Ninety day centres and community groups were contacted by phone and/or e-mail with an invitation to participate in the study. Eleven day centres were visited at which centre managers facilitated recruitment to this study onsite, enabling ten focus groups to be run over a five-month period. Interviews were conducted with carers of older people and informants who preferred this approach. The majority of participants, or older people to whom the findings related were in the 75–84 year age-band (n = 19), followed by 65–74 (n = 15) and 85 year and over (n = 2) (Table ). People who declined to participate in the study commonly perceived they did not have any dental need because they had complete dentures.
Demography of respondents participating in qualitative research on minimising barriers to dental care by age, sex, ethnic group and borough of residence
Main barriers to dental care
The results of this study suggest that there are five key areas which act as barriers to older people utilising dental care, when a need to do so was perceived. These are outlined in the first column of Table . One further issue identified was a lack of perception of need, particularly amongst people with complete dentures. Each of the barriers was identified as a factor which would cause participants to either forgo dental treatment altogether or delay it until they felt it was absolutely necessary (symptomatic attendance). Starting with 'cost' and taking each of the barriers in turn we examine the implications of the barriers themselves and suggestions made for removing these barriers by older people. The issues are illustrated by quotations and related to the literature and the wider context.
System changes to minimise barriers to dental care in older people in inner-city area characterised by social deprivation
Cost of dental care
The informants in this study included older people who paid NHS charges for dental treatment, those who were partially or fully exempt from NHS charges and people who paid for private treatment.
The actual costs charged to patients through either NHS or private practices for routine check-ups and dental treatments were widely held to be excessive amongst this sample of older people. This was identified as a major cause of infrequent or non-attendance. The majority of participants in this study use NHS dental services. This was largely due to the common perception that private charges were prohibitive. Even those who used the NHS system felt that, unless you were exempt charges, costs could be a barrier to older people receiving pensions.
If you've got fillings and x-rays you are paying quite a bit of money and as I said when you are a pensioner...it's not that I haven't got anything ...I get two pensions...so therefore I don't get anything – I don't get any benefits or pension credit because I've got two pensions. (53:90)
In some cases older people did not want to return to a dentist in order to avoid the embarrassment of a situation where they could not afford treatment as demonstrated below:
My daughter said, 'You should have said that you can't afford it.'; but I didn't like to, so I think I'm not going back. (41:204)
Amongst those using private dental services there was also the recognition that cost could be a barrier to private patients seeking non-symptomatic treatments:
I go to private dentists and I just can't afford to go for six-month check-up, it's too expensive. (36:31).
Dentures were raised as a particular issue for older people. From a cost perspective, some participants considered themselves fortunate to wear dentures, instead of having natural teeth, because of the widely held perception that they needed less dental treatment:
I'm one of the 'fortunate', if you can call it that way, having a plate on top and bottom, like I said the only times I go is if repairs are needed. (66:359)
For others, dentures did represent a cost issue for some participants and their peer group. Some indicated that dentures were not worn by their peers because they did not fit properly and alterations or new dentures were too expensive.
One of the reasons you see a lot of people who don't have their false teeth in is because of finance. (21:96; 101)
Don't forget we are all on small pensions and even if you've got a company pension it's still not enough to go and pay £50 or a £150 for a bottom plate. (21:30)
Indirect costs include expenses other than the dental treatment itself that add to the cost of going to the dentist. The biggest indirect cost identified by this age group was transport. This was a particular issue for people without friends or family to accompany or drive them to appointments. Even where cars were available, it was suggested that public transport may be the cheaper option when additional expenses, such as the London congestion charge (daily charge for driving in central London during the working day) and the cost of parking, were taken into account.
The one I go to now is the congestion charge; you can't go by car because you can't pay eight pounds every time. I've got to get a bus to go down there. (23:309)
One of the biggest issues that emerged relating to transport, was the time of the appointment. In London, people over the age of sixty or registered disabled are entitled to a 'freedom pass', which allows them to travel free on London's public transport network after 9 am. When an appointment is too early in the morning, older people are not able to use their free bus pass. Therefore using public transport might represent an additional cost to dental care.
