Help the Ageing
With more people living longer, the healthcare system is coming under increasing pressure, especially the dental services available to those living in care homes
Scotland’s ageing population is presenting new challenges to our healthcare system. One of the most pressing is the lack of dental services made available to residents of care homes.
The Scottish Government has recognised the seriousness of the situation – the recently published Oral Health Improvement Plan (OHIP) has a section entitled ‘Meeting the Needs of an Ageing Population.’ However, there are demands to make sure that efforts are neither piecemeal, patchy nor lacking in proper funding.
Peter Ommer, Clinical Director (Dental), NHS Ayrshire and Arran, said: “To understand the current situation you have to look back at the past. Previously, care homes had residents mostly in their 60s, 70s and 80s who had no teeth and relied on dentures. That made the provision of dental care quite straightforward
“However, now homes are full of people who are living into their 80s, 90s and beyond, taking a plethora of medications, have more of their own teeth and have undergone a variety of procedures such as root treatment and having implants fitted. That makes the picture far more complex.”
He pointed out that the medication older people take can often affect their bones, saliva and other functions making teeth far more prone to decay and complicating treatment. Food is often ‘spiced up’ with sugar to compensate for failing taste receptors and there can be difficulties with poor nutrition. Care homes can be subject to high staff turnover and often homes find it difficult to provide continuous staff training.
Compounding the issue is the possibility – even likelihood – that the older person involved is living with dementia. It all makes for a very difficult situation with a multitude of barriers that may discourage many GDPs from getting involved.
Equally daunting can be the paperwork involved. The GDC requires that every patient must have a written treatment plan that they must give informed consent to. If, however, you are dealing with a person classed as lacking capacity, it is essential to observe the relevant legislation and involve other parties such as a Welfare Power of Attorney if one exists.
This can result in a long-drawn-out process, especially if there are no living family members or the only remaining relative lives abroad.
Similarly, providing operative dentistry in a care home setting is fraught with difficulty – there is a limit to what can be done safely. Even assessing someone in their own surroundings then bringing them to the surgery for treatment can present challenges. They may use a wheelchair or Zimmer or are so frail that they need ambulance transport.
However, such transport in Scotland will not deliver to a high street dental practice, only to a hospital or, on very rare occasions, a health centre. What’s more, your patient could find they are one of many passengers and spend long hours travelling while others are picked up and dropped off.
“Most GDPs don’t enter care homes, arguably because it’s an environment that’s outside their comfort zone”
Adults with incapacityOG
Many older people in care homes may have an Adult with Incapacity (AWI) certificate in place for areas of health and social care, which can make delivering treatment a minefield that must be navigated with proper legal authority.
The Adult with Incapacity Scotland Act and the Adult Support and Protection Act (2007) protects anyone over 16 who is classed as lacking capacity. A Welfare Power of Attorney or Welfare Guardian must be in place to look after that person’s health interests and rights.
Dr Petrina Sweeney of Glasgow Dental Hospital said: “If neither is in place, any treatment must be authorised by the person’s nearest relative/carer. If there are no living relatives things become even more complicated, and you may have to involve professionals such as a hospital consultant or general practitioner.”
Dental treatment requires a specific time-bound AWI certificate. It may last six months, during which time you can carry out a full treatment plan if required. After six months it has to be re-written. The maximum period is three years, but that would only allow general oral care. Any other specific course of treatment would require a separate authority covering the time that treatment takes.
What’s more, you would need a separate certificate to administer a general anaesthetic.
Although most GDPs don’t receive training in this field once they’ve left dental school, regulations say that any dentist can work in a care home. Of those that do, some are keen to provide ongoing care to existing patients, others simply want to help care homes and their residents. Peter said: “However, most GDPs don’t enter care homes, arguably because it’s an environment that’s outside their comfort zone and one where there is the risk of being faced with medically or behaviourally complex cases.”
