Oral Health Improvement and Dental Services in Scottish Prisons

3. Dental services

3.1 Many prisoners come into custody from areas of substantial deprivation with very high levels of treatment need. These circumstances are often compounded by a history of prolonged substance misuse, tobacco use, excess alcohol consumption and infrequent dental attendance when outside the prison.

3.2 Prisoners entering a custodial environment who have been using drugs can undergo detoxification in prison. This process leads to renewed awareness of oral problems which may have been ignored whilst using drugs. Acute dental pain may also be experienced by prisoners experiencing withdrawal, with consequent demands for care. It is important under these circumstances to balance the important long-term benefit of prevention with short-term pain relief.

3.3 Prison is often viewed as an opportunity to take stock and to address health concerns during what is for many prisoners, a period of relative stability. Approximately 70% of prisoners reported attending the dentist whilst in prison; this is demonstrated in the 2011 study^[11]. This would indicate that there is a clear opportunity to tackle dental disease and provide oral health information and oral health education.

3.4 Currently, a prisoner accesses dental treatment within Scottish prisons by making a request for a dental appointment and being placed onto a waiting list. Prisoners with more serious needs are seen more urgently. However, achieving consistency remains challenging, particularly in remand and short-stay prisons, where transfers of prisoners are frequent and courses of dental treatment may not be able to be completed.^[19] Also, the service has historically been mainly directed at relief of pain and delivery of routine dental treatment, with limited time available for prevention of disease within the dental surgery setting.

3.5 Dental teams within prisons have traditionally consisted of a dentist and dental nurse. Hygienist services were available in only a limited number of establishments, dental therapist services were not available within the pre-NHS transition prison dental service and technician services were outsourced on a local basis. All establishments offered part-time services and the adequacy of the level of provision was unclear.

3.6 Prior to November 1^st 2011, each individual prison was responsible for the level of dental service provided and the associated contractual arrangements. For each establishment the need, demand, supply and resource available for service provision varied;

Issues to be considered when addressing need:

• Very high levels of need
• Dental self-care neglect
• Balancing treatment need with health promotion
• High levels of drug misuse and smoking
• Poor nutrition

Issues to be considered when addressing demand:

• Very high levels of demand
• Interruptions to treatment
• Continuity of care affected by prisoner transfer and release
• High levels of failed attendance

Issues affecting supply

• Staff availability
• Availability of surgery time
• Sessions shortened by security procedures
• Availability of oral health promoting activities

Issues impacting on resources

• Increasing cost of dental care products
• Replacement cycle for equipment
• Availability of health promotion and dental treatment sessions

3.7 Following November 1^st 2011, funding to support the delivery of dental services was transferred from the Scottish Prison Service to NHS boards on the basis of historical allocations. The Memorandum of Understanding^[20] underpinning the transfer intended that NHS boards and the Scottish Prison Service funding and resources be jointly and regularly reviewed, taking account of value for money. It was intended that key variances, investment and disinvestment should be subject to joint appraisal, with sufficient time given to stakeholders to assess and respond to developments. Additional investment in dental services would therefore be subject to this process.

3.8 At induction prisoners will have the opportunity to make staff aware of any dental or oral problems they are experiencing and will be informed of the arrangements to access dental care.

3.9 It is clear that prison staff and prison health centre nursing and medical staff can support dental teams. This can be achieved by providing initial advice and management, including appropriate access to oral analgesics, to prisoners experiencing an acute dental problem when the dental team is not on the premises. Prison staff and healthcare teams should agree protocols which allow for this. The care pathways described in the guidance for Managing Acute Dental Problems^[21] are a particularly useful resource.

3.10 A dental service will be available to all prisoners. Prisoners historically should have had access to an examination by a dentist within ten weeks of placing a request. It is hoped that in the medium-term this timescale could be reduced. However the ability to reduce the waiting time will be dependent on the demands for emergency care made on the dental team and is therefore dependant on the stability of the prison population within each establishment.

3.11 Following examination, the care pathway will be based on need and will take account of the length of sentence. The level of healthcare to the prison population should be similar to that which is available to the community outside prison.^[22] Therefore Boards should provide dental care and treatment to prisoners in line with that care and treatment available under Determination One of the Statement of Dental Remuneration,^[23] taking full account of each individual's clinical need and suitability for that treatment and the degree of post treatment supervision available. Boards should consider what 'prior approval' and quality assurance arrangements should be in place in prison settings.

3.12 Where a prisoner is on remand, sentenced to one year or less, or due for release within six months, treatment equivalent to that detailed in Section XII (Occasional Treatment) of Determination One of the Statement of Dental Remuneration should be provided, unless exceptional circumstances dictate that additional care is essential.

3.13 The service will be delivered by an appropriately trained and qualified dental team, registered with the General Dental Council.

3.14 It is recognised that the length of dental sessions will vary for each establishment due to different regimes. The length of the session should be agreed between the NHS Board and the prison to maximise the availability of the dental team. Prison staff are key to ensuring that the session is as efficient as possible by delivering the expected number of prisoners at agreed intervals to the dental surgery. The number of sessions provided will in the first instance be based on the historical level of provision. It is noted that prisoners in Scotland have poorer dental health than their UK counterparts, that the demography of the prison population is changing and that the stability of the prisoner cohort varies between establishments. Therefore Boards should keep the level of provision under review with a view to increasing it to meet the oral health needs of the local prison population rather than meeting a notional target of sessions per week.^[23]

3.15 Access to out of hours care will follow general guidance from the NHS in Scotland and should reflect the timescales currently in use in NHS Scotland.^[25] Examples of care pathways are shown in Appendices 1 and 2;

• Emergency - contact with health professional provided within 1 hour.
• Urgent - contact with health professional provided within 24 hours.

3.16 Encouraging prisoners to have ongoing dental care during their sentence will enable the dental team to complete all dental treatment in advance of release. Qualitative data from the 2011 study^[11] showed that many prisoners knew how to access dental care within the prison setting but were unsure of how to access care on release. All prisoners being released should be offered support to maintain their oral health and to register with a dentist, in order to build on any improvement in oral health achieved whilst in prison. Clear throughcare pathways should be developed for prisoners.