1. Improving dental access, quality and oral health in prisons and detention centres A toolkit for good practice in the commissioning of oral health services John F Beal MBE Consultant in Dental Public Health, NHS Yorkshire & the Humber Hon Senior Clinical Lecturer, University of Leeds

2. Milestones in developing prison dentistry Survey by Gerrish and Forcyth, 1995 Modernising dental services for prisoners, 2003 DH capital funding - £4.25m 2003-2006 PCTs responsible for prison health services, 2006 Dentists with a Special Interest in Prison Dentistry, 2007 Establishment of National Association of Prison Dentistry UK 2008

3. Oral Health of Prisoners Oral Health in England has improved enormously over 30 years Inequalities still exist matched to areas of social exclusion 50% of prisoners are unemployed before sentencing Enter prison with poor oral health Untreated disease about 4 times greater than general population from similar social backgrounds Dental attendance less than general population Needs have often not been met within prison

4. Reason for last visit to dentist (%) (25-34 year-olds)

5. Need to give guidance to PCTs to help them in reviewing and commissioning prison dental services To support prison dental teams to improve the oral health of the prison population To ensure that dental care for prisoners is in line with that available for the rest of the population taking into account their greater needs

6. Working Group members Liana Zoitopoulos, Cons Special Care Dentistry, NAPDUK John Beal, Consultant in Dental Public Health, SHA Wade Houlden, Prison dentist, NAPDUK Judith Husband, Prison dentist Tony Jenner / Sue Gregory DH DCDO Mark Johnson, DH Offender Health Numa Kapur, Prison Dentist, NAPDUK Theodore Papadakis, SDO Kings College Debbie Parkin, DH Offender Health Eric Rooney Consultant in Dental Public Health, PCT

7. Department of Health policies General –Health reform in England: update and commissioning framework, 2006 –World class commissioning, 2007 Dental –Modernising dental services for prisoners, 2003 –Choosing better oral health, 2005 –Delivering better oral health, 2007 –World class commissioning; Improving dental access, quality and oral health, 2009

8. Some guiding principles Need for prevention as well as treatment Requires shift in resources towards prevention Bear in mind health inequalities are now recognised as contributing to likelihood of offending and re-offending Oral health promotion needs to be embedded within “Healthy Prisons” strategy

9. Model for commissioning prison and detention centre oral health services

10. Oral health needs assessment Develop service specification Review service Reshape existing service or market test Manage performance and support quality improvement

11. Review of service Exit questionnaires to prisoners to evaluate the care received Oral health assessment on transfer or release similar to those on entry to measure differences in oral health and needs while in prison Assessment of oral health behaviour to assess effectiveness of OH Promotion Views of the dental team Assessment of prison environment eg healthy menus, types of drink available as indicator of dental team influence on healthy prison

12. Prevention and oral health improvement (OHP) OHP programme embedded in prison health promotion strategy – CRF approach PCT lead prison support Smoking cessation Oral health promotion programme Prison lead PCT support Healthy menus Available sugar-free drug substitute prescribing

13. Challenges to PCT High oral health needs Complexity of care needed Low priority of health promotion Lack of skilled workforce Organisation of emergency and referral systems Quality of care Challenges to prison Nutrition Shortened sessions / cancelled attendance Lack of space Litigation Turnover of population Demanding patients Outdated clinical facilities Continuity of care

14. 1.18 Prison Dentistry Emergency –severe facial trauma, severe bleeding –immediate access to hospital A & E Urgent –dental pain, minor trauma –dentist within 24 hours (or appropriate practitioner) Routine –Dentist within six weeks from the time of asking.

15. Waiting times in days for routine dental treatment all prisons in Yorkshire & the Humber, September 2006 (National guideline)

17. Green Indicator Access standards for dental care reflect general access guidance in all of the following areas: –Emergency Care –Urgent Care –Appointments Amber Indicator –Access standards for dental care DOES NOT reflect general access guidance in all areas, but there IS an action plan in place to achieve the access standard. Red Indicator Access standards for dental care DOES NOT reflect general access guidance in all areas, and there IS NO action plan in place to achieve the access standard.

