Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd

Health, Social Care and Sport Committee - Fifth Senedd

27/09/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns
Dai Lloyd Cadeirydd y Pwyllgor
Committee Chair
Dawn Bowden
Julie Morgan
Rhun ap Iorwerth

Y rhai eraill a oedd yn bresennol

Others in Attendance

Andrew Powell-Chandler Pennaeth Polisi Deintyddol, Llywodraeth Cymru
Head of Dental Policy, Welsh Government
Benjamin Lewis Cymdeithas Orthodontig Prydain
British Orthodontic Society
Christie Owen Cymdeithas Ddeintyddol Prydain
British Dental Association
Craige Wilson Bwrdd lechyd Lleol Cwm Taf
Cwm Taf Local Health Board
Dr Caroline Seddon Cymdeithas Ddeintyddol Prydain yng Nghymru
British Dental Association Wales
Dr Colette Bridgman Prif Swyddog Deintyddol
Chief Dental Officer
Dr Richard Herbert Deoniaeth Cymru
Wales Deanery
Frances Duffy Cyfarwyddwr, Gofal Sylfaenol ac Arloesi, Llywodraeth Cymru
Director, Primary Care and Innovation, Welsh Government
Karl Bishop Bwrdd Iechyd Lleol Prifysgol Abertawe Bro Morgannwg
Abertawe Bro Morgannwg University Local Health Board
Lindsay Davies Bwrdd Iechyd Lleol Prifysgol Abertawe Bro Morgannwg
Abertawe Bro Morgannwg University Local Health Board
Professor Alastair Sloan Ysgol Ddeintyddiaeth, Prifysgol Caerdydd
School of Dentistry, Cardiff University
Professor David Thomas Deoniaeth Cymru
Wales Deanery
Tom Bysouth Cymdeithas Ddeintyddol Prydain
British Dental Association
Vicki Jones Bwrdd Iechyd Prifysgol Aneurin Bevan
Aneurin Bevan Local Health Board

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Lowri Jones Dirprwy Glerc
Deputy Clerk
Rebekah James Ymchwilydd
Researcher
Tanwen Summers Ail Glerc
Second Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:31.

The meeting began at 09:31.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Croeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. 

O dan eitem 1—cyflwyniadau, ymddiheuriadau ac ati—a allaf estyn croeso i'm cyd-aelodau y bore yma? Rŷm ni wedi derbyn ymddiheuriadau oddi wrth Lynne Neagle. Gallaf ymhellach egluro bod y cyfarfod yn ddwyieithog. Gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o’r Gymraeg i’r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. Gallaf ymhellach hysbysu pobl y dylid dilyn cyfarwyddiadau’r tywyswyr os bydd y larwm tân yn canu. 

Welcome, everyone, to the latest meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales.

Item 1 is introductions, apologies, substitutions and declarations of interest. I'd like to welcome my fellow members this morning. We have received apologies from Lynne Neagle. I will also explain that this is a bilingual meeting. You can use the headphones to hear simultaneous translation from Welsh to English on channel 1, or amplification on channel 2. I would also like to let people know that you should follow the ushers if there is a fire alarm. 

2. Deintyddiaeth yng Nghymru: Sesiwn dystiolaeth gyda Chymdeithas Ddeintyddol Prydain
2. Dentistry in Wales: Evidence session with the British Dental Association

Wedi cymaint â hynny o ragymadrodd, fe wnawn ni symud ymlaen, felly, i eitem 2, a'n hymchwiliad ni heddiw, sy'n mynd i gymryd drwy'r dydd, gyda nifer o wahanol o fudiadau o'r byd deintyddol o'n blaenau ni—ein hymchwiliad ni fel pwyllgor iechyd i mewn i ddeintyddiaeth yng Nghymru. Mae'r sesiwn dystiolaeth gyntaf gyda Chymdeithas Ddeintyddol Prydain. Felly, i'r perwyl yna, rydw i'n falch iawn i allu croesawu Dr Caroline Seddon, cyfarwyddwr Cymdeithas Ddeintyddol Prydain yng Nghymru, Tom Bysouth, cadeirydd pwyllgor ymarferwyr deintyddol cyffredinol Cymru, Cymdeithas Ddeintyddol Prydain; a hefyd Christie Owen, swyddog polisi a phwyllgor, Cymdeithas Ddeintyddol Prydain. Croeso i'r cyfarfod yma. Diolch yn fawr i chi am eich tystiolaeth ysgrifenedig ymlaen llaw—bendigedig. Ar sail hynny, fe awn yn syth i mewn i gwestiynau. Mae gyda ni rhyw dri chwarter awr. Mae'r meicroffonau yn gweithio'n awtomatig. Nid oes dim rhaid ichi gyffwrdd â dim byd. Felly, i'r perwyl yna, awn i'r cwestiynau cyntaf, o dan ofal Rhun ap Iorwerth.  

With those few words, we will move on to item 2, our inquiry today, which will take all day, with a number of organisations from the world of dentistry. We are looking into dentistry in Wales. The first evidence session is with the British Dental Association. So, to that end, I am pleased to welcome Dr Caroline Seddon, the British Dental Association Wales director, Tom Bysouth, chair of the Welsh general dental committee, and Christie Owen, policy and committee officer of the British Dental Association. So, welcome to this meeting. Thank you very much for your written evidence. That was splendid. On the basis of that, we'll go straight into questions. We have about three quarters of an hour. The microphones will work automatically. You don't have to touch them. So, to that end, we will go to the first questions from Rhun ap Iorwerth.

Diolch yn fawr iawn. Croeso atom ni y bore yma, a diolch am y dystiolaeth ysgrifenedig, sydd yn fanwl iawn. A alla i ddechrau drwy jest ofyn i chi, ar lefel uchel, os liciwch chi, i roi trosolwg inni o'r prif feysydd sy'n peri pryder i chi am gontract 2006?

Thank you very much. Welcome this morning, and thank you for the written evidence, which is very detailed. Could I just begin by asking you, on a high level, if you like, to provide us with an overview of the key areas of concern regarding the 2006 contract?

Diolch yn fawr. Thank you for your question. There are several key levels of concern with the 2006 contract. The first is access to dental care. At present, we are seeing patients doing 90-mile round trips to be able to access NHS dental care. We're seeing a situation where, at present, only 15 per cent of practices across Wales are able to accept a new patient under NHS regulations, and more worryingly, only 28 per cent taking on new child patients under NHS regulations. Now, this is going to lead to an incredible amount of unmet need and an incredible amount of disease burden. But, that burden also then gets passed on to other elements of the health service. So, where patients can't see their dentists, it doesn't mean that the dental problem is going to go away. It stays there. It exacerbates. It gets worse. Where do these people go? They go to their GP, out of the mistake that they can help. They go to A&E—they think they can help. That puts pressure on all other pressurised parts of the health service. So, by effectively getting dental access right, we improve other areas of the health service. So, that's the first area, in terms of access.

The second problem is: how does this contract impact on practices? We know at the moment that the contract is a target-based contract. It rewards for doing things. It does not reward for prevention. So, this means that where dentists take on high-needs patients—patients that need more work—they are unable to complete their contract activity, because they are getting paid the same for doing one filling on somebody compared to doing, let's say, 15 fillings on the same person. So, those in those higher-need areas, where the bulk of the tooth decay exists, are effectively getting penalised for trying to take on these high-needs patients. This means that they fail to hit their contract target and if they fail to hit their contract target, money is then taken back by the health board. This means that, first, the practice is then less able to take on other patients, because they have less money, but also, this money, often, is then lost to dentistry. You've seen in our submission the details of the £20 million-worth of clawback over a three-year period, which is actually very variable across Wales. There are some health boards where clawback is much greater, some to a lesser extent. Some health boards are actually investing their clawback money back into local services, but others, unfortunately, use it to plug holes in other budgetary areas. So, that's the second key area.

The third part is the sustainability of dental services under the NHS. We've seen dental practices close and dental practices having to hand their contracts back. Now, partly, this is due to the recruitment crisis that we've got ongoing. You may have seen in our submission and our evidence to the Review Body on Doctors' and Dentists' Remuneration that two thirds of practices are struggling to recruit dentists. Now, this then links back to being able to do your contract. If you can't recruit a dentist, you can't do your contract and then this leads to patients being disenfranchised. And also, where we can't recruit dentists, we can't do our contract, this affects the overall viability of the practice and that practice is a small business, particularly in rural areas. We talk about the effects of the banks closing and schools closing, but if we start to see dental practices closing, that's another thing that shows us services getting taken away from rural areas and making rural Wales a much less attractive place to be. So, where practices have struggled, they have to give their contracts back and this leaves patients then disenfranchised from dental care and, in fact, it's almost that vicious cycle. I've got a diagram here with lots of interlinking lines; it's a very complex picture.

09:35

That's a very, very good summary, if I may say, and there are other elements—we'll go into those in detail, and we'll talk about orthodontics and all that kind of thing, as well. Again, at a sort of high level, the reform that has been pushed out through pilots and the development of those pilots—do they offer a better way forwards? What are the benefits and do they go far enough, these changes?

I would say at the moment the reform is too early to tell. So, over the last 12 years of this contract, there's been reform in various different shapes or forms and we're on to another version at the moment. In some practices in each health board area—as of October, that's what the plan is—practices will be testing a slightly amended version of the current contract where some of their activity target is taken away in exchange for collecting data. So, we still have the main drivers of the problem, which are the activity targets. So, at the moment, we're not really testing something that's going to show much behaviour change. The chief dental officer says it's giving practices a bit of leeway space—yes, we agree with that, and yes, we are behind the concept that, yes, we need to change things, as the evidence that we presented shows we've got a problem. But I think what we really need to do now is to make sure that the health boards are really on board with contract reform. Because what we're concerned about is that health boards may think, 'Well, actually, is there going to be a risk to the amount of patient charge revenue that comes in?' So, where patients are paying for dental care, are they going to be concerned that their budgets are going to go down and they're going to lose money? But, as we've illustrated before, if we get dentistry right, we get the rest of the health service right, vicariously, and that money will then come back at a later stage.

I wanted to talk about clawback. Thank you very much for your paper; it was really interesting. Tom, I think you began to explain it a little bit, but I couldn't quite work out why dental practices wouldn't be able to fulfil up to 95 per cent of the contract that they're given. So, could you just explain this units business a little bit more?

A unit of dental activity—it measures itself, it doesn't measure anything else. So, when a patient is seen under an NHS arrangement, various treatment is assessed and when the treatment is completed, the dentist gets awarded a unit of dental activity. Now, as I hinted before, you'll get paid the same for doing one filling as you will, let's say, for doing 15 fillings, taking three teeth out and doing three root canal treatments on the same patient. What this is doing is making the patients who are the most high need the least welcome. And it's penalising the dentists for taking the time to go through prevention, because prevention is not paid for within the current contract. So having a good detailed discussion, for instance, isn't just, 'Brush your teeth better', because what I'd say to you, Angela, wouldn't be the same that I'd say to Rhun or anyone else, because your individual needs are going to be very different. And so, having the ability to be properly awarded for prevention is key.

But going back to the clawback question, let's say, in my practice, I've got lots and lots of high-needs patients. So, it's taking me three or four times as long to get the same activity totals as someone who's actually got a very low-needs practice and could just tick along and see one filling, half an hour's work—they get their three UDAs. I could be spending three hours to get the same three UDAs, but the amount of work that's actually been completed is vastly different. If we speed that up over the course of the year, the person who has failed to hit their 95 per cent may actually have done much more in terms of work than the person who has hit their target. So, it gives that very strange perverse incentive, and then we see the clawback, that the money is taken back, and, as I alluded to before, where the money is taken back, it then impacts on the practice's ability to see additional patients. Does that answer the—?

09:40

It was just a question on the UDA, so that I understand. A unit of dental activity, in my head, then, is one course of treatment for one patient. So, that might be one filling, a small filling, or that could be several fillings, but it's one course of treatment for one patient—that equals one unit of dental activity.

And just to add to Dawn's question: what is a course? Is that over a year? Somebody might have a filling now and then come back in six months' time and have another filling—they're obviously a different treatment regime.

So, a course of treatment under the NHS is as long as it takes to get the patient's oral health secure. Now, to some extent, that's almost a difficult question to answer, because how long does it take to get someone's oral health secure? So, let's say you come in and there is decay on one tooth, we fill that and that tooth is filled, there's no other decay around the mouth, the gums are stable, there's no sign of mouth cancer or excess wear. That person is then deemed dentally fit, and then we'd like to see them again at an allotted time according to how at risk we think they are of having more problems. So, units of dental activity are awarded as either one unit of dental activity—which, essentially, is examinations—three units, which covers fillings, taking teeth out and root canal treatments—and then 12 units if you do anything, for example, like crowns or bridges or dentures. So they're in those three discrete bands—

So, one course of treatment would be one of those three, and the patient may then come back in six months' time, they could come back in a year's time, for example, and then have another one of those.

So, I was really shocked by the figures from Hywel Dda and from Powys teaching board, because if we follow your logic, then are we really saying—? So, what's the problem there? Because I can't believe that Powys and Hywel Dda have got areas of multiple deprivation that far outstrip any other areas that they should be so much worse than the likes of Aneurin Bevan or Cardiff and Vale or Cwm Taf, or, in fact—well, any of the others. Because they're shockingly worse.

Absolutely. Part of it is related to recruitment. We know that recruitment of dentists in these areas is much more difficult, and if we can't recruit, we can't do a contract, and so this is where it skews it a bit, as you say about the deprivation data. If there's no-one there to do it, then it doesn't matter how deprived the people are; the work isn't going to be done, and so the money has to get—

But these are clawback figures. That's what I think I'm puzzled about. So, there's 19 per cent clawback in Powys, there's 19.6 per cent clawback in Hywel Dda, and the next worst one would be Betsi at 5.5 per cent. So, those two health boards are clawing back so much more. That can't just be because they haven't got the people, because if they didn't have the people, they wouldn't be able to give out the contracts in order to claw them back. So, what's the reason for the clawback happening to such an extent?

I do think that recruitment is an element, and recruitment has been worsening. There have been practices that have closed because of recruitment issues. I can think of two. There is one in Builth Wells that had to close—it had to shut its doors because it couldn't recruit. There was a chap in Knighton who, for two years, was trying to recruit and he had to hand his contract back. And so, those will come into that area there.

Yes, sorry—I'm conscious of time. There's so much more to ask on the clawback system.

Well, just one quick one. How could it be improved? How could we improve the clawback system?

So, I think a key improvement of the clawback system would almost be to remove it, because it exists as that noose around the neck, that worry of hitting that 95 per cent, because what that does is that risks modifying behaviours. We want dentists to treat the patient, whatever is in front of them, and treat whoever walks in through that door fairly and equally. Where you've got that sort of threat of money being taken back because you happen to take on a lot of people who are requiring much more work, requiring much more of your time, it almost acts like you're just being judged on your numbers, when that number you're being judged on actually doesn't really mean anything. It doesn't mean you've done more or less work than anybody else; it means that, within this particular contract, you have failed to achieve because of the problems within the contract.

09:45

Okay. I think that's nice and clear. Moving on to recruitment issues—Julie.

Right. Thank you very much. What about low morale amongst dentists? And you do say that there is low morale. Why is that, and what are you doing about it?

Morale has been on the slide for some time. Part of that relates to the current contract, and people seeing, for the reasons that I've said before, that they can't do the dentistry that they'd like to do. They're being judged by targets, they're being judged by numbers, let's say, rather than the quality of treatment—the positive, better treatment outcomes. And so, when you feel like it's just your numbers that you're getting judged by, then that can demotivate and demoralise as well. In terms of what's being done—. So, we are very keen on contract reform and reforming the contract. And you'll hear later about what Welsh Government are doing to try and look to change—as the Chief Dental Officer says, change the whole system of dentistry in Wales. And a key point of that is really freeing the dentists to do the things that they're good at, which is provide good-quality, bespoke healthcare on a person-to-person basis, without being—free of punitive targets, of worrying about having money being taken back at the end of the year just because of the people who have happened to walk through your door. And so, we support—. We support that, but we really want it to go further. We've had various tests of contracts being done, for the last 10 or so years, in various different guises, and there are some dentists now who are thinking, 'Well, is this going to go anywhere? We've seen something happen for a couple of years, it then sort of comes away. Someone else comes in, and something different happens there.' And they're getting a bit concerned and they are continuing to see that, well, not much is changing. And so we want to really urge Welsh Government to put real pressure on the health boards and say, 'Right, let's engage with this. Let's really engage with contract reform, really test it, really pilot it, and free up dentists—take away the restrictive and punitive targets—to provide good-quality dental care.'

And you think it's these targets that demoralise dentists, then.

A target, it's—. Targets are good for some things.

We do need to have targets, but, unfortunately, the way these targets are developed, they don't actually measure what you do. You're being measured on some sort of proxy that is no indication of the dentistry that you've done. And, as we've said before, it's that classic example of the people in the high-needs areas, who require multiple work, and taking three or four times longer to do that bit of work and getting paid the same, which seems bizarre. It's almost taking your car to the garage, having one tyre replaced, and then the garage getting paid the same if they replace all four of your tyres as well. It seems a bit daft. And that really contributes to poor morale.

And this is the feedback you get on why it's difficult to recruit or to retain.

Absolutely. And because of—. It's a bit of a vicious cycle. We get those practices that struggle to hit their targets, so they experience clawback, so they're less able to invest within their services, which means they're less able to recruit. So, they experience—. They can't do their targets, they experience clawbacks, so they can't invest as much, so they can't recruit. And we get these vicious cycles that go round.

We have a good example of two prototype practices still operating a capitation contract in Swansea. We went to visit both of these prototype practices. And it was very striking, when we spoke to the dentists and the other members of staff, that morale was actually very good. And the way they described it, because they weren't constrained by these UDAs, because they were working on a preventative contract and working to help patients improve their oral health, they felt that they were practicing the dentistry that they'd been trained to do. It was very striking. And, from that point of view, the BDA would have liked to have seen the prototype practice contract actually extended, but that didn't occur, because the new CDO introduced this new contract that's now being trialled. We were quite disappointed from the point of view that it wasn't really giving an opportunity for the prototype capitation contract to really make its mark. One of the criticisms that was levelled at the prototype contract was that access was reduced—the number of patients being seen was reduced. In the early days, that was true and that's because a preventative programme takes time to get installed. You have to spend a lot of time with patients—you can't do it in 10 minutes. But what we saw with the later figures was that the access numbers were improving and, if they'd been given enough time, they would have been able to demonstrate that this was working and that the number of patents being seen was being maintained. This is our argument: because you keep changing the pilots every few years, you're not giving it a chance to embed. We think that the capitation is better for patients and is better for dentists. It's certainly much better for their morale.

09:50

Reit, symud ymlaen i wasanaethau orthodontig nawr ac mae yna gwestiynau gyda Dawn.

Right, moving on to orthodontic services now, and there are questions from Dawn.

Diolch, Chair. So, around orthodontic services, I'm guessing some of the answers may be similar, but I'm not entirely clear about how the orthodontic services are funded, because it's slightly different from the UDA, but we do see quite a large disparity in terms of waiting lists across the health boards—again, Hywel Dda is significantly worse than Aneurin Bevan, for instance. What do you think the causes of the delays in providing the service are? Are they largely similar to the issues in general dentistry or—?

So, it's slightly different. Within orthodontics in Hywel Dda, yes, there is a huge waiting time—five years approximately—and that's starting to get to the stage where it's causing problems, with patients having to wait so long that you're missing the optimal time window to provide the orthodontics. Part of that in Hywel Dda relates to that you've got one provider of orthodontic services across a huge, huge area. So, people across the whole area are having to travel to one place. Now that's fine if there is capacity there, but, when you've got a waiting list of five years, it's clear that the capacity levels just aren't there. 

Across other areas—where you have local orthodontic networks and you've got a few little smaller practices that can take on and be more flexible with need, that's where we see areas improve. But I think the key point as well is, because the waiting lists get so long, that changes dentists' behaviour, so they're, 'I need to refer this person in a couple years; I'll refer them now so that I know that they're going to—by the time we work through the waiting list—get seen at the appropriate time', which makes it worse. Whereas, if that waiting list were a manageable size, then that wouldn't happen and so you'd get a much more streamlined view and patients would follow through.

I understand what needs to be done. What I don't understand is why these waiting lists are increasing. Is this also a recruitment and a budgetary problem? Is Hywel Dda experiencing far greater issues with recruitment than, say, Aneurin Bevan, which clearly doesn't have anything like the same level of waiting lists for orthodontic services?

In terms of—. I suppose the way the contract is awarded in Hywel Dda, it's awarded to one practice that has at present two orthodontists, and, if we consider the size of the whole area—

That's how they awarded the contract for orthodontics.

As my case list tells me.

