Introduction

Prior to the start of the COVID-19 pandemic, in 2019, an estimated 280,000 people were homeless in the UK.1 Many studies have shown that the homeless population suffer from much higher levels of oral disease.2 This was illustrated in a recent survey by Groundswell charity, whereby 90% of their participants reported issues with their mouth, 60% had experienced pain and 70% reported lost teeth since becoming homeless.3

People experiencing homelessness often find it difficult to access general dental services and are instead much more likely to attend hospital emergency departments for urgent care.4 This pattern of attendance is often due to numerous barriers in their day-to-day lives. Examples include: chaotic lifestyles; having to meet more urgent needs such as finding accommodation; dental anxiety; safety concerns; financial restrictions; not having an address; and uncertainty about available dental services.5 The structure of the NHS dental health system also presents many barriers to access for homeless populations. Some of these include cost, inflexibility of appointments, limited collaboration between services, lack of training/skill development and staff concerns about treating homeless patients.5 Meanwhile, it is recommended that to improve access, change must start from health services by taking into account homeless peoples' needs and tailoring resources to meet them.5 Considering that the vast majority (over 80%) of dental care is delivered via general dental practices in the UK,6 there is scope for providing services to individuals facing homelessness. In this article, we aim to introduce the model of a dental initiative, which provides insights into addressing some of the barriers facing homeless populations in accessing dental services.

How the initiative started

The initial planning for this project started two years ago, when the practice's principal developed the idea. He stated: 'toothache probably rates about 8-10 on a pain severity scale, yet it usually takes minutes to resolve. With this in mind, I felt it was my duty to address this problem for vulnerable communities who cannot access regular dental services. This way, I was making a difference'.

As a result, the project was officially launched in October 2020, during the COVID-19 pandemic. It is run in a predominantly private dental practice in Acton, West London.

Reasons for attendance and services provided

Since the start of this project, the dental team has identified two main reasons for attendance of homeless patients:

  • When individuals experience dental pain and need emergency care

  • When individuals go through a 'turning chapter' in their life, whereby the poor appearance of their teeth becomes a concern and barrier to progress. If adequate dental care is provided, it can help to improve their smile, which can subsequently lead to other positive outcomes such as improved confidence and motivation. The individual is then more likely to be able to succeed in other areas such as employment, education and personal relationships.

To meet the above demands, the practice provides services under the categories of emergency and routine dental care as follows:

  • Emergency dental care is provided as and when needed throughout the week, usually on the same day or as soon as an appointment becomes available

  • Routine dental care is provided on selected day(s) of the month. At present, the practice principal directly liaises with the dental team and homeless charity staff in order to select one Sunday per month for this purpose. This is usually organised 1-3 months in advance. A date is selected based on the availability of staff and patients and is open to change depending on the circumstances of individuals involved.

At this early stage of the initiative, patients are only accepted for dental care via referral from managers working in charities or organisations related to homelessness. This is believed to make the vetting process more accurate because staff in these organisations have usually developed a closer relationship with homeless individuals. For a patient to be accepted, two forms must be completed. First, the referring organisation signs a referral agreement form, which states the mutual rights and responsibilities of the referring organisation and dental practice. Then, eligible homeless clients are provided with a patient referral form that states the mutual rights and responsibilities of the patient and dental practice.

The dental practice's criteria for accepting patients include those who are rough sleeping, homeless, living in temporary accommodations, on a move-on pathway (from supported accommodation to a permanent home), vulnerable migrants and refugees who experience homelessness. There is currently no catchment area for this project and patients are accepted from any distance, though the majority are referred from local boroughs in London. All patients are required to arrange their own means of transport to and from the practice and in some cases this can be done in liaison with their referring charities and organisations.

During a patient's first appointment, a dental examination will be carried out where patients are asked about their priorities and preferences for treatment. Depending on these and clinician diagnosis of patient needs, a treatment plan will be agreed between the clinician and patient. All comprehensive dental care needed to maintain oral health and function is available to homeless patients. These include oral health promotion, fillings, extractions, hygiene/periodontal treatment, crowns, dentures etc. More advanced treatments such as bridges and implants are also available for patients that are considered high priority, especially if there is an aesthetic necessity regarding the patient's recovery from their homeless journey. As a result, dental care has become part of the overall rehabilitation and recovery of patients during their journeys out of homelessness.