I got the other week an appointment at quarter past nine, it cost me three pounds to get there because for my bus pass was too early. (24:332)
Fear of the cost of dental treatment
In addition to the direct or indirect cost of treatment which caused a barrier to attendance, fear of the potential cost and the embarrassment of being unable to pay was a barrier to accessing care.
I'm just afraid of what they are gonna charge. (12:1012; 1022).
Whilst a small number of participants stated that cost was not an issue in utilising care, the majority of participants stated that cost or the fear of cost was the most significant barrier to utilisation.
Minimising Barriers Associated with Cost
A range of suggestions was made about how barriers related to the cost of dental treatment could be removed (Table ). These related to removing or mitigating the direct costs of dental treatment for older people, and particularly of denture related costs; providing more information for older people on the costs of treatment so that decisions can be made according to actual costs rather than through fear of potential costs; and providing more NHS dentists so that all older people have access to NHS dental care should they want or need it. One participant suggested that all NHS dentists should be contracted to see a certain number of older people as a proportion of their patient list.
Suggestions relating to the direct costs were primarily focused on decreasing the cost of check-ups and of specific treatments. The vast majority of participants suggested that free dental check-ups should be made available for older patients. This was suggested as a self-evident solution requiring no further explanation.
Check-ups should be free. (66:465)
A further suggestion was that if check-ups were free then they should also be compulsory, reducing the problem of non- or symptomatic attendance.
Make it compulsory for sixty and over to have a regular check-up without having to pay for that, probably it will remove the fear of how much is going to cost. (13:597)
Reductions in costs were also suggested by those who felt that some payment was necessary. Proposed reductions ranged from twenty to fifty per cent discounts or means tested costs levied according to personal circumstances. However, others considered that care needed to be free in order to remove the very real barrier of cost, regardless of personal circumstances, as was originally the case when the NHS was implemented.
Actually, it would be helpful for older people to have reduction. If you need treatment you should pay accordingly to your own circumstances. (66:465; 483)
If it was free for everybody they would go, because you are on benefit you get it free, because you can't afford to pay but it doesn't mean that with the income she's got coming in, she can afford to go the dentist...it should be totally free after the age of sixty, doesn't matter what your circumstances are. (36:660)
Fear of the cost of dental treatment
Lack of information about the cost of dental treatment led older people to fear the cost of treatment and often to irregular attendance. The example of a participant who realised that they qualified for a flat fee payment in the new system. However, even then there was the need to plan ahead for the payment.
I couldn't afford to go to the dentist at the cost is now, I would be like I can't go this year, I'll go next year... I know now how much I pay and I pay that much for whatever I've done, so that is quite good really. (63:486)
Fear of dental care
Fear of dental care represents the fear of the pain related to dental treatment. This feeling of anxiety associated with going to the dentist was one of the most commonly mentioned issues among dentate older people (Table ). During the focus groups, participants tried to formulate theories on why people are frightened of going to the dentist. Three factors were deemed important. The first was linked to bad personal experiences of dental treatment, often related to treatments received in childhood. The second factor was related to negative perceptions of dental treatment and encompassed the sound of the drill; unwelcoming or threatening features of the dental surgery itself; anticipation build up caused by long waiting times and negative images portrayed through the media. The final factor identified related to the character of the dentist providing the treatment, and their ability to put the patient at ease. This issue is explored in the final section of the results and was closely linked to fear and its management. The minority of people who did not experience fear of the dentist attributed this to improvements in dental equipment, techniques and pain relief, and the manner of the dentist themselves.
Personal bad experiences
For the vast majority of participants, fear of dental treatment was related to their personal experience and often, although not always, originated from childhood experiences.
A lot of fear really is from when you're young, when I was at school. When you went to a dentist, they never used to use injections. (23:485)
I think it's the experience you've had. My son, I took him to the dentist when he was two and he had a very bad experience of taking a tooth out and he still, he's forty something now, he hates going to the dentist and this goes right back to when he was a baby. (62:198)
While most individuals attributed this fear to bad experience during childhood, bad experiences during adulthood might be just as traumatising. Whilst some people had never conquered their fear, other individuals had overcome it by understanding the introduction of modern equipment and techniques in dentistry.
