HSC(6)-20-23 PTN 20

Eluned Morgan AS/MS

Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services

Our ref: MA-EM-0959-23

Russell George Chair

Health and Social Care Committee

SeneddHealth@senedd.wales

18 April 2023

Dear Russell,

Thank you for the Committee’s report of 13 February following the inquiry into dentistry in Wales.

I have carefully considered the 16 recommendations of the Committee and enclose my written response.

Yours sincerely,

Eluned Morgan AS/MS

Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services

Canolfan Cyswllt Cyntaf / First Point of Contact Centre:

0300 0604400

Gohebiaeth.Eluned.Morgan@llyw.cymru Correspondence.Eluned.Morgan@gov.wales

Bae Caerdydd • Cardiff Bay

Caerdydd • Cardiff

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Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi.

We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding.

Written response by the Welsh Government to the Health and Social Care Committee report following their inquiry into dentistry in Wales.

February 2023

1. I would like to thank the Committee for the report on their inquiry into dentistry in Wales. I am pleased to say the Committee’s recommendations generally support our current policy direction.

2. We are in the midst of the most significant change to the dental system in two generations. It should not therefore be a surprise that there is some disquiet while this much needed change is brought about. The Welsh Government is firmly committed to reorientating dentistry to a preventative model that delivers care and treatment on a risk and needs basis. The dental contract is just one part of this major reform, and I am pleased that this is recognised in the committee’s recommendations.

3. In the next 12-14 months our focus will inevitably need to be on negotiating the new dental contract. This is the cornerstone for the delivery of primary care dentistry and once fixed in place will enable us to develop and build the wider dental system on top of a secure foundation.

Detailed responses to the report’s recommendations are set out below:

Recommendation 1. The Welsh Government must ensure that consultation about potential changes to the dental contract should, other than in exceptional circumstances, take place no less than 6 months before the reforms are planned to come into effect.

Welsh Government Response: Partially Accept

We would always seek to involve the dental profession in any changes at the earliest possible opportunity. Indeed, if changes are designed using a social partnership model the consultation takes place during the development of the agreed solution which mitigates the need to consult. That is our ultimate aim, where all interested parties work together to identify and agree solutions.

The Welsh Government accepts that the contract variation offer for 2022/23 was issued later then we would have wanted. However, the COVID-19 pandemic was an exceptional circumstance. Faced with the option of delaying reform for a further year, with no new patient access for another year, we made the decision to press ahead with contract variation. For the 2023/24 variation offer we commenced the consultation via engagement events in September 2022 and made the written offer in December 2022. This is the approach we would hope to continue taking which strikes a balance between engagement to shape policy and giving time to reflect on the final offer.

There has been some recent criticism due to the contract variation notice (CVN) for 2023/24 being issued at the end of March 2023. The is the legal vehicle for enacting the variation offer that was made in December 2022. No changes to the volume

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metrics were introduced by the CVN save for a clarification on over performance of the new patient metric which introduces a consistent approach and is in the practices’ favour compared to the previous year.

Financial Implications – None.

Recommendation 2. The Welsh Government must monitor the provision of patient appointments to ensure the right balance is being struck between prevention, needs- based care, urgent dental provision and seeing new patients, and report back to this Committee prior to making any further changes to the dental contract.

Welsh Government Response: Partially Accept

We would be content to provide the committee with a report on activity in relation to care and treatment delivered in 2022/23 under the reform variation. This could be submitted in the Autumn term if agreeable to the committee.

The direction of travel for 2023/24 is already set with the reform variation offer having been issued to practices in December 2022. We have since written to the British Dental Association (BDA) setting out our intention to commence formal negotiations on a new dental contract and asking them for their negotiation mandate. We hope that 2023/24 will be the last variation year and that through tripartite (BDA, NHS, Welsh Government) negotiations the changes will be agreed through negotiations using the principles of social partnership. It is likely that changes to the GDS contract regulations will need to be consulted on formally which will provide the committee with an opportunity to feed in their views.

Financial Implications – None. Legal costs arising from legislative changes are provided for within existing programme budgets.

Recommendation 3. The Welsh Government should explore options for a centralised waiting list and report back to the Committee on progress by the end of 2023. As an interim measure, the Welsh Government should ensure every health board establishes a centralised waiting list for its area by the end of 2023.

