The role of the dental team in promoting health equity

Key Points

• Stresses oral health inequalities are a major public health problem.

• Highlights dental teams are in an important position to actively engage in promoting oral health equity, both for their patients and the wider community.

• Suggests dental professionals in particular have a role to play as advocates for policies to tackle oral health inequalities.

Abstract

A recent important report endorsed by several prestigious and influential medical and dental organisations has outlined what health professions can do to reduce health inequalities. Despite overall improvements in oral health in recent decades, there are unacceptable inequalities in oral diseases. Urgent action is needed to reduce these unfair and unjust oral health inequalities that exist across society. Primary care dental teams are in an important position to become actively engaged in promoting oral health equity, both for their own patients and the wider community. This paper highlights practical ways that dental teams can become involved in action to reduce oral health inequalities.

Introduction

The UCL Institute for Health Equity recently published a major report outlining how health professions can contribute to reducing the unfair and unjust health inequalities that exist across society.¹ The report Working for health equity: the role of health professionals was endorsed by a host of prestigious and influential medical professional organisations including the Royal Colleges of Physicians, Psychiatrists, General Practitioners, Paediatrics and Child Health, and Obstetricians and Gynaecologists, and many other allied health professional groups. In recognition of the relevance and importance of the topic of oral health, a number of important dental professional groups including The Dental Schools Council, The Faculty of Dental Surgery, Royal College of Surgeons of England, The Faculty of General Dental Practitioners (UK), Royal College of Physicians and Surgeons of Glasgow, The Royal College of Surgeons of Edinburgh and The British Association for the Study of Community Dentistry also all supported the publication.²

The dental profession is now part of a powerful coalition of professional groups committed to tackling health inequalities. This paper highlights practical ways that the primary care dental team can promote oral health equity for their patients and their wider community. The NHS is going through yet another period of major structural, organisational and policy change. In England, a totally new commissioning and organisational landscape has been created with the formation of NHS England. A unique opportunity now exists to integrate action on tackling both oral and general health inequalities. The time for this action is now.

Nature of challenge

In recent decades in the UK and other developed countries, oral health has steadily improved for the whole population. Caries rates have reduced dramatically among children and young people³ and levels of edentulousness have declined significantly, even among the oldest people.⁴ Nevertheless, unacceptable marked inequalities persist in oral diseases. As all dentists know, dental caries, periodontal diseases and oral cancers are more prevalent among poorer sections of society.⁵ It is important to recognise, however, that poorer oral health is not confined to only the most disadvantaged segments of the population, so simply targeting those groups is not the solution. Inequalities in health exist across all groups within society in a socially graded fashion in a step-wise manner: the social gradient. Those at the top of the social gradient have better oral and general health than those just below them and that pattern occurs right down the social scale because exposure to almost all risk factors is inversely related to social position. From early life to old age, clinical and subjective measures of oral health are socially graded in the same consistent stepwise fashion.⁶ The social gradient is a universal phenomenon found across different countries and populations, for both general and oral health outcomes. Reducing health inequalities is therefore everybody's business as it affects the whole of our society, not just the poorest. To reduce the social gradient in health actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage.⁷

An extensive body of international research has explored what causes this universal social gradient in health.⁸ The conclusion is the overriding importance of what is termed the social determinants of health inequalities; 'the conditions in which people are born, grow, live, work and age; and the structural drivers of those conditions – the inequitable distribution of power, money and resources'.⁸ Oral health inequalities share a common set of causes as inequalities in general health, highlighting the need for an integrated approach to promote greater health equity (Fig. 1).⁹ The complex and inter-related causes of inequalities requires coordinated upstream action including healthy public policy and the creation of supportive environments for good health. However, healthcare systems including primary care dental services also have an important contribution to make in reducing inequalities.

