Problems with health care delivery

Earlier chapters have highlighted the influence the medical model of health has had on both the philosophy of health care and the structures devised to deliver health care including dental care. The overriding influences of the medical model are the downstream focus on treatment of disease and the communication gap caused by differing concepts of health and need held by lay people and health professionals. Problems with health care delivery operate at a macro level (i.e. overall policy for and structure of health care) and at a micro level (how health care is delivered, one-to-one communication, and interaction with the patient and members of the dental team). Chapter 18 has described some of the specific problems with health care at the macro level. In this chapter we shall also look at some of the problems with how health care is delivered and problems with health services at the level of the user and the provider of health care. What should good health care look like? Maxwell (1984) defined six characteristics of a high-quality health care. Services should to be equitable (fair), accessible, relevant to health care needs, effective, efficient, and socially acceptable. There are recognized inequities in how health care is distributed; urban areas are often better provided for compared to rural areas, and hospital-based health care consumes more resources than community-based care. Not everyone has equal access to health care; for example, people living in deprived communities with greater health need have fewer doctors and dentists compared to richer areas with fewer health care needs. This phenomenon has been described as the inverse care law (Tudor Hart 1971). Uncomfortable choices and rationing have to take place in allocating health care resources. Ideally, these decisions should be based on the greatest health need (and the capacity to benefit) rather than who has the loudest voice. The focus on treatment inherent in the medical model of health means that resources are spent on high-technology medicine and hospitals, while programmes to prevent disease are poorly supported and resourced. There is an expectation that there will be a magic bullet for every health problem, yet most chronic diseases have no cure. People learn to adapt and cope with their chronic illness rather than recover.

Prevention for people with disabilities and vulnerable groups

In this chapter we will look briefly at the prevention needs of people with disabilities and people who are vulnerable and require special care dental services for reasons that may be social. Within this group there will be a spectrum of people with needs and dependencies. Not everyone described as belonging to a vulnerable group in this chapter would identify themselves as disabled; nevertheless, what they have in common are a range of factors that put their oral health at risk, make accessing dental care complicated, or make the provision of dental care complicated. These factors may include a ‘physical, sensory, intellectual, mental, medical, emotional or social impairment or disability, or more often a combination of these factors’ (GDC 2012). People with disabilities have fewer teeth, more untreated disease, and more periodontal disease when compared to the general population in the UK (Department of Health 2007). Good oral health can contribute to better communication, nutrition, self-esteem, and reduction in pain and discomfort, while poor oral health can lead to pain, discomfort, communication difficulties, nutritional problems, and social exclusion (Department of Health 2007). As discussed in previous chapters, the important risk factors for oral diseases include: high-sugar diets, poor oral hygiene, smoking, and alcohol misuse. They are also shared risk factors for chronic non-communicable diseases such as respiratory diseases, cardiovascular diseases, diabetes, and cancers. The basic principles and approaches for the prevention of oral diseases in disabled people and vulnerable groups are similar to those described in previous chapters; however, there is a need to recognize that the context, the circumstances, the settings, and the opportunities for prevention will be slightly different, depending on the groups. For example, some disabled people (e.g. people with learning disabilities) may be reliant on others, such as family, carers, health care workers, to support basic self-care and to access health services. Other vulnerable groups such as homeless people live independent lives but lack access to basic facilities such as drinking water, and a place to store toothbrushes and toothpaste.

