National Assembly for Wales

Bore da. Croeso, pawb. Welcome to the Health and Social Care Committee meeting this morning. First of all, can I welcome Jane Dodds, who's attending this morning due to her interest in this subject area? Jane is attending under Standing Order 17.49. And with that, I move to item 1. There are no apologies this morning, and if there are any declarations of interest, please say now. No. That's great. And, of course, as always, the meeting is bilingual, so questions and answers can be in Cymraeg or English.

I move to item 2, and item 2 is our fifth oral evidence session to inform our inquiry into dentistry, and we have a panel this morning from the British Association of Dental Therapists. I'd like to warmly welcome our witnesses this morning and perhaps ask them to introduce themselves for the record.

Hi. My name's Fiona Sandom. I am a dental therapist, based up on Anglesey, and I am current chair of the British Association of Dental Therapists.

Diolch yn fawr. Thank you, both, for being with us this morning. If I could perhaps ask an opening question, perhaps to set the scene as well, I wonder if you can just provide us with a brief outline of the roles played by dental therapists, hygienists and dental nurses. That would help us set the scene for the session this morning, quite helpfully, I think.

We're grouped in a group called dental care professionals, and they include dental nurses, who generally assist the dentist, or the hygienist, or the therapist to undertake dental treatment. They can take on extended duties—supplying and administering fluoride varnish to teeth, they can take radiographs, and other things as well. So, there are a few additional duties they can do to extend their scope of practice and be used within a skill-mix team. Dental hygienists generally provide periodontal treatments—so, treatments for gum disease, looking at prevention—and they're able to take radiographs, diagnose and interpret within their scope of practice, so they can see patients directly, currently, in the private sector but not on the NHS. And dental therapists take on all the duties of a dental hygienist. However, they can restore both primary and secondary permanent teeth as long as that restoration doesn't involve the nerve of the tooth. They can take impressions, they can treat primary teeth, but they also can extract primary teeth and put on something called a stainless steel crown, which is a preformed metal crown that goes on the teeth. We can work in all sectors of dentistry—so, in NHS, private practice, community dental service, hospital dental services—providing a wide range of treatments.

Thank you. That's helpful at the beginning of the session, to set out the—. I didn't know the definitions between each, so that's really helpful. Thank you, Fiona. Right, the next set of questions, Rhun ap Iorwerth.

Yes, absolutely. So, I totally agree with Mari. There are a number of issues as well, as I see it. First of all, we only have one dental school in Wales, who train I think it's 17 dental therapists and 12 or 14 dental hygienists; we've got a new school up in Bangor that is training 12 dental hygienists a year. But the sorts of numbers we're talking about to be able to make a difference need to be much higher. That's the first thing. The second thing is there's a lot of confusion about NHS rules and regulations. Dentists, it's considered, are the only ones, at the moment, to be able to open a course of treatment, due to having a performer number. So, currently, we have to rely on a dentist seeing those patients and referring to us. There is an issue around local anaesthetics, but that is being addressed, and I think, probably by the end of next year, that will be sorted. However, there are a lot of barriers to be able to move forward within the NHS, within skill, to promote skill mix. There's a lot of work been done over the years, and we know that, of the NHS banding system, band 2s, which are three units of dental activity, a dental therapist could carry out 80 per cent of those treatments if they had access to be able to open a course of treatment and be able to supply and administer local anaesthetics. So, yes, as the British Association of Dental Therapists, as a dental therapist, we're very much for promoting skill mix and using skill mix; it's about changing the behaviours within practice and also making sure the barriers and mechanisms are there for that.

So, if you think about the way we've described dental therapists—. So, we would be able to examine, diagnose, treatment plan and deliver treatment for about 80 per cent of band 2 treatments. So, we're looking at being able to take care of your routine low-risk patients, your routine amber and red periodontal patients. We'd be able to look after most of your amber patients, and we'd be able to maintain people who have need, which would free up the dentist, who's the most expensive member of the team, to be able to do the more complex things that it takes five years to train to do, as opposed to three years to train to do. So, we could be able to deliver root canals, complex dentures, complex work, things that perhaps our older population may need, and we know there's an access issue for older people as well, and being—. Someone once told me that a civil engineer knows how to dig a hole but you never see them holding a shovel, and, in dentistry, that's exactly what we do. I don't know if that helps put it into some context.

So, NHS rules and regulations—there is some confusion, because, in England, they're undergoing system reform as well, and they're saying it's semantics and it's the way you read the regulations. But, over the years, we've been told that, in order to open a course of treatment, you need to have a performer number, and you can't have a performer number unless you've completed dental foundation training or completed, as an overseas dentist, something called PLVE, which is a performers list validation by experience, and only a doctor or a dentist can hold a performer number. Therefore, we are unable to hold a performer number, therefore we are unable to open a course of treatment.

The other thing around it, which I'm going to bring up now, because—. Dental hygienists and therapists are generally subcontractors to the dentist, who holds the contract. Therefore, we deliver and supply NHS treatment and contribute to that performer's, that dentist's, pension fund, maternity fund, anything like that, and yet, we, as self-employed subcontractors to the NHS, are not benefiting from any NHS benefits whatsoever. So, we're expected to provide our own pensions, our own sick pay insurance, maternity pay and things like that. So, there's a very big divide between dentist and hygienist and therapist in terms of working in the NHS, which can often mean that dental hygienists in particular will work in the private sector rather than go and work in NHS practice.

We've got some questions on that later.

Yes. It strikes me that—. My opening question was on how to make use of the full skills within a wider workforce and, if it's not a joined-up workforce, it's very difficult to make that happen, it strikes me, and maybe there are some recommendations that we could work on around that.

Yes. I think we've got some questions around that from other Members later in the session, Fiona, as well.

Okay, thank you.

Lovely, thank you, Chair. Diolch.

Thank you. Diolch yn fawr. Jane Dodds.

Yes. So, obviously, I totally agree with what Mari said. I think we can't really speak for dentists and the reasons that they don't want work in the NHS and why they choose to work in the private sector. I think, in terms of for myself, I work in an NHS practice that has a private practice. I prefer working in the NHS practice because I get to use all of my skills as a therapist. When I work in the private practice it's totally as a hygienist, but what I am in control of is that I am an autonomous practitioner. I am able to treat and screen and with those private patients do what's necessary, and not necessarily what the dentist has told me to do, because of that whole performers structure. I think, if you want to encourage dental therapists into the NHS and hygienists, obviously, there are more—. It's not about the money—that's not the bottom line—it's about working conditions. It's perhaps having some—. It's about, perhaps, being able to access NHS education. There's a lot of mandatory training out there that the NHS provides that we can't tap into and we have to go and seek it elsewhere. Sometimes we can get it free through Health Education and Improvement Wales, which is great, but, other times, if that doesn't fit in with your timetable, you might have to pay for it and things like that.