Figure 1

Conceptual framework for social determinants of oral health inequalities.⁹ Adapted from the WHO Commission on Social Determinants of Health Framework⁸

Moving the agenda forwards – opportunities for clinical dental teams

Primary care dental teams are in a distinctive position to become actively engaged in promoting oral health equity, both for their own patients and the wider community. Dental teams have ongoing contact with many sections of their local communities and across the entire age spectrum from infancy to old age. Dental teams get to know families and understand their lives in great detail through continuity of care often over many years, and some cases across generations of the same family. A trusted professional relationship is often established providing unique insight into patients' lives. Within local communities dentists are also respected professionals with a high standing and position of influence and authority. Dental teams are therefore ideally placed to take action on some of the social determinants of oral health inequalities in their local communities. Various opportunities for action will now be outlined.

Importance of workforce education and professional training

To enable dental care professionals to successfully tackle oral health inequalities and to take action on the social determinants of health, they require the necessary knowledge, skills and attitudes. The BDS and other undergraduate programmes, postgraduate education courses and CPD training should all cover the fundamental concepts relating to the social determinants of health and oral health. All members of the dental team need to understand the nature and causes of oral health inequalities, and be aware of examples of effective strategies to promote oral health equity. Key skills required to tackle social determinants include communication skills, developing partnerships, advocacy and lobbying skills. Practice-based skills also include taking a comprehensive social history and making referrals to relevant social, welfare or other agencies that have the appropriate expertise to deal with complex personal and family problems.

The General Dental Council (GDC) should place greater emphasis on oral health inequalities in future revisions of curriculum guidance to dental schools. The Dental Schools Council endorsed the publication of Working for health equity and is committed to encouraging dental schools to place greater emphasis on the social determinants of oral health in the undergraduate dental curriculum.¹ However, all members of the dental team need to be equipped with the necessary understanding and skills to empower them to be more engaged in this agenda. Dental deaneries, local education training boards (LETBs) and other training bodies therefore need to develop and extend relevant educational opportunities.

The need to understand oral health needs of the local population

A major first step in addressing oral health inequalities is to understand the nature of the problem to be addressed. Unlike many other medical clinical conditions that may require complex and expensive diagnostic testing, most oral diseases are relatively easy and simple to diagnose, either in a clinical environment or in epidemiological surveys. To assess the oral health needs of patients it is important to include relevant social information in history taking, in addition to the core clinical and behavioural information collected. Recording background social data, for example occupational status, systematically on all patients provides a useful database of patients' characteristics and may help in developing a profile of the practice population.

Dental professionals need to reorient their perspective away from solely considering an individual clinical view, the 'clinical gaze', to one that also considers a wider population focus. Adopting a broader population perspective may help practitioners to appreciate the 'bigger picture' beyond the confines of their clinical setting. Useful epidemiological data on the oral health status of children (5-, 12- and/or 14-year-olds) living in the local area may already be available through contacting the local consultant in dental public health. Other local surveys of different population groups including, for example preschool children and older people living in care or nursing homes, may also have been conducted and reported in the Joint strategic needs assessment (JSNA) reports available from the local public health department. Public health departments may also be able to provide useful details of the local population in terms of the socio-demographic and economic profiles of local neighbourhoods. This will provide a good overview of the nature and diversity of the local population.

Focus on early life – foundations of good health

A key recommendation in the Marmot Review on health inequalities was the importance of giving every child the best start in life.⁷ Routines and behaviours established in early life often track into adolescence and adulthood and are therefore very important. Dental teams are in a key position to support and help pregnant women and families with young children. Oral diseases can have a significant negative impact on the quality of life of pregnant women, nursing mothers and preschool children.¹⁰ For example, severe untreated caries may not only cause pain, discomfort and disruption to sleeping and eating habits, but may also adversely affect child growth and school performance.¹¹ It is therefore of paramount importance for dental professionals to provide appropriate prevention and high quality treatment to these groups. Dental teams may need more training and support to develop their clinical and management skills needed for the effective care of preschool children. In addition, creating a more 'child friendly' practice environment where young children feel more at ease will be helpful. In some areas dental professionals have established effective links with their local children's centres and primary schools to facilitate access to dental services and to provide oral health support and advice.

