Increasing access to dental services
NHS Kensington and Chelsea (NHS KC) worked with social marketing consultancy Lamerton Swales on a project to increase self-referral rates to NHS dental services and improve overall oral health in under 18s and adults.
Following a comprehensive phase of scoping research, the team identified the need to improve confidence in and the reputation of NHS dentistry in the borough, by improving service provision and capacity and using PR and communications to promote services.
The intervention mix developed to address low uptake of NHS dentistry in KC consisted of: improving service provision and capacity through a Quality Outcomes Framework (QOF); online toolkit of resources for dental practices; multimedia registration campaign; and a child oral health programme.
- 2.9 per cent increase in adults accessing KC NHS dentistry from 2007/08 to 2009/10
- 4.4 per cent increase in children accessing NHS dentistry from 2008/09 to 2009/10
- Increase in children receiving a fluoride varnish, from under 1 per cent of children in 2008 to 10.5 per cent in 2009
- Reported improvements in service provision, such as extended opening hours and offering ‘child-friendly dentistry’
In 2008, NHS Kensington and Chelsea (NHS KC) had the lowest number of adult and child NHS dental patients per population in the country. When patients did visit the dentist, it was for symptomatic and severe treatment, rather than preventative. Patients in Kensington and Chelsea (KC) had the third highest proportion of Band 3 activity (remedial work such as crowns and bridges) and the third lowest proportion of Band 1 (check-ups) in the country. Children were more likely to have fillings as a first treatment and the number of child NHS patients seen in the 4 most northerly wards was approximately 25 per cent lower than the London average.
The number of patients visiting NHS KC dentists in the previous 24 months was in slow decline; from 43,642 at the end of March 2006, to 40,194 at the end of June 2007, to 35,619 at the end of June 2008. This decline resulted in the borough being designated ’red’ in September 2008 under NHS London and Department of Health (DH) criteria. From 2006 to 2008, the number of dental practices providing NHS care in the borough fell from 34 to 17, yet in the financial year 2007/08 not all contracted Units of Dental Activity (UDA) were used.
Oral health is poorer in areas of highest deprivation. The north of the borough was prioritised as it represented the most deprived wards in the borough. There was a cluster of practices in the north accounting for over half the UDAs commissioned. Therefore, capacity could be met if access was increased. There was a higher than average proportion of 0- to 19-year-olds in the wards, with 3 of the 4 wards having a 0- to 19-year-old population more than 25 per cent higher than the borough average.
One of the priorities in NHS KC’s 2008-10 Oral Health and Dental Commissioning Strategy was to commission a needs assessment and social marketing campaign to increase the numbers of people seeing a NHS dentist and to promote better oral health. A strategic Dental Steering Group (DSG) was set up in May 2008 to oversee the project.
1. Increase self-referral rates in under 18s and adults not using any dental services at all (defined as those who had not been for 2 years and over), as opposed to those not using NHS dental services (i.e. accessing private dental services)
2. Improve overall oral health in these groups
The aim was not to transfer patients from private to NHS practices if they were already exhibiting self-referring behaviour. Healthcare Commission statistics indicated that 40 per cent of the borough used private dental services.
Instead, the target audiences for this project were:
- Under 18s in North Kensington with a nil or low referral rate to NHS dental services, who did not use private dental services
- Adults in North Kensington who did not use any dental services at all, but were entitled to use an NHS dentist
- Under 18s and adults in North Kensington, not using any dental services, who had made an appointment with an NHS dentist but failed to turn up
- Remaining borough residents who fit into this category
The secondary audience was:
- NHS dentists in KC
Tertiary audiences included:
- Schools, workplaces and social settings
- Oral health and health improvement teams
- PCT dental commissioning teams
An extensive scoping exercise was undertaken between August and October 2008 by social marketing consultancy Lamerton Swales and Isis Green Research Solutions Ltd.
- Collation of existing statistical data provided by NHS KC
- A systematic review of the scientific literature concerning access to dentistry
Primary data collection commenced with engagement of key stakeholders and tertiary audiences. These groups included healthcare professionals, academics, dental practices and industry specialists, with the aim of building a context and background to the project.
