Models of dental care for people experiencing homelessness in the UK: a scoping review of the literature

Abstract

Background People who experience homelessness have poor oral health and face barriers to accessing care. Recommendations have been outlined for health services to address their needs, termed 'inclusion health'. The Smile4Life report recommended three 'tiers' of dental service: emergency, ad hoc and routine care. Other medical services have developed into different models of care, for example mainstream practices with enhanced services for people who experience homelessness. There is little understanding of how inclusion health recommendations have been implemented across dental settings.

Aims To describe and compare dental services that exist for people who experience homelessness in the UK.

Methods Two Medline searches were performed in October 2020 to assess the models of dental care for people who experience homelessness in the UK.

Results Nine dental services in the UK were identified who treated people who experience homelessness. Most did not explore definitions of homelessness. There were a mixture of models, including using blended approaches, such as different sites and appointment types, to flex to the needs of their population.

Conclusion Many services that are dedicated to treat this population are based in the community dental services which allows for flexible models of care due to sporadic patient attendance, high treatment requirements and complex needs. More research is required to determine how other settings can accommodate these patients, as well as understanding how more rural populations access dental care.

Key points

• Different models of dental care have been recommended for people experiencing homelessness in the UK.

• This review of the literature reveals the different locations and models of care that have been evaluated in the UK.

• This population have high dental needs and struggle to access dental care. Various solutions have been implemented across different services depending on the needs of their population and the resources available.

Introduction

Vulnerable groups and people who face social exclusion are more likely to experience poor oral health than the general population¹ and therefore have a higher need for oral health care services. They are also more likely to experience barriers to accessing these services.²

In particular, people experiencing homelessness suffer from tri-morbidities of poor mental health together with poor physical health and substance misuse or addiction.³ These can all lead to significant harm to the individual, including a negative impact on their general health, wellbeing and social interactions, as well as their oral health.^3,4

Classification of homelessness

The European Federation of National Organisations Working with the Homeless have attempted to classify homelessness by developing the European Typology of Homeless (ETHOS).⁵ This categorises people affected by homelessness within a broad context of accommodation-related definitions (Table 1).

Table 1 ETHOS classification of homelessness. Reproduced with permission from Amore et al., 'The ETHOS Definition and Classification of Homelessness: An Analysis', European Journal of Homelessness, 2011, FEANTSA⁵

Recent figures have estimated that 320,000 people are homeless in the UK, which is roughly one in 200 people.⁶ This is an increase of 4% on the previous year. During the COVID-19 pandemic, 14,610 people were housed temporarily in homeless hotels in the Everyone In campaign from March to May 2020.⁷ Everyone In required local authorities to urgently house rough sleepers and those at risk of homelessness in order to protect their health and reduce the transmission of COVID-19.⁸

What is more, there is an uncertain number of 'hidden homeless' who are not known to the authorities. They may be 'sofa-surfing' or sleeping in cars, on public transport or in the countryside.⁹

Homelessness and oral health

Many studies indicate that homeless people have poor oral health and experience higher levels of dental caries and periodontal disease than the general population,^4,10,11 and that oral health is a source of decreased oral health-related quality of life⁴ for this population. Many will access services that are unequipped or inappropriate as a result of difficulties accessing dental care, for example, 36% of rough sleepers have accessed accident and emergency (A&E) departments because of toothache.¹⁰ This can cause inefficiencies, with an attendance at A&E costing the NHS £419,¹² but also, many A&E departments do not have access to a dental or maxillofacial departments so cannot effectively manage dental problems.¹³

Several barriers are encountered when designing and delivering services for these groups of patients, such as higher failure-to-return rates, high levels of dental disease, stigma from the profession and difficulties in communication. These barriers can result in failed attempts to sign up to a dentist, with only 36% of rough sleepers in London being registered with a dentist.¹⁴

Designing dental services for people who experience homelessness

Recommendations have been outlined for health services aimed specifically at homeless people. The Smile4Life survey¹¹ recommended comprehensive dental services for homeless people consisting of three 'tiers' of service:

• Emergency dental services for those unable to take advantage of routine dental care

• Ad hoc or one-off 'occasional' single-item treatments that can be accessed without the need to attend for a full course of treatment

• Routine dental care or a full course of treatment.

