Access all areas

Remote and rural communities need health services like the rest of us, but attracting dental professionals to live and work among them appears to be a hard sell. Why?

18 December, 2018 / indepth
 Stewart McRobert  

Over the last few years, various reports on healthcare workforces have highlighted that there is a continuing difficulty in recruiting to posts that serve remote and rural populations.

This poses a significant potential issue in Scotland, which, according to Scottish Government figures, classifies 70 per cent of its land area as “remote rural” with a further 28 per cent classified as “accessible rural”. Seventeen per cent of Scotland’s population resides within this rural land area, with more over 55-year-olds living in remote rural areas than in any other type of area in Scotland.

Scotland clearly needs to be able to provide accessible dental services to people living rurally, but it seems that living and working remotely and rurally may not be attractive to dental professionals.

Those electing to practice in urban, densely populated areas cite concerns around access to support and allied services for their patients; potential issues with accessing their own professional training and CPD; and the more personal issue of maintaining personal and professional distance with their patients while living in smaller, more isolated communities.

Those that work in remote and rural areas, however, clearly do not feel the same. Instead, they talk about the breadth of practice they can undertake; the strong professional relationships they can build with their patients; and the quality of life available to them personally. With more and more training and CPD available on-line, and access to courses in an increasingly wide variety of physical locations, training doesn’t seem to be an issue either.

Of course, the attractiveness, or not, of working in remote and rural areas is really down to the individual, but there is no doubt that accessing services can be an issue for patients.

Many people living and working in rural communities have professions which operate outside the more urban 9-5, and work in locations where taking an hour off to pop for a check-up is simply impossible.

But what does this mean in reality, and what is life really like for dental professionals who choose to provide services to them? We spoke to dental professionals and patients to find out the good, and the bad.

Island life

The pros and cons of operating in remote and rural areas have been examined by Hannah Cousins and Anmar Al-Ansari. The pair are final-year dental students at the University of Aberdeen and each spent four weeks at the Western Isles Dental Centre in Stornoway in early 2018

Here they describe their experiences and also those of  dentist Matt Alexander, a former Aberdeen student, who now works for the public dental service on Lewis and Harris

It’s part of the ethos at the Institute of Dentistry at the University of Aberdeen – give senior students clinical experience through outreach in remote and rural locations. So, it was no surprise to final-year students Hannah Cousins and Anmar Al-Ansari when they were told that they would be part of an outreach programme in Stornoway during early 2017.

Instead, the eye-opening came when they had completed their placement and realised that life as a dentist in Scotland’s Western Isles is far from bleak and windswept.

“Spending time in Stornoway has been one of the highlights of our dental journey so far,” said Hannah. “Having the opportunity to explore a new place, and experience an alternative clinical setting, has been crucial for personal and professional development.”

Both began with few pre-conceptions: “I didn’t know what to expect in terms of the location,” said Anmar. “I knew it would be a very different environment from the one I’m used to and I was a little apprehensive about treating a smaller population where everyone knew everyone else. However, students who had gone before only had positive things to say about the experience.”

“Since access to services was Historically poorer than it is now, people on the islands appreciate the service they receive”
Hannah Cousins

Hannah explained: “I’m from London originally and many of the places I’ve explored during my time in Aberdeen are new to me. I tried to go with an open mind and take it for what it was.”

They found a dental centre in Stornoway that is part of the town’s hospital campus. It has 12 surgeries and is staffed by half a dozen dentists. The public dental service (PDS) based there is the only place on Lewis and Harris – and surrounding islands – where you can receive dental treatment, though there are plans to set up a general dental practice in the near future.

Over and above the points raised by Matt Alexander (see page 29 ), the two students had a few observations of their own. “People on the islands recognise that it is more difficult to deliver a service in a remote and rural community and, since access to services was historically poorer than it is now, they appreciate the service they receive,” said Hannah.

Anmar added: “Dentists we spoke to did say there is the potential for professional or social isolation. Therefore, among other things, you have to be proactive in involving yourself in the community.”

“Dentists we spoke to did say there is potential for professional or social isolation, so you have to be proactive in involving yourself in the community”
Anmar Al-Ansari

After completing their outreach, the pair compiled a list of the benefits they believe can be had from practising in this type of remote and rural location.

