The committee's discussion
- Care home policies on oral health and providing residents with support to access dental services
- Oral health assessments and mouth care plans
- Daily mouth care
- Care staff knowledge and skills
- Availability of local oral health services
- Oral health promotion services
- General dental practice and community dental services
- Economic evidence
- Evidence reviews
Evidence statement numbers are given in square brackets. For an explanation of the evidence statement numbering, see the evidence reviews section.
The committee discussed the fact that oral health care may be a low priority for many care homes, but agreed that like other aspects of personal hygiene, having a clean mouth is a basic human right. The committee noted that when someone is unable to maintain their own oral health they should be given help to do so. The committee discussed the range of factors affecting residents' access to dental services. It noted the need to provide residents with high quality daily mouth care that meets their preferences and needs.
The committee also highlighted the important role care home managers have in maintaining or improving people's oral health, and how practice and training in this area of personal care varies. The committee discussed the lack of nationally agreed occupational standards for delivering oral health in care homes, but acknowledged this was outside the scope of this guideline. It agreed that there is an urgent need for guidance in this area and the committee hoped this guideline will raise the national profile of oral health in care homes.
The committee acknowledged that the population of adults living in care homes reflected a wide age range (18 upwards) and that they come into residential care for a variety of reasons and varying lengths of time [EP2].
Many residents, including younger adults, are vulnerable and need the support of others for their personal daily care. Some enter for short periods either for respite care or to recover from illness, then return home to continue an independent life in the community. The committee also discussed that many older adults in care homes have poor physical health that means their life expectancy could be between 18 and 24 months.
The committee considered recent initiatives to help older people to live independently in their own homes for longer. It noted that such initiatives may take time to have an impact. In addition, members thought they might lead to an increase in the number of people needing more complex care once they are in a care home.
The committee noted that most older people living in, or likely to move into a care home may have factors in common that could affect their oral health. For example, they may not have benefitted from the introduction of fluoride toothpaste in the 1970s. In addition, they may have been brought up in a time when both patients and dentists regarded it as the norm to have teeth removed and dentures fitted as young adults.
The committee noted that some people in care homes are unable to express their own needs. The committee acknowledged the serious challenge this presented and agreed that health inequalities and inequity should be a core consideration in how all the recommendations are implemented.
The committee recognised that many care home managers:
may lack knowledge about local dental services and where to go for reliable information
are uncertain about the costs of dental care and exemptions
are unclear about who is responsible for supporting residents so they can use dental services
are concerned about the availability of care staff to take people to the dentist.
The committee considered research from 3 high quality evidence reviews conducted by an independent review team. Members noted the lack of research about the oral health needs of younger adults in care homes.
The committee noted that oral health research tends to use clinical dental indices (such as the plaque, gingival and denture plaque indices) as outcome measures. It observed that by looking only at clinical outcomes, the research does not reflect other outcomes that are more important to people, such as wellbeing. The committee also noted that there is no accepted mechanism for converting the resulting 'scores' into outcomes that matter to patients, residents or carers, such as improved self-esteem, dignity, or quality of life.
The committee considered that the choice of measures in the past may have hindered high quality research to develop innovative person-centred outcome measures. It discussed the urgent need for measures and study designs to capture the perspective of the full range of residents living in care homes.
This would include how much importance residents, or those who care for them, place on having a clean, pain-free, healthy mouth. It would also include how poor oral health may affect the care they receive, and how their dignity and individuality are respected and understood (especially with regard to wearing and removal of dentures).
The discussion below explains how we made recommendations 1.1.1–1.1.6.
The committee noted the absence of evidence of effectiveness on access to dental treatment and regular dental examination in care homes in England [ES1.17]. This was despite the comprehensive approach taken by the review team and the amount of national and international evidence it evaluated. The committee took this into account when considering their recommendations for research.
