Health, Social care and Sport Committee

Inquiry into Dentistry in Wales

A response by Welsh Dental Committee

The Welsh Government’s dental contract reform

The current GDS contract has no incentive to treat patients with high needs, in an ideal world the low needs patients would balance out the high needs patients but in practice this is impossible to achieve and hence practices are sometimes reluctant to accept new patients because of their potential need. That said it is difficult to balance any remuneration system as it is inevitable that some operative procedures will take less time than others.

GDS contract reform is in general supported by WDC. This will provide practitioners with the opportunity to develop new ways of working including the potential to skill mix within the dental team. It is anticipated that practitioners will welcome the focus away from Units of Dental Activity as the sole measure for activity. More meaningful data is expected at the beginning of 2019 to evaluate the success of the programme.  However, it is vital that any reforms have embedded the ability to accurately assess quality and performance.

How ‘clawback money’ from health boards is being used

Anecdotal evidence would suggest that there is variation on how recovered money due to underperformance is used by health boards. Strict ring fencing would ensure that funds intended to be used on dentistry are actually spent on dental services. That said capacity of some practices to use additional funding is limited for example due to recruitment difficulties. Health boards should be encouraged to use recovered funds to develop alternative models of delivering dental services, for example in some areas salaried general dental practitioner posts may be more attractive. There are examples where this has been successful.

Issues with the training, recruitment and retention of dentists in Wales

Training pathways may need to be reviewed including entry to dental school. Local students from lower socio economic back grounds may not have the same advantages than students in private schools and it may be sensible to offer some applicants alternative pathway into getting into dental school such as completing a “pre-year”. Increasing the number of local applications may also increase the number of Welsh speakers. Developing training pathways to enhance the skills of the workforce are also being encouraged and it is anticipated that progress in the next few years will help to develop dentists and DCP’s with additional skills.

Policy over the last few decades has also led to recruitment difficulties, for example there has been an increasing number of dentists working part-time. Dentists who have recently retired who formally were happy to practice a few sessions a month are no longer willing to do this as the current requirements to practice are financially prohibitive for the level of remuneration that a few sessions would generate. Increasing requirements and the nature of the contract have resulted in an ever increasing number of the workforce to move away from providing NHS care. In fact anecdotal evidence would suggest that many dental therapists and hygienists can earn considerably more in the private sector than a qualified NHS dentist. Altering pension contributions and benefits further increases the move away from NHS dental practice.

Recruitment into the community dental service improved following the 2008 contract. In addition the difference between the English system and the Welsh system was considered advantageous for Wales. The investment in past years by WG into the community dental service was also welcomed and had a positive effect on recruitment. However negative changes such as a reduction in pension benefits will erode the momentum achieved and result in increasing difficulties in recruitment.

There continues to be a significant recruitment and retention issue in relation to specialists and the move towards community based specialist services.  Welsh Government should look to prioritise and invest in the development of the smaller dental specialties outside the Dental Hospital.  This should be driven by the need of the population with current resources relocated if necessary.  Substantive and training positions should have a significant if not completely community based element to them.

Welsh Government should establish and develop a programme for intermediary dental services.  This would encourage GDPs to upskill, remove pressures from specialist services and provide a framework for career development. This would help with retention of young dentists.

The provision of orthodontic services

There have been various debates around orthodontics for several years. Orthodontic practice is generally accepted as being more lucrative than general dental practice. However in order to practice a formal specialist qualification is usually required which does involve a significant period of further study. If there was no NHS funded orthodontic treatment then children from lower socio economic backgrounds would be unlikely to afford the cost of private treatment which would almost certainly be in the thousands. This would effectively “label” poorer children via their malocclusion and disadvantage them in life.

That said remunerating GDS orthodontic contracts at the start of the treatment means that regardless of the outcome the orthodontist will get paid in full. It would be sensible to link the final payment with an independent and robust outcome measure to ensure satisfactory results and value to the tax payer.

It may also be an appropriate time to look at the health benefits of orthodontic therapy based on the IOTN since it can exclude patients who’s need may be high and vice versa. 

Orthodontic managed networks are now established in Wales but they can on occasions work as a provider network rather than in the wider benefit of the population and dental services.

The effectiveness of local and national oral health improvement programmes for children and young people.

Designed to Smile was introduced to get teeth in contact with fluoride by establishing brushing as the norm for these children. Before the programme there was little change in the caries rate for young children. Since it was introduced we have seen large falls in decay rates for 5 year olds in a short timescale. In 2021 we expect to collect data to demonstrate whether there is a longer term impact of D2S on caries in the permanent teeth of 11-12 year olds.

GDS contract reform will allow a focus on 0-3 years as well in addition to the community dental services, general dental practices through the programme will be able to step up on the level of prevention.  There is a need to expand this programme to other vulnerable groups.