Negative perceptions of dental treatment and the dental environment
Negative perceptions related to dental treatment were considered to enhance fear and anxiety of going to the dentist; these include the sound of the drill:
The sound of that drill used to drive you mad; I did run out of the dentist once. (31:154)
unwelcoming or threatening features of the dental surgery itself:
I don't like when they have got all these photos all around, showing all about teeth, you are waiting to go in and you sit there with these horrible teeth. (42:155)
anticipation exacerbated by long waiting times:
I think the fear is in the waiting. When you've got to make an appointment, the next two or three weeks while you are waiting for him to fit you in. (66:167; 174)
and negative images or references to dentists, portrayed through the media:
(Talking about a TV programme called 'My family') so watching things like that on the TV can put the fear of going (to the dentist) in people. (13:520)
Uncertainty was also deemed to be an important factor with fear stemming from the unknown, and fact being replaced by imagined horrors.
Minimising Barriers Associated with Fear
The main suggestions made for minimising fear of dental treatment focused on moderating the influence of personal bad experiences by acknowledging that treatments have advanced significantly and are less painful than they were in the past; and by reducing negative perceptions of dental treatment through looking at ways of minimising the noise of the drill, reducing waiting times and improving the dental surgery environment.
Most participants declared that they had conquered their fear related to previous bad experiences by understanding the improvements in dentistry since their childhood and achieving patterns of attendance rather than avoidance.
I think as you get older you are not as frightened as when you are a child, are you? The more you go the better is. (34:835)
I think dentistry has improved since I was a child during the war. 51:202)
Another option suggested was to provide services differently for older people at day centres and community groups, enabling a wider outreach approach to care. This service would be led by dentists from the dental hospital and should include talking to patients about the benefits of good dental hygiene and regular dental attendance, checking their teeth and taking them to the dental hospital if further treatments were needed:
Yes, some people have fear, but if they go on a coach with six other people, they won't be so frightened. (21:463; 467)
Suggestions on improving the environment in which dental care was provided were made relating to the reduction of fear. One participant was particularly scared of the drill and made two suggestions to minimise the sound of dental treatment. The first one referred to 'silent drills', as this individual believed that in other countries the treatment was completely silent.
In dentistry, in America they do have silent drills, you don't hear the drill at all and why can't we have that sort of things in National Health? (36:211)
The second suggestion related to the use of earplugs during the treatment to reduce the noise.
I like what my dentist tried: ear plugs, this is what you pay extra for with private dentists. (36:716)
The same participants also stated the importance of relaxation techniques in dentistry.
They should know some relaxing system. (36:802)
Furthermore, shorter waiting times for care and between appointments would mean less time for anxiety:
Cutting down the waiting time that means cutting down the fear. (66:181)
There were also suggestions as to how the surgery could be made more welcoming and less intimidating by distractions such as fish tanks, televisions, magazines in a comfortable environment:
I can think of a waiting room comfortable and tidy, sit down and read a magazine. (66:523)
All of these were seen as positive features of the surgery making the experience less frightening and may be summarised as distraction, relaxation, and outreach services.
Availability of Dental Services
Availability of dental services, or the lack of, was identified as a key barrier to the utilisation of dental services amongst respondents. In the context of the study the concept of availability of dental services refers to the distribution, and the perception of the distribution, of NHS dentists in the three London boroughs of Lambeth, Southwark and Lewisham. There was a widespread perception amongst respondents that there was a shortage of NHS dentists, and that dentists were moving from the public to the private sector in increasing numbers. This perception seemed to be based as much, if not more, on the experiences of 'others' and on the portrayal of dentistry within the media, rather than on personal experience.
Some of the older people interviewed described a personal experience involving the lack of NHS dentists in the area where they lived or concerning NHS dentists moving to the private sector. Both these aspects were related to utilisation through the cost of dental treatment or the fear of the cost of dental treatment. There were several issues associated with the move of NHS dentists to the private sector. Many participants stated they were not able to afford the cost of private dentists and had to look elsewhere for NHS care or stay away.
