Summary of: Targeting dental resources to reduce inequalities in oral health in the North East of England – a health equity audit methodology to evaluate the effects of practice location, practice population and deprivation

Key Points

• Provides a way for PCTs to use locally available data in order to undertake an equity audit.

• Demonstrates the impact of practice location and population demographics on uptake and usage of dental care.

• Practices and services which are located in more deprived areas will facilitate greater uptake from the local population.

• Undertaking an equity audit will aid PCTs to reduce inequalities in oral health.

Abstract

Aim To use nationally available data sets to undertake an equity audit to support the targeting of resources to meet the needs of patients from deprived communities, in areas where levels of poor oral health remain higher than the rest of the population as a whole.

Methods Postcodes of 224,107 patients in County Durham were matched to Lower Super Output Areas (LSOA) for each practice. Deprivation scores were identified for each LSOA. The postcode of dental practices (59) was matched to the LSOA and the practice population divided into quintiles from the most to the least deprived areas.

Results Results indicated that the more deprived the area in which a dental practice was located, the greater the proportion of the practice population accessing care from the most deprived quintile. The size of the practice alone was not directly related to meeting the needs of a more deprived population.

Conclusions The methodology used in this study can be used to identify inequalities and inequities in oral health in different areas. In the audit area improving access to dental services for those in most need, was best tackled by targeted investment into dental practices located in deprived communities. Audits are recommended to insure a fare distribution of resources to meet local population needs.

Main

D. P. Landes and C. Jardine British Dental Journal 2010; 209: E3

Editor's summary

We often seem to touch in these pages on the unexpected complexity involved in providing oral healthcare. If it is not a matter of finance then it is of clinical practicality and evidence-based practice, and if it is not about organisation it is about biological variation.

This paper aims to inform decision making at a local level by examining the structure of the population attending practices and the factors that act as influencers to, and barriers against, that attendance. Overall, the location of the practice was found to be a significant element and while this might seem obvious, it is valuable to have confirmation that a community is more likely to seek care if it is not only conveniently placed geographically but actually felt to be part of that same community.

As with most good research though, it throws up as many additional questions as the original ones it set out to answer. In this regard, while the information gleaned can be used by PCTs to inform investment decisions to create equitable services for the community as a whole, it may also mitigate against the personal services demanded by the individual, as our Commentary points out. This also serves to highlight the ongoing dichotomy, if not conflict, in the provision of dentistry between public health provision on the one hand and serving individual demands on the other through one-to-one, professional-to-patient service.

If there was an easy answer we would have doubtless have discovered it by now but the ongoing process of research of this nature ensures that as we make our choices in terms of the resources we allocate, both individually and collectively, we are better informed in our decision making and thereby more likely to invest wisely.

The full paper can be accessed from the BDJ website ( http://www.bdj.co.uk ), under 'Research' in the table of contents for Volume 209 issue 3.

Stephen Hancocks, Editor-in-Chief

Author questions and answers

1. Why did you undertake this research?

Our PCT was involved in the dental access programme where additional resources were provided to invest in new dental services. The research was undertaken to inform the investment process by the PCT for new dental services, to insure that investments were made in those areas where services would be of most benefit in reducing inequalities in oral health.

2. What would you like to do next in this area to follow on from this work?

We would like to take this work forward by identifying the natural communities around dental practices in order to better understand why people access services and also the barriers to services. Working in a deprived area of an ex-heavy industry base related to coal mining, railways and the steel industry means that our communities have tended to be very stable and are dispersed in discrete, smallish populations, compared to the large areas of inner city deprivation. Our current knowledge of service utilisation by this community is incomplete.

Comment

Many commercial organisations such as supermarkets and insurance companies seek to understand who is using their services, to inform their marketing and increase profits.

The principles, tools and techniques employed by such organisations are increasingly being used within the public sector and particularly within the NHS, to understand more about the users of services with the aim of improving equity and fairness.

This paper uses techniques to segment the population according to their deprivation status, and applies them to a section of the North East population who attended an NHS dentist in County Durham.

For each dental practice in County Durham, the group of patients attending that practice have been analysed to determine the structure of the practice population and this has been compared to the population of the areas in which the practices are situated and to the population of County Durham as a whole.

The paper reports that the structure of the population visiting an NHS dentist in County Durham is very similar to the structure of the resident population of County Durham and further analysis shows that the practices in more deprived areas serve a bigger proportion of patients who live in deprived areas. The authors report using this evidence to inform future primary dental care commissioning and investment decisions.

Whilst the study shows equity of access to services, the techniques described could be further employed to compare in more detail the services delivered and to gauge the equity of clinical care provided.

The importance of this paper is in highlighting that PCTs are using these techniques to support investment decisions and to ensure fair and equitable services for their populations. This objective does not always sit comfortably with dental providers' focus on services to meet the demands of individual patients. This paper and the techniques employed within it could usefully be used to discuss the concepts of demand, need and equity in local commissioning of primary dental services.