Okay. I understand. I understand. So, we've seen the electronic referral system now, which is in the process of being developed. Is that likely to bring about some of the required changes that you're talking about?

So, the electronic referral system will have a few benefits. It will firstly allow the dentist to see where the referral is in the system, and ideally allow the patient to see where the referral is in the system. Because a lot of the time that the referral management people spend is in dealing with questions: 'Where's my child in the waiting list?' Being able to see where it is will reduce that down. Yes, it will, in theory, allow improved monitoring of the system, but I think, until we have that additional output at the end to be able to—. Simply just moving to a system where, instead of posting a referral off, we do it online, that itself won't suddenly take three years off the waiting list. It will help in terms of transparency of the system and seeing where things are—helping dentists, helping patients. However, I'm not sure that without, again, further investment in the orthodontic service and reforming how the contract awarded, that will provide the necessary reduction in wait time.

09:55

Right, so you need more bodies performing the duties, and you need the health boards to be looking at the way in which they award the contracts for orthodontics, yes? Okay. Thank you.

Reit, symud ymlaen i adran arall rŵan, ac rydym ni yn ôl efo Rhun ap Iorwerth. 

Moving on to another section, and we're back with Rhun ap Iorwerth.

Yes, just a couple of questions on oral health improvement programmes. How do you assess, either of you, where we're at with programmes? The overall Welsh programme is coming up to 10 years old now, I think, isn't it? How is it working, and what are your concerns, especially in relation, perhaps, to the ages of children that the programmes are limited to?

So, the Designed to Smile programme, which has helped to reduce the amount of tooth decay in school-age children in Wales—. Now, it's had a re-focus, looking at those particularly in the 0-3 group. Now, that's great, because we know that tooth decay starts early—you get it early, and you can help them to reduce the ongoing spread. What we're concerned about is then what happens to these four and five-year-olds, and we're very worried that they are going to fall in the gaps, because the community dental service used to run the Designed to Smile programme for the older children. As that's been stepped back to the younger children, you've got children of four and five and six who may not actually have access to a regular high street dentist, and the ones that'll be in the most need will often be the ones that'll be least brought to the dentist. And so we're worried that they may then slip through the cracks, and we may then see a little bubble again of more tooth decay, more problems, coming up later on. So, yes, we are fans of Designed to Smile, but we would urge then a continued investment into that to be able to help the oral health of all children, and a consideration of targeted programmes aged specifically across the whole school spectrum, because we get another spike of tooth decay in the teenage years. 

The re-focus required the same amount of money to be used. There wasn't an extra injection of cash. And what we've argued is that a relatively modest amount of money, say, an extra £2 million, would protect the older children, so they'd continue to get the fluoride varnish treatment that they're now going to miss out on. They'll only get the tooth-brushing in schools programme, but they won't get the fluoride varnish treatment. It costs about £4 million a year. Now, you compare that figure against the figure for clawback, and what we're arguing is that we only need a fraction of clawback to be reinvested in that way. It's a national programme, but it's delivered through the health boards, so there must be a way that some of that clawback money could be reinvested on a health board level into the Designed to Smile programme to protect the fluoride varnish treatment.

The response has largely been around, 'Well, if we re-focus on the younger children and get that right, then your worries will be less so', but I—

Yes, because, mentioning that 40 per cent of decay in five-year-olds is there in three-year-olds, yes, absolutely, we accept that. We agree that we get it early, we start—. But we need—. But that doesn't help the children, the four and five-year-olds now. It might help the four and five-year-olds, who are currently two and three, in a few years' time, but it needs that action now to prevent ongoing decay, ongoing problems.

And it's a critical age, when the permanent teeth are coming through, and it seems perverse to withdraw that protection for the permanent teeth for these vulnerable children who wouldn't otherwise see a dentist.

And, presumably, you opposed—. When this re-focus was taking place, you pointed out, 'You're not quite getting it right here'.

We did. We went public with it.

Why do you think that wasn't taken on board? Because I find it hard to—. I'm not a dentist, so I don't know, but I do have teeth and I have children. [Laughter.] It seems odd, with the BDA arguing quite strongly that missing on four and five and six-year-olds and that key age, that that wasn't reflected in that renewed focus.

I think, as Tom has already said, we're not disputing that the younger children do definitely need focus—by the time they get to five, a lot of the damage has been done—but we're arguing that, for the future of these children, and even into adulthood—as Tom has said, this is a preventable problem—it can make a big impact. So, I think that it is budgetary in the sense that we definitely do need to focus on younger children, but that doesn't mean that the older children should be left out.

10:00

Can I ask you how bringing prevention into a contract—and I'm not just talking for children here, but for all patients—how that would work best? We have some pilots, and you mentioned in Swansea some practices where prevention is contracted. How could it work best, do you think?

The key point about prevention is it takes time and it's a personalised message to each person. The messages we give to different people around the table are based on their personal circumstances. It's allowing and accepting that there's going to have to be a lag phase in terms of—. We take the time to talk about oral health, talk about how to manage your mouth, how that links to your general health, how we can, by improving oral health, improve general health. We have to be very open to say that, actually, whilst we're doing our prevention bits, we might happen to be able to see fewer patients and do less treatment. But, as the oral health of those people that we're spending greater time with improves, they then need less work, which then means we can see more people a little bit further down the line. I think the key point about prevention is that lag phase, that, as we spend more time with more people, it might, to start with, impact on the ability to see new people. However, if we let that run through and we see the positives from prevention, we can then see more people and it then allows the system to take on a greater level of capacity, if the baseline prevention levels are achieved. 

And you contract that by paying for time spent discussing prevention with patients.

Yes, it would be something very different from the current system, where you are paid an amount for doing something that doesn't actually mean anything.

I just wanted to come in on the prevention agenda that Rhun has raised with you. A couple of years ago, on a different committee, I sat on a report on Designed to Smile—I'm not sure if Julie was part of that.

And I did enter that committee report a sceptic, and I emerged a complete convert. Perhaps you could just enumerate for us in the committee the effect, or how many children up to the age of 10 or 12, et cetera, and the rates of fillings, because we were hearing about children having seven, eight, nine fillings by the time they were 10 or 11, and I found that absolutely shocking. So, I just wonder if you could perhaps put a scale for us, because then we understand where we're going with the prevention in younger and marginally older children.

Absolutely. It's a variable picture across Wales that we see. In pockets of deprivation, we see children requiring lots and lots more work, whereas, in other areas, there's a lot less work. In terms of specific numbers, I'm going to be honest, I'm not going to be able to provide them right now, but I know my colleague Dave Johnson, who's the chairman of community, would be able to have those numbers—

—off the top of his head, and he can, I'm sure provide those for you.

Absolutely. I think that would be useful. We'll feed those back in to you as soon as we're able to get them to you.

Just following that up, I do remember in that report, we were very impressed, and we visited a school, didn't we? 

And we saw what was happening. So, are you saying now that the fluoride gloss is not given to five, six, seven-year-olds?

As the Designed to Smile programme has been refocused, that bit has been taken away from those older children. Now, those who have access to dental practices, if they require it of their dentist, the dentist will do it, but this then links back to access. Currently, if we think about how only 28 per cent of practices are taking on new children, not every single child in Wales gets seen by the dentist. So, invariably, there are going to be some children who are going to definitely miss out on getting fluoride varnish on their teeth, by the refocus of Designed to Smile and because practices then can't take them on. 

So, this was previously done in schools, was it, or—?

Yes, Designed to Smile is mainly a school-based programme. 

Obviously, it will go to nurseries to reach the younger children. In terms of success rates, the latest figures show that there's been a decrease of about 12 per cent in decay in the children in the programme.

Before we leave prevention, can I just ask, from the Chair, with my other hat on as a GP—? In terms of the preventative work that dentists do, it is pivotal in discovering various oral cancers, because by the time they present to the GP it's usually too late. So, we depend on our dental colleagues to discover these things. Do you want to elaborate on that?

So, as well, oral health and general health can go a bit further than that. We know of established links with diabetes and we know, particularly when we come to gum disease and losing bone around the teeth, that the health of your diabetes can be linked to the health of your mouth, and vice versa. And where we see improvements in your mouth health, your diabetic control can improve. We're also seeing growing and emerging links with heart attacks and strokes, related to the levels of inflammation around the mouth. If we get access to dental care, and we get good education on this—we get people looking after their mouth and their teeth better—we then see those improvements in other parts of the health service as well. This can relate also to care homes as well, where we're seeing, particularly, risks around aspiration pneumonia with people whose false teeth don't get removed or get cleaned in the care home. There's a huge build up of bugs and bacteria. They breathe in, where does that go? Into the lungs, and then we see problems on that, and that then puts demands on an already stretched health service. These links are growing all the time. We're learning more and more about things each way. By improving the dentist's ability to be open, honest and talk about that, we can then see positive health outcomes all round. 

10:05

Good. This is inspiring an extra couple of questions before we end up with Rhun. Angela, then Dawn. 

Mine goes slightly back to access, but it bounces off the Chair's question. Of course, if you're going to go into hospital and have an operation of any significance whatsoever, one of the pre-op questions is all about your teeth, because it's obviously—. People who are not registered with a dentist in Wales, what's their recourse if they need to have treatment before they can have an operation, which could be for something serious like the heart? Where do they go? Is there a system in place for those people?

Sorry. Can I just interject before Tom answers the question, just to clarify a point? People don't register with a dentist. That stopped quite a few years ago. Just to make the point—you don't register with a dentist. In theory, that gives patients the opportunity to move between dentists, because you don't stay with one dentist. 

But in my—. For example, if you are not very wealthy and you need to have a NHS dentist and you cannot afford a private dentist, in my patch, which is Hywel Dda, you cannot get to a dentist for love nor money. So, if you have to go in and have a major operation, and you've got to get some dental work sorted, I just wondered if there was a system in place to deal with people, because otherwise their operations are being held up or they have to have the operation anyway and then they're at greater risk of infection, because we know that poor dental health is a route for infection into a human body. 

Absolutely. So, again, returning to the point about registration, some health boards commission in-hours access, which is generally for emergencies only. So, if you've got a toothache, you can get the tooth removed and have a root canal treatment started. But your point is perfect to show that, because of the problems with access, we're getting knock-on effects and knock-on impacts and there is very little that some people can do. 

Okay. Dawn, briefly, and then Rhun to finish. 

Thank you, Chair. I just wanted to be clear, because most of your concerns appear to me to be around the contract—the current contract—and you have made some recommendations in your paper about what you think needs to happen. I just wonder if you could just expand ever so slightly on that, because you're not saying, are you, that the UDA should go, but it should have different values and there should be a more generic funding arrangement. Is that really what you're suggesting? 

Dentists would like the UDA put in the bin. 

The UDA and its meaningless value have contributed to the situation that we're in. So, yes, we appreciate there has to be some sort of measure. You can't just say, 'Here you go and get on with it'. There needs to be some sort of measurement. These measures have got to be meaningful. They've got to show the quality of what's being done and take into consideration the type of patients that you are treating.  

So, you're suggesting then that there should be a budget allocated that would include all dental activity, including prevention work—the whole thing is taken in the round, yes?  

Yes. Prevention should be a really key part of any future dental contract and it should be the heart of it, and, then, yes, of course, there's always going to be a need to provide replacement work. We've got a group of people called the heavy metal generation, who are people often in their 40s, 50s, 60s, 70s who've had a lot of dentistry done. Now, these people are going to have a huge need for work over time, because every filling breaks at some stage, crowns need replacing, bridges fail. So, there's a big population bubble coming through the system that is going to require a lot of work over the next few years. So, prevention—absolutely. But we need to realise that dentistry is still going to need to be performed. 

So, a quick-fire—not registering with a dentist is new to me; I didn't realise that that's how it worked. If you want access to a dentist because you've taken on yourself, 'I need to get my teeth checked, not because I've got toothache, but because I need to get my teeth checked,' how do you get into a dentist?

10:10

So, I'm a general dentist, I work in a high-street practice. We see our ongoing patients out of goodwill. 

But if you've never seen me before—I want to come and see you for the first time.

So, we have to work within our contract allowance and we get funded for x amount of units of dental activity. We have to make that last throughout the year. If we suddenly start to do all of them in one go, we don't get funded for the extra that we do.

And I'd go to 20 different dentists and none of them could see me, and then I'd end up having to go through the emergency route, because I have toothache.

Unfortunately.

If you're accepting—. If you have some scope to take new NHS patients, do you look at me—? It's a moral question, really. What risk is there that a dentist looks at somebody and says, 'No, I'm not going to take you on. You look to me as if you might have a lot of work that needs doing on your mouth. I'll wait for somebody who looks as if they're going to be easier for me'?

You're right, that is a moral question. The moral and ethical dentist would say, 'Okay, there you are, Rhun, we've got to take you on. There we go, we've got to do what we've got to do,' and, unfortunately, suffer the consequences, which is not really an ideal system for anyone.

There is a risk, and this is why practices can be very reticent to take on because of the business risk that that then puts on them and their overall viability.

Next, with children, I find it personally appalling that a single child could be without a dentist. Could we be able to, through different contracts, give a guarantee that every child in Wales has regular dental treatment?

I think the key point there is of different contracts, because we know the demands of the people of Wales are different in different areas. The chief dental officer has mentioned some sort of blended approach to contracts going forward, and that does sound a very reasonable idea, that, particularly, yes, with children, because dental disease is preventable, and we get good habits in early—being able to offer all children access to a dentist under the NHS would be fantastic. 

Of course it could be done. Could it be done with some fairly basic steps?

Potentially, I don't think it's beyond the realm of particularly difficult matters. The current access that we've—. At the point when we take on, something will have to give within that, because we've got an amount of funding that currently covers 55 per cent of the population, there or thereabouts. So, adding in all these children suddenly—what would have to give if we're doing it within the same budgetary envelope? Those are probably the practicalities.

And that brings me on, in a minute and 50 seconds, to the question I was meant to ask on data: do we know how many children haven't got access? And looking at it slightly more broadly, where are we at in terms of the kind of data that you need in order to tell us are we meeting Wales's dental needs, what needs to be done, what needs to change in order to see more patients and improve dental health and so on?

I think it's abundantly clear we're not, because 7,000 children per year are still having rotten teeth taken out under general anaesthetic, which shows that there's clearly an absolutely huge unmet—

Seven thousand. It was higher—it has been as much as 9,000. It's gone down, but that's still 7,000 too many having rotten teeth taken out under general anaesthetic.

Yes, put to sleep.

And the Government produce dental activity figures, and approximately 33 per cent of children haven't seen a dentist in the last two years. 

Thirty-three per cent of children. 

A dentist in the last two years.

It was religious in our house, really, and it should be in everybody's. But, in general terms, data—we need more of it.

Particularly in private dentistry, because we have little data on that. And, obviously, when we're looking at Wales, it's very hard to see a big picture of where people can access dentistry, how they're accessing dentistry, when there's a large part of dentistry that we can't see.

So, private dentistry, which is the reality for far too many of us, because that's the only way to get dental treatment—those private practices don't feed through the data that could paint a national picture.

They're under no obligation to do so.

10:15

Yes, I just wondered, picking up the issue of private dentistry—are there many practices that are just private and don't take NHS at all? I say that because that's happened recently in my constituency, where a dental practice has stopped taking NHS patients. Is that common?

Yes, there are many practices—

It's something you may do. You may want to look to work in more of a certain particular area within dentistry. You may want to direct your skills in a slightly different way to what the NHS contract can offer you.

I was shocked, I have to say, that people were moving to pure private.

I'm shocked that we've managed to keep to time. 

Diolch yn fawr, bawb. Dyna ddiwedd y sesiwn. Diolch yn fawr iawn i chi am ateb y cwestiynau mewn ffordd mor fendigedig, a diolch ichi, unwaith eto, am eich tystiolaeth ysgrifenedig ymlaen llaw. Fe allaf i gadarnhau y byddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma, er mwyn inni allu gwirio eu bod nhw'n ffeithiol gywir. Gyda chymaint â hynny o ragymadrodd, a allaf i ddiolch yn fawr i chi unwaith eto? Ac fe gawn ni'r tystion nesaf i mewn. Diolch yn fawr iawn i chi.

Thank you very much, everyone. That's the end of this session. Thank you for answering the questions in such a splendid way, and thank you again for your written evidence that we received beforehand. You will receive a transcript of these proceedings to check for factual accuracy. With those few words, I would like to thank you again, and we will receive the next witnesses. Thank you.

3. Deintyddiaeth yng Nghymru: Sesiwn dystiolaeth gyda Chymdeithas Orthodontig Prydain
3. Dentistry in Wales: Evidence session with the British Orthodontic Society

Felly, rydym ni'n symud ymlaen i eitem 3 ar agenda'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon y bore yma. Rydym ni'n parhau efo'n hymchwiliad i mewn i ddeintyddiaeth yng Nghymru. Mae'r sesiwn dystiolaeth yma gyda Chymdeithas Orthodontig Prydain, ac i'r perwyl yna rydym ni'n falch o groesawu Benjamin Lewis, orthodontydd ymgynghorol Ysbyty Maelor Wrecsam ac Ysbyty Glan Clwyd, o Gymdeithas Orthodontig Prydain. Croeso i chi. Diolch yn fawr iawn i chi am yr holl dystiolaeth ysgrifenedig ymlaen llaw, ac yn seiliedig ar y dystiolaeth yna, a chryn dipyn o'r dystiolaeth arall rydym ni wedi'i chael ar y maes yma, fe awn ni'n syth i mewn i gwestiynau. Fel sy'n draddodiadol yn y pwyllgor yma, a wnaiff Rhun ofyn y cwestiynau cyntaf?

So, we move on to item 3 on the agenda of the Health, Social Care and Sport Committee this morning. We continue with our inquiry into dentistry in Wales. This evidence session is with the British Orthodontic Society, and to that end we're very pleased to welcome Benjamin Lewis, consultant orthodontist at Wrexham Maelor and Glan Clwyd hospitals, from the British Orthodontic Society. Welcome to you. Thank you very much for all the written evidence we received beforehand, and based on that evidence, and quite a lot of the other evidence that we have received in his area, we will go straight into questions. As is traditional in this committee, Rhun will ask the first questions.

Bore da. Diolch am ddod atom ni. Wrth baratoi am y cyfarfod yma heddiw, un peth roeddwn i'n ei ddysgu oedd cymaint o waith sydd wedi cael ei wneud yn y blynyddoedd diwethaf yn edrych ar wasanaethau orthodontig yng Nghymru, yn gwneud argymhellion ynglŷn â'r newidiadau a allai wneud y gwasanaeth yn fwy effeithiol. Y cwestiwn, felly, ydy: beth sydd wedi digwydd o ganlyniad i'r holl adroddiadau yma? A ydych chi'n gweld bod argymhellion pwysig wedi gwneud gwahaniaeth?

Good morning. Thank you for being here. In preparing for this meeting, one thing that I learnt was how much work has been done in the last few years looking at orthodontic services in Wales, in making recommendations about changes that could make the service more effective. The question, therefore, is: what has happened as a result of all of these reports? Do you see that the important recommendations have made a difference?

Thank you. I think that the instigation of managed clinical networks and the strategic advisory forum in orthodontics has been instrumental in changing the landscape, from an orthodontic perspective. The vision of Welsh Government, the vision of the previous chief dental officer, Professor Thomas, and the current dental officer, Colette Bridgman—it's leading the way. And, in fact, Wales is way ahead of England with regard to orthodontic strategic advice. The establishment of the MCNs across the three areas of Wales actually makes the interconnection between the health boards and the providers much more linked, and I think it's crucial that all stakeholders are fully involved in that process, whereas in a lot of places in England, the procurement services haven't actually engaged very much with the providers, and so, a lot of the managed clinical networks that are actually over the border are, in essence, local orthodontic committees just with rebadged names, and the input of health boards is fundamental to actually progressing a strategic overview.

10:20

That's good, and we should celebrate where the sector and the people working on the coalface believe the right strategies are being put in place. There's a difference between strategy and overall aim and the reality. Where is practice perhaps not matching the overall strategic objective at the moment?

There have been big inroads into actually streamlining contracts so that—. Historically—as you'll be aware, the new dental contracts, which came in 2006, pretty much set in stone where orthodontic provision and dental provision was, because whatever was done on a fee-per-item basis was then converted into units of orthodontic activity. That basically fixed the output of orthodontic treatment unless there's been any other commissioned clinical services from health boards. That wasn't necessarily needs-based in the localities; it was where people wanted to set up a practice and stuff like that. Now, that generally tended to be around high population densities, so that works, roughly, as a model for urban areas, but the connectivity to more rural areas is much more difficult.

So, when we heard this morning already about problems in Hywel Dda where there's only one practice that's been awarded orthodontic contracts, would that be—?