- Street survey – 233 surveys were completed by residents in selected wards that had some of the lowest self-referral rates in the borough
- Waiting room survey – 280 self-completion questionnaires were collected from patients attending 6 dental practices in the north of the borough
Initial audience segmentation was informed by the literature on oral health and access to dentistry and locally available socio-demographic and behavioural data relating to dental attendance in the borough. Two target groups were identified for behavioural analysis via focus groups:
- Under 18s and parents
- ‘Dental resisters’ (irregular or non-attendees)
Focus groups were also conducted with the following groups:
- Older people – to explore issues from a generational perspective
- School nurses – to garner views and experiences of professionals directly engaged with children and parents
- Mums and toddlers – to understand the attitudes and perceptions of parents towards oral health before children’s teeth were fully formed
- Young people aged 14 to 18 – to understand why access decreased sharply from age 17 onwards
- Black and minority ethnic (BME) groups – to uncover facilitators and barriers that may be specific to BME groups, such as need for a translator
- Somalian community – as a case study
Findings from the primary research were thematically analysed using the Health Belief Model as an analytical framework.
Barriers and benefits
While the majority of respondents valued good oral health, there were very few perceived benefits of regularly visiting the dentist and many barriers.
1. Local dental services:
- Unable to find a suitable dentist
“Now I can't find a dentist that I can trust, I have been having problems for small time, I have pain in my tooth...but I can't find a good dentist.” Egyptian Female (Parents)
- Dentists not accepting NHS patients
“I've been experiencing problems getting seen by the NHS dentist and they seem to stay for six months and then they leave and so they will be saying to me we don't have an NHS dentist at the moment but we could do private.” Black British Female (Parents)
- Lack of child-friendly dental services
“There's no toys in the corner…If you put the kids down they are going to trash the place.” White British Woman (Parents)
- Mistrust of dentists
“They beat around the bush and use terminologies that you might not be familiar with. They could just say what it simply is. Try and sound much bigger than it actually is and charge a bit extra.” Black British Female (Dental resisters)
- Apathy and low perception of need – Residents equated good oral health with no pain or trauma and were unlikely to act unprompted. Pain and trauma were the cues to action in making a dental appointment
“I don't have any problems with my teeth...if it ain’t broken why fix it?” Black Caribbean Male (Youths)
- Negative or unpleasant experiences
“I could hear when people came in for their appointments and people were treated appalling with great disrespect, and then the clinic was cancelled and there was never any attempt to contact people that had appointments to cancel their appointments, even though the dentists knew they wouldn't be there. So people were taking time off work coming into a dentist appointment and finding there was no dentist there.” White British Female (School nurses)
- Availability of appointments and lack of reminders
“Even my last son I had to take and even that one had a bad experience as well because he had two of his teeth coming out and I want him to have brace and then we waited for one place to the other. I waited so long until today is still waiting is over 4 years.” Black Caribbean Female (Dental resisters)
- Cleanliness and hygiene of dental practices
“It has crossed my mind because you do think, I wonder if, ‘cos they come out the room so quick, a person leaves and, do they change the tray?” Iraqi Female (Parents)
2. Fear and phobia:
“They [my children] are petrified. So I've actually passed it on to them. Because I'm so scared, although I know they need to go to the dentist, I feel sorry for them because I know what it is like.” Moroccan Female (Parents)
3. Financial cost:
“I would wait until there is a problem because I don’t want to spend unnecessary money. Because they might just tell me the same thing over and over again, that there is nothing wrong”. Black British Male (Youths)
Specific behavioural barriers within the BME community were identified, such as the need for translators and information in different languages, advice on what was acceptable during fasting periods such as Ramadan, and the option to request same -sex- dentists.
However, it appeared that the behavioural barriers facing the majority of the BME community were those faced by the majority of residents of the borough in terms of a low perception of need, reinforced by phobia or fear, memories of unpleasant experiences, perceptions of poor hygiene and a lack of appropriate services, such as child-friendly dentistry, out-of-hours opening and pleasant reception areas.
