This example describes the development, implementation and monitoring of a community-based fluoride-varnish programme in an inner-city London borough. The programme aligns with recommendations set out in the NICE guidance for oral health promotion including:
- Recommendation 1: Ensure oral health is a key health and wellbeing priority Health and wellbeing boards and directors of public health should: Make oral health a core component of the joint strategic needs assessment and the health and wellbeing strategy. Review it as part of the yearly update.
- Recommendation 16: Consider fluoride varnish programmes for nurseries in areas where children are at high risk of poor oral health
- Recommendation 20: Consider fluoride varnish programmes for primary schools in areas where children are at high risk of poor oral health
Contributing authors: Dr Wendy Bellis, Sanoj Majeed; Professor Richard Watt and Dr Andrew Read.
Aims and objectives
- To provide 2 fluoride varnish applications per year to children aged 3-10 years, in children's centres, selected schools (up to year 5) and other selected early year's settings in Islington.
- To increase the number of children and their families accessing local NHS dental services.
- To improve oral health and reduce oral health inequalities in children in Islington, by increasing access to fluoride, dental services and oral health promotion.
- Provide a high quality, evidence-based service which represents good value and is responsive to local needs and guidance and policy across Islington and nationally;
- To strengthen relationships with stakeholders in schools and children's centres in Islington to secure their participation in the programme.
- Work collaboratively with the Islington Oral Health Promotion Team; Heads of Primary Schools, Nurseries and Children's Centres; Early Years Foundation Stage; Healthy Schools Team; Community Link Workers; Health Visitors; Family Support Workers; Dental Public Health; Dental Commissioners and a wider group of stakeholders.
- To work with home-school liaison staff to find out how to maximise contact with parents/carers, to explain the project and obtain consent for fluoride varnish application.
- To improve access to local NHS dental services by children and their families by signposting all children to local dental services and promoting regular dental check-ups.
- To identify and urgently refer those children who require dental treatment to local dental services.
- To carry out health promotion sessions with parents/carers, explaining the project and gaining consent for the fluoride application, as well as providing important information about how to prevent dental caries through appropriate fluoride use and access to dental care.
- To provide topical application of fluoride varnish twice a year in the school, children's entre and other selected early years settings, to children aged 3-10 years (year 5) only, where parents/carers have consented.
- To refer children to other services when needs other than dental care are identified, e.g. child protection cases.
- To contribute to an increase in regular NHS dental service attendance by all residents including those from BME groups and those for whom English is not their first language.
- To use a preventive focus to address oral health inequalities in Islington
Reasons for implementing your project
In 2011, there were 206,100 residents in Islington. Twenty percent were between 0-19 years old, and this group is expected to increase by 16% in the next 20 years. Islington is the most densely populated local authority in England and one of the five most deprived boroughs in London. According to the Child Poverty report (2011), 43% of children in Islington are living in poverty. Dental decay is one of the most common chronic diseases, despite being entirely preventable.
In Islington, tooth decay is a significant problem; epidemiological surveys show disease levels to be higher than both regional and national levels (6). In addition, persistent inequalities exist with trends suggesting that dental disease is increasingly concentrated in population groups suffering social deprivation or exclusion, including young children. Socially excluded and disadvantaged people suffer the effects of poor oral health with the added disadvantage of poor access to dental care and preventive services. Young children with high levels of decay are more likely to require extractions under GA with the associated costs of hospital admission.
Dental public health programmes, which are the responsibility of local authorities, should be commissioned following strategic planning. There is good evidence that in addition to place-based generic health improvement activities, which will address some of the common risk factors for dental decay, strategies to increase the exposure to fluoride are effective.
Islington Public Health worked with commissioners and providers of dental services to produce a detailed oral health needs assessment and an Annual Public Health Report which focused on oral health in Islington. This highlighted higher levels of dental caries in Islington 5-year-olds compared to other London boroughs. In addition, much of this disease remained untreated. The data showed a significant association between deprivation and dental caries, and also low dental attendance, in this age group. In response to this, a local oral health commissioning strategy was developed. In addition to the established "Brushing for Life" programme which involved the distribution of fluoride toothpaste and advice to parents of young children, the strategy recommended a community-based fluoride varnish programme to further address oral health inequalities in young children.
How did you implement the project
An "oral health champion" - in the form of the local Director of Public Health - was an essential element in influencing the local commissioning agenda. Public health support for investment in dental public health allowed the commissioning of an extensive oral health needs assessment and the publication of the Annual Public Health Report in 2009 which was entirely devoted to oral health. The piloting of a community-based fluoride varnish programme was an integral part of the subsequent oral health commissioning strategy. The local community dental service was commissioned to deliver the pilot programme for a period of 10 months from September 2010.