I always went to a National Health one, but then they completely went private, I can't afford their prices. (12:89)
I should have gone to a National Health (dentist) one but I went to private but it cost me too much money in the end, I'm frightened to go back. (41:83)
The difficulty of locating another NHS dentist when necessary was also raised:
We can't go to the dentist because there are not enough NHS dentists. (21:278)
One individual reported that they changed dentist four times in two or three years because they all went private, but in the end, they found an NHS dentist.
It was really hard finding a National Health (dentist) but I did! (63:379)
Perceptions of lack of NHS dentists mainly involved the move towards the private sector as illustrated in the quotes above, and the ability to find a dentist able to take on NHS patients. It was suggested that many dentists in the NHS sector had already reached maximum capacity for NHS patients. So simply finding an NHS dentist was not necessarily sufficient, a fact backed up by the experiences of two respondents.
I can go to the dentist legless...with no legs, maybe one arm, blind in one eye and they'll say: 'No, I'm sorry, we can't take you on'. (21:291)
It's very hard and I went up to *** and they said 'no, we're full up and there's nothing we can do about it.' (24:62)
All of the above views were related to informants' personal experience. The generally widespread view of dentists 'turning private' was held by the vast majority of participants, although many did not actually have personal experience of the move.
Every time you find a National Health dentist; they go private, don't they? (65:331)
This was seen as a particular problem for older people who could often not afford private care, and was identified as discrimination.
(They are all going private) which I think it's a bit unfair...(on) elderly people with low incomes. (12:109)
Although a minority view, some participants did acknowledge the availability of NHS dentistry in the area:
We are in a part of the country where there are quite a few National Health dentists, but I think in other parts of the country people queue like at Starbucks for the dentist. (51:399)
Even here, however, a problem was identified relating to a lack of knowledge about where the services were located and how to access them.
... Well, there are some but you've got to find them and know where they are. (B1:62)
Minimising Barriers Associated with Availability
Few proposals were suggested to tackle both a lack of NHS dentists but clearly there is a need to address the reported gap in information on how to access those dentists who are practicing NHS dentists and have spaces available (Table ). One suggestion made was that all dentists should be compelled to take on a certain number or percentage of older people.
The only way that could be improved is that the government makes all dentists treat pensioners free of charge. They should say that you must have ten pensioners on your books, or twenty pensioners or whatever. (21:391; 406)
One practical suggestion was that information on available NHS dentists should be displayed at doctors' surgeries.
I think you should be able to find out through your doctor surgery. GP should be the coordinator of all your health. (51: 162; 174)
Your Health Centre should be your centre point for everything. (B1:413)
Participants from ethnic minority groups also expressed the importance of having information about dental services in different languages available at day centres, which in many cases represented the link between these individuals and society.
Access to Dental Services
In the context of this study, 'access' refers to all the steps taken by older people in the process of seeking dental care. This area therefore includes all of the different phases from making initial contact with the dental practice to physically being able to get into the surgery and starting treatment. Issues around access emerged as a barrier for older people in seeking and receiving dental care in this study. The issue was not, however, homogenously distributed across the participants and varied significantly according to personal circumstances. Access was a particular issue for people in the 75–84 and 85+ age groups and for people living alone without social support. Problems were identified at all stages from making the initial appointment to travelling to the surgery and accessing the premises. Mobility problems were raised, as was the issue of lack of social support and isolation.
The main problem identified in relation to the appointment system related to the inability to make appointments more than a few weeks in advance. The inability to book the next six-monthly check at the time of the current appointment led to additional stress for people who wanted to plan in advance and not have to worry about forgetting to arrange the next appointment at the right time:
So they couldn't give me a six months, I've been there for many years, but she said if I phoned up a fortnight before I want to go she'd say if she could get me in. It doesn't make you feel settled, does it? (31:319; 401)
The uncertainty of not having the next appointment booked was felt to be unsettling. There was also acknowledgement that the appointment system had improved for many people; this was seen as a positive move:
Dental appointments seem to have improved quite a lot. (51:385)
Travelling to the dentist may also represent a significant barrier for older people using both private and public transport. In the majority of cases, the older people in this study did not own a car or have access to one; therefore, they relied on public transport or on other people to take them to the dental surgery.
