Agenda item

The Director of Public Health along with the Integrated Care Board submit a set of reports to update the Public Health and Health Integration Scrutiny Commission on:

a) Oral Health Survey Results

b) Water Fluoridation

c) Oral Cancer Action Plan

d) Access to NHS Community Dentistry.

The Director of Public Health highlighted that there were a series of reports contained within the item in which the Chair invited each report to be taken individually.

The Acting Consultant Lead for Public Health presented the report in relation to the oral health survey results in which it was noted that:

·       Oral Health Surveys are usually undertaken every two years by the Office for Health Improvement and Disparities as part of the National Dental Epidemiology Programme. The Survey includes a random sample of 5-year-old children attending mainstream schools.

·       During 2021/22, 866 children were examined as part of the survey equating to 17% of all 5-year-olds attending mainstream city schools.

·       The survey found 37.8% 5-year-old children examined had decay. This was higher than the 23% national average with Leicester ranked 9^th highest of 132 upper tier authorities and 2^nd highest amongst comparator authorities.

·       The prevalence of decay has remained consistent in 5-year-old children since 2017 but has reduced since 2012 where around 50% of examined children were found to have decay. Work is ongoing to further reduce decay in the city.

·       There was a significant decrease of dental fillings with more 5-year-old children living with untreated areas compared to the 2019 survey. This was likely to have been influenced by Covid-19 and reduced dental access.

·       Variances were identified across the city with North Evington and Wycliffe wards with significantly higher decay.

·       Activities are ongoing to reduce tooth decay in children, including supervised tooth brushing in schools and early years settings, although not all have restarted following the pandemic; providing training sessions to health professionals; and issuing oral health packs at food banks and health visits.

The Commission commended initiatives to encourage supervised toothbrushing in early years but raised concerns around the limited access to dentistry to prevent or treat tooth decay.

In response to Members comments and questions it was noted that:

·       The oral health survey results were illustrative of 2021/22 and whilst it would inevitably take time to address issues, there is ongoing partnership work to improve oral health across different settings and there may have already been some improvement.

·       Supervised toothbrushing paused during the coronavirus pandemic and not all settings have re-engaged. There has been a good uptake in early years settings but not all children access this provision, so focus is being targeted to encourage uptake in schools. It was agreed additional information would be shared on the roll-out of the programme.

·       There are disparities of tooth decay in 5-year-old children across wards although they can also hide issues and therefore MSOA can provide more informed understanding. It was agreed that data collection areas and maps could be provided. Variances in tooth decay amongst wards and ethnicities is complex but attributing factors may be cultural, deprivation, lack of access to NHS dentistry etc.

·       The survey does not provide information to gather data regarding if a child has been to a dentist or how recently; where a cavity has been filled an inference can be made that they have seen a dentist. Information may be available from data collected in the Children Health & Wellbeing Survey and it was agreed this would be reviewed and information shared.

The Chair invited the youth representative to participate in the discussion and in response to questions and comments it was noted that:

·       Tooth decay in 5-year-old children has improved although is still higher than many other areas. Water fluoridation is an option that can help reduce decay.

·       Data is collected for ethnicities of children in the survey and most health outcomes along with gender and deprivation etc as structural factors in communities.

·       The oral health survey of 5-year-old children is determined at a national level and conducted every two years as a mechanism to collect data and track for the future. Surveys are carried out between years for other age groups and settings.

The Acting Consultant Lead for Public Health was invited to present the water fluoridation report and it was noted that:

·       Fluoride is a natural chemical that can be found in some water supplies and can be added to toothpaste and food to prevent tooth decay. Water fluoridation is the controlled adjustment of adding a concentration to the water supply. Around 10% of the nation has fluoridated water but there hasn’t been much change since the 1980s.

·       Evidence illustrates water fluoridation is effective with 35% fewer decayed, missing or filled baby teeth and 26% reduction in permanent teeth. Comparator authorities with water fluoridation also have lower tooth decay.

·       It is proposed that water fluoridation be requested for Leicester due to tooth decay prevalence in the city although the process would take approximately 5-10 years. It would require writing to the Secretary of State for consideration; if approved a feasibility study would be required; followed by a consultation if deemed feasible; the Secretary of State would need to review consultation responses and if supported would require legal agreements and appropriate infrastructure to be established.

·       Other local authorities, including Nottingham and Nottinghamshire have written to the Secretary of State for consideration. Public Health are liaising with colleagues in the region and in early discussions with Leicestershire and Rutland as it is anticipated that implementation may be more likely if there is a consensus to fluoridate a wider area.

The Chair highlighted 1.6 million people will see fluoride added to their water supply following a consultation in areas including Northumberland, Teesside, Durham and South Tyneside and therefore a direction Leicester should consider requesting.  

In response to comments and questions by Members and youth representatives it was noted that:

·       Local Authorities previously had responsibility for water fluoridation but the power to determine whether to fluoridate water and the associated funding of costs has reverted to Government who liaise with water companies. The larger the coverage area of water fluoridation the more cost effective it is likely to be although the process is likely to take years for implementation if agreed.

