Select Committee on Welsh Affairs Minutes of Evidence


WRITTEN EVIDENCE FROM THE BRITISH DENTAL ASSOCIATION WALES/CYMRU

House of Commons Welsh Affairs Select Committee Inquiry—NHS Dentistry in Wales

  1.  The British Dental Association (BDA) is the trade union and professional association for dentists practicing in the UK, representing 22,000 members working in all aspects of dentistry, including general practice, salaried services, the armed forces, hospitals, academia and research. BDA Wales represents all those members who practice or work in Wales.

  2.  BDA Wales welcomes the chance to input into this inquiry and aims to cover four main areas of contention: Recruitment and retention, the new general dental service (GDS) contract and proposed NHS patient charges regime, historic underinvestment in NHS, and the relationship between the dental profession in Wales, the Westminster Department of Health (DH) and the Welsh Assembly Government (WAG).

  3.  A recent study by the British Association for the Study of Community Dentistry (BASCoD) in 2005, has revealed a widening gap in the levels of decay in children's teeth in the poorest and richest parts of Britain. Areas with the lowest rates of tooth decay are exclusively in the south of England and the Midlands. The worst areas are restricted to parts of Wales, Scotland and the north of England. Three areas of Wales are in the top 10 black spots for five year olds with decayed, missing or filled teeth (DMF)—Merthyr has the worst record with a DMF of 3.73, Blaenau Gwent was fourth with 3.49 and Caerphilly was eighth with 3.2.[1]

RECRUITMENT AND RETENTION

  4.  According to a parliamentary answer in the Welsh Assembly, for 2004-05 there were 1,024 general dental service dentists (headcount) in Wales, This figure includes new graduates currently in vocational training posts and others working as assistants[2]. If these are excluded the number of "principle" dentists is 927, one fewer than in September 2000[3]. In addition there were 112 dentists (89 whole time equivalents) in the community dental service (CDS).[4] Denbighshire Local Health Board has the highest number of dentists per population and Ceredigion the lowest.

  5.  The dental profession is an ageing profession in Wales with more than 56% aged over 40. Up from 48% in 1994. The largest rise was in the 50-59 age group which rose from 110 (13% of all practitioners) to 229 (22%).[5]

  6.  From this academic year Cardiff dental school has seen a 17% increase in dental training places, with 64 first year undergraduate places. However, while this increase is welcome, Wales does not produce enough dentists and has been a net importer of new graduate dentists for the last 10 years. In England there are plans for a new dental school, but other than sustaining the increased number of places at the Cardiff dental school there are no plans for a new dental school in Wales. The Dental Workforce Advisory Group (DWAG) recommended that the number of undergraduates in training in Wales should be increased to 74. They also recommended the number of hygienist/therapists being increased to 20.[6]

  7.  Data made available to the DWAG showed that Wales lagged behind other parts of the UK in its dentist to population ratio. Wales has one principle dentist to 3,169 population compared with Scotland which is 1:2,619. If we were to bring Wales into line with Scotland we would currently require an extra 44 dentists, but Scotland has acknowledged that it is 215 dentists short.[7]

  8.  The BDA is deeply concerned by these figures and is worried that there is no evidence that the WAG has formalised plans to improve this situation. In addition, they have no structured plans for the recruitment of overseas dentists. In England, the DH recently announced the successful recruitment of over 200 directly recruited Polish dentists, plus a further 290 overseas dentists recruited by individual PCTs. While in England the DH finances post-graduate deanery programmes of £100,000 to support overseas and refugee dentists, such as financially supporting them for attendance at a course for the International Qualifying Exam (IQE), there are over 50 dentists in Wales attempting to pass the IQE, that are having to totally self fund. This clearly puts them at a severe disadvantage to overseas and refugee counterparts living in England and thus is doing nothing to encourage overseas dentists to locate to Wales.

  9.  Dentists have a career break for a variety of reasons and getting them to return to frontline dentistry is an issue for both the DH and WAG. Both the DH and WAG ran a keeping in touch/returning to dentistry campaign which offered grants and support to those dentists thinking of coming back to dentistry. In Wales last year there were five or six returnees, but the scheme has been abandoned this year due to a cut in the funding of the Dental Postgraduate Department. A number of applications for the scheme were received which could have been transferred to England but WAG has refused to fund them in England. This is very disappointing and is an example of a lack of cross-border co-operation. This could well result in Wales losing well-trained and experienced dentists, all due to a lack of WAG-DH governmental cooperation.