It has been recommended that the oral health care needs of homeless people could be addressed by a mixture of mainstream and dedicated provision that acknowledges the additional needs of homeless people. The British Dental Association¹⁵ and Faculty of Inclusion Health¹⁶ have made recommendations for addressing the dental needs of the homeless population (Box 1).

The health needs of this group are becoming more of a priority on a national level, with £30 million committed in the NHS Long Term Plan to provide health care services for people who experience homelessness¹⁷ - this includes oral health.

Other primary care services across England have been evaluated and have shown that various models have been developed; however, little is known about their effectiveness, staffing, service design or cost-effectiveness in engaging and treating people who are homeless.¹⁸ The services evaluated were mostly general medical practice (GMP) services and did not focus on dental services. They identified four specialist homeless health care models:

• Mainstream GMPs that holds regular sessions for people experiencing homelessness in a drop-in centre or sees them at the GMP

• Outreach team of specialist homelessness nurses that provide advocacy and support, dress wounds etc, and refer to other health services

• Full primary care specialist homelessness team that provides dedicated and specialist care. Co-located within a hostel or drop-in centre

• Fully coordinated primary and secondary care that provides an integrated service, including specialist primary care, outreach services, intermediate care beds, and in-reach service to acute beds.¹⁹

There is a gap in knowledge of how dental services have implemented these recommendations and their effectiveness mapped to the local needs and geography of a service's population. Information and data have yet to be fully compiled to investigate the national picture of 'inclusion oral health'.

Box 1 Faculty of Inclusion Health and BDA's recommendations for dental services for people who experience homelessness

• Inter-service communication and an agreement of what constitutes best practice for delivering socially inclusive dentistry

• Production of a central hub assimilating data and providing an overview of the oral health needs and services available

• Targeting of areas with the greatest need for dental care and the fewest available resources to meet that need that is, equitable funding and service development

• Requirement of different modes of delivery to address different categories of need in different localities, which should include a mix of 'safety-net' services delivered at fixed sites, for example based at facilities for homeless people and outreach clinics (to include mobile dental clinics) and mainstreaming to local NHS primary dental care

• To ensure mainstream services must not deliberately prevent access by excluded groups

• Provision of preventative advice and support from dental practitioners in homelessness services to raise awareness of dental hygiene and encourage improved self-care

• To work with the next generation of dental practitioners, through dental schools, to increase their awareness of the needs and perspectives of homeless patients

• Flexibility in dental services, in terms of locations and opening hours

• A combination of fixed location and outreach provision - 'outreach-inreach'

• An integrated, multidisciplinary service provision and coordinated case management to deal with the individual's needs

• Clinicians with appropriate clinical expertise to enable people who experience homelessness to access mainstream dental services wherever possible.

Information taken from^15,16

The scope of this review

In summary, people who experience homelessness experience poor oral health and many barriers to accessing dental care. There is little understanding of how 'inclusion health' recommendations and guidelines have been implemented across dental settings to address the needs of this population, in comparison to medical models. With different commissioning arrangements across different settings, as well as the potential varying needs of different homeless groups, how do we design effective and impactful services across dentistry in the UK?

This scoping review aims to describe and compare models of dental services that exist for people who experience homelessness in the UK.

Methods

Two literature searches (Fig. 1) took place in October 2020: Medline (n = 5), the British Dental Journal (n = 2) and The King's Fund.

Fig. 1

PRISMA flow diagram of literature search

As discussed, there are a wide range of terms to describe homelessness. The search terms used attempted to cover this wide range (Table 2). The exclusion criteria were:

Table 2 Eligibility criteria

• Population - children were excluded as they do not fall into the remit of special care dentistry in the UK (this review was completed as part of a MSc in special care dentistry). Prisoners and people in institutes were excluded as they are housed within institutes which have health care, including dentistry, provided

• Studies that only described the oral health of people who experience homelessness. Anything published before 2010 would be unlikely to still be providing a service and population and organisational changes will be significantly different. There have been significant organisational changes within NHS dentistry since the implementation of the 2006 NHS general/personal dental services contract, for example, where units of dental activity (UDAs) are used to commission and remunerate dental services in England and Wales

• Services outside the UK.

Further evidence was included through personal and professional networks where papers had not been published yet (n = 2), presented at conferences (n = 1), or published in grey literature (n = 1).

Quality assessment

It was not possible to use a universal tool to appraise all the studies, since there were several different types of studies included; although on the whole, the majority were service evaluations. An unpublished paper was excluded from analysis as it was incomplete in its data analysis. Another paper published was an additional paper²⁰ describing the same service in operation, and so these papers were evaluated together as one study.