  • Consistency – being able to treat generations of families and build a lasting rapport with them provides great job satisfaction; the movement of people is less in comparison to a big city practice
  • Community – a sense of togetherness in the dental team and between clinicians and patients cements a positive working environment
  • Career – as there are fewer members of staff employed by the NHS dental service compared with the mainland, healthcare professionals have more autonomy in terms of career development and shaping of the service
  • Complexity – staff and students are encouraged to provide more complex treatments within their skill set to avoid sending patients off the island for treatment. They also noted the warm welcome they had received from colleagues in the dental centre and the wider community – and they confirmed that their horizons had been broadened. “I would never have thought about practising in somewhere like Stornoway before I went there. Now, I would certainly consider it,” said Anmar.

Community cohesion and complex treatment

Hannah and Anmar interviewed Stornoway dentist and graduate of the University of Aberdeen  Matt Alexander about his experience on the island.

An inherent sense of community, friendly people and a dental centre that’s modern, well-equipped and has been designed with teaching in mind. It’s simple for Matt Alexander to list the benefits that drew him back to Stornoway. During his time as a student he enjoyed his outreach placement in the town and subsequently decided to complete his vocational training (VT) there.

He believes that working in a remote and rural service during VT offers specific benefits. “As access to secondary care services is challenging, referral is considered only where absolutely necessary. Exposure to, and involvement with, more complex treatment planning was certainly of great benefit to
my personal development.”

In terms of advantages for patients, the close-knit environment can help in the process of promoting oral healthcare. An example is the success of the Child Smile programme on the island, which is extensive and well received.

Matt explained: “We have an annual themed ‘Child Smile’ week. During this week, school-aged children come into the dental centre for a check-up and are allowed to explore the facilities. This allows children to become more familiar with the dental environment and encourages their oral health to be closely monitored.”

The challenges to delivering services including staff recruitment and retention. “Most dentists who work in the service are not originally from the islands,” said Matt. “We also have to compete with logistical difficulties; for example, sending lab work to the mainland means turnaround times can be slower.”

Similarly, patients can be faced with limited choice when it comes to treatment. At the moment, the Western Isles Dental Centre is the only practice on the island and it delivers NHS care solely. However, there is an aim to open a new centre offering private treatment, which will provide residents with greater options.

Operating in a remote location most often means dealing with a smaller community of people. This could throw up sensitive ethical issues for the unwary.

“There is always a potential for there to be confidentiality issues,” said Matt. “In a remote or rural community you are more likely to see patients and their families outside of work. As one of a relatively small group of healthcare professionals you tend to be fairly well known. In general, the staff know many of the patients and their families outside of work so this has to be kept in mind.”

On a personal development level, it can be challenging to fulfil CPD requirements. This almost always involves travelling, although Matt said there are provisions in place to facilitate this. “CPD is carried out through a combination of travel to the mainland and online learning.

“There is always the potential for professional isolation, and it is necessary to take a proactive approach in combating this. We do have some practical courses on the island, but these tend to be those relevant to all members of the team, for example, training on medical emergencies.”

All at sea?

Fishermen spend a long time a long way from home. Their precarious living makes it difficult to maintain a regular oral health routine, and many suffer the consequences. An initiative by three charities has helped to bring the treatment to the patients and encourage in them an awareness of the importance of their dental wellbeing 

Few, if any, UK workers operate in more remote conditions than the country’s fishermen.

Their working pattern is wholly unpredictable. They spend long days miles from home, in the middle of turbulent seas, operating at the limit of physical and mental endurance. It’s no wonder they find it difficult to follow a regular, consistent oral health routine.

As a result they are one group of people who can benefit from help to look after their mouth and teeth.

Recently, a short series of Health and Wellbeing Days in took place in Peterhead. They were organised as part of the wider Seafit programme being delivered by The Mission to Seafarers and the Seafarers Hospital Society. Dentaid, the charity that provides emergency dental provision for people who are not able to access NHS dentistry, was there to help treat those fishermen who were able to attend.

Naomi Roche, Project Manager at Dentaid, was one of those helping out. She said: “Fishermen live a precarious existence. If they don’t go out to sea and get a catch they don’t get paid. So that’s their first priority. When it comes to dentistry, even if they are registered with a practice, they often miss appointments. For most, their dentition is quite poor. There are some exceptions, of course, but many of the guys who do the day-to-day fishing face the biggest problems.”