I want a dentist where I can get to easily because I can't travel too far. (55:472)
I can't do walking. (24:342)
One of the biggest issues that emerged in relation to the appointment was 'timing'. When an appointment was set too early in the morning, older people were not able to use their free bus pass as described in relation to 'costs'. Further costs were also identified for the smaller number of people travelling by car. Again, additional costs such as the London congestion charge and parking costs were identified as pushing the cost of dental treatment out of reach:
The dentist I go to now is in the congestion charge; you can't go by car, because you can't pay eight pounds every time... when my wife was alive I could take her because she was disabled, I had a disabled disc and everything, so I could park anywhere but now I can't do that, now I have to pay. (23:309)
The issue of isolation was also raised as a potential problem. This was a significant issue for the oldest participants and raised predominantly by the oldest (85+) males either in relation to travelling to the surgery or in the case of particular treatment such as sedation. In both cases the presence of somebody else was required and the lack of it emphasised their social isolation:
When you have a sedation somebody has got to go with you, you can't go on your own. (11:838)
A lot of elderly people are on their own and the biggest problem is getting somebody to take them to the dentist, nine out of ten of them their children are away. (21:18)
As the older people in this study were not always able to find someone to accompany them to the dentist, this issue often led to non-attendance. Mobility was another common issue highlighted across the focus groups. A number of the participants had difficulty walking and the lack of disabled access in some surgeries was raised.
My only thing is that he's up the stairs and it's difficult for me to go up the stairs. (54:1)
In addition, two carers of older people with significant health and mobility problems were interviewed; both had tried to access domiciliary dental care services on behalf of their clients:
It was a big problem getting somebody (to provide domiciliary care), I spoke to my dentist, I spoke to a lot of local dentists, they were not willing, they said: 'we'll come, we'll come when we've got time' and nothing happened, so then I went to the GP and I said 'look, I'm a bit concerned, you never know' and then the GP phoned up the *** hospital and then they (community dental service) came along. (A1:23)
While this person was able to arrange treatment, a less persistent carer might not have been successful in gaining information on the service. The carer was impressed with the organisation of the service:
It was a perfect service. We did not have to pay at all for that. They wanted to do a perfect job and get the dentures perfect. She came backwards and forwards until the job was done perfect. The convenience of it when you have someone disabled like my mother who cannot move from the waist down and cannot leave the house was marvellous. My mother was delighted with the service and thanked them for coming to the house. (B2:197; 202; 206)
This seems to suggest that, whilst mobility issues are a problem for those who are less disabled, there are services better equipped for those with higher needs, should they persist and find out about the service. Thus, it is the majority, for whom mobility problems are less severe but nevertheless still consider this aspect of access is a barrier to treatment.
Minimising Barriers Associated with Accessibility
Few suggestions were directly put forward as to how access could be improved; however system changes to address the barriers are outlined in Table . Whilst medical visits were already available at some day centres and community groups, there were no equivalent dental services. To solve issues associated with travelling to dental practices and isolation, participants proposed that a mobile dental team should visit day centres and community groups, giving older people a dental examination and taking them to the dental hospital if further treatments were needed. Home visits were also hailed as a good idea for those with more severe mobility problems. This suggests the need for proactive commissioning of care for older people.
