Cynulliad Cenedlaethol Cymru

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.

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.

Angela, moving on.

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—?

Dawn, on this point. 

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—

And that's within one course of treatment.

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.

Excellent. Thank you. Back to Angela. 

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.

[Inaudible.]

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

Yes, the agenda's so huge.

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.

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.

Because you do need to have targets—

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.

Okay, Julie?

Yes, thank you.

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—

So, is that the way that the health board—?

That's how they awarded the contract for orthodontics.

Oh dear, right. Okay, that's fine.

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.

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.

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. 

Was the renewed focus driven by budgetary pressures?

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.

What kind of response have you had to those requests?

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—

And this is a chief dental officer—

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.

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.

Yes.

Okay. Angela.

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.

Yes, I was on that committee.

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—

Perhaps a note, Chair. 

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

It just puts it in context for us. 

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.

Julie.

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

We did.

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. 

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. 

Right. 

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. 

Thank you. 

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?

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.

So, you're not going to see me—

Or anybody called ap Iorwerth. [Laughter.]

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.

But there's a risk, clearly, that—

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. 

Could it be done?

So—.

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 a year.

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.

In Wales, under 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. 

Again, 30—?

Thirty-three per cent of children. 

Have not seen—

A dentist in the last two years.

That's not great.

No.

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.

Okay. Interesting.

Julie, final question.

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—

Is that common, to move to all private like that?

Yes.

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.

Okay—

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. 

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.

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?

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.

That's just for orthodontics.

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—

You need a legacy system running alongside it.

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 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

It's really interesting; you paint a complex picture.

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.

Is that statutory, the two years?

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.

Wow, that's some training pathway.

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.

Yes. 

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 is all—. Right. 

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—

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.

But by the university.

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.

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

Is there not a cross-border arrangement, then?

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.

Okay. We need to move on.

Just one last question on this issue.

If it's a short one.

I was very surprised—

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.

Why?

That's set by the university. 

Oh right, so that's just their choice.

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. 

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.

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, it's just coming online now, isn't 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.

Until you've cleared the backlog, yes.

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.

Yes, absolutely. Thank you. Thank you very much.

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. 

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

Our old ones.

The 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.

Eastside.

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.

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, thank you.

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—

That's the suggesting I'm making.

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.

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.

So clawback doesn't happen in those—?

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?

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

All of it? All of the clawback?

All, yes.

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.

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.

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.

Thank you. Anybody got anything to add?

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—

Yes, I was going to ask you about that.

—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. 

And they can get access, can they?

They can get access.

They can get access guaranteed at that age.

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.  

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—  

Nought to—

Five-year-olds. So, that's it's—

We thought it was nought to three-year-olds. 

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 channeling those probably to the community dental services to be able to try and see if we could get those seen sooner rather than later.   

Can we aim for universal access to all children? 

Yes.

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.'

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 ensue 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.

Just testing.

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 applicants 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—