Evidence-based practice

In the last 40 years, the needs of and demands for health care both in the UK and worldwide have increased dramatically. These increases are related to the population ageing, the development of new technologies and knowledge, rising patient expectations, and associated increases in professional expectations about the possibilities and potential of health care (Muir Gray 1997 ). In this period, the key policy concerns of the international health care community have been about containing costs and enabling equitable access to high quality health care, while also ensuring greater accountability, patient satisfaction, and improved public health (Lohr et al. 1998). Health care resources are finite and must be shared equitably on the basis of need, capacity to benefit, and effectiveness. The use of high quality research evidence and guidelines to inform individual patient care and population health care have become central to this process. In the mid-1970s, various writers began to question the effectiveness of medicine and the increasingly wider influence exerted by the medical profession on society. For example, McKeown (1976) mapped mortality rates for the main killer airborne diseases (tuberculosis, whooping cough, scarlet fever, diptheria, and smallpox) against contemporary advances in medicine from the mid-19th century to the early 1970s. He found that the declines in the incidence and prevalence of communicable diseases had occurred before their microbial cause had been identified and before an effective clinical intervention had been developed. McKeown concluded that the declines in mortality rates were not attributable to immunization and therapy and suggested the declines could more reasonably be attributed to better nutrition and improved housing conditions which had occurred over the period. Allied to McKeown’s historical analysis was the work of Archie Cochrane who evaluated contemporary clinical practice in the 1970s. In his seminal work Effectiveness and Efficiency , Cochrane (1972) showed that many medical treatments provided in the NHS were ineffective, inefficient, and founded on medical opinion rather than on a rigorous assessment of efficacy and effectiveness. Box 7.1 defines the terms efficacy, effective, and efficiency.

The structure of the NHS in the UK

The National Health Service was created at the end of the Second World War. Its structure has remained relatively stable until the 1970s. Since then, politicians have continued to reform it at an ever-increasing rate and, in 2012, the biggest change to the English NHS structure was implemented (Reynolds and McKee 2012). The question as to why the reforms are being undertaken is crucial. Growing demands, changing epidemiology, better understanding of the determinants of health, and evolving societal values have all influenced the process. Perhaps most crucial is the latter. It is probably more appropriate to describe the current NHS as four differing NHS care systems that are coterminous with the legislative bodies that exist within the UK, namely England, Northern Ireland, Scotland, and Wales. Not only are the planning arrangements becoming more divergent, but also the philosophical approach underpinning each system is beginning to follow very different paths. The NHS has almost never taken a typical theoretical planning approach but rather has evolved due to the wide range of factors and influences involved. These include the changing power of health care professions, the need to ration services, adoption of economic theory (market forces and the internal market), and, not least, changing governments with differing political stances. The importance of understanding the history of the service and the lessons of the past are that they inform the present and can provide an indication of how the future may look. This chapter outlines the major influences on the NHS since its inception, describes the major problems currently faced by the NHS, and provides an overview of the ways in which clinical services are currently delivered. It will not give a detailed description of the structure of the health service, not least as by the time the book is published a new structure will exist. The current structure of the health service in each of the four countries of the UK will be available on this book’s website, and updated as changes occur.

Overview of epidemiology

How tall is the human race? What is meant by being short? Walking down the street, one will see people of various heights and a degree of variation exists. Some people are shorter than others, but when is someone abnormally so? How is it possible to make this judgement? By recording the height of everyone it is possible to start to produce a picture of people as a whole. Such terms as minimum, maximum, and mean give an indication of the distribution of heights. The science used to collect and examine data in this way is known as epidemiology. Epidemiology is defined as: . . . The orderly study of diseases and conditions where the group and not the individual is the unit of interest. . . . Mausner and Kramer ( 1985 ) state that epidemiology is concerned with the frequencies of illnesses and injuries in groups of people as well as the factors that influence their distribution. By investigating differences between subgroups of the population and their exposure to certain factors it is possible to identify causal factors and consequently to develop programmes to alleviate the problems. The critical issue is that knowledge is gained by studying patterns in groups as opposed to concentrating solely on the individual. This chapter gives an overview of the uses of epidemiology in dentistry and describes the main principles of this subject. Epidemiology in dentistry operates in three broad fields. These are: . . . 1 the measurement of dental disease among groups within the population in order to understand factors that influence the distribution; . . . . . . 2 identification of factors that cause conditions; . . . . . . 3 evaluation of effectiveness of new materials and treatment in clinical trials and assessment of needs and requirements for dental services within the community. . . . Undertaking epidemiological investigations requires a series of standards and procedures; measures must be made to an agreed common standard, in a methodological manner, and, when necessary, using an appropriate random sample.