Yes, very much so, but the problem is you've got to have economies of scale, and that's where—. You know, I think there's very much of a—. In an ideal world, everyone would be treated by a specialist. However, unfortunately, we don't live in an ideal world because the topography of Wales means that, actually, you can't expect patients to travel two hours-plus each way for an orthodontic appointment, which is every six to eight weeks. The impact of that on their education, their work, on their family—everything like that, and, also, that's assuming they've got a car to actually do that. Otherwise, you're relying on public transport networks, which is going to take all day. And it's where, actually, dentists with special interests have a fundamental role in actually helping provision of equitable care across Wales. 

So, do we need to nuance the overall strategy in order to reflect the realities of Wales? And whilst the strategy that you've spoken positively about might work well for urban areas, actually, there needs to be a little bit more leeway within that strategy to reflect the fact that in Hywel Dda, as we heard, there are issues that can't be—[Inaudible.]

I think so. I think there's got to be flexibility and I think that flexibility has got to be within each health board because each health board will have their own individual challenges, and I think, again, that's where the MCNs—if you've got all stakeholders involved—. You know, obviously I can only speak from my experience in north Wales, but we're very, very fortunate to have full engagement of the health board and, actually, we input into the oral health strategy group to get an overall plan. Now, we're not unrealistic: we realise that there is a finite pot of money, and, actually, you've got to be as efficient as possible with those resources, and there are pulls on those resources from a, sort of, child dental health perspective, from an orthodontic perspective, from a general dental perspective. I'm a firm believer in the actual philosophy of: Welsh Government is for prudent healthcare—you've got to make it count. You know, it's taxpayers' money, we've got to spend it wisely. But I think it's got to be set up in a way that, actually, is going to service the communities in the most effective manner. 

It's funny—. Resource, then, is the biggest barrier, you think? Because I know of dentists in the north-west of Wales who are capable and have the capacity to increase orthodontic treatment—they apply, they're perhaps given a green light that then turns back to red, and they're not able to provide the kind of treatment that they are able to. Is resource the main barrier there?

10:25

I think it can be. Obviously, from an Anglesey perspective and stuff like that, there are, potentially, challenges again in terms of dentist special interests, because actually getting to any specialist—. You've got Bangor, but you also have dentist special interests, but all their treatment plans have to be done by a specialist. So, again, it's about getting that connectivity with a local specialist. That doesn't necessarily need to be consultant-led, but about having that working relationship with those individuals to actually be able to formulate a treatment plan so that it could be done at a locality that is more convenient to the patient and also about monitoring those cases as they're going through treatment.

Historically, a lot of the units of orthodontic activity that have been attached to general dental practice contracts have been a legacy from the 2006 era. Sometimes, you get additional uplifts, but it's usually non-recurring. So, sometimes you can be given an uplift, and that applies generally to dentistry. So, 'We've got some clawback money from one area; we'll apply it to the other, or we're not going to meet the UDA targets that will actually convert that to the UOA target', which is potentially easier to meet, however it's usually non-recurring and it's usually relatively last-minute. The health boards, certainly in north Wales—Betsi Cadwaladr has been much more proactive about trying to issue anything in a more timely fashion to allow people to actually utilise those funds before year end.

We heard the BDA telling us this morning, in no uncertain terms, that they want the UDA binned. Does starting again and building a new contract, which may involve preventative elements and so on, and also bringing orthodontic activity into that, resolve some of these issues—starting again?

I think in an ideal world, you have a clean sheet of paper and you design a service that is fit for the population that you've got. The problem is that we have so many legacy issues and legacy waiting times. In Wales, we've got in excess of 25,000 patients waiting either for treatment or for assessment.

Orthodontics, yes. So, how on earth do you say, 'Actually, this is what we want the new system to be—', but you've then got to think about this backlog issue—

Yes, and I know that, obviously, previously it's been discussed that one-off treatment waiting list initiatives—it's not going to work in orthodontics, because it's done over 18 months or two years. So, you've got investment of actual people into that system. You can't magically make orthodontists appear out of the system to deal with that backlog of patients and all the other infrastructure that goes along with it. I think you've got to have a much more cohesive plan about how you're going to get those waiting times down, and that means increasing activity. 

Now, we've got the retendering system that's gone on, and, again, I think that that, with competitive markets, has been helpful in reducing the unit of orthodontic activity value, but I think it's fundamental that, actually, the overall contract value remains the same so that any savings from that are reinvested into service provision. The danger is that if, say, for instance, in north Wales, you've got a 20 per cent reduction in UOA value, because of the MCN's input into that process, the actual contract values remain the same or are actually increased in some areas, following the needs assessment. So, you've got an increase of 30 per cent of activity with only a 13 per cent increase in cost. The benefit of that is that it means that, actually, the practices could all have the potential to alter their treatment model, because they know that their overall income stream is not going to reduce, and it was done over a longer period: say, you had a 10-year contract with a break clause at year 4, then it gives the confidence to the actual practice to invest in altering the skill mix. Because it's not an overnight thing—you've got a year's training for an orthodontic therapist; you've got to select them, usually from one of the members of your team, to go off that year, and you've got to backfill that team. They have then got to be monitored and supervised closely over that first year when they're on the job, training, and then you can incorporate them into the actual practice as a fully fledged member of the team. That takes time.

I think the concern is that, in some areas, you're potentially looking at reducing the UOA value, but actually reducing overall contract value, and that is potentially unsustainable. I think you've also got to be mindful about how much you reduce the UOA value as well, because we know that rural areas are harder to recruit to and certainly that there are some areas—especially in bodies corporate where they haven't actually got their own individual financial investment within that business model—where, sometimes, you can have a higher turnover of staff and it can be harder to recruit. If you're not getting the remuneration, then people will say, 'Well, actually, I'm going to live where my family is, in the city, rather than travel.' I think that's it: it's difficult.

10:30

Okay. We'll move on formally to the recruitment issue, Angela.

First of all, Benjamin, could you just outline the training pathway of an orthodontist?

Yes. So, first of all, you have to go through dental school, which is five years' training, then usually—for instance, myself, I graduated from Liverpool after five years of training, I then did two years of general professional training, which is sort of our equivalent of foundation training, in both general dental practice and community dental services.

Vocational training. At the time when I did it, it was VT. So, you got to do the foundation. One year was statutory; I chose to do two years because it gave me a broader breadth of experience in both community and general dental practice. After that, I then went on to two years of maxillofacial SHO training—so, senior house officer training—and that gave me the sort of broad base of all the different specialties within dentistry. I then went on to three-year specialist training, which incorporates a higher qualification at Master's or doctorate level, and that's attached to dental hospitals. So, my training was in Sheffield. And then, at that point, you get your end of specialist training. So, at that point, you can step off that training pathway and go and work in primary care as a specialist in primary care. Alternatively, you can go on for additional training, which is two to two and a half years to become on a consultant training pathway. And then you have, again, another exit exam at the end of that from the Royal College of Surgeons.

In the sense of, I moved to Wales to start my consultancy, and, within six months, I'd had my 10-year reunion from dental school. So, it's a long pathway.

So, obviously, after your five plus one, you can go off and be a dentist in a private practice or an NHS practice or a hybrid practice. Was the two years of the maxillofacial element that you did, was that a choice option? Would somebody who just wanted to be an orthodontist have to do that little bit as well? There is a point to all my questions.

I think the orthodontic via national recruitment is very competitive, and therefore you want to show that you have a broad range of experience. I think that's important, because, even though I don't expose canine teeth any more, I think it's important that I know what is viable, because I'll be looking at an orthodontic case and going, 'I can bring that tooth down and save restorative burden in the future.' However, actually, if, from a surgical perspective, it's actually not possible, or what I'm going to request is not going to be technically viable or something like that, then it's important for me to recognise that. So, I think that having that broad base of experience is invaluable when you're actually treating patients.

So, your final two to two and a half years, obviously, as a consultant, that's hospital based.

The three years to become the specialist, do you have to be attached to a hospital like—?

It's primarily done all within secondary care settings.

It's all. Because there is a significant amount of supervision that is required. So, with my trainees, I see pretty much all their patients every visit, for like one-to-one training and stuff like that. And the difficulty of—. There has been talk previously about trying to move that into a primary care model. The difficulty of that is being able to structure a primary care model that will actually be suitable to give adequate training, adequate supervision, but also be able to remunerate the supervising orthodontist appropriately for the loss of activity from their own clinics to actually undertake that training. And what you don't want to do is make the training less complete by doing that.

So, we recently did a report on getting more Wales-based doctors, so I'm kind of going down the same route with this. So, essentially, let's say we have somebody who starts off at 18, they go into Cardiff University dental school, they do the five years, then they will have to go out somewhere and do one or two years of experience. That's mandatory. At that point, they would then seek to find a hospital that would take them on to complete the next stages of their training, so that they can become a consultant—and they obviously have to be attached to a university to do that.

Yes. All training is usually attached to a university. The academic component is only for the first three years of specialist training.

Right, okay. So, why do we have such a problem then in getting—? Why do you think we might have such a problem in getting Welsh students back into the consultant-led orthodontic training element around Wales? Could you expand a little bit more on the problems you've faced in north Wales? And also, obviously, that's spread out to west Wales, as we've heard earlier. What I'm trying to understand is, is there a—? You made the comment that everybody has to compete for a training place, so the academic bit will be at Cardiff University, because they're the only providers of it in Wales, and therefore, if they want to go and work for Betsi Cadwaladr or Hywel Dda, or whatever, as the practice—

10:35

No, you see, it's all linked. So, basically, as you go through national recruitment, you choose a training—. You go through national recruitment and you'll have stages of interviews, you'll be ranked as a candidate and then, once you've got your ranking, you'll submit your preferences, so, your preference where you want to go. So, if you came top in the interview, you basically will get your choice of where you want to go, but you'll rank every single job that's available and then it basically marries everyone up. So, depending how well you did at the interview, you'll get maybe your first choice, or you might get your third choice or you might get your last choice. So, it depends on that. If, for instance, someone wants to come to Cardiff and they were born and bred in Cardiff, but someone has come higher in the interview and has put that down as one of their options, then they'll get preference to be put into that position.

And, who does the ranking, then? It's not the university who chooses—

No, no. The ranking is done as part of the interview process.

No, no, by the national recruitment.

I see. So, we can't, for example, suggest gently to Cardiff University that they might like to give an extra ranking point to a Welsh speaker, for example, in order to encourage someone from Wales to be in a Welsh—

No, because even if you could do that as part of the national recruitment, it would not necessarily mean that that person is still going to—. It would apply to their overall score within the recruitment; it wouldn't actually mean that they're less likely, then, to tag in to Cardiff University. The only way of doing that is coming out of national recruitment.

Right. So, we could end up with Welsh students going to Sheffield or somewhere else that's got dental, but we can also, conversely, have people who are not necessarily born and bred in Wales who are coming in here. Why wouldn't they want to stay, then, if that's where they've done their training and that's where I guess they're going to make their friends and build their social network? What would be the barrier and could you just elaborate on the north Wales issue?

It's difficult, really. Usually, people settle where they've put down roots. So, if they're in a long training pathway, then they'll tend to settle around there, because they'll buy a house, get used to the local community. The orthodontic training is very intense, so your scope for socialising a lot is reduced. In essence, you're doing a full-time job plus doing a Master's at the same time. When I was over in Sheffield, I worked like billy-o during the week and tried to have the weekends off, so that my fiancé could come over and I could see her and stuff like that, but I was full at it all that time, so there wasn't much time for me to go out, or set down potential links in that area, because it's so intense. So, sometimes, people then go back to where they've set up other links, which are dental schools or where they've done their other training and stuff like that.

North Wales has had quite a big benefit from bursaries and stuff like that, where they've encouraged people who are doing dental training to come back to north Wales to do their vocational training and stuff like that, but you've got to have the places available for them to allow that to happen. But that's been quite successful in the past. North Wales, when I was looking at consultant jobs, it was a combination of job satisfaction, but also where I wanted to live. And my experiences of coming with my family to Anglesey, Bala and stuff like that was one of the draws for me, before I had children, about where I wanted to bring up my kids. So, the location of where I'm going to work and the environment was a big pull for me. But also, I wanted job satisfaction, so therefore, one of the criteria of me coming to work in Wales was the fact that I had a training post.

So, I was linked into that, and that was organised via Liverpool, because geographically, it works easier. So, all the academic components were done in Liverpool, so I've now just completed my third trainee from there and that's been under Liverpool via Health Education England in Manchester. However, as of last year, that Welsh post was pulled because HEE didn't fancy paying 25 per cent of the money for a student who has been trained partially in Wales. But the Wales Deanery have been very, very supportive and they've helped us to recoup some of that funding, so that, actually, now, my future trainee, who will start on Monday, is linked via Cardiff, but will have their academic component via Liverpool, because it's geographically more straightforward.

10:40

That's certainly complicated. I'm not quite sure I followed all of that.

What we have is, basically it was a somewhat stressful process, because I'm a firm believer that having a trainee in the department is the lifeblood of the department. It keeps everyone on their toes because the trainees ask very annoying questions that really test your boundaries and stuff like that, so it keeps you up to date and it's a really good thing to have in your department. I'd have been extremely disappointed to have lost my trainee, in the sense of, you know, the trainees get good training. Every single one of my trainees has had some sort of award at the end of their training. The last cohort have had the gold medal. Liverpool actually have three gold medals, and they only normally give one, so actually the quality of the training they're receiving is absolutely superb. I'd have been really disappointed to have let all that hard work over the last nine years go because we hadn't been able to continue that training. So, the training that happens is that they're basically in dental school for part of the week, then in district general for part of the week, and then one day a week is usually academic, so they'll do all their lectures, research and everything like that in one day. 

Sorry, Chair, if I could—. Just on that, what I was trying to get at was you said that Liverpool pulled the plug because—

No, Health Education England.

I beg your pardon. Health Education England pulled the plug because they didn't want to be paying for 25 per cent of somebody that was then going to be working in Wales.

And also there's pressure on them to get training numbers in other specialties, so they'll say, 'We want to reduce orthodontics numbers generally, so what we'll do is—.' Actually, for the north-west it's probably more equitable to reduce a training post that's not actually—well, the general component is in Wales, not England. So, that was pulled. And, you know, politically, I can understand that.

I understand that. That was why I was just asking whether there were not any cross-border arrangements that would prevent that kind of thing happening—a kind of, I don't know, a clawback.

But then you've got to have—. The difficulty then in trying to get that post running again is trying to get the funding streams in place. So, Liverpool, unfortunately, because HEE was saying, 'Well, actually, we're going to move our component of the finance to a different specialty', say, oral surgery, there is pressure on Liverpool to match their input into the funding stream into that other post that they're going to create as well. So, it was like a double whammy. So, I lost lots of funding there, and there are lots of negotiations about whether I can have access to Liverpool from a training point of view.

I think it's really good that trainees aren't just with one unit. I think you want to give them a broad experience, and therefore it's important that they have access to different consultants. The point you made about, actually, we want someone to train in Wales and go through and be a consultant in Wales; I think that's good, and it streamlines it, but sometimes you can miss the bigger picture. I think it's sometimes good to go out and see how things are being done differently and then come back. I've made a conscious effort of making all my training posts in different areas, so that I could actually try and pick up different things from different areas, because everyone does things differently.

Oh, sorry. North Wales. Is that—

No, it's course fees. I was very surprised to see there was an income differential of £23,000 a year— 

Potentially.

—potentially, between a trainee in England and Wales. Could you just expand on what the cause of that is?

England have adopted a set pay for specialist trainees, which starts at £46,000; Wales starts at £36,000. So, you've got a £10,000 difference to start with from that point of view, and course fees are higher at Cardiff.

That's set by the university. 

It's funny—things are very different now from when I did my training. I'd wanted to be a consultant orthodontist since the age of 12, so I was quite clear about where I wanted to be and what I needed to do to get there, and I would have done anything to get on that training pathway and to follow through all the bits and pieces. Trainees now have spreadsheets about—. Because national recruitment has changed everything a lot, so basically you have carte blanche about where you potentially go, they all have spreadsheets about what course is running, how much the fees are, how much they're going to get paid, all this sort of stuff, all the other things that go into that, and that's been a change, probably, in the mindset from people having to pay for university and stuff like that. They're far more financially aware and that potentially is a disadvantage, not only for standard one to three-year training, but also for the four/five training, because if you've spent three years as a trainee for specialist training at a significantly reduced salary compared to your peers who have not done specialist training, then to do another two years can be difficult, especially if you've got a family and stuff like that, and you've got another calls and commitments. If you go for your five plus one and you go and work in general practice, you'll get up to good remuneration relatively quickly. If you're going on to specialist training, you end up taking a much lower wage for a longer time; you don't buy a house quicker. So, there are lots of disadvantages financially of doing that, and, basically, your heart's got to be in it to get through to the other side.

So, that's part and parcel of the difficulties, and I think recruitment—when you get to consultancy, recruitment's got to be hot at the health boards. In north Wales, we had a candidate who we trained in Wales—they did orthodontic training in Wales—they then became a specialty doctor at Bangor, and they then decided to look at succession planning well in ahead to try and get everything organised. They've then done their consultant training at Liverpool and tied it in at Glan Clwyd already. They were a Welsh speaker. It would have been absolutely brilliant. And the logistics of actually getting through the recruitment process in the difficult financial climate that we had meant that she went to Ireland and worked in Waterford. And you just think, after all that effort that has gone into getting someone who was a perfect candidate for that job, succession planning, all those sorts of things, it just went to nothing—extremely disappointing. 

10:45

Okay. Moving on, and time is marching on, so we need some agile questioning and some agile answering. Julie. 

Right. We've already covered waiting times a bit, but, just to ask a few more questions, I think you said earlier on there are 25,000 people waiting. Does that mean some of those will never be seen? 

No. Hopefully, they'll all be seen. The difficulty is if they move on to another things. It depends; if they go on to move house, move education, or something like that, then potentially they might not be seen. I think some of—. That is a breakdown of people waiting to be assessed to see if they need orthodontic treatment, and also patients who have been assessed and require orthodontic treatment. So, the method of assessment is different in primary care and secondary care. So, often in primary care you will get referred. You will not be seen until there is a slot to do your treatment. So, then, the person is drawn off their waiting list and seen. If they're suitable for treatment and need treatment, well then they'll be given it, of course; if they're not, then it'll be said and they'll be discharged at that stage. So, a patient could be waiting 18 months to be told, 'Actually, no, you're not qualified for treatment', or, 'You're not suitable for treatment'.

In secondary care, we tend to see patients in a quicker way, so the initial assessment is quicker. They're then assessed and then either advice is given, they're referred off to a more appropriate service—that might be primary care—or they're added to a secondary care treatment waiting list for that orthodontic treatment or surgery treatment type of stuff. 

And the reason for these waiting lists you said earlier was legacy issues. 

Legacy issues, and also Professor Richmond's report has indicated that there's enough resource within the current budget to allow for treatment of all the patients, but that's based on—. First of all, that's based on a third of 12-year-olds, which, if you look at the 2003 survey, it indicated that, say, 8 per cent of 12-year-olds actually had fixed appliances on, and then another 35 per cent would actually justify treatment. So, that's actually 43 per cent, not 33 per cent, so there's potentially a differential anyway in some of our basic assumptions about need. But some of those patients won't have dental health that would sustain orthodontic treatment, and the slight irony is the fact that, actually, if you manage to get dental health up to a good standard, it might mean that there's a greater requirement or a greater need for orthodontic treatment in patients that have a suitable dental foundation to do it.    

So, 43 per cent—so, nearly half of 12-year-olds need orthodontists. 

Forty three per cent. And that was based on index of orthodontic treatment need 4 and 5, with an aesthetic component of 8 to 10, which is more stringent than our current NHS acceptance guidance that we have currently.  

Right. No, it just seems a very high figure. Why is it so high? 

Malocclusions are—it's genetic factors, so it's a whole raft of genetic factors. So, prominent teeth, increased risk of trauma, things like that—it's about 8.8 per cent of patients who have prominent teeth—crowding. Genetically, the size of teeth and size of jaws are on different genes, so it doesn't match. And there's a racial side of things, so I get Afro-Caribbeans who have generally wider, broader arches, and therefore have less issues with crowding, whereas an Anglo-Saxon sort of cohort, and the Celtic cohort that we have, generally have more prominent teeth and more crowding. We can blame our ancestors, unfortunately, for that.

10:50

Not blaming anything on anybody. Dawn, are you going to wrap this session up?

Yes, just a couple of quick questions, really—more general questions, on the basis of what you've been saying. Is there anything that you think that Welsh Government could do proactively to help around the situation with waiting lists, or do you think that everything that can be done has been done? What do you think?

