National Assembly for Wales

Bore da. Good morning. Welcome to the Health and Social Care Committee this morning. This morning's session is a virtual session, so some witnesses and Members are joining virtually, others are here on the Senedd estate. And as always, questions and answers can be given either in Welsh or English. I move to item 1. We have one apology this morning, from Jack Sargeant. We have no substitutions, and if there are any declarations of interest, say now. No.

In that case, we move to item 2. Item 2 this morning is our first evidence session into dentistry. So, I'm very pleased to welcome our four witnesses this morning. I'd be very grateful if they would perhaps introduce themselves for the public record.

Okay. My name's Yvonne Jones. I'm a specialist in orthodontics, and I work in the community dental service in Merthyr, and I'm chair of the south-east Wales orthodontic managed clinical network.

Morning, Chair. My name's Russell Gidney. I'm a general dental practitioner, working in Chepstow, and I'm here today as chair of the British Dental Association's Welsh general dental practice committee.

Morning, Chair, morning, everyone. My name's Dan Cook, and I'm a general dental practitioner in Newport, and I'm vice-chair of the Welsh general dental practice committee. As Russell was saying, he's the chair, so I'm here in a supporting role as well.

Good morning. My name's Benjamin Lewis. I'm a consultant orthodontist in north Wales. I'm the chair of the north Wales orthodontic managed clinical network, and representing the British Orthodontic Society today.

Lovely. Thank you, all, for being with us. If I can perhaps ask Russell Gidney and Dan Cook the first question: how long do you think that it's likely to be before we see the backlog issues caused by the pandemic catching up with themselves?

There's a lot to that question, because when you talk about the backlog caused by COVID, you assume that we were in any way without a backlog before we went into COVID. So, the state of play typically within Wales, within the UK, is that about half the population are seen with a dentist at any one time. So, there has always been a large chunk of the population that's not been seen. So, the backlog that's been generated by COVID is really the pause, the hiatus, in treatment for the patients who have been already with a dentist. And the management of that is now being slowed down because we're also then trying to manage some of those patients who have not been seen. So, fundamentally, there's no movement in terms of workforce, there's no movement in terms of budgeting that we're working within. So the amount of treatment that we're providing is still roughly equivalent to about half the population. So, the simple answer to your question is 'never'—we don't have the resources to manage.

And just perhaps give us a view of to what extent the backlog was there before the pandemic, and how the situation has worsened, I suppose, as a result of the pandemic. So, the extent of the backlog before the pandemic.

So, before the pandemic, the BDA did some research at that time, and I believe it was something like 80 per cent of practices were not able to take on patients, pre pandemic. There was a recent bit of research done by the BBC, where they were phoning around practices, trying to register patients, and it was close to 100 per cent that wouldn't take patients on. Now, those practices are taking patients. In my practice, we've got around about 1,000 patients on a waiting list. So we are putting names on a waiting list, but realistically we're telling those patients that we just have no idea when they'll get seen.

Yes.

For me, it's a very similar situation to what Russell was saying earlier. The backlog long predates COVID. Budgets for NHS practices were fixed, certainly in England and Wales, they were capped, from the financial year 2006-07 onwards, which is quite a long time ago now. And the budget has more or less, with some small exceptions, been frozen in aspic since then, and decisions have been made at Welsh Government and Westminster level to retain that cap at half the population having funding for dentistry. And that's something that's been done over and over again. So, by the time COVID came, it certainly wasn't the first nail in the coffin. We were a long way down the river of what I fear is the death of NHS dentistry in Wales and, potentially, in the wider UK as well.

Thank you. I think some of the Members will probably dig into some of your opening comments as they come to ask their questions. And Benjamin Lewis, if I can ask you—in the response from your organisation, you’ve referred to orthodontic provision as being in a dire state. Perhaps you can just expand on that a little.

By all means. I think it's fairly similar to what Russell and Dan have said. As Dan said, orthodontic provision, in essence, was capped in 2006-07 when the units of orthodontic activity were introduced. Although there will have been a number of needs assessments since then, and that that could have resulted in some increased orthodontic commissioning, the problem is that there's already a backlog, and most needs assessments don't take into account, actually, how to address the backlog that has already been created. So, if you’re lucky, it will keep in line with current need, but there's always going to be a waiting time to actually access treatment because of that.

COVID then made everything worse, because treatments ceased, and when treatment did recommence or activity recommended, it was focussed on those with the greatest clinical need, so those ones who would become at risk if they weren't seen, which were those patients in active treatment. So, it meant that new cases weren't started. So, the backlog that was, say, previously two to three years to actually get seen—then you just added the length of COVID on top of that.

In addition to that, when you look at current commissioned activity, we're undercommissioned according to need. So, Wales, generally, is about 76 per cent of need, but that will vary region to region, and that's historic. So, for instance, Cardiff and Swansea will over-commission for the number of 12-year-olds, which is what the need is based on. So, it's usually about a third of 12-year-olds. So, Cardiff and Swansea will over-commission, but that's because of the geography in south Wales where high-population densities would have the location of specialists, and patients from more rural areas would commute into those high-population densities, such as Cardiff and Swansea.   

Okay, thank you, Benjamin. Did you want to come in, Yvonne? Don't feel that you have to.

I'd just agree with that. And also, as well, I think we have to take into account the fact that, actually, looking at the commission according to need, populations in areas have actually increased, so that puts extra demand on services as well.

Sure, sure. Thank you. I know that Members will want to dig into some of what you said in your opening comments. Sarah Murphy.

Thank you, Chair. Thank you, all, for being here today. You've all already, I suppose, referred to some of the statistics and data that are available on this, and it does help—it's what we need, really, to get a picture of what is happening across Wales. But, to come to Russell and Dan with this first question, there have been responses to the committee's consultation referring to the lack of data to actually give that clear picture of dental services in Wales. So, can you be more specific in terms of what information is currently available for NHS and private dentistry on the number of people on a waiting list to access a dentist? How many people have access to a dentist at all? And how long do those with access to a dentist have to wait for an appointment?

Russell.

Go on.

There isn't a lot of data available nationally, because most of the waiting lists are held locally by practices. Practices are independent contractors, as you probably all know, and they have to manage their own waiting lists. So, in my practice, we may occasionally be asked for approximate data from the health board regarding how many patients are on our waiting list. I think it's in the region of 300 at the moment for new patients, and we've still got a wait of maybe 1,500 existing patients we haven't seen since COVID. So, there isn't a nationally held waiting list—they're only really estimates. Would you agree with that, Russell?

Yes, absolutely, because a lot of the problem that we face is that we are all independent businesses, and our information is held locally. So, actually, there is no collation of the general dental practice data centrally that can be used. Some of the health boards, as Dan said, have got a waiting list, which could be into tens of thousands of patients looking for care. Our area, as I said, it's held locally, so we both have our own list. But what we don't know, of Dan's 300 patients, they may all be on my list as well. We just don’t have that information.

What's the knock-on effect of this?

In what manner do you mean? 

For you, I suppose. For dental practices, what do you see as being the outcome of this? What kind of effect does that have?

And if I can add to that, you talked about there not being any national data—should there be?

I certainly think that locally held within health boards is a better way of processing, because you speak to the patient experience of this, and they'll phone around hundreds of practices trying to get access. They'll end up on the list of multiple practices, so when we then try and phone patients to get them in our practice to be seen, we're wasting time phoning patients who've actually seen someone else, or they've been to Dan for their care and they realise I'm closer, so they'll jump between practices.

So what's the better way of doing this?

I believe that a centrally held waiting list is more efficient for both patients and practices. 

I think at health board level, certainly, the funding can follow the demand, and at national level to health boards as well, then. Because the more granular the data is—to use a real committee term: 'granular'—to use the granular data of areas and health boards, and also localities within health boards, helps to direct the funding. Funding in dentistry in the main has been based upon historical activity from the 1990s and 2000s, really, hasn't it, still? And that doesn't always follow where need is greatest.

The knock-on effect, if I may come in and answer that as well, is that we're constantly turning away patients, and they'll say, 'I bet you could see us if we paid privately', and we have no capacity for that, either. We're really absolutely full with patients. Staff get sick of it, staff are upset because they have to turn patients away and, 'I'm in pain here. You're meant to be caring for us. We've come here because it's the NHS. You should be caring for us.' It's always my staff who have to face patients and tell them, 'I'm sorry, your child can't be seen', and you can think, 'Surely you can squeeze them in.' We've got 30 patients squeezed in already in a session, in a day. We just can't do it, and it's awful. We can't do what we want for all these patients—what they need, more to the point.

Sarah, do you mind if I ask another question on this?

Absolutely, Russell. Yes, of course. 

Why is there not a central waiting list within health boards? It sounds like you're saying this is a good idea; it seems a good idea to me, what you've said, so why hasn't that been done in the past? Because if that was done, it would achieve what you said. 

It's not in our gift to do that, obviously; it's up to the health boards. 

So why aren't they doing it, I suppose? Why haven't they done that?

I honestly don't know.

That's a good answer, then.

Honestly, I'd rather say that than try and give you some waffle about it. The thing is, that's our opinion. I think I'm pretty much on the same page as Russell with this, that it would work better at local level. I think practices have been given the autonomy to decide their own waiting lists, but also, it has been quite convenient, I think, for practices to have to do all the admin. There's no funding available for all the extra work that practices have to do. Funding's less than it was when there wasn't a shortage, and there weren't so many waiting lists. So it's quite convenient, I think, for practices to have to shoulder the burden and the cost of managing waiting lists and turning away the angry parent whose child can't be seen. It's a lot easier for practices to do that than for health boards to have do it. That may give you a clue as to why it has never been done in the past.

Is there any disadvantage to practices of there being a central waiting list? Is any practice going to say, 'Well, I don't really like the health board having a central waiting list'? Is that possible?

The only problem I can see is that practices, as you may know, dentists are—I don't know if we're unique in the NHS, but there aren't many other types of practitioners who are penalised every time a patient misses an appointment. And the amount of penalty, the equivalent of targets missed can vary from in the region of £25 to £250, depending on what appointment was missed, and that's something that the practitioners have to bear out of their own pockets. There may be a concern that practices could be made to see patients again who they know have been poor attendees in the past, and who they know are going to cost them a lot of money, which is going to push practitioners out of the NHS more, potentially. Is that something that you would agree with, Russell?

Yes. If I may, Chair, the one advantage with the practice holding its central list is that it can, to some extent, try and triage those patients. So we can then try and prioritise based on need, although that's obviously difficult to do because, when patients learn that that's what we're doing, they'll give us the answers that they need to give to be seen. But the central waiting list would then give us that demonstration of need, which we don't really have.

Sure. Sarah.

Thank you. And then to Ben and Yvonne, on the information available on orthodontic capacity and the number waiting for services across Wales, and the length of the wait, what is available and is it a similar situation?  

If I may start, Yvonne. Orthodontic waiting lists are held locally, as was mentioned previously from a dental point of view. The e-referral system will give you some idea of the number of patients who have been referred, so that gives you some good baseline data. Each region can stipulate how it wants to manage waiting lists, so that will vary between regions in Wales. For instance, down in south Wales, they've got a centrally held waiting list for orthodontics, and patients then are drawn off when capacity occurs. In north Wales, the geography plays an important role. So, we have geographic spread. In primary care, the orthodontic specialist practices are based in high-population densities such as Bangor, central around Rhyl, Deeside and then in Wrexham. We decided as a managed clinical network that it didn't make sense to have a centralised waiting list, because you could, in theory, then have a patient living in Wrexham who was then asked to call down for treatment in Bangor. So, it was more sensible to have a local waiting list that was more appropriate for the geographic needs and the transport infrastructure for that population base. 

