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Improving dental access, quality and oral health in prisons and
detention centresA toolkit for good practice in the
commissioning of oral health services
John F Beal MBEConsultant in Dental Public Health,
NHS Yorkshire & the HumberHon Senior Clinical Lecturer,
University of Leeds
Milestones in developing prison dentistry
• Survey by Gerrish and Forcyth, 1995• Modernising dental services for prisoners,
2003• DH capital funding - £4.25m 2003-2006• PCTs responsible for prison health services,
2006• Dentists with a Special Interest in Prison
Dentistry, 2007• Establishment of National Association of
Prison Dentistry UK 2008
Oral Health of Prisoners• Oral Health in England has improved enormously
over 30 years• Inequalities still exist matched to areas of social
exclusion• 50% of prisoners are unemployed before
sentencing• Enter prison with poor oral health• Untreated disease about 4 times greater than
general population from similar social backgrounds
• Dental attendance less than general population• Needs have often not been met within prison
Reason for last visit to dentist (%) (25-34 year-olds)
0
10
20
30
40
50
60
70
80
Trouble Check-up
Prison
ADHS
• Need to give guidance to PCTs to help them in reviewing and commissioning prison dental services
• To support prison dental teams to improve the oral health of the prison population
• To ensure that dental care for prisoners is in line with that available for the rest of the population taking into account their greater needs
Working Group members
• Liana Zoitopoulos, Cons Special Care Dentistry, NAPDUK
• John Beal, Consultant in Dental Public Health, SHA
• Wade Houlden, Prison dentist, NAPDUK• Judith Husband, Prison dentist• Tony Jenner / Sue Gregory DH DCDO • Mark Johnson, DH Offender Health• Numa Kapur, Prison Dentist, NAPDUK• Theodore Papadakis, SDO Kings College• Debbie Parkin, DH Offender Health• Eric Rooney Consultant in Dental Public
Health, PCT
Department of Health policies
• General– Health reform in England: update and
commissioning framework, 2006– World class commissioning, 2007
• Dental– Modernising dental services for prisoners, 2003– Choosing better oral health, 2005– Delivering better oral health, 2007– World class commissioning; Improving dental
access, quality and oral health, 2009
Some guiding principles
• Need for prevention as well as treatment• Requires shift in resources towards
prevention• Bear in mind health inequalities are now
recognised as contributing to likelihood of offending and re-offending
• Oral health promotion needs to be embedded within “Healthy Prisons” strategy
Model for commissioning prison and detention centre oral health services
Commissioning Prison and
Detention Centre Oral Health Services
or
Review service
Decide priorities-Assuring Minimum Standards
Shaping supply
Managing Performance & Supporting Quality Improvement
Oral Health Needs Assessment
Understand the establishment
Type and numbers
Turnover
Future Plans
Demography
Input from prison service
Use existing research and epidemiology
Develop Service specification
Scope
Prevention and oral health improvement
High quality, safe clinical care:
Urgent
Routine
Specialist
Demand management and referrals
Links to other services
Quality and risk management
Prison Health support
Research
Service Review
Assess against service specification
Work with existing or new providers
Re shape and refocus the existing service to deliver the service specification in partnership with the existing provider
Procurement process
Tendering process through “Supply to Health” or local process
Market Testing
Assess needs-Map the base-line
Strategic decision required
GDS contractPDS agreementPCTDS service statement
Amended to reflect the service specification
Appropriate measures of activity and quality and clear agreements about breaches and sanctions
Regular reviews including feedback from the prison healthcare team and patients
Strategic evaluation and review
Model for commissioning prison and detention centre oral health services
• Oral health needs assessment
• Develop service specification
• Review service
• Reshape existing service or market test
• Manage performance and support quality improvement
Review of service• Exit questionnaires to prisoners to evaluate
the care received• Oral health assessment on transfer or release
similar to those on entry to measure differences in oral health and needs while in prison
• Assessment of oral health behaviour to assess effectiveness of OH Promotion
• Views of the dental team• Assessment of prison environment eg healthy
menus, types of drink available as indicator of dental team influence on healthy prison
Prevention and oral health improvement (OHP)
OHP programme embedded in prison health promotion strategy – CRF approach
PCT leadprison support
• Smoking cessation
• Oral health promotion programme
Prison leadPCT support
• Healthy menus
• Available sugar-free drug substitute
prescribing
Challenges to PCT
• High oral health needs• Complexity of care needed• Low priority of health
promotion• Lack of skilled workforce• Organisation of emergency
and referral systems• Quality of care
Challenges to prison
• Nutrition• Shortened sessions /
cancelled attendance• Lack of space• Litigation• Turnover of population• Demanding patients• Outdated clinical facilities• Continuity of care
1.18 Prison Dentistry
• Emergency – severe facial trauma, severe bleeding– immediate access to hospital A & E
• Urgent– dental pain, minor trauma– dentist within 24 hours (or appropriate
practitioner)
• Routine– Dentist within six weeks from the time of
asking.