18. Oral health Promotion Unit GDPDwSI in Prison Dentistry Specialist service providers e.g. Specialists in Special Care, Restorative Dentistry, Oral Surgery Oral Health Improvementvvv Needs assessmentvvv Routine dental carev v Secondary care and referralsv v Emergency dental carevvv

19. Research Research is fundamental to successful World Class Commissioning Need to be able to demonstrate better health and well-being and better value for all Research needed on ‘barriers’ in delivering dental care to a prison population Research on dental care for vulnerable groups eg drug abusers, mentally ill and persons with a history of violence

20. Future workforce availability Consider recommendations from review of workforce issues for prison doctors Teaching prison dentistry in dental undergraduate and DCP curriculum National clinical attachments in prisons Opportunities for placements in prisons for training and development

21. Service specification (1) Service aims –Primary dental care –Secondary care and access to specialist services –Emergency dental services - minor (local) and major (hospital) –Oral health promotion –Oral screening and needs assessment –Research

22. Service specification (2) Target group –normally any inmate who requests Location –ideally near to other primary health services Hours –number of sessions –start / finish time –arrangements for out of hours emergencies Treatment pathway –Including referral to and from the service

23. Entry to the prison/detention centre: Initial assessment according to prison protocol No dental treatment requested Patient returns to wing. Dental treatment requested Patient remandedSimple dental treatment or emergency care offered Patient convicted Routine Dental care and prevention aiming at meeting all treatment needs due to longer stay in prison Emergency care offered by prison primary dental team. Patient placed on waiting list All treatment needs met. Prisoner placed in recall system Incomplete care due to discharge or transfer to another prison If discharged contact dental services in community to ensure continuity of care If transferred then ensure all dental records and treatment plan available Prisoner discharged Contact dental services in community to ensure continuity of care Specialist care offered in hospital by referral.

24. Entry to the prison/detention centre: Initial assessment according to prison protocol No dental treatment requested Patient returns to wing.Dental treatment requested Patient remandedSimple dental treatment or emergency care offered Patient convicted Routine Dental care and prevention aiming at meeting all treatment needs due to longer stay in prison Emergency care offered by prison primary dental team. Patient placed on waiting list All treatment needs met. Prisoner placed in recall system Incomplete care due to discharge or transfer to another prison If discharged contact dental services in community to ensure continuity of care If transferred then ensure all dental records and treatment plan available Prisoner discharged Contact dental services in community to ensure continuity of care Specialist care offered in hospital by referral.

25. Entry to the prison/detention centre: Initial assessment according to prison protocol No dental treatment requested Patient returns to wing.Dental treatment requested Patient remandedSimple dental treatment or emergency care offered Patient convicted Routine Dental care and prevention aiming at meeting all treatment needs due to longer stay in prison Emergency care offered by prison primary dental team. Patient placed on waiting list All treatment needs met. Prisoner placed in recall system Incomplete care due to discharge or transfer to another prison If discharged contact dental services in community to ensure continuity of care If transferred then ensure all dental records and treatment plan available Prisoner discharged Contact dental services in community to ensure continuity of care Specialist care offered in hospital by referral.

26. Service specification (3) Skill mix –dentist / DwSI / specialist / DCPs (including extended skills) –case mix model Staff –induction –qualifications required / checked –CPD –peer review and audit Premises and equipment –responsibilities for maintenance and repairs –ordering of supplies –standards and regulations eg H&S, COSHH, radiological

27. Service specification (4) Laboratory work –registered technicians / comply with H&S –arrangements / costs / turnaround times Activity measurement –moving away from purely numbers of patients –PCT and dentist should get monthly DSD report –possible use of case mix model

28. Service specification (5) Clinical governance (responsibility of Prison Partnership Board) –reporting mechanism –quality and standards – including unique NHS number, process for staff concerns and patient complaints, day book and records, DRO inspections –H&S including decontamination, training –CPD for all registered staff –Patient information – rights in relation to dental care in prison and following transfer or release

29. Service specification (6) Clinical governance (contd) –induction including confidentiality, security, safety, complaints –efficiency including keys or collection of dental team, appointment system, filling cancelled appointments, avoiding cancelled sessions, prison providing information on likely length of stay –cover for planned / unplanned leave, security clearance for replacement staff Finance

30. Thank you If you have any comments or suggestions please let us know by contacting one of the NAPDUK representatives on the Working Group