Access to so many NHS benefits—. An NHS e-mail would actually get us a blue light card, through which we could then get some NHS benefits, but we can't even get one of those. So, I think there's a lot of, I hear a lot of people saying, low-hanging fruit and quick wins. There are quite a lot of them in terms of enticing dental therapists into the workforce, and it's not about cold, hard cash. A lot of it is about perhaps other benefits.  

That's helpful, Fiona. You mentioned more low-hanging fruit. You've mentioned two items. Is there anything else you want to add to that list?

Oh, I don't know. 

That's fine. If you think of something later on in the session, then raise it. 

Yes, sure. 

Sorry, Jack wants to come in. Jack Sargeant. 

Yes. Thanks. Diolch, Cadeirydd. Just very quickly on the NHS e-mail, because we've heard this in the past from other questions, what is the problem with, or what is the barrier to you having an NHS e-mail? Or is it—

We're not NHS employees. 

Okay. So, that's the only barrier. 

Yes. As far as I'm aware, if you're not an employee of the NHS, then you can't have an NHS e-mail. And we're not, because we're subcontractors. 

Okay. That's useful to know. Thanks. 

Chair, can I—?

Joyce Watson. 

Good morning both. Just to explore, you've said you're—. We know you're self-employed—we've seen and heard that evidence a few times—if you work within NHS practices, because you're employed by the dentist. If you're in the private sector, does the same thing apply? I'm just trying to get my head around why it is, if you've got the same terms and conditions and the same status, that you can't get the training, and what the barriers are. And if I've mixed all that up, then you can put me right. 

Yes. So, basically, I've had a history of working in the community dental service up here in north Wales in private practice and then in general practice, so I understand how it works. If you work in the community dental service, you are paid by the NHS directly, and therefore you can use—it's called the electronic staff record—and you can access mandatory training on ESR, which is an e-learning platform, and all of that is available to you.

If you work in an NHS practice or a private practice, you are not considered a member of the NHS. In the NHS practice, you are a subcontractor to the dentist, and we are—. We generally don't work in one practice five days a week; we generally work in different places at different times of the week. So, we tend to be on either a day-rate model or an hourly rate, and holidays and things like that are not included, so we're seen as self-employed. And therefore, because we're not employed by the NHS in that practice, unlike practice nurses—. So, if you go into the medical model, it's a different funding model, and so an NHS medical practice nurse will be an NHS employee, whereas we don't have that status. And I don't know what it's to do with, but it's something to do with the different funding models and the way medicine is different from dentistry. 

Thank you. 

Thank you. Sarah Murphy. 

Thanks, Chair. Thank you both for being here today. Just to ask some questions then about the use of dental care professionals within service areas. So, in your opinion, are dental care professionals used more effectively in some dental service areas than others—so, for example, in the community dental service, compared to the general dental service? If I come to you first, Fiona, would that be okay?

Yes, sure. Dental nurses are utilised in all areas, in all service areas, because we can't work without a dental nurse. We need a chaperone, and a lot of the treatment we carry out requires a dental nurse. However, often a hygienist, if we're short-staffed, will be left without a nurse and carry on treatment by themselves just because of the nature of it. So, that's the first thing. 

I would say, in the community dental service, there is more potential to use skill mix because there are no barriers. So, to open a course of treatment in the community dental service, you don't need to have a performer number, because the funding mechanism is different to the funding mechanism for GDS. So, there is the opportunity. I know that dental therapists and hygienists are being used in the Gwên am Byth programme. We've been using dental nurses for a long time in the Designed to Smile programme, and there is a greater opportunity because there are fewer barriers. It depends how that clinical director and the service lead wants to develop it, but there is that opening up. 

In terms of NHS practice, the way the contract works now, it does very much promote the use of dental therapists, and I think, if we could get this barrier of direct access, or this performer number issue, sorted out, it would promote itself much better because of the way the metrics are and the key performance indicators. It does make it a much better way. That's all great, but even so, I'm not sure we have 200 therapists in Wales.

Right. Okay. Thank you very much. Mari, did you want to come in?

Thank you very much. And my second question. The British Association of Dental Therapists's written evidence says that there has been a change in the working patterns of dental hygienists and therapists, so more are working part time now. Could you give us some information on why this change has taken place, and what you think the impact of this has been, please? Shall I come to you first this time, Mari?

Thank you very much. Fiona.

I agree very much with what Mari says. If we're working as a therapist in NHS practice, our book is set out and there is very much a pressure. If you've put in two fillings and a scale and polish and some x-rays, that's what's done in that half an hour, and that is hard work. It's irreversible treatment, so we're cutting into tooth tissue and restoring teeth, so it is very much—. There's a lot of pressure on a dental—[Inaudible.] They say that dentistry is one of the most stressful things. Well, we're doing exactly the same, except like Mari says, we don't get the break of maybe doing an examination or a review appointment. We are expected to do what's in our book for those seven hours, which can be quite physical.

I think, as well, the pandemic didn't really help the situation, because we were shut down as hygienists and therapists. Being in a self-employed state, that was quite scary for a lot of us. We found different ways and different methods of working, and looked at different career options as well—not necessarily leaving dentistry altogether, but moving into other areas. So, there are a few reasons. And I suppose the other thing that we really must consider is that the workforce is mainly made up of women, so we naturally have career breaks to have children, and perhaps once having had children won't go back to working full time. So, you have that as another issue as well.

Thank you both very much. Thank you, Chair.

Jane.

Diolch, Mari. Fiona, just very quickly, a percentage. 

I think there are two problems. We're not back to normal because we've got a new way of working. We've got system reform, so our metrics are different. Every patient we see now hasn't seen a dentist for two years; they haven't had treatment. So, those people who probably were ticking along fine with their gums are probably needing a little bit more help, and for those people who may have fillings, some of them need repairing, or they've got new cavities. So, the people we see have more disease at the moment, and it's going to take us a couple of years to get that balance back. We've got a two-year backlog and a new way of working, so no, we're not back to normal. I know the metrics of seeing new patients and the recalls and everything else are helping to get there, but it's not dentistry that's at fault, I think it's the pandemic—we still have the remains of that that we're still trying to treat as well. 

The new ways of working would have been coming in any case, wouldn't they, regardless of the pandemic. Have I got that right? But, what you're saying, Fiona, to sum up, is that the response to this is that it's the catching up of those who haven't been seen for two years and the additional problems that are being created.

Yes. 

Thank you. Gareth Davies. 