THE NEW GENERAL DENTAL SERVICE (GDS) CONTRACT

  10.  In the 2002 white paper Options for Change, the Department of Health and the BDA agreed that any new contract must:

    —  allow dentists to spend more time with their patients;

    —  adopt a more quality-driven and preventive approach to oral health; and

    —  improve the working lives of the dental team.

  11.  Throughout this reform process, the Department of Health stated that "of central importance is the ending of the treadmill"[8]. In 2001, the Audit Commission compared working as an NHS dentist to life on a treadmill. The BDA estimates that an NHS dentist needs to see 40 patients a day to meet the patient demand and cover the costs of the practice. The profession welcomed this aim. Breaking the link between treatments provided and remuneration received would indeed improve dentists' working lives could attract additional dentists to work in the NHS.

  12.  The Welsh Assembly Government has cautiously followed the "English model" towards the proposed GDS contract, but has made two significant improvements—changes to the output leeway and monitoring trigger. The DH claims that to "get dentists off the treadmill" they are going to set the individual practitioner contract values according to the level of item of service activity and earnings in the current year, minus 5% activity. In Wales, the proposed level of activity for equal funding is going to be lower- 10% less. This is a very welcome move for dentists in Wales as, in theory, it gives them more time to spend with each patient, offering preventive care and advice and gives them a slight freedom from the treadmill. In reality we are concerned that as dentists are already working to address the needs of the people of Wales who have poorer oral health than in England, there will be little opportunity to free up time without affecting the standard of service and waiting times for treatment. The monitoring trigger, a device used by PCTs and LHBs to oversee activity outputs by individual practitioners, and is one of the contract measures—in England a 4% drop in agreed activity triggers an investigation by the PCT and has to be made up within 60 days. In Wales the LHBs will not contact practices until the contract figure falls by 5% from the agreed contract value and, if there is good reason there will be no need to make up the difference. This is particularly pertinent in the transitional period where dentists and LHBs will have to get used to the new ways of working very quickly. Again, this is advantageous to NHS dentists in Wales as it theoretically allows them flexibility and time to deal with the additional demands of administering a practice which include more clinical governance activity, the training requirements of staff, especially dental nurses and increasing health and safety requirements related to recent legislation.

  13.  However, WAG has been slow to develop its strategy for the future of dental services. The regulations for the dental charges have only just been discussed in the Welsh Assembly Health and Social Services Committee and only then was the first draft available to members. This slowness by WAG to develop their policies for implementing the changes has raised significant anxieties in general dental practitioners, who are effectively running businesses, need to be assured of a degree of financial stability related to their NHS commitment so that they can develop their business plans for the coming years. There is also deep concern whether the WAG and LHBs will have the necessary funding to fund these wide ranging reforms in Wales.

  14.  BDA Wales has been concerned for some time that the LHBs lack expertise to implement these reforms. Dental leads at the LHBs have voiced disquiet to us that they lack guidance from the Welsh Assembly Government and are thus unsure how they should be taking the reforms forward locally. Dental practitioners feel that LHBs need to be seen to be doing something but then concentrate on easy fixes such as governance issues. They lack confidence with WAG's ability to support them financially on issues such as variations in patient charges and any proposed growth in patient numbers.

  15.  In spite of the intentions of Options for Change, BDA Wales feels that the new proposals do not encourage disease prevention and the maintenance of good oral health, because lifestyle advice/education on a good oral health regime does not specifically attract any Units of Dental Activity (UDAs) (The basis of the new system is that a contractor will complete a number of UDAs as set by the local PCT in return for set monthly payments). Prevention could be encouraged if it separately generated UDAs. These might be variable depending on the patient; for example, preventive care for children might generate a greater activity measure than that for adults.

  16.  A third major principle of the Options for Change report was that any new system should be tested before being rolled out across the country. To this end, the Modernisation Agency first ran field sites and then supervised Personal Dental Services (PDS) pilots to test new ways of working. While one or two aspects of the new General Dental Service (nGDS) contract proposals have been tested in PDS agreements—some in large numbers of practices—the UDA output system and proposed dental charges regime is entirely untested. Not only does this belie the oft-repeated comparison between the uptake of PDS pilots and the expected success of the new contract proposals, it also makes the new system inherently risky for dentists and the NHS. In Wales, it could be argued that the system is even more open to the charge that the new UDA and dental charges systems have not been tested—pilot PDS scheme have been established very slowly and were only given the final go-ahead in April of this year. As of November 2005, BDA Wales has been led to believe that 48 practices are involved in the pilot PDS scheme.