Waiting times have just increased massively. As I mentioned before, we're currently, across Wales, under-commissioning according to the number of 12-year-olds on the national census in 2021. And waiting times were, say, two years in primary care, even longer in secondary care prior to COVID, and they've just gone up exponentially as a result of COVID. Some units, certainly in secondary care, across Wales aren't even operating at full capacity, because there are still legacy issues within departments, because their departments are still partially with other specialties because of the restructuring of hospital acute sites during the COVID pandemic. 

In addition to that, we've actually got delays with patients when they come to the top of the waiting list and are ready to start treatment, when we're making sure that they're actually dentally fit. So, sometimes they might need oral hygiene instruction, some restorative work, or even when they get extractions. So, as part of orthodontic treatment, a proportion of patients will need extractions. We will then see them, refer them off to their general dental practitioner for extractions, and it could be six months before they're actually seen for those extractions. Within that time period, those patients then might lose motivation because they're treatment is dragging out. That motivation might affect their levels of oral hygiene, which ironically then makes them not an orthodontic candidate.

In secondary care services, where all our cases are often multidisciplinary, so we refer on to our maxillofacial colleagues or our restorative colleagues, waiting times within their specialties also affect us. So, again, for instance, in north Wales, just because of the case mix that's there, there's a lot of skin cancer work. Obviously, because it's cancer, that takes priority over dental work. So, the waiting times for, say, exposure of impacted canines, which can cause damage to adjacent teeth, has tripled during the COVID pandemic and beyond. 

Thank you very much. Yvonne, did you want to come in as well? 

Yes, I just wanted to clarify, actually, with Ben that it's south-west Wales where they have a centrally held waiting list. Here in the Cardiff area, so, south-east Wales, the practices all hold their own waiting lists, so it's not a centrally held one. And also, in the area I work in Cwm Taf, we have one specialist practice in Bridgend, and all the patients from general dental practice in Cwm Taf, a lot of them have to travel all the way down here to Cardiff, and get referred down here to Cardiff. So, it's a long way to travel for a lot of patients. 

But, yes, they've all had backlogs. The recent figures for here in Cardiff that I've had is that if they're an urgent case, then the referral to assessment can be from six weeks to 12 months, and then from assessment to treatment, it can be two to 12 weeks. And then for routine, you're looking at 21 months up to four years for the wait, and then again into treatment. But, obviously, treatment is then, if a patient needs treatment, because they can't access general dental care for extractions or healthcare, then they're having to wait even longer before they can start their orthodontic treatment.

Sarah, Ben wanted to come in. Dr Lewis.

Yes. Ben, did you want to come back in?

Thank you. Just following on an excellent point Yvonne made there: as we were coming out of COVID, the Chief Dental Officer for Wales at the time, Dr Bridgman, quite rightly said that, 'Actually, all the capacity we've got should be focused on those with the greatest need.' So, those patients who were coming through were assessed by the referral—information that's on the referral—to say, actually, was there a clinical risk with them waiting a long time. So, those patients have been pushed to the fore when accessing care. The problem was, historically, before COVID, especially in primary care, it was on a time-served basis, unless there was anything really obvious on the referral form. So, you could tell patients, 'Actually, our waiting list is two years. So, you're likely to wait two years until you get seen.' Now, we can't tell patients how long they're going to have to wait, because that is all dependent on the number of urgent patients that comes through, based on evidence of clinical need from the referral. So, it's really hard to give patients any definitive information, which—. Prior to COVID, although not ideal, patients actually were very accepting of, actually, it's a finite amount of resource, if they want treatment on the NHS, then there's inevitably going to be some wait. And they were very understanding when we said, 'Well, it's going to be two years until you can access treatment.' The problem is, now, it's very unsettling for them, because they don't know—is it two years, is it four years? And we know, from the community health council report that came out a couple of years ago, how much impact that has psychologically on these patients, especially young patients in their formative years, when, actually, it can affect education, it can affect their social groupings, it can affect confidence. It has a massive impact on them, and now these patients aren't going to be even seen until they are 16, 17, 18 years old, and, actually, we don't know about the actual long-term psychological effect that has on these patients.

Yes. Thank you, Ben. I just wanted to just as well come back to what you said, Yvonne, because, obviously, we have quite a good comparison there with the data that's available. So, you said that Cardiff and South Wales West do it differently. Do you have an opinion on which system works better, then—centrally held or not?

There are advantages to both, I think, but I think it can be difficult if it's held centrally; it depends on the person who's going to be triaging those referrals, orthodontic referrals, to pick up those who potentially are going to be urgent cases. So, there are swings and roundabouts for both. There can be advantages in the fact that, if one practice is seeing patients quicker, then, obviously, they might be able to see some. But the defining factor, actually, in all of orthodontic treatment is the fact that the practices are commissioned for a certain number of units of orthodontic activity. So, that means that they can only treat a finite number of patients each year. So, there's no capacity to say, 'Okay, we've got capacity'; it's, 'We've taken on all these patients, so we've met our target; we can't treat any more, although we potentially have got the capacity to do it.' So, maybe that's something that needs looking into.

Yes. Did you have any further questions, Sarah?

I was just going to ask, just to everybody, really—I think, Ben, you touched on this—to what extent are there currently inequalities in access to dentistry and orthodontics, and who do you think is most likely to be affected, then, by the current problems? And is there, then—you know, coming back to the data and the evidence, is there any available on which sectors of the population and geographical areas have better access than others?

Did you want to come in first, Dan Cook, on that point?

No. Please answer that first. I just had a little point to come back with in support of what Yvonne was saying, but you can come in now, Yvonne, please. Yes.

Well, I think it is actually those who are of a lower socioeconomical background who are actually going to lose out in all this, because (1) a lot of them will have to travel to access care, whether it be dental treatment or even orthodontic treatment, which impacts on costs for the parents, with all the travelling and days out of work, days out of school, and also, potentially, if they really feel that they don't want to wait and they want to maybe access private treatment, they can't access that treatment; that's denied them.

Just before I bring Dan Cook in, I just want to come back after Dan to you, Dr Lewis, because you've outlined a situation. I just wondered if there's a solution you would recommend as well to what you just outlined, but I'll just bring in Dan Cook first. 

Yes, it's just tying together something that I've said in comparison with what Yvonne just said. I believe—and Yvonne can correct me on this if I'm wrong—I believe the orthodontic budget was limited; it was set at the same time that the general dental budget was. And this has been happening since 2006, when COVID was something that was unheard of, in the distant future. If there's a huge area—a huge need rather—in an area for either orthodontics or general dentistry, practices can't respond to that. I had a brilliant graduate—I've had a lot of brilliant graduates working with me, but I had a lady in particular who wanted to stay working in Newport. She was excellent, there was huge local need, the health board was very supportive, but there wasn't any funding. If she'd been an orthodontist and this was an orthodontic practice, it would be exactly the same issue. The budgets are set and have been capped year upon year upon year, whether it's general dentistry or for orthodontics, or other specialist services in primary care in dentistry, and that has been the bottleneck. The problem is that's now set in stone. So, graduates are coming out and thinking, 'Well, the NHS don't want me, why should I really look for a career there? They've limited the budget; I'll have to go and work privately.' It's no wonder that's happening, is it?

Are you going, Russell, to talk about workforce issues?

No, I'm just going to talk within that same point. Just to say, it's something that, if you look at the media side of it, patients don't understand, and I think a lot of people don't understand. If you look at the comments that come repeatedly, it's, 'Well, this practice is telling me they can see me privately. Why are they being allowed to see me privately and not see me on the NHS? They've got an NHS contract.' When, obviously, we're working to that cap that's set, and, actually, the practice staff, over the last few years in particular, have dealt with an awful lot of aggression directed towards the practice because of that. 

Worse still now, people are being told in the Senedd, and in other places, that dentists have been bringing everyone back too often and that's the problem, and now that's, 'Hey presto, that's been fixed.' So, all these extra appointments are supposedly available and practices can just see people. We've got people coming in saying, 'Well, they've said there are all these extra appointments. Why won't you see me? You're just looking after existing patients. Why won't you see us?' It's a tough time, isn't it? 

Yes. Thank you, Dan. Dr Lewis, did you want to come back in?

So, I think the topography of Wales is significant on access. We're reliant on either personal transport or public transport, and we know that public transport can be a little bit hit and miss in certain small villages around Wales. And patients will travel an hour, an hour and a half, each way to access appointments, and these are every six to eight weeks. So, the effect that that has on education, on work for those that are bringing them, the need for a family support network that actually is going to bring these children to these appointments—it's significant. 

There's going to be a publication in the British Dental Journal of an NHS [Correction: 'a Welsh NHS orthodontic'] workforce survey, the first comprehensive one we've done in Wales. And, as part of that, we've created a map of Wales of where all the orthodontic providers are. It's quite stark—these vast swathes of Wales where access to orthodontic providers is just miles and miles and miles away from where they're actually located. And I'll be more than happy—. It's due to be published in the autumn, so, once it's published, I'll be more than happy to forward it to the committee, because, as I say, the map is quite stark and, I say, disproportionate where the providers are placed. 

So, in a nutshell, the solution is?

I think—. There's no national solution to these things; I think it has to be done locally, because what would be right in Cardiff is not going to be right up in north Wales. I think it has to be tailored to the population. So, for instance, historically, we'd have a number of different tiers of orthodontic providers. You can have dentists with special interests, who are general dental practitioners with expertise in orthodontics. You could have specialists in primary care, and you can have specialist consultants in secondary care. Each will treat a different cohort of patients, according to their need. Some areas have not really got many dentists with special interests, because they were all very much in high population densities and therefore specialist practices had economies of scale, and that's what worked best for cities such as Cardiff, Newport, Swansea. 

So, in north Wales, the geography rules. So, actually, we can't really expect patients to travel a three-hour round trip to access care, so, we have maintained a dentist with special interests network to allow, actually, more local treatment to be provided under the support of the specialist. However, the succession planning is there. And I don't know if you're going to come on to retention and recruitment later on, but—

We are. We are about to, actually. So, I might bring in Joyce Watson at this point so we can move on to, perhaps, that area. Joyce Watson.

Yes. I want to talk about workforce and recruitment, and I notice that you're talking about north Wales and south Wales, but I live in west Wales, which is even more remote—so, just saying. You've already mentioned workforce recruitment, because the parameters of earning are so restricted that people think, 'What the heck, I'm not going to bother.' But are there other issues that you want to bring forward? It might be worth asking at this point how long does it take to train a dentist, if those are the people we're relying on.

If I may first, for me, I think the earning issue can be a bit of a red herring and gets focused on too much. A lot of the reason where we're talking about NHS versus private, which I think is what you're alluding to with that—. Sorry, were you—

Not really, I'm talking in general. Because you mentioned it, you said that people were looking at it and thinking—you just said it a few minutes ago—that they might not bother, that the NHS isn't open to them, because—

It was me who said that.

—the budgets—well, somebody said it—were capped.

Yes. It's not in terms of their individual pay packet or their earnings, it is in terms of funding being available for them to make a service. So, if you have a graduate doing dental foundation training after they qualify in an area like Newport, where there is a high need, but provision is less than it needs to be and they want to stay and there's a practice that wants to expand and support them to do that, the funding isn't usually available. Now, that's what I meant, rather—. So, when that's the position in much of Wales, it's little wonder that practitioners choose to advance their career privately. That's the issue rather than, necessarily, their individual earnings. I hope that clarifies what I—.

Yes—[Inaudible.] Anyway, still.

There are a lot of factors that sit within that, and a lot of the motivation can be the ability to take care of their patient, to spend time with their patient, actually to move away from bureaucracy. Typically, for myself, I always have a little bit longer for a private check-up than with an NHS check-up. I've never felt I did different with the patient other than have time to chat and maybe go through advice, or just ask how their day is and build a relationship with them or go through costings and that side. Actually, now I spend longer on my NHS check-ups doing the bureaucracy that has to go with it. It's not adding to the patient care, it's filling in the forms, and a lot of times, as that's always changing, we end up filling those in two or three times because the validation goes through those. So, a lot of our time is taken away from delivering what we want to be able to deliver, which is that care to patients.