The Critical Appraisal Skills Programme tool was used to critically appraise the studies where qualitative methods were used and no studies were excluded on the basis of quality assessment. The models described in the studies were analysed to describe and compare the different elements of the service design (Table 3).

Table 3 Comparison of the models of dental services for people experiencing homeless in the UK

Results

Location and access to services

Most of the dental services in this review which serve people who experience homelessness were based in London and the South East (n = 7), as well as other urban areas, such as Manchester or Plymouth (n = 2).

The majority of the services centred around fixed sites (n = 7) and outreach initiatives (n = 5) and some used mobile dental surgeries (MDSs) (n = 4). Outreach varied from having one outreach site to up to 12. On the whole, the majority of studies have a blended model, using more than one location or method to access and care for these patients. Only one study²¹ described the provision of domiciliary care.

Those services which used an MDS to provide care described the careful planning and risk assessment of providing care in this way. The majority of studies were situated in primary care, mostly based in community dental services (CDSs) (n = 6), although there were services based in general dental practice (n = 1), a hospital (n = 1) and a voluntary service in 'pop-up' homeless centres over the Christmas period (n = 1).

It was recognised by many services of the need to have an easy-to-access service to remove barriers to care for homeless populations, so many adopted self-referrals (n = 5), but on the whole, there were multiple routes into the services, including professional referrals from health and social care professionals, as well as signposting from the services' outreach.

Workforce

Most services used salaried staff to deliver the service (n = 6) and many also used trainees or dental students to deliver care, oral health promotion (OHP) or facilitate signposting to the service (n = 4). One service used volunteers (n = 1) and only one service used self-employed staff. Some studies^21,22,23,24 also described the use of dental care professionals (DCPs) in delivering their service, either in the form of a link worker (LW), dental nurse or project manager to facilitate access to the service (n = 2) and to be the first point of contact for the patients, or to deliver OHP as part of the offering of the dental service (n = 2). LW activity was also measured,²¹ which demonstrated cost-effectiveness of the role.

Appointments and attendance

There was a blended approach of both fixed and drop-in or flexible appointments being offered. Some of the services did not describe the nature of their appointments (n = 3) - one of these can be explained as it was an OHP service only.

Some services described the frequency of clinics, although none described their opening hours. The voluntary service only operated for six days a year over the Christmas period, but other services offered clinics every fortnight or more frequently. Three studies^14,24,25 were pilot services without a long-term sustainable service.

High failure to attend (FTA) rates were described in some studies and 27-68% of patients seen did not complete their treatment.^21,22,23 This resulted in many studies describing methods they implemented to reduce this or maximise the clinical time available. Many of the services used similar methods, such as reminders, being flexible, and using trusted people (such as LWs) to escort patients to their appointments.

A positive observation mentioned by several studies was that once a patient made their first dental appointment and had a positive experience, many remained in contact with the services and expressed a commitment to returning for further treatment or regular dental check-ups.^14,22

Treatment

Many studies described the high level of treatment needed by their patients, with the majority providing both urgent and routine dental care.

Urgent treatment accounted for 9.4% of appointments for one service,²³ and another²¹ concluded there was greater need for urgent treatments using an MDS (54% of appointments) than a fixed-site clinic. Urgent care was prioritised by all services, as well as meeting the expressed need of the patient at their presentation appointment where possible. Interestingly, Simons, Pearson and Movasaghi described how their evening emergency dental service was not accessed by anybody who experienced homelessness, despite the most commonly expressed need of patients accessing their daytime homeless service was severe or constant pain (40% of attendances). Moreover, only 16 Band 1.2 courses of treatment had been submitted for the 350-patient sample taken, which suggests that although pain is a primary complaint for these patients, their issues are more chronic and they are less likely to access urgent courses of treatment (Table 4).