Based on these findings, various recommendations were made to:
- Improve confidence in and the reputation of NHS dentistry in the borough, by improving service provision and capacity and using PR and communications to promote services
- Introduce a registration scheme
- Implement a branded Childsmile style scheme for children and outreach programme in schools
- Achieve 100 per cent accreditation of NHS KC dentists to the British Dental Association (BDA) Good Practice Scheme
The research findings and recommendations were presented to the project Steering Group, who agreed to take forward most of the recommendations. A comprehensive programme was subsequently developed, consisting of the following elements.
Improving service provision and capacity
To improve the clinical standards, customer choice and range of services, the NHS KC commissioning team introduced financial incentives for quality improvements in NHS dental practices via a Quality Outcomes Framework (QOF). This included:
- Meeting NHS KC’s child- and family-friendly dentistry criteria
- Offering same sex dentists if requested by patients
- Actively promoting and offering translation services for patients
- Providing relaxation techniques for anxious patients
- Providing extended opening hours
- Providing advice on fasting (for example, for Ramadan)
- Achieving the BDA Good Practice Awards
Marketing agency Golley Slater was commissioned to develop a package of materials to support NHS KC dentists to meet the new QOF criteria. This online resource included:
- Communication about NHS KC’s key criteria and requirements for improved services
- Guidance and advice on implementing new services and improving the customer experience
- A generic suite of marketing materials to improve customer engagement and relationship management (CRM), such as:
- New patient welcome, recall and letter templates
- Templates for adverts, promotions and direct mail
- Templates for child-friendly materials
- Staff training links, online forums and relevant web links
Multimedia registration campaign
Golley Slater was also commissioned to develop a multi-media advertising campaign to launch in early 2010, encouraging people to register with the primary care trust (PCT) so they could be contacted and offered appointments.
Capturing and processing data:
- A borough wide awareness raising PR campaign encouraging residents to register with a dentist was developed with relevant messages about the importance of oral health and preventative treatment
- Freepost cards were produced for distribution throughout the borough (for example through pharmacies, community groups and GP surgeries), inviting residents to complete their contact details and return them
- Other KC organisations were also sent freepost cards to include in scheduled mailings, such as the Royal Borough of Kensington and Chelsea’s (RBKC’s) council tax mailing
- Residents could select which dental service they required from a list, for example child-friendly, postcode specific, or out-of-hours
- An online and freephone facility offering the same registration process was set up to accompany the campaign
- Promotional material (posters, leaflets and badges) were sent to all outlets offering the freepost cards (including other KC NHS services, local schools and voluntary organisations) to advertise their availability
- A fulfilment house processed the freepost cards and answered the freephone line to register people
- The data was sorted by postcode and customer orientation, then passed on to the PCT, which passed it to the relevant KC NHS dentists
- There is a dentist to suit everyone, whatever your need
- KC offer child- and family-friendly dentists – all you have to do is register
- KC dentists offer translation and interpretation services – all you have to do is register
- KC dentists understand your anxiety and offer relaxation techniques if you’re nervous – all you have to do is register
- Not everyone pays – children, pregnant mums and people on benefits are exempt
- Children under 16 should be taken for regular check-ups every 6 months
- Adults may only need to attend regular check-ups once a year or every two years – it’s not that onerous
- NHS KC is tackling oral health as a priority
- Friendly, encouraging, positive and understanding of any fear or phobia barrier
- Registering is the call to action
Child oral health programme
NHS KC established an ambitious programme, based loosely on the Scottish Childsmile programme and branded the Bigger Smiles campaign. The campaign combined a series of interventions, some of which are still ongoing or have yet to be implemented.