I think, fundamentally, you've got to make sure that, actually, the amount of funding that's there is used in the best possible way. Now, if that's, as I mentioned before, a reduction in the UOA value, then that money is reinvested into the system to actually make sure that, year on year, we have enough capacity to treat, on average, the number of patients who need to be seen. And, ideally, what you'd like to do is have an excess so that can start slowly eating into the backlog. And that's not going to be a quick process, but, hopefully, that'll start reducing the backlog over a finite time, and that could be five, 10 years, but I think you've got to play the long-term game on this.

The introduction of a new electronic referral form I think is well overdue, and I can understand Professor Thomas's frustration, when he wanted to push with that years and years ago, and yet the IT infrastructure wasn't sufficient for it.

Yes, and I think that's going to be brilliant. I don't think it's—. But you've got to remember that there's a two-year backlog, so actually any gains you're going to make with the new referral system are not going to be seen for many, many years.

And the idea of that is it will be able to try and triage patients much, much better. Hopefully, with a new system, you'll get rid of needing the dentist to know that much about IOTN, because the actual system will say, 'Has the patient got this abnormality? Great, you tick that box', and that will allocate it, hopefully, to the right provider. So, depending on the complexity within the algorithm, that should hopefully direct you to either primary care or secondary care, and you can make that much more nuanced. It'll also be better for data collection. So, actually, we'll be able to know what patients are going where, and everything like that. In England, they've had a centralised waiting list, whereas, in Wales, it's probably going to be—it's still individual practices that hold their waiting lists. But it'll help prevent any duplicate referrals. I think sometimes that's a bit of a red herring, because it's often being used as, 'Well, the waiting lists are so big because of duplicate referrals', where dentists have referred them to multiple practices. That will potentially inflate the overall baseline wait—you know, waiting numbers—but it won't actually affect treatment. Because a patient who goes to practitioner A, is seen for an assessment, and has the brace is fitted, isn't then going to go to practitioner B. So, actually, that won't increase capacity or anything like that. I think the introduction of the e-referral system is going to be good, but it's not going to necessarily address capacity. What you are going to probably see is a massive drop-off in referrals for the first six to nine months, because people don't like change, and therefore referring dentists are going to be reluctant to use the new system initially, until they get used to it, and then you'll get that back—increase again.

Okay. So, finally then—I'm conscious of time—are there any other outstanding issues relating to orthodontics that you feel we ought to be aware of? That might be a really big question, and I'm conscious—

I think we have to be mindful of making sure that we're getting maximum utilisation of the funding stream, and that we don't—that any cost savings increase activity. That also gives security to the practice to invest. I think you need to have, like in north Wales, long-term contracts—with break clauses, so that everyone's happy from that point of view, but that gives them time to invest. I think we need to think about succession planning, and significantly—especially in the secondary care services. Primarily, the secondary care services waiting times are down to recruitment. My waiting list has gone up by a year, because I lost my staff grade, for various reasons, and it's been very difficult to try and recruit into that post. And when there are fewer hands, unfortunately, patients have to wait longer, and it's very unfortunate. It's not what I want; I want to be able to treat my patients in a timely fashion. And all my patients are prioritised, so the most needy get treated first, but it means that some of the other ones, for whom there's no risk to them by waiting, they just have to wait longer. And that's unfair, because there are psychological impacts in that.

That's an interesting point, actually. So, waiting times are not necessarily just based on the date on which somebody is referred; it is the urgency of the treatment as well.

Yes. And, again, the new referral system will hopefully help to prioritise patients. So, when I get a referral in, they're all prioritised, so I'll be prioritising for a new patient clinic—so some patients might wait 26 weeks, if they're routine; some patients might be seen within six weeks, depending on what their clinical need is. Once they're seen, then they go on the treatment waiting list, and again that depends on priority. But, as I say, sometimes you can have surgical cases—massive jaw discrepancies—but they're not going to come to any harm if they wait, so they're going to have to wait. But yet, psychologically, that has, potentially, a big impact, especially during the formative years of their life. Your heart just goes out to them.

10:55

Hapus? Reit, diolch yn fawr iawn i chi. Dyna ddiwedd y cwestiynu. Diolch yn fawr iawn hefyd am y dystiolaeth ysgrifenedig ymlaen llaw. Diolch yn fawr iawn am eich presenoldeb y bore yma ac am rannu'r wybodaeth. Rydw i'n siŵr ein bod ni i gyd wedi dysgu llawer am orthodontics—diolch yn fawr iawn i chi. Mi fyddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma i allu gwirio eu bod nhw'n ffeithiol gywir hefyd. Wedyn, gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i chi i gyd.

Gallaf i gyhoeddi i fy nghyd-Aelodau y cawn ni doriad nawr am 10 munud a dod yn ôl am 11:05. Diolch yn fawr.

Happy? Right, thank you very much. That's the end of the questions. Thank you very much also for the written evidence that we received beforehand. Thank you for attending today and for sharing the information. I'm sure that we've learnt a lot about orthodontics. You will receive a transcript of the proceedings today to check for factual accuracy. So, with those few words, thank you very much. 

I can announce to my fellow Members that we'll now have a break for 10 minutes and come back at 11:05. Thank you very much.

Gohiriwyd y cyfarfod rhwng 10:56 ac 11:08.

The meeting adjourned between 10:56 and 11:08.

11:05
4. Deintyddiaeth yng Nghymru: Sesiwn dystiolaeth gyda Chonffederasiwn GIG Cymru a chynrychiolwyr o fyrddau iechyd lleol
4. Dentistry in Wales: Evidence session with the NHS Confederation and representatives of Local Health Boards

Croeso nôl i gyfarfod y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru, a pharhad o’n hymchwiliad heddiw yma i ddeintyddiaeth yng Nghymru. Mae’r sesiynau tystiolaeth yn mynd ymlaen drwy’r dydd, ac rydym ni yma rŵan, a’r sesiwn ddiweddaraf ydy un â Chydffederasiwn y Gwasanaeth Iechyd Gwladol a chynrychiolwyr byrddau iechyd lleol yma yng Nghymru. Ac i’r perwyl yna, rydw i’n falch o groesawu Lindsay Davies, pennaeth gofal sylfaenol uned gyflawni gwasanaethau sylfaenol a chymunedol Bwrdd Iechyd Lleol Prifysgol Abertawe Bro Morgannwg; Karl Bishop, ymgynghorydd mewn deintyddiaeth adferol, bwrdd iechyd Prifysgol Abertawe Bro Morgannwg; Craige Wilson, cyfarwyddwr cynorthwyol gofal sylfaenol, gwasanaethau plant a cymunedol, Bwrdd Iechyd Lleol Cwm Taf; a hefyd Vicki Jones, cyfarwyddwr clinigol y gwasanaethau deintyddol cymunedol ac ymgynghorydd mewn deintyddiaeth gofal arbenigol. Croeso i’r pedwar ohonoch chi. Diolch yn fawr iawn am dystiolaeth ysgrifenedig ymlaen llaw. Yn ôl ein harfer, a chan fod amser yn pwyso rhyw dipyn, awn ni'n syth i mewn i gwestiynau, ac mae Angela Burns yn mynd i ddechrau.

Welcome back to this meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales. This is a continuation of our inquiry today into dentistry in Wales. The evidence sessions are ongoing throughout the day, and we're here now, and our latest session is with the NHS Confederation and representatives of local health boards here in Wales. To that end, I'm pleased to welcome Lindsay Davies, head of primary care, primary and community services delivery unit, Abertawe Bro Morgannwg University Local Health Board; Karl Bishop, consultant in restorative dentistry, Abertawe Bro Morgannwg university health board; Craige Wilson, assistant director of primary care, children’s and community services, Cwm Taf Local Health Board; and also Vicki Jones, clinical director of the community dental services and consultant in special care dentistry. Welcome to you four. Thank you for the written evidence that we've seen beforehand. As usual, and as time is going on, we will go straight into questions, and Angela Burns will start.

11:10

Good morning. Thank you very much indeed for all your papers. I would like to just talk about the Welsh Government's dental contract reform. We've had quite a bit of evidence this morning from other stakeholders about their views on it, and I note from your combined submissions that there are positives and negatives to it. So, I just wondered if, for the committee, you could expand on those in a little bit more detail. 

Shall I go first? At ABMU, we've been very positive about it. You'll have seen that there are four dental contract reforming practices being taken through this first phase that we've been in for the last year. But we also had two prototype practices that we'd been supporting for a number of years before that. We were very pleased to support that because, as you'll have heard and you've seen from the evidence, there are serious flaws within the existing dental contract that we felt militated against the provision of good oral health. This is—although it's just a small reduction in the UDA target, at least it's giving some elbow room, financially and time-wise, for practices to start looking at things differently and seeing if they can open up their ways of working to provide a more holistic approach.

We were confident in ABMU—. Having had the two prototype practices for a number of years, we were confident that, although there might be an adverse effect on patient income—going down—that would affect finances and be a risk to the health board, we knew that that came up again after a while, and therefore felt that we could take what would be seen by others as the risk of saying, 'Yes, we'll take down that target.' But the evidence that has been gathered from the practices by Public Health Wales has been absolutely crucial in confirming that. The programme didn't go as fast as we might have thought in the first place because everybody wanted to be confident that what they expected to find was going to be true. I'll pause at that point.

We have sought expressions of interest for the next wave of practices in ABMU. Including the Bridgend element of it, a further 10 practices have come through—not the overwhelming interest that you might have expected, or might have been expected, because of the risks associated with it, which we've highlighted in our returns as well, including the fact that single-handed practices perhaps don't have, literally, the room to accommodate a wider skill mix. But we're confident that we can move onwards and upwards this year and beyond.

Can I just—? I think the key thing here is that this programme is evolving, and we are giving it time to evolve. So, the prototypes—we learned a lot from them. Early on, we weren't seeing necessarily what we expected, but, after a three-year cycle, particularly if you are looking from a clinical point of view, we started to see what we would expect from a treatment, planning and care provision point of view for a patient. It's not a snapshot over a year; it's over a period of time. That gave us a lot of confidence, and Welsh Government a degree of confidence, to be able to go to a contract reform programme.

But the contract reform programme is evolving as we go along. We had meetings this week around it. So, there's no clear process overall. There's a direction that we want to go in. But it is evolving as we are rolling it out, and that's a big step, I think, from the 2006 position, where there was an overnight change to the contract, and that caused major problems for everyone, whether it was health boards, or providers of the services as well. It certainly is beginning to show a change in treatment planning. So, we are seeing dentists looking more broadly. It's given them more flexibility, although only limited at the moment, to look at the patients' needs more broadly, rather than being driven by a target.

From a health board perspective, that also then brings more challenges because we are obviously having to manage these contracts from a performance and quality side of things, and there's the new development coming into that. But that's part of our evolution as we are going through that process at the moment.    

One of the things that that we've heard quite a bit so far this morning is about the importance of preventative. So, is the 10 per cent—? You know, we've learnt a lot about contracts today, haven't we? [Laughter.] I don't think we've really understood much of it, on some of the more arcane elements. Is that 10 per cent enough, or has that been raising concerns in practices, and is that one of the reasons why they're not coming forward to take part in this?

It is in part, isn't it? The way this scheme was first presented to us by colleagues in Public Health Wales and the CDO was that the 10 per cent would be taken off, and all they'd have to do for that was complete the ACORN—assessment of clinical oral risks and needs—data. Certainly, in our health board, we were saying, 'Well, hang on. We want a bit more than that.' Certainly, if there were any promise of taking off more in the target, we said, 'No, no, we have to be sure that something changes.' And, as Karl has said, behaviours have changed and we felt some confidence in saying, 'Yes, we can go further', because the information from ACORN data showed the practices where they had scope to decrease their recall intervals, et cetera, which has been one of the banes of the previous contract, the way it's been applied. And they realised that they did have some wriggle room.

But the extent to which they did or didn't have capacity to do any more than just fill in the forms is very much dependent on the size of their UDA rate to begin with. So, practices with a big UDA rate of £35, or whatever, already have dental hygienists et cetera in their mix. The smaller practices and the ones with a low UDA rate just don't have that at all. So, a lot of practices are very reluctant to join when it's just 10 per cent, because they say it will make very little difference.

But what will make a difference, we now believe, is the innovation fund that the CDO is giving out on top of the contract. So, the 10 per cent, not much difference—we can see evidence that it's increased access in our reforming practices and practices that have a higher UDA rate than others, and definitely our prototypes. Our prototypes definitely did increase access. But there won't be much movement. 

11:15

When you say prototypes, is that the prototypes for this or is that the prototypes for the—

Our old ones.

The old ones that predated this.

Because they did seem to be very successful, didn't they?

That's right. You visited it.

I did. I was trying to remember and tell the Chair. Was it East—?

Eastside. Yes.

So, we had two prototypes—Eastside and Belgrave. One of the good tests we've got with the current reform programme is that Belgrave have another practice in Pontardawe—a very different demography there—and we feel that, between them, we'll get a lot learning out of that.

But the 10 per cent is perceived by many practices as not enough, and you can understand that. It depends on their circumstances. 

Can I just add that increasing that percentage, obviously, isn't without risk to the health boards from a financial perspective? Because, as we increase the percentage, there's a reduction in the patient charge revenue that the health boards would receive or would offset in terms of the cost of that provision. So, what we will have to make sure is that, if there is any further increase, we have robust monitoring arrangements in place in terms of what's happening around the assessment and the treatment of those patients, because, at the moment, there are fairly limited outcome indicators around the new dental contract.

We've spent quite a lot of time understanding it from the dentist down, in terms of charging. Could you just expand on that a little bit—how the health boards—? What criteria do the Welsh Government use to award a health board a particular sum of money to provide new services, or it's from the health boards—

The dental contracts were set from 2006, so, their actual values are set on that, and the UDA values are set on that. The contract, at the moment, obviously, is about achieving 95 per cent. There's a 10 per cent allowance, obviously, now, with the new dental contract reform. But that brings with it—. During the pilot in the last 12 months, it varied between practices in terms of whether there's been a loss in terms of the patient revenue charges, which makes the service, obviously, more expensive in terms of affordability.

So, the two are just—. Oh, I didn't realise that. So, the two are just completely divorced then? The 10 per cent is divorced from being attached to a—.

No, it's not, but, when a patient goes to the dentist and they pay the money, that money then is offset in terms of the overall payment to that dentist. So, if those payments are not being made because, actually, you've got 10 per cent where we are not actually recovering that income, as you increase that—

Because you're looking at, advising, checking oral health, oral hygiene—

Yes. That amount of revenue increases.

So, you only get paid for the doing of something, not for advising on something.

Yes. And that's why, in part, in terms of the incentives from Welsh Government now, in terms of getting 10 per cent of your practices to undertake the contract reform, there's a sum of money, then, to offset any potential loss of revenue.

11:20

So, final question, really: from what you say, this new system may well work on the larger practices, so how on earth will it ever be able to scoop up—? I mean, in my health board, we have many, many single practitioners. How will they ever be able to really take part in this new way of working?

I suppose it's similar if you're looking to general medical services. It may be about practices working collaboratively in clusters where they have access to a therapist or a hygienist for a period of time. That's probably the only way it's going to work for the smaller practices.

That's certainly how this reforming group, if you like, we've set up in ABMU have indicated they would. It's easier said than done, because they are all businesses and reluctant to share, but that principle is already there, as Craige said—the same as with GMS. I think it's possibly the practices who are—. It's not, perhaps, sometimes, just because they're single-handed, as the ones that are locked into a contractual arrangement with that one associate delivering dental services. What they're needing to do is to get their dental associates onto an employed basis, and it's easier said than done to do that whilst you've got somebody in post. That's what the bigger practices, the Eastsides, et cetera, have gradually done. As people have left, they've replaced them with a different skill mix of staff, but breaking into that sometimes takes some pump-priming, which is why 10 per cent is not quite going to do it.

Sorry, last, last question: so, a single dental practice will have a dentist that will look at people, but are you saying that, in order to add value to their contract and to get the 10 per cent, they really have to start pulling in people like hygienists and all the rest of them? Of course, that collaborative kind of working sounds great if you're in a population area where you've got enough dentists around and a reasonable travel time, but they might have an associate who wouldn't be a hygienist or whatever; it would just be another dentist. So, really, they've got to get rid of the other dentist in order to get what we would have called in medical terms a 'healthcare professional' around them.

Not necessarily, because I think the whole point of this at the moment is that there's a degree of flexibility as it evolves and it reflects the population and the practices. So, for example, in the scenario you were talking about, that dentist, within the contract, could go to work within the community dental service one day a week and upskill themselves, but then free capacity within their own practice for a dental care professional, like a therapist, to go into that. So, it's changing that model. It also gives us the opportunity to upskill individuals. I know we're going to talk, obviously, about careers, but actually individuals are seen to develop within general practice, not just after going into specialist programmes. So, it's actually that there's more flexibility around that. A lot of it will need a little bit of innovation and a little bit of thinking outside the box as we start to do it, but those sorts of practices are not excluded from this; it's just a different way of developing it, going forward, suitable for that population and the practices there.

And the new contract, or the proposed contract that's being rolled out slowly, will enable that as time buys in.

We would hope so. Can I just add one thing? This is not a new contract. It is a contract reform. I think the Minister would be quite twitchy if we said it's a new contract. It's a contract reform.

Okay, we'll reform to the next questioner, then. Rhun.

A very good morning to you. Just some question about clawback, if I can, which is described in the Welsh NHS Confederation's paper given to us as 'money recovered for underperformance'. Is use of the word 'underperformance' fair, considering why targets aren't met by some practitioners?

I think it's a fairer term than 'clawback', because that implies we're aggressively taking away moneys from contractors—

It depends on the degree of underperformance. As we've said, we expect them to perform up to 95 per cent and then they can keep their moneys. So, at 95 per cent, we as a health board are still paying them 100 per cent. If you looked at it cynically, contractors who deliver to 95 per cent are getting that 5 per cent moneys as a loan from the health boards, and that could be rolled on, year on year, as long as it's hit 95 per cent. What we're most interested in is, obviously, incentivising them to get them up to 100 per cent and clawing back, if you like, moneys from contractors who consistently perform below 95 per cent because we want to reinvest that in people who do, because, otherwise, we end up with a massive underspend.

11:25

We know what 'performance' means in general terms. People understand what performance means: performance-related pay, people underperforming, not doing what they should. It may well be the case, because of the UDA structure, that a dentist is not able to meet the number of patients you want them to see because they have a high level of people with serious dental health problems and they're dealing with patients in blocks of three, four or five fillings at a time rather than somebody who's fortunate enough to be in an area where people have better dental health. That's not a dentist underperforming; that's a dentist meeting the needs of his or her population. That's why I'm suggesting 'underperformance' is rather unfair.

I suppose the thing to say is, obviously, contracts have been in place for 12 years and they're based on that baseline from 2006. So, they were performing at that level when the new contracts were put in place. Yes, the new dental contract is now in place to try and address some of that and to promote the preventative agenda, and we recognise, particularly in areas of high deprivation, such as the one we serve in Cwm Taf, that that may be the case, but what we've actually found is that, because some practices have not achieved their UDA targets, we've actually then been able to redistribute those UDAs to those areas of higher need, and in particular with us, to Merthyr Tydfil. And what we've seen since we've made that change is that, actually, we're seeing a higher number of adults and children who are accessing the dentist. So, it may be that the UDA levels now are at a more appropriate level for that particular practice. 

But you'd accept that some practices have an inherently better chance of hitting their targets than others.

Definitely. And we've tried to do something about that this year. We, basically, completely agree with you, and one of the areas where we spent moneys this year—recovered from last year, reinvested this year—is to raise the UDA rate to £25 for those practices that were beneath that, on the condition they met certain quality criteria, including opening up access, et cetera, because we did completely acknowledge that—particularly, I think, it was a Pontardawe practice—they were saying, 'We cannot treat people in this area for £23.50 a UDA when we're having multiple visits, with people coming back for 10, 12 fillings compared to getting the same money for one or two'.

What the BDA are suggesting, of course, is that whilst there may be real merit in increasing the payment for UDAs in parts of Wales, actually, what we need to do is scrap the UDA programme. 

Yes. I wouldn't disagree.

I don't think many people would support the UDA concept. As a clinician, I could never work and deliver within that environment, given some of the issues, especially for the high-need areas. I think everybody recognises that, and I think that contract reform is a way of moving towards that and putting the UDA as a background issue but giving flexibility within it. I think health boards are also developing more intelligence around their practices. ACORN is a good example because it gives a good indicator of population need—real need—and of what's going on there, and I think health boards are sensitive to these issues. So, in our health board and, I think, others, we're constantly engaging with practitioners, and if they are underperforming—and that's the technicality within the regs—we're having that communication with them very early in the year, and there is a degree of flexibility. So, for example, if we see practices in high-need areas that have taken on lots of new high-need patients and they're not hitting 95 per cent, we don't have any issues with that because it's within a context. So, as long as we're understanding and engaging with practices, we don't have a problem.

