Nigel Jones speaks to Mili Doshi about a programme that has been working to improve oral health for older patients in hospitals…
Earlier this year I attended the Westminster Health Forum, where images of older hospital patients’ mouths in a terrible state were shown. These pictures were truly shocking and highlighted the issue of the mouth being ignored – through lack of awareness, rather than intention – by staff.
It was part of a presentation about Mouth Care Matters, a programme started in 2014 and funded by Health Education England Kent, Surrey and Sussex, to improve the oral health of older hospital patients in the region. To find out more about the programme I spoke to its hospital clinical lead Mili Doshi…
Nigel Jones (NJ): Can you share with us the aim of the Mouth Care Matters programme?
Mili Doshi (MD): We wanted to improve mouth care in hospitals and care homes and raise awareness of how important having a healthy mouth is for the rest of the body. This is not a project about dentistry but about how all health care staff need to support patients with mouth care for them to have a clean and comfortable mouth. For example, if their mouth is not being cleaned regularly and effectively – which we found was often the case in these settings – that can lead to a greater risk of aspiration pneumonia which is very serious, or problems eating and a poorer quality of life.
We also didn’t want to just create a report about why things needed to change; we wanted to go out and find out what the problems were, find realistic ways to solve them and have a platform to share resources.
NJ: What kind of problems did you find?
MD: It was a real eye-opener. In our own hospital, and we found this to be the case in all hospitals across the UK, mouth care is often carried out by healthcare assistants who frequently have no training.
Mouth care was not recorded in patient notes and often the care was using a pink foam swab dipped in water. Patients were suffering from very dry mouths due to medication, mouth breathing, systemic conditions, etc., which meant it was hard for them to swallow, or the mouth would be covered in sticky, dried saliva.
There was a real lack of awareness among staff about how important oral health is. Hospital staff, including the medical teams, didn’t know it was linked to cardiovascular disease, diabetes, pneumonia, etc. or that those sponges can be quite dangerous because the ends can detach and they can aspirate. We found the same lack of awareness about the importance of oral health in care homes.
NJ: I went to the Westminster Health Forum earlier this year where a colleague of yours described some of the things you were finding and showed some awful photos of people’s mouths. Can you share some of the stories of patients you’ve come across?
MD: Absolutely. Case studies of patients is one of the key ways we’ve changed the perception among care home and hospital staff of how important this issue is and why training is needed. They help to identify that often small changes in care can make a big impact.
Most people wouldn’t leave the house without brushing their teeth, yet when they go into a hospital or care home, dentures can be left in for weeks because patients can’t get them out and no one would be looking in their mouths and helping to take them out or clean them. There was a case of someone whose denture was left in for two months after they were admitted to a surgical ward and the patient was complaining for weeks that their mouth was sore but there were no notes about oral issues.
There have also been cases where a failure of someone looking in someone’s mouth or providing mouth care had serious results. In one case a lady nearly died because her tongue was stuck to the roof of her mouth and she wasn’t eating or drinking because it was so dry. It wasn’t because staff were purposefully not carrying out good care, they just didn’t know what to do.
NJ: It is genuinely shocking to hear of these cases. What kind of work have you been doing as part of the programme to tackle this?
MD: Most of our programme has been in hospitals, and in 13 trusts across Kent, Surrey and Sussex we employed a Mouth Care Lead who could establish mouth care training, work with procurement to ensure they have the right products – as this was a key issue, they simply didn’t have the correct toothbrushes or things like dry mouth gels – and ensure the hospital has a proper mouth care policy and paperwork.
We also did a lot of practical, hands-on training on the wards, which went down really well and was an important part of the programme. We carried out a health economics assessment which showed that the training we delivered had changed people’s perceptions about the way they care for their own mouth and their dependents, whether they’re older or younger. It also showed that for every pound invested in this kind of training, there is £17 worth of social improvement.
NJ: How hard can it be for patients like these to access dentistry?
MD: It can be very challenging. Often patients who are in hospital or rehabilitation centres will have no access to a dentist. Many patients need surgeries on the ground floor, accessible by wheelchair, or if they have a mental health issue they might need to be treated by someone who’s had appropriate training. There’s also a much larger number of patients who find it hard to leave their homes and need domiciliary care, but there seems to be less and less dentists providing that service because it’s not funded in their contract.
The population of special care patients is going to increase in number and complexity and the services need to match this. There are some great NHS general dental practitioners who will see the mild to moderate special care patients, and the more they can see the less pressure on the salaried dental service. Special care patients who are in pain should not have to wait months before being able to access treatment.
NJ: What kind of future do you see for the Mouth Care Matters programme?
MD: Our project was initially rolled out from East Surrey to 13 trusts in Kent and Sussex, and this year to another 30 across the country. We’re also working with Great Ormond Street to do Mini Mouth Care Matters for children in hospital.
As this was a programme, it always had an end date but there is so much work that still needs to be done in care homes, for people in mental health hospitals, people with learning disabilities – that’s what we’re trying to fight for at the moment, to keep the programme going and extend it to other trusts. We have lots of programmes aimed at children, such as Dental Check By One and Starting Well, but we also really need to think about the adults and increasingly complex older population – we need Ageing Well.