Agenda item

The Scrutiny Panel will receive:

 

·        an overview of Public Health’s responsibilities in respect of oral health;

·        statistical data and information in respect of oral health in Middlesbrough and the impact of Covid-19; and

·        details of any future developments and innovative practice that plan to improve the oral health of Middlesbrough’s population.

The Director of Public Health was in attendance to present:

 

·        an overview of Public Health’s responsibilities in respect of oral health;

·        statistical data and information in respect of oral health in Middlesbrough and the impact of Covid-19; and

·        details of any future developments and innovative practice that plan to improve the oral health of Middlesbrough’s population.

 

The Director of Public Health explained that oral health was an important public health concern and could have a significant impact on society and individuals.

 

The scrutiny panel was advised that the extraction of decayed teeth had become the most common reason for the hospital admission of under-18-year-olds in England.

 

Members heard that poor oral health could affect children’s and young people’s ability to sleep, eat, speak, play and socialise with other children. Other impacts included pain, infections, poor diet, and impaired nutrition and growth. It was commented that poor oral health also had wider impacts for families, for instance - if a child missed school or a parent needed to take time off work to take their child to receive dental treatment.

 

It was highlighted that there was a significant link between deprivation and poorer oral health. Poor oral health increased the risk of many oral health related illnesses (dental decay, tooth loss, oral cancer) and impacted on a person’s quality of life.

 

It was commented that poor oral health may be indicative of dental neglect and wider safeguarding issues. Members heard that dental neglect was defined as “the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development”. It was explained that dental teams were able to contribute to a multi-agency approach to safeguard children.

 

The scrutiny panel was informed that extractions under general anaesthetic were not only potentially avoidable for most children, but also costly. It was commented that the cost of extracting multiple teeth for children in hospitals between 2011-2012 cost the NHS £673 per child, which had equated to nearly £23 million that year. Members heard that approximately 20 years ago, there had been an initiative to reduce the number of extractions performed under general anaesthetic in hospitals and facilitate extractions in dental practices under local anaesthetic. It was commented that the current costs of extractions in hospital settings would be lower than that of 2011/12, due to the shift in how extractions were now performed.

 

Members were informed that across the North East and North Cumbria there had been no significant improvements in oral health for 5-year-old children. It was commented that Middlesbrough had significantly more dental decay than the England average. Furthermore, Middlesbrough had the highest rate of dental decay in 5-year-olds across North East and North Cumbria, in terms of lower-tier local authorities in the area. The rates were socially patterned and typically the poorer and more deprived areas experienced higher rates of dental decay. However, it was explained that although Hartlepool had a similar deprivation profile to Middlesbrough, the area’s rates of dental decay were significantly lower, as residents had access to a naturally fluoridated water supply.

 

The scrutiny panel was shown data pertaining to drilled, missing and filled teeth in 2019 and subsequently in 2022, which demonstrated the consequences of tooth decay.

 

Members were advised that a further census survey of 5-year-old children was planned for 2023/24, which would provide a larger sample size and enable analysis of data at a ward-level to identify health inequalities and the impact of Covid-19. Furthermore, it was envisaged that the survey would also provide insight around access to dental care.

 

Members heard there had been a significant increase in dental decay prevalence from age 3 to 5 years old in all areas of the North East and North Cumbria. In Middlesbrough, there had been a doubling of decay in the same cohort of children from the age of 3 to 5, which was demonstrated by the most recent surveys undertaken in 2020 and 2022. It was explained that the increase in rates of dental disease could be explained by the decay process i.e., it could take 18 months or more from the start of decay (enamel decay) to progress to a stage when a filling was required (dentinal decay).

 

The scrutiny panel was advised that early diagnosis (enamel decay) and treatment with fluoride could reverse the early decay process. It was commented that dental attendance when teeth first came through (check at age 1) could provide opportunities for prevention advice and fluoride intervention to reverse the effect of early decay. It was also highlighted that optimising fluoride interventions (fluoride varnish) within dental practices, and supervised toothbrushing programmes in schools, could reduce the significant increases in disease rates in very young children.

 

In terms of the oral health of adults, Middlesbrough’s adults (27.9%) suffered more oral health impacts than the average for the North East (22.6%) or England (17.7%). Therefore, it was evident that poor oral health in childhood unsurprising continued into adulthood.

 

Members heard that the Health and Social Care Act (2012) amended the National Health Service Act (2006) to confer responsibilities on local authorities for health improvement, including oral health improvement, in relation to the people in their areas. It was explained that local authorities were statutorily required to provide or commission oral health promotion programmes to improve the health of the local population, to an extent that they considered appropriate in their areas.

