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


Response on behalf of North Wales Community Dental Service

North Wales Community Dental Service (CDS) welcomes the opportunity to contribute to this Consultation on Dentistry in Wales.  The response highlights what has been already been achieved by the CDS in north Wales and identifies opportunities that could further enhance the contribution that the CDS could make towards achieving a healthier Wales.


The Welsh Government’s dental contract reform

According to General Dental Service (GDS) data released 30th August 2018 access to dental services in BCUHB remains the second lowest in Wales; 49.5% of the resident population having been treated in the GDS in the 24 month period ending March 2018.  This compares unfavourably with Wales (55%) and falls well short of that achieved by the best in Wales (ABMU 62.6%).  The data that informs these access levels relates to GDS and although they include the salaried GDS (CDS/PDS) they exclude data relating to patients who are treated solely in CDS and those treated under private arrangements.  Data is collected via FP17W forms which are submitted to the NHS Business Services Authority.  From May 2019 it is intended that CDS activity will also be captured by submitting information in the same way.  This will provide a more comprehensive picture of NHS primary care access. There is however, concern regarding the capacity of IT infrastructure support in Health Boards.  Additionally, the requirement for dental software upgrades need to be ascertained as a priority.


A survey conducted by the British Dental Association in 2017 found that only 15% of practices in Wales were accepting new NHS adult patients and 28% accepting new child patients.  Waiting lists were also operating at a number of these practices.  In contrast, 72% of practices were willing to accept patients under private arrangements. Data is not available by Health Board.


The lack of access to GDS in north Wales disadvantages those people most in need of a service and results in a high volume of calls to NHS Direct and attendances at Emergency Dental Service clinics.  It also impacts on the ability of the CDS to achieve its strategic objectives which are identified in the strategy document, Services for Smiles (2017-2022).


Welsh Government’s vision for dentistry recognises the need for system change and to this end has introduced a programme of GDS Contract Reform.  With the support of the Primary Care Resource Team, four pilot practices are already participating in this initiative in north Wales and additional practices are in the process of being recruited.  The CDS has indicated its interest for a salaried GDS (CDS/PDS) practice to be included in the extended programme.


Units of Dental Activity has generally not been a popular system with the dental profession with the focus being on treatment and not promoting a preventative ethos.  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 introduction of the Assessment of Clinical Oral Risk and Need (ACORN) at least once a year for all patients attending NHS primary care dental services (GDS and CDS) will, in accordance with Prudent Healthcare principles, enable treatment provision to be focused on those most in need of care  and for appropriate recall intervals to be applied.  It is considered that a disproportionate amount of resource is being expended on the ‘worried well’; a cohort of patients with low rates of oral disease who are attending at unnecessarily frequent intervals.  Releasing time dedicated to seeing these patients will release appointments for patients with greater need who are currently unable to access care.  Increasing GDS access in this way will benefit the CDS enabling it to concentrate on providing care to the most disadvantaged people in our society.


Contract Reform also promotes skill mix in the delivery of care and shifting the balance of some specialist treatment, traditionally provided in hospital, to the community setting. 


The CDS is already contributing to providing primary care access as identified below:-


·         The CDS organizes and coordinates the Out of Hours Emergency Dental Service (EDS) which is provided at CDS sites across North Wales utilising a workforce comprising GDS and CDS staff.  Attempts have been made to improve access to rural areas by expanding the service to include sessions at Bethesda and Dolgellau.  The CDS facilitates emergency/urgent care for those children and vulnerable adults who have been provided with a CDS code by NHS Direct.


·         The CDS/PDS model, in essence a Salaried General Dental Service (GDS), was introduced by Welsh Government in 1996.  Commencing in 1997 services were introduced utilising this model in geographically/socially disadvantaged areas or in areas where there was a dearth of primary care provision.  Currently there are 3.5 WTE dental posts providing NHS primary care access under these arrangements in north Wales.

One example is the service introduced to service Llangollen and Corwen utilising a mobile dental unit.  When access improved in Llangollen the mobile was used as a fixed site providing a service to Corwen and environs.  As part of the Corwen Health Centre Development the mobile is now being replaced with a two surgery dental facility which will open in October.  It will provide both salaried GDS and CDS services utilising skill mix.  This model has the advantage of facilitating care closer to home and the seamless transfer of patients between CDS and GDS in this geographically remote area.