No. We have that flexibility within our budgets. We just accept that because of the circumstances there. So, we wouldn't automatically pull it back because we understand the context.

But that's not universal, of course, that's a decision taken—

It's a health board decision, yes.

Okay. Thanks for that. Just moving on, it says here, at point 20 in the paper:

'Health Boards are using clawback money to invest in primary care dental services and making these services more accessible to vulnerable patient groups.'

I have no doubt that that is happening in areas. A suggestion is clearly being made to us—certainly, it has been made to me personally outside this committee—that money taken as clawback from dental contracts isn't necessarily all put back into dentistry. Can you, hand on heart, say that you think it is?

11:30

I can categorically give you the assurance that we've invested in other services: in conscious sedation, in—

I can't give that reassurance. We've been quite open in ABMU's return about the fact that, two years ago, for various reasons—some inherent in the contract, and others local—we had a significant underspend and we were not in a position to reinvest it at that time. It was £2.2 million. What we've had since then, because we realised that there was a bit of an inevitability about our continuing to underspend and, therefore, it would go to the bottom line, we came up with a three-year investment plan, based on the predictability of underperformance moneys likely to be coming through, and where we needed to reinvest. We came to an agreement within the health board, and then with Welsh Government colleagues, that we would invest additional moneys over a three-year basis until we could guarantee we could spend the whole ring-fenced moneys by a year and half's time.

The particular circumstances that meant that we were unable to invest all the moneys were, no. 1, as we've already talked about, the vagaries of the contract, and, No. 2, for particular local reasons, to do with a perception that the LDC developed that we were not being open and transparent in the way we were re-awarding activity, the health board decided it would adopt a formal tendering process any time it was reinvesting moneys. And though that's marvellous in that it's definitely open and transparent, it takes an awful long time, and we found ourselves unable to reinvest in-year. But now that we have a three-year plan and we've engaged the staff required to ensure that we can keep up to speed, we have illustrated where we invested moneys last year, with £600,000 to £800,000 more this year and next year, and we'll reach the ring fence within two years.

I fully recognise that you're talking from the perspective of individual health boards as well. We need to have an all-Wales outlook. Again, from the paper, health boards are using clawback funds to support the preventative agenda. It sounds positive. It's not what we're hearing from the BDA:

'clawback funds are being used to fund Fluoride Varnish courses.'

We were told specifically by the BDA that fluoride varnishing isn't able to be done through current systems and they tell us they have made a request that money should be taken out from the clawback pots and reinvested in things like fluoride varnishing. So, it doesn't correlate with what we're hearing.

I certainly can assure you that, in Cwm Taf, that's exactly what we've done, because we employed our own oral health educators and we've trained them in fluoride varnishing. Therefore, those schools not covered now by Designed to Smile are now being covered by our own oral health educators, who are applying fluoride to children in those non-Designed to Smile schools.

I want to make it very clear we don't believe that there aren't pockets of good practice. You wanted to come in.

Just to say, from an Aneurin Bevan health board point of view, that clawback moneys have been used to put into place minor oral surgery services. We have a domiciliary service close to home, whereby the community dental service works very closely with the general dental services and, as part of that, we've looked at prevention. We have an oral health improvement practitioner who works with the general dental service practitioners and actually provides the preventative side of the contract for them.

We've increased our prison dental services. We've actually increased our access to urgent care and, also, we've invested some moneys into trying to reduce lists in orthodontics and put in some non-recurring moneys as well. So, anything that has actually come back to the health board, we've actually tried and looked at population need, looked at the reasonings behind the issues that the LDC are coming up with, and also the other people who are in the health board and actually targeted the funding towards those.

11:35

The microphones work automatically. You don't have to press anything. 

Could I just add one thing? We're also moving a little bit from services being ring-fenced, not financially but from a clinical point of view, because there are boundaries that overlap between general dental services, community dental services and specialist services. What we've tried to do is look at the whole system as far as investing is concerned, because if you press one little bit, another bit comes out. So, for example, we've looked at intermediate services that speed up processes for patients to access specialist care rather than going to a hospital site. So, that is part of our budget because it's actually taking pressures off general dental services for those groups of patients and also reducing waiting lists and targeting the more vulnerable. So, it's actually looking at a whole system, so although budgets are GDS or hospital, we're actually now looking at them as a whole system across the board. And all of the initiatives we're doing with the general dental services at the moment and general practitioners are moving them into that programme to say, 'Let's enhance your skills as part of that.' And some of the clawback money that we've had—I hate that word, 'clawback'—we've invested into that side of things as well. So, there's a different environment out there at the moment rather than just completely ring-fencing the budget for this particular bit of the service. As a health board, we look across the whole service now.

Okay, time is marching on so some more agility. I know Julie is very agile, so Julie. [Laughter.] 

Yes, thank you. Thank you, Chair, very much. [Laughter.] Good morning. I wanted to ask you about training, recruitment and retention. So, what are the main challenges facing the training of new dentists in Wales?

Are you happy for me to open that? I think the dental ones are no different to any other healthcare professionals at the moment. So, if you're a medic—and I sit around with medics all the time—they're having similar sorts of conversations. I don't think there's a simple answer to it but there are lots of key bits that I think we all seem to feel are important to that. There's certainly a generational issue. When I went through, the first thing I wanted to do was own my own practice. That's changing. The new guys coming through don't want that; they're looking at more life-work balances, which is great. You can't criticise that, but it does affect the dynamics, particularly in their late 20s and early 30s because they don't want mortgages, they want a bit of flexibility within that.

They're looking more broadly in the sense of their career over 30 to 40 years and what they want to do during that period, so that changes those early days. So, the younger dentist side of things—we are now dealing with a different group of individuals and I think, in Wales, because of the peculiarities just generally, as in medicine, and we have to look a bit more innovatively at how the demands of those individuals—. It's not like when I went through when it was very predictable, really. That's one issue with it.

I think the younger dentists coming through don't like the new contract. It's as simple as that. We see them in our health board from a training unit, where they have a very protected environment, and those within general practice, and you do see the sparkle go from their eye after a year or so because that contract is not a good environment. So, some of the changes we were talking about earlier on will start to affect that.

There is still a line between Wales and everywhere else. I speak to my colleagues in England and they say, 'I'm not going to Wales because—'; they see it as a barrier. So, it's how we break that down. One of the ways Wales has started to break that down and hopes to break that down is with something called national recruitment. So, a number of the key parts of the career pathway, where there's dental foundation training, dental core training, specialist training—a lot of those now are in national recruitment. And the idea with that is that we attract people in from England to come into the area, good people, and they will stay. We're finding that they're not necessarily staying; they're coming down, they're doing a year and then moving back to where their roots are. So, national recruitment is almost counter-productive at the moment—that's the feeling we are getting in our health board, that individuals who are coming in under national recruitment are not staying after a year or so. 

Specialist training is another layer within that. Very similar—the issue with that is that specialists, when they go through the training, to keep them they need the next bit and we're not really good sometimes at thinking ahead four or five years to say, 'Actually, this is what we want from a service point of view.' I think a lot of the training programmes need to be service-driven going forward, not historical, what's happened in the past. What are our service needs? We mentioned minor oral surgery, special care dentistry. We really need to be bumping up the training for those individuals and modern training, because that's what the service will need going forward, and having those individuals working within a primary care, community care environment rather than a hospital.

So, there's a whole range of things in there. I'm hoping HEIW, the 'I', our innovation, will be a key bit, because I think that's where we have to do. We have to start thinking outside the box.

11:40

What do you think is the most important thing that could be done that would make people want to stay in Wales, or come to Wales, to begin with? Because you've obviously listed quite a few barriers, many of them are historical barriers.

My personal—. This is a personal thing, and especially if you're looking at general dental services—there's a huge gap, I think, between foundation training and what goes on next. Young dentists want to see a career, a lot of them will go off and do courses et cetera and then maybe go into private practice. We need to look at what their aspirations are within the service point of view—from that point, and through to their early 30s. And also that transition from a practice point of view—how do you support them in a contract that people are uncomfortable with, but how do we take them through that?

There is a gap there, I think, at the moment, from early years to the early 30s, from a career point of view, especially for the NHS side of things. I think if we start plugging that, then we will attract people into Wales because we'll be doing something different and they see a future for them in Wales that is in line, and supported, by the health boards and the NHS and HEIW. So, I think that's the key bit to that gap there. We're losing a generation there, I think.

I just wanted to add about specialists and consultants. The experience we've had in Aneurin Bevan university health board is that, for the past two and a half years, I've been trying to get a paediatric specialist in dentistry. I'm thankful to say I interviewed last Friday, but it has taken a very long time. One of the reasons for that is that so few specialists in paediatric dentistry have been trained in Wales. That has actually been addressed recently, and I know that we've got two new specialist paediatric training pathways that will be starting in September. But that being said, to try and attract people over from England and from elsewhere into Wales has been quite difficult for us.

I'm really mindful of the fact that we've got people who are living over in Bristol, for example, who, now that the bridge toll will be disappearing, maybe we'll be able to start to attract. And the person who I interviewed is actually from Bristol who would be able to be coming across the bridge. So, that's very useful for us.

The other aspect about the retention and recruitment is about dental care professionals. We've been talking about the reform for the general dental services, and without having the numbers of dental care professionals trained and being able to support us, and certainly, with our dental nurses, attracting in our areas of deprivation and getting them to start working in our local general dental practices, it's really important that we have support and funding in order to be able to move the new contract on—it's not a contract, the new reform, and that's another issue.

Yes, the word is 'reform' not 'new'. It's time we moved on to a—. Sorry, we're going to have to cut to orthodontics, I'm afraid, now, because of time. So, some reformation of orthodontics rather than new, if you like.

Thank you, Chair. I'll try and wrap my question up—three questions—I'll try and wrap them all up into one, actually, because what we've heard is that the provision of orthodontic services is not consistent across health boards. We heard that in Hywel Dda, for instance, there's only one provider. Cwm Taf have specialist providers in Cardiff but not in Cwm Taf and so on. So, that was the first point. The second point, obviously: the inconsistent levels of waiting lists. And, again, we heard that Hywel Dda—very high; Aneurin Bevan—very low. That is problematic.

So, what is it that we can do to address those two issues: the consistency of service and the levels of waiting times? So, if we deal with those two things first, please.

I can start off. I can't speak for other health boards, but, obviously, I'm aware of them. One of the issues you've indicated is a geographical issue—the further west, the further north you go, everything becomes more difficult, and that's not unique. I think the answer to that is to look at different models of delivering care, using orthodontic therapists, dental care professionals, as part of a network. That needs the profession as well as health boards to engage on that concept to facilitate the development of those networks where you haven't got the traditional model of three dentists working together, you've got one dentist and three dental care professionals, as part of a network that allows access into community clinics, where you don't necessarily need a dentist going there all the time. So, it's changing the model of delivery to reflect the skill mix that we're developing as well. That's one issue around that.

The other issue from a waiting list point of view is that I think we are sensitive that the waiting lists are not robust at the moment. They're slightly different in different areas. In our area, we've got a waiting list to treatments, other areas have got waiting lists to assessment and then treatment. We've got straight to treatment, and even within our own health board it's different between different boundaries, and we try and encourage referrals to the shortest waiting listing, which is between nine and 12 months, compared to the longer ones, but dentists like to refer into their areas. One of the areas around that is to give patients more choice and give them the information to say, 'You could go in different directions.' But I think the orthodontic waiting list, we know, anecdotally and from our own experience, is not particularly robust at the moment. Steve Richmond's report has highlighted that. And I think from a health board's perspective, we are now looking more proactively at the waiting list. E-referrals are going to help us with that—

11:45

—because we will have a lot more information coming in real time. What we won't have is outcome, which is the other bit with that. It's all right to say, 'What's coming in and what's happening there?' So, we will work on that, and that will give us real time information to be able to inform the public, inform dentists and also inform the profession as well to say, 'Actually, this is inappropriate'—the wrong word—'but it can wait, maybe three years' et cetera. But that's that piece of work that—. I think most health boards are holding back on e-referral because that will automatically give us that real time data around it and robustness.

So, you think that that is potentially key to the—

It's a major issue. I think that's a major issue for all referral, because that will give us a pattern of referral to be able to target resource into areas that we feel need more support, but we'll have the information behind it to be able to make those decisions.

The provision of services, of course, as you've already identified, is different depending on different areas. Somewhere like Hywel Dda is very different to somewhere like Cwm Taf, so in Cwm Taf, you've effectively outsourced your specialist services to Cardiff and Vale, but that's easier in a populous area where you've got good transport links than it would be in somewhere like Hywel Dda where that's just not doable. So, presumably, that's all part of the process that you have to go through in terms of ensuring your consistency. Yes, okay. I think that's fine, Chair.

Good. Time for Rhun to wrap up on matters pertaining to children.

Yes, just very quickly, your written evidence mentions inequalities that persist in children's oral health in particular. How do you think that those inequalities can be reduced? As a background, we discussed this morning how appalling I and my fellow committee members feel it is that any child should be without regular access to dental treatment and that surely we should be aiming for nothing short of universal access.

Maybe if I can start off on that, because we recognise in Cwm Taf, obviously, that dental care in our under-fives was the worst in Wales and we've had to do something about that. So, last year, we started off an initiative called Baby Teeth Do Matter, and we started that off initially in Merthyr Tydfil where we've aligned general practice with dental practitioners so that either the dental practitioner or a dental therapist actually goes into the baby clinics—so health visitors and one thing and another—and are part of the team there. And we're encouraging mothers that as soon as the first tooth appears, actually, they need to go to the dentist.

We've run that pilot now for just over a year and as well as the concerted effort in Merthyr Tydfil, we've also advertised more widely within Cwm Taf. Consequently, in Merthyr Tydfill, we've seen nearly a 40 per cent increase in the number of under-twos who've attended, and we've also seen significant increases across Cwm Taf. There's been a ripple effect and we've got 1,500 more children who are now attending the dentist than the reference period in the previous two years. 

They can get access.

We're very fortunate in Cwm Taf that, at the moment, we've got over 50 per cent of our practices that are actually taking on, and we've got that provision in Merthyr Tydfil—actually, more than 50 per cent in Merthyr Tydfil, so that's one reason we started off there. It has clearly been a success. There's been a ripple, as I said, across Cwm Taf in terms of the numbers. We've also seen a ripple effect in terms of adults, because when they're bringing their children along, they're also accessing dentistry as well. So, we've seen about a 4,000 increase in the number of adults who've accessed a dentist as well in the last 12 months.

So, the next stage now, obviously, is to expand that service and, at the moment, I think we've got another nine practices across Cwm Taf that have said that they're interested in taking on that initiative. It doesn't work for everybody, but clearly it's made a significant difference where we've introduced this in Merthyr Tydfil.  

11:50

What happens to today's four and five-year-olds, not the one and two-year-olds that will be four and five, who hopefully will have benefited from programmes like that, and the general Welsh thrust of targeting the younger children? What happens to today's four and five-year-olds who we know can't get access to dentists at all, and it's still a rather crucial age in terms of their dental health?  

In terms of the Designed to Smile programme, which I'm sure that you're all aware of, the actual direction is to nought to five-year-olds now, and each of the health boards—  

Five-year-olds. So, that's it's—

No, it's nought to five-year-olds, so therefore they're actually included in it. The four to five-year-olds will be included in Designed to Smile. It's a targeted programme, as you know, that's for the areas of the fourth and fifth quintile of areas of deprivation. But, each of the health boards have actually been quite creative in the way that they're actually starting to look at those children who are not accessing dental care. For example, in Aneurin Bevan Local Health Board, we have dental therapists who used to do the fissure sealing programme who are now working with Flying Start health visitors, going into the health visitor hubs, using mobile dental units, using those dental therapists who have actually got those skills to be able to do check-ups, but also to apply fluoride varnish to try and target those very difficult-to-reach children, and therefore working as well with local—. We have, in Aneurin Bevan, seven access dental practices, whereby we're then referring those children on to those practices so that they're seen. So, we're doing something that's similar to Craige, but we in Aneurin Bevan are looking at it in a different way, and using our therapists to actually do that quick check-up first, so that they can identify those children who really are high need who've already got decay. And they would be channelling those probably to the community dental services to be able to try and see if we could get those seen sooner rather than later.   

That's definitely the aim. We've been doing quite well working in, not silos—I'll try to avoid that—but the theme throughout this has been more integrated working. So, Designed to Smile, which always did work quite closely with the community dental service, is now under the new guidance they had last year, which lowered the age group they should be focusing on, and it was also encouraged—advised strongly—in the circular that they needed to be training the health visitors, midwives and school nurses formally, and engaging with all the training practices. They're doing that, so they're working more closely with the general dentists as well as working alongside the health visitors, which they are in our health board and others, so picking them up there. We've basically made sure that our primary care team, our Designed to Smile and CDS teams, work like that, and if they find, as they sometimes do, that a dentist is not accepting children, they're on the phone straight away and we sort that out.   

There's also a Designed to Smile e-learning programme called 'Designed to Smile into practice', and that is actually going to be a link for general dental practice, so that they understand the concept of Designed to Smile, understand the concept of prevention and, actually, it's part and parcel of a quality improvement programme whereby they're able to, using that methodology, achieve their silver award in terms of quality improvement. So, we're all aligned together, trying to work together, in trying to target those children that are actually not accessing dental care in different ways.

I just thought, picking up your earlier point about fissure sealing and the moneys for that, there's actually provision in the circular that has changed the direction of Designed to Smile to pass resources across to general dentists to facilitate them being able to do that. 

We also work very, very closely with the health visitors. For example, in Aneurin Bevan, we have an oral health toolkit whereby the health visitors, when they see them at certain ages, are able to identify those children that are not accessing dental care. And we've been working with those health visitors to be able to identify those children not accessing it, and move them on to those dentists that are actually accepting new dental patients. So, there are all sorts.

There's also another programme, called Lift the Lip, which has just been piloted. I know that it was in Swansea and in north Wales. It comes from Australia and New Zealand, where you have healthcare professionals asking parents to lift the lip so that they are able to see whether or not these very young children have already got decay in their teeth. It's been very successful. The health visitors have said, 'Rather than us giving information about oral health, we're actually seeing these things and understanding how important it is to identify these children and move them on to those services where they need to be seen.'

11:55

Can I just add one thing, which is slightly different? We're also seeing, when we talk about children, that the late adolescents are becoming a vulnerable group with high needs because they're going outside parental control, et cetera. So, there is a move to start looking at that group as well. And, sadly, particularly with me around this table, the other big pressure group for us is the ageing population with complex medical needs, who are already having complex dentistry during their lifetime. That's going to be a huge responsibility and target for us as health boards to ensure that they have access to care, whether that's in care homes, but more likely within their own homes as well. That's another big pressure for us. But we are beginning now to focus on that as we start to develop some of these programmes.

It's especially important, as we've discovered already the link between dental disease and heart disease, but that's more for another day.

A allaf ddiolch yn fawr iawn ichi i gyd? Mae'r amser wedi dod i ben ar gyfer y sesiwn yma rŵan. Diolch yn fawr iawn ichi am eich presenoldeb yn y lle cyntaf, am ddarparu'r wybodaeth ysgrifenedig ymlaen llaw a hefyd am ateb y cwestiynau mewn ffordd mor fanwl, aeddfed a graenus. Diolch yn fawr iawn ichi. Gallaf gadarnhau y byddwch yn derbyn trawsgrifiad o'r trafodaethau yma i allu cadarnhau eu bod nhw'n ffeithiol gywir. Gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i chi.

Gallaf gyhoeddi i'm cyd-Aelodau nawr y byddwn yn torri am egwyl o hanner awr dros ginio a byddwn yn dod yn ôl i fan hyn am 12:35. Diolch yn fawr.

I'd like to thank you all. This session has now come to a close. Thank you very much for your attendance, firstly, and for providing the written evidence beforehand and also for answering the questions in such a detailed, mature and polished way. Thank you very much. I can confirm that you will receive a transcript to check for factual accuracy. With those few words, I'd like to thank you very much.

I can announce to my fellow Members that we will now break for half an hour for lunch and we'll come back here for 12:35. Thank you.

Gohiriwyd y cyfarfod rhwng 11:57 a 12:39.

The meeting adjourned between 11:57 and 12:39.