The committee noted that a key theme in review 2 (which appraised guidelines and reports of best practice), was the need for residents to have access to dental care to maintain good oral health. This was highlighted in 18 documents, including 13 guidelines from the UK, US, Australia and Canada [ES2.6].
The need for regular dental examinations at appropriate intervals was a key aspect of 11 best-practice documents [ES2.6]. In addition, 4 guidelines highlighted the need for collaboration among a range of health and care home professionals.
The committee was aware from topic experts that residents (regardless of age, physical or mental health) sometimes refuse or resist dental examinations and mouth care. This is just the same as they may refuse any other type of medical examination or personal care. The committee acknowledged that there was a lack of awareness about the importance of oral health and providing access to dental services for adults who live in care homes. It recognised the need for care home managers to include a policy on how to manage personal care or any treatment needs in these circumstances.
Evidence from 37 studies in review 3 (including 12 good quality and 12 moderate quality) showed that organisational policies on oral health are a key factor in improved oral care. This included 2 controlled studies and 1 uncontrolled before-and-after study of moderate-to-good quality [ES3.4, ES3.5].
The evidence also showed that care home policies that included regular mouth care routines and dental examinations, supported by good communication and accountability to ensure those routines were followed, were associated with improved oral health and better mouth care. Not having these elements reduced the likelihood of benefits.
Eight studies were conducted in the UK, others were conducted in countries with similar care systems or settings. The committee noted the considerable amount of research involved. Combined with members' own expertise and experience, they agreed it was important to make a recommendation.
The committee was aware of NICE's guideline on suspected cancer: recognition and referral, which highlights the role of dentists. The committee agreed this guideline added weight to the argument that it is important to provide dental services for adults living in care homes. It also noted the role of the wider dental or care team in ensuring that any suspicious lesion is seen by a dentist.
In addition, the committee noted that NICE's guideline on dental recall had a maximum recall period of 24 months for those over 18, with shorter intervals for those with ongoing treatment or disease management needs.
The committee agreed that both these NICE guidelines strengthened the need for this current piece of work. But they do not overcome the problem of how to identify residents' oral health needs in the first place.
The committee reflected on the consistency of these themes across multiple guidelines, as well as their applicability to UK practice, as summarised in review 2.
The committee noted there were resource implications for care home providers and managers, community dental services and commissioners of services [EP1]. But it agreed that these activities should be happening as part of the duty of care to adults living in care homes, although they recognised the effect this may have on care home resources including releasing staff for training.
The committee recognised that making recommendations for regulators (such as the Care Quality Commission) was outside the scope of this work. But it wanted to ensure the audiences for this guideline recognise that there is a duty of care for managers in these settings to meet the general oral health needs of their residents. Of particular concern were circumstances in which vulnerable people may not be able to tell anyone that they have pain or discomfort in their mouth.
The discussion below explains how we made recommendations 1.2.1–1.2.4.
The committee recognised that poor oral health may occur before people move into care. For example, as someone's dementia or physical illness worsens, they often find it increasingly difficult to look after themselves. The committee was therefore concerned about the potentially large number of vulnerable residents who may have unmet oral health needs when they are admitted to care homes.
The committee noted that the oral health of short- as well as long-stay residents (including younger adults) could deteriorate as a result of poor daily mouth care or poor diet. For example, not removing or cleaning dentures, for whatever reason, causes a build-up of food debris in the mouth. This, in turn, could lead to life-threatening conditions such as aspiration pneumonia.
Members, including topic experts, acknowledged that even at its very best the admission process could be an overwhelming experience. This is particularly true for people coming into a new environment that could become their permanent home. Including an oral health assessment may need additional resources, but the committee agreed it is important.
The committee also noted evidence from 3 moderate-to-good quality qualitative studies in Australia and Canada [ES3.8]. This showed that support from family, friends and other residents helped residents maintain or improve their oral health, and improved access to dental services. The committee noted that the support of family and friends could be invaluable, but it had to consider residents who had lost contact with family or friends.