Collaborations

It was recognised early on that running this project is not possible without a strong working relationship and collaboration with outside organisations. The main collaborations for this project are with homeless charities and organisations and a dental laboratory, both of which are described below in more detail.

Homeless charities and organisations

Collaborating with homeless charities and organisations is an essential component of this project. This is because individuals experiencing homelessness often face competing priorities and barriers on a day-to-day basis. This can mean that they may not be able to attend dental appointments as regularly as non-homeless patients. As many homeless individuals have close communication with charity staff and a level of familiarity already exists, collaborations were built with these organisations since the start of the project. This enabled charity staff to act as intermediaries in developing more trust between patients and the dental team. Throughout this initiative, homeless charity staff have successfully performed the following roles:

  • Identify homeless patients who are likely to be suitable for treatment in general practice

  • Liaise with the dental practice in order to arrange appointments at a time and date that is most suitable for patients

  • Accompany individuals to their appointment and often stay in the practice until their session is complete.

Dental laboratory

The practice has developed a close working relationship with Estetica Dental Lab, a leading UK dental laboratory that agreed to provide all types of prosthetic and restorative treatment for homeless patients. Further, this lab has agreed to provide all services free of charge, as well as using the same material and procedures as for non-homeless, private patients. This initiative fitted well with the long-term vision of Estetica Lab, which included providing some level of voluntary services to marginalised communities from the outset. As a result, the organisational structure, goals and facilities of the lab were found to be important in success of this collaboration. The lab's ethos has been to create an environment that is friendly, open and has a strong element of communication. This means that the organisational goals of the company are shared and discussed with the staff, who are often happy to be a part of its long-term vision. Collaborating in this initiative has further reinforced the positive culture of the lab and staff have found it rewarding to be part of the recovery journey of patients who are experiencing homelessness.

Financial considerations

Although financial considerations were initially an important concern, these were alleviated over time due to the willingness of the dental team members, homeless charity staff and dental laboratory to provide voluntary, unsalaried services on selected days. Regarding the dental laboratory, its manager funds staff wages and costs of materials via the company's funds, so that staff are paid for the work that they produce and homeless patients receive all services free of charge. While recent advances in dental technology (such as the use of milling machines for prosthetic work) have made the financing of this project more sustainable, it still requires significant dedication and commitment, which has been made possible in collaboration with the laboratory staff and dental clinicians involved. This meant that the only remaining expenses were running the practice and the use of materials for direct restorative treatment. Considering that the significant expenses associated with staff wages and laboratory work were eliminated, these remaining costs have been covered by the practice without imposing a significant financial burden. Because the practice has a very small NHS contract, they currently do not use NHS funding for any of the services provided to homeless patients (including patients who are exempt from NHS payments).

Additional support for patients

Besides providing dental care, the practice arranges for a range of additional support on days that are allocated to homeless patients. This includes regular collaboration with local soup kitchens, cafes and restaurants, which provide food and snacks (Fig. 1).

Fig. 1
figure 1

a, b) Staff from a local cafe provide catering on days that are dedicated to homeless patients

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The practice staff also make efforts to create a welcoming atmosphere by occasionally inviting local music bands and arranging seating outside of the practice (due to COVID-19 restrictions) in a way that patients and staff can socialise and interact while waiting for dental appointments. There are also occasional visits by local pastors and support workers, who provide spiritual and psychological support for patients. The above help to provide a positive environment, whereby individuals can strengthen their social connections and systems of support. Emphasis is placed on making patients feel welcome and creating interpersonal relationships, which has been found to improve motivations of everyone involved.

Key learning points

Management

Providing dental services to homeless populations often needs ongoing support and direction from the practice principal and management team. In this case, the initial idea for this project was proposed by the practice principal and the practice management team was asked to implement it in collaboration with the rest of the dental team.