Okay. So, do we understand fully, and we have touched on it, the recruitment problems across the area—you've looked at north Wales and south Wales, but, as I said, I'm from west Wales—and what the problems are in terms of the incentives to keep people in priority areas of need?

There's always been a problem with recruiting graduates, I think, to west Wales. West Wales has had a—I wouldn't say acute shortage, but it's a chronic shortage. This has been going on for a long time, and I'm sure you've heard this over and over again from local people and constituents et cetera. Part of the problem, perhaps, stems from that west Wales is quite a long way from a dental hospital and a dental school as well. So, north Wales, certainly north-east Wales, is not far from Liverpool. Perhaps you could argue that north-west Wales and Bangor or Anglesey are a little further away from anywhere as well. It's the west coast, really, isn't it, what we may consider north Wales, the whole west coast of Wales. Cardiff—Newport, Swansea, to a lesser extent, and Bridgend are all reasonably close to Cardiff, so there is that spread of graduates within the area that they qualified in. West Wales has never had that, and that's possibly where this has started from. As a result, many years ago, there's been a—. Long before budgets were capped, there's always been a shortage in west Wales and, unless I'm mistaken, the funding packages that have been agreed when the budget cap was brought in were often based on historic levels of service provision, which in west Wales was quite little, because there was actually a shortage of practitioners, rather than a shortage of need. They mistook funding for need and, actually, the areas that had the most dentists were not always the areas in highest need. West Wales has always suffered from that, as have other rural areas across the UK. It's a big problem. Cornwall and the Isle of Wight spring to mind as areas that have had similar problems.

So, how do we fix it? We know what the problem is.

It's not something we can fix overnight. We're looking at years of underfunding and lack of resources. My personal opinion is that we should try and focus on the training of undergraduates in dentistry across Wales. We need a plan for the long term. Quick fixes aren't going to sort this out. I know there have been successes where undergraduates have spent some time in Wrexham when they've been in north Wales. They possibly need to look at familiarising dental students, undergraduates, with what all of Wales has to offer. Because for a lot of them, it's the M4 into Cardiff out of England, or elsewhere, and they don't get to see what brilliant places some of these places would be to work. And just getting the introduction, making them feel like they know the whole of Wales as a nation, and not just around in Cardiff—that's what would help in west Wales, but that's going to take years to do. 

You asked earlier about the training of dentists. It takes five years to do the basic dental training, the academic training, and then at least another year in practice afterwards doing professional training. So, that isn't going to fix things overnight, but, certainly, on a 10 or 15-year forward planning basis, to set something up, looking at expanding dental training into west Wales, as they've done in England in Plymouth and Truro with Peninsula Dental schools, something like that would be a really good idea. And that's not necessarily the opinion of the BDA—I don't know; it's my personal view on it. I don't know what you would think. From an orthodontic point of view as well, would that sort of thing help?

Yes, it would. On top of the general dental training, then they go on and they do the two-year foundation, and then to become an orthodontist, they have to go back and train again in a dental hospital, within a hospital setting. That takes three years, to qualify as a specialist orthodontist, but if you then want to go and be a consultant, that's another two years. But I think maybe as well we ought to concentrate on trying to promote dentistry for local Welsh people, and encourage that. If we take on and train more Welsh students at Cardiff, and try to encourage local recruitment, then we're likely to retain those people here in Wales.

Russell, you wanted to come in.

If I may. I think we can perhaps obsess slightly less about points on the compass and more about rural and urban, because mid Wales has a major issue as well. The modelling that we have within practice generally suits a larger population. When we start talking about the skill mix and using dental professionals, we're talking about practices that have two or three dentists, a therapist and a hygienist—these people working. There's actually quite a large population that's needed to support those, so the whole modelling that we have is actually geared more towards those population centres rather than the rural community. 

The issue also, then, is actually getting people into the NHS career pathway. It's not somewhere that people generally want to work. And a lot of the issue is the general motivation in terms of the time that's spent away from patients on admin that's not contributing. There is no career path for a general dental practitioner in NHS dentistry. If you upskill, if you develop new skills, you will get paid less, absolutely, within the NHS. I know it sounds bizarre—I can see the look on your face. At the moment, I'm on the reformed model, Dan's on the units of dental activity model. Fundamentally, there's a very simple credit for that patient. So, I get a credit when I complete the assessment of clinical oral risks and needs, the risk assessment form, and it goes through. Whatever treatment I do on that patient, the more treatment, the less that actually comes in to the practice. So, if I upskill so I can introduce more skills into the practice, I can do more complex treatment on those patients, which means I actually then have to spend more time and be able to see fewer patients towards my target. 

Dr Lewis wanted to come in as well on this point.

Following on from the points that have been made, on recruitment and retention, most graduates and professionals will either settle around where they've got a link to the area or where they've trained. So, if we're not providing incentive for them to train in a particular area, we're going to decrease our pool of people who are going to stay. That comes down to job opportunities—if you've got an area that's a renowned area for training, so people go, 'Actually, I'm going to pick that, because it's really, really important.' But because of our national recruitment now, for most dental training jobs, applicants will rank jobs. And that will be ranked on location, but it'll also be ranked on pay. And the pay scale for dental trainees in Wales is significantly less than in England.

As an example, my registrar, who's just finished, when he first started as my registrar in Wales, he was being paid £8,000 a year less than one of his peers in England. So, a person in England who is doing exactly the same job was getting 21 per cent more in his wage than my registrar was. That will affect people, and will affect the current crop of graduates coming through who've just left dental school with £100,000-worth of debt. So, actually, the finance is going to be very important about attracting people into areas. And that's not just dentistry, because, obviously, the pay scales for trainees will affect medicine as well as dentistry. The new graduates are savvy people. They will look at, 'How much did it cost to do my training?' As in, if you have to do a Master's, how much are each of the university fees for that, what are the locations like, what is the wage, and everything like that. Because they have to make ends meet.

We have to be looking at trying to recruit more people from our own localities. We've got the Seren project, which is fantastic. They've just started the Aspire to Care project. These are fantastic initiatives to actually encourage local people to go into medicine, dentistry, but also the other professions, such as physiotherapy, nursing and everything like that. Because a dentist on its own cannot function. We need all the support infrastructure, such as therapists, such as nurses, such as administrative, and to focus on just one aspect is missing the point, to a certain degree. But we have to think about how models are set up. So, when we're looking at increasing the skill mix, from an orthodontic point of view, it's efficient to have a therapy-based model. So, you have a number of therapists, but they need to be supervised by a specialist, so you have a pyramid model.

When we did our Welsh NHS workforce survey, we noticed that, actually, a third—. We had a 70 per cent response rate, so 70 per cent of all orthodontic practitioners [Correction: 'NHS orthodontic practitioners'] within Wales responded to the survey. Out of that, a third of all specialist practitioners in primary care were looking to cease orthodontic activity in the next five years. If you've got a therapy-based model, then that's the linchpin that holds everything together. So, unless you get another specialist to replace that and provide the treatment plans and supervision for the therapist, the whole system falls apart. And, as Yvonne said, to train an orthodontist, it takes a significant amount of time. So, we've got to be thinking about the long-term recruitment and retention. It's not a quick fix, but we need to be thinking about succession planning now.

Can I just check, Joyce, did you have any further questions?

You've answered the second question.

I know Dan Cook wanted to come in, but we're a bit short of time. So, did you have any further questions to ask, Joyce?

No, I think we've got the idea about the morale.

Just quickly, Dan, and I think Yvonne looks like she wants to come in as well.

Really, really quickly, on something that Ben said, which is that dentists can't act alone—you're completely right. Dental nurses are overstretched, the pay isn't great in dental nursing and they don't have access to NHS pensions or any of the other benefits, and they're working hard day in, day out. My nurses work their fingers to the bone so hard, and they're just not recognised. They're not treated as NHS people, and that's wrong. That needs to change.

And the solution? What should change?

There needs to be a mechanism by which dental nurses with NHS commitment, as dentists do, can be somehow recognised and be given access to NHS pensions or other benefits, or something equivalent to it.

Okay. Yvonne Jones.

I agree that we need to look at the pyramid situation, but you need that orthodontist at the top to train it. But also, there are dental nurses. We need more courses that are accessible for dental nurses that don't cost a lot of money to train them up to do other skills as well. So, we have to think about the bigger picture, not just concentrate on dentists and orthodontists. 

Thank you. And if you can give me a 10-second answer, or a very short answer, Russell Gidney. You talked about bureaucracy with NHS paperwork for patients, and I think you also talked about admin not contributing. Just to confirm, are you saying that there's too much paperwork associated with NHS patients, and what's the solution?

Less paperwork. [Laughter.]

But presumably there's paperwork there for a reason. 

We've been filling in these risk assessment forms, the ACORN form, which I'm going to assume you're aware of, and that data is supposed to be building up profiles of the practices, to look at local commissioning and balancing of funding based on the local need. Well, actually, that data, we're now being told, isn't robust enough to be of any use to that commissioning. We're still putting in those forms. They take about 10 per cent of our time away from providing patient care. 

Okay. That's helpful. Gareth Davies. 

Thank you, Chair. Good morning, everyone. You've answered a lot in your answers already, but can I just push a little bit more on private provision and the reasons why NHS dentists are going to private? Like I say, you have answered those questions, but are there one or two overwhelming factors? I know pay is a big one, and you've mentioned paperwork as well, but is there a big elephant in the room and one substantial reason why there is such a transition? Do you think that will widen the inequality of access to dental treatment for people? 

Why is this happening? Give us the answers—[Inaudible.]  

In questions recently, the health Minister was quoted as saying that 14 per cent of contracts have been handed back. That's one in seven contracts that have been handed back, and that's not accounting for reductions in contracts; that's just a full hand-back of contract. The reason, I think, that's contributing to such a high level of hand-back at the moment, is, actually, the changes that are being brought forward. So, we have a new set of targets that were brought in in April 2022. We were given around about three or four weeks' notice to actually adapt our practices to these charges—practices often book in four, five months in advance—which is unfeasible. I'm working within those targets. At a half-year review, I'm on about 25 per cent of my target. Now, we're told that there will be some allowance, but potentially my practice is looking at being at about half of its target; looking at half its money being taken back off it. That may or may not happen, but that level of uncertainty—. Would any of you be happy not knowing what you were getting paid at the end of a year, and carry on working in that job, if you potentially halve your funding? And obviously that affects not just myself, the dentists that work with us, but all the staff that work within there. The uncertainty and pressures that that's bringing in to practice has, I think, a huge effect on practitioners.  

What's the difference in pay, then, between an NHS dentist and private, roughly? 

I couldn't give you exact figures. There will be outliers, such as practitioners who specialise in, for example, implants, which are not available on the NHS. Typically they would probably earn quite well. For the majority, I think, it's more about workload and work-life balance, and having the reward of being able to upskill, gain new skills, and spend the time they want to with their patients. So, for the majority, I don't think there's actually a huge difference, but I don't have a breakdown of figures that would give you an accurate response. 

That data is available. I know the BDA have requested it before, and other groups have, from HMRC. I don't have it to hand either. It's not as big as you might think, but it is available, if you wanted to look it up. 

We'll drop a note afterwards— 

Yes, please do. 

That would be great. Thank you. 

I appreciate that. Just finally, how much is known about the number of patients paying for private orthodontic treatment? Does this cause a two-tier system, in effect, then? 