Members agreed it was important to include family and friends where they were in regular contact with residents on a regular basis. But they believed it was also important to ensure the needs of all adults could be reasonably addressed.
Qualitative evidence from review 3 confirmed that having a standardised, validated oral health assessment tool, along with any associated training, was likely to lead to improvements in residents' oral health. (This was also identified in 1 moderate quality quantitative uncontrolled before-and-after study.) This evidence also confirmed it would remove barriers to accessing dental treatment [ES3.3].
The committee acknowledged the value of 3 evidence-based assessment tools described in the review of best practice reports and guidelines [ES2.1]: the Brief Oral Health Status Examination (BOHSE), Revised Oral Health Assessment Guide (ROAG), and the Oral health assessment tool. But members noted that nursing skills may be needed to use the BOHSE and ROAG.
Committee members noted the strength and consistency of the guidelines and best practice evaluated in review 2. This supported the need for an oral health assessment on entry to a care home, 'as a gateway to ensure unmet dental treatment needs are identified'. This was conveyed in 13 guidelines from specialist professional bodies and 14 other guidelines [ES2.1]. Some of the latter (for instance, The oral health assessment tool – validity and reliability Chalmers et al. 2005, see the Oral health assessment tool) were considered to be of high quality.
The committee discussed the evidence set out in review 2 about the Oral health assessment tool [ES2.1], and the systematic validation and standardisation work undertaken by the authors [ES1.1, ES1.2, ES1.3]. The testing for ease of use by a range of care staff and residents added further weight to the committee's deliberation. This included evidence that it had been tested with residents who have dementia or communication difficulties.
The committee recognised the complex needs of some residents, with many having long-term chronic conditions or needing the support of others for their daily care. The committee was also aware of the high staff turnover in some care homes. It agreed that using the Oral health assessment tool is likely to result in a more consistent, improved approach to mouth care in all care settings and by all relevant care staff. Members also recognised staff changes or shift rotations would not affect the way it is carried out.
The committee was aware that the Oral health assessment tool has not been standardised for use by non-medical care staff in the UK. The committee considered the views of care home managers on this. Care home managers agreed that the tool could be used in a care home setting, although care staff may need to be trained to use it [EP3].
The committee recommended starting mouth care immediately for residents who need support. It also recommended that care homes consider completing an oral health assessment on admission, or at least within a week of the person being admitted (sooner for people on short stays).
The committee also agreed that whatever was recommended it should apply to all adults coming into a care home, not just long-stay residents. This includes those coming in for respite care or to recover from an illness or fall.
The committee considered it imperative that care staff who complete the oral health assessment should have the necessary confidence, skills and knowledge, including the ability to treat residents with sensitivity, compassion and dignity. The committee also discussed the importance of care planning in relation to daily mouth care, oral health improvement and access to dental treatment. Members felt strongly that any assessment was of little value unless it resulted in actions that are included in the resident's care plan, and are delivered, regularly monitored and evaluated.
The committee reflected on the concerns and views of care staff and care home managers as set out in the qualitative evidence and expert papers. The members agreed being able to conduct an oral health assessment was an important opportunity to increase care staff's oral health knowledge and skills. The committee acknowledged that carrying out an oral health assessment using the evidence-based Oral health assessment tool may be a new process for some care home managers, and the time and resources that may be involved in embedding this in practice. Nevertheless, members believed this to be an essential component in promoting oral health for this population.
So the committee agreed that the Oral health assessment tool could be considered for use in all care settings by care staff who undertake the admission assessment, at admission or as soon as possible afterwards. It also agreed that it could be used on a regular basis to maintain residents' oral health. This is because the Oral health assessment tool:
may be used with any care home resident
does not need specialist nursing training
is standardised and validated for use in similar care home systems
would support care home managers in implementing the recommendations consistently
would reduce variation in practice and improve quality of oral health care across the care sector.