  17.  This risk might have been avoided had UDAs been piloted. In addition, this new system will be implemented at the same time as the new system of patient charges are due to take effect, further increasing the uncertainty surrounding the new system and the serious financial risk to LHBs.

DENTAL CHARGES

    —  Preventative treatment at Band 1—£12.00  (English Band 1—£15.50)

    —  Simple treatments at Band 2—£39.00  (English Band 2—£42.40)

    —  More complex treatment at Band 3—£177  (English Band 3—£189.00)

    —  An urgent course of treatment banded at Band 1—£12.00  (English Band—£15.00)

  18.  The BDA does not consider the banded charges system as necessarily fair. Such a system does nothing to promote a preventative approach to dentistry—there has not been an appropriate analysis of the differences in patients' financial situations, for example, those people that could find the new system unaffordable, eg older people on fixed incomes.

  19.  The BDA is also alarmed that the DH or WAG has not attempted to pilot a banded charges system in a single practice operating under PDS arrangements. (The PDS was established in 1997 and was designed to offer more flexible, locally-agreed ways of working, away from the current fee-per-item system, between individual dentists and Primary Care Trusts (PCTs/Local Health Boards (LHBs).

  20.  It is vital that the DH and WAG find an effective way of communicating these changes to patients. It must not simply rely on dentists to explain them. The BDA is concerned that given this new patient charge banding system is to come into effect on 1 April 2006, along with the new general dental service contract and the need for dentists to know how the new Units of Dental Activity are going to work, there will be a relatively short time to inform and educate patients about these wide ranging changes.

  21.  However, what confuses matters further is the WAG policy of free dental check ups for under 25s and over 60s. While BDA Wales supports this preventative oral health measure, there will be further confusion for patients about the level of treatment they can receive free because anything else within Band 1, such as a scale and polish or an ex-ray, will incur the full £12.00 charge.

  22.  During the debate on the draft regulations by the Welsh Assembly Government Health and Social Care Committee[9] an amendment to the regulations was passed that would allow the prioritisation of services to children if that was what the LHB wished to commission. The amendment allows this in both the PDS and nGDS contracts. Whilst we understand that this is still subject to a legal opinion to its validity, we welcome this amendment as a means of ensuring that NHS dentistry continues to be available to the young people of Wales.

  23.  Dentists are required to provide only what is clinically necessary so that the dentition is adequately restored to function. However, the proposed new NHS patient charges system creates an incentive for patients to demand more per charge-paying course of treatment than would previously be carried out and, in other situations, for the patient to delay necessary treatment in order to pay less.

  24.  The urgent/emergency band at the price of £12.00 undermines preventative care, as patients may choose to wait for an emergency and then to claim that they had needed urgent care rather than a "routine" course of treatment which could attract a higher charge. This provision does little to encourage patients to keep regular appointments with their dentists and encourages poor oral health.

HISTORIC UNDERINVESTMENT IN NHS DENTISTRY

  25.  The National Audit Office (NAO) report in November 2004 found that since 1990-91, "NHS spending on General Dental Services (ie high street dentists) per capita has increased by 9%, compared with 75% increase in overall NHS funding per capita".[10] The NAO also noted that, in the five years after the early 90s fee cut, there was year-on-year under spend totalling £330 million, or some 5% of gross expenditure.[11]

  26.  In July 2004, the DH announced £368 million extra investment would be allocated to NHS dentistry in England. In Wales, £5.3 million over three years has been allocated to support dental reform—pilot PDS growth fund money and monies to underwrite any shortfall resulting from the changes to NHS patient charges, £510,000 has been given to six LHBs to enable them to purchase additional dental sessions and £440,000 will go to LHBs to support them with dental changes, such as supporting their dental advisory committees or developing dental leadership skills.[12] However, BDA Wales would contest that the extra LHB funding is reaching frontline dentistry, with very little of it actually being directly implemented on the ground. The £440,000 was allocated equally to the 22 LHBs, each receiving £20,000. We were told by LHBs that they had received no guidance as to how these funds should be allocated to practices or how it should be used.