Table 4 Dental treatment provided

It was also noted that for some services, using an MDS, together with the sporadic attendance of patients, had implications on the type of dental treatment provided. Although an MDS can be fully equipped, more simple dental treatments were offered in order to maximise clinical time. Using an MDS in tandem with a fixed-site surgery in some services enabled patients to have access to all dental procedures, for example, referring patients to be seen in clinics for surgical extractions. One service also offered more specialist services, as it was able to refer to the other services within its CDS, as well as having access to specialists in special care dentistry.²¹

A full complement of routine dental treatments was described among the studies. Only three studies described a breakdown of treatments provided (Table 4). A large amount of treatment needed was described, with high numbers of Band 2 treatments throughout all three studies, that is, extractions and fillings. More complex procedures were, on the whole, rarely offered, such as root canal treatment and crown/bridgework, with only three and one treatment completed, respectively. Although, it is impossible to differentiate these treatments from other Band 2 or 3 treatments as grouped together in an NHS course of treatment.

The voluntary Christmas service had introduced a pilot providing a same day field laboratory denture service in its most recent years of operation. Paisi et al. also demonstrated the high need for dentures, with 72 dentures being made for the 89 patients. This supports previous evidence that there is a high need for dentures in this population.¹⁴

Finances have been reported as a major barrier to accessing dentistry for homeless groups which each of the services addressed by providing free-to-access care, or at least free-to-access urgent care, with exemptions to NHS charges required for routine care.

The studies which described free-of-charge dental treatment were all services working outside of the NHS primary or general dental services contract (PDS/GDS), either in a hospital service, or a voluntary or pro bono service. Of the CDSs providing care under a PDS contract, one reported losing 73.2 UDAs over 30 months in treating urgent patients who were unable to pay and didn't have a valid exemption to NHS dental charges. Another reported one in five of the service users at the hostel service were not in receipt of benefits and could not afford NHS dental treatment.²⁶ In comparison, in the service based in GDS, this situation occurred approximately once a month.

Simons, Pearson and Movasaghi found that 80% of their patients were in receipt of benefits which made them eligible for free dental treatment, with significant differences between the largest three ethnic groups. Only 49% of patients from Eastern Europe received benefits compared to 97% of the Irish/English patients and 81% of the Bangladeshi patients. Only 5% of the patients attending the fixed-site surgery were not in receipt of benefits compared to 25% accessing the MDS. This is compared to Daly, Newton and Batchelor, who found 200 of the 204 patients sampled were in receipt of benefits.

Multidisciplinary care

While the majority of studies were situated in primary care, there was integration within the wider health and social care networks. This included being co-located at the same site as other health services or food facilities, or in open access day centres with social and housing services.

Some services used other stakeholders and team members to engage their population of patients to either engage with the service or to facilitate research surveys, while many engaged with a wide variety of other stakeholders for referrals and signposting.

Definition of homelessness and patient demographics

Most of the services cared for 'homeless' patients, with little inspection of other stages of homelessness (n = 5), followed by hostel dwellers (n = 4), rough sleepers (n = 3), those in temporary accommodation (n = 3) and those rehoused (n = 3). For those studies which examined the definition of homelessness in more depth, the majority of their service users - 49-69% - were rough sleepers.

The demographics of the patients treated in these services reflects the general trends of the demographics of people who experience homelessness in the UK, with 84% of rough sleepers identifying as male and 80% aged 26 and over.²⁷

There were some variations however, for example, in some areas of London, there were a high proportion of patients of Eastern European origin (41.3%) (Table 5). Some services also discussed difficulties in communicating with patients whose English was not their first language and the importance of being able to access interpreting services, such as Language Line.

Table 5 Patient demographics of studies which evaluated their service users

Feedback

No patient perspective or feedback was evaluated in five of the studies,^{14,21,26,24,28} but for those that did, feedback from patients, staff and volunteers was, on the whole, positive.

The positive impacts of the dental services evaluated included:

• Improved oral hygiene

• Enhanced nutrition

• Improved confidence and self-esteem

• Increased trust in health professionals

• Employment opportunities

• Increased capabilities to engage with drug and alcohol services.

Patients' positive feedback described the development of trust between them and the service, including having understanding and non-judgemental staff. They also preferred elements of the service that were flexible and convenient to them, such as close proximity to clinics to where they were staying, same day treatments, appointment reminders and flexibility of appointments. Dental team feedback included positive comments surrounding providing treatment for this population being very rewarding and making a difference to a patient's life. Some services gave positive feedback on the use of the different skill mix, including using dental trainees to expose the next generation of dentists to these communities. There were also comments made which suggested having salaried staff increased flexibility when providing care for this group, allowing the clinician to spend longer with their patients to see to their dental needs and build trust.

Improvements suggested by patients was a greater availability of services that they could access any day of the week and an increase in awareness of the services.