 

It was advised that local authorities were required to provide or commission oral health surveys. Members heard that the oral health surveys were conducted as part of the Public Health England (PHE) dental public health intelligence programme, which was formerly known as the national dental epidemiology programme. It was explained that providing or commissioning oral health surveys involved:

 

·        assessing and monitoring oral health needs;

·        planning and evaluating oral health promotion programmes;

·        planning and evaluating the arrangements for the provision of dental services; and

·        reporting and monitoring of the effects of any local water fluoridation schemes covering their area.

 

It was advised that previously local authorities had the power to make proposals regarding water fluoridation, however, the Health and Care Act 2022 had moved responsibilities for initiating and varying schemes for water fluoridation from local authorities to the Secretary of State. Members heard that local authorities had a duty to conduct public consultations in relation to any proposals put forward by the Secretary of State.

 

It was advised that the National Institute of Health and Care Excellence (NICE) had published guidelines to improve oral health by developing and implementing a strategy to meet the needs of people in the local community. It was explained that the future development of such a strategy would aim to promote and protect people’s oral health by improving their diet and oral hygiene and by encouraging them to visit a dentist regularly.

 

In terms of prevention for children, Members heard that there were toothbrushing programmes currently being delivered by Tees Oral Health Promotion in primary schools and early years settings. In addition, the Eat Well Schools and Early Years Awards aimed to raise awareness of the importance of oral health, as part of a 'whole-school/settings' approach in all primary schools, secondary schools and early years settings. It was also added that Health Visitors undertook 2/2.5-year reviews, which involved advising families to register with a dentist.

 

In terms of prevention for adults, the Management of Undernutrition South Tees (MUST) programme was delivered in care homes, which offered oral health advice and training to staff members.  The MUST programme had also been involved with Teesside University’s ELDER Study, which aimed to improve the oral health of older adults by using milk supplemented with fluoride and probiotics. In addition, there was the Caring for Your Smile programme.

 

In terms of training, the toothbrushing schemes involved staff members in schools and early years settings being trained to deliver oral health advice and information. Midwives and Health Visitors promoted oral health and completed oral health training. It was commented that there were oral health campaigns in care homes and staff members received oral health training, as did Public Health Nurses working with Looked After Children. In addition, all staff members working with vulnerable groups in health and social care received annual oral health training.

 

Members heard that access to NHS primary dental care for children in March 2022 had not fully recovered to pre-pandemic levels and it was lower (48.5%) than in 2020 (67.8%). The reduction in the number of children accessing dental care, since the pandemic, was not specific to Middlesbrough and reductions had been experienced across the region and across the country. It was confirmed that the impact of the pandemic on residents accessing dental care had been significant for the North East. Furthermore, it was explained that the post Covid-19 recovery position was also replicated for adults (39.9% compared to 63.4%) in Middlesbrough.

 

The scrutiny panel was advised that the 0-19 Healthy Child Programme in Middlesbrough had shown registrations with a dentist (for children aged 2-2.5 years old at the health visiting mandated visit) was now 60%. However, it was clarified that pre-pandemic figure was approximately 85%.

 

In terms of water fluoridation, at a population level, fluoridation was the most effective way of reducing inequalities, as it ensured that people in the most deprived areas received fluoridated water.  It was advised that water fluoridation needed to be part of an overall oral health strategy.  It was commented that initiating and varying schemes for water fluoridation was now the responsibility of NHS England and the Secretary of State. However, it was highlighted that local authorities played a key role in public consultation, which would continue to be an important part of any future water fluoridation proposals. It was explained that it would be difficult to fluoridate the water in small geographical locations, such as Middlesbrough or Stockton individually. It was clarified that water fluoridation schemes seemed to be introduced across larger geographical areas, as they were dependent on the location of each water supply.

 

In terms of future work, the following areas were outlined to the scrutiny panel:

 

·        an Oral Health Strategy would be developed for Middlesbrough and the Tees Valley;

·        the Dental Epidemiology Survey for 5-year-old children would be conducted in 2023;

·        the delivery of oral health promotion training to all front-line practitioners would continue to ensure staff members could provide advice on the importance of oral health;

·        healthy environments would be promoted to improve oral health and the Healthy Weight Declaration provided a framework to encourage drinking water, sugar free food and breastfeeding;

·        oral health promotion would be incorporated in existing services for all children, young people and adults at high risk of poor oral health;

·        the delivery of supervised toothbrushing programmes in early years settings and schools would continue;

·        fluoride varnish programmes in areas where children were at high risk of poor oral health would be considered; and

·        evidence-based interventions to improve oral health in Middlesbrough would be reviewed over the next 5 years.

 

A Member commented on the importance of promoting oral health. The Director of Public Health commented that the fluoride varnish programme aimed to increase protection to children’s teeth, in a relatively simple way, and encourage parents to register their children at dental practices.

 

A Member commented that previously dentists had visited schools and undertook dental checks for children. In response, the Director of Public Health commented that there were challenges in recruiting and retaining dentists to work on NHS contracts, therefore, there was insufficient capacity to provide dentists in a school setting.