Ensuring equity of access and quality of treatment outcomes

One of the core professional goals of primary dental care services is to provide accessible and appropriate services to the local population. Reviewing the accessibility of the practice entails more than simply considering whether or not the surgery is accessible to disabled people and wheelchair users, important though that is. A broader concept of access is needed such as that proposed by Penchansky and Thomas,¹² which encapsulates a range of dimensions such as acceptability, affordability and accommodation. Conducting a patient satisfaction survey to assess users' perceptions of the practice may provide useful information on issues that may need to be addressed. Of particular importance is a review of the appointments system, including how requests for emergency appointments are dealt with. A degree of flexibility may be required to accommodate individuals and families with more chaotic lives. It is also important to consider how the oral health needs of vulnerable groups such as housebound older people, disabled people and the homeless are best met. Linking with the local salaried dental services may be valuable in providing care for these vulnerable groups.

A team approach

To be successful in tackling oral health inequalities requires the active engagement of all members of the dental team. Practice principals may lead and coordinate action within the practice and beyond, but it is vitally important to delegate roles and responsibilities to other team members. For example dental nurses and hygienists have important roles to play in supporting the preventive care of patients. They should be aware of the fact that the causes of dental conditions, such as sugars consumption, smoking and poor hygiene are causes common to most non-communicable diseases. Therefore, their activities should be integrated and consistent with other health workers. Reception staff have a key role in welcoming all members of the community and signposting patients to other local services and agencies. Ensuring staff members are properly trained and have access to relevant resources is essential.

Delivering evidence-based clinical prevention

It is fundamentally important that dental teams provide up to date evidence-based clinical preventive care to their patients. This should be tailored to the needs of the patient and should aim to prevent oral diseases and promote general health, where applicable. A third edition of Delivering better oral health will soon be published and this will provide comprehensive guidance on all aspects of prevention including appropriate use of fluorides, tooth brushing and oral hygiene advice, and the prevention of erosion.¹³ Guidance is also given on healthy eating advice, guidance on stopping smoking and alcohol misuse support. This is in recognition of the importance of these shared risks on both oral and general health. A new section will also provide guidance on supporting behaviour change among dental patients. A key element of this is understanding the processes and barriers involved in changing health-related behaviours, and the support and assistance patients need to achieve sustained long-term change in behaviours.

To reduce oral health inequalities within a practice population preventive care and support should be targeted to those with a recognised increased risk of future disease. In the current NHS dental practice pilot schemes in England, a Red Amber Green (RAG) system based upon patients clinical, medical, social and behavioural profiles is being used to identify higher risk individuals. Patients with more complex social, medical and behavioural needs will require extra time and care to enable them to benefit from preventive support. Well-developed communication skills and effective team working are essential.

Need for signposting and linking with local partnerships

It is neither feasible nor realistic to expect dental teams to deal with all the difficult needs of their patients. Signposting and referring patients with more complex needs to appropriate local services is therefore essential. For example, dental patients who are heavy smokers, or dependent drinkers, or those with an eating disorder all require more specialised support and advice from the relevant clinical service. In addition to these more obvious clinical referral networks, by recognising the broader social determinants of inequalities it is also important to facilitate access to other support services that may assist vulnerable patients and their families. In some larger general medical practices staff from the Citizens Advice Bureau and other welfare agencies provide 'advice clinics' to patients who have particular problems with housing, welfare benefits, debts and immigration. Similar arrangements could be set up in larger dental practices. At the very least, contact information about these services should be available to dental patients.

In England, Health and Wellbeing Boards are now responsible for conducting the Joint Strategic Needs Assessment and producing the local Joint Health and Wellbeing Strategy. It is important for dental professionals to be aware and, where possible, become involved in these strategies as they provide opportunities for local partnership working and the chance to raise the profile of oral health among local decision makers and commissioners. In other parts of the UK similar strategic opportunities for partnership working exist.

