1. Introduction

The Centre for Oral Health and Related Research at Leeds University’s School of Dentistry has joined with the Leeds NHS EAT to reconfigure an existing service, providing cost-effective, affordable, convenient, accessible emergency dental care, breaking down the barriers of patients’ anxiety, fear, language, pain, and cost. Currently, dental-related patients who attend their General Practitioner (GP) out of hours did not have the access or the confidence to use their local dental emergency service. Therefore, the purpose of this study was to explore the views of dental patients who had made use of their GP out-of-hours service and whose pain was associated with teeth or dentures and who were referred to the hospital dental emergency triage arrangements to Leeds Dental Institute.

Leeds has a growing, diverse population, relatively healthy in terms of non-communicable diseases such as cardiovascular disease and stroke. However, knowledge of local oral health inequalities is limited. Nationally, around 25% of adults do not visit a dentist. Leeds dental access rates are similar to the national average. There is a large gap between the study findings and the Leeds NHS England Area Team (NHS EAT) data, which shows that one third of people visiting their General Medical Practitioner’s out-of-hours service are going with dental-related problems. When residents from deprived communities seek help for dental-related problems, the usual out-of-hours provisions do not cater for these patients. There is a mismatch between patient demand and service provision. The potential for dental professionals to impact on oral health inequalities is an underutilized resource.

1.1. Background and Significance

Our ED service currently manages dental emergencies very well for a proportion of patients, but better management could prevent significant pain, high levels of sepsis, widespread searching for pain relief, morbidity due to ill-fitting or inappropriate dressings, anxiety and fear, degrading public image, and further costs to the health service. Ambulance service practice has introduced locally directed patients to our ED and collaborated in pain relief, providing a positive oral health impact for some and demonstrating the ability to extend the regular use of that facility for other potentially planned oral care measures.

Population oral health indices in are high and many patients require urgent/emergency intervention. Dental emergencies, equivalent to front-of-mouth problems, involve moderate to severe pain, swelling and loss of function in a relatively limited area. They are categorized more generally than most conditions owing to their finite number, progressive severity and scope for categorization across several dental fields and specialties. Yet, immediate access to dental clinics is not stage-managed and potential patients therefore present, sometimes several times or for a long wait, at the local emergency department (ED) instead.

2. Current State of Emergency Dental Care in Leeds

Leeds City Council commissioned the Institute of Health Sciences and Public Health Research, University of Leeds to undertake a scoping study aimed at understanding patient problems and dissatisfaction with emergency dental care in Leeds, identify issues that may lead to patients experiencing preventable dental conditions that require emergency dental management, and understand more about the experiences of patients attending A&E Departments at hospitals in Leeds with oral/dental health problems. Leeds City Council and other local stakeholders, such as NHS Leeds, PCT, have begun actions to improve access and treatment. This has included increased funding for local dentists through the addition of separately commissioned contracts for severe pain. This targeting has improved dental access for patients acquiring symptoms of acute dental distress. It remains, however, that a significant proportion of dental presentations to Leeds A&E remain the symptom of pain. Moreover, the additional dental access funding has been provided at the expense of other primary dental care budgeting arrangements; is not without problems of its own, mainly in areas of quality of patient care and practice additional workload cost support; and is unlikely to be funds secured beyond March 2015. The main strength of the current approach relies on the A&E departments that Leeds hospitals provide, as places where both general and local anesthesia, and emergency dental treatment, can be accessed. The pressures building on these departments to provide this care, however, are continuing to increase. Data on severe plc requiring dental admissions to hospital, or self-presentations to A&E, for financial years 2013/2014 and 2014/2015 have surpassed previous levels of presentation. Severe plc hospital admissions in these two recent years look likely to increase by as much as 24% over previous years. There has been a similar increase for self-presenting dental plc to A&E. The reasons for this increase are believed not because of an increased unmet demand for emergency dental care brought about through existing primary care dental access funding problems or past systems of dental registration, but instead out of increases in population and cost of living pressures, with increased numbers of patients unable to afford emergency dental treatment; the increasing problems patients have trying to find access to an NHS dentist. The absence of an NHS dental contract in Leeds that can provide NHS hospital-based dental care may compromise these structural responses in the longer term. In the absence of an integrated NHS dental contract with both primary and secondary levels of care, it cannot be assured that the workload from A&E plc hospital admissions, and self-presentations for plc dental care, in Leeds can be managed safely for ‘end of the dental freedom’ in England. In the shorter term, the pressure may be relieved by new potentials in patient self-management. Data published by the NHS suggests that in units providing an Emergency Department in the UK, with an AE plc in 2012/2013 where presented with a dental problem. Data from the Leeds Teaching Hospitals Trust shows admissions in the acute hospitals. The combination of the presenting data at hospital A&E departments where dental plc problems are managed merely combines to make the apparent unsustainability of these trends.