·       Fluoride can be found naturally in some areas and a controlled amount is added when water fluoridation is approved. It was agreed that information would be checked and shared to provide assurance of concerns regarding environmental impact.

The Acting Consultant Lead for Public Health presented the oral cancer action plan, and it was noted that:

·       Oral cancer affects areas such as the lips, tongue, cheeks or throat whereby Leicester has the highest rate and mortality in England. Mortality in the city has been rising and more rapidly to other similar parts of the country.

·       Treatment outcomes are better where oral cancer is detected early and individuals are encouraged to see a dentist or GP if they have symptoms. Issues with GP and dental access can however impact the opportunity to identify signs earlier and symptoms are not as well known.

·       Risk factors attributed to oral cancer include, smoking, smokeless tobacco, heavy alcohol consumption and HPV.

·       An oral cancer action plan has been developed with three strategic priorities including; improving awareness of signs and symptoms; reducing prevalence of risk factors; and improving access to medical and dental advice. A multi-agency working group has been established to meet and implement actions.

The Commission highlighted concerns around the rates of oral cancer and mortality in the city and the impact of limited access to GPs and dentists when residents may have symptoms to be detected and treated early. Further concerns were raised regarding the quality and access to recent data. It was agreed that health partners would provide access to appropriate data, but that necessary data publishing would need to be adhered to. 

In response to comments and questions by Members and youth representatives it was noted that:

·       The high rates of oral cancer in the city is complicated and attributed to many risk factors including smoking prevalence, low uptake of the HPV vaccine and levels of deprivation. The Health Protection Board have examined data to request health colleagues support outreach to communities.

·       There is no evidence currently regarding use of vapes and oral cancer, but this will be monitored. Vaping is deemed to be safer as an alternative for people who smoke but are not encouraged generally.

The Head of Primary Care Services (East Midlands) presented the access to community dentistry report on behalf the Integrated Care Board in which it was noted that:

·       There are national issues with accessing NHS mainly due to discontent with the national contract. Provision to dental care in Leicester generally has good provision with 68 primary care dental contracts, 10 orthodontic services and 2 urgent care practices. The city has also had the least contract terminations across the wider Leicestershire and Rutland region. Access has been restored quicker across the region following the pandemic than other areas.

·       A national dental recovery programme was recently published that the ICB will take into account as part of the development of their Dental Access Plan linked to the ICBs 5-Year Plan.  One of the initiatives focusses on building the workforce as currently it is difficult to recruit to NHS dentistry. The programme also includes a number of initiatives to sustain and improve access including ‘new patient’ payment and an increase in the minimum UDA value from £23 to £28. In the city, 22 dental providers have received an increase in contract values and 2 have reduced their level of activity to bring up their UDA.

·       The recovery programme also includes provision to improve the dental workforce by training in dental schools with contracts post qualification to provide NHS access. Promoting the use of skills-mix is also being explored to champion additional roles to undertake appropriate work.

·       The Oral Needs Health Assessment for Leicester, Leicestershire and Rutland is being developed which will identify issues as a MSOA level in order to focus and target commissioning in areas most in need. It is anticipated to be published by the end of May and will be shared with the Commission.

The Commission welcomed the recovery plan to improve access to NHS dentistry but raised concerns surrounding the performance of commissioned contracts given Leicester’s ranking as discussed in the oral health survey and oral cancer reports.

In response to Members and youth representative comments and questions it was noted that:

·       Data from contracted providers illustrates around 43% of children in the city have accessed dental care compared with 35% nationally. Work is ongoing to support recruitment of children health promoters and encourage supervised toothbrushing programme.

·       Clinical guidance has been issued meaning that it is no longer a requirement for 6 month recalls and therefore resources can be used most effectively. Every patient should be risk assessed to determine the frequency of visits dependent on need, but children should be seen more regularly. Those with braces would be assessed to require more frequent visits and would also be seen by an orthodontist.

·       Contract management enables performance to be reviewed and dental practices to receive patient premiums where delivering in accordance with requirements. Where practices are not performing, the intention is to work with providers as opposed to terminating contracts to retain NHS access. 

·       Latest guidance from the Department for Health and Social Care provided a commitment to reform dental contracts and provide elements of flexible commissioning to target areas where access is required to prioritise patients, thereby improving earlier access and preventing worsening conditions.

The Deputy City Mayor for Health, Social Care and Community Safety noted that health partners are required to benchmark against national figures but requested for future papers that comparable authorities be used to provide a more informed view of the city’s position.

AGREED:

·       The Commission noted the reports.

·       The Commission supported the proposal to write to the Secretary of State for water fluoridation in Leicester.

·       Additional information to be circulated.

·       Item to remain on the work programme for further consideration; including oral health survey, oral cancer action plan, local oral health needs assessment and NHS dentistry recovery plan.