Antenatal and postnatal:
- Oral health trainers (OHTs) were recruited to conduct targeted visits with mothers within three months of giving birth and offer advice and information on the importance of gums, jaw development, use of dummies, early habits and good personal oral health
- Both mother and baby would be offered their first appointment and registered with their local dentist through the home visits
Zero to three years:
- Regular oral health visits
- Baby dental ‘passport’ provided with the Red Book
- Mother and baby dental appointments offered from six months
- Follow-up to confirm attendance at dental appointments
- An oral care pathway developed for children aged zero to three years, covering breastfeeding, weaning, teething, brushing, speech development, diet and nutrition, and fluoride varnish at three years upon entering nursery or the children’s centre
Outreach fluoride varnish programme:
A separate steering group was established to pilot an outreach fluoride varnish campaign in schools. Members included: Healthy Schools, RBKC, Family Support and Children’s Services teams, a dental public health consultant, oral health promoter, school nurse and head teacher.
The campaign was:
- Targeted at children aged three to six
- Piloted in a primary school within one of the target areas
- A theatre group engaged children in a song and dance routine before they received fluoride varnish from a qualified dental practitioner, nurse or therapist
- At the end of the visit, children were given a goody bag with a free toothbrush, toothpaste and materials
- OHTs recorded applications and the results stored with the school records
- Absent children could be followed up and contacted by a local dental practice
This campaign was piloted across 2 days in October 2010, with 120 children aged 4 to 8 in St Cuthbert and St Matthias primary school, based in Earl’s Court. The pilot was coordinated by Lamerton Swales on behalf of the PCT.
Despite a tricky consent process, requiring four sets of documents in three different languages for parents of the students, the pilot outreach event achieved impressive results:
- 106 consent forms were returned (out of 120 sent out)
- Of those returned, 97 were positive consents
- 93 children successfully received fluoride varnish applications
- 29 children were referred for treatment (2 urgent)
Child-friendly award scheme:
NHS KC established a Child-Friendly Award Scheme, which dental practices in the borough could apply for. Award criteria included the use of instruments specially designed for children, flavoured numbing gels, toys and books in reception areas, relaxation techniques and certificates to award attendance. Those meeting the criteria would be entitled to display the Child-Friendly logo in their window.
Partnership with GlaxoSmithKline Consumer Healthcare (GSK)
A key aim of the Bigger Smiles child oral health campaign was to reinforce the importance of oral health to children and ensure they associate dentistry with a positive and enjoyable experience. This meant providing children with a fun experience and good quality products, such as toothbrushes, toothpaste and other collateral (like toothbrushing charts and certificates). In developing the campaign, NHS KC had a programme strategy, but no fun products.
The project team approached a number of commercial companies in the hopes of recruiting a private sector partner to bring additional resource to the campaign. GSK responded positively to the invitation. The company recognised that it had the collateral in the form of the Aquafresh product line and various materials (toothbrusing charts, certificates, Nurdle Passport and colouring pads) featuring the Nurdle characters, but no direct-to-child outreach programme (most of its consumer activity was online and advertising to mums or via dental professionals). Working together on a child oral health campaign therefore gave both NHS KC and GSK the opportunity to benefit from each other‟s complementary expertise and resources.
The commissioning process for new practices in the borough and incentives for quality improvements in existing practices began in June 2009. Although the PCT initially found it difficult to effectively promote the process and align it to the commissioning cycle and quarterly reports, it did achieve some success and momentum began to gather.
Child-friendly award scheme
This scheme was piloted during July 2009. Six dental practices received the dentist’s child-friendly pack, which was produced by GSK and included a passport stamp, Nurdle stickers, a Nurdle World poster and a colouring-in pad to hand out to patients. Upon successful pilot, the scheme was further developed and is due to be launched in 2011.
The online toolkit launched in December 2009 and all NHS dental practices were trained and issued with login details. Uptake of the toolkit was mixed – some practices (namely the practice managers) used it extensively, especially to support providing child-friendly materials, while other practices used it less.
The registration campaign was piloted in 39 pharmacies between 15 January and 15 February 2010 with posters, leaflets, pharmacy bags, badges and a briefing pack containing information, FAQs and a ‘trigger’ script. Following its success, the campaign launched on 15 February 2010 – campaign materials (registration leaflets, cards and posters) were rolled out across the borough in clinics and hospitals, schools, libraries, community centres, Jobcentres, retailers and leisure outlets.