Welsh Government Response: Accept

Officials are already in discussions with Digital Health Care Wales (DHCW) to scope a design for an all-Wales dental waiting list. Initial indications are that this can be delivered within the next financial year and finances have been set aside to fund the project.

Some health boards already have arrangements in place to maintain a waiting list. We would suggest that for those that don’t, putting one in place in the same time frame as the all-Wales solution is unnecessary.

Financial Implications – Funding already identified from existing programme budgets.

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Recommendation 4. In order to reduce inequalities, the Welsh Government must ensure each health board provides information on how to join a waiting list for dental services that is available in a variety of formats and languages, not just online, by the end of 2023.

Welsh Government Response: Partially Accept

As outlined under the response to recommendation 3 we believe this is best resolved by delivering an all-Wales solution and we are committed to delivering that solution in the 2023/24 financial year. Implementing a new system will require a public communications campaign, including new public information resources for accessing dental care. This aspect of the project will provide the opportunity to address the recommendation to ensure information is available in a variety of formats.

Financial Implications – Development and implementation funding for a central waiting list is provided from existing programme budgets.

Recommendation 5. The Welsh Government should review the data collection requirements for NHS dentists in order to simplify the process and reduce duplication. This review should be completed by December 2023 and the findings reported back to us no later than March 2024.

Welsh Government Response: Accept

The dental reform programme is supported by a number of workstreams. In order to increase the opportunity for dentists to engage in the reform programme a new workstream was created last autumn. We will ask this working group to review this recommendation and identify options to minimise administrative burden.

Financial Implications – None.

Recommendation 6. By the end of summer term 2023, the Welsh Government should provide this Committee with a clear plan and timescales for how it will introduce a single software system for use by all dentists across Wales, followed by six-monthly updates on progress. The plan should also include details of how Welsh government will engage with private practice.

Welsh Government Response: Reject

We welcome the recommendation in principle. However, whether it is feasible given the private/NHS mix or even wanted by the profession is not certain. Any implementation would also require a significant procurement process. We will use existing channels to engage the profession in this proposal and undertake an options analysis by the end of the summer term 2023. This will include potential risks, benefits and costs and provide firm evidence for taking forward this recommendation.

Any decision to implement this recommendation would also be linked to the negotiations for the new dental contract which are unlikely to conclude by end of this summer term. Once the negotiations have concluded we would be happy to update the Committee.

Financial Implications – None at this time.

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Recommendation 7. In its response to this report, the Welsh Government should tell us what it is doing to obtain a clear understanding of the barriers to vulnerable groups accessing dental services and where inequalities lie, and whether there is a need for further research in this area.

Welsh Government Response: Accept

There is a need for additional research in this area and officials have already commissioned research around access to dentistry, pharmacy, and allied health professionals. The specification for the research includes a requirement to identify barriers to access for vulnerable groups.

This project is due to report at the end of May 2023 and will be made available for the committee to consider.

Financial Implications – Costs of the research are funded from existing programme budgets.

Recommendation 8. The Welsh Government should ensure that the dental workforce strategy reflects the changing aspirations and the need for a wider skill mix within the workforce and is published as soon as possible. On the basis that the Minister for Health and Social Services expected to receive the draft in December 2022, the final strategy should be published no later than spring 2023.

Welsh Government Response: Accept

The draft workforce plan was seen as intended and we have since been working with HEIW on finalising the plan and financial costs. Unfortunately this has delayed formal publication until July.

Financial Implications – none

Recommendation 9. The Welsh Government should bring forward the legislative changes needed to enable dental therapists to have a performer number as a matter of urgency and provide us with a timescale for this.

Welsh Government Response: Accept

Following the announcement by England that Dental Therapists and Hygienists will now be permitted to open and close courses of treatment officials have sought and received fresh legal advice on the legislative barriers preventing this being mirrored in Wales. In summary, lawyers have advised that Dental Care Professionals can provide NHS dental services providing they have the clinical experience, training, qualifications, competence, and indemnity required to enable them to properly perform any dental services. Therefore, there is no need for legislative change at this time.

Officials are now preparing communications to health boards to clarify how this change will be operationalised for next financial year.

Financial Implications – none

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Recommendation 10. The Welsh Government should explore options for the establishment of a dental school in North Wales and report back to us on its feasibility by July 2024.

