Progress on recommendation 5
Dental care provision and commissioning needs to improve to meet the needs of people in care homes
As well as aiming to maintain and improve the oral health of people in care homes, the NICE guideline aims to ensure that they receive timely access to dental treatment. In our 2019 Smiling matters report we found that where people's needs were being met, care homes gave examples of dentists providing routine check-ups, ongoing treatment, and emergency care – both in and outside the care home.
However, in that report, even before the pandemic, we found that people living in care homes and their carers often found it difficult to access routine NHS dental care. We therefore made recommendations around reviewing how domiciliary care is provided to the care home sector, and exploring how local health networks can develop services, capacity and information to meet the needs of those living in care homes to address health inequalities.
Access to dental care
From our inspections in 2022, it was clear the care homes that were best able to care for the oral health needs of their residents were the ones that had timely access to dental care.
"There aren't really any current challenges to providing mouth care. We encourage all the staff to support people to brush their teeth twice a day. We make sure they have six monthly appointments with the dentist. We are quick to identify if [people] are in pain and follow this up with the dentist."
(Care home manager)
However, one of the strongest themes to emerge from our 2022 review was the extreme challenge care home providers were having in accessing dental care for people using services.
"A resident complained of toothache and when we contacted the dental surgery we were told to contact 111. I spent 2 hours on the phone arranging a consultation at a designated dental facility. We arranged a staff escort to get the resident to the appointment and a special taxi because he uses a wheelchair. Although he arrived on time, the dental staff said he was late and the dentist refused to see him. We have now been referred to another dental facility but we are still awaiting an actual appointment."
(Care home manager)
In 2019, 6% of care homes told us that the people who used their services could 'never' access NHS dental care. In 2022, this figure has sharply risen by more than 4 times, to 25%. The number of care homes always or mostly always able to access routine dental care fell sharply, from 67% to 35% (figure 5).
Figure 5: Can residents access NHS dental care routinely?
As we highlighted in our most recent State of Care report, COVID-19 had a severe impact on NHS dental services and there was a significant reduction in the number of treatments delivered for everyone across the country. Issues with accessing NHS oral care experienced by the general population could be exacerbated for people living in care homes, due to reduced independence and mobility and a lack of dentists who are able or willing to visit care homes.
We often heard that dentists would only see patients in an emergency, and then when routine appointments were available there was a significant waiting list. As well as contributing to poorer dental health of people in care homes and their potential distress, this could also serve to undermine the positive oral health support given by care home staff.
"There have been issues accessing dental support during the COVID-19 pandemic. A lot of the time people have to be in pain before the dentist will see them. Often routine dentist appointments are being cancelled, as there have been no reports of immediate concerns. This makes it so much harder to identify problems and proactively take action."
(Member of care home staff)
We also heard of examples of people living in care home being removed from practice lists because they have not visited for a long time, despite not being able to visit face-to-face during the pandemic, or because they had conditions that may have made them less mobile.
Access to private dental care, on the other hand, has improved overall since our 2019 review. Though the proportion of care home providers who reported they could 'always or mostly always' access private care decreased slightly, the proportion who reported they could access private care 'sometimes' doubled (from 25% in 2019 to 50% in 2022). The proportion who said they could 'never' access private care fell from 28% in 2019 to 8% in 2022.
Although private care provided a solution for some people, not everyone could afford to pay, or they felt the impact of the greater cost.
"I had bad toothache a few months ago and the service recommended a private dentist near us. I got an appointment, and I was happy with the work done but I was charged an enormous amount of money."
(Person living in a home)
As a potential alternative to attending a dental practice face-to-face, care home staff and stakeholders told us they would benefit from having a greater ability to speak to dentists or other dental care professionals in certain situations, to help offer support and advice when necessary.
"We record the medical history and the appointments on our monitoring software. Sometimes the dentist will give a phone number and then we can phone them straightaway if there is an issue."
