Dentistry

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This is a study about the experience of dental services by BME communities in Kensington & Chelsea & Westminster (KCW). It aims to capture and analyse the experiences and views of the community and the relevant health professionals in order to recommend how existing services may be improved.

This study also forms a race equality impact assessment designed to assess how the current approach to the provision of dental services is affecting BME communities.

In this study, 51 interviews were conducted with residents in KCW. The sample of those interviewed is not representative of BME residents in KCW in general but consists of a group who are most likely to experience deprivation. The sample consists of high proportions of women, people on benefits, and people who are not fluent in English. However, most of the group have been living in the UK for sometime and are familiar with the benefits system and other entitlements.

In addition, 7 dentists and 2 commissioners were interviewed.

Main findings:

• The majority of the sample visit the dentist frequently
In total, 39/49 people have been to a dentist within the last two years.

Furthermore, 31/49 people attended their last appointment with an NHS dentist within the last two years (the other appointments were abroad or private). This figure (63.3%) compares well with the national average in England for adults having attended an NHS dentist within the last two years (49%) or the average in Westminster (37.1%) and in Kensington & Chelsea (19%). In addition, 21/49 people have attended a dentist within the last six months.

• The sample surveyed have a much higher rate of extractions than the general population
Amongst those whose last dental visit in the UK was to an NHS dentist,

30.8% had an extraction at their last appointment (compared to 20% for those who saw a private dentist at their last appointment). In comparison, the percentage of courses of treatments that contain an extraction amongst adults in England is 7.9% In contrast, our sample seem less likely than the average KCW resident to have band 3 treatments such as crowns, bridges or dentures (10.3% compared to 60% band 3 treatments for those who had private treatment). In Westminster the proportion of band 3 treatments is 13.5% and in Kensington & Chelsea it is 14.3%.

The issue of why this section of the community is having a disproportional high rate of extractions but a correspondingly low rate of band 3 treatments that could prevent or ameliorate an extraction needs to be investigated further. It may be that the communities represented in our sample are less assertive than the general population or are less able to communicate their preferences and are therefore more likely to accept the option of an extraction over other more time-demanding treatments. Furthermore they may be less likely to ask for a bridge or

dentures or may be more susceptible to the suggestion that such treatments should be done in the framework of private treatment. It is important to note that a scoping report for NHS Kensington & Chelsea stated that the proportion of band 3 treatments varies dramatically between practices without any discernible geographical link for this. The issue of whether there are financial or other disincentives for dentists carrying out complex treatments as suggested by the survey for the London Assembly in 2007 also needs to be investigated.

• Over 40% of our sample who have had NHS treatment at their last UK appointment are not happy with the treatment they received and a third would not go back to the same dentist
This compares to 20% not being happy with the treatment they received at their private dentist but 80% not being happy to attend the same dentist, mostly because of expense. Some of this discontent with NHS treatment is attributed by patients to inadequate clinical treatment such as fillings falling out soon after they have been placed, mistakes (e.g. a bridge being accidentally removed, a wrong injection being administered), experiencing pain, teeth being extracted too soon without the dentists trying to save them and generally rushing treatment and not being interested in treating the underlying causes of their problems. Some patients thought that these problems were caused by poor communication, more specifically that the dentists did not listen to them. Others thought the problem lay with the dentist's attitude towards them –that they were rude, did not explain the treatment properly and treated them without respect.

• Although dentists say that they do not use interpreters because they do not need them, the evidence suggests that they need interpreters but do not use them because they do not know how to do so.
All the dentists said that interpreting by friends and family was usually satisfactory and 6/7 dentists said that they had never used interpreting services because they had never needed to. Nevertheless, 3 dentists mentioned that there had been occasions when treatment had to be postponed and the patient turned away because the patient was not able to understand what the treatment would involve. Among the interventions required to communicate with patients were a dentist ringing other patients and asking them to interpret over the phone, a dentist ringing her own father and asking him to interpret and patients ringing friends to provide telephone interpreting. Two dentists said that interpreting by friends and family occasionally caused difficulties such as when the interpreter's English was not good enough to do the job and when the person interpreting interfered with the patient's decision-making process. Six out of seven dentists agreed that less than perfect communication inhibits the service patients receive. They said that communication was essential for informed consent, for reaching a correct diagnosis and for the patients to understand the treatment plan so that they come back to complete the course of treatment. Patients also needed to realise how serious their problems were, so that they did not underestimate or overestimate the severity of their condition.

It was initially assumed that the staff at dental practices knew how to book interpreters, so this was not an interview question. However, during the course of the interviews and from the shadowing results, it became apparent that dental practices do not know how to book interpreters. In 2 practices, the receptionists said they did not know how to book interpreters and asked for the information. In another, the practice manager said she had tried to book an appointment but she had been told by the service provider that the practice would have to pay the costs. In another practice, the dentist said he used to book interpreters in the past but that the last few times he had tried, no interpreter had been available.

• Patients prefer using formal interpreters to having friends and family interpret for them
In both focus groups, all the people who use friends and family to interpret for them or who speak to the dentist in English but struggle when doing so said they would prefer to use official interpreting services.

• Our sample underestimated the importance of giving up smoking for maintaining good oral health and overestimated the importance of using mouthwash and avoiding tea and coffee
When asked which were the top 5 priorities for maintaining good oral health 26/50 included using mouthwash, 21/50 included avoiding tea and coffee and only 15/50 included quitting smoking.

Recommendations:

Interpreting

Dentists and practice managers should be shown how to book interpreters.

Such information should be communicated in person since the local NHS have already sent this information to the practices but the practices are still unable to use it. Practices should be told to ask patients whether they need an interpreter and the local NHS should make it clear that interpreters should be provided in order to meet the legal requirement to provide equitable access.

Ethnic monitoring

The local NHS should provide training to dental practices to record ethnic monitoring statistics properly and ensure that this is done. Information about which communities are more likely to have their teeth extracted and which communities are least likely to have time consuming treatments including crowns, bridges, dentures and root canals needs to be collected and analysed.

Private treatment

There should be tighter enforcement of the regulations regarding practices suggesting to patients that private treatment is better (from a non-cosmetic perspective) or that it is their only suitable alternative. Dentists should be asked to show that before performing a private treatment, they offered an NHS alternative.