It would be good if we had like a mobile service and then the mobile service can come to the community centre and then we have an interpreter here as well. (C1:205)
It's difficult to get to the dentist. What about a dentist coming to you? (14:808)
For those who were willing and/or able to travel to the surgery, the need for disabled access and overcoming problems with stairs were highlighted:
It would be nice if it was on the ground floor. (42:544)
Characteristics of the Dentist
The final barrier to utilisation of dental services by older people identified in this study related to characteristics of the dentists themselves and their mode of working. Issues raised here related to the communication skills of the dentist and confidence in the dentist as a practitioner; perceptions of the public/private divide in relation to standards of treatment; and experiences of dental hospitals. The personality of the dentist seemed to have a big role in orientating positive or negative feelings towards dental treatment. There were many statements describing how a friendly, polite and professional approach could facilitate positive feelings in older people; on the other hand a hasty manner was seen as a barrier to dental treatment. A range of generally negative views of dentists were displayed:
(Dentists X) is a bit rough. (62:233).
They are not interested in human beings, it's only work coming in, they are only interested in money. (24:265)
These views were not substantiated or explained even when respondents were questioned further, but appear to be part of a broadly negative view of dentists amongst the informants. The move of NHS dentists into the private sector appeared to add to the negative view of dentists. This was viewed as a sign of their disinterest in people and desire for money:
They are all going private which is a bit unfair. Elderly people with low incomes...it makes you think they don't want to treat your teeth. (12:105; 109; 113)
Even those dentists who did remain in the NHS did not escape negative feedback and it was suggested that NHS treatment was a second rate service. Some respondents in this study felt that NHS dentists were not able to provide the same quality of treatment as private ones, issues which they associated with time and care:
I think they (private dentists) take more time and more care (than NHS dentists). (36:240)
I find NHS dentists, I mean all the ones I've been to, to be inadequate. If you go privately then they do what I want them to do, I find the National Health dentists do what they want to do. (36:44; 52)
A participant, who was entitled to a reduction on the cost of NHS dental treatments, stated that their dentist was not spending an appropriate amount of time in performing the different treatments needed.
I think when you're not paying a lot you don't get the same service than people that do pay.(63:17)
These examples seem to suggest that the dentist has an uphill battle no matter how they choose to practice and suggests that more needs to be done to improve the profile of dentists generally amongst older people and to enhance the importance of caring for older people amongst dentists.
Older people were very aware that the local dental hospitals were training hospitals. Depending on the severity of the case, in dental hospitals, patients may be seen by consultants or supervised students. Many participants stated that they did not feel comfortable with students and they preferred a qualified dentist with more experience:
Don't forget that dental hospitals are training hospitals. So it's very difficult to get older people to go, they get a bit nervous, they don't wanna see the young student, they wanna see the doctor or the actual dentist rather than a student. (21:574; 578)
In general, the majority of older people seemed to feel more at ease with a more experienced dentist.
Minimising Barriers Relating to Characteristics of the Dentist
Recommendations on improvements that dentists themselves could make revolved around the manner of the dentist (demonstrated as professional, interested and caring) and taking time to talk to patients. This can be developed by a range of changes in the system (Table ). The way in which a dentist welcomes, greets and talks to patients was highlighted as very important to this age group, particularly in helping to reduce fear or anxiety. This includes talking patients' through experiences.
Some dentists can make you feel totally relaxed straight away not only by being a friendly personality, but incorporating that into a professional approach. (14:913)
A nice manner is important to put people at ease, he used to say exactly what he was going to do. (51:239)
These responses suggest that a professional, polite and friendly manner, in combination with information giving and demonstrating technical skills all help to promote confidence in the patient. Time was also identified as a key factor, both in putting the patient at ease and ensuring the treatment is completed in a satisfactory way.
I think you've got to have confidence in the dentist because I'm nervous. When I get in there and they are nice to me, I can relax and it's not too bad. (41:504)
(It's very important) if they take their time, not rushing as well and take their time with you to see if you are alright. (34:589)
Views were divided, however, on whether a lack of time was a characteristic of the NHS payment system or of individual dentists. In one case a change in management of patients was blamed:
He does it all in half an hour and I don't think that's enough...I'd rather go back two or three times. They used to take time, I used to go back to do different things, now this one, he does it all at once and to me that's not good. (63:26; 242)
Older people welcome a mature professional approach from dentists which combines good communication skills and technically competent clinical care in an unrushed manner, taking on board patient preferences for how care is delivered.