12:35
5. Deintyddiaeth yng Nghymru: Sesiwn dystiolaeth gyda Deoniaeth Cymru ac Ysgol Ddeintyddiaeth, Prifysgol Caerdydd
5. Dentistry in Wales: Evidence session with Wales Deanery and the School of Dentistry, Cardiff University

Croeso nôl i bawb i sesiwn y prynhawn o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Rydym ni'n cynnal ymchwiliad heddiw i ddeintyddiaeth yng Nghymru. Rydym ni wedi cael bore o gymryd tystiolaeth oddi wrth gwahanol fudiadau. Rydym ni hefyd wedi derbyn toreth o dystiolaeth ysgrifenedig oddi wrth bawb. Mae'r sesiwn dystiolaeth ddiweddaraf yma gyda Deoniaeth Cymru ac ysgol ddeintyddiaeth Prifysgol Caerdydd. Felly, i'r perwyl yna, rwy'n falch iawn i groesawu'r Athro David Thomas, cyfarwyddwr addysg ddeintyddol ôl-raddedig, Deoniaeth Cymru; Dr Richard Herbert, deon cyswllt, Deoniaeth Cymru; a hefyd yr Athro Alastair Sloan, pennaeth yr ysgol, ysgol ddeintyddiaeth, Prifysgol Caerdydd. Croeso i'r tri ohonoch chi. Diolch yn fawr, fel rwyf i wedi'i ddweud eisoes, am y dystiolaeth ysgrifenedig ymlaen llaw. Mae'r meicroffonau yn gweithio'n awtomatig, so nid oes eisiau cyffwrdd â dim byd. Felly, yn ôl ein traddodiad, awn yn syth i mewn i gwestiynau, ac mae gyda ni rhyw dri chwarter awr. Felly, dechrau efo Rhun. Na, sori; dechrau efo Dawn.

Welcome back, everybody, to the afternoon session of the Health, Social Care and Sport Committee here in the National Assembly for Wales. We are undertaking an inquiry today into dentistry in Wales. We've had a morning of taking evidence from various organisations. We have also received a vast amount of written evidence from everybody. This latest evidence session is with the Wales Deanery and the school of dentistry, Cardiff University. To that end, I am pleased to welcome Professor David Thomas, director of postgraduate dental education, Wales Deanery; Dr Richard Herbert, associate dean, Wales Deanery; and also Professor Alastair Sloan, head of school, school of dentistry, Cardiff University. Welcome to the three of you. Thank you very much, as I've already said, for the written evidence that we received beforehand. The microphones work automatically, so there's no need to touch anything. As per usual, we will go straight into questions, and we have about three quarters of an hour. So, we'll start with Rhun. No, sorry; we'll start with Dawn.

12:40

Keep up. [Laughter.] Good afternoon. Nice to see you all. From evidence from the school of dentistry—. This is a question to all of you, but the evidence that we have from the school of dentistry states that you're not struggling to fill undergraduate places each year, but there are still relatively few applicantions from students in north and west Wales. Do you think that that is the case, and, if so, is there any action that could be taken to try to improve that situation?

So, yes, we don't have a recruitment problem. So, we're recruiting anywhere between 590 to 670 applicants to the school of dentistry. That's around about five to seven applicants per place that we have. We have 70 places available. Going back over the last five years, we do have an issue, mainly with applicants from across Wales, where our application rate from Welsh students is around about anywhere between 11 per cent to 15 per cent. So, for example, for 2017, of the 561 applicants that were scored to be offered a place at the school, only 62 were Welsh applicants, which represents about 11 per cent.

Now then, when we look at that conversion into interview, we are looking at well over 50 per cent of those students were offered interviews through our multiple mini-interview process. So, they went forward for interview. And, of those 53 per cent that we interviewed, we were making the best part of 75 per cent of those students an offer. So, of the 62 applicants that were from Wales, around about 30—almost half—were actually being made an offer. But we consistently have struggled, and I've gone back over the last few years—. We are having an application rate from areas of Wales that's anywhere between 11 per cent and 15 per cent. So, we have work to do to go into those areas, which has been set out in a programme of work that I've initiated as the head of school.   

Sure. So, have you been able—? You said you've initiated a piece of work around that, and that's to be welcomed. But have you been able to ascertain any particular reason why that should be? Do they apply to schools in England?

Some do. Some do, and some students in the north apply at Liverpool and Manchester. I'm an external examiner for year 1 BDS at Liverpool, and a good percentage of their undergraduates that I have been seeing in year 1 are from north Wales. I actually think that we're not getting into some of those schools and environments to show the aspiration of the students we've got for the chance and the opportunity to come and study dentistry and to study those higher level subjects within their own country, and within the UK. I think we have a real problem of getting a reach into those students. So, my challenge and my view is to actually put ambassadors—. We work with the Welsh Dental Society to use practitioners as ambassadors to go into those schools and those areas, with documentation, to talk about dentistry as a career and the opportunities that the students can have. And we have also student ambassadors that can do the same as well.

Of course. Okay. And, of those students, how many of them—whether they are from Wales or elsewhere—actually stay in Wales to practice afterwards? Do you know?

No, because—

Well, dental foundation training is the year immediately after they graduate, and, on average, it's about 30 of the Cardiff individuals that are on our Welsh schemes. The range is from 21 to 34. I've looked at it, and, going back for the last four or five years, we're looking at that sort of range. It's fairly consistent in that it doesn't go outside of that.

Okay. Okay. Just a general question about funding for the school of dentistry: are there any issues with that at the moment that you've got particular concerns around? 

So, funding is essentially three reasonably separate strands. Student fees come into the university, which come in centrally to the university, and I have a one-year expenditure budget. Student fees, as I put in my evidence, tend to cover the cost of the academic staff that are employed by Cardiff University. The majority of my clinical academics are employed full time by Cardiff University. I have my non-clinical staff, who teach years 1 and 2 but also lead a lot of research in the school. And we have a non-staff budget, so I can actually have career development and professional development within the school. So, that's one stream. That's the money that comes in there, and, obviously, the Higher Education Funding Council for Wales money comes into the centre as well.

The infrastructure where the students are placed comes through dental SIFT, which is money from Welsh Government that actually comes directly into Cardiff and Vale health board. It doesn't come to the dental clinical board, which is the clinical board for dentistry, which is based in the dental hospital, it doesn't come to the university or to myself as the head of school—it goes into Cardiff and Vale, where it is not protected from many of the cost-reduction processes that are in place within Cardiff and Vale. That's about £12.8 million. It has been reasonably around that for the past three or four years, and I'm just waiting to—. I get a copy of the SIFT letter. It's called dental SIFT—service increment for teaching. I get a copy of that letter every year from Elaina Chamberlain and her office, once we've had ministerial approval of the SIFT allocation.

Our outreach places—. We put our students into clinical practices in the community dental service within Wales, and also we have a couple of other outreach places in England. That money and that funding comes from medical SIFT, which is about £1.1 million. So, there are three separate strands for that.

Is there an issue around funding for SIFT? I have concerns, because that money is never ring-fenced—it's part of the cost-reduction programme that Cardiff and Vale put in place. We deliver the activity and we can continue to deliver the activity, but there's no doubt, with those cost-reduction pressures, it puts pressure on my clinical staff in terms of working in an environment that is safe for patients.  

12:45

So, from your point of view, then, would that be more of an issue of the administration of those funds rather than the amount—in the sense that, if you had everything that was allocated to Cardiff and the Vale, it would be okay? I mean, you could always do with more money.  

I could always do with more money. It's essentially flatlined for about two or three years, so there will be the inflationary questions there, no doubt. And, of course, when we're putting some of that—we have to pay for placements when our students go up to Wrexham, for example. And, of course, the health board there and our colleagues there require a certain amount for accommodation and for the clinical placement. Those prices, those rates, may increase. If our funding has flatlined, there are additional pressures there.

The university has pressures as well. There's no doubt, in the higher education sector, with the flatlining of fees, there are pressures. So, I can't always find some of the money within my other budgets to up that. But if I could have that SIFT controlled within the school of dentistry, alongside the dental hospital and the dental clinical board, I think, actually, there is a lot more we can do. And certainly, we can take some of the pressure off some of my clinical staff.

We have an environment where I need one student supervised—not by one member of staff to one student; I have about six students to one member of staff. And that also means you've got six patients, six students, one clinical supervisor. And I'm not prepared to increase that number. It's quite critical that we maintain that number.

Could I just add that, obviously, the introduction of the new NHS body—? Health Education and Improvement Wales will be responsible for dental SIFT in the future and the commissioning of dental SIFT. So, I think there's hope that we may well be able to commission the service in a different way in the future. But, obviously, it's not going to happen in the very short term, because, obviously, the organisation doesn't start until Monday. There's all the chaos that—

Yes. Tuesday, everything will be fine. [Laughter.]

Probably Wednesday or Thursday might be more appropriate. [Laughter.]

But I think that the idea of that SIFT going to the clinical body or bodies is sensible, rather than it coming to the university, although that's an option we can look at, because the dental hospital as a centre for excellency, if you like, for dental education, is a three-legged stool. It's clinical service and clinical provision, it's education and it's research, and NHS staff are equally as important to the delivery of all of that, alongside university staff. So, it has to be seen as one big entity if we're to be efficient and innovative in how we drive dental education forward. 

Okay. I was going to ask you a question about the—. Thank you for that. I was going to ask you a question about the cost pressures on students, but you'd already said, actually, you don't actually have a problem recruiting students to the courses. Is it far more expensive—

Dentistry is far more expensive. 

—to study dentistry in Wales than in England?  

No, I don't think so. I think, actually, it's postgraduate study. I think Ben mentioned in his evidence earlier on this morning about the cost of fees for postgraduate degrees at Cardiff University, but, generally—. Alastair would be in a better position to answer.

Fees-wise, we're the same across the sector in the UK. So, from an undergraduate perspective, Cardiff University plays on its strength of being in a capital city the size of a large town. It's cheaper to live here than it is to live in Manchester and to live in London. So, we're attractive as a university city. The issue will be, I think, that numbers are falling across the sector, so—. Not drastically—no dental school is struggling to recruit—but the numbers, certainly in the last four to five years, have reduced a little bit. That may be to do with the cost of student education now, and the perception of fees and what student fees are there.

12:50

The other thing, Alastair, to mention, of course, is that students in dentistry, in the final three years, work a 42-week year, and it's a very intense course. I don't know any dental student that has a job outside of their studies, and so they have to support themselves for 42 weeks of the year, so obviously their rent and living expenses are much more to the fore, and I guess that's true of medicine.

True about medicine—and the length of course, as well.

The length of course is four years, so the average, I think—. [Interruption.] A five-year course. The average, I've been led to believe, of debt, student debt, is between £40,000 and £50,000.

And rising.

And rising, absolutely, yes. It was from the evidence that we'd had from the British Orthodontic Society. They were talking about orthodontic academic postgraduate qualifications and that Cardiff uni had one of the highest course fees—

Not from this year onwards.

I had a robust conversation with the chair of our academic and recruitment panel, because we were significantly out of kilter.

That's been addressed.

Excellent, excellent. Okay, just a final question from me to the deanery, really. Your written evidence refers to dental care professionals and skill mix. Can you tell us what you consider is the importance of the role of dental care professionals, and how they can support improvements in the dental sector?

They're absolutely paramount. In fact, we should be using dental care professionals more. Certainly, I'm sure the chief dental officer later will be telling you about the GDS reform programme and how dental care professionals can be used. For example, at the moment, we have about 5,000 dental registrants—that's dentists and dental care professionals. Three and a half thousand of those are dental care professionals. We need to be using, certainly, dental nurses more. We certainly have a very active postgraduate training programme for both dental nurses and dental care professionals. We have a foundation training programme for therapists. So, we are absolutely supportive of those members of the team.

The wider skill mix is something that dentistry needs to embrace. There is evidence that dental care professionals can be used very successfully. You may not know—Dr Lloyd may know—I was chief dental officer here until 2016, so it's something that I've advocated in the past. In fact, the former GDS reform programme—all of those prototype practices replaced dental associates with dental therapists, because it was seen that that was a more effective use of the team, using a more preventative approach to dentistry.

There's also a significant reward for the individuals involved, because, if you upskill them, it gives them a career pathway within the practice. They feel more valued; they feel that they get a greater reward and greater satisfaction from doing the job. The concept behind it, really, is that dentists should do only things that dentists can do, and other people should be developed and upskilled so that they can provide that service. It's very expensive to train a dentist.

Absolutely, and this is very much the model that we've looked to adopt in other parts of the health service, so there's no reason why dentistry shouldn't.

It's £35,000 a year to train a dental student; £11,000 a year to train a therapist—and a shorter course. Obviously, they can't do as much, but there's certainly—

But what they can do, they can—. Yes, absolutely. Yes, okay. Thank you. Thank you very much. Thank you, Chair.

Hapus? A symud ymlaen i Rhun.

Happy? Moving on to Rhun.

Yes, a number of questions on recruitment and retention. Just picking up on a couple of issues already discussed, when we've been looking at medical training, people are aghast that the figure of the proportion of medical students in Wales who are Welsh domiciled is as low as 25 to 30 per cent. Obviously, with dentistry, it's much, much lower than that. What's been done to try to address that? Everything from guaranteeing an interview to Welsh-domiciled students—potential students, rather—making applications, other positive discrimination measures that have been considered in medicine, for example. 

12:55

So, when I took over as head of school last August—I was in transition for six months before that—we had something called a periodic review, which is a university process that happens every five years. So, this gave me an opportunity to look very carefully at a number of key areas in the school, one of which was recruitment of Welsh-domiciled students, and one was also recruitment of Welsh-speaking and first language Welsh speakers into the school who could then, hopefully, when qualified, return to a community where they can practise through their own language. What we've done in—. This document reports next week. So, we submit that to the university next week, and there is a meeting at the end of October with an external panel that will talk to us about that and give us feedback and comments. 

Will that be a public document at that stage? Is it something that can be shared with us or—?

I think the periodic review can be a public document. It's not a closed document once it's reported—

I'm just thinking in terms of if it's information that we could—.

As long as I—I will double-check with the university, but I'm more than happy to make that available. 

I'm more than happy to make that available. 

So, hopefully, by the end of October, recommendations we're making ourselves—it's very much a self-evaluation—. One of those is actually creating documents now and actual information about the programmes bilingually, so we actually make those fully bilingual, the website becomes fully bilingual, and then we are actually now going into those areas and schools where we want to try and attract applicants and that's both with our students, it's working through the Seren network for medical and dental recruitment. In fact, I have an e-mail that I just replied to last night to go to a workshop or send some of my staff to a workshop at Parc y Scarlets at the end of October. It's about inspiring and actually telling those students what we can do. So, it's being very proactive and going into that area and those communities.

And it appears from some figures out last week that there's been some success in medicine in increasing the number of applications from Wales significantly. 

There has. There has, absolutely. 

So, you're confident that you can head on a path that gives you similar results in—

I see no reason why not. We had, in the last 12—so, in the last round since I took over, we had an increase of about 15 to 20 more applicants. That was with trying to get this off the ground. We're now in a position where we will be actually proactively going into schools and promoting dentistry and looking at applicants.

And I'll ask this as well, because these are all questions that are coming via me, but, from dentists on the whole, people that I know: is there room, do you think, to develop dental training alongside the new centre for medical education in Bangor? Because I'm told by dentists that they would like that to be a means to increase capacity in dentistry as well. 

I think that in the future there will be—. We were talking just outside this room, actually, about developing a new process for dental training. I think we can't just look at undergraduate and postgraduate training as separate entities. We need to be thinking about a longitudinal approach, which would mean developing a new approach from the undergraduate perspective, having a hub-and-spoke system. At the moment, as you know, we have two outreach centres for undergraduate dentists in Wales: one in Mountain Ash and one in St David's. Also, the students go to Wrexham to the community dental services. We have two outreach centres for postgraduate dentists, in Porth and in Baglan, but none of these people actually meet each other. So, it seems to us—Alastair, myself, and Richard—that we need to be thinking of a bit more of a flexible approach, and we'll probably need to have more spokes centres, and that would include places in west and north Wales.

So, my vision—. It will transcend my time as head of school, but my vision would be a smaller hub, as David says, where you have specialist clinics, oral surgery, oral medicine, orthodontics, paediatrics, a phantom head clinical skills laboratory and an initial clinic for our very junior students to have clear supervision. But the opportunity to build on what is a key success for the school, which is our outreach, is there, and I would like to see more—managed carefully—creative spokes, working with colleagues in postgraduate where we have the establishment, and we can get foundation trainees, with undergraduates, with dental care professionals. And putting actually—. Using the potential opportunity in the north would be fantastic.

And that's a means to increase potential capacity for—

I think it will, because the more outreach places we have, the more opportunity of choice we give to the students. So, certain students might want to go to the north, and certain students may want to stay in south Wales, but we can give that opportunity of choice, as long as we can maintain the standard of clinical education that they get. 

The two postgraduate units, dental foundation training units, that we've got, one in Porth and one in Port Talbot, were sited in those locations because they were areas of high need, and I think that we would be looking to develop these spoke units in areas of high need, working with Welsh Government and the local health boards. We need to think long term as to how we’re going to develop the workforce that we need for the future, and it doesn’t happen even in five years; it’s a long process, particularly if you’re going to go on and develop specialists. We need to find ways to encourage people and incentivise—if that’s the right word—people to work in those areas and to want to work in those areas.

13:00

Okay. The national UK recruitment process—what are the elements of it that perhaps aren’t working as well as they could in relation to Wales and our needs for—

We’re talking about dental foundation and national—

There are three recruitment processes. Richard is obviously responsible for the dental foundation one, and then there are also—the next level up is the dental core trainees and then specialist training. So, they’re all national but they are slightly different processes, but Richard might be able to articulate the foundation issue.

I think it’s important to understand why that national recruitment process came about. It was an agreement between ourselves, England and Northern Ireland to go into a national recruitment process that was a cost-effective, transparent process that was fair to all the applicants. It is a process that very much follows the way the medics have gone with that, and it fills all our places in Wales. So, those are the positive sides to it.

One of the issues that were highlighted was that, yes, it fills your places, but does it fill places with dentists who are likely to stay and work in Wales in years to come?

Well, I can tell you that, once we get dentists to come and work for us—the number of Cardiff graduates, as I’ve said, averages about 30, but the number of people who do DFT, dental foundation training, in Wales who are retained in Wales in their first year afterwards is between 45 and 50. So, there’s a range of 38 to 60 in any given year, and that’s between 50 per cent and 65 per cent retention. So, we’re retaining more than just the Cardiff graduates, and that is for that year.

There are disincentives to that if they’re going to go on into dental core training currently. They may have been addressed in the new review body review and then the decision on—Welsh Government’s decision to increase things by 2 per cent for doctors and dentists, but we haven’t actually seen the document yet. Once we see the document, we will know whether they’ve addressed it, but currently there is a very marked difference between the salary in dental core training and dental core training in England, and when I say very marked, it is very marked. I mean, dental core trainees are £4,000 worse off in Wales. And when they’ve got the levels of student debt that they’re bringing forward, that is a big issue. In dental core training year 3, that is a £12,000 gap.

Is that something that can be addressed? It's just a financial question, a question of resources.

I think it is a financial question. It’s a financial question for Welsh Government, it’s a financial question for the local health boards, because, if you have dental core trainees at level 3, then they are costing them a lot of money, and that money has to be found if it’s going to be an award.

And are you seeing evidence that people are putting Cardiff or Wales lower down their list than—

Yes. It’s the Welsh dental core training posts, and we are getting people who jump out of the posts—

We do have people who have actually taken the post and then realised that the money is different to England and have then rejected the post. We’ve had two or three people this year who have been in that position.

I think the other thing to note, though, is that dental core training, unless you’re going forwards in specialty training, is entirely voluntary for dentists. So, some people think twice about doing dental core training because they don’t really need to do it. Eighty per cent of dental graduates go into general dental practice after their first year, so we’re talking about small numbers here. For example, the third year dental core training numbers—I think there are five dental core trainees in Wales. 

It’s the same, really, with specialty training, and I think Ben articulated that quite well—the problem that we have. Although we would want a Cardiff graduate or someone who wanted to live in Wales, not last year but the year before, I think, in orthodontics, in the national recruitment programme, we had the No. 1 and No. 2 picks from the whole of the United Kingdom come to work in Wales, which is a real fillip for us, I think. But, obviously, the cost of specialty training does put people off.

Something that Ben didn't mention is that, when a specialist in orthodontic finishes their orthodontic, the three year bit, they are earning nearly twice as much as a consultant is earning, who has to do five years' training. There seems to be a bit of a problem, there, when you're training someone to be a consultant and they can earn more in private practice.

13:05

And that feeds back to me with the other side of what I have to manage, which is my staff, because my clinical academic staff—I have a nice mix. I have some superb practitioners who come and spend half a day or a day a week working at our clinics, and they are phenomenal educators and phenomenal clinical teachers, but I need core staff in the key specialty areas. And what I want to try and do is not be top-heavy. I really want to bring in younger, enthusiastic, innovative specialty trainees and those who are just coming through specialty training to be my next senior lecturer, honorary consultant in restorative dentistry or in orthodontics or in oral surgery, and allow them to progress a career within academic dentistry. So, we have to—that was my thing, when we first came in—. That longitudinal thought process of how we work with this, I think, is critical, because it is a closed loop, actually, because I need those youngsters to come and work in the school.