In an attempt to start tackling these issues, the OHIP spells out new domiciliary care provision. Specifically, the Scottish Government intends “to develop an accreditation scheme for GDPs with the necessary skills and equipment to see patients in care homes. These practitioners and their teams would work with care home staff to ensure adequate preventive care is in place for residents, complementing the PDS, which will continue to provide those procedures that cannot readily be done by a GDP. With the increasing numbers of people living in care homes, it will be necessary to ensure the PDS are only used for patients requiring their advanced skills as in a shared care model”.
Plans are under way for an eight-day training programme for GDPs. This will involve two 20-strong cohorts with sessions taking place in March and April 2019 in Edinburgh and Glasgow. They will cover areas such as Adult With Incapacity (AWI) certification, and participants will gain greater understanding of the complex medical situations that can arise.
Health boards are currently recruiting interested GDPs, most likely individuals who are already working in care homes. Once they have undertaken the training they will work with the PDS in a buddy system to gain a full picture of the care home system.
Peter welcomed this move: “We want to encourage co-operation between GDPs and the PDS.”
Efforts to register every care home with a GDP have already taken place, with one scheme under way in Greater Glasgow and Clyde Health Board area. “It has been largely successful,” said Dr Petrina Sweeney, Clinical Senior Lecturer/Honorary Consultant at Glasgow Dental Hospital and School.
“It has taken a couple of years and it benefited from being in line with the thinking of the former Chief Dental Officer. However, across Scotland there’s a patchwork approach and other health boards have done things differently. Hopefully, the aims set out in the OHIP will bring consistency.”
Petrina recognised the lessons that can be learned and emphasised how working in this area often requires a change of mindset for GDPs: “It’s vital they can recognise what ‘normal’ looks like in an older mouth. Medication can have knock-on effects; for example, the mucosa can look and react differently than before. Naturally, a GDP will want to create a ‘perfect’ mouth condition, but the reality is that the person they are treating might have a few months to live; is it the dentist’s job to create a perfect smile or to make that person comfortable?
“We appreciate that people feel wary about being accused of neglect but in many cases lots of intricate work cannot be justified. With older mouths it’s most important to make sure they are functional, reasonably clean, and not sore. That improves the patient’s quality of life – they can eat, are comfortable and somebody can keep their teeth and mouth clean.”
Given her role, Petrina is acutely aware that it’s not just the population that’s changing, dentists are too. “Because society in general has become more litigious, younger dentists are more aware of potential risks. At the same time, compared with previous generations, they receive training that covers a very wide spectrum.
“Special care dentistry itself became a specialty in 2008 and at Glasgow Dental Hospital we deliver a full curriculum. We start in BDS2 right through to BDS5. students get taught about all aspects of special-care dentistry, and a big part of that is dentistry for older people.”
Caring for Smiles
It’s hoped that the ambitions outlined in the OHIP will build on initiatives such as the Scottish Government’s Caring for Smiles project, which promotes oral hygiene in care homes. The campaign has been rolled out across the country. However, it faces several issues, not least the high turnover of care home staff, which undermines efforts to establish ongoing care.
Petrina said: “Since 1980 I’ve worked with lots of excellent people to improve oral care in care homes, for older people and other vulnerable groups. Campaigns work as long as you provide support. The minute you stop and the staff/management change everything falls apart. It’s not fair to blame carers. They have competing priorities, not simply looking after someone’s teeth, but all aspects of their welfare.
“The truth is that often there are too few staff, they don’t get paid enough or trained enough. There needs to be a change in ethos and people need to understand how the mouth provides an insight into the body’s overall health.”
Nevertheless, with Caring for Smiles working with well-established GDPs and the PDS, oral hygiene will improve, leading to better health and saving money. Peter said: “A major cause of death in care homes is pneumonia, and one of its main causes is lack of oral hygiene. We can reduce the need to protect someone with antibiotics simply by brushing their teeth. It is well recognised that improved oral hygiene for all patient populations would save millions of pounds in hospitalisation and avoid more complex treatment.”