A media campaign ran from 8 February and 12 March 2010, promoting registration on tube posters, bus headliners and shelters, telephone kiosks, waiting room screens at Chelsea and Westminster Hospital, and in local press, related online media and council tax communications.
NHS KC had planned to establish a process whereby new patients registering with a GP would automatically be registered with an NHS dentist too. However, this required separate agreements to be established between the PCT and GPs, so a decision was taken not to pursue this. Nevertheless, registration leaflets were made available in GP surgeries and newly-registered patients were encouraged to also register with an NHS dentist.
The new QOF was part of the commissioning process and was therefore managed by the PCT commissioning team. Golley Slater, Lamerton Swales and the Head of Communications at the PCT monitored the registration and media campaign.
While Lamerton Swales managed the overall project, the PCT had limited capacity to implement and deliver. A Dental Access Officer and team of OHTs were therefore recruited in January 2011 and October 2010 respectively, which helped manage and integrate the project into existing workstreams. However, establishing the business case to fund the OHT team was a lengthy process and took nearly 12 months, during which work had to be prioritised.
Due to the complex nature of the interventions and the fact they spanned across departments and roles (including public health, commissioning and provider services), there were issues with consistent leadership and ownership of the project, and this caused problems with decision making and accountability.
“A compartmentalised culture doesn’t enable multi-disciplined interventions to flourish and can create confusion as to who is responsible for implementation and delivery. Lack of overall accountability meant that when problems were encountered, it was often unclear who could resolve them and how. This lengthened much of the implementation and delivery processes, as negotiation and compromise accompanied every stage of operational delivery.” Louise Pinkney (Managing Director, Lamerton Swales)
The skills and commitment of the agency, Golley Slater, were excellent and ensured delivery of the media, PR and registration campaign in a tightly managed process. GSK provided materials and support during the pilot phase, allowing the team to develop accurate insight for the child outreach programme and ensuring the development process was efficient and effective.
Partnership working was very successful. The partnership with GSK enabled a more creative approach and demonstrated a different attitude and way of working to the PCT. The partnership with the British Dental Association was also very successful – it provided credibility and a structured, recognised process for dentists to sign up to.
Independent evaluation of the project was undertaken by Isis Green Research Solutions Ltd and Lamerton Swales, using a mix of qualitative and quantitative research methods.
NHS KC provided statistics on quarterly dental access, treatment and UDA figures. Three time periods were evaluated to allow for a comparison of the possible impact of the social marketing project against existing practice, and to distinguish the QOF efforts from the multimedia registration campaign that was launched later. The baseline comparator period (T1: April 2007-March 2008) was chosen, which represents the time period immediately preceding social marketing activity in the PCT. T2 (April 2008-March 2009) covered the period when the QOF elements were launched and T3 (April 2009-March 2010) covered the QOF pilot and multimedia registration campaign.
Golley Slater collected monthly figures of the number of people registering under the multimedia campaign, campaign awareness and routes to registration.
Telephone interviews were conducted with 12 dental practices that took part in the project and other key stakeholders. These focused on exploring whether practices were delivering the requirements of the QOF and their experiences of using the online toolkit.
