Research Summary | Published:

Summary of: Developing dental services for homeless people in East London

BDJ volume 213, pages 360361 (13 October 2012) | Download Citation

Subjects

Abstract

Objective The aim of this study was to describe the dental services delivered by the Community Dental Service (CDS) of Tower Hamlets (TH) and City and Hackney (CH) for adult homeless people in 2009-2011, to assess if the service met its planned objectives and to report the outcomes of the dental care provided.

Method TH and CH CDS provided a nine tier dental service for homeless people during April 2009 to September 2011, in which the dedicated mobile dental service (MDS) and the dedicated dental clinic (DDS) provided 3,102 dental appointments for homeless people. Data collection from a random sample (n = 350) of record cards of adult patients who were homeless and offered oral care from these services was conducted, in collaboration with an analysis of appointment books, service delivery rotas and day sheets. Patients' oral findings, treatments, challenges as well as feedback received from the service users were recorded and evaluated against the planned objectives.

Results One thousand two hundred and twelve (39.1%) of these appointments went to the 350 patients whose record cards were examined as part of this audit. One of the record cards randomly selected had incomplete date and was excluded from the results, so data was presented on the 349 complete record cards. The age range of these patients was 18-74 years, with a mean age of 38.46 years ± 9.1 standard deviation (SD) with 80% of the patients (n = 281) under 50 years of age. Forty percent of these patients presented in pain with a further 5% complaining of swelling and infection, 99% of people required treatment and only nine people had no decay, three of whom were edentulous. Two hundred and thirteen (61%) patients completed their treatments, which took between 1 to 18 appointments, but only 97 (27.8%) patients did so without any failed or cancelled appointments. Of the 128 (36.7%) patients who were lost after the first appointment, only 15 (11.7%) did not receive any treatment; most had been treated for pain with temporary fillings, extractions, permanent fillings and management of swelling. Sixty-seven band 1, 16 band 1.2 (emergency only), 148 band 2 and 52 band 3 courses of treatment were submitted.

Conclusion This study showed a significant need for services providing oral healthcare for this population and highlighted that flexibly delivered dental services, embedded in local health and social networks, seemed to promote uptake in these clients who normally find it extremely difficult to find dental care services elsewhere.

Key points

  • Improves the evidence base for the effectiveness of targeted service delivery to special care groups.

  • Provides information for other dental services to consider when developing and assessing special care services.

  • Describes how increasing accessibility of dental care to homeless people led to a decrease in the loss of clinical time due to failed or cancelled appointments.

Editor's summary

Over 2,000 single people per year access the Tower Hamlets (TH) homeless services; 1 in 12 children in TH live in homeless households; in a single year about 350 individuals are contacted by services in TH.1 These numbers grow year on year.

Homeless people are a high-risk group for oral and dental disease but providing them with dental services can be difficult. Unless they are in pain, dental care could be a low priority; seemingly the least of their worries'.

It has been recommended that a combination of both mainstream and dedicated services, such as mobile dental services (MDS), should be used to address this problem. This BDJ paper provides a rare example of evidence for the effectiveness of dedicated service delivery. It shows that targeting special care dental services, though costly, is successful.

Figures in the study reinforce the significant and shocking need for dental care amongst homeless people: 99% seen required treatment and only 6 out of 346 (dentate) homeless patients had no decay.

The evidence in this study certainly leads to high level recommendations about the development of services for homeless people and other special care groups. However, it also contains practical suggestions of how services can be improved on a day-to-day basis. For example they found that a high rate of patients were failing to attend their appointments with the MDS – to help with this one of things they implemented was to simply ring and remind all patients and key workers the day before and a half an hour before the appointment. Every little helps.

To learn more about dental care for homeless people both in community dental services and the general dental service, I recommend you also read the BDA's report: Dental Care for Homeless People (accessible online at http://www.bda.org/Images/homeless_dec20_2003.pdf).

The full paper can be accessed from the BDJ website (www.bdj.co.uk), under 'Research' in the table of contents for Volume 213 issue 7.

Ruth Doherty

Managing Editor

Author questions and answers

1. Why did you undertake this research?

As part of working to protect services for people with special care dental needs we need to ensure our services are value for money with effective outcomes for our patients. We conducted this research primarily to establish if the homeless service we provided was of a high quality, represented good value for money, was flexible and responsive to this very vulnerable group. We wanted to improve the evidence base for service delivery to special care groups and provide information for other dental services to consider when developing and assessing services and we wanted to address the BDA publication of 2003 that requested more systematic and quantitative research was carried out into the appropriate clinical mode of treatment for homeless people in different settings.

2. What would you like to do next in this area to follow on from this work?

We would like to work with the NHS commissioners of these services to explore different avenues of providing care for those homeless people who are neither exempt nor have the money to pay for their dental care. The current provision of emergency care only for this group produces a barrier to improving their oral health.

There are no randomised controlled trials providing evidence and assessing the effectiveness of a targeted oral health prevention programme for this group, we would like to work with other agencies to investigate this in the future.

Commentary

In terms of accessing dental care, homeless people are considered to be a 'hard to reach' group and flexible modes of delivery of dental care are advocated to enable them to access it.2 These flexible modes include drop-in clinics, flexible hours of opening and taking dental services closer to the client via mobile dental services (MDS) and dedicated dental services (DDS) at day centres and hostels. While such approaches have been advocated for a long time, there is little evidence that they work or what they might cost.

This interesting paper by Simons et al. describes the challenges and costs of providing dental care to homeless people in an inner city setting. The role of non-clinical line workers in particular was seen as key to maintaining continuity of care and highlights the importance of having an understanding and links with other agencies providing health and social care to special need groups. The authors found that the MDS appeared to be most effective at encouraging attendance amongst younger, more vulnerably housed people and those who were not claiming benefits. The MDS also appeared to be more effective at encouraging uptake of care. There was, however, a price to pay. Some tentative costing by the authors suggests that the MDS UDA costs were 2.4 times the UDA cost of providing a service in a salaried dental service. Elsewhere, concerns have been expressed that the provision of special dedicated services ghettoises homeless people and disables their use of mainstream primary health care services.3 It might also relieve mainstream healthcare services of their responsibility to enable access.

The lack of evaluation of clinical service delivery is a particular concern in special care dentistry where many innovative interventions for 'hard to reach' groups are implemented, but rarely evaluated robustly or reported upon.4 In a time when we are expected to do much more with fewer resources, it is important that we begin to develop an evidence base underpinning the delivery of flexible services to 'hard to reach' groups including homeless people. Some of the answers may be unpalatable; however, without a true costing of services and an assessment of all outcomes, it becomes impossible to identify what works and what does not.

References

  1. 1.

    CHAIN. Annual Report for Tower Hamlets April 2011 - March 2012. (accessed Oct 2012).

  2. 2.

    British Dental Association. Dental care for homeless people. London: British Dental Association, 2003.

  3. 3.

    . Research in special care dentistry. J Disability Oral Health 2011; 12: 146–147.

  4. 4.

    , , . From the margins to the mainstream: collaboration in planning services with single homeless people. London: West London Health Authority, Church action for the unemployed, 1989.

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Affiliations

  1. Senior Lecturer/Academic Lead in Special Care Dentistry King's College London Dental Institute

    • Blánaid Daly

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DOI

https://doi.org/10.1038/sj.bdj.2012.911