Challenges reported from the dental team were mostly surrounding the challenges of treating patients who have high FTA rates and who have comorbidities that make their management challenging. One service reported the lack of full use of DCP skill mix, as well as recommendations to find sustainable sources of funding rather than relying on pro bono clinics.

Stakeholders valued seeing the dentist on site rather than another member of the dental team, and repeatedly there was feedback of the need for an on-site dental presence, clinic, drop-in or aftercare, as well calls for more joint working between dentistry and other homeless services, such as GMP clinics.

Discussion

The services included in this review used blended and flexible approaches in the delivery of dental care for people who experience homelessness, using what resources were available to them to adapt to the additional needs of these patients.

Frequency of services varied greatly, from only six days a year²⁹ to up to 12 MDSs and 16 fixed site sessions per week.²¹ Some services were pilot or temporary services^14,20,24,25 and others were longer-term regular services.^{21,22,26,25,28} This could have influenced the model of care chosen, for example, prioritisation of urgent care rather than rehabilitation of patients. Several of the studies demonstrated a high demand for their dental service, either by receiving feedback from patients to increase the frequency of the service,^22,29 or by actually increasing the number of clinics provided.²³

Dental models of care in this review trended towards three patterns of delivery (often more than one of these was implemented per service):

• Mobile services - using an MDS, or in one case, domiciliary care

• Outreach - to promote 'inreach' to fixed sites and deliver OHP

• Providing dental care as part of a multidisciplinary team (MDT) - working with other health and social care teams and stakeholders, or having clinics co-located within services that homeless people accessed.

Mobile services

Some studies showed that using an MDS increases engagement, particularly when working collaboratively with stakeholders and LWs, as well as carefully planning the location of the MDS.²¹ The MDS seemed to provide care to a different type of homeless group than fixed-site dental clinics; there were younger people, fewer of them were in receipt of benefits, and there was more emergency care.²¹ As well as this, more rough sleepers seemed to access this model of care and shorter courses of treatment provided.²¹ This may reflect the varying immediate needs and priorities of people who sleep on the streets compared to those who experience other forms of homelessness.

Domiciliary care was only included as a model in one study, despite the high populations of people who experience homelessness who are admitted to hospitals or hostels with increased frailty and co-morbidities.³⁰ Almost 75% of homeless GMPs offer clinics within hostels or day centres,¹⁸ which suggests there is also a need for a domiciliary model of dental care for this group. Providing domiciliary care could be an alternative model of taking care into communities where a MDS is not available or appropriate. When considering this, appropriate risk assessment should be carried out according to guidelines.³¹

There are some limitations of providing mobile clinics. They have increased costs, with a UDA on a MDS costing 2.4 times more than a UDA at a fixed site.²¹ Using an MDS might be a more effective model for certain populations of people who experience homelessness, so a more expensive model could be justified on the local needs of the population. In fact, longer term, using a model which has a high initial cost in the long-term could be more cost-efficient when weighing up reduced attendances for unscheduled dental care, A&E or FTAs at fixed-site services.³²

Outreach

The use of outreach in order to promote 'inreach', where providing screening and signposting in the community leads to follow-up at a fixed-site clinic, was used in several studies, often facilitated by the use of DCPs, trainees or students. There are limitations with outreach alone, where very little dental treatment is usually offered on-site. Feedback from service users and stakeholders in two studies suggested more 'on-site care' as a way to improve the service.^23,28 Signposting to a fixed clinic also relies on the patient attending their follow-up appointment, and without support, such as from an LW or peer advocate, which can be a challenge.

Providing care as part of an MDT

The importance of collaboration between dental services and other health and social care providers was highlighted in several different ways.

Development of bespoke service models using local stakeholders who work with people who experience homelessness, by managed clinical networks (MCN),³⁷ is recommended, as different populations and areas will have varying access to services.

The NHS Long Term Plan¹⁶ confirmed that all areas of England should be served by integrated care systems (ICSs), where health and care organisations, including the voluntary sector and social enterprises³³ across an area, coordinate services to improve health and reduce inequalities. In primary care, integration of services has been developing with the use of primary care networks (PCNs).³⁴ Some PCNs have had initiatives to improve the health of their homeless populations, including the use of coordinated multidisciplinary 'pop-up' clinics.³⁵ The inclusion of oral health within these networks has yet to be demonstrated, although stakeholders to be included within PCNs has been stated to include dental providers.³⁴

When developing dental models of care for people who experience homelessness, partnership working within an ICS or PCN should be considered, led by local MCNs. Engaging with existing services that this population accesses can increase the impact and access to dental care by:

• Creating effective and coordinated referral pathways

• Collaboration with stakeholders and service users with planning of the service and access to people with lived experience of homelessness to inform service design

• Reduce no shows with supportive peer advocacy and chaperoning of patients to appointments

• Sharing of patient information while adhering to data protection legislation.