The structure of dental services in the UK

This chapter will briefly describe how oral health care may be managed and organized and how health workers may be remunerated. This will be followed by a short outline of the ways in which oral health care is provided in the UK. A separate overview of dental care professionals (DCPs) is presented in this chapter. The reform of the NHS is ongoing, so this chapter discusses principles rather than detail. Since the devolution of health care to governments in Scotland, Wales, and Northern Ireland, variations in provision are occurring across the UK and some of these differences are highlighted. If oral health care is to be provided it has to be funded. The money has to be derived from the public and this can be either from individuals or from taxation. Within the UK there are a variety of ways in which oral health care is funded. Figure 19.1 shows the possible flows of money. The model that exists in the UK is in the main centred on routes 1 and 3, based on taxation, either direct or through national insurance contributions, and its subsequent allocation to various public-funded services, including dentistry. In Germany, the arrangement is slightly different in that third-party insurance groups are involved and a proportion of an individual’s annual salary is allocated to health care. A third model operates in the USA under the guise of managed care. Individuals buy into a care plan that is organized by a health care company, which subsequently contracts with dentists to provide a level of care. In route 2, the public pays the dentist directly for his or her services; this is a private arrangement. A third party may intervene to control pricing. For example, Dutch and Swedish adult dental care is now mostly in the private sector, but each year the profession negotiates the scale of fees with their government. The subsequent distribution process for paying oral care workers is illustrated in Figure 19.2. There are again three mechanisms: . . . 1 A purely private arrangement. . . . . . . 2 The state pays the total cost. . . .

Fluoride and fi ssure sealants

Fluoride has made an enormous contribution to declines in dental caries (Kidd 2005; Murray and Naylor 1996). Fissure sealants are a proven preventive agent. This chapter provides a brief overview of the history of fluoride and presents a brief synopsis of the mode of action, method of delivery, safety, and controversies in the use of fluoride. A public health perspective on fissure sealants will also be presented. An account of the history of fluoride can be found in Kidd (2005) and Murray et al. (2003) and is summarized in this section (see Box 12.1 for key dates). In 1901, Frederick McKay, a dentist in Colorado Springs, USA, noticed that many of his patients, who had spent all their lives in the area, had a distinctive stain on their teeth known locally as ‘Colorado stain’. McKay was puzzled and called in the assistance of a dental researcher G.V. Black. They found that other communities in the USA had the characteristic mottling. Their histological examination of affected teeth showed that the enamel was imperfectly calcified, but that decay in the mottled teeth was no higher than in normal teeth. McKay suspected that something in the water supply was producing the brown stain, and more evidence came from Bauxite, a community formed to house workers of a subsidiary of the Aluminium Company of America (ALCOA). A local dentist noticed that children in Bauxite had mottled teeth, whereas children in nearby Benton did not. McKay investigated the problem but was unable to find a cause for the staining when the water supply was tested. In 1933, Mr H.V. Churchill, Chief Chemist for ALCOA (anxious that aluminium would not be blamed for the mottling), analysed the water and found that the fluoride ion concentration in the water supply of the Bauxite community was abnormally high (13.7 ppm). He tested other communities affected by mottling which had been previously identified by McKay and found that they too had high levels of fluoride present in the water supplies.

Sugars and caries prevention

Dental caries remains the single most important oral condition treated by the dental profession on a daily basis. From a public health perspective, the prevention of caries is still therefore a major challenge. As outlined in Chapter 4 , before effective prevention can be delivered the cause of the condition needs to be fully understood. In addition, the disease process should be clear. This chapter will review the evidence on the aetiology of dental caries and present an overview of preventive measures that can be adopted at an individual clinical level, as well as community wide. Dental caries occurs because of demineralization of enamel and dentine structure by organic acids formed by oral bacteria present in dental plaque through the anaerobic metabolism of dietary sugars. The caries process is influenced by the susceptibility of the tooth surface, the bacterial profile, the quantity and quality of saliva, and the presence of fluoride which promotes remineralization and inhibits the demineralization of the tooth structure. Caries is a dynamic process involving alternating periods of demineralization and remineralization. However, the majority of lesions in permanent teeth advance relatively slowly, with an average lesion taking at least 3 years to progress through enamel to dentine (Mejare et al. 1998). In populations with low DMF/dmf levels, the majority of carious lesions are confined to the occlusal surfaces of the molar teeth. At higher DMF/dmf levels, smooth surfaces may also be affected by caries (Sheiham and Sabbah 2010). Many different terms have been used to name and classify sugars. This has caused a degree of confusion amongst both the general public and health professionals. In recognition of this, an expert UK government committee—Committee on Medical Aspects of Food Policy (COMA)—has recommended a revised naming system, which has now become the standard classification of sugars in the UK (Department of Health 1989). The COMA classification is based upon where the sugar molecules are located within the food or drink structure. Intrinsic sugars are found inside the cell structure of certain unprocessed foodstuffs, the most important being whole fruits and vegetables (containing mainly fructose, glucose, and sucrose).