(Member of care home staff)
"I am mindful that progressing day-to-day care needs to be backed up by a pathway that enables the [adult social care] sector to go to people when they need advice."
(Dental professional and academic)
Experiences of care – dental problems have a real impact, but the right support can make a difference
Darren's grandfather is 89 years old and has lived in a care home for a couple of years. Staff help him wash and dress in the mornings. He is able to feed himself and has mental capacity.
Darren is the main carer for his grandfather's care, so is the main contact for the home.
The care home doesn't have a visiting dentist so Darren has to take his grandfather to appointments, using the same dentist he has seen for years.
Darren's grandfather complained to care home staff that he had pain in his mouth, which was causing him pain and difficulty eating. The staff changed his meals to soft foods and asked Darren to arrange a dentist appointment.
The dentist explained that it was a nerve issue and that he would need to be referred to a hospital. The dentist gave him antibiotics in the meantime in case of infection.
Darren's grandfather got a hospital appointment after a few weeks. However, the hospital cancelled the appointment which left him in pain. Darren called the hospital to complain, and was sent a new appointment. This was cancelled again at short notice.
Darren contacted the dentist who was very helpful and spoke to the hospital and suggested that he complain to the ombudsman, as it was unacceptable to cancel when his grandfather was in pain and unable to eat solid foods.
Darren's grandfather eventually got the treatment he required and has had no further issues with his nerve.
(Interview with a member of the public. We have changed people's names)
Dental access – challenges and solutions
Another theme raised during our 2022 review was the increasing lack of dental workforce, both in terms of numbers of staff, but also those that were suitably qualified to meet the growing needs of people living in care homes.
"The number of community dental staff is decreasing in England, and it seems like the workforce that is specifically designed to care for the most vulnerable is actually decreasing, when the needs of this group is actually increasing."
(Representative of professional body)
We highlighted NHS workforce shortages in our State of Care report in October 2022, with the number of dentists performing NHS activity per 100,000 population falling from 44.1 in 2014/15 to 42.9 for 2021/22. We noted how this varied by region, with the number of dentists per 100,000 population highest in London (49.8) and lowest in the Midlands (42.0).
In our discussions for this progress report, it was widely recognised that the solution to improving access to dental care for people living in care homes did not simply mean commissioning more dentists or community dental services, but rather in 'skill mix', which involves embracing the benefits of using the whole dental team.
For example, training care home staff to make oral health part of daily practice does not necessarily have to be done by a dentist, and could be picked up by any member of the dental team who is suitably equipped.
"We ask a lot of people who've had fairly limited training and are stretched in terms of personal care needs and the number of people they're supporting. They need backup and we, the dental system, need to create that backup as part of the care pathway. There is a huge scope for skill mix to be used here."
(Dental professional and academic)
"Embracing skill mix properly allows for more capacity in the system, rather than diverting the most expensive resource (the dentist) to do it alone."
Making the most of the skill mix of the whole dental team to serve a whole community, including people in care homes, is also highlighted in Health Education England's Advancing Dental Care Review Report:
"It is imperative that a future dental workforce be trained with an optimal skill mix to meet the health needs of the general population and the specific treatment needs of the older and disadvantaged cohorts... This must include a comprehensive oral health improvement programme delivered by the appropriate members of the dental and wider healthcare team, including the delivery of dental care to populations outside traditional workplaces."
Beyond the benefits of providing timely dental care to people living in care homes, we heard how promoting skill mix could support career progression for all members of the dental team, offer variety to a working week, and encourage people to become champions for oral health within their communities.
"[Skill mix] also supports career pathways for dental nurses and other dental care professionals. Outreach provides opportunities and allows people to connect with their communities etc... Over time we'd expect all of their skillset to grow."
In our 2019 Smiling matters report, our engagement activities told us that one of the main challenges to people in a care home being able to access NHS dental care was a lack of dentists who were able or willing to visit care homes (to provide a domiciliary service). Our external advisory group, which included representatives from the dental and care home sectors, said one of the key reasons for this was the lack of financial re-imbursement to dental practices following the changes to the General Dental Services contract in 2006.
