1. PHRN Dental Theme Two Years On Martin Tickle Research Director Oral Health Unit - National Primary Care R&D Centre Professor of Dental Public Health & Primary Care School of Dentistry: The University of Manchester

2. StructureStructure Why do we need research in prisons?Why do we need research in prisons? Progress on the research programme of the dental theme of PHRNProgress on the research programme of the dental theme of PHRN Demonstration project – preliminary resultsDemonstration project – preliminary results ReflectionsReflections Next stepsNext steps

3. Why do we need research in prisons?

4. ChallengesChallenges PCTs responsible for commissioning prison dental servicesPCTs responsible for commissioning prison dental services Major issuesMajor issues – High need populations – Need to provide equivalent care but with restricted resources – Unique environment – security concerns – Workforce issues – recruitment, professional isolation Poor evidence basePoor evidence base

5. Contribution from research Provides knowledgeProvides knowledge –To inform commissioning decisions –To inform clinical care delivery

6. Spin off benefits of research Spin off benefits of research Reduces professional isolation and supports professional developmentReduces professional isolation and supports professional development Improves quality of careImproves quality of care Helps recruitment and retentionHelps recruitment and retention

7. Progress on the research programme of the dental theme of PHRN

8. PHRN programme PHRN programme Formal launch – Sharing Good Practice Conference York 4-5 th May 2005Formal launch – Sharing Good Practice Conference York 4-5 th May 2005 Network of research supportive prisonsNetwork of research supportive prisons Network of research active individuals working in prisons - http://www.phrn.nhs.uk/Network of research active individuals working in prisons - http://www.phrn.nhs.uk/ Scoping exerciseScoping exercise Small demonstration projects in each areaSmall demonstration projects in each area

9. Scoping exercise Systematic reviewsSystematic reviews Listening exerciseListening exercise –Workshops –Interviews Identify and prioritise research needsIdentify and prioritise research needs Feed into DH research commissioning frameworksFeed into DH research commissioning frameworks

10. Dental Theme scoping exercise Systematic review of literature – completeSystematic review of literature – complete Very few papers - all descriptive epidemiologyVery few papers - all descriptive epidemiology No information about effectiveness of interventionsNo information about effectiveness of interventions

11. Research priorities What interventions are effective in improving health of prisoners? What interventions are effective in improving health of prisoners? How can promotion of healthy eating\smoking cessation be supported? How can promotion of healthy eating\smoking cessation be supported? How can the surgery down time be minimised? How can the surgery down time be minimised? Is screening of prisoners effective? Is screening of prisoners effective? Effective use of skill-mix Effective use of skill-mix A society for prison dentists A society for prison dentists

12. Specific request from CDOSpecific request from CDO Strategy for Modernising Dental Services for Prisoners in England – April 2003Strategy for Modernising Dental Services for Prisoners in England – April 2003 –Standards for service delivery Over £4.5M injected into prison dental servicesOver £4.5M injected into prison dental services Has strategy\additional funding improved prison dental services?Has strategy\additional funding improved prison dental services? Evaluation of Prison Dental Services

13. Demonstration Project Developing and testing a screening tool to identify prisoners with urgent treatment needs

14. Aims of demonstration project Development and testing of a standardised assessment tool to identify prisoners with urgent treatment needsDevelopment and testing of a standardised assessment tool to identify prisoners with urgent treatment needs Identify and catalogue difficulties of running research projects in the prison settingIdentify and catalogue difficulties of running research projects in the prison setting

15. BackgroundBackground Recently admitted prisoners have severe dental problemsRecently admitted prisoners have severe dental problems Remand and short stay prisoners have difficulty keeping appointmentsRemand and short stay prisoners have difficulty keeping appointments Most services run on a part time basisMost services run on a part time basis On admission all prisoners have 24 hour, then 48 hour health assessmentOn admission all prisoners have 24 hour, then 48 hour health assessment No standardised system of dental assessmentNo standardised system of dental assessment

16. Screening as a process Identify the target population Identify the population at risk via a screening test Attendance for a diagnostic test Identify individuals in need of treatment via a diagnostic test Those in need of treatment receive appropriate treatment

17. BackgroundBackground Collaboration with Queen Mary’s and GKTCollaboration with Queen Mary’s and GKT Dental Pain Questionnaire (DePaQ) Dental Pain Questionnaire (DePaQ) 2 page questionnaire 2 page questionnaire Categorises patients with pain into three groupsCategorises patients with pain into three groups –Irreversible pulpitis and periapical periodontitis –Reversible pulpitis and dentine sensitivity –Pericoronitis Successfully tested in NHS – enables categorisation into Urgent and Non-UrgentSuccessfully tested in NHS – enables categorisation into Urgent and Non-Urgent