The recent survey we've done was only looking at NHS providers; that was the reason why I was looking at it. Of the NHS providers that responded, less than 12 per cent of their overall working week was spent providing private care; the rest of it was all NHS. As has previously been mentioned, we're capped for the number of patients we can see. We have to fulfil the NHS obligations, and anything else is obviously up to the individual practitioner, if they've got any more spare capacity to potentially provide private treatment. NHS orthodontic treatment is only accessible to those with a demonstrable need, and, in primary care, under 18 years old. The private aspects will include adults, it includes those that don't qualify for NHS treatment, but it will also include some patients who do qualify for NHS treatment, but, because of the waiting times to access care, have chosen to access that care on a non-NHS basis. But I think we don't have to make the assumption that they can afford to pay privately. They're making a choice to pay privately. Often, the parents are making a choice at the expense of other aspects of their lives. So, just because they are paying privately, it doesn't mean they can, actually, within the family unit, afford that. It's just because they feel the commitment to their own children that, actually, they're going to make sacrifices in other areas to make sure that their children get more timely things. So, potentially, it does create a two-tier system from that perspective.

Thanks for that answer. Just to push a little bit more on that two-tier system in emergency cases. In a worst-case scenario, somebody's in a dire situation. They are in excruciating pain. Dentists are full to capacity. Are there contingency plans in place for those cases happening, so that people aren't in dire pain for days, weeks, months? I get e-mails from constituents, and I'm sure that other Members do here. People are in excruciating pain, and they just have nowhere to turn to. So, what is the plan in those situations? 

So, just to come back to your question, and to clarify, 'Are there two tiers?' Yes, absolutely, there are two tiers. There is provision within the health boards for access. So, we've worked with Aneurin Bevan, both of us, and Aneurin Bevan commission sessions with practices to provide care for patients who are struggling to be able to access and register regularly. But that is then seen as just a one-off appointment. They are seen to get them out of pain. Then, temporary work—it might be antibiotics, it might be a temporary filling; it's only really buying them months of time before the problem recurs. And obviously, the burden is just snowballing over time.

It's fire-fighting, isn't it, rather than dealing with the underlying cause. But in the short term, we have to have that. We talked to Joyce just earlier about how we could look at long-term training spread across Wales. But with this, there needs to be that. It is available. It would be interesting to get figures from health boards, actually, on how quickly patients are seen. Some of my emergency patients—. We do emergency sessions as part of my working week, alongside my existing patients. Some of them do have to wait a little while to get through, although the health board, I think, is trying hard to find sessions for them. But there's so much need out there, there's only so much that you can squeeze out of this chronically underfunded system.

Can I just check, before I move on to Joyce and then Rhun—have you got the capacity to stay a little bit longer beyond 10.30 a.m.? I have asked that question to Dr Lewis, especially, because I know that you have got patients to see, and the last thing that we want to do is delay you from that. Are you okay to stay until 10.35 a.m. or 10.40 a.m.? 

Yes, that's no problem at all.

Is that okay with the other witnesses?

I'm happy to stay longer.

Yes. I have got patients to see in Newport at 12 p.m. 

That's fine.

I should be okay; 10.45 a.m. should be my absolute limit.

I needed to check that, because our inquiry can't stop you from seeing patients, clearly. Joyce, you have got about five minutes, and then I want to just allow 10 minutes for Rhun at the end. Joyce Watson. 

Except I wasn't expecting you to come back to me.

Oh, well, I'll come to Rhun first, if you want to, and then come back to you. Rhun ap Iorwerth. 

Thank you. I think that we need to be thinking of short, medium and long-term strategies here. There is no quick fix. Because, fundamentally, it is all about capacity, and that capacity will be determined by workforce, unless we address the workforce issues, nothing will alter. When you have got individual courses of treatment, such as an extraction, restoration, and that sort of stuff, they are relatively simple, and so waiting list initiatives will work quite well for those, because they are short courses of treatment and things like that. Orthodontics isn't. You're looking at two years plus-worth of treatment. So, what you have got to think about is actually making sure that you recruit staff, not only to address the shortfall, but actually, that you have got opportunities to make sure that you don't destabilise services by employing someone just to deal with a waiting list initiative over a two-year period, but then not for the long term. Because you're unlikely to recruit the right sort of candidate if they know that it's for a relatively short-term contract.

So I think you've got to be looking at increasing funding to make sure that you're addressing the needs for the current cohort of patients, and as we know, the population has grown, so therefore the need has increased as a percentage, or has maintained the percentage but increased because the population is growing. But then you also need to look at backlogs, and actually, that needs to be brought into the commissioning cycle so that, over time, you are gradually going to reduce those backlogs, but in a sustainable way. Practices in primary care are independent practices. Therefore, they need to be able to have the confidence that any investment is going to be viable, especially if they're taking bank loans. In the current circumstances, banks are extremely prudent in how they're going to invest their money, and if, actually, the business case doesn't add up, then they're not going to get the money to invest anyway. So, in primary care, you've got to have sustainability over a long period of time.

In secondary care, it's about making sure that we're maximising the workforce, making sure they're actually aware, making sure that the support staff are suitably trained and remunerated, because obviously there are potentially banding issues in secondary care for dental nurses, so we can train them up to have additional skills that would free up the specialist. However, then we can't remunerate them appropriately because they're stuck at their current banding, and therefore inevitably will look for a job where they can utilise those skills but get paid appropriately. So, that has a knock-on, and then you end up going through the training cycle over and over again. 

We've also got to look at training locally, and make sure that we're encouraging clinicians to come from our local areas so that they're more likely to go back to those local areas. Again, there are lots of good initiatives, but they need to be—. We almost need to ensure that we're promoting that at universities so that we can try and get more local graduates in, and staying around. That goes the same for postgraduate as well. So, that's going from not just orthodontics, but dental foundation training, dental core training, and actually making sure that we're delivering that. And it's not just about pay, it's about training opportunities. As Dan and Russell have mentioned, we want to be professionally satisfied, and we don't want to think that we've come out of dentistry and after five years of training and that's it for the next 40 years. We want to be continually developing our skills to give our best to our patients, and we've got to have an opportunity to do that. It's a waste not to be able to provide those services in the NHS. 

On local training, I and colleagues fought hard to get a medical school in Bangor, and I am clear in my mind that we need a dental school there too, for exactly the reasons that you outlined. Is that an ambition that you would share?

The health board, to be fair, has been very proactive. Pete Greensmith, who's the acting dental director, has introduced and helped with the academy [Correction: 'helped with the setting up of the dental academy'] in north Wales, which is very good, and that will help local provision. It will help local provision in the general dental services. It's not necessarily going to help provision in the specialist services, because their training pathway is completely separate for that. And again, I only know about north Wales; there are probably very innovative things happening in south Wales and west Wales as well, but I only know about north Wales. 

But they've introduced a sort of—. They've tried to do dental fellowships, so they've introduced areas such as oral surgery where the health board has paid for someone to do a diploma and hopefully a Master's in a particular speciality, but with that, they come and work in areas such as Anglesey, and they then are meeting a local need from a general NHS [Correction: 'general NHS dental'] point of view, but they're also increasing their own skills, which will hopefully then deliver that to a local population afterwards. Well, because that's over a three, four, or five-year time frame, they're more likely to have set down roots, they're more likely to have moved their family there, they're more likely to have invested in the community, in schooling and everything like that, and therefore they're more likely to stay in the area. 

Yes, and potentially have the full undergraduate experience in years to come as well, linked to the medical school. Thank you very much for that. So, again, to you in the room in Cardiff, a list of the priorities, then—the things that we really need to focus on doing as a matter of priority. And that may well mean those are the financial, standing priorities, too, or maybe not. Maybe you could comment on that. 

I would fully agree with Ben that workforce is a big issue, but we have to be mindful that we're working within that capped budget, and when we talk about workforce we talk about funding. So, just to reiterate what we said before, the budget for general dental services is for roughly about half the population, and every time that we are giving somewhere else, we are taking away from something. So, at the moment we're looking this year within Wales at about 100,000 new patients being seen, and there are some questions around that as a genuine metric. But, that is only being seen by removing our access from the patients that we would have seen historically, and actually, for the 100,000 that we're seeing, it might be 150,000, 200,000 that we're losing because they're the more stable patients, for the guide. Everything within that is give and take.

But, for us, from a general practice point of view, and obviously the point of view of the orthodontics as well, the priority has to be prevention. The majority of our time is spent treating what is an entirely preventable disease—decay and gum disease are preventable diseases—and that feeds into patient education and motivation, and things like the Designed to Smile programme, which showed fantastic success rates. The BDA has argued repeatedly that that should be expanded to actually reduce that burden. Every filling that we can reduce now, that filling will need replacing in 10 years' time, 20 years' time. That effect is cumulative, going through the years.

But, to introduce that prevention will produce a real reduction in what we do day to day. The use of dental care professionals, that skill mix, is rightly spoken about as the way to introduce that, but the maths within that has to be very carefully considered. If we employ a therapist in the practice, a therapist might have a salary probably around about two thirds of that of a dentist. That's probably questionable as a figure, but that's only a small proportion of that cost of the provision of the service. The majority of the cost actually comes in the surgery expenses—the materials, the employing of a nurse, the employing of receptionists, the lighting, the energy bills—all of those things that come with it.

So, if we were to take a dentist and replace them with a therapist, the cost saving may actually only be around about a sixth. And obviously, that dentist then is not working; they haven't got funding to work. We're not then able to give them another job to do without bringing in more funding. So, fundamentally, the asks are very clear and very easy, but until we can actually have honest conversations about what we can do with the budgeting that's there, rather than masking what we're losing to provide that new access or that new service, then realistically, I don't think we're ever going to get anywhere. It's actually honesty that is my biggest ask of what we need—an honest conversation about what we can do with the funding we have available. 

Thank you. I have one other specific question, but just to give our other witnesses an opportunity, is there anything that you would like to add to what we've heard already in terms of priorities? 

I'd like to add that I really do think we need to concentrate on oral health, promoting that, and getting parents involved in looking after their children's teeth, because there are still far too many children now who have general anaesthetic for extractions. And then, the long-term impact of that is that they lose space as their adult teeth come through, and then the impact is I then see them to take out further teeth and straighten their teeth. So, if we can get parents on board looking after their teeth, then not only does it reduce the burden on general dental services, it reduces the burden on orthodontic services as well. So, I think that is where a lot of money and time needs to be concentrated. 

And general medical and other services as well. 

Yes, general medical services as well, because also, if the general diet is good, we're going to have less obesity and other health problems. 

I'll bring Ben in in a moment. Doesn't Designed to Smile, though, help with that, Yvonne? 

It has, but I don't think it's—. I don't know how much of an impact it's made. I haven't got the figures for it. 

Designed to Smile was a 15 per cent reduction in decay in the ones who were seen, but it's currently, I think, only just being reintroduced, and it's quite limited within its remit. We've argued repeatedly that that should be expanded to offer more. 

And does it need to be expanded because the certain age groups that it was covering were being missed during the course of the pandemic? 

That whole age group was being missed. So, Designed to Smile was looking at bridging the gap between deprivation areas, and it did a very, very good job of that. But, what we can see is that, up to the age that it was treating, it has reduced that deprivation. But, we have no idea if those trajectories still say the same after that, or if they'll then spread out. The deprivation still exists, and hasn't changed.  

Sure. Ben, you want to come in. It will have to be brief because we're coming to an end now. Dr Ben. 

Yes. Just two very brief points. The first one is: people aren't going to be able to access orthodontic treatment unless they've got an adequate dental foundation. So, if they haven't got adequate oral hygiene, they won't be able to access orthodontic treatment. That can be a very good motivating factor for people to get up to a satisfactory level of oral hygiene, which hopefully they'll maintain for the rest of their lives with all good habits. But, it also does tie into those who don't get access to dentists and dental advice, which often is lower socioeconomic groups, who can be disproportionately affected from not accessing orthodontic treatment. 