·         Direct access has been introduced with a cohort of dental therapists/hygienists trained to triage and treat children and older people living in care homes.  They are able to carry out treatment for patients within their range of competencies with upward triage to a dentist as necessary.  Some dental nurses have also been trained to apply fluoride varnish which they can deliver within preventative programmes and in surgeries.  Cognisant of Prudent Healthcare principles these developments free up dentists’ time to concentrate on procedures that only they can deliver.


·         A new cadre of Dental Healthcare Assistant (DHA) was introduced into north Wales CDS in August 2010.  The DHA is able to relieve the dental nurse of non-clinical administrative tasks and assist with decontamination procedures.  This development increased access to patients and was recognised by Welsh Government as an example of good practice.  The Job Description has been shared with other HBs and the model has been adopted by ABUHB.


·         In north Wales the shifting of the balance from the acute to community setting has already commenced. 

A Consultant in Paediatric Dentistry, based at Alder Hey Hospital, visits north Wales on a quarterly basis.  Assisted by CDS dentists, she provides a service for north Wales’ children at Holywell Community Hospital.  Additionally, outreach cleft palate clinics from Alder Hey Hospital are supported by CDS dentists.

Two dentists have been accredited as Dentists with Special Interest (DwSIs) in Orthodontics and a further two provide an Intermediate Tier Oral Surgery service.  These developments with Consultant/Specialist oversight alleviate pressure on the hospital disciplines by reducing their waiting lists for the less complex treatments and take care closer to where patients live.

Unfortunately, several attempts to recruit to the vacant Consultant in Restorative Dentistry post have so far proved unsuccessful.  However, an expression of interest has recently been received.  The CDS has therefore become increasingly involved in supporting the Head and Neck Cancer Multi Disciplinary Team with Specialists in Special Care Dentistry (SCD) arranging the provision of essential treatment and preventative advice before cancer therapy can commence.  This development has been recognised as an example of good practice worthy of adoption by other units.


It is considered that the CDS has further contributions to make to Contract Reform as detailed below.


·         Expansion of the Salaried GDS (CDS/PDS) model within a managed service has the potential to improve NHS access, especially in rural and socially deprived areas of north Wales.  This model does not operate in a mixed economy and provides a purely NHS service.  Those patients seeking aesthetic dentistry or complex restorative treatment (e.g. implants) are referred to colleagues in GDS.


·         By creating a pathway for progression of the DHA model the post holder would be able to apply to become a trainee dental nurse and subsequently qualify as a dental nurse eligible to study for additional qualifications.  The pathway opens up further opportunities for pursuing a career as a dental hygienist, therapist or dental health educator.  

An expansion of the DHA cadre in CDS has the potential to widen access to employment in areas of social or geographic deprivation in line with Welsh Government policy and to create a source of qualified nurses for all branches of dentistry.  It is intended that a bid will be submitted to the Welsh Government Dental Innovation Fund to progress this development.


·         There are also opportunities to build on the successful Direct Access initiatives for therapists and hygienists e.g. to prescribe radiographs as an extended duty.


·         The service has a wealth of experience in delivering dental nurse training (commenced 1976). It has a history of achieving exemplary examination results exceeding the national average with a number of students having gained national awards.  North Wales CDS would welcome opportunities to be involved in the establishment of the National Training Faculty and the provision of training courses.


·         The CDS strategy, Services for Smiles, identifies the need for the development of Consultant posts in Paediatric Dentistry and SCD.  With Consultant supervision available locally, the introduction of further training posts in these disciplines could be facilitated.  Discussions are ongoing regarding the possible options available to enhance the availability of consultant paediatric dentistry sessions in north Wales.


·         In the absence of a dental hospital and difficulties in recruitment to some specialties the expansion of the intermediate care DwSI (DES) role is envisaged to support the HDS and GDS.  In an attempt to make specialised services accessible to NHS patients the CDS has been proactive in identifying training opportunities and enabling CDS and Salaried GDS (CDS/PDS) dentists to pursue postgraduate qualifications in a number of specialised areas.  This is addressed in more detail in the section on training.   