Thank you very much, Chair, and good morning. I know we've covered quite a lot on the disparity between the private sector and NHS pay and conditions, but I just want to ask what each body could do better to bridge that gap and make terms and conditions better—whether that's on your end of the bargain, or whether that's on the NHS. How could both work better together in order to bridge some of these gaps?

Who would like to go on that? Fiona.

The difference between NHS and private practice, as a hygienist or a therapist, is the bottom line, the hourly rate. It's different, it's higher. And there are fewer of the NHS rules and regulations—well, there are no rules and regulations in terms of those in the NHS, so that makes it much easier. And then, in terms of the NHS, if we see a patient who has seen the dentist and it's been a while, and they've got another cavity, we will then have to go up and speak to the dentist to change that. So, it's frustrating working in the NHS as a dental therapist. Most of us want to do it, because it's the only place we get to use our full scope of practice, but the barriers are rules and regulations, human medicines regulations, and all of that, really. 

I think what I'm trying to get at, really, is to look at what each individual could do more—maybe have a bit more collaboration and working together in order that they can improve staff terms and conditions. Do you think that's something that's achievable, or is that a bit pie in the sky?

I don't mean to be disrespectful, but I don't think you quite understand the restrictions of the rules and regulations.

Okay.

Tell us. 

Okay. So, a patient comes in, they go for a check-up with the dentist, they say, 'Right, Fiona, can you do the periodontal treatment on this and these fillings that need doing?' And then I do that, and then I see that something else needs doing. I can't really change that treatment plan, because I'm working from the prescription of a dentist. Under the GDC rules and regulations, it says I can alter the direction but not the course of treatment. So I then need to go upstairs, or wherever, knock on the door and say, 'Excuse me, I've got local in this side, I need to do this filling for such and such, can I do it?' I'm disturbing the dentist, they don't like that, and that's actually a patient-safety issue, because there's evidence to say that if you disturb somebody when they're mid treatment, they're more likely to make a mistake. I then have to go back down to my patient and say, 'Right, we can do this now, thank you very much.' It doesn't look very professional, as a first thing, because I've got to work through those rules and regulations.

The second thing is that I'm now disturbed as well, so there's a patient risk there. I then also am probably running late now as well, so there's another pressure. And that is just not a nice way of working. Now, you could say, 'Well, you don't need to do that piece of treatment now. You could do it next time', but under the way the payment system works, it's not affordable for the practice for me to do that. So, I now have the stress of a patient, I have the stress of treatment, and I have the stress of running late, and I've also upset the dentist as well. That's not a great way of working. But if I'm in private practice and I see that, it's fine, because I'm working to my own treatment plan, to my own way, so I don't need to disturb the dentist, I don't need to stress myself out, I don't need to make myself run late, and I'm probably being paid a higher rate. Does that kind of explain it?

That's really, really helpful. And what can we do more to tempt dental therapists out of private practice into the NHS? What are job vacancies like? Do they get filled? Are there opportunities for people to go into the NHS from there if they aspire to or choose to take that career path, and, if not, what barriers are in place to stop them doing that?

You can find work as a dental—[Inaudible.] What dentists will do is they'll say, 'Come and join us as a dental therapist', and generally you'll work as a private hygienist. It's only in the NHS where they really want dental therapists because of the work we can do. I am asked often, 'Do I know of a therapist?, especially, as you know, in Anglesey, like in the south-west of Wales, it's really hard to recruit dentists. So, there are always ways of looking after people working. So, there's that. Dentists are quite keen up here to use therapists and to develop them, but you can't get hold of a dental therapist.

When somebody goes off to do hygiene or therapy from north Wales, they'll go to Manchester, Liverpool, Leeds, Cardiff, and then quite a lot of the time, they don't want to come back because they've spent three years in a new city—they love it, they've made friends, they've got digs and everything else. Trying to rent a house up here in north Wales, when you're newly qualified, is impossible. Whereas, I can stay in Liverpool, in my old Liverpool digs, and earn the same money or I have to try and rent a house here where everything is a holiday let. So, it's very difficult. One of the ideas with Bangor University setting up a hygiene programme there is that they will take local people to develop and create career pathways for, but a hygienist is not going to bridge the gap, because we've still got a lot of restorative treatment to do, so we do need more therapists and they need to be home grown. The only way you're going to get people to work in NHS practices is supply and demand. And by that I mean there are not enough dental therapists to be going everywhere, or otherwise we could pick and choose.

Thank you very much.

Jane.

Yes. Thanks, Mari. I think Mari makes a good point; we are used to travelling. If you live in a rural area, you're happy to get in your car, it's not a big deal. So, I think people don't mind travelling and we're very used to that. I mean, obviously, we've had situations in the past where people have had to travel from Anglesey to Dolgellau for dental treatment—that's not right. But generally, they're happy to travel.

A couple of things about mobile dentistry, because I've worked in them. Generally, in the summer, they're super hot. In the winter, your feet are freezing, because you've got air going underneath it; it's a truck or a trailer or whatever. It would work. I can see how it would work for schools. So, I know there's a large population between your 12 and 18-year-olds that don't really see the dentist as often as they should. And perhaps going into secondary schools, that would be a way of dealing with that, especially in your lower socioeconomic areas where we know that poorer people have more disease, and so, that would take away having to come out of school for those socially disadvantaged as well, so I can see how that would work. It would be a very expensive service; it's not the cheapest way of delivering dentistry, and you've got to have people working in them as well who want to work in them. I spent many years on Designed to Smile in there doing fissure sealants—I can't even remember when—in the early 2000s, and yes, we could see a lot of children, and it was a good way of doing it. Consent is an issue, because you have to get parental consent, and then it's a massive administration burden if the parent's not there. So, you've got the captive audience, and you don't get failure rates, but there is an additional administration burden, going from past experience. But I can see how it could work, and you could put places in rural areas. One place that springs to mind straightaway is somewhere like Bala. They haven't got a dentist; never had a dentist for years and years and years, and perhaps you could set up a mobile unit there.

But my argument would be: why don't you build a community dental clinic or a public dental service clinic there? And that's a permanent solution to the problem, as opposed to a temporary solution. In those rural areas, why don't we have salaried staff where it's difficult to recruit and retrain? And if you're working under the pressures of the NHS units-of-dental-activity treadmill system, have a salaried service in those really difficult areas to recruit people, but make sure that there's some kind of accountability, because I think salaried services are subject to abuse as well. I'm just going on now. Sorry.

Thanks, Fiona. Fiona, in response to Gareth Davies, you outlined the ways that you have to work within the NHS and you took us through that example, but what needs to change? How can you address the issues that you gave in the example?

