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