The discussion below explains how we made recommendations 1.3.1–1.3.4.
The committee noted evidence from studies in review 2 that families and carers of people in care homes may not understand the links between good quality daily mouth care and health and wellbeing. (This includes the value of using routine dental examinations to detect early signs of mouth cancer.)
The committee considered evidence in review 1 about the effectiveness of using sugar-free chewing gum containing xylitol [ES1.11, ES1.16]. It noted moderate evidence from a UK study that this improves oral health outcomes for older people in residential care, compared with usual care.
The committee agreed that sugar-free gum may offer some benefit for adults of any age with natural teeth, if they wish to use it or it is part of their usual routine. However, the committee considered that it may not be suitable for all residents, including those with dentures and any who may have difficulty swallowing. Members also agreed that it may not be practical for general use in all care homes. One topic expert member pointed out that some service providers may find it difficult to get.
Members agreed that sugar-free chewing gum containing xylitol could be included as part of a range of good quality oral health interventions for all adults. This is provided that the person has had an oral health assessment and their personal needs and preferences have been taken into account. The committee discussed evidence about the effectiveness of chlorhexidine presented in review 1. This reported both improvements [ES1.8, ES1.9, ES1.10, ES1.11, ES1.13, ES1.14] and adverse effects [ES1.15] during use. The committee was also aware of reports of an anaphylactic reaction to chlorhexidine and the fact that the Medicines and Healthcare Regulatory Authority has issued a drug safety notice about hypersensitivity (Chlorhexidine: reminder of potential for hypersensitivity).
Taking into account the vulnerability and heterogeneity of the population, the committee did not recommend chlorhexidine for everyday use for all residents. This is because it was unlikely to be the most effective or acceptable intervention for residents. The committee was also concerned that promoting a single product such as chlorhexidine may be regarded as promoting the medication of people living in care homes, some of whom will already be taking or given many medicines.
Topic experts on the committee stressed that although chlorhexidine is used to combat a range of mouth infections, it will not remove dental plaque entirely (plaque build-up can lead to dental decay or gum disease). So it is not a substitute for effective toothbrushing of natural teeth or dentures [ES1.10, ES1.11, ES1.12, ES1.13, ES1.14].
The discussion below explains how we made recommendation 1.4.1.
The committee discussed evidence from 46 studies in review 3 [ES3.1, ES3.2] on how care staff knowledge about oral health and skills to perform daily mouth care affects the oral health care of residents. Six of these studies reported that sufficient or improved oral health knowledge and skills helps promote access to dental treatment services.
Two studies (1 good quality and 1 moderate quality) reported that if the care home had a positive attitude to oral health care this tended to lead to dental team involvement [ES3.6].
The committee agreed that it was important to tackle the lack of knowledge, skills or understanding about the importance of oral health for residents among care staff, care home managers and dental teams [ES3.9].
The committee debated at length whether to recommend that care homes appoint an oral health champion. Although members acknowledged that appointing a 'champion' for any topic sometimes works very well, they also considered that good practice varied. The committee decided there was a benefit to having 1 staff member lead but to leave the choice to appoint a champion to local decision makers.
The discussion below explains how we made recommendations 1.5.1 and 1.5.2.
The committee discussed the fact that many people in care homes have unmet oral health needs and that commissioners of NHS and public health services have a duty of care to ensure those needs can be met. They agreed that current funding structures and arrangements for dental services provided for care homes were poorly understood and confusing.
The committee discussed the evidence presented in evidence review 3 [ES3.6] about how some general dental practitioners do not like, or are anxious about, providing residents with routine care and treatment.
Although the committee acknowledged these findings, it also considered expert testimony [EP1, EP2] that suggested the limitations of the current dental contract may contribute to the lack of dental service provision and treatment for care home residents. The committee believed including general dental practitioners in this guideline would encourage service development and improve access to dental treatments for residents.