Well, if I could see my patient directly, diagnose and examine the treatment plan within my scope of practice, carry out my treatment without the barriers of opening up an NHS course of treatment, without the barriers of local anaesthetic—that's a whole other issue with that, but I think that's being addressed—and I could do that, then I could close that course of treatment down and I could upward refer to the dentist if there was anything that I couldn't do to complete that course of treatment—so, if there was a permanent extraction or a root canal needed, or a new denture or a crown, I could then refer up. So, all of that work that would have been done by the dentist, I can do, and I'm autonomous and accountable for that treatment myself. It's working off a prescription and the GDC regulations that make that not possible.

And why can't that change happen?

Because I can't open an NHS course of treatment, so I can't see the patient directly.

And why is that?

Because I don't have a performer number, because I'm not a doctor or a dentist.

Right. So what—

It's the performers list regulations and the NHS rules and regulations.

So, would you say that those—? So, the performance—say that last bit again, sorry, Fiona. The performance number—

Yes. The performer—. Apparently, being on the performers list gives you the right to open a course of treatment, and your performer number identifies you for that course of treatment and puts everything onto Compass, which is the system that measures the dentist's contribution. So, currently, what we're doing is we're doing treatment under a dentist performer number, closing the course, and so we are therefore contributing to that dentist performance.

Right. So, how can that change?

Change the rules and regulations. Make us able to open a course of treatment.

Jane.

I'll take this. So, yes, you can, apparently. I spoke to the deputy chief dental officer about two or three weeks ago. He was asking BADT's opinion on direct access, and apparently, yes. There isn't anything particularly in the rules and regulations, and there's nothing particularly in the performers list regulations. It's a misunderstanding, but, generally, we've been told since 2006 that we can't open a course of treatment. Suddenly, it's changed, but when I spoke to Warren, he said that the biggest issue is around the BSA, which collects the data, and that can only—BSA is the business service authority, and they are the only people who can—they can only pay to a dentist or something. So, there is quite a lot of work being done around it, and it probably is something that will be addressed. It needs a change in legislation, I think, to make the profession, as therapists, happy, because if you can imagine that, for 16 years you've been told, 'You can't open a course of treatment because of this, because of that.' All of a sudden, now it becomes a popular thing to do, they're saying, 'The regulations don't mean that.' I can't find anywhere where it categorically says that we can do that, so I think there need to be some areas cleared up about the rules and regulations, some real guidance from either the chief dental officer, from Welsh Government, from whatever that, actually, we can do this.

And then the second thing is that you can't expect us to work under the NHS with more of a risk with direct access, because we will be autonomous practitioners, without any of the NHS benefits that are currently paid to the dentists. Now, I know what you're going to say to me, you're going to say to me, 'But that's going to cost us a lot of money.' My answer to you is, 'Actually, it will be cheaper, because you'll be paying us at our rate, rather than paying for the work that we do to a dentist.'

No, that's Warren Tolley, the deputy chief dental officer in Powys.

Jane and I know Warren as well, so there we are. That's helpful, and you've probably added to our questions for this afternoon's session with the Minister and the chief dental officer—so, thank you—in that particular section, Fiona. Right, Joyce Watson.

I just want to clarify, really. You've explained it, so we think we understand it now—I'll put it like that. Is there tension between the dentists and the therapists in terms of who gets paid for what? Because what you've explained, if I've understood it right, is it's paperwork. It would be more cost-effective to pay the therapist to do the work than the dentist, if I've understood it right. Therefore, I was wondering whether there is a tension, beyond the paperwork, that exists or could exist in the practice—I don't know the answer.

I don't know the answer either. I don't know that dentists would be very happy if you start paying us some of their pension that we've been earning for them over the years [Laughter.] Maybe. But, if it contributes to workforce and it contributes to patients being seen and it means that dentists can work more efficiently—so doing more of the more complex treatments, the tier 2 treatments—it's got to contribute to everybody's working practice and working life. 

Thank you. I just thought I'd raise it. I'm going to go on to recruitment now. We've heard a lot about recruitment already and we've heard that there is a lack of supply of dental care professionals. One of the questions is for me to ask you if you agree with that, but you've already made that perfectly clear. You talk about insufficient training and career development opportunities, how can we make a recommendation to the Minister on the way forward? What are the answers?

More dental therapy training places; taking those dental therapists from areas where there are dental population issues; perhaps changing the way that we deliver education just down in Cardiff and maybe look at satellite schools in Bangor and Aberystwyth—Bangor has already got the hygiene programme, maybe that could set up a school of therapy and also maybe work closely with Aberystwyth University. Bangor University has a blended learning and distance learning nursing programme, so they're already experienced in that, so there are ways of doing that. Those therapists could contribute to those populations while they're training, because obviously they need patients to see and treat. Then, in order to keep the therapists in the service, one of the biggest things is, over the past years, there's not really been—. The NHS contract really wasn't great pre what's been going on now for therapists. So, a lot of therapists couldn't get jobs, especially down in Cardiff where they trained, because they've got a whole dental school and they're chucking out therapists and hygienists, so there's more demand for jobs down there, or there's an oversupply of dental professionals. 

We run something in Health Education and Improvement Wales called the Wales dental therapist foundation training scheme, and I know that they're increasing their spaces to 20 this year. But, if we were to make it mandatory in Wales, if you wanted to work in the NHS and open a course of treatment—like it is for dentists; they have to do foundation training to get their performer number—three things would happen. First of all, you'd get therapists who work as therapists and they wouldn't de-skill in that very important first year. Secondly, you'd get therapists contributing to NHS dentistry, which they don't have to do right now; they train for free with their bursary and don't necessarily contribute back into the NHS practice. And thirdly, you'd get a very skilled team member, who, once they've spent probably a year back in their home town doing foundation training, they're more likely to stay.

Thank you.

Rhun.

Just a very quick question around the Dental Academy Bangor. I'm on the website trying to find a Welsh version here, but I can't—that's another point entirely. I campaigned for the medical school in Bangor that is coming. I am convinced that we need a dental school in Bangor as well, and they kind of go alongside each other. We haven't got enough capacity, as you say, in training dentists and all the other members of the dental workforce in Wales. Can you just confirm for us that the dental academy in Bangor, which is a privately run dental academy, does not do the same job as a dental school would? Because it's often batted off to me when I call for a dental school, 'Yes, we've got a dental academy'.