Organisational culture

Before the start of this initiative, the practice had already established a largely staff- and patient-oriented organisational culture. This meant that the practice principal supported the management team, who in turn, supported staff members to provide a patient-centred focus to their dental care. This includes placing an emphasis on building rapport with patients, taking into account patient priorities and preferences, flexibility, ensuring strong communication and feedback systems within the practice.

All protocols and processes have also been developed in accordance with this ethos and the practice has implemented the same principles for its homeless services. Staff and patients are encouraged and supported to propose their ideas and input in order to audit and refine protocols and processes over time. The interior architecture and design of the practice is also built in accordance with its staff and patient-centred organisational culture. The practice is located in a spacious building with two floors; while all dental treatment and decontamination rooms are based on the ground floor, the first floor is dedicated largely to an eating area, communal seating, a large games room and an office. This has provided plenty of opportunities for staff to communicate, socialise and have fun beside their daily work routines (Fig. 2).

Fig. 2
figure 2

Some members of the dental team providing voluntary services on days that are dedicated to homeless patients

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Safeguarding and safety

The selection of patients who would be suitable for treatment in general practice was an initial concern for the dental team because of safeguarding and safety concerns. This was alleviated soon after the homeless charity staff started collaborating with this initiative. The significance of this is two-fold: first, patients are selected by homeless charity staff who already know them well and can confirm their suitability for dental treatment in general practice; and second, charity staff accompany patients and often stay for the duration of their dental treatment, therefore providing additional support if and when needed.

Positive impacts of the initiative

Despite initial concerns and considerations, the success of this initiative has meant that members of the practice's dental team are happy to continue providing voluntary care on dedicated days. This was largely brought about by close personal contact of staff with homeless patients and getting to know them more closely as individuals. Witnessing the positive impact of dental care on an individual's wellbeing, confidence and life journey has created many memorable experiences for the practice team. Hearing patients' life stories appears to be an important component of this process and staff have overall found it a very rewarding experience. This is reflected in the following quotes from staff working in the dental practice, laboratory and homeless charities:

  • 'As I came from a war-torn country where everyone there needs help, I really believe that there is happiness in giving. I felt so happy being able to help in this initiative, especially seeing a smile on every single face after each treatment was done' (Alaa, dental therapist)

  • 'I am so proud to be part of this project. It is the best feeling ever to see people smile. We are really changing peoples' lives' (Madalina, head nurse responsible for managing the homeless weekend sessions)

  • 'As part of Angelo's team and working in an extremely busy lab and still being able to contribute to less fortunate people's welfare by offering free dental products shows that there is always room for help no matter the circumstances. I believe that Angelo and Dr Radi's project is greatly admirable and I am glad to be part of it. Being able to produce smiles that break down any social barrier is exceptionally fulfilling' (Sara, lab technician, Estetica Dental Lab)

  • 'The psychological impact on the homeless of having teeth problems while sleeping on the streets is another big negative thing for people to deal with. And when these issues are lifted from their shoulders, it makes such an amazing difference to so many peoples' state of mind, lifting them out of the crisis of pain. We're so glad that Dr Radi and his team are making such a big difference to so many people in need' (Mark, former homeless client and founder of charity, City Harvest)

  • 'This project has been instrumental in keeping our homeless clients' oral health in good condition. So often, when you are on the street, you forget about being healthy and cannot afford these treatments, but this project makes a great difference to the clients. Being able to get treatment within 48 hours is incredible and so beneficial to all of our clients' (Ian, Acton Homeless Concern charity).

Conclusion and future plans

Given the current climate of the COVID-19 pandemic, dentistry and general practice, providing voluntary dental services may appear to be a difficult task. Our aim was to show that given the motivation, adequate facilities and collaborations, it is possible for colleagues in general dental practice to provide care to patients experiencing homelessness. It is our view that the rewards of this work often outweigh its challenges and we are keen to continue discussions on this topic among the UK dental community. For colleagues who may be interested in collaborating with this initiative or who would like more information, please contact alshaikhradi@hotmail.com.