No doubt the Scottish Government will hope that Caring for Smiles will have the same widely acknowledged positive impact as Childsmile, the campaign designed to reduce oral health inequality and improve access to dental services for Scotland’s children.
However, matching that success could prove difficult. Petrina said: “Childsmile has been very well funded and prescriptive – everyone across the country has followed the same approach. The results have been phenomenal.
“However, Caring for Smiles does not have the same financial backing and health boards, while recognising the principles underpinning the campaign, sometimes struggle to implement it in a uniform manner. The idea of Caring for Smiles is great, but you have to put money into these things to make sure they are successful.”
Despite these reservations, there is some evidence of success. Peter highlighted an example in Ayrshire where all care homes are signed up to Caring for Smiles, and a stripped-down version was introduced in the intensive care unit in Crosshouse Hospital. “Healthcare staff had been cleaning mouths using a sponge and mouthwash. We gave them some better options and dramatically reduced both the number of antibiotic treatments and cases of aspiration pneumonia.”
“Caring Smiles does not have the same fiNancial backing [As Childsmile]. the idea of caring smiles is great, but you have to put money into these things to make sure they are successful”
Cash is king
Both Peter and Petrina are well aware that the goal of attracting more GDPs to work with care homes will depend to a great extent on cold, hard cash. They know GDPs are business people as well as highly skilled professionals being asked to do something different by tailoring treatment to people’s quality of life. And they know dentists must be adequately compensated.
Peter noted: “As health boards, and as a country, we are saying to GDPs ‘We will help you develop your skills, and the Scottish Government is looking at the financial package to recognise the accredited dentist who can take on this type of work.’ This shows the Scottish Government is willing to invest more in front-line care and it will pay dividends when we have fewer referrals to treatment in secondary care, which is significantly more expensive and more burdensome for the patient.”
While finance is fundamental, communication is the secret to success when it comes to smoothing out the steps of the process. “Everyone involved should be clear when a patient is at the stage where she/he should be being treated by a GDP or the PDS. The PDS should be the shoulder between primary and secondary care, delivering both, and supporting the GDP, as and when necessary.”
“GDPs simply don’t have the time to go through a convoluted process trying to make contact with, for example, a cardiology or haematology consultant. In those cases, a strong relationship with the PDS can come into play. PDS dentists are often familiar with the processes – they know the right people to contact and how to contact them.
“If you have an integrated system where each care home has an accredited GDP as well as the PDS dentist, then patients can travel along different stages of care in a seamless way.”
There remains widely expressed concern about the level of specialists in special care dentistry in Scotland. As patient conditions become increasingly complex more specialists are needed. However, Scotland currently has the grand total of one specialist in training.
The specialty came into being in 2008 when a small cohort of self-trained experts were recruited to pass on their skills to the next generation. However, many of those are nearing the end of their working life. As a result the number of specialists on the register in Scotland will reduce by 50 per cent in 2025 compared to 2015.
“We are wasting the talents of dedicated, skilled and intelligent young people who are keen to specialise in this area”
Petrina said: “We currently have four consultants in special care dentistry, one of whom is about to retire. I am also nearing retirement at which point there will be two consultants for the whole of Scotland. We are not a big country, but we need more trained specialists in this field.”
As always, finance is the overriding issue. At the moment there are no funded specialist posts available. In turn that lack of opportunity discourages training organisations; National Health Service Education for Scotland (NES) is understandably reluctant to invest in training specialists who end up working as non-specialist dental officers. “It’s sad, because we are wasting the talents of some incredibly dedicated, skilled and intelligent young people who are keen to specialise in this area,”
According to Peter there is no need to have a special care consultant backed up by a team of specialists in every health board area. “Each board is different – compare NHS Greater Glasgow and Clyde with NHS Orkney – so they might not all merit a specialist.” Instead, he believes there are sound arguments for a regional model with every health board having access to some element of specialist support. The aim is to have services delivered as close to home as possible and avoid a situation where patients must travel a very long way for a brief consultant appointment.