2.1. Availability of Services

84% of people with “Worst access to NHS dentist at PCT level for working age population for emergency admissions related to dental problems” were from 12 PCTs and Leeds. “The number of patients who attend doctors’ surgeries with a dental problem and are referred onwards (DOCS referrals) or who attend accident and emergency (A&E) departments is seen as an indicator of access to dental services. The costs of DOCS referrals are available from the Newcastle Dental Hospital and indicate a severe dental problem. The cost of A&E treatment is not readily available and has not been pursued.” The report goes on to say that both these indicators are likely to be underestimates of people who might benefit from dental care: if the hospital is too far away, if patients are not from the local commissioner’s area to seek hospital care and where a dental hospital is part of a teaching hospital providing care for people who would not seek care elsewhere.

In the Anger Public Health Observatory Report, which carried out an analysis on the use of hospital services and access to dentists in different parts of the country, the top 11 PCTs with “Worst access to NHS dentist at PCT level for working age population where demand is high or very high” included one ward in Leeds.

At present, dental services in the U.K. consist of dental secondary care (in hospital clinics) and primary care dental services, provided by the NHS and by a high proportion of dentists in private sector practice. In Leeds, access to NHS dental services is low, especially for emergency appointments.

2.2. Costs and Affordability

For others, both the absolute cost and the manner of payment are potential significant barriers to access. This project is concerned with improving access to the emergency dental services that are publicly funded but recognize that private general dental services are the main means of accessing primary care dentistry in the UK and in Leeds. For those who do not have access to private dentistry or for those who do not have their treatment costs covered, affordability is clearly a significant issue influencing access to emergency dental care. Pre-existing dental health care inequalities are likely to be exacerbated if affordability is a major barrier for those with the greatest health care needs. The extent to which patients are entitled to publicly funded dental care and the costs which patients have to meet can be complex. The private sector is the major player in general dental care and has a significant effect on the costs of dental care.

The affordability of emergency dental care can be a critical consideration for patients. “Affordability” can refer to the absolute or relative opportunity to pay: it embraces, on the one hand, the relationship between individual economic status and ability to meet costs and, on the other, the overall price level. It also embraces the manner and conditions of payments, including any demand for immediate cash payments. The price of treatment clearly affects affordability. There are those who would argue that, with resources to be allocated by the public sector according to several criteria, price should not be a consideration of these.

3. Barriers to Access

Oliveira et al. noted several reasons why patients are not accepted during consultations, including the exhaustion of the attendance quota and the time during which the emergency consultation started, dentists’ incentives (their salary is not linked with the number of patients attended to), as well as the working hours of the clinics in question. Some patients report discrimination. These results also reflect the reality of the city of Leeds, England.

Those in the general population who have a regular job, are married, and have private insurance more frequently go to the dentist for scheduled appointments. On the other hand, those from a lower economic class, the unemployed, guides, or pensioners opt for emergency care. In the case of the Portuguese National Health Service, people often have had to queue up a whole night in order to access dental care services on the next day, and at very specific moment. Those with a low educational level and those who have yet to use dental services more often describe barriers in establishing contact with medical provision. In other cases, the fact that the health services do not allow the direct booking of appointments or the combination of services hinders access.

3.1. Financial Barriers

* Financial Barriers * Perceptions of Accessibility * Opening Hours * Rurality * Inequality of Access * Minority Ethnic Health Needs * Language Barriers * “Surgery”? What, Toothache, Here?

Improving access, the first approach we considered is financial barriers. One patient said, “The first question with a lot of people is, ‘What’s it going to cost me?’ If I get fined for doing 35 in a 40 area, I know it’s going to cost me £60. If I start getting toothache and it’s two o’clock in the morning, and I can’t get out of bed, then how much is it going to cost me to get to a dentist?’ If you tell me how much, and say it will be £50, or that it’s a minimum of £50, then okay, but if you can’t tell me anything, then I won’t bother you. If I go to a dentist at 5.30 on a Friday afternoon, then it’s a case of, ‘Come back on Monday’.” Another said, “If they’re in real bad pain, and they’re NHS, there’s nowhere they can go to get anything done.” Both private and NHS dental patients reported that an inability to pay for care was a significant barrier in gaining access.

3.2. Geographical Barriers

Ideally, it will also encourage the reduction in car usage and increase sustainability of access. Not having car use adds £150 a month to the cost of living. These are estimated figures with positive public health and environmental benefits. There is also a ring-fenced type of public money available to extend such a service, but concern has been raised as to whether it would reduce the ability of existing public transportation systems to be financially sustainable. Some argue that “the exception of local geographical location of services, the addition of yet another free bus provision… is not innovative, it is yet another handout.”

Lack of services available in outer geographical areas, such as Colton and Rothwell, will discourage people from accessing them. If the nearest service is unavailable, people will tend to either not access the service at all or rely on an unsuitable alternative (e.g. leaving the problem until the next time the Leeds dental institute is open for walk-in), leading to unnecessary suffering, public cost, and dental admissions. Local access means that it is easier to travel to these services without car ownership, maintain civic links by having services located in local centres, and ensure that people develop an ongoing relationship with a dentist – a vital part of maintaining oral health and a reduction in the shedding of preventive step-ups.