The committee believed that if the outcomes of these actions help residents maintain their oral health, they are likely to be cost saving to both the NHS and care systems (see committee discussion in economic section). These savings would be made from the opportunity costs of supporting residents to gain access to multiple treatments if their oral health declines. It would also avoid the knock-on effects that lack of dental treatment may have on residents. (Such as their ability to maintain an appropriate nutritious diet and other basic needs, as described in the economic evidence section.)
The committee recognised that additional resources would be needed to implement regular mouth care routines if this was not already current practice. But this is likely to be more than offset by the benefit to residents in terms of quality of life. Identifying problems early will also reduce the likelihood of future treatment costs.
The committee felt it was important to ensure the recommendations in this guideline are linked to NICE's guideline on oral health: approaches for local authorities and their partners to improve the oral health of their communities.
Members agreed that access to dental services to identify oral health needs was a basic right. They also agreed that being unable to access dental services for unmet treatment needs was an inequity in service provision that should be highlighted and addressed. They considered that the lack of good quality research on effectiveness reflected a general lack of understanding of the importance of mouth care (and oral health generally) for people in care homes.
The committee agreed that it was important for care home managers to know:
they can raise concerns, and which organisations to raise them with, if there is a lack of local dental service provision
who to inform when local care home residents have oral health needs
whose role it is to support service development based on identified needs.
Members also agreed that implementing these recommendations would lead to systematic, less variable access to dental treatment at an earlier stage. It would also reduce inequity by improving residents' quality of life and reducing avoidable oral health problems. They believed that this could lead to potential health and social care cost savings.
The discussion below explains how we made recommendations 1.6.1–1.6.3.
The committee recognised the importance of collaborative working by a range of dental services and the care sector to improve oral health in care homes. Members noted that 4 UK guidelines (appraised in review 2 and rated moderate to high quality using AGREE) emphasised collaborative working and the central role of care home managers. But there was little evidence of their effectiveness [review 1].
Based on the review of best practice [review 2] and expert testimony [EP1, EP2], topic expert members agreed that collaborations and links should be developed between dental services and care home managers.
The committee recognised that oral health promotion services could offer local care homes support and advice to help meet residents' oral care needs. This includes developing and providing educational materials and training, and help to link up with local dental care and public health services where there may be unmet treatment needs [EP1].
The committee was unable to make specific recommendations about the role of diet, alcohol and tobacco or increasing access to fluoride products (including fluoride varnish programmes) for adults living in care homes. That was because no specific studies were identified that reported oral health outcomes for this group. The committee agreed that advice and support from local oral health promotion services would help care homes meet the needs of their residents.
The committee recognised that current practice varied around the country, but understood that similar services were offered through existing local arrangements.
The discussion below explains how we made recommendations 1.7.1–1.7.2.
The committee considered that general dental practice should act as a first point of call for routine and preventive care and dental treatment in care homes.
The committee heard evidence from review 3 [ES3.6] on the views of general dental teams about providing routine dental care or treatment for adults in residential care (including 8 studies conducted in the UK). The evidence suggested that the dental practitioners interviewed were unwilling to provide services in care homes for several reasons. These included a lack of time, funding, suitable equipment and training to meet residents' particular needs.
The committee recognised that although some practitioners may be limited in what they can do, they would be able to advise care homes what dental services were available in their area under local arrangements.
The committee acknowledged that dental care or treatment carried out in a clinic may be safer and more effective for some residents [EP1]. It discussed the potential lack of specialist equipment and what equipment can be taken into a care home. The committee also discussed the need to maintain the same levels of infection control as in a clinical setting, which it believed was possible.
The committee also acknowledged that access to off-site dental services may be difficult for many residents, not just those with mobility issues. Community dental services, including special care dentistry teams, can provide dental treatment to residents who have complex oral health needs, a disability or medical condition (see NHS Choices information on NHS dental services). This includes people:
with moderate and severe learning and physical disabilities or mental health problems
with medical conditions who need additional dental care
who are housebound or homeless.
