Oral health improvement strategy for priority groups

Chapter Six Learning from previous work

This chapter considers preventive programmes which could be applied to the priority groups.

6.1 Childsmile

The value of individuals and organisations working together to improve health was recognised in many of the responses received to Scotland's Consultation on children's oral health.⁶⁵ As a result, a number of preventive programmes targeted at children have now been successfully put in place across Scotland.

The Childsmile Programme⁶⁶ which includes: Childsmile Core, Childsmile Practice, Childsmile Nursery, and Childsmile School, works through a combination of local measures such as toothbrushing, and by making best use of the skills of a wide range of professionals from across a range of disciplines. New roles play an important part. There is a strong emphasis on partnerships in education and health. We have found that this approach is effective in preventing dental disease and in safeguarding the oral health of children.

The Programme distributes toothbrushes and fluoridated toothpaste to children, and supports families, by giving them the information and guidance they need to care for the oral health of their children from birth through nursery and on to primary education. Public Health Nurses and trained dental health support workers help families, and play a vital role in linking to the dental team. Children in the nursery and school schemes also have fluoride varnish applied directly to the teeth. Schools play their part in supporting Childsmile in schools and nurseries.

There are important lessons which can be learned from what is already working for Childsmile. Many elements of this programme may also benefit vulnerable and dependent adults and these are already being incorporated into the priority group pilots ongoing across Scotland to improve the oral health of vulnerable adults.

6.1.1 How the "Childsmile" approach might help Vulnerable Adult Patients:

Targeted prevention of oral disease for those most in need.

Providing information and training, dental care materials and appropriate preventive services.

Using the skills of professionals in new roles such as Dental Health Support Workers and Extended Duties Dental Nurses.

Using the skills of a wider range of health and social care professionals who come into contact with vulnerable and dependent adults.

6.2 Dental Priority Group Pilots

6.2.1 Older People and those with Special Care Needs

A number of authoritative documents have been published which set out guidelines and standards for the oral health care of those in care homes.^65,67,68

Much good work is already taking place across Scotland to prevent oral diseases and to improve the oral health of the most vulnerable in our society. A number of models are outlined below:

Looking after older people:

The Lifesmile Project, NHS Lothian

The Lifesmile Project in NHS Lothian,⁶⁹ has piloted an initiative to improve the oral health of older people in care homes, by supporting staff to implement the NHS QIS Best Practice Statement: "Working with dependent older people to achieve good oral health". The project works with volunteer homes across Lothian.

The key elements of the programme include:

Delivering oral healthcare training to all nursing/care staff.

Providing oral healthcare materials to all residents.

Providing additional support from dental health support workers.

Establishing a new referral process for residents requiring dental treatment.

The Fife Oral Care Award

The Fife Oral Health Care Award⁷⁰ seeks to raise standards of oral care provision for residents within care homes in Fife. Currently 52 care homes across Fife are taking part in the scheme. The Award is made for successful completion of a number of good practice criteria.

Key elements of the programme include:

Staff training in oral care in DVD and online formats.

Completion of an oral health assessment for residents within one week of admission and on a rolling basis every 12 weeks.

Ensuring that teeth are brushed on a regular basis, using an appropriate toothpaste.

A dental referral for residents.

Joint working between the community dental service and the care home to ensure patient's mouths are healthy.

Six-monthly fluoride varnish for residents at high risk of decay.

Information for family members.

The North Ayrshire Pilot Project

The North Ayrshire Pilot Project⁷⁸ differs from the Lifesmile Project in that it worked with all care homes across North Ayrshire, not just those which volunteered. The project has been implemented in 25 care homes in North Ayrshire and the key elements of the project are:

Implementation of a training and support programme to improve the oral health outcomes of older people in care homes in North Ayrshire.

Development of a resource pack which includes recommended oral health assessment tools and other paperwork, relevant oral health related information, referral advice and contact information.

To implement a strategy to raise awareness of the Community Dental Service within care homes and to encourage care homes to ensure all residents are appropriately referred for preventive care and dental treatment when necessary.