And the second is not my area of expertise at all, but when we're looking at the skill mix in general dentistry, as Russell said, when you're looking at the cost-effectiveness of providing a certain treatment element in primary care—we, obviously, moved away from fee-per-item back in 2006—I think it's got to be recognised that, if you're wanting to employ dental therapists, they can provide a certain cohort of treatment. That's usually the simpler treatment. So, if you're using them for the simpler treatment, it means the dentist doing the more complex treatment, which, per unit cost, is more expensive. So, in contract reform, from my point of view, looking from the outside, it is irrational not to actually make sure that those more complex treatments are remunerated appropriately, because, otherwise, you will get a massive shift of people not wanting to do the more complex treatments, which denies NHS patients the care, or they move into other provision mechanisms that will allow for that to be done.

Thank you. Right. It's a very quick question, to Russell, perhaps, that'll help us with the next session that we have this morning. The Gwên am Byth services for older people: give us a top line of where you think we're at and where the main challenges are to make sure that that Gwên am Byth programme is working well.

Do you want to take that, Dan? Do you know more about Gwên am Byth than I do?

Yes. It'd be quite a good one to ask to the community dental service representatives as well, wouldn't it, who I think you spoke to earlier in the week. It's not really my area of expertise, I'm going to be honest with you, Rhun—I'd rather not speak on their behalf.

It has again been severely affected through COVID. So, it was the outreach, the support, the education, the whole preventative side that sits within the elderly community. But it's had to stop through COVID; the access has not been there to do so. Any benefits that have been gained over the previous years will be lost and, again, need to double down.

Yes. We're told it's restarted pretty well, actually, but I was just wondering if there were some comments this morning. That's perfectly fine if you don't want to add anything in particular there. Thank you. Thank you, Chair.

Joyce, any brief questions to finish?

I was going to ask that question, so that's been answered. I think we've got the answer to the backlog. The current situation in hospital dentistry, which is a question for Ben, probably, so I think we've covered everything.

I think you're asking about hospital dentistry specifically, I suppose.

So, again, there are just massive backlogs. Hospitals have been affected because they're on acute sites, so therefore, during COVID, many staff were redeployed onto the wards, or their departments were remodified to provide different types of services. Some departments haven't got their full surgery space back, so that limits, automatically, the capacity that they can provide in that service. I think there's a sense that, often, things are crisis driven rather than forward planned. So, for instance, if you've got a need for x number of specialists, whether that be orthodontics or restorative, for instance, sometimes, you employ one, even if there was a case of need that said, for instance, 'In north Wales, there's a benefit where, actually, when we looked at the numbers of the patients and the age demographics, then we need at least 1.5 if not two full-time restorative consultants'. We employ one, because that meets the target for the oral cancer multidisciplinary teams, and therefore the pressure is off, then, to employ anyone further. And I think the recruitment and retention systems in a lot of organisations isn't as effective as it should be. So, we're missing out on opportunities. When someone becomes available, we want to snap those people up and get them, because it is harder to recruit in Wales, and the further west we go, the harder it is to recruit as well.

I think we also need to be looking at symbiotic relationships as well. So, if someone's come in, often by the time they come to consultant level and specialist level, they've got other commitments. They've got a family, they've got a partner who has a job, and I think we need to be looking in totality at these individuals, because we want them to settle in Wales and become part of the fabric of society. Therefore, we should be saying, 'Actually, such and such has got this job, so chances are their partner will have a job that we need as well.' So, we need to be looking far more holistically at that and promoting the benefits of Wales, not just on the professional side, but the social side, the cultural side and things like that, but making sure that, actually, when we're comparing against the other home nations, the headline figures are understandable. For instance, if you employ a consultant in whatever specialty in Wales, it appears on the advert that you get paid less to start with and you get paid less at the end. Now, actually, the progression through the pay scale is better in Wales than it is in England, but people, unless they're interested in that particular job, will not look at the nitty-gritty. They will just take the headline fact, and if, actually, they've got two places to move to, one that may be more geographically convenient and appears, on the face of it, to have a higher, better remuneration, well, actually, they're obviously going to choose that job unless there's a desperate pull to that other area. So, I think we've got to be better, from a Welsh point of view, at marketing all the many benefits that we have in Wales to try and attract people not just to come for the short term, but to actually stay, for them, for their kids, and hopefully that will propagate through.

Can you just clarify something in terms of hospital treatment? When you get patients who have cancer of the mouth, who would be dealing with that, and would those people be seen with the urgent need that is required?

Just briefly, if you can, Ben.

They're seen by the maxillofacial facial team, but any reconstruction is seen by the maxillofacial facial team, possibly orthodontics, but very rarely for that cohort, but mainly by the restorative team. So, it's having adequate access to both the initial treatment, which is obviously the removal of cancer and any radiotherapy, but just as important is the rehabilitation, because that's where patients are going to need to get their lives back, and that's with the restorative team. They're seen as urgent priorities, so they're seen within a two-week time frame, and that will displace other activity, which has a knock-on effect on other disciplines. 

And, Russell, you wanted to come in, but can I ask you about domiciliary care as well—if you can comment on that?

Yes, okay. Just briefly, on the hospital care, Ben alluded to it before, but, actually, a lot of the pressure could be taken off hospital care by fixing the GDS contract and the problems within there. Ben spoke about special interest contracts, but, even below that, allowing dentists to expand their skills and manage more of those patients. There are patients I refer that I could quite ably manage if I was supported to do so.

Domiciliary care, unfortunately, is falling largely short. Again, community dental services provide a lot of domiciliary care, but, within practices, within the pressures that we're working with within our contract, the vast majority of practices that have been engaged in domiciliary care are stepping away from that now to try and manage their own local business pressures. So, it is an issue and, again, the fix, I think, is the fix of the general contract to allow people the freedom to do those things.

And a very final question, if I can, to Russell and Dan: who do you think are the most impacted by problems with access, both in terms of sectors of society and geographical areas, and the solutions, the answer to that?

Go on, Dan.

I think there are those who can't afford private dentistry. There's that, isn't there? There are people in rural areas, and we've talked about west Wales as an example—north-west Wales, amongst other areas. There are people new to Wales who can't get on lists because they've maybe come in to Wales, or people who haven't had an historic relationship with an existing practice. We know that people in lower socioeconomic groups tend to visit less often. I think there's data on that. So, the health inequality and inequity is amplified by any capping and any restriction in funding, such as that which we have in Wales.

I think, anywhere, that deprivation is going to get amplified as we go forward, and particularly for the children who aren't getting the chance to get those early interventions. The filling they have now will be treatment that they'll need for the rest of their lives, but they're not even getting the chance to build the same relationships with dentists that they have in the past, because they're just not getting opportunities to see them.

One more thing about what Ben said, and I can finish on that, if I may. I know I'm being quite verbose today about this, but when we're talking about oral cancer provision, when there's such a focus on—. Certainly, if we'd gone into contract reform, I wouldn't have been able to make my targets; I would have had to have seen patients who are high risk for oral cancer less often than I think they safely can be seen. That's one of the reasons I didn't go for contract reform. So, unless you've got the patients coming in to general dentists to be diagnosed, you could have the best multidisciplinary team, and you've got excellent ones in Wales, but if the cancer isn't diagnosed—and it's often a cancer without symptoms in the early stages—they're not going to get seen. So, they're one of the patients who suffer massively from bringing it all together—the high-cancer-risk patients—where practices may end up, if this trajectory continues, with a policy forcing them to see these patients less often.

Yes, thank you. We've really come to the end of our time now. You were looking like you might want to say something briefly, Yvonne Jones.

I was just going to say that, previously to all this, we actually took part in the orthodontic managed clinical networks. We're engaged with the Welsh Government through the strategic advisory forum in orthodontics, and I think that's a worthwhile forum for us to get together, and we discuss with the chief dental officer and we come together to provide national guidelines—

Does that not happen now?

No, we've not had any for quite a while, and I think—

Why is that?

—there are moves for it to maybe be disbanded. Well, it stopped during COVID, and then we've not met again since, and obviously now we've got a new chief dental officer. So, I think—

Okay. Just briefly, what were the benefits of that forum?

Well, we helped put together national guidelines, and helped steer the national agenda on orthodontics, because we can't do that locally through our MCNs.

Okay, that's interesting. Thank you. Maybe we can pick up on that. Thank you ever so much for your time this morning, and thank you to you all for agreeing to go a little bit over as well. It was a fascinating session. Both organisations gave very comprehensive consultation responses, which is really helpful for our inquiry. We'll send you a transcript of proceedings of this morning's session. If you feel you want to add to something, then please do, but this is the first session of many, so, if you do have time to listen in and you feel you want to come back on any point that others contribute towards the inquiry, then we'd welcome it for you to drop us a note on that. Thank you very much for your time this morning. It's been a fascinating session. 

Thank you. 

Thank you very much. 

Thank you. 

We'll take a 10-minute break and we'll back at 10:55.

Welcome back to the Health and Social Care Committee. I move to item 3, and we're continuing with our evidence in regards to our dentistry inquiry. I would be grateful if the witnesses on this next panel could just introduce themselves for the public record.

I'm Dr David Tuthill. I'm a consultant paediatrician at the Children's Hospital for Wales, but today I'm officer for Wales for the Royal College of Paediatrics and Child Health.

I'm Helen Twidle, health and social care policy officer for Age Cymru.

I'm Heléna Herklots, the Older People's Commissioner for Wales.

Lovely. Thank you all for being with us this morning for our second panel today. Is there sufficient data available, do you think, to determine where the inequalities in access to dentistry in Wales are, and how many older people and children are waiting to see a dentist? So, this is a question about data and that data being available. Who would like to go first on that?

Do you want to go first?

Okay. I can't give you specific data from the Royal College of Paediatrics and Child Health, because that's not a set we collect, but from our experience of people, and certainly reading the news reports last year, and speaking with some children across Wales, and young people and families, they do find that accessing a dentist has been a problem. I think that tends to be in areas of low socioeconomic wealth, and so I think there's probably an inequality, but I don't personally have those data. That's not a set that we would keep, but it's something our members tell us seems to be occurring.

I suppose the question is not so much about asking you about what the data might say, but whether the data is available. I think your answer is that it isn't, by the sounds of it.

I can't provide it to you, but there may be others that can.

I've not been able to find that sort of level of data either. My searches may be quite awful, but I do know from the surveys that we've done that there's a huge problem in older people's access to dentistry, and increasingly so over previous years, but we don't have enough responses to say what those sorts of levels are, and where the pinch-points are and where it's worst.

Okay. I'm kind of reading in between the lines that the answer to my question, I think, from you both, is that there probably isn't that data available, by the sounds of it.

It would seem so, and I'm not sure how you'd actually collect it. You'd need a whole-population level to look at where it is.

Do you think it's important to have that data available?

I think it would be very useful. I mean, there are ways of doing it as an estimate, at the very least, looking at the population, who is registered, who doesn't have access, and working it out that way, just as a ballpark figure. But without the data on where the worst areas are, it's very difficult to plan for improvement, despite all the additional funding that has been put in and the changes in contracting that have been put through. Without that data, how can you plan for the level of need that there is out there?

Lovely. Did you want to come in at all, Heléna?

Yes. I agree with that, that the data isn't there. That, of course, makes it very difficult to make sure the right provision is in place, if we don't know what the level of need is. I think that's particularly acute for older people; quite often, even when information is collected it's not broken down by age, so you can't actually see within populations or within the older population what the level of need and access is. Of course, it makes future planning really difficult. If we don't know what our baseline is, it makes it incredibly difficult to plan effectively for the future as our needs change. So, one of the issues with an ageing population is that the needs of dentistry are changing as well. Fundamentally, without that information and data, it renders older people's experiences invisible, actually, because we can't see what's happening. We can't see where the gaps are. We can't see in terms of the population overall the impact on older people's health and well-being. So, I think it's extremely welcome that this committee is looking into this issue of dentistry, and the data issue is one that really needs improvement.