During discussions about the practical daily care of dentures (full or partial), the committee considered how to reduce the risk of dentures being lost or there being confusion about their ownership.
Topic experts on the committee said denture loss and identification was an issue of concern for many residents and care staff in care homes. Although they recognised there might be some stigma around marking dentures for residents, they agreed that, on balance, offering help with marking or recommending marking be included during the manufacturing process would be beneficial with no or minimal resource implications. They noted some laboratories do this routinely.
There is very limited published economic evidence on interventions to improve the oral health of care home residents. In the absence of such evidence, NICE would usually develop a bespoke model to estimate cost effectiveness, ideally using our preferred method of cost–utility analysis.
NICE explored this approach after identifying evidence that poor oral health may be associated with cardiovascular disease and respiratory disease (utility values are available for these health states, so a cost–utility analysis would be possible). However, on further examination and after discussion with the committee, we decided that the evidence was insufficient to show that poor oral health directly causes these diseases. So we did not develop a cost–utility model.
Based on the evidence available, it was apparent the economic analysis would be limited to measures of oral health. Moreover, given the lack of evidence on health-state utility values related to oral health, the committee supported development of a cost–consequences analysis, rather than a cost–utility analysis. It favoured this approach because it can capture a wide range of benefits. However, the outcomes of the source studies were limited to clinical measures and so the economic model analysis could not, as had been hoped, report on a wide range of benefits.
The committee agreed that the effectiveness review had identified the best available evidence to inform the analysis and 2 interventions were included:
These interventions mirrored the types of approaches the committee was considering making recommendations about.
The perspective of the cost–consequences analysis was a single care home. The time horizon was 2 years, based on the average length of stay for a resident reported in the literature. The inputs included:
number of residents
percentage of residents who need help with daily oral care
whether residents use manual or electric toothbrushes
roles of staff carrying out the interventions
whether the time of staff who attend oral education training is 'back filled'
number of education sessions to ensure all relevant staff are trained.
The first intervention cost £15,154 (£379 per resident) over 2 years. Of this, the education programme (1 hour in year 1, 1 hour in year 2) cost £299 (£7.50 per resident). The remaining £14,855 (£371 per resident) was the cost of providing residents with oral care over 2 years.
The second intervention cost £30,241 (£756 per resident) over 2 years. Of this, the education programme (4 hours in year 1, 2 hours in year 2) cost £719 (£18 per resident). The cost of oral care was the same as in the first intervention. The generic care plans cost £178 to create, and carrying out a 20‑minute oral health assessment for every resident cost £391 (£9.80 per resident).
Monitoring the care home's compliance was a substantial cost. The base case assumes this takes the care manager 2 minutes per resident, per day, costing a total of £14,275 (£357 per resident) over 2 years.
One-way sensitivity analyses showed that the largest effect on total cost was determined by parameters using up a large amount of staff time, such as providing daily oral care (if a lot of residents need help) and monitoring compliance.
For example, the analyses above assume a total of 5 minutes per day of a care assistant's time for each resident who needs help with oral care (2.5 minutes, twice daily). If this time is doubled to 10 minutes per day (5 minutes, twice daily) the cost of the providing residents with oral care over 2 years is doubled from £14,855 (£371 per resident) to £29,710.
The above analyses also assumed that residents' families pay for toothbrushes and toothpaste for residents who need help with their oral care. However, the committee estimate that 10% of residents do not have family who visit. On this basis, and assuming that manual toothbrushes are used, the cost of the first intervention increases marginally from £15,153.92 to £15,195.71 and the second from £39,249.65 to £39,282.75.
The committee considered both training and oral care to be relatively low cost but was reluctant to make any judgments about whether the interventions represent good value for money. This was partly because the significance of the changes in clinical indices reported in the intervention studies (such as the gingival index) were difficult to interpret. But it was also because the opportunity costs – that is, the value of different activities carried out by the care home that might be displaced as a result of such provision, such as treating pressure sores – were unknown.