It’s easy for fishermen to find themselves in a damaging cycle; because they miss appointments they get removed from their dentist’s patient list, which leads to increasingly poor oral health.

“One fisherman I interviewed hadn’t been to a dentist for 12 years”

Naomi Roche, DENTAID

Naomi said: “One person I interviewed during the Health and Wellbeing Days hadn’t been to a dentist for 12 years. People fall out of the habit of attending, or don’t even get into the habit in the first place. Worryingly, some end up self-administering pain relief in the form of alcohol or drugs.”

It’s not a question of ignorance. Naomi noted that everyone she spoke to knew they should clean their teeth twice a day. However, crack-of-dawn starts and long working days meant other tasks took priority.

At the same time, the fishermen were conscious of their poor dentition. “Self-esteem was an issue – many talked with their hands in front of their mouths,” observed Naomi.

“It’s a community where there’s a lot of bravado. Rather than address a problem they might ‘get busy’ or ‘persevere’ until any pain abates.”

Even the chance of a free check-up could be met with a certain wariness. “It takes one of the guys on board, especially a skipper, to say they are going to get their health/teeth checked before others will follow suit.”

“it’s vital to look after the crews if we want to have a successful fishing industry”

Naomi roche

And, like in every community across the land, there is a section of people who are genuinely nervous about visiting the dentist. “That’s something we’re conscious of during

our sessions,” said Naomi. “We don’t ship people in and out. Instead, I sit down and get their medical history, which often leads on to conversation about their background, family circumstances and so on. It helps them relax before they see the dentist.”

One of Dentaid’s main aims is to help people achieve a level of dentistry that makes them feel less self-conscious and more confident about using NHS dental services regularly. And the Seafit programme is a UK-wide initiative that will see activity across a number of the country’s ports.

The goal is to make sure the health and wellbeing of fisherman is not overlooked. At the moment It appears the crucial factor is the skipper – the most enlightened are always ready to look after the interests of their men.

Naomi believes that lack of care is not just bad for individuals but has wider implications. She noted: “ It’s vital to look after the crews if we want to have a successful fishing industry.”

Practicality the key

Fisherman based in the north-east of Scotland do have services they can access, but despite best intentions that’s not always possible.

Diane Lawson is oral health team leader, Aberdeenshire North, based in the Childsmile Department at Ugie Hospital in Peterhead and volunteered to help Dentaid. She explained: “At present access to emergency dental treatment for non-registered patients is through a system known as DIAL where you leave a message and your call is returned usually within an hour with an appointment time and dental practice to attend. This could be anything from two to 35 miles away.

“Outwith normal working hours people are referred to A&E who will only treat bleeding, swelling and trauma.

“There is also a service on Friday evening, all day Saturday and Sunday morning, but it is based in Aberdeen.”

Diane, whose partner is a fisherman, said the issue is not accessing a NHS dentist since most are aware of DIAL and use it when necessary.

“The issue is the practicality due to the working patterns of the fisherman. Fisherman may only be onshore for a very short time when the boat arrives back into port. They land the fish, take on food stores, ice and boxes and often return to sea within six hours.

“At the same time a trip has no set time, it could last anything from seven to nine days, but there is no guarantee. This makes follow up appointments difficult.”

Seafit support for seafarers

The Seafarers Mission and the Seafarers Hospital Society held Health and Wellbeing Days at Peterhead between 2-4 October.

Two emergency dental clinics were held and a total of 21 patients were seen – a mix of UK nationals and others from abroad who were contracted to UK boats.

The Dentaid team comprised two dentists, a dental nurse, Dentaid CEO Andy Evans and Naomi Roche.   

Free emergency dental treatments were available to all fishermen. Those treatments included:

  • extractions
  • fillings
  • scale and polish
  • fluoride varnish.

All patients had oral health screening including oral cancer screening.

If anyone needed further investigation they were referred to local NHS hospital services or a local practice.

After treatment every patient had the chance to speak with an NHS professional regarding oral health and hygiene.

The Health and Wellbeing Days were part of the Seafit programme and also included blood pressure, cholesterol and diabetes checks. The fishermen were able to speak with health professionals about alcohol abuse, depression and cancer.

Tags: live / remote and rural / work

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