Select Committee on Welsh Affairs Minutes of Evidence

Examination of Witnesses (Questions 60 - 79)



  Q60  Nia Griffith: They cannot use it for other things.

  Dr Wills-Wood: Yes.

  Q61  Mr Jones: I had a concern expressed to me by dentists that once a dentist leaves the NHS it is practically difficult to attract him or her back into the public sector. You have actually touched on this to a certain extent in your previous answers but is this a fair perception? Is the feeling within the profession that once a dentist does leave NHS practice he or she will not return?

  Dr Wills-Wood: Yes, that is correct. Probably if an LHB is realistic about trying to attract a dentist back into the NHS, it will not be what we would call a general dental service contract, it will be through a tailored personal dental service contract.

  Q62  Mr Jones: May I ask how optimistic or pessimistic you are about the future, therefore, for the size of the NHS profession in Wales?

  Mr Geddes: It depends on how bright your crystal ball is. I do not believe that dentists will depart from the NHS in droves, I think we will see a gradual diminution in the type of services being offered within the confines of an NHS contract. We have already said that the funding is guaranteed for three years: dentists have an amazing ability to make things work and we have seen that through the contracts of 1990 and again the revisions in 1992, and if they really want it to work they will find a way of making it work. With this potential contract there are a few restrictions on them which might make it a little more difficult, but I think many of them will stay for the period which has guaranteed income which is for three years, and during that time hopefully they will come to some view as to how they want to continue in their practices after that.

  Q63  Mr Crabb: Given your comments about the new contract merely stabilising the current levels of NHS commitments towards dentistry, or a gradual diminution in the services as you have just suggested, does this new contract not represent a massive missed opportunity to really reinvigorate NHS dentistry?

  Mr Geddes: I would say yes, but that is my personal view. The substantial under-investment in NHS dentistry over the last 10 years has not been addressed and I think the promotion of public health and the promotion of oral health within the practice is not identified in this contract, so I would say that that is a fair comment.

  Q64  Mrs James: When you used the word prioritisation I was particularly interested in something that you mentioned in your paper about services to children. Speaking as the aunt of a four-year-old child who cannot get dental treatment and who has actually been removed from his local dentist list, I am obviously particularly interested to this as I have to explain to my family as to why a four-year-old is not registered for dental services. You mentioned that a regulation was passed that allowed the prioritisation of services to children, but that is subject to legal opinion. Could you explain to me what that legal opinion is?

  Dr Wills-Wood: The Welsh Assembly have the view that, yes, they would like to prioritise children's health throughout Wales. Where it stands at the moment is that the lawyers have to say that this is correct, dot the i's and cross the t's. What we are saying is that there seems to be nothing to stop local health boards after April 1 commissioning off us individually children's dentistry and, hopefully, dentistry for exempt people, so the scenario you describe would hopefully go because the local health board will say we would like to commission off you under a personal dental service the treatment of so many children within their local area.

  Dr Wills-Wood: This particular amendment came up as part of the scrutinising of the regulations by the Assembly's health committee 10 days or so ago. The amendment was passed which would allow local health boards to prioritise their services to children in much the same way as they have done for some of their medical services, but there was a degree of confusion in the Committee as to whether or not they had the powers. They passed the amendment, but then they were not sure whether they actually have the power to do that.

  Q65  Mrs James: This is the issue of the devolved and the non-devolved.

  Mr Geddes: It is a bit confused, yes.

  Q66  Mrs James: Good news, I am sure, for parents of children like my nephew.

  Mr Geddes: The Assembly Government has in its other medical services been able to prioritise. We were the first to have a child commissioner, for example, we have the ability to do that.

  Q67  Chairman: The Audit Commission has described the life of a dentist as being on a treadmill. You may have answered this question, but do you think that this new contract begins to address this serious matter?

  Dr Wills-Wood: Looking at the contract value I have personally I do not believe that the treadmill issue has been addressed. In some respects the treadmill has become worse, because this has now become a cash-limited contract in that we have to do everything now within a fixed budget. As it exists now we have the ability to increase the revenue to the practice if we increase the number of hours we work or if we employ more dentists, but under this new contract it is cash-limited and the treadmill will stay there.

  Q68  Chairman: Is it the case that, with hindsight, you would have done it rather differently and that you might strike out on your own in Wales and not rely on an England and Wales contract?

  Mr Geddes: I think that would have been a wonderful opportunity had we had it. The Assembly is obviously guided by what has been going on in England because the underpinning legislation is England and Wales legislation, so they have to remain within that. They have had opportunities to vary the contract and are intending to do that; for example, the 10% leeway on performance is double what it would be in England. We have to look, with the NHS contract now, towards developing it over the next three years and getting the local health board who are there to provide services for their local populations, to work out what their population needs and then prioritise the service to address those needs.