Could I just make one more point on that issue?

We're talking about the longitudinal issue. Okay, we've recruited people and we've retained young people and they've done their postgraduate training. What do they do next? And that's a big issue for us, because if we've got a contract sum that remains the same, apart from inflation, we can't create new positions for dentists or dental team members, so we need to be thinking—. I provided some recommendations in my evidence that we need something after people have finished their training so that they can continue down a career pathway in general practice. At the moment, that's really not available, so we need to be working quite closely with local health boards and Welsh Government to try and deliver that.

And your written evidence also talks about solutions on recruitment and retention that have been developed in other parts of the UK that perhaps we can learn from. Which are the ones that stand out for you?

Well, in Scotland—Scotland have introduced similar schemes to the sort of scheme that we had in north Wales. I think, again, Ben articulated that. But there are golden hellos, there are incentives to move to areas of difficulty—the Highlands and Islands would be an example—different rates of pay for different places. There are a number of incentives. The deanery, for example—I notice some deaneries are offering to pay people's specialty exam, their first attempt, and things like that that wouldn't cost a lot of money, but may just make the difference in getting people to work in places that are hard to fill.

And are ideas like that being progressed adequately in Wales, currently? Are we gaining some ground on this?

I think there's always more that you can do. We need to have a meaningful discussion with local health boards, not just with regard to that, but it's how we meet the needs of the public in terms of their requirements, how we provide the workforce, how we retain that workforce there and how we use the existing dental funds to create the career opportunities that allow somebody to stay in an area. It's not one or two years after, because, if there isn't a job opportunity, you've spent all that money and they've gone. We've got to find ways of extending that and keeping them there.

There are initiatives that we could think about, but, you know, we're talking about the skill mix— what we want from those people is we want to develop them as professionals. We want them to have the opportunity to enhance their skills, to deliver tier 2 level treatments that might previously have been carried out in a hospital. That can be delivered much more cost effectively in primary care and we need to promote those individuals to acquire the skills to do that. They will be the leaders of the future, and we need to help them become leaders, developed and trained to have the leadership skills, and then support them to have practices where they lead, or to have units that the health boards are providing where these individuals can be employed to lead.

13:10

Wyt ti'n hapus? Mae'r cwestiynau olaf yn yr adran yma o dan ofal Dawn Bowden.

Are you happy? The final questions in this section are from Dawn Bowden.

Thank you. I think you've partly answered some of these points already in earlier questions, about retention in particular. What I was particularly interested in was, in your written evidence, you talk about the data that's available to track career progression when dental graduates go on to complete the foundation. So, I think you were hoping that Health Education and Improvement Wales might improve that data collection in future. How does that work?

Yes, I'm hoping so, because obviously the deanery at the moment has a responsibility for training at dental foundation, core and specialty levels. However, the new role of HEIW will also be to lead workforce planning. Certainly, workforce planning in dentistry—the last workforce planning exercise, I know, because I commissioned it, was 2012, so it's six years out of date now, really. Certainly, in terms of workforce planning, one thing that you need is proper information. So from my perspective, we need to be setting up a scheme in HEIW where we do actually gain the relevant demographic data that we can use to plan services effectively.

So that's the key. What do you use at the moment, then?

Basically, Alastair will know where everyone comes from, from the point of view of the dental school. We know, from a dental foundation training point of view—

We conduct an exit questionnaire to establish where they're going. Now that data is not entirely robust, because obviously some of them may not know exactly where they're going at the time when we ask them. Once they've left us, you can't always get back in contact with them.

We know a lot of the data, and we know that it's quite clear that undertaking dental foundation training in Wales is a significant factor in the decision to stay and work in Wales, because it is, but the ones that leave Wales, we don't know, and even the ones within Wales, once they've left us, there's no national tracking system. We probably need that.

There is a generational issue, of course, as well for us. A minority of people will do some work here in Wales and they will go to Australia, backpacking, and they'll come back to Wales or even they'll go off to Thailand—whatever—and we can't really follow their progress.

I was going to say that there are some practical obstacles to tracking that sort of data, regardless of how robust it might be, you can't—

It's impossible sometimes.

The easiest are the graduates, because we have the annual destinations of leavers of higher education survey that the graduate has to complete. So, we know from COPDEND, from foundation training, where they're going. That can be formally confirmed by the students in the annual DLHE survey, so the university has that data as well. That information is vital for the university for its position within the league tables in terms of its annual surveys and things like the Times Higher Education rankings and the good education, good university guides.

Okay. I've just got one final question, Chair, if I might, on the oral health improvement programmes. So, again, from the school of dentistry, could you just outline the work of the oral health information unit and how, in your view, that's affected the overall improvement in oral health?

So, first of all, the actual unit itself is led by Professor Ivor Chestnutt, who's one of my academic members of staff—a professor of dental public health—but we actually, through money from Welsh Government, employ Miss Maria Morgan, who is one of our senior lecturers, who does all the actual analytical data, working with Nigel Monaghan and other colleagues across the deanery and Welsh Government.

What it's done, I think, is give us data that puts Wales in quite a unique and strong position, because I think, compared to England, we have a good handle on the oral health of the nation as it stands at the moment, and where interventions may be needed. It certainly is critical to driving success in research applications in large-scale clinical trials such as the sealant varnish, which is one of our more successful ones, and also the Designed to Smile trial that we've had.

It's also beneficial to the generation of undergraduate students to have an individual in the school who's teaching them and actually giving them information and teaching them about public health, but in real terms, using real data and real information. So, I fought to make sure that we maintain that link with Welsh Government and that the oral health information unit should stay within the school of dentistry because it benefits research, it benefits output and knowledge of the oral health of the nation, but it is also used as an educational tool for the undergraduates coming through. I think it's a powerful position and a powerful unit within the school.

13:15

From my perspective, it's provided the evidence for the effectiveness of Designed to Smile. It's shown that the number of general anaesthetics in Wales has reduced substantially in the last five or six years. So, I think it's, essentially, of absolute importance that we retain something like that, which provides, not just information, but also advertises the advantages of coming to Wales to work.

And data from that and the unit itself have been a key part of a very large National Institute for Health Research application that's been led by one of my clinical members of staff. It's currently under review. It's a choice between two bids. Ours is between Cardiff and Bangor and the other bid is over in England. NIHR may choose to fund one or the other or none, which has happened in the past as well. But there's no doubt that the strength of the bid that's been put in and the grant has been led by data that's come from the information unit and the work that that unit does.

Dyna ddiwedd y cwestiynau, felly diolch yn fawr iawn i chi. Dyna'r sesiwn wedi dod i ben. Diolch eto am y dystiolaeth ysgrifenedig y gwnaethoch chi ei chyflwyno ymlaen llaw a diolch am eich presenoldeb y prynhawn yma. Mi fyddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma er mwyn i chi gadarnhau eu bod nhw'n ffeithiol gywir. Gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i chi.

That is the end of the questions, so thank you very much. The session has come to an end. Thanks again for the written evidence that you presented beforehand and thank you for attending this afternoon. You will receive a transcript of these proceedings so that you can confirm that they're factually accurate. But with those few words, thank you very much.

6. Deintyddiaeth yng Nghymru: Sesiwn dystiolaeth gyda'r Prif Swyddog Deintyddol
6. Dentistry in Wales: Evidence session with the Chief Dental Officer

Symudwn ymlaen i'r tystion nesaf nawr. Croeso i'n tystion diweddaraf a mwy amdanyn nhw yn y man. Rydym wedi cyrraedd rŵan eitem 6 ar agenda y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon heddiw a pharhad efo ein hymchwiliad i ddeintyddiaeth yng Nghymru. Rydym wedi bod yn cynnal trafodaethau ac wedi bod yn derbyn tystiolaeth gan wahanol fudiadau ym myd deintyddiaeth drwy'r dydd.

Felly, rydym wedi cyrraedd y sesiwn dystiolaeth olaf yma gyda Phrif Swyddog Deintyddol Cymru. Felly, rwy'n falch iawn i groesawu i'r bwrdd Dr Colette Bridgman, Prif Swyddog Deintyddol Cymru; a hefyd Frances Duffy, cyfarwyddwr gofal sylfaenol ac arloesi Llywodraeth Cymru; a hefyd Andrew Powell-Chandler, pennaeth polisi deintyddol Llywodraeth Cymru. Croeso i'r tri ohonoch chi. Diolch yn fawr iawn am eich tystiolaeth ysgrifenedig ymlaen llaw. Ar sail hynny, fe awn ni'n syth mewn i gwestiynau a hefyd, nid oes angen cyffwrdd â'r meicroffonau o gwbl—maen nhw'n gweithio'n awtomatig. Felly, gyda chymaint â hynny o ragymadrodd, awn yn syth mewn i'r cwestiynau cyntaf. Angela Burns.

We'll move on to the next witnesses now. Welcome to our latest witnesses and more about them in a minute. We are now on item 6 of the agenda of the Health, Social Care and Sport Committee today and a continuation of our inquiry into dentistry in Wales. We have been having discussions and receiving evidence from various organisations involved in dentistry all day.

So, we have now reached the last evidence session with the Chief Dental Officer for Wales. Therefore, I am very pleased to welcome Dr Colette Bridgman, Chief Dental Officer for Wales; and Frances Duffy, director of primary care and innovation at the Welsh Government; and also Andrew Powell-Chandler, head of dental policy at the Welsh Government. Welcome to the three of you. Thank you for your written evidence that we received beforehand. On that basis, we'll go straight into questions and also, you don't need to touch the mikes—they will work automatically. Therefore, with those few words, we'll go straight into questions and the first questions are from Angela Burns.

Thank you very much, Chair. Good afternoon, and thank you for your papers. In the written evidence from the Cabinet Secretary, he sets out the Welsh Government's five key priorities for 2018 to 2021 and one of them is sustained and whole-system change, underpinned by contract reform. Do you think you could just give us a quick overview of how well you think that's doing and whether that will actually achieve the sustained and whole-system change that you seek?

Yes, thank you. Previously, there has been piloting of the contract reform in Wales in a number of practices—I think, eight—and the learning from that has led us to believe that it's not just tweaking of contract that's going to deliver transformation here and that we need to take a much wider view of the whole system, including supporting patients to take a step up in understanding oral health and oral health literacy, and dental teams being able, and feeling that they’ve got the conditions right, to deliver prevention, and that the use of the whole team could be so expanded to give us more effective, more efficient services. And although the contract reform is one supporting component of that, we recognise from that early learning on the original pilots how much more we need to do.

13:20

And could I ask you? Some of those pilots were moved forward without actually the use of the dental units at all, and it was all about prevention, and they did appear to be very successful, and I wondered why, because they were quite radical. They weren't just a tweak of the old contract; they were a complete departure from the old contract. You've just said, 'We don't need a tweak of the contract; we need something new.' But it does seem to me that what you're doing with the 10 per cent lift that you're giving to practices is that, actually, it is a tweak of the current—in fact, I think I had the temerity in an earlier session to say 'the new contract', and I was told, 'No, no, no, it’s just a reform.' So, it seems to me that this is a tweak, rather than a whole new approach, and the whole new approach that did appear to be so successful in some of the pilots has been disregarded, and I just wondered why you've made that choice.

First of all, it absolutely has not been disregarded, the value of those early pilots, and a couple of practices in particular, both of whom we're very much supporting to stay as they are or to actually continue to develop. Sometimes, when people make changes, those two particular practice providers and leaders actually changed whole systems. It wasn't just that they used the opportunity of having no targets set, but they took the opportunity to change the skill mix in their teams, to look at the needs of their patients. And one in particular started to have, and produce, information and personalised advice, and that’s exactly the direction we're taking. It’s not a case of disregarding it at all, because both of those two practice leaders are very much involved in the process now of deciding how we get that to be rolled out and adopted by more practices.

But, in not all of the practices in that original piloting process did we see those changes in. So, we need to understand and, more importantly, be able to report and measure the impact and change, so that we can support more to have the conditions that are correct to increase prevention, to use the skills of the whole team, and to deliver the excellence that we see in those two prototypes.

I think I wouldn't be understating it, or indeed overstating it, perhaps, to say that the evidence that we've heard, and the evidence we hear outside this committee, indicates that many dentists are very unhappy with the current contract, and I'm not entirely sure that they are jumping up and down with joy at the alteration to it and the 10 per cent, especially as that appears to only suit, at the moment, perhaps the larger ones who have got the bandwidth to make some of those preventative health changes. As we know, Wales is a very far-flung country; we have a lot of one-man—two-person, I should say—bands out there and they don't have the right skill mix, and so, for them, it’s very difficult to get any traction with this new pilot.

So, do you think that this contract reform will actually be able to allay their fears, and in a timely manner? Because I know that you're saying that some of it's going to be rolled out—you know, you're going to add on a few more next year, but that’s still only going to be, I think, about 10 per cent of the contracts. So, that still leaves an awful lot of people out there without preventative care, a lot of dentists who are pretty unhappy, because they feel they are under the cosh, a lot of the clawbacks going on—you know, a lot of the same old, same old. And I just wanted to know whether you felt that the pace of change, and that change in that contract, are going to make that much difference, say, in the next five years.

I would certainly hope that, within the next five years, we'd see considerable change. And just to really emphasise that the 10 per cent allowance is just to allow us to build evidence, to understand the needs of the patients that are currently accessing NHS dentistry. And I think we now know that that was what was missing from the early piloting. So, that allowance is just a little bit of headspace, a little bit of room. It’s hard to say without evidence, so that we can move forward, understanding what we need to change, as well as what we need to measure, that we do it in a way that supports cultural change, not just in the practices, but within the health boards who contract-manage and invest the money that Welsh Government is putting into dentistry. So, the 10 per cent allows maybe one session a week, if you like, or a little bit of time just to collect need and outcome measurement. We've never done that before in dentistry in any consistent way, but the impression of dentists coming along—. We've held a number of engagement events, and held a symposium for the first time last year for anyone in dental practices or health boards who wanted to come along, and it was so well attended we had to change venue. We are seeing interest in this.

I absolutely understand that the way the targets are monitored and UDAs are applied to practices are demoralising when it results in clawback, particularly when a practice is working in an area of high need or where the price of the UDA is very low. So, again, I come back to that's why it's not just about the number of UDAs, but the value that we're expecting from the investment and the opportunity to increase your skill mix use, and the opportunity to engage your patients in what a care pathway looks like.

We have got good evidence that quite a large number of patients who currently use NHS services in Wales have relatively good oral health, and, again, we have to start to work with patients and the public in their use of the dental services so we can support teams to open up access and to see those with greater need, and to feel that they're supported and the business model works so that they could be welcomed into NHS practices.

13:25

I think my final question, Chair—and I stand to be corrected on this; I don't think I misheard a bit of evidence earlier on—. I'm sure there was a comment that said that the new reform might improve prevention but a negative consequence could be that it would reduce access because of the current number of dentists that we have, the hours that they have and the way the units work. I thought that one of our witnesses said—it was just a passing point, but I wanted to explore it with you—that that could impact on their ability to meet the 95 per cent, even with the 10 per cent headroom, but also that there was a fear from those who hadn't taken it up that actually it could impact on access because they weren't able to take on more people, I guess, or treat them, or whatever.

I wonder if that comes from the experience of the early piloting. Where there was no measurement of need and risk, I think the practices entered into providing prevention without that support of expanded skill mix and without the support of personalising that preventive advice and attendance on need. So, access fell and activity fell, so health boards couldn't just continue or expand or roll that out further without understanding why that was happening. I think our assumptions, which I feel are safe, are that all of those who were attending, including those who were relatively well, got more time and got more prevention whether or not it was needed—more of it and additional prevention. That's why it isn't just a touch of a target that's needed here, and we've taken steps to expand skill mix.

Just yesterday we launched the making prevention work in practice training so that dental team members can lead a whole different way of approaching providing care within their practices as part of this reform programme, and a faculty of dental care professionals has been established, working with Bangor University. We have some exceptional leaders and dental care professionals in Wales who are very, very keen to be able to support practices work in new ways, so that we wouldn't see access fall but that we would see what you need, in terms of your contact with NHS dentistry, is appropriate to your needs and not just on demand.

We actually found that some of the early evidence from the pilot practices has shown that access has actually gone up, and that would be where the practitioner is talking through the care and need that individual needs, and actually finding they don't need to come to the dentist so often—they don't need to come every six months and they can push them out to nine months or a year. So, it's actually creating the capacity to see more patients.

I think also, as Dr Bridgman was saying, we're taking an evaluative approach, because when you do make a substantial change to something, you need to make sure that you've not got the unintended consequences. So, that was a concern about some earlier successes in the first pilot, but you need to actually thoroughly test that. And, as Dr Bridgman is saying, it needs to be more than just the contract itself and the way that you measure the whole wider system. So, with the approach taken to building it up over a couple of years, we get that strong evidence, we understand the consequences, and we understand the wider support that's required to achieve the outcomes that we want. 

13:30

Can I just clarify before we go on—? I mean, we took some quite strong evidence this morning that people—basically, dental practitioners on the enamel face, I suppose—wanted to bin the whole UDA process. I mean, they have provided quite stout evidence that that's what their preferred option would be. So, can you give us a stout defence of the current UDA system if we are going to keep it in a reformed, reformed, reformed, never 'new', contract? 

We certainly accept that UDAs, as a measurement, are a poor measurement of what is being delivered and sometimes called 'performance'. But, we do need to replace—. It's public money. It's quite a large sum in Wales that's invested in NHS dentistry. Therefore, we do need a measure of what impact that spend in health is having. That's why we are starting with 10 per cent to get the need, risk and outcome measures correct and developed. It's only been a year that we have been in that. At this stage, we now have a consistent measure. The dental teams call it the ACORN, where they collect consistently the complexity of the patient in terms of their wider health and social standing, and the clinical needs that they have, in terms of the top two dental diseases in decay and periodontal disease. That's starting to give those practices real evidence of what their practice population looks like, and how that compares perhaps to what we know about the community that they work in. From that, in year 1 it's a needs assessment. By year 2—is the disease level still the same—it becomes an outcome measure.

I think we also are looking at quality measures on the delivery of, for example, fluoride varnish, and the numbers of unique patients that are coming and how frequently they are attending. We have set, working again with the clinical teams, a set of expectations around care pathways and the delivery of preventive interventions and advice that the dentists and the dental nursing and dental care professionals in the 22 practices have worked on to produce. So, that group of tools now is ready for the next group, and where we don't want to hold anyone back—. Particularly, ABMU, as a health board, are working with the two prototypes and are very clear about the benefits of removing UDAs. But, we need to evaluate the impact and we need to understand what changes are happening and what more we need to do.

So, you are moving towards, would you say, eventually removing UDAs? Is that what you're saying?

I think there are a number of elements to any contract measurement: the numbers of patients, their needs, quality markers, and then, of course, activity. We need dental teams to do good dentistry when disease is diagnosed. So, there will have to be some type of activity measure, and we definitely accept that the UDA is not a good activity measure. So, it will have to be replaced with something. But, as we move towards getting this direction right, and putting all the other components of change that we need in place, the UDA can become a less important measure. In our contact with health boards, we are very much encouraging them to look beyond just a percentage of UDAs to measure performance of an NHS practice, or a practice with an NHS contract.

I think the general dental practitioners would concur with that view, really, because—. Well, we've taken evidence that there are various perverse incentives within the UDA system as regards activity levels that are not rewarded within a relatively fixed banding structure—so, perverse incentives not to tackle multiple issues in the one patient, which surely cannot be right. But also, just because we can count something, it doesn't give you a quality estimate, does it? So, presumably we are going to be more subtle than that as we move forward as well. 

Yes. So, the health boards that have involved practices in contract reform are receiving a report. Public Health Wales leads have been very much supporting this. So, they see the contract delivery as units of dental activity—yes, reported—but then, also, the numbers of unique patients, access if it's rising, the needs of those patients, and some quality markers. So, those templates are going to support practices in making individual decisions with practices who hold NHS contracts on how well they're meeting expectations of what we need to see change. 

13:35

Leading on from that, and given the inherent reality that some practices in more deprived areas will find it more difficult to reach their UDA targets, isn't clawback inherently unfair? 

It certainly can be very demoralising and it can be unfair. However, again, it's public money. If you as a provider have been given a contract, and for reasons such as you haven't been able to recruit, you haven't been able to provide a service, then the health boards—it's legislation—need to take that money back, because a service has not been delivered.

I think the difficulty and the perverse incentives arise whereby the UDA targets are seen as the only measure and, perhaps, a practice is in a very high-need community or that the value and the price of that UDA is very low. So, it's not setting the conditions right to deliver and they find it difficult if they do the ethical, moral thing to see new patients, to accept allcomers and to provide the dentistry that's required.