  27.  The remaining £550,000 related to the previous year's Doctors and Dentists Review Body Report (DDRB) recommendation that resources should be made available for dental practices providing NHS care to meet their costs in preparing their practices for the contract changes. Guidance to LHBs on its use was issued[13]. It was to be allocated according to practices' patient list size and varied from £250 for a practice with fewer than 100 patients to £1,500 for one with more than 2,000. We have been unable to ascertain if all of this fund had been allocated but would comment that its method of distribution outlined in the guidance was inequitable and did nothing to encourage the smaller practices, many of which are providing a valuable NHS service using part time practitioners, to stay within the NHS.

  28.  Vocational Training in Wales has also received additional funding. In April 2003 the Welsh Assembly Government announced that an incentive grant of £5,000 would be available to Vocational Dental Practitioners (VDPs) who joined an approved training practice in eligible areas of Wales. The practice could also receive a grant of £15,000 to enable it to meet the standards needed to become a training practice providing that it was able to attract a trainee. As practices needed to undertake any required modernisation before recruiting a VDP, and there was no guarantee that they would, uptake of theses grants was low[14]. In May 2004 the Minister at that time announced increases to both the trainer grant and trainee salary. VDP salary is now £2,868 higher than similar schemes in England and the grant paid to trainers is £1,656 higher. We fully support both of these measures, not only as a way of encouraging NHS dentists to take on VDPs and offer expert advice and opinion in their training, but also as an incentive for VDPs to continue their much needed dental work in Wales and not to re-locate away. The Marches scheme was designed to attract trainers and VDPs from outside Wales but to provide their academic training in Wales in a block release format. It has been well received by both English and Welsh dentists, but cross-border issues have been strained on this issue by English PCTs refusing to fund new training practices who wish to join this scheme. There are concerns about the continuing viability of this scheme once the current course finishes. The Welsh Dental Initiative scheme, introduced originally in 1995[15] offers financial assistance to dentists who are prepared to establish new, or expand existing practice in designated areas defined as those with a particularly unfavourable dentist: population ratio.

    To qualify for the funding a new dentist who had not previously worked in Wales had to be introduced into the practice and they had to remain for five years. This has causes much ill feeling amongst dentists who were already providing NHS care in Wales in the designated areas, especially those who had only recently established and had borne the capital costs of the practice themselves. The costs of buying dental equipment are quite high and any assistance, especially when it is for a new practice is welcome. The maximum grant was £40,000 per practice and while this amount is encouraging, the number of conditions attached to it made it less than promising for Welsh GDPs. Currently there are conflicts between LHBs and WAG over the number of grants allocated in an area and should the practice decide to proceed with a pilot PDS agreement, any unpaid proportion of an Initiative grant is being withheld. The introduction of the new contract with it new funding arrangement—a set level of funding for the year, will make it difficult for practices to make improvements and, replace equipment without it affecting their profitability.

RELATIONSHIP BETWEEN DEPARTMENT OF HEALTH AND WELSH ASSEMBLY GOVERNMENT AND SUMMARY/RECOMMENDATIONS

  29.  We are deeply concerned that while WAG have been following the "English model" for the new NHS GDS contract and patient charges regime, with a few notable improvements to support Welsh NHS dentists, they have been incredibly slow in implementing the changes and in advising dentists in Wales about their intentions. Dentists in Wales are used to this and to the legislative lag that result from the National Assembly for Wales processes. It took 19 months for a change to the current regulations to allow payment of an assessment fee for non registered patients in pain to get through the WAG legislative process. The contract and new patient charges regime is to start in England and Wales on 1 April 2006 and while the DH have been slow in letting English GDPs know the final financial settlements (only on 2 December 2005 it was confirmed by the DH that details of how much NHS GDPs will be entitled to under the reforms and the level of service they will be expected to provide in return had been sent to individual GDPs), dentists in Wales have not yet received these important figures. This is creating considerable anxiety among our members as they hear the reaction of colleagues in England.