  Q69  Chairman: Come 1 April will it be called a Welsh contract or an England and Wales contract?

  Dr Wills-Wood: I believe it is going to be called a Welsh contract and the Welsh Assembly will be sending out a template for that contract.

  Q70  David Davies: You mentioned two significant improvements in terms of what the contract offers. Can you tell us what further improvements you would also like to see and how are the improvements which you have mentioned—which I am not quite sure I have fully understood, they seem quite technical—are going to make Wales a more attractive place to carry out dentistry?

  Mr Geddes: How the contract value is being set up is on a historical work basis and a historical amount of funding, so last week every practitioner in Wales received a sheaf of papers which outlined the amount of work that they have done in a period of a year up to 30 September this year. That is converted into things called UDAs—units of dental activity—and that is matched then to the funding. The way that could be improved is that we have issues of poor oral health in Wales. The 10% reduction, it has always been suggested, would give us the opportunity to do in practice those things that we currently tend to do at weekends and out of   hours—all the practice administration, staff training, governance issues and that sort of thing tends to be done outwith practice hours at the present time and the idea was that that 10% diminution in clinical, hands-on dentistry would allow us to do that in the practice framework. The reality, because of the poor oral health of parts of Wales, is that some practitioners simply will not have that free time because the needs and the demands of their patients will be such that they will still be working at the same pace as they are currently working, if not more, to try and resolve their poor oral health problems. I am, perhaps, somewhat sceptical that there is going to be a diminution of the output to start with, I think we will find that dentists actually still do the same amount of work that they have historically done and still have to do all the other things outside hours, for which they will not be remunerated of course.

  Q71  David Davies: Is there any right of appeal to dentists, for whatever reason, who were working less than their usual capacity over the 12 month period used to calculate the contracts?

  Mr Geddes: Yes, there is. People who have been sick or ladies who have been on maternity leave, if they have had had a low contract value given to them then they do have the opportunity to talk with the local health board and have that raised.

  Q72  David Davies: What further improvements would you like to see to the contract?

  Dr Wills-Wood: Stuart talked about the things that dentists do on the weekends and that we are meant to be doing in this 10%. Clinical governance is obviously one of the foundations of NHS Wales and I would like to see a contract to have the units of dental activity linked to clinical governance so we can see quite clearly what is the clinical aspect of the contract and what is the clinical governance aspect. We are very concerned that clinical governance will become more and more burdensome and will take more and more time on us, and that 10% will just disappear overnight.

  Q73  Mr Jones: One matter that emerged from your paper that concerned me particularly was that disease prevention and education in oral hygiene do not actually attract any units of dental activity; that seems to me to be a fairly major omission from the contract. Is that something that you would be pressing for inclusion?

  Mr Geddes: Preventative advice has never been remunerated within the NHS scheme and this was an opportunity to bring that particular part into the contract. It would be good to have that as an allowance if we could bring it off, yes.

  Q74  Mr Jones: Have you made representations to the Assembly Government about that?

  Mr Geddes: Yes, we have.

  Q75  Mr Jones: Have you had a positive or a negative response?

  Mr Geddes: We have not had a response.

  Q76  Hywel Williams: Going back to the units of dental activity, just for information purposes how are these established for new dentists or people coming into the profession if they are based historically on previous activity?

  Mr Geddes: We think that the only way they will be able to do this is by looking at practice averages within the area in which they are proposing to work, and it would be down to individual dentists to negotiate that with their local health boards. The difficulty that local health boards may have, of course, is that funding is not there either because if it is a new practice they simply do not have a funding history, and they will have to either rely on taking funding from somewhere else or going back to the Assembly and trying to tap into the pot which the Assembly has allocated for allowing growth in practices, but that is not a terribly big pot and of course it is competed for over 22 local health boards in Wales. So there are difficulties for the local health boards there.

  Q77  Hywel Williams: For an expanding service that might potentially be a substantial problem.

  Mr Geddes: It could be, yes. A new practitioner wanting to establish in an area will have to work very hard with the local health board to get a contract value and the local health board will have to guarantee the funding.

  Q78  Hywel Williams: Can I just ask you about the banding system? It is just something that has been put to me that there might be some perverse incentives in the banding system for patients to, for example, hold back on treatment in order to be put at a lower banding charge because they would be getting emergency treatment rather than treatment in the normal cycle.

  Dr Wills-Wood: One of the things we are unsure about with this new contract is patient behaviour. We have found that any changes to dental charges in the past have always altered patient behaviour and this is a tremendous change in the way that patient charges are to be charged and collected and, literally, we do not know how the patients are going to respond. There is an indication at the end of the day that if they could hold off and just have their emergency treatment they may well do that, so when we were talking about promotion of oral health and things, that will disappear.

  Q79  Hywel Williams: Emergency treatment will be in Band One then.

  Dr Wills-Wood: It would be equivalent to Band One, yes.

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