So, we've very much been encouraging health boards to look at those wider measures and to not base clawback decisions on simply a percentage of UDAs alone, and to take into account the price of those UDAs, and, if they were more at average, whether that practice would be apparently failing. And a number of health boards have taken quite significant steps towards that. We've also made a commitment that there's a price—and I call it 'price' rather than 'value'—below which a UDA should not fall, because it's not corporately responsible to expect a dental practice to deliver a service if the funding is insufficient. 

That's positive. I'm glad that LHBs are being encouraged, and I'm glad to hear that some LHBs are taking action. That would suggest that there are some LHBs that aren't, and that could be leading us towards a situation where we lose dental capacity. Are we moving towards a situation where you can be confident that what you're encouraging to happen is actually happening across the board throughout Wales? 

I think so, yes. I think you heard from the health boards earlier—the ones certainly represented here—that they were doing what they could to reinvest wherever possible. 

One step back from that, just to stop clawback in the first place, I think, is something that needs to happen. We can come on to the use of clawback money afterwards, if that's okay. 

I think it's picking up what Colette was saying about asking health boards to look at the contract as whole in terms of what is being delivered to the numbers of patients, the value, the cost of the UDA, where the practice is located. And just working with them—we've been saying to them, 'Don't just look at the performance, if you like, of the practice at mid year and end year; work with them throughout the year. If they are encountering difficulties in delivering, what are those and can you work with them to help overcome them?'

So, what evidence should we look at? This is a short inquiry by this committee, but in our day-to-day work, in holding the Government to account, what should we look for—just for an overall reduction in clawback money, or money clawed back? 

It's that term 'clawback'. I think what we want to see and what we've been holding health boards to account on is that the dental budgets for those health boards without an approved integrated medium-term plan are still ring-fenced. So, the option lies for Welsh Government that if they do not spend that ring-fenced budget, we can recover it. We would want to encourage them, in all instances, to use that money, whether it's what is originally allocated to practices or what may be recovered through underperformance, to be spent on dentistry. And, yes, I think that is what we've been holding health boards to account on and encouraging them to do. 

But I hear stories, as I'm sure you do, of goalposts being moved and dental practices being given new targets, and then those targets being withdrawn and clawback happening before they have a chance to even realise the targets and that kind of thing, which suggests the lack of—or the destabilisation that’s happening in some parts of Wales. Would you agree that that is an unacceptable picture and that this is happening?

13:40

I’m going to come back to other evidence again because I think what’s been really interesting to watch, particularly with the clinical teams, is that they will have evidence as well of the needs of patients coming to their practices. Up to this point, it’s been a bit anecdotal—you know, 'I’m seeing patients who need x number of extractions or restorations.' Once they’re collecting—and this little bit of headroom gives them the chance to do that—the need and risk of the patients, it could be that some of those practices in our very high-need areas are maybe seeing too many patients and that the UDAs assigned to that contract are too great in number. But until we have that evidence, which is why it’s so important to get that measure consistent and correct—. Then, the practices will be able, working with the health board, to look at the whole picture of the contract performance. And I think that clawback then, if we’re seeing improved access, if we’re seeing quality markers being delivered and high needs of patients that are actually evidenced, then I think questions would be, 'Why on earth would you clawback if those conditions were present?' But we don’t have that evidence yet.

It has come up in evidence earlier today that we have a lack of data—sorry if somebody else had planned to ask question on data—in particular in relation to children. We don’t know how many children aren’t getting regular access to dental care. I think that’s awful. Is there a general job of work that needs to be accelerated much more than is currently the case for gathering data on what our dental needs are as a country and how they’re being met?

Completely, and we’ve a very good epidemiological survey programme, but we also need the attendance at services. Again, it touches on the wider system changes that we need to see. So, one of the things is that we know the numbers of children, by age group, who attend general dental practices through NHS contracts in any given two-year period, and it’s quite high—it’s about 66 per cent. What we don’t know is the numbers who are attending community dental services, and those are our specialist services that would be open to children perhaps who’ve got additional needs, perhaps medical needs or who perhaps don’t have routine attendance patterns in their family. Because they’re not collected on what we call the FP17, we can’t add those to the figures because they could be duplicate, but it will be more than that 66 per cent. We just can’t confirm exactly.

But another thing in the Designed to Smile programme that we’ve done is very much start to link that work beyond the community dental services into other groups and integrate it with health visitors. The health visitors, who are involved in the Lift the Lip project, have actually been collecting and asking at the checks that they do routinely, 'Have you taken your child? Have they had access to primary care dentistry?' I think once we’ve got the community dental service contacts as part of the access measurement and we have measures of all the children who are seeing all the health visitors in Wales, we will have a fairly accurate picture beyond who’s not attending and why, and then what we need to do about that.

And you’re confident that, apart from children, the data-gathering process or the prominence of data in planning services is moving ahead.

Certainly in numbers it’s data-rich for dentistry. What we don’t have and what we’re addressing as part of the reform programme is that need and risk of the individual patient. Colette was talking about the community dental service. They’re moving into the same process we do to collect data for the general dental services from June next year. So, from that point, we will be able to know exactly how many children are going, and at each age as well, from nought to one, two to five or whatever we want to look at.

Recruitment. Of course. Moving on to recruitment and retention of dentists, we know that we have particular problems in rural parts of Wales in particular—not exclusively rural; parts of post-industrial Wales as well. Can you give us an overview of where you think we’re at in terms of addressing some of those well-established recruitment and retention problems now?

I don’t think this is just peculiar to dentistry. It is more challenging to attract professionals and health professionals to some of our more rural areas. Many young professionals want to work in urban places. I think one thing that is available through the contracting mechanism we have in dentistry is that health boards do have flexibility to make it more attractive, and again, where we see opportunities for that we would encourage them and have those conversations, such as having a longer contract time, so if you're going to come and invest and open a practice, you need a longer contract period that gives you some stability and that is available and can be done within this contract. Also, by removing a certain number of UDAs from a contract. We're seeing that in a number of health boards, where they allow a stepped up approach to building a practice. And also trying to encourage people from those communities to apply for dentistry and to encourage. I think that's another thing that a percentage of people want to return to where they've been brought up themselves, and to make those opportunities become a reality.

13:45

Are you as gobsmacked as a lot of people would be if they knew the figures about how few dental students or Welsh-domiciled dental students there are studying dentistry in Wales? It's incredible. Because the equivalent figures for medicine would be something like 25 per cent compared with 60-odd per cent in Scotland and 90 per cent in England. For dentistry, it must be—what? Five?

Yes, it's lower than that. Is it as appalling as I think it is?

It has been a topic of conversation when we do meet and talk to Cardiff dental school leads, and there's been a relatively new dean at Cardiff—I think you've already heard evidence from Professor Sloan. There's going to be a workshop later this month, working to start to say, 'Why is this happening and what can be done about it?' It has certainly been something that we've addressed in our interface meetings with them.

The figures do fluctuate, so, year on year does seem to be different, and, of course, some of those students—and again, this is going to be something that is part of the consideration—from north Wales would prefer to go the dental schools in Manchester or Liverpool in terms of accessing and getting home.

Yes, but it is remarkable. One in 10 dental students in Wales are from Wales. It's incredible, really. Would you support measures, positive discrimination—?

Absolutely. And, we've asked those questions directly. Another thing that we've been exploring with Health Education and Improvement Wales leads is to look at, post qualification, the first year afterwards, when dental students embark on a dental foundation training year. And, at the moment, we're working up an agreement—they have to take part in the whole national recruitment—and asking, 'Can we do anything to say to those dental students qualifying from Cardiff that before we put the places that are available into the big ring, "if you want to stay and work in Wales, we're going to look at our own recruitment"?'

Are you able to do that? Because it's an England and Wales thing. Are we able to break off and do our own thing?

It's been explored. There are some advantages in a system that's up and working and running, but I certainly think it's worth considering—

—and it is being at the moment.

I think that's also part of our ambition with Health Education and Improvement Wales that we have a much more focused approach, because it is a much wider issue than dentistry. So, we've worked, first of all, from the ministerial taskforce, which looked at the primary care workforce generally. We've had some successes with 'Train. Work. Live.' and some of the incentives around GPs, and I think that's an area that we need to explore wider with the dentistry profession. But certainly, that's some of the challenges we're putting to our newly launched Health Education and Improvement Wales to take forward some of those issues.

Can I just come in on that, following on from what was just said? Have we got any information or any data about—? Is it just that students in Wales are not choosing dentistry or are they choosing dentistry and choosing to study somewhere else? I take your point about north Walians; they may well prefer Manchester and Liverpool to be closer to home. But, do we have any information or data about the number of students from Wales who may be going to train in England, so that it's not an issue with dentistry, it's maybe an issue of where they would prefer to be?

13:50

I would suspect HEIW, the deanery leads would have a much better understanding of that, because I do think when they embark on dental foundation training, those details of home domicile, the universities would have that. So, I would have to look into it and answer that at a later stage.

That's fine. It seems to me, from conversations that I've had with students, a lot of them at that age do want to get out and see the world and go somewhere else, and so it's almost the next stage after that—what do we do, once they've qualified, to get them back, if they want to spread their wings and be somewhere else to train? Ultimately, we need them back here practising, don't we?

Absolutely. Yes, we do.

You'll be interested in my bring your skills home policy that I've proposed within my party currently. We'll have a conversation—

It's too late to get your vote in now. [Laughter.]

How interested or how proactive are you in pursuing increasing capacity in undergraduate dental training in Wales? I know we've been pushing as a committee, and we have as local politicians, for the creation of a medical training centre in Bangor in partnership with Cardiff University. It is happening, it's great, but pharmacists come to me and say, 'Could you please push for a pharmacy school there as well? We need it.' I've had dentists come to me and say, 'Could you please push for there to be dental training provision in Bangor?' Is that something that you'd like?

Actually, it's already currently in place. The dental students from Cardiff do have—

As in, full undergraduate training in Bangor is what's happening with medicine from next year.

One of the things I said earlier that we needed to do in the system was to increase the skills of the rest of the team. So, what we haven't done is try to expand that by reducing the numbers of dental training places. The advice is to keep that steady while we look at expanding. And what we are doing in the north, having established a faculty of dental care professionals with Bangor, is to see training of some of the rest of the members, and the leadership of the quality of that training, and the monitoring of that, working closely with the General Dental Council in doing that, to see that placed in the north. So, I think some of the future needs of the workforce in Wales will be led, and certainly available north, and I think Cardiff dental school have also expressed an interest in having more than just modules of time up there with the students. So, I think that's beginning to happen.

Yes, just a couple of questions on the orthodontic services. We've had quite a lot of evidence about the lengthy waiting times for orthodontics in some health boards and the particularly stark contrast between somewhere like Hywel Dda and Aneurin Bevan, for instance. What support do you think health boards need to actually improve that situation? 

There's been considerable work done in Wales, certainly, by my predecessor, led by Professor Thomas, in looking at the efficiency and the effectiveness of the care delivery. There was quite a lot of what you might call repeat reviews and assessments that could have been directed towards case starts and treatments. So, having done quite a bit of that work, some of the health boards have got a legacy issue with the numbers of children that are waiting, and then that introduces a system flaw that, if you're a primary care dental practitioner and you want to make a referral for an orthodontic assessment, you're aware of those waits, and then add to the problem by referring perhaps too soon. Sometimes it's a waiting list for assessment of whether or not the treatment is needed.

So, it's a different approach by different health boards, then, in terms of referring.

The strategic leadership and direction has been quite well led nationally, and we have a number of active managed care networks in orthodontics who understand now what it happening. It differs from health board to health board in the legacy issue, where they perhaps had a smaller number of providers and where there were contract issues within a smaller number, which can leave you with quite a problem with the size of waiting list that needs to be validated. Some on that list could be duplicates. Some, perhaps, don't need—. The issue with orthodontic care, also, is that a child might have a clinical need, but they also need to want and be suitable to have six-weekly appointments over a two-year period for orthodontic treatment. It's some of those other assessments that need to happen within those waiting lists. But I don't disagree that some of that legacy wait needs investment and I know that the health boards, where that's a particular issue, have plans to do exactly that. 

13:55

Sure. And is the e-referral management system likely to help with that?

It will help. Again, the managed clinical networks have used a consistent pro forma that tries to support primary dental care—almost decide and understand the indicator of orthodontic treatment need. Moving to an electronic system supports that to happen and it would almost turn the tap down on adding to waiting lists, because those who have been sent too early would be returned to the general dental practitioner with a note that this child doesn't need to be referred for, perhaps, another couple of years. The assessment of need is done on measurements, so even if a practitioner may not fully understand how to do an IOTN, the support of that electronic system—it guides you through, actually, the decision and provides all the information that a specialist would need to decide the level of severity of the malocclusion. So, it will help, but I also think we'll need to work on what's in the system currently and how to address some of those.

So, this is really an improvement for the future rather than—

Yes, and one of the things that we've said very clearly needs to happen is that, where it's been almost a shoe-box system of first come, first served, and then, when you get to the top of the list—. We really need to see some clinical prioritisation in there, so that those children who are older—so, we really need to get the orthodontic care provided before the age of 17—those who have more severe treatment needs, are prioritised, and more routine cases perhaps can take a slightly longer time to wait.

So, it's not a different approach in each health board, because the guy from north Wales who was in, from the British Orthodontic Society, was saying that they certainly do treat on the basis of need rather than—

Yes. North Wales have been particularly successful, and I think, through Ben Lewis's leadership, they've reworked with their local orthodontic providers to seek efficiency and effectiveness. And the clinical teams, I think, understand what now needs to happen. Perhaps some of the MCNs have not been quite so proactive, but we do have a strategic advisory forum, where these examples of good practice are shared. We've just continued to work with those health boards where demand is causing issues and complaints to understand what they need to do next.

I think the electronic referral will give them timely evidence and information again, which—again, if the waiting lists are just in the practice and providers, it's hard for a health board to plan the services around that until they fully understand and validate who and what is on those lists.

It's good to see that there's some sharing of good practice, because I think one of the constant sources of frustration that we have in a number of inquiries, isn't it, is where we see good practice in certain areas and it doesn't seem to get rolled out elsewhere, and we're constantly reinventing the wheel in different places. But, anyway, thank you for that.

Can I just ask two final questions just around the oral health improvement programmes? There seem to have been some very positive results, particularly in the Designed to Smile programme. Do you have any future plans in terms of building on that programme?

I think Wales is and should be rightly proud of the excellent population oral health programme that Designed to Smile is. When I came to Wales just over two years ago, I realised that this was a programme that needed investment—needed that investment to remain. But I also saw that aspects of the programme—. There was a research paper published by Professor Ivor Chestnutt, from Cardiff University, which demonstrated that the fissure sealant as a preventative intervention was as effective as fluoride varnish application, but one costs very much more. So, one of the things that we did was to look at the Designed to Smile programme and say, 'This needs to go from good to great'. We had a specialist from Public Health Wales join on the strategic leadership of that and we also are aware that our poorest access is in the nought to fives and that some of the disease that is present at five is beginning at an earlier stage. So, we need to start the brushing and to start primary care access much younger. The Designed to Smile teams—. We really wanted to make it—. It's everybody's business, oral health. We really need health visitors, general dental practice teams, to understand that getting fluoride on the teeth through a daily brushing habit is what we’re trying to achieve. And by removing some of what we saw was less effective—fissure sealant delivery at a later stage—we were able to use that resource more effectively and expand the number of children actually receiving the benefits of Designed to Smile.

14:00

In the year 1 and 2 age group.

We’ve got more children than ever—it’s increased markedly in the last couple of years—who are receiving varnish and who are brushing. So, not only have we been able to expand it to the nought to five groups but to include more nurseries and include more schools and more settings. And I think that it's now at about 98,000 children are brushing daily, and we've got more than 23,000 receiving applications of fluoride varnish twice a year, and a further 23,000 receiving it once a year. So, it's expanded markedly following that refocus. And what it's done really, I think, is to consolidate the really good parts of Designed to Smile and take new evidence. And one of the pieces of evidence that's also very compelling is that, once disease is present at five, that disadvantage is taken through life. So, one of the most important things to do was to ensure that that prevention was going in at a primary stage, and we need to get as many children decay-free, and to take it from—it was almost half, when this started, of children reach school with decay. It's down at about a third, and, by expanding it into that nought to five, we should see further falls.

It's also much harder to target when you start to get disease levels falling. So, the extension and the refocus also included the third quintile of deprivation, as well as the fourth and fifth. So, we were able to take more settings and more schools into play. And the teams in Designed to Smile have really stepped up to that and understood what evidence is out there, what did we know five and 10 years ago when this was being established and what do we now know, so that this excellent population programme really goes from strength to strength.

Sure. I was just going to say: is there a case, then—? Because we've heard some evidence, or suggestions, that the whole oral health improvement programme should be extended to older children as well, and we've heard some evidence about, particularly, teenagers—we have difficulties with teenagers' oral health now. So, is there a strong case for improving these types of programmes?

It's interesting. Again, I think this touches back on system and change that—. Just a couple of years ago—I think three years ago—it was found that nearly 60 per cent of 15-year-olds in Wales had active decay. That's quite a burden of disease. And that's the group that didn't benefit from Designed to Smile. So, I think we do have problems with our young adults and the burden of disease, but it's really difficult to do a population programme for that age group. What we are doing is we're doing an epidemiological survey to understand the problem, and I think that's where our primary dental care teams come in—by stepping up prevention, increasing access. And, I think, sometimes, when I hear some of the experiences—and I went up to Tredegar to meet some of these teenagers, some of whom are losing their permanent teeth in large numbers. It's quite a surprise that that even happens when it's a preventable disease. And I think that goes right back to why we want to open up access for all groups, particularly those in high needs groups in Wales, and to support practices that may need to take a teenager with that level of disease through quite a long process of change in a given year to try and turn around and maintain and get on top of that disease process. So, it is a group that we're looking at.

But I think, again, as we start to tackle oral health, and they have done that so well through this population programme, another group that I think is very interesting—and, again, it's the general dental practice teams that provide most of the care and most of the contact—is our older age groups, our 50-plus groups. Significant work has been done in care home programmes, but it's again looking at a more primary prevention, that prevention isn't just about providing interventions for children, but seeing prevention as being important for adults later in life, and I think, again, some of the expertise and capability that we have in Designed to Smile could certainly start to explore that. I know that, through Public Health Wales leadership and specialists involved in that programme, we're starting to see those conversations happen.

14:05

Mae'r cwestiynu ar ben, felly. Diolch yn fawr iawn. Fe wnaf i ddweud bod y sesiwn hefyd ar ben, felly. Diolch yn fawr iawn am eich presenoldeb. Diolch hefyd am y dystiolaeth ysgrifenedig a gafodd ei chyflwyno ymlaen llaw. A gaf i gadarnhau hefyd y byddwch chi yn derbyn trawsgrifiad o'r trafodaethau yma er mwyn i chi allu cadarnhau eu bod nhw'n ffeithiol gywir? Ond, gyda gymaint a hynny o ragymadrodd, fe hoffwn i eto ddiolch yn fawr iawn i chi. Diolch yn fawr. 

The questions have come to a close. Thank you very much. The session has also come to a close. Thank you for your attendance. Also, thank you for the written evidence that you submitted beforehand. I can confirm that you will receive a transcript of the proceedings so you can check for factual accuracy. But, with those few words, I would like to thank you again. Thank you. 

7. Papur(au) i'w nodi
7. Paper(s) to note

I'm nghyd-Aelodau, rydym ni'n symud ymlaen i eitem 7 nawr a phapurau i'w nodi. Byddwch chi yn amlwg wedi darllen y llythyr gan y Coleg Nyrsio Brenhinol ataf i fel y Cadeirydd ynglŷn â'r symposiwm Brexit. Roedd Rhun a finnau yn y cyfarfod ac roedd popeth yn edrych yn dywyll ddu arnom ni ar ôl i ni adael Ewrop yn nhermau'r gwasanaeth iechyd. Ond rydym ni wedi nodi hynny. Nid oes angen dweud dim byd pellach, rwy'n cymryd. Nac oes.

For my fellow Members, we now move on to item 7, papers to note. You will have read the letter from the Royal College of Nursing to me as Chair regarding the Brexit symposium. Rhun and I attended the meeting and everything was looking very dark after we leave Europe in terms of the health service. We have noted that. I don't think there's anything else to note on that. No. 

8. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o'r cyfarfod
8. Motion under Standing Order 17.42 to resolve to exclude the public from the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Reit, symud ymlaen i eitem 8, a chynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod. A ydy pawb yn gytûn? Mae pawb yn gytûn.

Okay, item 8 is a motion under Standing Order 17.42 to resolve to exclude the public from the rest of the meeting. Is everyone in agreement? Yes.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 14:06.

Motion agreed.

The public part of the meeting ended at 14:06.