He insists dentistry is ideally suited to regionalisation. “We need to work much smarter. Cases, where a frail patient needs the use of a hoist, for example, can be carried out locally, while specialist or consultant input can be advised remotely through the employment of technology, for example using video conferencing and an intra-oral camera to show the mouth, and with X-ray or blood results relayed electronically.”
Both say that the new domiciliary care provision can be a start. If a significant number of GDPs are prepared to lend their expertise in care homes that pattern will become normalised, and the advantages – for patients, families, care homes, professionals, the healthcare system and the country as a whole – will start to flow.
“The OHIP has useful ideas on preventive care, but integration of services is essential,” said Petrina. “Unfortunately, we are trying to do things on a shoestring. If we could do the same ‘spend to save’ approach with Caring for Smiles that we did with Childsmile we would make substantial savings in the long run.”
She highlighted the approach in palliative care and the end-of-life setting where, she said, oral care is treated with respect. “We have done a lot of work with hospices over the last 20 years, and they have been methodical and careful to establish an evidence base for everything they do. As a result, the oral health care in hospices is of a very high standard.”
Peter added: “The fact that people are living longer and are living with more of their own teeth is a credit to the NHS. What we have to do from a dental point of view is catch up with the delivery of the care that this positive result requires. In truth, this is a learning process that we are still going through.
“I believe today’s GDPs have expanded their knowledge and expertise in different areas of dentistry. We need to keep evolving our approach in this area rather than assume we have it right. The OHIP opens the door but it’s how we proceed–and how things are funded–that will make the difference.
A project to test simple interventions
The topic of dental services for care homes is not unique to Scotland; it is a subject that needs to be tackled across the UK.
A research project involving Queen’s University Belfast is being undertaken to identify the efficacy of a series of simple interventions that it is hoped will have a meaningful impact for care home residents.
Dr Gerry McKenna (pictured) of Queen’s is one of those involved. He said: “This is a collaborative project. It is funded by the National Institute for Health Research (NIHR) and we are working with colleagues in the University of Bangor in Wales, as well as University College London, the University of Newcastle and the University of Glasgow.
“We are all aware that there is an increasing issue around the oral health of older people in nursing homes. It’s fair to say that their oral health has changed dramatically over the last 20 or 30 years.
“I’m also aware that there needs to be a very strong package of education for care home staff. There tends to be very high staff turnover in some places so anything we put in place must be long lasting.”
Part of the impetus for the project are recent NICE guidelines (NG48 Oral health for adults in care homes) and the starting point will be to implement a number of interventions in 12 care homes in Northern Ireland, with another 12 homes in London subsequently taking part.
“We are currently going through ethical approval and will look to recruit care homes from May 2019 onwards. The project will run for 12 to 14 months.”
According to Gerry, there are huge variations in practice across the UK. “In some places the community dental service is very active in looking after residents and in other places private GDPs look after patients – it’s very much on a home by home basis. This piecemeal approach has given rise to some of the issues we want to address.
“We are putting the emphasis on prevention and simple measures from the outset and hopefully getting away from big interventions further down the line, with teeth having to be taken out under general anaesthetic.”
It is recognised that residents may have a multitude of conditions and require a huge amount of help from staff, but it is hoped the project will help emphasise that oral health must be a priority, otherwise the consequences are serious. “There are lots of other things care staff have to consider but oral health is overlooked and it should be brought higher up the agenda,”
Looking close to home ,he said there is no policy similar to Scotland’s OHIP in Northern Ireland, though it’s an issue that needs to be addressed. “It may be that this piece of work we are doing over the next couple of years can contribute. I know that it is something the BDA in Northern Ireland is very keen to take forward.
“As someone who is very much involved in this area, I would like to see greater emphasis on how we care for older patients, not just those in nursing homes but pragmatic treatment planning for older patients in dental practices.”
For more information on the project click here