No. So, a bit of context for you. I was working in the All-Wales Faculty for Dental Care Professionals, which was commissioned to get the dental hygiene school at Bangor, and there is a hope to bring on a therapy school. Now, the academy is hopefully going to be placing the dental hygiene students there, and there is appetite to put, if we were to get a therapy course, dental therapy students there, which, obviously, will contribute to the population of Bangor receiving dental care. It isn't a dental school. The idea behind it is to help facilitate the hygiene training, have a community dental service and, on the middle floor, it's got an academy. The idea is to try and upskill local dentists to be able to do more complex treatments, to become 'dentists with a special interest' is the term—DwSIs. And so they would become more skilled, because they'd be able to do more complex endodontic treatment, more complex oral surgery, which would, again, stop having to refer to secondary care, which, obviously, is a much more expensive place to have treatment—so, being able to do it in primary care and upskilling our dental practitioners in the area. The other hope is that, when we get foundation training dentists in, it's seen as a good place to work, not only because of work-life balance, but also because you can have a career pathway as well. That's the basic ethos behind the academy, as well as, absolutely, delivering dental treatment and dental provision, but also to try and upskill NHS dentists.

And for the record, I welcome having ac academy; anything that can upskill the workforce is good. But you would welcome a recommendation, for example, from us to your push towards having a second dental school in Wales.

Absolutely. We've only got one dental school in the whole of Wales.

Yes, and we'll add pharmacy to that as well. We need these things, and building that around the new medical school in Bangor makes sense. Thank you.

Thank you. In your response to Joyce Watson about development opportunities, you didn't mention, but you mentioned it earlier, the NHS training hub that you haven't got access to. I forget what it's called.

ESR.

ASR. So, wouldn't that be—? Wouldn't you not add that to the list as well in terms of helping to improve training opportunities—access to the ASR?

ESR. It's electronic—

ESR.

ESR, yes.

ESR—that's it. It doesn't matter what it—. It's a training hub, anyway, isn't it, for NHS staff. My question was: wouldn't you, then, also want access for non-NHS staff to that training hub?

Yes, if we're contributing to NHS treatment. And it's the same for dental nurses as well—

You can't get that access at the moment, and if you had that access, that would help in terms of training and development. 

Yes.

Yes. Okay. Great, thank you, Fiona. Jane, did you want to come in at all on this point? No. Jack.

Diolch, Chair. In your opinion, do dental care professionals feel recognised for the work they're doing in dental care services? I want to try and get this, because we've heard a lot. Yes or no? I know that puts you on the spot, but we've heard a lot today.

I think you can't put us all into one category. So, dental nurses, I feel, probably don't feel very well respected at the moment. They were treated poorly during the pandemic. Hygienists and therapists, we just didn't work, but the nurses were there with the dentists, and their responsibilities were increased threefold, fourfold. They were wearing all the PPE. They didn't receive much recognition for the very hard work they did, and I think the dental nurse population has dwindled because of that, because they found it easier—and, actually, better pay, better conditions—working in Lidl. And I know this is brought up a lot of the time, but it's true. We've got dental nurses out there working for minimum wage. They're registered professionals with the General Dental Council, they have to pay their own indemnity, they have to make sure they keep up to date with their continuing professional development, and yet they're paid the same as somebody that—. And it's more favourable hours, and flexible working. Dental nurses in particular, I would say, probably not at the moment. Hygienists and therapists, we’re kind of a little bit—. You know, if we’re not happy, we move. If we’re not respected, we move.

Okay. And I could see Mari, I think, agreeing with the points being made there.

And you also mentioned earlier, Mari, you’d like more of a say in how you work. Is that correct?

Diolch, Mari. I think you both have made that point very clear, and it’s certainly something for the committee to look at and discuss at the end of this. Before I move to one final important question, Chair, I’ll perhaps put on record our thanks as a committee to dental nurses for all the work they did. I think it would perhaps be important for us to put on the record now.

It falls in line, actually—. You mentioned dental nurses, and all the trauma, let’s put it that way, that they went through during the pandemic. But overall in the dental care profession, and I want to look at the NHS here, do you think there’s enough attention to professional and staff well-being?

That’s a very good point, and I think that’s definitely something we’ll—. Essentially, e-mails are excellent, but if they’re not practical, then what’s the point?

Fiona, do you have anything to add on that point?

Yes, I do. I was in a meeting, and there was a request by a dentist for some protected time to do QI—quality improvement—and a big discussions about whether the health board could give them protected time, et cetera. And then we moved on to another subject, and it was about dental nurse training, and they welcomed the new dental nurse training at Llandrillo college, but really they felt that it was a really big disruption, because they were taking the nurses out of practice for the whole day, and it was much better for the practice if they did it at night. Why I tell you this is it’s a demonstration of the double standards. So, dentists being asked to do QI—quality improvement—they wanted protected time for it. Dental nurses going to earn a professional qualification, a registrable qualification, need to do that in their own time at night, after a busy day at practice. You can’t have that double standard, and what you do have right now is you have that double standard. You have dental care professionals that are expected to do everything in their own time, and dentists that are working in the NHS expect to have protected time to do anything they're asked to do. 

So, with everything that we've heard today from the whole session, do you think a recommendation to the Minister—obviously, we would have to discuss this as a committee—but do you think there'd be a need for a call from us as a committee for parity of esteem between dental care professionals and dentists, essentially? 

Absolutely, yes. That would be really welcome. 

I can't promise that, Chair. [Laughter.] It's up for discussion. 

Thank you, both. We've got our last evidence session at 1 o'clock today with the Minister and officials. Is there anything that you think that we should be questioning the Minister on that's not been drawn out through our questions today? Is there anything you want to add to anything you've said over the past hour that will help us? 

Because of the reform going on in England, as an association we created a SurveyMonkey. We then sent it to our members, but we also put it out to the wider hygiene and therapy population. There are about 6,000 hygienists and therapists in the whole of the UK. Some of those numbers are doubled because, like Mari and me, we're on the register for two things. We had 2,500 responses to this. Eighty two per cent of dental therapists want to work in the NHS, so it's not that we don't want to do this. This is something that we've been campaigning for for a very long time. We want to be able to use our full scope of practice and the skills we've trained quite hard to do. However, some kind of recognition of the fact that we are working within the NHS and contributing to the NHS would be welcomed by us as a profession, because currently it's almost seen like, 'Oh, let's just open it to therapists. They won't want anything extra'. And we don't want anything extra; we just want parity. 

Yes. Thank you. Thank you, Fiona. Mari, anything you want to add? 

Thank you, both. It's really helpful to highlight those points at the end of the session, and for the additional statistics as well from the survey of members, Fiona. So, diolch yn fawr iawn. Thank you very much for your time today, and, of course, by all means listen to the session with the Minister later, and if you think there's something that comes out of that session you think is helpful for us to know, then by all means drop us a note and add to anything you've said to us this morning following that later session today. But, diolch yn fawr iawn. Thank you very much to you both for being with us today. Fiona, it looks like you've got your hand up again, sorry. 