And perhaps if I can ask you all what you believe is the priority at this current time in terms of addressing access to dentistry and addressing the inequalities that exist. What's the priority?

If I might come in at this point. I think, in the short term, there are a couple of things that can be done. From the feedback I and my team have from older people, the issue of communications and information is another barrier. So, there have been changes in terms of dental contracts and things, but those changes aren't well communicated to older people. Many older people, particularly those over 75, don't have access to the internet or any online access, so it means that there need to be ways of informing people that don't rely on digital access as well. And also it's just incredibly difficult to know where to go to find a dentist. So, we know the huge problems in terms of a lack of NHS dentistry, but even when older people, out of sheer desperation, try and find a dentist that might be able to support them privately, it's difficult to know where to go. Health boards don't necessarily keep lists available for the public to be able to know where to go. So, information and communication is key and can be improved. It's not necessarily a costly measure, but it can be improved. 

The second thing I think—

How can it be improved?

Sorry.

How can it be improved?

So, very directly, in terms of the information that dental practices send out to their patients and to the wider community, the information that health boards hold, and the information that health boards provide. So, I think you should be able to go to a health board and say, 'Where is my nearest dentist? What services do they provide? Can you tell me how to get on a waiting list?' Those sorts of things. But, you can't really do that at the moment. 

Can you not do that?

No. The feedback that we've had from older people is that they've tried to access information via health boards and it's very difficult to get that. Now, of course, it may be that some are doing it better than others, but there isn't a consistent approach to that. So, if there is good practice, let's make sure that happens across Wales. But, certainly, the feedback from older people is that it's very difficult to get that information. So, I think that is an improvement that could be made.

The second area, and I think again in the short term, is all the work that can be done in terms of improving people's oral health and looking at prevention. So, in my written submission, I talk about the very good programme running in care homes to try to support people's oral health and support staff to have more confidence in dealing with that. So, I think prevention is a key issue as well. 

Fundamentally, it's going to come down of course to the funding and increasing the capacity in dentistry. But, I think there are these measures that need sorting now and can be, actually, put in place now to provide a further foundation for any future improvements that might be made in terms of funding and workforce.

Lovely. And the other members of the panel, in terms of priorities at this current time in terms of access to dentistry and combating the inequalities that might exist.

I'd agree with Heléna on the communication, because we've seen some incredibly poor communication about changes, people not understanding changes, particularly in moves to private healthcare, where the dentists are going private and the information passed on is only available online. The information—

You say that; can't somebody phone up a health board and just say, 'Look, I can't find my nearest dentist'?

The people who I've personally spoken to have had difficulty getting through and finding the right people to speak to. Those who have been able to get through get information on what is out there, but then calls show that there's no space on—.

Yes, so you're saying that, from your work and assessment, somebody might phone up a health board but perhaps the incorrect information is given or information is given and then when they phone the practice up, the information is different to what has been relayed to them via the health board.

They're given information on where dentistry may be found, but then when they make contact they can't get help. They can't even get on a list or they try somewhere else. And linked to that, there is also the issue of access and how they're going to get there in the first place, because if it's further afield, many older people don't drive, so if public transport doesn't get there, then it's of no use to them whatsoever.

Thanks. I think, in our submission too, we'd highlighted four areas for our recommendations: education, access, effectiveness and how to deliver fluoride to children's teeth. And I guess your question here is assessing the access and measurability of that, almost two of those points, really, with the third one being, if fluoridation is given to children early on, then by the time they get to old age, their teeth will be better and stronger to resist and need less dental input anyway.

But in terms of access, it's important that we measure the availability of dental access per area and that children have free and open access, and that children and families know to go there by their first birthday, so that the preventative aspects of dental health care can go on. I guess that also blends in with the education of families and healthcare professionals to let them know that that's an important first step: that by the first year, there's, you know, 'Lift the Lip' and all the rest of it, to look in the mouth, but that they also get children to see the dentist to be prevented from getting dental decay. That leads on to their exposure to fluoride, which I'm sure you're going to ask about later in this session. But on access, the college want children to have the same access across Wales, and we don't believe that's happening, although we can't provide you with absolute data on that; it's what our members tell us and families tell us, that access is difficult.

I think, locally, there is a central number for Cardiff and Vale University Health Board to ring. I can't actually give it to you, but when we were doing some work with the child protection group, we were trying to get ways of referring children who might be coming for child protection medicals to our dental colleagues, by tying that up, saying, 'Look, they're coming here for child protection, oh, look at their teeth.' That's often associated with neglect; they crossover—surprise, surprise—and, therefore, it's about trying to help them to find dental support for treatment or preventive work.

Sure, sure. Thank you. Sarah Murphy.

Thank you, Chair. Thank you, all, for being here today. So, we've looked at access to dental services, and you've all touched on it slightly here, but to look specifically now at oral health: is there a level of data available on the actual oral health of older people and children in Wales?

Yes. My understanding and there are oral health surveys and the data has shown that, roughly, at the moment, I think about 30 per cent of children have got some problems with their oral health, like decay and some filled teeth by the age of five. That is better than it was. I think about 10 years prior to that, it was about 45 per cent. So, it has got moderately better, but I don't see 30 per cent as good news, personally. I think it's still shocking that a 'preventable' disease—and it's the most common disease in childhood—that we allow children in Wales still to have that.

That's a combination, probably, of education, which we talked about, availability, brushing their teeth and that knowledge of families, but also it's a lack of fluoridation in water. We know that among the 6 million people in the UK who have fluoride in their water at supplemented levels to reach safe levels, they have about a third less decay. Public Health England have published their recommendations saying that it's financially very effective: you spend £1, you get £35 back. And by putting fluoride in children's teeth early on, they will get a lifelong benefit. I was speaking with a dentist recently, who said, 'Well, look, your dentine, by the time you get old and your gums have receded, is then stronger to resist the problems then.' So, we would want children to receive fluoride.

We support the Designed to Smile programme—that's been very good, and it's helped produce that, but whilst that's been going on, Wales has dropped to the bottom of the oral health league. And I don't think that's something we should take lightly. We've now got the worst oral health. I don't think the data are so clear for the last two years during the pandemic—obviously, accessibility to measure this has been harder and it'd be interesting to see where that goes. But several dentists I speak to would anticipate that those more at risk will have also suffered the worst oral health during this pandemic.

So, our college has adopted a policy, supporting all four chief dental officers who support water fluoridation, to bring it up to a level that should help children, and particularly the most vulnerable, who I think we are failing. And if you'd like a rights-based approach, I think we're failing under the United Nations Convention on the Rights of the Child, article 24: the right to the best health that children can have. We're not giving them that. We've got an easy, financially proven, effective public health measure that we're not implementing. We've put iodine in salt; we've fortified bread with folate to prevent neural tube defects. Why aren't we putting fluoride in water to a safe level? Fluoride is naturally in water; it's just not enough in Wales to protect our children's teeth, as part of that package of other things.

Okay. Sarah.

Yes, thank you very much. Heléna, would you like to come in?

Thank you. So, I don't know the current oral health across the older population in general, but one of the areas where we have been particularly keen to see improvements is in older people living in care homes. The British Dental Journal in their survey a few years ago saw that the level of oral health for residents in care homes was worse than in the general older population, particularly in terms of keeping teeth clean, but also levels of decay, levels of other problems; and of course, that having a general impact on their health as well. I think we see that, where older people might be particularly vulnerable, then poor oral health goes alongside that, so I'd expect to see similar issues around older people living in poverty, and, obviously, those cumulative impacts of poor oral health early in life causing greater problems in older age as well.

Of course. And Helen, are you aware of any data pointing towards the oral health of older people? And also just to add on, I suppose, and to all of you, what is the impact of this when people are waiting on these waiting lists?

I haven't been able to find any data on that. I haven't specifically looked for it, in all honesty. But from our survey responses, it is quite clear that oral health is reducing, from everyone that's responded. Seventy-five per cent weren't happy with access to dentistry. Of the pages and pages of comments that I've got, a lot of it is around, 'I can't get to a dentist. My teeth have deteriorated so much.' And when you couple that not only with age, but also the other factors—so, older people are more likely to be on medications that reduce saliva flow to the mouth—then they're at increased risk of all those things. So, the priority for their care should be higher, but they just can't get access to the dentistry that they need.

Thank you very much. Heléna and David, do you have examples as well of what impact this is having on people whilst they're waiting?

It's having a desperate impact on many, many older people. Some of the calls that we get are quite heartbreaking, really, in terms of what's happening. People are in agony, in a lot of pain, and it leads to further problems as well in terms of their health. But also, there are a lot of people I think who haven't been able to get dental treatment, and that's affecting their ability to eat, so they're becoming malnourished; it's affecting their confidence, as well, because they're not confident to go out because of the state of their teeth, so it's leading to greater isolation as well. And of course, it means that there are people who might have issues that would be picked up by the dentist—that's not happening as well.

The other thing we're hearing from older people is also just a sense of being very desperate about this, but being left just to try and find their own way through what is a complicated system. I guess that comes back to the point about information and communication. But people are feeling very let down and very vulnerable because they simply don't know where to go, and if they do find out where to go, they can't afford to get treated. So, I think it's a growing crisis, really, in terms of how many, many older people are faring at the moment, and it's extremely worrying.

Thank you. David, what impact is this having on children whilst they wait, in your opinion?

It can have an adverse effect on children. Obviously, dental decay, if it affects children, can give them pain, they can have time off school, and then, if they actually have to have teeth out, that's further time off school, and the family are financially affected because they've had to take a day, two days or three days off work; I think the average is about two days.

The last figures I saw show that we have got about 30,000 operations across the UK—I think it's about 3,000 a year in Wales—for general anaesthetic removal of teeth. It's the commonest operation we're doing—for preventable disease. This is shocking. And the delays in children—and COVID will have obviously adversely affected that—for outpatient treatment now have increased, because we weren't able to see so many children.

Operating theatres were particularly hit with the enforced slowness—and I don't mean that in a derogatory way, it's just because of what COVID did to the health service and how we had to cope with different things—and particularly operations were slowed down because of those things. So, it affects all the things you can think of.

And on the cosmetic thing that I think, Helen, you were talking about, that's another thing—for a child, if you've got dreadful-looking teeth, you don't feel as good. I grew up in a pre-fluoride age, and have ended up with lots of fillings because of it. That's not something we should accept any more. We really shouldn't.

Thank you very much.

Did you have any further questions, Sarah, or was that it?

I was just going to end by saying that, obviously, we heard from the panel beforehand about prevention, and you've all touched on this as well. Do you think there's enough emphasis on it, or do you think there is something else that can be done to help with this? I'm specifically thinking in terms of the waiting lists.

Who would like to go?

In terms of prevention, just having access to ongoing checks would improve things greatly for us as a starter. The crisis in dentistry at the moment means that they're not happening as frequently as they should be, and, as I've said, with all the comorbidities with older people, it's more likely that they are going to need them more frequently with age, as well as other age groups. But there's—. I've lost my train of thought.

Don't worry, I'll come back to you. David, I'm just going to ask about your comments about water fluoridation, and in your written evidence as well. I just wanted to understand that about what the role is for the Welsh Government and what role can they play in changing something. I'm not quite sure. I just want you to explain it to me.