Stakeholder engagement was key to successful implementation. Relevant parties that the team worked in partnership with included: primary schools and children's centres, local GDPs, local authority departments of education, early years and children's services.
Participating settings included 44 primary schools (in 19 of these over half of the pupils were eligible for free school meals), 16 children's centres and one special needs school. Shortly after commencement of the pilot, parental demand led to the age range being extended to include children aged up to 10 years. In addition to consent forms being sent to parents from the settings, the oral health promotion team held 108 promotional sessions with parents to maximise consent rates. The more informal approach of speaking to parents at school gates proved to be more effective than the more formal parent information sessions and parent evenings.Taking into account the learning from the pilot phase, a tender process commenced to appoint a provider to deliver a three year contract.
The main aims of the programme were:
- Provide two FV applications per year to children aged 3-10 years, in children's centres, the most deprived schools (up to year 5) and other selected early year's settings in Islington (target of 12,000 FV applications per year by the end of the contract term).
- Increase the number of children and their families accessing local NHS dental services.
- Improve oral health and reduce oral health inequalities in children in Islington, by increasing access to fluoride, dental services and oral health promotion.
The programme is commissioned by the London Borough of Islington Public Health department, with an annual budget of less than £200,000.
- Interim results following 33 months of programme implementation (July 2011 - March 2014):
- Number of fluoride varnish applications completed (Up to March 2014): 33,490
- Number of eligible children in participating settings (as of March 2014): 11,571
- Number of children with positive consent: 8,273
- Average proportion of total target group with positive consent: 72%
- Proportion of total consents resulting in fluoride varnish applications (%): 90%
- Percentage of settings receiving 2 fluoride varnish programme visits every year: 100%
- Proportion of total children (at time of giving consent) with no dentist (%): 27%
- Number of promotional sessions held: 422
After the first year of the programme, the team assessed whether those children identified by dental nurses as benefiting from a dental check-up/treatment at their first FV application, still had this need at the next FV application visit. It was found that 58% of the children whose parents had been sent a letter recommending they take their child to the dentist after the FV team's first visit, did not require a further letter at the next visit, suggesting that the child had been taken to a dentist. A similar assessment was done at the end of the second academic year which showed 55% of children may have received dental treatment following the referral letter by the nurses.
It was found that 8,273 (72%) of children in the target group had received positive parental consent to participate in the programme. The consent rate ranges from 59% in some settings to 88% in others. No correlation was detected when comparing percentage free school meals to consent given. This is a promising finding as it suggests that higher deprivation is not impacting on the programme achieving high levels of parental consent as was originally hypothesised. It also indicates that there does not appear to be any major barriers to the most vulnerable children participating in the programme.
In the first two years of the FV programme, the crude cost per FV application (calculated by dividing the contract value by the number of FV applications provided) was £18.17. In year three of the programme, the average cost per application reduced to £16.36 per application as the target of 12,000 applications was reached (and exceeded). If the provider continues to exceed their target in subsequent years of the programme, this amount should decrease further.
Key learning points
Planning and scheduling:
- Scheduling of visits to be done well in advance to take account of the daily routine of the setting and holiday periods.
- An appropriate amount of time should be left between the FV application and lunch/break time to minimise potential loss in efficacy as a result of food or drink being consumed soon after.
- Encourage settings with smaller eligible populations to attend FV application days at larger settings that they are in close geographical proximity to.
- Information leaflets should be translated into the main local languages with messages to reflect specific cultural concerns, e.g. statement of support from Islamic Council despite FV containing alcohol.
- The provider must build relationships with staff in settings and outreach workers to identify and encourage participation from the most vulnerable families, including those where language and/or low literacy levels are barriers.
- Substantial resource is required to publicise the programme, to recruit new participants and keep settings and enrolled participants motivated and engaged with the programme.
- Many residents are not aware that the local water supply is not fluoridated and it is therefore important to keep publicising the importance of obtaining fluoride from other sources.
- Ensure the programme integrates with other health promotion initiatives, e.g. Healthy Schools/Children's Centre/OHP programmes.
- Identify a link person in each setting and build relationships to ensure good communication between the FV team, settings and parents so that any concerns can be addressed quickly.
- Provide support to the settings where necessary, e.g. administrative support, so that staff experience minimum disruption to their day.
- Commissioners and providers must work in close partnership to drive innovation and improvement.
Yes, This programme is commissioned and funded by the London Borough of Islington (Public Health for Camden and Islington) and the service provider is Whittington Health NHS Trust Community Dental Service.