Oral Health and CVD Prevention – The Power of Making Every Contact Count (MECC)

We must seek any ‘silver linings’ for the NHS from the dark clouds of COVID. The Pandemic has focused minds on the challenge of reducing health inequality and reminded us that prevention is more effective and cheaper than medical management of disease. COVID has evolved innovative processes that embody collaboration and the principles of MECC. We have seen that a crisis situation can create opportunities for reinvention and that urgency can evolve sustainable change. It is important we embrace the momentum in reducing health inequality in this moment as a ‘call to arms’.

In my passion for reducing health inequalities, I am leading a programme with the Postgraduate Dental Dean at HEE Thames Valley and Wessex in collaboration with Reading University Healthreach team, to pilot a programme to develop the local oral health workforce to better mirror the community it serves. I believe that by having a workforce that is more representative of the community it serves, we will encourage better engagement by that very cohort of patients we are trying to reach in programmes such as Core20PLUS5.

Through collaborative leadership and MECC working, we are stronger in reducing health inequality.

The NHS Long Term Plan encourages collaborative working across NHS platforms to support early detection of high-risk conditions such as Hypertension, Atrial Fibrillation and raised cholesterol¹. Oral health settings offered an opportunity to support this programme. There was an average of 25.36 million unique presentations at English NHS dental surgeries per year between 2015/16 and 2019/20 (NHSBSA data) for all ages and 12.06 million for the same period for people aged 40 years and older. There was a clear opportunity for primary care NHS dental providers in England to case-find people with risk factors for CVD on an opportunistic basis, in line with MECC.²

In 2020 The Office of the Chief Dental Officer England commissioned an independent health economic review, supported by the NHS England and NHS Improvement CVD Team. We developed the PHE ROI tool to set out a costed proposal for primary care NHS dental providers in England to engage in case finding for people aged 40 years and older with previously undetected risk factors for CVD.

The model determined that £48,204,486 could be saved over a three-year period to NHS and social care.  This was calculated using half the number of over 40s (above) who present at dental practices (6,005,206) which projected 43,738 CVD events would be avoided over 20 years.

Endorsements were received from the British Heart Foundation /Primary Care Cardiovascular Society, Arrythmia Alliance and Blood Pressure UK for the programme.

Initial proof of concept pilots and then programmes were targeted to high Index of Multiple Deprivation (IMD) areas in support of the CORE20PLUS5 programme, specifically the hypertension case finding ambition in the Core20 cohort.³

In collaboration with Postgraduate Dental Deans in HEE North East, Yorkshire and Humber and Thames Valley and Wessex, initial 6 week small proof of concept pilots were set up. These pilots were in high IMD areas and returned a small but significant number of patients who required referral to GPs for a diagnosis: (23% hypertension referrals – awaiting GP confirmation of diagnosis). The team were also approached by Peninsula Dental School who are undertaking the research project ‘Case finding high blood pressure at the dentist: an examination of periodontal disease and the oral microbiome’. The school has services accessed by multiple areas of deprivation and current data shows from the 96 patients who agreed to have their readings, 19% were case found for hypertension.

The total in these cohorts to date is: 122 patients consented to take part and 19% were case found for hypertension and 4% case found for Atrial Fibrillation.

East Riding of Yorkshire Clinical Commissioning Group have found through their CVD Surveillance Data (PHE Fingertips, PREVENT and local health intelligence data) two areas of high CVD prevalence in high IMD areas and have commissioned a CVD case finding programme in two dental practices, that have capacity, situated in the heart of these areas.

Next Steps

In association with the Postgraduate Dental Dean in HEE Yorkshire and Humber, 23 sites situated in high IMD areas will utilise the Foundation Teams in primary care as part of their community project to case find hypertension and Atrial Fibrillation from December 2022. To prevent false positive readings, if clinical case finding reach the (NICE) thresholds, the patient will be guided to undertake 7 day home readings to support confirmation prior to referral for a GP diagnosis for hypertension. This has been supported by collaboration and free resources from Kinetik Wellbeing.⁴

The work in Peninsula Dental School will continue in line with the research project. The two commissioned sites in East Riding of Yorkshire will continue their case finding. The data for all sites will be evaluated further and made available to view. Peninsula Dental School is looking for funding opportunities to enable and lead similar case finding to happen in other dental schools that serve high numbers of the high IMD populations.

All case finding is being undertaken by Dental Nurses, Dental Therapists, Hygienists and Dentists and only in practices that have capacity to do so. Following the COVID pandemic, Oral Health inequality and reducing the backlog is still the priority for dental teams. We cannot support the reduction in one inequality at the cost of another, but it is clear how dental teams can play an impactful role in not only reducing oral health inequality but also general health inequality.

References

1. NHS Long Term Plan » Cardiovascular disease
2. MECC Consensus statement (publishing.service.gov.uk)
3. NHS England » Core20PLUS5 – An approach to reducing health inequalities
4. https://www.kinetikwellbeing.com/know-your-numbers-week-2022/

Shabir Shivji

Shab is an NHS Dental Practitioner, The Dental Regional Advisor for HEE SE Working across Thames Valley and Wessex, a Clinical Dental Advisor for NHS England South East and a Senior Dental Advisor CVD Prevention Lead for the Office of The Chief Dental Officer, England.

As an immigrant to England from Uganda in the 1970s, Shab has a personal passion for reducing inequality, particularly health inequality as he has perspective from the patient view from that experience.

Shab has had the privilege of seeing the impact of reducing oral health inequality that dental teams in England work hard to do and is a strong advocate for Making Every Contact Count and interprofessional collaborations as enablers for reducing health inequality.

In his various roles, Shab has had the privilege of working with strong, inspiring leaders, cementing his belief that strong Leadership is one of the many key levers in reducing inequality.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.