Service provision and capacity:
- 2.9 per cent increase in adults accessing NHS KC dentistry from T1 to T3
- 4.4 per cent increase in children accessing NHS dentistry from T2 to T3
- Dramatic increase in the reported number of children receiving a fluoride varnish, from under 1 per cent of children in 2008 to 10.5 per cent in 2009
- Most surgeries were able to provide a same sex dentist if this was requested
- The majority of dental practices felt they were able to adequately meet the language requirements of their patients
- Dentists felt that mildly anxious patients were treated adequately within their setting and that this was an integral part of their service. While this is a positive response, it suggests that patients suffering from moderate to severe dental anxiety and phobia may not be attending despite the efforts of the PCT to increase access
- The majority of surgeries reported offering some form of extended opening hours
- All surgeries were able to offer advice on fasting when this was requested
- The majority of dentists felt they were offering ‘child-friendly dentistry’, although what was understood by this was highly variable and selective
Multimedia registration campaign:
- The campaign resulted in relative early success with around 10 per cent of new registrations directly attributable to the campaign. However, the last three months for which data was available show a decline in the number of new patients self-referring
- The registration campaign was only able to convert one-third of registrations to actual patients. This suggests problems with contact detail recording systems and/or an underlying failure to understand the concept of the campaign
- The smaller proportion of registered patients who did not attend, cancelled or refused an appointment suggests that there remain behavioural barriers that reduce the importance of regularly accessing dental treatment, for whom access to dental services is triggered by pain or need
- The majority of KC dental practices were using NICE guidelines to guide patient recall
- Significant increase in treatment for both adults and children when T1 was compared to T3. In particular, band 3 treatment in both adults and children and band 2 treatment in children saw significant increases across the time periods evaluated, while over the same period band 1 and 2 treatment in adults declined as proportions of total treatment performed
- Feedback relating to the online toolkit was positive and was being used by most of the practices
Review and feedback
- A full report and evaluation were presented to the PCT senior management team and Board
- The scoping report was shared with over 90 stakeholders and distributed to over 12 other PCTs
- The team took part in the Jimmy Steele review (the government’s review of dentistry) during 2009 and the scoping report was submitted and acknowledged
- The team also presented to the Overview and Scrutiny Commission of RBKC and continued to send regular updates throughout the project
Sharing findings and learning
- Findings were shared at the Children’s Health conference, held in November 2010
- The project was entered into a number of awards in 2010, including the HSJ Awards and Guardian Public Sector Awards, and it was shortlisted for a Health Business Award.
Plans going forward
Following the success of the outreach fluoride varnish pilot, the Central London Community Healthcare (CLCH), which is made up of the three provider arms of NHS Westminster, NHS Hammersmith and Fulham, and NHS KC, assumed responsibility for rolling out the campaign across other schools in the borough.
Unfortunately, due to spending cuts within the PCT there are uncertainties over the future of the different elements of this project going forward.
Regular ‘reality checks’ helped keep everyone focussed on the shared outcome of improving oral health.
“Don’t lose sight of why you are doing any initiative. This programme aimed to improve the lives of young children who are suffering, through no fault of their own, from the problems caused by poor oral health. It is a source of pride to be part of the solution, yet people can get bogged down in their own priorities and areas of work.” Louise Pinkney (Managing Director, Lamerton Swales)
Creativity (like opting to work with GSK, commissioning a theatre company, planning in ‘school gates’, engagement with parents and developing clinical procedures) can be threatening to risk-averse individuals, creating barriers and delays for any project.
Mutual benefit puts partners on an equal footing, with everyone working hard to achieve success and solve problems. Equality and shared goals can overcome this. Take an honest approach about what each organisation wants out of the partnership at the start and keep an open dialogue if things go off course.
Patience and persistence
The need to understand all stakeholders‟ priorities and be sensitive to different cultures is standard in partnership working, but perhaps the biggest challenge is working with very different processes and timeframes. For example, the partnership contract between NHS KC and GSK ensured the interests of both organisations were fairly represented, which included joint press releases needing to be signed off by both organisations. This can have a longer turnaround and be subject to a much stricter sign-off process in big corporate organisations.
Likewise, achieving a partnership with the BDA and working out the practicalities of how to recruit the borough’s dentists on to the scheme required dedication on both sides. The initial recruitments yielded low numbers, so both partners had to manage expectations and work together to address this and find solutions.
Partners and other organisations can bring new skills and experience; embrace these and optimise them by sharing actions and responsibility. Where there are skill gaps, think laterally about how you can fill them without the need to fund them. For example, GSK took responsibility for developing the child-friendly packs – they had the experience of understanding the child oral health market. The Healthy School co-ordinators were able to help identify which schools to work with and persuade schools to join the campaign.