Welsh Government - Health, Social Care and Sport CommitteeConsultation: Dentistry in Wales

Response on behalf of the Community Dental Service Directors Group

The Group welcomes the opportunity to make a contribution to this Consultation.  

The Welsh Government’s dental contract reform

The Group is supportive of the philosophy underpinning contract reform with its emphasis on prevention and the reduction in inequalities in access to care.  We welcome the proposed new way of working placing prevention at the core of all dental service provision and with personalised preventative advice being provided for all patients.  The ethos is as relevant to Community Dental Service (CDS) as General Dental Service (GDS). 

Access to GDS varies across Wales.  Although the average for Wales is reported as 55%, it ranges from 45.6% in Hywel Dda to 62.6% in ABMU.  Access data relates to the proportion of the resident population treated in the GDS in the 24 month period ending March 2018.  The data that informs these access levels relates to GDS including Salaried GDS (CDS/PDS) but excludes information relating to patients who are treated solely in CDS and private patients who have not received any care under GDS arrangements.  CDS data is currently collected separately and reported annually by Stats Wales.  From May 2019 it is intended that CDS activity will be captured by submitting information in the same way as the GDS.  Whilst this will provide a more comprehensive picture of NHS primary care access it will need to form a new access base line as it will not be possible to compare with past GDS access data.  Whilst this development is supported there are concerns regarding the readiness of IT infrastructure support and the lack of non-clinical support (e.g. reception/dental healthcare assistant staff) in some Health Boards to be able to implement the changes required in the identified timeframe. 

An E-Referral system is also to be introduced across Wales enabling General Dental Practitioners to refer to hospital specialties and CDS electronically.  Whereas it is disappointing that some CDS suggested amendments to referral forms and medical histories have not been possible it is reassuring to learn that these will be considered once the system has been introduced.  The early adopters are scheduled to commence in November, with the programme being rolled out across Wales in the subsequent months.  A system will also be required to capture and report referrals to CDS from other sources e.g. Hospital departments, General Medical Practitioners, other healthcare professionals, Care Homes, Social Services.  It is suggested that there would be benefits in designing a system adopting the ‘Once for Wales’ principles.

Salaried GDS practices have been successfully introduced in some Health Boards utilising the CDS/PDS model introduced by Welsh Government in 1996.  Directly managed by the CDS it offers an alternative model of NHS dental healthcare provision.  The results of a BDA survey conducted in 2017 suggested that 72% of practices in Wales were accepting private patients whereas a mere 15% of practices were accepting new NHS adult patients.  Unlike GDS the salaried GDS model cannot operate in a mixed economy and is required to conform to changes in Welsh Government policy.  It provides a 'safety net' that can be utilised should practices close or opt out of providing an NHS service.  This model is deemed ideally placed to participate in the Contact Reform programme and to pilot new ways of working.

The use of skill mix is well embedded in CDS with Direct Access having been introduced and expanded.  However, there appears to be a range of pay scales being adopted across Wales and in some cases the gap between therapists and dentists is reduced to such an extent that it would be difficult to justify employing a therapist rather than a dentist with a much wider scope of practice.  It has been reported that this is also the case in GDS where dental therapists are seeking remuneration packages approaching those received by associates.  To reduce these inequalities and remove a possible threat to the development of skill mix it may be helpful if a decision on appropriate pay scales could be determined nationally.

With regards to the shifting of the balance from the acute to community setting, Intermediate Tier services have already been introduced by some CDSs.  They support the Hospital Dental Service (HDS) specialties e.g. endodontics, oral surgery and take care closer to where patients live.  It is expected that CDS dentists who have gained additional clinical qualifications and/or appropriate clinical experience will be seeking Dentist with Special Interest (DwSI) recognition as accreditation procedures develop. 

How ‘clawback money’ from health boards is being used

It has been frustrating to hear of clawback and dental funding not being invested in dentistry when there is evidence of the most vulnerable in society being denied access to services.  In some areas of Wales the investment in orthodontics is perceived to be disproportionate when people cannot access routine care.

Welsh Government funding for a number of initiatives granted to the CDS has been most welcome (e.g. Designed to Smile (D2S), Specialist sessions, Older Persons programme) and has enabled initiatives to progress.  It was anticipated that Health Boards would also invest in these programmes but this has not happened in most areas.  Additionally, some CDSs are experiencing significant budgetary reductions which is impacting on their ability to deliver their objectives.

Lack of access to GDS clearly impacts on the role of the CDS.  Nevertheless, some Health Boards appear reluctant to invest in salaried GDS posts that could cost effectively resolve some of the difficulties being experienced.

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

Overall, recruitment to the CDS in Wales appears to have improved since the introduction of the new contract (2008) although some areas are still reporting difficulties.  All branches of dentistry appear to experience difficulties in recruiting to the most western reaches of Wales.

Welsh is the first language for a significant proportion of the north and west Wales population; children and young people receiving all their primary and secondary education through the medium of Welsh.  It is suggested that ways of investing in the education of Welsh students, wishing to study dentistry, should be explored.

There appears to be a recruitment issue in relation to some specialties (e.g. Restorative Dentistry) and the move towards community based specialist services is therefore supported.  It is considered that developing training opportunities (e.g. clinical attachments) for GDS and CDS dentists are required to complement and support services in secondary care.  This would reduce waiting list pressures and enable career development and retention of primary care dentists.

The provision of orthodontic services

Orthodontic services continue to be provided by CDSs in some areas enabling vulnerable children or children living in geographically isolated areas to receive orthodontic treatment.  The clinicians offering this service work closely with the HDS and it is considered that training opportunities for DwSIs in orthodontics will need to be available in some areas of Wales.

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

National Epidemiological Surveys are led by Public Health Wales with local epidemiology coordinators responsible for the local organisation of the fieldwork which is carried out by CDS staff.

Although the dental health of 5 year old children is improving a survey of 3 year old children (2013/14) revealed that one in five children in the most deprived areas of Wales had already experienced decay by age three (2015/16).  With the aim of keeping children decay free by the age of 5.  Welsh Health Circular, ‘Refocussing of the Designed to Smile child oral health improvement programme’ (2017) places greater emphasis on preventative measures for children aged 0-5 and the inclusion of GDS teams in the delivery of this targeted programme.

Although there have been improvements in the dental health of older children they are not as striking as those experienced by 5 year olds.  The impact of D2S on the permanent dentition will not be realised until 2020/21.