Waiting times in days for routine dental treatment all prisons in Yorkshire & the Humber, September 2006
(National guideline)
0
25
50
75
100
125
150
175
200
225
A B C D E F G H I J K L M N O P Q
•Green IndicatorAccess standards for dental care reflect general access guidance in all of the following areas:
– Emergency Care– Urgent Care– Appointments
•Amber Indicator– Access standards for dental care DOES NOT reflect general
access guidance in all areas, but there IS an action plan in place to achieve the access standard.
•Red Indicator
Access standards for dental care DOES NOT reflect general access guidance in all areas, and there IS NO action plan in place to achieve the access standard.
Oral health
Promotion Unit
GDP DwSI in Prison
Dentistry
Specialist service
providers e.g.
Specialists in Special
Care, Restorative Dentistry,
Oral Surgery
Oral Health Improvement v v v
Needs assessment v v v
Routine dental care v v
Secondary care and referrals v v
Emergency dental care v v v
Research
• Research is fundamental to successful World Class Commissioning
• Need to be able to demonstrate better health and well-being and better value for all
• Research needed on ‘barriers’ in delivering dental care to a prison population
• Research on dental care for vulnerable groups eg drug abusers, mentally ill and persons with a history of violence
Future workforce availability
• Consider recommendations from review of workforce issues for prison doctors
• Teaching prison dentistry in dental undergraduate and DCP curriculum
• National clinical attachments in prisons
• Opportunities for placements in prisons for training and development
Service specification (1)
• Service aims– Primary dental care– Secondary care and access to specialist
services– Emergency dental services - minor (local)
and major (hospital)– Oral health promotion– Oral screening and needs assessment– Research
Service specification (2)• Target group
– normally any inmate who requests
• Location– ideally near to other primary health services
• Hours– number of sessions– start / finish time– arrangements for out of hours emergencies
• Treatment pathway– Including referral to and from the service
Entry to the prison/detention centre: Initial assessment according to prison protocol
No dental treatment requested
Patient returns to wing.
Dental treatment requested
Patient remanded Simple dental treatment or emergency care offered
Patient convicted
Routine Dental care and prevention aiming at meeting all treatment needs due to longer stay in prison
Emergency care offered by prison primary dental team. Patient placed on waiting list
All treatment needs met. Prisoner placed in recall system
Incomplete care due to discharge or transfer to another prison
If discharged contact dental services in community to ensure continuity of care
If transferred then ensure all dental records and treatment plan available
Prisoner discharged
Contact dental services in community to ensure continuity of care
Specialist care offered in hospital by referral.
Entry to the prison/detention centre: Initial assessment according to prison protocol
No dental treatment requested
Patient returns to wing. Dental treatment requested
Patient remanded Simple dental treatment or emergency care offered
Patient convicted
Routine Dental care and prevention aiming at meeting all treatment needs due to longer stay in prison
Emergency care offered by prison primary dental team. Patient placed on waiting list
Specialist care offered in hospital by referral.
Simple dental treatment or emergency care offered
Routine Dental care and prevention aiming at meeting all treatment needs due to longer stay in prison
Emergency care offered by prison primary dental team. Patient placed on waiting list
All treatment needs met. Prisoner placed in recall system Incomplete care due to
discharge or transfer to another prison
If discharged contact dental services in community to ensure continuity of care
If transferred then ensure all dental records and treatment plan availablePrisoner discharged
Contact dental services in community to ensure continuity of care
Specialist care offered in hospital by referral.
Service specification (3)• Skill mix
– dentist / DwSI / specialist / DCPs (including extended skills)
– case mix model • Staff
– induction – qualifications required / checked– CPD– peer review and audit
• Premises and equipment– responsibilities for maintenance and repairs– ordering of supplies– standards and regulations eg H&S, COSHH,
radiological
Service specification (4)
• Laboratory work– registered technicians / comply with H&S – arrangements / costs / turnaround times
• Activity measurement– moving away from purely numbers of
patients – PCT and dentist should get monthly DSD
report– possible use of case mix model
Service specification (5)• Clinical governance (responsibility of
Prison Partnership Board)– reporting mechanism – quality and standards – including unique
NHS number, process for staff concerns and patient complaints, day book and records, DRO inspections
– H&S including decontamination, training – CPD for all registered staff– Patient information – rights in relation to
dental care in prison and following transfer or release
Service specification (6)• Clinical governance (contd)
– induction including confidentiality, security, safety, complaints
– efficiency including keys or collection of dental team, appointment system, filling cancelled appointments, avoiding cancelled sessions, prison providing information on likely length of stay
– cover for planned / unplanned leave, security clearance for replacement staff
• Finance
Thank you
If you have any comments or suggestions please let us know
by contacting one of the NAPDUK representatives on
the Working Group