The committee considered that the use of clinical indices in studies of oral health was a serious limitation. It developed an evidence statement that it believes better captures the benefits of good oral health:
'There is evidence that oral health affects overall quality of life and wellbeing,. It seems self-evident that having a comfortable, pain-free mouth, with enough teeth to be able to enjoy food and adopt a healthy diet, would be important for the person and their close family and associates. This would be the case regardless of the person's age or other impairments. This observation is supported by research,.
In addition, having an acceptable appearance would be considered a social norm and an acceptable level of cleanliness in the mouth would be considered by most to be normal social behaviour.
All of these important outcomes are potentially compromised if daily plaque removal is neglected. If the mouth is not adequately cleaned, gum inflammation and its associated condition, irreversible periodontitis (gum disease), can cause bad breath, tooth loss, abscesses and pain. Toothbrushing with a fluoride toothpaste also helps prevent the development of dental caries (decay).
The effectiveness of plaque removal for slowing disease progression can be measured using plaque, periodontal, gingival and caries indices. These indices are measures of conditions that are known to affect speech, taste, pain and discomfort, chewing ability, self-confidence, ability to socialise, and sometimes daily life, particularly among older people. But the indices do not capture the other consequences of poor oral health.
The extent to which this occurs can be assessed using psycho‑social indicators such as the oral health impact profile.'
The committee noted that apart from the clinical impacts, many of the benefits captured in the statement above are not included in the cost–consequences analysis because of an absence of data, and should therefore be considered additional benefits.
Details of the evidence discussed are in evidence reviews, reports and papers from experts in the area.
The evidence statements or evidence summaries are short summaries of evidence. Each statement has a short code indicating which document the evidence has come from.
Evidence statement (ES) number 1.1 indicates that the linked statement is numbered 1 in review 1: 'Effectiveness'. ES2.1 indicates that the linked evidence summary is numbered 1 in review 2: 'Best practice'. ES3.1 indicates that the linked statement is numbered 1 in review 3: 'Barriers and facilitators'. EP1 indicates that expert paper 1 'NHS dental services commissioning: oral health for adults in care homes' is linked to a recommendation. EP2 that expert paper 2 'Oral health in residential and nursing homes younger adults' is linked. And EP3 that expert paper 3 'Oral health in residential and nursing homes: care home managers' is linked.
If a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence).
Recommendations 1.1.1–1.1.6: ES1.3, ES1.14, ES1.17; ES2.5, ES2.6; ES3.2, ES3.3, ES3.4, ES3.5, ES3.6, ES3.7, ES3.11; EP1, EP2; IDE
Recommendations 1.2.1–1.2.2: ES1.1, ES1.2, ES1.3; ES2.1, ES2.2, ES2.5; ES3.2, ES3.3, ES3.5, ES3.8; EP1, EP2, EP3; IDE
Recommendations 1.3.1–1.3.4: ES1.7, ES1.8, ES1.10, ES1.11, ES1.12, ES1.13, ES1.14, ES1.15, ES1.16; ES2.1, ES2.2, ES2.3; EP1, EP2; IDE
Recommendation 1.4.1: ES1.7, ES1.8, ES1.10, ES1.11, ES1.12, ES1.13, ES1.14, ES1.15, ES1.16; ES2.1, ES2.2, ES2.3; ES3.1 ES3.2, ES3.6, ES3.9; EP1, EP2, EP3; IDE
Recommendation 1.5.1–1.5.2: ES2.4, ES2.5, ES2.6; ES3.3, ES3.6, ES3.7; EP1; IDE
Recommendations 1.6.1–1.6.3: ES2.6; ES3.6, ES3.7; EP1, EP2; IDE
Recommendations 1.7.1–1.7.2 : ES2.6, ES3.6, ES3.7, ES3.11; EP1, EP2; IDE
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