How is it possible for us to join the session later on? 

At the end of this session, if you stay on the call, then the clerks will point you to the live link on the Senedd website. Well, I can tell you now. You go on to the Senedd website. Google 'Senedd.tv Health and Social Care Committee', and there's a link there so that you can watch the session live, and you can also watch it back later in the day as well by going to Senedd.tv. 

Oh, okay. That's great. Thank you very much. 

Lovely, thank you. Diolch yn fawr iawn. Thank you, and we really appreciate your time this morning. 

Moving to item 3, and there's a number of papers to note, too many to go through, but there's correspondence with the Ministers with responsibility for health and social services regarding the provision of written evidence and the Welsh Government's draft budget. There are a couple of items of correspondence with the Chair of the Petitions Committee, who also sits on this committee as well. There's correspondence between the Royal College of Nursing and the Minister regarding strike action, and the Welsh Government and stakeholders regarding an NHS executive for Wales. Are we happy to note those papers? Joyce Watson.

Can I comment on one of them, the one from the Petitions Committee? My colleague is sitting next to me. They asked if we're going to do any further work on endometriosis, because I noticed that there's a petition there, we know about it. I'm assuming you expect an answer, since you've asked if we're going to do any further work. So, have we responded? I think we ought to do some work on it.

I think we have responded, but I think that will also be noted in our discussion on our forward work programme as well. Is there anything you want to add, Jack, as Chair?

Where we are as a Petitions Committee is that we probably have taken it as far as the Petitions Committee can go. The decision of the committee was to bring it specifically to health, to see, for that discussion in our forward work programme, and also make Members aware that there are a number of people from across Wales who would like us to do something on this petition.

We will have some discussion on this when we discuss our forward work programme, and then we can reply further to the Petitions Committee, following that. Thank you, Joyce. 

We'll now go into private session—I move to item 4. I propose, in accordance with Standing Order 17.42, to resolve to exclude the public for items 5 and 7. Are Members content? Lovely. And that means we go back into public session at 1 o'clock today, for our final session on our inquiry on dentistry, and that session is with the Minister. Diolch yn fawr iawn.

Welcome back to the Health and Social Care Committee this afternoon. I move to item 6, and this is our final oral session to inform our inquiry on dentistry. I'm very pleased that Eluned Morgan, the Minister for Health and Social Services, is with us this afternoon for this session. I wonder perhaps if the officials could introduce themselves.

Good afternoon, I'm Andrew Dickenson, chief dental officer.

Prynhawn da, I'm Alex Slade, I'm director of primary care and mental health.

Thank you, all, for being with us this afternoon. The first question is from Jane Dodds.

Diolch yn fawr iawn, Gadeirydd. I'll ask the question in English. We've heard a lot of evidence, and I think we're all quite aware, that in Wales we have a two-tier system of dentistry. Can you tell us how you feel about that, please?

I'll start. First of all, thanks, Jane, for everything you've done to really highlight this agenda, because you have really made sure that I have been focused on this. One of the great benefits of our political system is that you're in touch with the public, so you can kind of feel what the issues are that the public are concerned about. Certainly, when I came in as health Minister, the number of e-mails that I was getting in relation to dentistry was really high. When you're health Minister, you can't focus on everything, so dentistry was one of the things where I have really focused. I have monthly meetings with my team just to make sure that we are addressing the kind of issues that you're concerned about, and that potential for a two-tier system is obviously something that we're concerned about.

In a sense, we have a two-system model anyway, because there is private dentistry and there's public dentistry, so that kind of exists anyway. The key thing for me was that we have to increase access for people who certainly need urgent care and increase access for people who hadn't been to a dentist for a long time. That why I think, for me, that reform of the contract was absolutely key. Because what we've seen now, and I don't know if you've noticed this, but I'm getting far fewer e-mails about dentistry now and people getting access. I think that's partly because our contract reform is really starting to bite; 90,000 new people have already had access, and we're expecting that to go to about 120,000 [Correction: '112,000'], I think, as a direct result of that new contract. So, I think that goes some way to addressing that concern that we have in relation to the two-tier model that you talk about.

Can I just ask a follow-up, please, Chair? Thank you so much. Diolch yn fawr iawn. You did mention yesterday about the number of e-mails, and I did check with my staff and maybe others did as well. There is a sense that people might have given up because they are not getting dentistry. But, I would like to hear from everybody here. It is the case that, if you're rich and perhaps don't need the regular check-ups, you can afford to go to a dentist. Definitely. You can go tomorrow; you can go next week. If you don't have the funds, you have to wait. And therefore, the experience is for people that there is a two-tier system, and that trust and confidence in the NHS system of dentistry is not there. I know, as adults, we've had to pay something—that's definitely the case—but I would be interested in hearing how you feel about the situation where rich people can afford to pay and get treatment, and poor people can't. 

Let's just be clear that 352,000 people this year have received free treatment, and the costs, the charges, in Wales for those who don't receive free treatment are significantly lower than what you'd be charged in England. In Wales, for example, for band 1, you would be charged £14.70; in England, you'd be charged £23.80. So, it's a significant difference, and when there's a cost-of-living crisis, that makes a difference. We're all under massive, massive financial pressure at the moment, but that is something that, I think, we're really proud of—that we've held those prices down, those charges down, for a while. I don't know, Andrew, if you'd like to come in. 

Thank you, and thank you for that question. In terms of a two-tier system, I think it's more complex even than that, because access to dental care is related to how patients are either able to access or afford the system, but also whether they actually are able to get through the treatment. One of things that we've noticed that's been highlighted through COVID is there are a lot of very anxious patients, a lot of phobic patients, patients who rely very heavily on our community dental service for accessing their treatment. So, when we're talking about the access within the general dental service, there are other parts of the dentistry services that are offering care for patients who are finding it very difficult to access. So, it's not, in my mind, as simple as, 'They can't get access to a dentist', there are other very complex areas behind all of that. 

One more.

I'm going to very quickly come back to you. We know of many people who are waiting years, because they can't afford to pay for a private dentist, to get onto an NHS dentist list—two years, three years. I know we've had the COVID time, and we heard some evidence this morning about the effect that has had, but I'm interested more in how that feels. How does it sit with you that rich people can afford to go whenever they like, for whatever they like, for their teeth, and poor people, who perhaps are the ones who need it the most, are the ones simply who just have to wait for the hope that there is an NHS dentist in their area who will be able to take them on? I'll leave it there. But if you could just talk about how does that feel.