Further development for dental models of care

Mainstream or specialised services

Some people who experience homelessness might not want or be able to access dedicated dental services, so efforts should be made to encourage integrating them within mainstream services. Within GMP services, there is a conflict of evidence to whether dedicated or mainstream practices are preferable, with one survey finding that 84% of people experiencing homelessness preferred to use a specialist service rather than mainstream practice,³⁶ while another survey of homelessness project managers found that the majority favoured integration into mainstream primary health care services for their clients and believed that separate services were divisive.¹⁸

Integrating this population into the GDS has challenges, such as high FTA rates and complex comorbidities as aforementioned. However, potential solutions could include:

• Practices or clinics that are convenient locations to services that homeless people already access could be 'buddied up'

• Sessions or slots for the buddy service, rather than named patient appointments

• Training and appointment of an oral health champion within the buddy service, for example, a hostel manager, to promote the service, assist with paperwork and facilitate appointments

• Considering additional remuneration methods, for example, sessional rates

• Close working relationships with the local CDS to support the management of patients with additional needs.

The pathway model

Engaging people who experience homelessness while they are admitted as inpatients could be a pathway to dental care, which is a model already present for medical services. Addressing oral health problems for inpatients could reduce time spent in hospital.¹³ However, not all hospitals will have pathways in place for dentistry or access to a dental opinion.¹³

There are also challenges when providing care for acutely unwell patients where dentistry might not be appropriate, such as acute sepsis. If this approach was to be implemented, joint working with health inclusion teams, medics and DCPs is recommended, with inclusion of the dental team within Multi-disciplinary Meetings where appropriate. Remuneration or service level agreements may also need to be negotiated between the hospital service, commissioners and other dental services (for example, a visiting domiciliary dentist or CDS).

Unanswered questions and further research

From this review, there is a lack of evidence of how rural communities access dental care. This suggests that these populations do not have access to dedicated dental services or do not access dental care at all. However, many people who experience homelessness will not disclose their housing status because of fear of stigmatisation,³⁸ instead using addresses of family, friends, or other organisations. Many DCPs probably manage these patients without knowing their housing status, as recording no fixed abode (NFA) status is not routine for dental services. Identifying patients who experience homelessness is therefore challenging and could be improved.

The majority of services identified catered for homeless white men. There may be specific considerations when designing dental services for other groups, such as women who might be fleeing violence, or asylum seekers who might have differing oral health needs.

We also do not know the impact of COVID-19 on how models of care have had to change as a result of infection prevention and control measures, changes in the location, and needs of this population and the backlogs in dental care.³⁹

This review has highlighted several areas for future research, including:

• Do people who experience homelessness access mainstream dental services and how do we incentivise access to general dental practice for these patients?

• How do more rural populations of people who experience homelessness access dental care?

• How do the 'hidden homeless' and other socially excluded groups access dental care, such as asylum seekers, vulnerable migrants, sex workers, travellers and women who experience homelessness?

• How has COVID-19 affected access to care for the current models of dental service?

• How do we record 'homelessness' status or NFA more consistently within dental services?

• Evaluation of dental team involvement as part of an MDT when providing care for people who experience homelessness as inpatients and as part of 'pop-up' clinics within primary care.

Conclusion

The majority of dental services that are dedicated to care for people who experience homelessness are located in London, the South East and urban areas. Most of these services cater for homeless men and there was limited investigation of how more hidden groups within homelessness, such as asylum seekers, women in refuges, or 'sofa surfers', access dentistry.

When designing models of care for these patients, most services used blended approaches, which flexes to the needs of the local population alongside using the resources available - using different sites (for example, fixed and mobile/outreach) and different appointment types (fixed and drop-in) to engage service users and break down barriers to care.

These patients are mostly seen in primary care by employed dentists working within the CDS. This allows for flexible models of care where patient attendance can be sporadic and where treatment needs are high, which can be challenging to manage within general dental practice.