Welsh Government Response: Accept

Expanding training provision for all the dental team is a key workforce priority moving forward. We know that people are more likely to work where they train and therefore, we must increase training opportunities in rural areas. This has already started with a phased approach to enhancing rural recruitment through a targeted training initiative for students graduating this September.

Financial Implications – none

Recommendation 11. The Welsh Government must provide assurance that oral health is being integrated into prevention policies such as Healthy Weight, Healthy Wales, and provide examples of where and how this is being done.

Welsh Government Response: Accept

There is a standard governance process for the development of policy within the Department of Health and Social Care. The Policy Forum is a key component of that process that ensures all policies being developed are reviewed and interdependencies by all policy leads in the department.

Priorities 1 and 6 of Health Weight Healthy Wales which focus on healthy eating choices are an excellent example of this policy contributing to improving oral health.

Financial Implications – none

Recommendation 12. The Welsh Government must ensure the Designed to Smile programme is restored to pre-pandemic levels as quickly as possible and provide an update to the Committee on progress by the end of the summer term 2023.

Welsh Government Response: Accept

We can assure the committee that the recovery of Designed to Smile (D2S) is progressing well. There are still some schools that are reluctant to re-engage for a range of reasons. The 2022/23 D2S annual report will be provided to the committee in advance of summer recess.

Financial Implications – none, the delivery of the D2S programme is funded from a ringfenced allocation to health boards.

Recommendation 13. The Welsh Government should carry out research to identify whether oral health programmes for up to 12-year-olds should be delivered through schools in all health boards as a preventative measure.

Welsh Government Response: Accept

Advice received to date has been that there is little evidence of clinical benefit for extending the Designed to Smile approach beyond aged 7. Children benefitting from the D2S programme will have normalised good habits around good oral health.

However, we do want to improve access to dental services for all ages of children

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and we know that the regular application of fluoride varnish is a proven preventative approach for tooth decay. We would therefore look to establish whether this is best or most efficiently done through a school programme or through primary care dental services.

Financial Implications – funding has been identified from within existing budgets to resource a research project.

Recommendation 14. The Welsh Government should explore options for expanding the Gwen am Byth programme into other residential settings, such as care homes for younger vulnerable people, sheltered housing and extra care housing, and report back on its findings to this Committee by the end of 2023.

Welsh Government Response: Accept

Since receiving the recommendation, we have established that some health boards, via their community dental services, already do engage with these types of services. Furthermore whilst the programme itself is aimed at older people living in care homes the resources are freely available through the Public Health Wales website - Gwên am byth - Public Health Wales (nhs.wales)

Financial Implications – none

Recommendation 15. The Welsh Government should commission research into the public health value of and attitudes towards introducing fluoride into the public water system in Wales and commit to publishing the findings of this research.

Welsh Government Response: Reject

The 4 UK medical officers published their view on this matter in September 2021 - Statement on water fluoridation from the UK Chief Medical Officers - GOV.UK (www.gov.uk). It’s public value therefore is not in question.

Up-to-date costings for implementation in Wales are not available but a Technical Feasibility Study carried out in 1997 by Hyder on behalf of the Welsh Health Authorities stated that the capital cost for installing fluoridation plant at each of the then 121 water treatment works in Wales was £21 million. The recurrent annual running costs were estimated at just over £1 million.

The estimated capital cost of introducing water fluoridation in the Dwr Cymru Welsh Water area of Wales would now cost over £38 million, taking inflation alone into account. The annual running costs of such a scheme are estimated to cost between around £2million.

Given the financial pressures at this current time, regardless of public opinion, it is unlikely that the Welsh Government could introduce Wales-wide fluoridation of its water supply. We would therefore argue that any research into public opinion at this time would not offer value for money.

Financial Implications – Not applicable

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Recommendation 16. The Welsh Government should review whether the current levels of funding are appropriate for the services to achieve what’s needed in terms of reducing the backlog and report back to this Committee by the end of the summer term 2023.

Welsh Government Response: Accept

We are working to establish the centralised waiting list. Once this is in place we will be able to establish the scale of people waiting for NHS dentistry. Based on this information we will be able to make an assessment of the level of funding required both for additional activity and additional workforce to undertake that activity. Within this assessment, and the reforms we are undertaking, we will also consider the appropriate skill mix to ensure that people received care from the most appropriate professional.

Financial Implications – unknown at present

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