As a Government, we are committed to addressing inequality. The direction that we give to our officials is, 'That's where you need to focus.' So, your concerns are absolutely what our priorities are, and that's why you will have seen that change in the contract reform reflected in what we're expecting them to do. Alex, if you'd like to expand on that.

Thank you, Minister. Actually, the underpinnings of dental contract reform are around access, prevention and quality, and changing the volume of activity. There is a workforce aspect, which is part of the reform programme, indeed, which is around expanding that capacity so more people can see dentists and dental professionals, but, actually, changing the current levels of activity from pre pandemic into where we are now. As the Minister described, 90,000 new patients having appointments—that's a big step forward in making sure that some of the individuals that you're describing are getting access to the right professionals. And this is a year where we're embedding dental contract reform and learning from that and engaging with the profession, but, as the Minister described, we're seven months in and 90,000 new patients are having access. Our original target was 112,000, so we're ahead of our schedule on that, which is a good position to be, but there is more to do to make sure that we're making sure as many people as possible can access the right dentistry for the preventative reasons. 

Thank you. I just think of my own experience. I've got my first check-up next month. That's my first check-up since pre-pandemic times, but that's with a private dentist, because I'm not able to get on to an NHS waiting list, not in Powys. I'd have to travel an hour and a half in order to do that. So, I've got an appointment next month because I can afford an appointment. I think that's the point that Jane is making, and that's why, in my mind, we've got a two-tier system, and I appreciate that you're doing what you can to address that, but that is the position.

I think the other thing that's worth pointing out, Russell, is that, actually, the kind of habit that lots of people have got into, and not everyone, because some people never go to the dentist, but some people go to the dentist very regularly for these check-ups. And I hope you saw, over the summer, our chief dental officer pointing to NICE evidence that suggests that, actually, if you've got healthy teeth, you can go for two years without having a check-up. And, again, the contract reform work is about just making sure that we tailor the recommendations to the individual. Would you like to—.

I totally agree. I think that, when we look at it in the totality that we've had, with COVID—. We've had a contract that has been very difficult for the dental practices to work against since 2006; we're going through a reform programme, which is, again, something that is new for the practices to have to work with; and the fact that the volume of patients that they can currently put through because of the pandemic recovery—. The majority of the patients that they are preferencing at the current time are those high-needs patients, the patients who are wanting emergency appointments. They are taking more time than we've been used to in the past, and then, underpinning all of that is obviously the workforce and the changes within that workforce. 

Sure. Rhun. 

Very briefly, I certainly don't disagree with the recommendations made by the professionals about how often somebody can get away with a check-up, but do you realise how empty it sounds to people when you're saying 'Hey, you don't need an appointment every six months; every two years will do', when they can't get an appointment at all? 

I guess, if those people who are going every six months, release those appointments, that means there's more room for others. 

So, it's the fault of people going every six months?   

No, no, no. We're not—

That's how it sounds. That's the emptiness of what people are hearing. 

No. Listen, we wouldn't be saying this, unless there was clinical evidence to back this up. I'm not saying it in order to take pressure off anyone.  

I don't disagree with it at all. 

This is NICE clinical guidance. 

Yes, yes. Nobody's disagreeing with that; that's fine. It's the impact on the people. Well, that, has, in fact, no impact at all on people who are unable to have a dental appointment every six months, two years, 10 years, whatever. 

But we're going to address that through the 112,000 new appointments that have now been released.  

Okay. Unless any other officials want to come in on that, I'll go to my next question. Minister, what data does the Government hold on the number of people waiting to access an NHS dentist? 

So, I think data is an issue for us; I think we've got to acknowledge that. There is a discrepancy, perhaps, between practice waiting lists and the health board waiting lists; there's an issue in terms of validation; it could be that people are on multiple lists; it's not clear what they're waiting for, so there are lots of different treatments that they could be waiting for, and I think that we do recognise that there's an issue here. We are working towards a digital solution in relation to urgent cases, and working with the 111 service on that, but I have now asked officials to explore a digital solution that could provide an all-Wales centralised waiting list, but it's quite complicated and not straightforward. Andrew. 

It's not. At the current time, we have a single once-for-Wales referral system into the secondary or the community care system, but we don't have anything going in the opposite direction for emergency patients coming from 111 or from their access to the practices. So, we know that some practices hold their own waiting lists. There are some centrally-held waiting lists within the health boards, but, of course, some patients are sitting on both; some might be sitting on multiple dental practice lists. So, we are trying to look at what could become a unified once-for-Wales referral system, so that we could monitor and we could track the patients, because, at the current time, if somebody has managed to secure a dental slot, they may still be sitting on a waiting list that is very difficult to validate. On a once-for-Wales-only basis, we could be validating that on a regular basis, which would give a more true reflection and allow us to track patients.

The other point just to make on that is that, at the current time, dental practices don't record their patients based on their NHS number, so it is quite complicated to track the pathway of a patient, but that's gone into our reform discussions, about how we can start linking patients to their NHS number.

So, I appreciate your honest answer—that it's a problem for you, Minister. But, for me, you started the session by saying you've got a real focus on dentistry, but if we don't know what the need is, then how can you resolve the issues, and how can you have the focus if you don't know where the need is?

Well, this is part of why I'm focusing on it, to resolve those problems. Data is key to everything we do. We've got to get to a much more evidence-based approach. One of the things that I have insisted upon is that I've been much clearer in terms of my requirements of health boards, and, within chairs' objectives, I have now made it a measurable target for chairs. I don't think they've ever had measurable targets before—it was a bit of a shock to the system. But dentistry is one of the very few things that I'm saying, actually, apart from waiting lists and cancer and all the other things, is on that list. 

So, we agree—I think we all agree—that we have to understand the level of need, so when are we going to get to a point when you'll be able to tell us, 'This is the number of people waiting on an NHS waiting list in Wales'? When are we going to get to that point? How are we going to get to that point and when are we going to get to that point?

I think that's a really good question, because one of the other areas I really focus on is digital. I focus on that on a monthly basis as well, and we have got a huge amount of work going on in digital in relation to the NHS, and it is complex, it's difficult, there are real workforce issues in relation to digital. People are finding it really difficult to recruit the technicians. So, this is not a fast piece of work; that's what I would suggest.

I'd agree, and there are some technical elements in the background. At the current time, we have 14 different practice management pieces of software that practices use across Wales, and that's embedded within their own business structure. So, anything that we start to adjust is going to mean 14 different pieces of software need to be looked at and potentially adjusted.

But it's a basic question: at some point we need to know how many people are waiting to access dental services, so when are we going to get to that point, because surely that's absolutely crucial? When are we going to get to that point?

If you want a digital solution, that's not going to be anytime soon, I shouldn't think.