How ‘clawback money’ from health boards is being used

There appear to be different approaches across Health Boards regarding the management of ring fenced primary care funding and ‘clawback’.


In view of the access problems being encountered in north Wales it is clearly evident that the ring fenced dental funding provided by Welsh Government needs to be spent on NHS dentistry to ensure that the population has appropriate access to NHS care.


Along with low UDA values it has been asserted that recruitment difficulties have compounded problems experienced by some practices.  It is suggested that, as is the case in medicine, salaried general dental practitioner posts may be more attractive to some dentists.


It needs to be noted that budgetary reductions have been applied to some CDSs.  In north Wales CIP/CRES has amounted to £0.6m (approx 1% of budget) since 2014/15 with no uplift in funding for non-pay items since 1998.  However, ring fenced funding for dedicated programmes has been received by the service in its entirety and never been subjected to CRES.


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

It has been noted that recruitment to the CDS in north Wales has greatly improved since the introduction of the new contract in 2008 with dentists living on the Welsh border favouring posts in north Wales rather than England.  Many of the CDS dentists working in north Wales live in Chester, Wirral, Liverpool or Shropshire. Recruitment to posts in north east and central areas does not therefore appear to be problematic although vacancies in west Wales are sometimes difficult to fill. 


The CDS already employs Specialists in SCD and Paediatric Dentistry.  SCD links have been established with Liverpool and a Consultant in Paediatric Dentistry from Alder Hey Hospital provides a service for north Wales’ children at Holywell Community Hospital.  However, this latter service is only available on a quarterly basis.  An StR post in Special Care Dentistry has been created from a dental officer post with the post holder benefitting from an exchange arrangement with Liverpool.  Although there are a number of Specialists in SCD available to provide supervision this arrangement fulfils the requirement for Consultant oversight of the post.


There continues to be a significant recruitment and retention 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 the development of 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 in secondary care, enable career development and possibly encourage clinicians to stay in the area.


A Final Year Dental Students Outreach Scheme (Cardiff University) has been operational for many years with all final year dental students attending Wrexham Dental Centre in groups of six or seven for a two week period.  The cohort has recently expanded from 75 to 80 students.  Already subsidised by the CDS, the continuation of this programme is currently under threat due to a rise in accommodation fees.  Discussions are on-going with Cardiff Dental School.


To date there have been three Dental Core Trainees (DCTs) accommodated at any one time in NWCDS.  Unfortunately, with the understandable reduction of financial support from the Deanery, the CDS funded post will be withdrawn in 2019.  It will be converted to much needed dental officer sessions in north-west Wales to improve access to vulnerable patients in that area.


As mentioned previously, a number of dentists have recently completed or are enrolled on MSc courses.  Two salaried GDS dentists are on MSc courses - one is to complete her final year of training in Endodontics and the second is part way through a course in Restorative Dentistry.  Both disciplines are difficult to access in north Wales under NHS arrangements.  Additionally, two CDS dentists are studying for MScs in Paediatric Dentistry and one is in the final year of a Masters in Clinical Dentistry in Fixed and Removable Prosthodontics.


A North Wales Dental Bursary Scheme for dental students living in north Wales commenced in 1995/96.  In the latter years a small number of therapists also received financial support.  Due to financial constraints the scheme ceased to be offered in April 2014 with payments for the last cohort of students ending in the academic year 2017/18.  The scheme successfully resulted in the majority of students returning to work in north Wales, including a number of Welsh speakers.  Those who could not satisfy the terms and conditions were required to repay their bursaries. 


Various surveys have reported that between 19 and 24 per cent of people living in Wales speak Welsh with the highest figures reported for North and West Wales.  In north Wales a gradient is evident from east to west with Welsh language usage being highest in Gwynedd and Anglesey.  In Gwynedd it is reported that 85% of the population speak Welsh on a daily basis and 31% attempt to use the language at all times when contacting public services. 


The importance of encouraging Welsh speaking dental students to return to north Wales is implicit.