Prevention and oral health education in dental practice settings

Prevention is a core element of the practice of dentistry in the 21st century. Of course the provision of evidence based dental treatment and surgical intervention are the main clinical roles for dentists, but, as health professionals, prevention is also a key responsibility (Department of Health 2012 ; Petersen 2009 ; Steele et al. 2009). Adopting a preventive orientation is relevant to all aspects of clinical care, from diagnosis and treatment planning to referral and monitoring procedures. Dentists and their team members have an important role in helping their patients prevent, control, and manage their oral health. Prevention is important for all patients, but support needs to be tailored to the needs and circumstances of each individual. It is also essential that any preventive advice and support is informed by scientific evidence to ensure maximum benefit is gained. Effectiveness reviews of preventive interventions have shown that many are ineffective and may increase oral health inequalities unless they are supported by broader health promotion interventions (Watt and Marinho 2005; Yehavloa and Satur 2009). Prevention in clinical settings therefore needs to be part of a more comprehensive oral health promotion strategy that addresses the underlying causes of dental disease through public health action, as well as helping patients and their families prevent oral diseases and maintain good oral health through self-care practices. Health education is defined as any educational activity that aims to achieve a health-related goal (WHO 1984). Activity can be directed at individuals, groups, or even populations. There are three main domains of learning (see also Chapter 9 ): . . . ● Cognitive: understanding factual knowledge (for example, knowledge that eating sugary snacks is linked to the development of dental decay). . . . . . . ● Affective: emotions, feelings, and beliefs associated with health (for example, belief that baby teeth are not important). . . . . . . ● Behavioural: skills development (for example, skills required to effectively floss teeth). . . . How do knowledge, attitudes, and behaviours relate to each other? For most people, in most instances, the relationship is complex, dynamic, and very personal; very rarely is it linear.

Overview of behaviour change

Many dental practitioners become very frustrated with their patients when they fail to follow advice given to improve their oral health. This failure can often be interpreted by dentists as a sign of disinterest, lack of motivation, or sometimes even stupidity! Such an approach helps no one. As has already been identified, to successfully promote oral health the dental team need to work with their patients in a number of ways. For example, to help them select a healthy diet, maintain good oral hygiene, or stop smoking, the dental team need to understand what factors influence these behaviours and how they can be altered successfully. This chapter therefore aims to review behaviour change to help you understand more fully how you as a clinician can help your patients successfully alter their behaviour to promote and maintain their oral health. Theories and models of behaviour change will be reviewed and consideration will also focus on the practical factors influencing the process of change. Before reviewing the theoretical detail of behaviour change it is important to restate a core principle of public health, that is, the importance of the underlying social determinants of health. A wealth of evidence has highlighted that individual behaviours have a relatively limited influence on health outcomes compared to economic, environmental, and social factors (Marmot and Wilkinson 2006 ; Wilkinson 1996). Indeed, oral health behaviours play a somewhat minor role in explaining oral health inequalities (Sabbah et al . 2009; Sanders et al. 2006). Any exploration of individual behaviour change therefore needs to take into account the influence of the broader factors operating at a macro level. However, for health professionals working with individual patients, helping people change their behaviour is still an important task within their clinical practice. Traditionally, health professionals have focused largely upon giving their patients information in an attempt to change their behaviour. Such an approach has, however, been mostly unsuccessful at securing long-term changes in behaviour (Sprod et al. 1996; Yevahova and Satur 2009).