Integrated health and social care for people experiencing homelessness

Implementation

Plymouth is a small coastal city with a population of 278,000. The city's health profile indicates deprivation and poverty are significantly worse than the England average and the number of people experiencing homelessness in the city has been rising. Like many deprived coastal areas there are significant challenges in accessing NHS dental care. As a result, there are over 22,000 people on a waiting list to access an NHS dental service.

While wishing to address the challenges in dental access for all residents, concerns were raised by political and civic leaders, community-based organisations, healthcare staff and public health officials regarding access to dental care for people experiencing homelessness.

In response to these challenges a team in the university, supported by community partners, developed work to profile the oral healthcare needs of people experiencing homelessness, their treatment needs, and the impact of oral disease on their quality of life. Throughout these projects, the principles of co-design, community engagement and working with peers and experts by experience was integral to the approach. One such example is the 'Teeth Matter' project, which explored motivational interviewing by 'Peer Educators' (individuals with lived experience of homelessness) to improve patients' removal of plaque by regular toothbrushing. This project was supported by peer researchers from the charity Groundswell and conducted in the community at a homeless hostel. This was the first oral health study to use peer researchers in its design and delivery. The study, among other things, investigated factors influencing oral health behaviours and access to dental care from the perspective of people with lived experience of homelessness and other stakeholders, including support workers, dental providers and other health professionals. In addition to informing the development of an oral health intervention project for people experiencing homelessness, research findings were used to feed into the development of the care pathway. The project, the design of which drew on interviews with stakeholders (homeless centre residents, and care/service providers) along with a student dental outreach project improved our knowledge of the oral health behaviours of the target group. It also provided a good understanding of barriers and enablers to taking care of their teeth and accessing local services. Through developing, implementing and evaluating the project, we made recommendations for engaging people experiencing homelessness with oral health promotion, which are included in the NICE guideline.

In response to the significant NHS dental waiting list in Plymouth Peninsula Dental Social Enterprise (the clinical arm of Peninsula Dental School at the University of Plymouth), established a community dental clinic in January 2018 for those experiencing homelessness. The clinic was initially developed as a pro bono contribution to the local community. Although initially, the clinic treated people experiencing homelessness, the care pathway was expanded to include individuals using drug and alcohol services, as well as vulnerable women who risk having multiple children removed from their care. The findings from the research work were and continue to be used to inform the development of the service.

The service has been evaluated using a mixed-method approach. Research findings indicate that, as well as helping patients with pain relief, functionality and motivation to look after their teeth, treatment impacts positively on their confidence, self-esteem, self-worth and aspirations for a new start in life. The acceptability and impact of service has also been formally evaluated from the perspective of patients, support staff and service providers. Due to its success, more recently the dental pathway has become fully integrated into the broader coalition, which has brought together healthcare, housing, social care, local government and the charity and voluntary sectors to address the needs of people in the city with complex needs. While these organisations worked together previously, the new initiative has formalised integration and reciprocity between different providers and services. The integration of the dental care pathway into such an alliance is the first example in the country of integrated commissioning and is built on the research and evaluation conducted by the university aligned to the principles within the NICE guideline.

Alongside promoting dental care access to people who find access to mainstream dentistry particularly challenging, ongoing outreach activities by a dental outreach team break down some of the stigma and apprehension around dental care among this population and provide oral health information and basic oral health supplies to support individual empowerment and self-care.