  30.  Cross-border co-operation between Welsh dentists, the DH and WAG is a significant issue for BDA Wales. Often our members and patients get caught in cross-border funding disputes, which, while important for the funding levels for those PCTs and LHBs involved, and for recognising devolved powers to WAG and LHBs, do little to encourage continuous good dental provision for Welsh patients. While a number of cross-border disputes have been highlighted in this submission, another specific example, and which has yet to be rectified, is orthodontic capacity in north Wales. Historically there have been referrals to Chester hospital, but now a Chester area PCT has refused to continue to fund these referrals and has left patients in north Wales without much needed and local secondary dental care. Yet, BDA Wales is led to believe that this Chester area PCT has always received a historic spend built in to take into account cross-border patient referrals and should continue to fund Welsh orthodontic patients. Equally, the LHB involved is a fault as well for failing to fund these referrals themselves. It is this sort of localised example, which has a profound effect on a significant number of Welsh patients which the DH and WAG should step in to resolve. Conversely, in Monmouthshire, Chepstow which as a population of around 12,000 has nearly 18,000 NHS registered dental patients many of who live in England and who currently are being provided with care funded by the LHB!

  31.  Whilst we have concentrated on the issues which mainly affect general dental practitioners we cannot fail to mention colleagues working in the salaried primary dental care service (SPDCS) and hospitals. In Wales, the Welsh Assembly Government is undertaking a review of the SPDCS, but is concentrating mainly on the management structure. It is also considering the English review of the service. We have previously mentioned that there are only 112 individuals working in the service and their major concern is that if GDPs leave the NHS, they will be called upon to increase their safety net function whereby patients who are unwilling or unable to access GDS services can be treated.

  32.  This will place incredible strains on a service which is already stressed, will result in the diminution of their specialised services to the patients who are unable to use the GDS because of a physical or medical condition and will hinder recruitment of new and retention of those currently in the SPDCS.

  33.  The Welsh Assembly Government also needs to undertake a review of the functions of the service and to ensure that there are arrangements in place through the LHBs to meet to needs of patients who do not seek regular care and who present with acute problems. Many of these patients end up in hospital casualty departments for whom this is totally inappropriate.

  34. In November 2005, the Secretary of State for Wales, Rt. Hon Peter Hain MP used his cabinet status to meet with the Secretary of State for Health in England, Patricia Hewitt, the minister with responsibility for dentistry in England, Rosie Winterton and BDA Wales representatives. This approach was very encouraging and we would urge the DH, the Secretary of State for Wales and the WAG Health Minister, Dr Brian Gibbons, to meet regularly to discuss NHS dentistry matters. BDA Wales believes that it would be helpful for patients and dentists in both England and Wales if there is regular constructive communication and sharing of good practice between the respective health departments.

5 December 2005



1   http://news.bbc.co.uk/1/hi/wales/4202912.stm BBC Online. Town tops child teeth decay list. Thursday 1 September 2005. Back

2   Vocational Dental Practitioners and assistant dentists provide NHS care but do not have their own contract number and work under supervision of principle dentists. Back

3   Health and Statistics Analysis Unit January 2001 Back

4   National Assembly for Wales record of proceedings. Written answers. WAQ41157. The number of NHS dentists in Wales Back

5   http://www.wales.gov.uk/keypubstatisticsforwalesheadline/content/health/2005/hdw200501251-e.htm National Assembly for Wales. Key public statistics. NHS Dentists 2004. Back

6   Report of the Dental Workforce Advisory Group published as an annex to "Route to Reform"-A Strategy for Primary Dental Care in Wales. September 2002.  Back

7   NHS Education for Scotland. 4th Workforce Planning Report. Workforce Planning for Dentistry in Scotland. June 2004. Stated that in 2003 there was a shortfall of 215 General Dental Practitioners. Back

8   Letter to dentists in England, from the Minister of State for Health Rosie Winterton, 12 August 2003. Back

9   Health and Social Care Committee meeting. National Assembly for Wales. 23 November 2005. Back

10   National Audit Office. Reforming NHS Dentistry: Ensuring effective management of risks. November 2004. Paragraph 1.12, page 12. Back

11   National Audit Office. Reforming NHS Dentistry: Ensuring effective management of risks. November 2004. Paragraph 1.20, page 12. Back

12   National Assembly for Wales Press Release. More dentists for Wales. 2 August 2004. Back

13   http://www.cmo.wales.gov.uk/content/work/chief-dental-officer/news-articles/Nhs%20Dentistry-letter-eng.htm Back

14   Welsh Health Circular WHC (2003) 49. Back

15   FHSL(W)35/95, FHSL (W)5/96, WHC (2002)18, WHC(2003)49. Back


 
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