4. Strategies for Improvement

The combination of political constraints and economic conditions described above presents a clear tension. Nevertheless, interviews, discussion, and report analysis revealed a number of options for improving access to affordable emergency dental care and many potential benefits from doing so. The main message of the report is that there is a will. Councillors, pharmacists, dental practitioners, public health professionals, church workers, and police officers all expressed a clear wish at least to see change if not to actively bring it forward. Most people spoken to in Leeds said they would like to see a 24/7 dental emergency provision and that they were willing to work towards this goal. The issue about how it might be funded remained clearly an open question, but where there is a will, there is often a way.

This report consistently highlighted a lack of community basis for dealing with the day-to-day dental aspects of oral health. Most of our interviewees recognised the wider population’s ongoing difficulty of regularly visiting a dentist, acknowledging that regular dental check-ups for prevention are for many an unaffordable luxury. This report further reinforces this lack and outlines the vital need for an easily accessible affordable dental crisis response alongside a greater level of education and prevention.

4.1. Community Outreach Programs

One limitation to community outreach programs is that patients are more likely to return for care when it is provided in a familiar environment. No matter how sterile the university environment may be, many patients refuse extractions due to fears of contracting infectious diseases. Similarly, though any required follow-up care would likely be performed at the university’s dental clinic, patients experiencing pain have difficulty traveling to another location, even when helped with bus tokens and additional services. Consequently, an overwhelming majority of the university-based clinic emergency access program patients seek extractions.

Community outreach programs across the United States, such as Give Kids a Smile and Mission of Mercy, along with schools of dental medicine offering free or low-cost services, pose potential advantages for increasing access to care. While these programs provide dental services, obtaining them also requires considerable effort on the part of the patient. In some cases, despite these efforts, there may still be unmet dental needs due to resource limitations. Under ideal conditions, the patient’s own dentist would offer emergency treatment or direct care at a dental practice or clinic where the patient would reach the next dental office visit to receive comprehensive care.

4.2. Policy Recommendations

The study shows that in a city with abundant demand for dental care, the supply of dental care increases (or is more accessible) with extended core hours among the limited supply of private practitioners. In the research city of Leeds (UK), this extended service is accessible to those who can afford the fees. For those with dental insurance, this can be sorted after treatment. The key recommendations that emerge from the research are that if financially viable, extended core hours should continue or increase and be integrated with the longer-term provision of care to alleviate pressure on the NHS service during normal hours. However, more information about the availability of affordable private emergent dental care should be made available to the public.

The final section examines policy recommendations that emerge from the research. First, if financially viable, extended core hours should continue or increase and be integrated with the longer-term provision of care. Second, more information about the availability of affordable private emergent dental care should be made available to the public. Third, the introduction of a good practice guide to complement the private dentist incentive in the form of (1) the provision of routine appointments within the month for patients exempt from NHS charges and children who attend an NHS opt-in practice, (2) having an effective referral system to NHS urgent care for those who attend a private practice, and (3) having a consistent management of NHS exempt patients for both NHS dentistry and private emergency care. Finally, recommended improvements to the NHS urgent care system.

5. Conclusion

Whether and to what extent this may be the case should be explored. This report focuses on dental problems in isolation, but these are part of wider problems of social exclusion – financial hardship, distress, social dislocation. Providing services to tackle the problems of dental care in the broader context of other distress may be a useful opportunity. Finally, LMC would like to thank the many service providers, including Local Emergency Dental Out Of Hours centres and NHS dentists, who are already working hard to provide dental treatment to local people in pain. Their commitment is appreciated and, more importantly, essential to safeguard the welfare of those affected.

The report suggests that the core of the problem may be that some NHS dentists do not see it as their role to provide emergency or out-of-hours cover to patients who are not yet fully registered with them, or who are registered but need care within contracted core hours. Of course, even more care is needed in tackling the underlying causes of oral health problems, including the key issues of poor diet, smoking, and excessive drinking. The money invested in providing better access to emergency dental treatment could improve access to preventive services, help patients in pain, and may also contribute to promoting wider strategic health aims.

Good oral health is fundamental to good general health, and severe dental infections can be life-threatening. There is clear indication of a need to provide better access to affordable emergency dental services in Leeds for local people with the greatest need. In the city, the greatest need is among low-income groups, particularly those who live in the most deprived communities. Both NHS dentists and Local Emergency Drug and Dental Out Of Hours centres have a vital role to play.

5.1. Summary of Findings

A comparable service in Lancashire provides not only its residents, and more difficult private goals to general dental practitioners, an alternative care option. As a way to increase emergency dental care access points within Leeds, we suggest a comparison between these differing pathways of practice registration. In particular, those geographically closest to the A&E serving these residents, who may potentially lose emergency status shortly. If the ordinance is to be retained, the method of funding attached to this model of care is another route, as every department has to deliver savings, must move its care delivery to primary care, or outside a hospital setting. It will also mitigate a lack of understanding amongst the profession, and not vocal community. Providing proactive oral hygiene advice and signposting patients to primary care NHS dental services post attendance is not the responsibility of the acute dental services, but they do it anyway. The profession has the skills and capabilities to do this. All in all, this produces a combined service of wider clinical inclusion, greater capacity, and improved community oral health data capture.