This is born out in the number of contracts that include domiciliary care. According to figures provided to us by NHS Business Services Authority, only 5% of contracts for NHS dental activity in England included domiciliary care in 2021/2022.
A lack of domiciliary services was also highlighted by care home providers in our 2022 inspections.
"We had a resident who is bed bound and also living with dementia. We could see from our oral hygiene measures that the lady's teeth required attention. Despite numerous attempts to engage a dentist (even consulting the GP to try and arrange this) we could not find a dentist who would visit... We were eventually referred to a local NHS facility but were subsequently told that there was a 12-month waiting list. The resident passed away before receiving any treatment."
(Care home manager)
Throughout our engagement for this progress report, we continued to hear that the changes to the general dental services contract in 2006 made it difficult for dentists to provide dental care in care homes.
"[One of the] main issues lies in commissioning. There is no longer an incentive for general dental practitioners to provide care to homes [beyond their good will]. [One solution] is using flexible commissioning – where we could say, 'we will support you to get an upskilled practitioner and will allocate you so many care homes to take care of. That way the practice then has then the ability and capacity to support these homes. In the end, it's down to funding."
(Dental professional and academic)
However, despite the COVID-19 pandemic hampering their development, we heard of numerous examples of commissioning being used to try and improve the oral health in care homes of people – through funding training, peer-to-peer support schemes, or increasing dental access.
Some of these projects acquired funding through external means, and others through a 'flexible commissioning' model – where a percentage of the practices' units of dental activity contract value is used to target local needs or meet local commissioning challenges.
One pilot project in the East of England:
- linked dental practices across integrated care system areas to care homes to develop training and upskill the workforce both within the practice and care homes
- also linked the pilot dental teams to special care services, which helped to improve communication between the dental providers, special care services and domiciliary services. The special care services also gave lectures to help develop the skills of the dental teams, who used these sessions to talk to each other peer to peer.
"The advantage of the pilot is that they had a dentist and dental care professionals supporting the care homes. There were monthly training sessions for the clinical delivery teams. It wasn't just a delivery of care model, it was about bringing the system along to primary care networks, local authorities, and the wider health and quality teams within the NHS."
Another regional pilot project involved integrating the oral health component from the Enhanced health in care homes framework. The project comprised of:
- dental professionals supporting care home staff through training, development of care plans, oral health policies and assessments, with the potential for dentists to give remote advice for particular people, using digital technology
- protected time with dentists to see those people in need and carry out face-to-face treatment.
"One key learning for us was that it is actually ineffective to get the dentist to 'knock on the doors' of care homes. Instead, it's key to have the dentists and the dental commissioners integrated at the level of the place-based partnerships, so that you can get the audience with the right people, and the engaged care homes who want to do something different."
"The practices themselves really enjoyed it, it's no secret that we want to do things to make the job more diverse."
A programme initially developed by dental public health in a local authority in the North East of England, and then implemented in another 3 local authorities, sought to identify the main gaps in practice relating to the NICE oral health guideline.
One of the authorities sent out a baseline questionnaire to 20 care homes and received 19 back. Some of the actions taken to address gaps in oral health practice included:
- an oral health risk assessment tool taken from Caring for Smiles: Guide for care homes was used to record details of the oral health needs of people living in the care homes and how to support them and their preferences
- a leaflet co-produced with people in care homes and their families included information on dental charges and how to apply for charge exemptions
- oral health promotion teams provided care home staff with information on dental services available for urgent and out-of-hours care.
Collaboration with the local authority was seen as crucial to the programme. In the past, oral health promotion teams had struggled to engage with care home managers, but the leadership of the local authority ensured good participation and high attendance at oral health training for care staff. This was reinforced by training attendance being monitored as part of the annual contractual assessment framework key performance indicator.