As a public health measure, one of the key things we want to do—and it has a downstream effect—is to reduce the number of children that get caries, that need to see dentists, and the frequency. That has benefits throughout the whole of health. By fluoridating water to a set level, you can improve the dental health of children for life, you can reduce the severity of dental decay and the frequency of it, and I believe you reduce operations in the low socioeconomic areas for tooth extraction by about 30 per cent to 50 per cent. So, it has a benefit, particularly for those who are economically deprived, and particularly if it's done universally, it covers everybody. When COVID happened and Designed to Smile would have struggled to deliver fluoride to children's teeth, because schools were closed, it would have still done that, ameliorating the problems—

So, why doesn't it happen, then? There must be another aspect—

That's a really good question. It's a public health measure that I understand the chief medical officers support in the four nations. Why isn't it being driven? I presume that's because of political opposition.

Why would there be political opposition?

I think some people view it as a right to not drink additional fluoride in water. My understanding is that's why the Scots didn't put it in there. It's been done successfully for 6 million people in Britain, and they have fewer tooth problems. There are rights-based issues from a children's perspective. Article 24 of the United Nations Convention on the Rights of the Child, which I think we've signed up to in Wales, says that every child has the right to the best possible health. Thirty per cent of children having dental decay by five isn't the best possible health, and we could have an intervention that would greatly improve that. We do other public health measures. I appreciate we're in interesting political times at the moment, but in Wales we still believe in public health, I hope. But we're not doing it for oral health.

Okay. There's an aspect there I hadn't really considered before, but that's a new point for me to try and knowledge myself up on. Gareth Davies.

Thank you, Chair, and good morning, everyone. I want to direct my questions around domiciliary dental care and the community dental service. What domiciliary care services are currently available out there, and is there sufficient provision to meet the demand and needs of patients? Considering the general picture, I suspect that's not the case, but could you expand a little bit more on what domiciliary dental services are available for elderly people?

I don't know about the volume. From speaking with colleagues working in that area, they would like there to be more provision. Providing domiciliary dental care, taking it out to people's homes, taking it into care homes, taking it elsewhere is really important, because there are so many people that cannot get to a dentist either for medical reasons or social ones. The services that are provided through those are very good, but provision across the board is putting pressures everywhere, as we know. From conversations we've had, it does seem like there isn't enough, but we don't know by how much, and, again, without all the data to say how many people need it where, it's very difficult to say how much is needed so that it can be planned accordingly. It's vital that those that can't get out and about can get access to that as well, because, obviously, it affects everyone's health. The lack of dentistry has such a knock-on effect on everyone else's lives, as Heléna said. It seems like it isn't sufficient, but we don't know by how much, basically.

I agree with that. I think where we've seen good programmes—the Gwên am Byth programme, the A Lasting Smile programme—in care homes, it's really positive. I think that's only still reaching about half the care homes, for example. So, that would be, again, an area where improvements could be made, and that's very much a preventative approach. I think it might be worth looking at the impact of that work in terms of older people living in care homes to see if similar initiatives could be taken forward elsewhere. So, for example, if you've got a sheltered housing scheme with a number of older people living there who might struggle to otherwise access dentistry, is there work that can be done in terms of good oral health there as well? Again, there's a lack of data overall in terms of what the level of need is and what the level of provision is, but it's clear enough from anecdotal evidence and from what older people tell us that there isn't enough provision there.

I'd also add into this that it is an issue about domiciliary provision, but it's also an issue about why people can't get to the dentist. One of the big barriers for older people is transport and, actually, sometimes, it's the transport that's the issue, not the dental service. And again, that is something that should be able to be fixed, whether that's around affordability, community transport or public transport. Sometimes, the barrier to good dental health is actually an issue of transport as well.

How are elderly people and people who can't get out of the house referred on to the community dental service, then? Is that from a dentist or another health professional that refers them on to that? How do they get into that system, then?

I'm not clear about the referral processes, and I suspect that many older people aren't clear about those as well. What I think should be the process is that you should be able to be referred from your GP, or from another health professional. So, it might be, for example, you're seeing a practice nurse at a GP surgery, and actually they've identified that there's a problem in terms of oral health and a referral is made. But I don't know the detail of that referral process.

Okay. Just finally, to open up to all, how much of an impact will waiting times and capacity in community dental services have on older people, children and those people who can't get out? Because you've obviously mentioned the lack of data and also the general picture, but what do you think will be the effects for that group of people? Because we've spoken a lot in our evidence sessions today about a two-tier system, inequalities in that dental treatment, so how do you think it will affect those groups of people?

I think it worsens inequalities that are already there: the inequalities of poverty; the inequalities if you're from a black, Asian, or minority ethnic group and your health status is likely to be lower; people living in rural areas; people who are not online. So, it's another factor, and these are cumulative. For many older people who can't access dentistry, that's just one issue that they're grappling with at the moment, along with the cost-of-living crisis. So, this is severe. It's severely affecting people's health and well-being. It's severely affecting their mental health. It's adding to isolation. It's coming on top of lots of older people having poor physical and mental health as a result of the pandemic. What we are seeing from many older people is sheer desperation and a feeling that they've been left alone to deal with this.

Thank you. Does anybody else want to comment on that last question?

I'd just back up what Heléna has already said in terms of that; the desperation of the people calling our information and advice line and not being able to get through to dentists, feeling completely abandoned by the promises of the money that they've all paid in all their lives and not being able to get the services when they need them. Someone said, 'It just feels like I've been thrown under a bus. Why can't I have the help that I need after working all my life and paying into the system?' And not having the ability to seek private treatment as well, because pensions are a fixed income and it's just completely unaffordable.

Many people have told us about how they've been forced to go private, but they'll only be able to afford to do a little bit of dentistry at a time, so there are more people waiting for treatment for longer as well, in that sort of sense. I spoke to one gentleman, who's got a range of comorbidities and really struggles to get out, and struggled to get a dentist, and he said, 'I can't smile, I can't laugh, I look 20 years older than I should'—because he was waiting for dentures for two years—and the effect that has on you is quite difficult to get over in words, but it's profound—it's profound, the effect it's having.

I can imagine, yes. David, any comments?

I think similar issues affect children. We've talked about oral health, pain, and, for children, they're dependent on adults to get somewhere. So, if there's a financial problem, and we know that oral health is worse in areas of socioeconomic deprivation, and access to dentistry appears, from what I hear, to be worse in those areas, you've got that double whammy, and then they're the children with the worst outcomes—the delays in getting care. So, I think, it's particularly affected those communities of socioeconomic deprivation, amongst others, and the children get pain, time off school, and then, with the cosmetic things you mentioned for children if they've got lots of poor teeth, they get bullied because their teeth are awful. So, I think, a different end of the spectrum, but very similar effects, and how the poor oral health of some children is adversely affecting them in many ways, compounded by COVID and the effects that's then had on us.  

All the wider things. 

Yes. So, I think that's why we need to look at a solution downstream as well, not just adding more dentists in, but what can we do to prevent it, and we've mentioned a couple of those already. 

Thank you very much. 

Rhun ap Iorwerth. 

Yes, the programme was suspended during the pandemic. It was reintroduced last summer. I haven't got the latest figures on how many care homes have now taken part, but there was a really positive effort to get more engaged by having a slightly stripped-down version of the programme. And, certainly, we know that it does have a really positive impact in terms of the oral health of older people living in care homes, but also a positive impact in terms of staff as well, in terms of training and support, and greater knowledge about how to look out for oral health. I don't know what the latest figures are in terms of all the care homes that could potentially be on it, but it's welcome that it now has restarted. 

I think it's been around the half of care homes, hasn't it? But the latest figures we have are: pre pandemic, 310 care homes fully participating, 124 partially, and, in 2021-22, already up to 300ish again and, actually, nearly 200 participating partially. So, it looks positive, but, as you said 10, 15 minutes ago, improvements could be made. Let's look at what improvements you've identified perhaps that could be made. Bringing more care homes into it would be presumably one of them. Give us more of an idea of how you think this could be improved. 

Certainly, we'd want every care home—. We have about 1,000 care homes in Wales and about 20,000 older people living in care homes. So, we'd want everyone to be able to access that programme. Some of that is about making sure we have the staff from the dental side to be able to run that, but the other side of it is, also, we know a lot about the pressures on care homes at the moment in terms of workforce issues there and care staff, so they need to be able to manage that as well. I think it's great that we've got nearly half either fully or partially implementing it, but, in order to get that other half on, I think it's going to be about working with the care homes, understanding what their pressures are in terms of staffing and making sure that support is there from the dental service as well.

As I indicated earlier, I think the success of this programme warrants a look at whether this is an approach that could work elsewhere. So, could that work in other settings where older people live, for example in extra-care housing and sheltered housing? Is there something that could be done similarly out into the community? Is there a way of taking this sort of programme further out into the community as well? Because this seems to be a really good preventative programme and one that has evidence of impact and improvement, and I’d really like to see how that can be further developed and built on, with the priority being getting all care homes on board to start with.

And a suggestion was made that it could be expanded to adults with learning difficulties, for example—the same kind of programme but for a different cohort. But before we dig into some of the points that you made there, I wonder if Age Cymru have some general thoughts as well, Helen, that you can share with us on the efficacy of the programme in general.

Yes, my thoughts are similar. We would want to see it in every care home. Obviously, every resident in every care home doesn’t get access to the community dentistry service, but they do get improved oral health. So, the wider stuff around improving the dentistry available in the community would help the Gwên am Byth programme not have to do so much. It’s already very busy, there’s a lot going on, and I hadn’t heard those figures about the amount of resumption, so that’s really good to hear, Rhun. We would like to see that widened across all care homes and in extra care and sheltered housing. There are lots of places where it would be beneficial, and that’s bringing care closer to home as well. Heléna’s already spoken of the difficulties with transport, so having that sort of community element in many more community settings would also help.

There are of course difficulties there in terms of you can’t take every piece of dentistry equipment out to a care home—x-rays and all the rest of it—so there’s still a need for the other side of dentistry. But, particularly, we’d like to see whether it would be feasible and sensible to include fluoride varnishing for care home residents as well. That’s proven in children. I’m not an expert. I did read through the gov.uk guidance on each area, which did seem to suggest that it’s beneficial to adults as well, but, on the preventative side, it would be good if we could get that through there as well, I think.

Interesting to hear another comment on fluoridation there. I was, Chair, incidentally, brought up in an area where fluorine was added to our water and my teeth are better as a result of that, so I can vouch for that. Back to you, commissioner: the issue of capacity to deliver—how much of a concern is the training needed in order to deliver Gwên am Byth well, especially in the context of high turnover of staff, and so on? What ideas do you have on how you make sure that the capacity is built up to deliver this to more individuals and more care homes?

I think it is very much a factor of the pressures on care homes generally at the moment. We know staff have been through a really difficult time during the pandemic. We know there are workforce shortages, so if you have a situation where there’s a lot of pressure on staffing in care homes, this is effectively another piece of training, another bit of support, another additional area of work. You can see why some are maybe struggling to get that capacity to do that. So, I think part of this is actually addressing those issues in relation to care homes. That’s about workforce, that’s about pay and conditions, and all those issues have a bearing on this.

I think the other side of it is also being able to maybe promote the programme more, promote the impact more, make sure that care homes are aware of it and get that support, and maybe even thinking about prioritising residents within the care home for that support. There’s probably a piece of work to do to understand better why those care homes who haven’t taken up the programme haven’t done it. So, I’m not aware of any work being done with care homes to identify, ‘Well, why haven’t you taken part in this programme? What are the barriers? How might we help you with those barriers?’, and that probably needs to be part of the roll-out of the programme during its next phase.

And finally from me, perhaps, are you hearing evidence that there is more pressure on Gwên am Byth to deliver because of problems of access to community dentistry—the first thing that came up in this session today?

We’ve not had anything directly through on that in terms of—. Obviously, we are mainly getting older people coming to us directly, and their families, on that, so we haven't had anything directly on that. 

Okay, thank you. Is it a concern that there's more pressure to get the preventative right to work with older people in care homes, because they might find it difficult to find a dentist to register with, and the lack of capacity makes it difficult to strengthen Gwên am Byth in that way? 