General dental practitioners as local employers

The NHS is the largest employer in the country and therefore has an important role to play in supporting, nurturing and developing its staff, including promoting their health and wellbeing. Large acute hospital trusts are very important local and national organisations; they have influence and control over large budgets and therefore considerable purchasing power in terms of employment and commissioning decisions. Although much smaller in scale, the thousands of dental practices across the country are collectively employers of a considerable number of staff and they also have a key role in recruiting, training and employing local people. For example recruiting and training young people as trainee dental nurses can make a contribution to the economic and employment opportunities of the community.¹⁴ Employing and training local people may also benefit the dental practice by forging links with the local community and improving communication with patients.

Organisational and management structures and policies need to be developed to ensure that recruited staff are properly trained and supported in their roles. Increasing opportunities for career development now exist for members of the wider dental team with the advent of extended duty dental nurses and greater autonomy for dental care professionals. Links to local further education colleges, LETBs and universities are important to embed these initiatives with training organisations.

The role of advocacy – supporting action on determinants of inequalities

As many of the factors that affect oral health inequalities lie outside of the direct influence of the health sector, dental professionals have an important role to play as advocates and instigators of change. As health professionals, dentists are experts in oral health, and as trusted and respected members of their local communities have influence locally, and acting collectively, as well as at a national policy level.

Local dental committees and British Dental Association (BDA) local branches could become more actively engaged in matters beyond clinical concerns. Influencing Health and Wellbeing Boards and Local Authority Health and Scrutiny Panels to focus on issues relevant to oral health and inequalities may be a first step to influencing local policy decisions. Local Professional Networks (LPNs) also provide an opportunity to coordinate oral health improvement strategies (further information in Appendix 1).

At the national level dental organisations such as the BDA, British Association for the Study of Community Dentistry, British Society for Disability and Oral Health, and British Society for Paediatric Dentistry all have a potential major influence on national policies linked to tackling oral health inequalities. It is encouraging to see in a recent BDJ editorial that the new President of the BDA, Barry McGonigle advocated action on policies to reduce sugars consumption across the population to combat caries and obesity.¹⁵ Indeed the BDA has recently joined forces with the Academy of Medical Royal Colleges to lobby for policy and legislative changes to reduce sugars consumption, including a 20% tax on sugary drinks and tighter controls on food advertising targeting young children.¹⁶ Concern over childhood obesity has placed a spotlight on sugar and the urgent need for effective policies to reduce sugars consumption. Collectively dental organisations acting together and in coalition with other health and campaign groups are potentially a powerful lobbying force for such changes in policy.¹⁷

Box 1: Appendix 1

The role of Local Professional Networks

The concept of Local Professional Networks (LPNs) was first documented in the NHS Commissioning Board's June 2012 publication Securing excellence in commissioning primary care, which outlined how they could facilitate clinical input and leadership in service improvement and commissioning. Since April 2013 dental LPNs, otherwise referred to as Local Dental Networks (LDNs), have been established across England, being hosted and supported by the area teams of NHS England. LDNs provide a vehicle through which grass roots dental clinicians can develop and own an oral health strategy, in response to a needs assessment informed by the expertise of Public Health England to identify local oral health inequalities. This ownership may act to empower local dental clinicians to deliver their strategy to achieve greater oral health equity within the communities they serve. These local dental clinicians include all dental practitioners working across primary care as well as clinicians across secondary care and the salaried services. Engaging with clinical commissioning groups and pharmacy LPNs provides an opportunity for a multidisciplinary approach to improving oral health, while interfacing with local Health and Wellbeing Boards helps to deliver an agreed local agenda of oral health and dental services improvement.

Dr Amit Rai, Chair Dental LPN, Surrey and Sussex

Conclusions

Urgent action is needed to reduce health inequalities. As outlined by the recently published report Working for health equity,¹ primary dental care services have an important contribution to make to tackle health inequalities. A range of practical measures can be implemented by dental teams, which can make a real impact in reducing existing oral health inequalities. In particular, dental professionals have an important role to play as advocates and instigators of change in policies relevant to promoting oral health equity.