82 per month to maintain dental fitness; thus, minus the States subsidy, parents pay on average £7.82 per child per month. The highest average fee charged to parents by any one dentist to parents across the children in their care is £16.33, several dentists do not levy any charge on parents and provide the service remunerated by the States subsidy only.

Young people aged 11 to 18 are eligible to join, as can people up to the age of 21 if they remain in full time education. The scheme has an element of means testing – being open only to Islanders with a household income below £46,000. However compliance with this income test among members is not audited.

As set out in the Act of the States, the JDFS accounts are independently audited. Clinical outcomes are also audited once every three years by an independent UK consultant. The dental health of children on the  scheme  is  exceptionally  high  –  suggesting  services  are  provided  to  a  high  standard  by  the community dentists.