It is encouraging to note that Welsh Baccalaureate is now accepted as an A-level for entry to Cardiff School.  It is considered that schemes that could encourage students from north Wales to return once qualified should be investigated.  This would benefit recruitment to all branches of dentistry.


Although this section specifically addresses and seeks information in relation to dentists we consider it relevant to mention an issue that has emerged in relation to dental therapists


As mentioned previously, Direct Access training (children and older people) is provided by the CDS for dental therapists/hygienists and Inhalation Sedation Training is also provided for dental therapists.


Having seized training opportunities, some therapists in the CDS are understandably seeking financial recognition for their extended role.  However, it has been noted that the gap between dental therapist and dentist pay is narrowing and this is likely to make the choice between employing a dentist, with a wider scope of practice, or a dental therapist more difficult.  It has also been reported that therapists in GDS are seeking remuneration packages comparable to associates.


The provision of orthodontic services

The North Wales and Powys Orthodontic Managed Clinical Network (OMCN) has been instrumental in the recommissioning of PDS Orthodontic contracts and the Accreditation of Dentists with Special Interest (DwSIs).


Orthodontic DwSIs are of particular importance in north Wales in enabling children in geographically and/or socially disadvantaged areas to benefit from orthodontic treatment in the primary care setting.  The service is provided by GDS and CDS dentists.  Orthodontic DwSIs in the CDS also provide sessions in the HDS with this close liaison facilitating care being provided closer to home with shared care and transfer of patients between services operating as deemed appropriate.  Other initiatives and achievements will have been highlighted in the OMCN response to the Inquiry.


The OMCN considers it essential that a DwSI training pathway is developed for succession planning to ensure that this service remains available for vulnerable patients and those living in geographically remote areas of north Wales.


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

The field work for Welsh National Epidemiological Surveys is conducted by CDSs led by local epidemiology coordinators.  The national benchmark for the child dental heath surveys is a north Wales dentist with an MSc in Paediatric Dentistry.


Epidemiological surveys of 5 year old children have shown that the incidence and prevalence of dental disease in Wales continue to improve with children attending schools in the most deprived areas experiencing the greatest improvements.  This has been attributed to the impact of the targeted Designed to Smile programme.  However, 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, Refocusing of the Designed to Smile child oral health improvement programme (2017) identifies the strategy for the future of D2S.  It places greater emphasis on preventative measures for children aged 0-5 and the inclusion of GDS teams in the delivery of this targeted programme.  The actions identified for the CDS in the circular have been implemented and D2S Dental Health Educators have already delivered the recommended input to Vocational Training Practices.


There do however remain some concerns regarding the dental health of older children.  In 2013, the National Children's Health Survey reported that almost two thirds (63%) of fifteen year old children in Wales had obvious decay experience with 28% having active, untreated decay.  These rates were higher for children living in socially deprived areas.  It has been shown that GDS dental attendance is poor in the 18-25 age group.  It is suggested that older children are rendered dentally fit before they leave school and that access to GDS is actively facilitated for this cohort.


The series of surveys of 12 year old children show that there have been statistically significant reductions across all health boards for DMFT (Decayed, Missing and Filled Teeth) between 2004/5 and 2016/17).  However, the reduction in active, untreated decay levels in north Wales does not appear to demonstrate the reduction experienced by other Health Boards.  In 2020/21 children who participated in D2S before their permanent teeth erupted will be surveyed and the longer term impact of D2S on caries in the permanent dentition of 11-12 year olds will be determined.  These children are already aged 7-8 and may have received fissure sealant treatment before it was withdrawn but could already have experience of decay in their permanent teeth.  North Wales CDS wish to make a research proposal in relation this cohort.


Local preventative programmes have been designed for a group of particularly vulnerable people and have been recognised as examples of good practice by Welsh Government.  Seren o Wên, a programme for children with learning difficulties, complements D2S and Gwên Wen, a programme for adults with Learning Difficulties have been operational for a number of years.  Unfortunately the roll out of these programmes has not been as rapid as planned due to reductions in CDS budget.  Similarly, it is likely to be difficult to meet the Welsh Government target date of 2020 for rolling out the Gwên am Bythprogramme to all Care Homes in north Wales without further investment.