Many of the features of these initiatives could also be applied to the care of other vulnerable groups. We are able to learn from this work and to build upon it when seeking a common approach to preventing oral diseases for vulnerable people.

The "Open Wide" Project

Some care homes provide more specifically for adults with additional needs. The Open Wide⁷² project, which is focussed on adults with additional needs within care homes in East Ayrshire, has broadly the same three elements as the North Ayrshire Pilot for older people.

This training aims to enable care support workers in:

Referring to dental services as required.

Training for staff in daily oral healthcare.

The use of appropriate paperwork to support oral care, including: an oral health risk assessment, an oral care plan and documentation of daily care.

6.2.2 People Experiencing Homelessness

For individuals and families experiencing homelessness, simple things which are normally taken for granted by those with a permanent home, such as keeping clean, and finding and preparing food, are not always easy. Basic survival often takes a higher priority than healthcare. The lack of a permanent address means that keeping in touch with the doctor or dentist is often very difficult,^73,74 making the practical side of attending the dentist and ongoing care with health professionals challenging.

Partnership between the full range of organisations in contact with people experiencing homelessness is the key to successfully improving the oral health of homeless people. Organisations involved in the provision of care and shelter to homeless people include:

• NHS boards.
• Local authorities.
• Social Work departments.
• Voluntary sector organisations.

Homeless people themselves also have a valuable contribution to make in identifying their needs.

The Smile4life³⁷ survey showed that people experiencing homelessness prioritised their lives in accordance with their perceptions of their specific and complex needs. How people experiencing homelessness prioritise their current life circumstances is of central importance to their readiness to access oral healthcare and influences the degree of engagement which they are willing to accept.

Some progress is being made with organisations and individuals working together. However, this has often been patchy and has not been consistent across Scotland. A number of examples of good practice have already been developed through implementation of Health and Homelessness Action Plans within NHS boards.

NHS Highland: The Streetwise Directory

The Streetwise Directory⁷⁵ has been developed through a partnership with NHS Highland, Inverness Council for Single Homeless and Highland Council. The Directory assists service providers in pointing homeless people to the right services. The programme has helped to develop a network of service providers that did not previously exist.

The services that are included in the Directory are based on a broad interpretation of the range of services that homeless people may wish to access, bringing together leisure and educational opportunities and information on accessing health services. This is achieved by giving homeless people information about the health services that are available, and information on how these can be accessed.

NHS Lanarkshire: Something to Smile About

The "Something to Smile About"⁷⁶ initiative was developed by NHS Lanarkshire to support staff working with homeless people within the health, local authority and voluntary sectors. The key aims of the project are:

To help homeless people change their oral health-related behaviours.

To encourage them to carry out regular oral hygiene.

To provide them with information to enable them to attend a dentist.

Key features:

Assisting staff to give oral health promotion messages by providing an oral health training resource for staff working with homeless people.

Helping staff to make referrals to dental services.

Assisting general dental practitioners to be more aware of the issues facing the homeless and providing training to help to engage appropriately with homeless people.

The training resource used in "Something to Smile About" included advice about good oral hygiene, healthy eating and modifying harmful behaviour such as smoking and excess alcohol consumption.

The Lanarkshire Programme has now been evaluated and we know that the training provided is important and highly valued by staff. However, overcoming the immediate and pressing problems of the homeless people remains challenging and must be recognised when helping homeless people. We know that information about local dentists is extremely helpful to staff working with homeless people. However, homeless clients have different needs and not everyone will be at the same stage when engaging with a programme. Not all will be ready to visit a dental practice, so flexibility is needed when planning services.

Again, many common themes such as training and information needs have emerged from the development of new models of care for homeless people. The findings of the various pilots taking place across Scotland will help to inform the direction of future dental programmes to improve the oral health of homeless people in Scotland. However, the problems and lifestyle of the individual homeless person or family will also influence what will be successful. Therefore, some elements of the core preventive programme will have to be tailored to an assessment of individual need.