There were a couple of things there. One is you need to be able to have dentists to refer on to if you identify issues and problems. So, you're skilling up and supporting staff in care homes to provide that level of support and that knowledge of oral health. If they identify serious issues, they need somewhere to refer on to, so obviously that's an issue. 

I think the other issue—and it's not directly related to the Gwên am Byth programme—is where older people are still registered with the dentist that they had before they moved into a care home. Sometimes, that can be some distance away and, actually, what we saw as a result of the pandemic and the restrictions on visiting and going out from care homes was that older people lost the opportunity to go to the dentists that they were registered with, for example. There probably is, therefore, an issue about, actually, within the care home, where residents are registered with dentists and how easy it is for them to access those dentists, if they're still able to go out of the care home to see their dentist directly. 

Thank you. Diolch, Gadeirydd. 

Joyce Watson.

I'm going to move on now to a different age group, with the Designed to Smile programme and older children. We've got good evidence that the Designed to Smile programme did work; it had some positive results. We also know that, like other things, in the pandemic it was all halted. So, I don't know whether you can give us any evidence or if there is any evidence about that two-year halting of the Designed to Smile programme and the effects that it might have had.  

Thank you very much for your question. I've looked at Designed to Smile evidence before, and I think that was part of the reason we have seen a reduction in some dental caries and things in the preceding 10 or 11 years it's been running. In that, if I call it a 'ranking league', unfortunately Wales was mid table before of the four nations, and now we've dropped to the last one, despite Designed to Smile and that's when it could be delivered in its full capacity. As paediatricians, we worry that the, let's call it, last two years peri-COVID have resulted in that not being able to run at full speed, and those in the most deprived communities won't have had their teeth brushed as often. So, we anticipate a worsening over the coming year, or two, three years, of oral health, because that cohort of children that have been born in that time may not have gone to the dentist. 

I talked previously to the chairman, saying that the recommendations that should be made is that children are seen by one year of age to go to a dentist, to get that preventative message out. As far as I could see, that probably wasn't going to be possible during COVID because the dental surgeries were shut. It's not criticising them; it's just a fact of life. So, we anticipate things getting worse. And I think one of the things that COVID has taught us is to think, let's say when the next pandemic comes or the next crisis comes, or the strikes are on, or whatever it be, how do we maintain children's oral health. And I go back to one of the measures probably we should do, I think, in terms of what the college has campaigned for, which is to fluoridate water, because unless that actually stops upstream in your fluoridation bit, it's going to carry on having beneficial effects, whether COVID is there or not, and it kind of pandemic-proofs us, if there is such a phrase—forgive me for inventing it—for the future. 

So, I think, in summary, Designed to Smile is helpful and we do support it as a college, but it would have been difficult to do, and we anticipate data showing that children in that birth cohort for that year having worse health because fluoride just won't have got to their teeth as effectively, and it having the effect that we talked about earlier—affecting adversely the most deprived communities in Wales because of access. 

I would just like to ask your opinion on whether it should be expanded for the six to 10-year-old age group, because it currently doesn't reach those now.

I think it's really interesting. I probably need to go and ask a dentist, but if it's getting children into good habits that they then start doing themselves—we talked about the tooth-brushing buses they've got at school, and all those sorts of things, in a deprived area—it might need mutating into a different form. As children get older, you want to develop independence rather than dependence, and one of the—. An at-risk group, say, for children particularly, are those whose parents may not be as knowledgeable, or have learning difficulties, or children with special needs, because they may be orally sensitive. There are a whole range of children's groups that might be more at risk, and if that helps them—. I can't tell you about the data set for that; I don't know if there's evidence that that works in that older age group. It's an appealing prospect that it probably should, but I suspect it might be less effective than the under-fives. But it's a good question; I can't fully answer you on the basis of data, which is normally, as a doctor, how I would want to answer your questions.

Can you answer this one? Maybe you can't—

I'll try.

Is there any available information on the oral health of the 12 to 21-year-old group, and if there is, is there a gap in provision for that age group?

I would need to go back—. I used to get some of my information from Rhian Morgan in Cardiff University, who was looking at dental health rates, oral health in children, and I think it's less available for older children, and in the last two years particularly, there's been a paucity of information. I did some work a couple of years ago, about three, four years ago when I was looking at effectiveness of Designed to Smile and whether communities were aware of it, and, actually, not so many communities were aware of it as one would've thought. And we found that, I think at that stage, it was 13 per cent of people who didn't have their children registered with a dentist. And that was a snapshot of about 250 children who came through the children's hospital. I suspect the issues—. If we can train children and get them doing it themselves and let them know—the education of children and their families in simple dental health—and make each contact count as a healthcare professional with those children would be a helpful way forward. I think they are an at-risk group, because that's when independence starts and people sort of say, 'Why do I have to brush my teeth? Can't I drink fizzy drinks all the time?' and all the rest of it. And supporting children through adolescence is going to be a key time, up until, I suppose—when do you end being a child, depending on how you define it? So, legally 18, obviously, but I think we need to support, because they'll have different needs to the under-fives, but still the same thing of dental health, brushing your teeth twice a day, putting fluoride toothpaste on it, spitting, not rinsing, those kinds of common messages, and avoiding fizzy drinks and regular— . The more times you put food in your mouth, that actually drops the pH and attacks the teeth. So, I think there's a particular group that we need to take care of. I don't know if the data is so readily available for their decay rates, as it is in the younger children.

Okay. Cheers.

Thank you, Joyce. Dr Tuthill, you mentioned children's oral health dropping in a UK league table; I think it was from a higher position to the bottom of the UK league table. Have I got that right?

That's my understanding. Whereas all nations have had an improved—. Pre COVID I think are the data where we've got to, and I don't think we've got good data peri/post COVID, if this is post COVID yet. Wales, I think we're mid table; I think the Scots have the worst oral health for children. They've moved ahead of us. So, it has improved. As I say, the figures generally given are about 45 per cent of children before, now down to 30—that is good news. But I think in doing that, our rate of improvement has been less than our Scottish cousins, and they now have a lower rate of overall. That was the situation pre COVID is my understanding.

Why do you think that is?

Our Designed to Smile programme was modelled on a Scottish programme, and it might be that that's been more effective. We presumably then, in our—. The essence of it, though, is that fluoride isn't getting onto children's teeth, and they aren't brushing them well enough in Wales, compared to other areas. And that issue, could we have a universal programme that helps them and then reduces it universally, as they've got in the north-east of England, as they've got in Birmingham, or areas of Birmingham, which covers 6 million people, and it's proven to be effective, would move us up the leader board, for want of a better word, in simple parlance. We're all wanting to get the best for children, and yet, I don't necessarily see these two as exclusive—Designed to Smile and water fluoridation.

Right. We've got Public Health Wales coming in to give evidence next week, so this is something that we can certainly take up with them. Have Members got any other questions, before I ask the last question, at all? No. Really, just to give you the opportunity, as we draw this session to an end, if there's anything that you want to say that you think needs to be—. If there's anything that's not been drawn out through questions that you want to say that will help our piece of work, then just to give you an opportunity here, really. But, also, to consider, perhaps, in your final thoughts, about the cost of living and what impact that has as well, both for children and older people. If you could, perhaps, comment on that as well. But, are there any other final thoughts that you might have for this session?

Can I answer that in reverse order, then? In terms of the cost of living, that has been something that's concerned paediatricians. We've just issued a toolkit for paediatricians to try and engage with families and ask relevant questions, and to try and draw out problems. There have certainly been members of our college around Wales and the UK who have said that families are finding it expensive to come. I think this was mentioned; visits to the dentist in the elderly community or people who may either have access problems because of mobility, or financial issues. That has come up recurrently for paediatricians over recent months as a cost-of-living problem. So, I think we would probably have similar, albeit a different age group, issues there to access. 

Just to summarise, I think we talked about the education of both children and families and the education of health workers. I did some work about eight or nine years ago with Mrs Hingston, the paediatric dentist in the Heath, and not all healthcare workers were really signed up to simple, basic dental messages, and they were unaware of them. So, that education side is one of the key points that we've talked about. We've talked about access, and you started the committee hearing about that. We know that, pre COVID, it was 13 per cent of children, in my small, ad-hoc study in Cardiff, and that's probably got worse. So, access needs to be good. We've talked about fluoridation, both with water, which our college would support, and the Designed to Smile programme, which we also support, and how that's affected children.

The last point would be measuring the effectiveness of this. We talked about some data. I think we've got that under-fives, pre COVID, and, I'm sure, my anticipation and other dentists is that this is going to have dipped down, I'm afraid, or got worse during COVID. But, having those data, the effective access to dentists, and, the bottom line is how good is the health of children, and measuring that regularly so that we can see the effectiveness of these programmes. I think those would be the four key areas that we would want: education, access, fluoridation, and effectiveness. Thank you.

That's clear. Thank you. Helen.

We've already spoken about the cost-of-living crisis and how that affects generally anyway. That does affect people's ability to go to different places, to be able to get to dentists, to pay for services. We've certainly seen that the delays in being able to access dentistry mean that people's teeth are in much worse health when they need to go private, so that's widening the two-tier system because they're having to pay an awful lot more, and other people are going without completely. We would like to see better information about how services are changing, because people don't understand why the changes have happened in terms of access and we'd like to see more services closer to home overall and look at how patients are prioritised for treatment. So, all the dentistry guidance speaks—. There are separate chapters: there's one on decline and how our teeth go down; there are others relating to medical factors; there are others relating to a whole range of things. And if you piece all those pieces together that affect older people, it's huge. But, all that information isn't in one place, so, going forward, we'd like to see better prioritisation and matrices so that dentists, through training and the rest, can understand the wider effects of the delays, and then that will help things in the much longer term.

Thank you. Heléna.

Thank you. Just one point, really, to add, which is to make sure that we remember the huge diversity of the older population. So, when we're talking about the older population, there's a range of different needs and circumstances. We haven't touched on specifically people living with dementia and their carers, but I think that's a particular group for whom it can be very difficult to access dentistry, and, sometimes, if you're living with dementia and you're finding communication more difficult, it can be more difficult to explain that you're in pain or that you're having a problem with your teeth, for example. So, I think, in the committee's work, looking at the needs of older people, it's just remembering that diversity of the population and thinking about unpaid carers as well, who often set aside their own health needs to look after their loved ones, but might be, therefore, particularly missing out on important issues around dental care.

In relation to the cost of living, it's just exacerbating the problems that we've already discussed. And, for older people, many of them are already going without food, they're already literally turning off their lights, literally turning off their fridges, so dental care falls very low down on their list of things that they can pay for. So, it is just further exacerbating an already very difficult situation.

And in terms of measures to improve this, I would agree with those that have been highlighted earlier, really. And I think information and communication is something that should be able to be improved relatively quickly, and then learning from the very positive practice that we've seen in terms of the Gwên am Byth programme in care homes, and looking at how we can roll out that sort of approach further afield. 

Thank you. Can I thank you all for your evidence this morning, and your written evidence as well? It's very much appreciated. We've had two very interesting sessions this morning at the start of this inquiry. So, if you do listen to the rest of the inquiry, and have time to do so, then please do feed in if you pick something up from others who give evidence. But we'll send you a copy of the transcript of proceedings as well, so please do review that and let us know if you want to add anything to what you said today. So, diolch yn fawr iawn. Thank you for being with us today. 

Thank you very much. 

We move to item 4, and there are just two papers to note today: correspondence between the committee and the Deputy Minister for Mental Health and Well-being in regard to mental health. So, are Members happy to note those papers? Thank you. 

We move to item 5, and I propose under Standing Order 17.42 that the committee resolves to exclude the public from the remainder of today's meeting. Are we content with that? Thank you. In that case, we go into private session.