18. MethodsMethods All patients on urgent treatment list attending dental services of Brixton and Belmarsh prisons – aimed for N=200All patients on urgent treatment list attending dental services of Brixton and Belmarsh prisons – aimed for N=200 Pilot questionnaire – literacy issuesPilot questionnaire – literacy issues Administered by nurses who deliver 48 hour assessment (screening test)Administered by nurses who deliver 48 hour assessment (screening test) Clinical examinations by trained and calibrated examiners (diagnostic test) blinded to screening test outcomesClinical examinations by trained and calibrated examiners (diagnostic test) blinded to screening test outcomes

19. ResultsResults Lost Belmarsh due to increased securityLost Belmarsh due to increased security Fieldwork planned for 6 weeks – took 4 monthsFieldwork planned for 6 weeks – took 4 months Stopped when N=100Stopped when N=100 Principal problemsPrincipal problems –Lack of authorised staff –Prison Officers –Behaviour of prisoners

20. Flow Diagram 96 subjects in total 69 categorised at screening & clinical examination 15 stated they had pain at screening but no urgent need at clinical examination 4 no pain at screening and no urgent need at clinical examination 1 no pain at screening but urgent need at clinical examination 5 had an incomplete questionnaire and urgent need at clinical examination 2 prisoners had incomplete questionnaire and no urgent need at clinical examination

21. Results - frequency distribution at screening

22. MethodsMethods Irreversible pulpitis, periapical periodontitis and pericoronitis Reversible pulpitis and dentine sensitivity Incomplete questionnaire no pain no pain Urgent treatment need Non Urgent Treatment Need = =

23. Two by two table for expressing the results of validation study for any screening test Result of screening test Diagnose positive (a+c) Diagnose negative (b+d) Test positive (a+b)True positive (a)False positive (b) Test negative (c+d)False negative (c)True negative (d) Screening Test Validation Result of gold standard (diagnostic) test

24. Screening Tests Sensitivity = True positive rate How good is the test at picking up people who have the condition? a/ (a+c) Specificity = True negative rate How good is the test at correctly excluding people without the condition? d/ (b+d)

25. Results – sensitivity and specificity Diagnosed Urgent Treatment need Diagnosed Non-Urgent Treatment need Total Screened Urgent Treatment need 39 (81%) 32 (67%) 71 (74%) Screened Non-Urgent Treatment need 9 (19%) 16 (33%) 25 (26%) Total484896

26. ConclusionsConclusions High sensitivity –efficient at picking up individuals with an urgent needHigh sensitivity –efficient at picking up individuals with an urgent need Poor specificity – inefficient at excluding individuals who have non-urgent treatment needsPoor specificity – inefficient at excluding individuals who have non-urgent treatment needs Lack of candour will always be a problem?Lack of candour will always be a problem? Subjective vs professional judgement of need?Subjective vs professional judgement of need? Is this test useful?Is this test useful? –Only need to see ¾ of population but miss 1 / 5 of those with urgent treatment needs

27. Difficulties of running research projects in the prison setting

28. ProblemsProblems No problems with healthcare staff, or the prisonsNo problems with healthcare staff, or the prisons Prisoners – unpredictable behaviour and unpredictable attendancePrisoners – unpredictable behaviour and unpredictable attendance Security – getting subjects to the health care facilitySecurity – getting subjects to the health care facility Staffing – recruitment of staff with security clearanceStaffing – recruitment of staff with security clearance Prison officers – institutionalised resistance?Prison officers – institutionalised resistance? Research a low priority - interferes with prison targetsResearch a low priority - interferes with prison targets Dental Issues – low priority compared to other health problemsDental Issues – low priority compared to other health problems

29. Reflections after 2 years

30. Thoughts on research in prisons Prison dentistry needs a research basePrison dentistry needs a research base The PHRN is a first stepThe PHRN is a first step Significant difficulties of deliverySignificant difficulties of delivery Are research outputs worth the effort?Are research outputs worth the effort? RAE – main driverRAE – main driver –High quality outputs

31. Pros and Cons for an Academic Pros and Cons for an Academic Pros Adherence to protocols by prison healthcare staffAdherence to protocols by prison healthcare staff High disease adult populationsHigh disease adult populations Accessible populationAccessible population High consent ratesHigh consent rates Cons Bizarre behaviour –Adherence to protocols by subjects –Response bias Additional complexities of ethical approval process Extended recruitment periods Loss to follow up Lack of control Unpredictability

32. What next?

33. Next Steps Complete demonstration project – qualitative research identifying barriers to undertaking high quality researchComplete demonstration project – qualitative research identifying barriers to undertaking high quality research Network of research hosting prisons – can they provide solutions and deliver?Network of research hosting prisons – can they provide solutions and deliver? Will funding materialise?Will funding materialise? –PHRN –Other DH funding streams Will other academics become active in this field?Will other academics become active in this field?