 

A Member raised a query in respect of water fluoridation. In response, the Director of Public Health commented that there had been discussions to determine which areas would find water fluoridation most beneficial and the issue was being considered at a national level. It was commented that writing to the Secretary of State could be beneficial in demonstrating why the local population would benefit from a fluoridated water supply. It was explained that providing a fluoridated water supply would be dependent on how the water supply was constructed and mapped, taking into account the boundaries of each local authority in the area. A Member commented that it could be beneficial to lobby Government for region-wide fluoridation. The Director of Public Health commented that Northumberland and Durham had both undertaken work to consult with communities and explore the introduction of fluoridated water schemes.

 

A Member expressed concern in respect of the high levels of dental decay that had been reported for Middlesbrough’s children and the widely reported oral health illnesses that impacted on a child’s education.

 

A discussion ensued and Members commented that a fluoridated water supply and improving access to NHS dentistry were highly important when looking to improve the oral health of Middlesbrough’s population.

 

It was explained that encouraging families to register with dentists generated an increased demand for NHS dental practices and unfortunately, currently, there was not capacity to meet that demand.

 

A Member raised a query regarding the practices that could be adopted to improve oral health. In response, the Director of Public Health advised that brushing teeth well, at least twice daily, reduced the incidence and severity of tooth decay. It was also commented that the consumption of sugary drinks and food should be avoided as sugar dissolved enamel, creating holes or cavities in the teeth. It was added that a child’s oral health was dependent on family routines, which were often inter-generational.

 

A discussion ensued and comments were made that financial constraints of families may limit the ability to afford the basic products necessary to maintain oral hygiene. It was also commented that a lack of financial resources had resulted in workforce impacts for dentistry and limited the range of oral health promotion work that could be undertaken.

 

A Member raised a query regarding the roll out of toothbrushing programmes. In response, the Director of Public Health advised that supervised toothbrushing programmes were delivered in primary schools and early years settings throughout the borough.

 

A Member raised a query regarding fluoride varnish programmes. In response, the Director of Public Health advised that once applied, fluoride varnish kept protecting teeth for several months.

 

A Member raised a query regarding access to dentistry. In response, the Director of Place Based Delivery for North East & North Cumbria Integrated Care Board (ICB) advised that the gap between dental care demand and available provision had been acknowledged and a primary care dental access recovery plan was being developed to address the issue. It was advised that the ICB was working with its partners to develop the recovery plan. It was commented that, across the country, dental services continued to struggle from the impact of Covid-19. There had been pressures in respect of the number of dental practices offering NHS dental treatments and that had impacted significantly on parts of the local area.

 

Members heard that the work being undertaken by the ICB and its partners primarily focussed on three phases:

 

1.      taking immediate actions to stabilise services that were already in place;

2.      in the medium-term, taking a strategic approach to workforce and service delivery to increase capacity; and

3.      in the longer term, developing an oral health strategy to improve oral health and reduce pressure on dentistry right across the Tees Valley.

 

The Director of Place Based Delivery advised that the ICB was working with dentists and partners across Tees Valley to increase NHS 111 dental clinical assessment capacity, increase out of hours treatment services, create access to additional treatments and increase the number of dental appointments available for the local community. A key challenge for the ICB was to increase the number of dental practitioners working in the area to ensure sufficient dental services could be provided for the local population.

 

The scrutiny panel was advised that a more comprehensive overview of the strategic work that was being undertaken by the ICB would be shared with Members, following the meeting. Members heard that the information provided would include details of the actions being taken to improve access to dentistry and create additional capacity.

 

A Member commented that it would be beneficial to receive information on the reasons for dental practices choosing to go private or reduce their NHS patient commitment. The Director of Place Based Deliver advised that the specifics for rationales that had been given, would be shared with the scrutiny panel.

 

A Member raised a query on the link between deprivation and oral health. In response, the Director of Public Health explained that children and adults in deprived communities had poorer oral health due to poorer diets and a lack of regular toothbrushing routines. The Director of Place Based Delivery explained that the negative impact of deprivation on oral health was not dissimilar to the impact of deprivation on general health outcomes. The importance of preventing tooth decay, by providing targeted support and raising awareness in deprived areas, was highlighted.

 

A discussion ensued and it was agreed that in order to improve the oral health of Middlesbrough’s population, residents needed to adopt behaviours that supported oral health and dental care services needed to be accessible.

 

A Member raised a query regarding the recruitment of overseas dentists. In response, the Director of Place Based Delivery advised that enquiries would be made to clarify the process for contracting dentists, including those overseas. It was confirmed that once that information had been obtained, it would be shared with the scrutiny panel.

 

A discussion ensued and it was commented that a national dental contract reform was required to enable the challenges encountered, in respect of contract arrangements, to be fully considered and addressed.

 

AGREED

 

That the information presented at the meeting be considered in the context of the scrutiny panel's investigation.