It's not me that wants that. I'm asking you as the Government, as the Minister—you need to know how many people are waiting for dental services. When are you going to be able to know that information?

Well, across the whole of Wales, I think we've got pictures, haven't we? We've got pictures of what's happening locally. What we don't have is the whole of Wales, and it's about the accuracy of the data that we have—it's the fact that they may be on multiple lists. That's what we're concerned about. 

If I could just add to that, we are at the present time trying to identify why people are on waiting lists. It's not just for emergency or urgent access; it is for routine. People are looking to restore a regular pattern, and it's teasing out who is sitting on those waiting lists at the current time, and that's where a single, once-for-Wales, run by the NHS, number will be easier to track. 

It has been suggested by other witnesses that we need a validated waiting list by health board area. So far, I'm not understanding how you're going to get to that position. Tell me specifically what the plan is for you to be able to find out how many people are waiting to access dental services in Wales. Talk us through that specific plan—how we get to that point. 

That's what I've asked officials to explore. 

So, can you tell us what it is, what you're doing?

There's a two-step process, Chair. The first is to have the digital system put in place, and, as Andrew described, that has to integrate with the current practice systems. There is definitely an appetite for moving from 14 to one, which will give us opportunities around integrating in-hours and out-of-hours, given the 111 relationship—so, some more transparency on availability. So, there's the tool in order to do that, and, as the Minister described, that will take time to scope, procure, pay for, et cetera.

The second part, and perhaps the more complex part, is the validation of those lists to identify where people have sat on a list for a couple of years and, like you described, Chair, taken an alternative option because you can choose to, because some people may have gone to urgent dental care and been treated in another way, but they wouldn't have been removed off the list. So, in many respects, the validation is the complicated part, that each health board will need to assess who is still on that list, just like many other waiting lists, to actually know that that's how we prioritise and—

But can you give us any idea about the timescales of that work, and when we will be able to know how many people are waiting for dental services in Wales. 

I think it's very difficult, Chair, to put a time frame on that in light of the budgetary position, because we don't know how much it will cost to put in place a digital solution. So, I'd be hesitant to put a time frame on that, but, as the Minister indicated, it is a priority to scope that at the moment, and we've been asked to. 

Okay, I could go on, but I've got two other people that want—. Jane, you want to come in. 

Thank you for the question. Specifically 'no', because, of course, we don't hold centralised waiting lists, but one point I would draw to your attention is, out of the 90,000 new appointments, 36,000 of those have been children who've been seen. So, as well as the wider programmes such as Designed to Smile, which obviously is focused at younger age groups, a lot of the new access that has been created through this work has been focused at children—actually, proportionately more children than adults if you look at the split of age groups. 

And a lot of the data that we work to is about completion of courses of treatment, and we get that data through the NHS Business Service Authority. And there's always a time lag throughout the financial year because they submit their claims when the treatments have been undertaken. So, it's very difficult to have a real-time estimate of how many children are going through the system, and, of course, that will impact on how many are waiting. But, in addition, there are other opportunities. So, again, there's the community dental service that picks up children who have special requirements and special needs, and we have the Designed to Smile programme, which, while it's not a full dental service, is supporting young children getting into a habit of lifetime dental support and dental care.  

Thank you. We've got a lot to get through, so I've just got another question on dealing with the backlog because we asked the panel this morning about whether they are still having the effects of the pandemic, and they are because they are now seeing people for the first time since before the pandemic. So, how are you supporting the dental services in clearing that backlog that there currently is within the dental services? 

Well, you know we did put some investment in to make it easier and better, and more protection for people in practices to protect themselves from COVID. You've got to remember that COVID is still with us, and this is an aerosol-generating activity that we're engaged with. That hasn't gone away, so we have to put those protection measures in place. 

I think, specifically, it's not about—. I appreciate that, but I'm specifically asking about the backlog and helping to reduce that backlog. 

Sure. 

And this is where within the contract variation for this current reform system, we've asked the dental practices to look at their patients on a needs and a risk-based process. So, what we are noticing is that they are ensuring that patients who are high needs, high risk or urgent patients are getting that—

Are seen first, yes. So, the question that follows from that, I suppose, is that those who are not high risk perhaps then are being pushed further down the list, and then building up problems that could be presented in future years. Is that something that's recognised?

Well, in the same way as people on general health waiting lists, we have to take the urgent cases first, and the less urgent cases, yes, go on the waiting list—that's evident.

Okay. Thank you. Gareth Davies.

Thank you very much, Chair, and good afternoon. I want to talk about the operation of dental services and ask how you're ensuring that the pressures within dental services in general do not impact negatively on other dental services. An example of that could be the community dental services being used to relieve access in other areas. So, what's your plan in that regard?

So, community dental services, obviously, is a salaried model and provides access to people who are unable, generally, to get general dental services—so people perhaps with special needs or mental health problems, physical disability, long-stay care residents, vulnerable groups, and, obviously, emergency dental care as well. So, those are the areas that are prioritised, and, obviously, if you prioritise those, you're deprioritising something else. Andrew, do you want to—.

Yes. And the community dental service offers a parallel career compared to the GDS system. And when we were talking about workforce issues, there are a lot of dentists, particularly in the early stages of their career, who are now looking at the community dental service as a career option. And so, we are using the Welsh health circular for the community service to support that expansion of the community, so that they can recruit more staff. They are already looking at recruiting specialist services into the community—so, it's the midway between the primary and the secondary care services, and, again, that will take the pressure off the secondary care. But we're aware that the community dental services provide a very active role within Wales, not just caring for the vulnerable, but also those high-needs patients, they run some of our emergency service, as well as the epidemiological surveys, and Designed to Smile, Gwên am Byth, which are very active programmes that we're trying to restore. And so, therefore, the community are looking at how they ensure that any changes that are happening in GDS don't impact. And I think we're probably going to be seeing over the next few years a blurring of the boundaries between primary care and the community services, because there are transferrable skills that can move both ways.

Thanks. And in that sense, then, are you putting frameworks in place to stop the potential impact on vulnerable groups, so that they are indeed protected and we can still ensure that elderly and vulnerable people in society can still feel confident that they do have a dental service in place, despite some of the problems in the other sectors in primary and secondary dental care?

Correct. And that's why the Welsh health circular has been amended to give that direction towards health boards to support the community service, particularly with all the groups that you've just mentioned, which, of course, then takes some of the pressure off primary care, because they won't be seeing all of that high-demand patient coming through, because they can be seen in the community service.

Okay. Thank you. In written evidence from the Welsh Government, it states that the ambition of the reform programme is to align dentistry with the accelerated cluster development system. Could you provide a little bit more information on this, and how the Welsh Government is encouraging integrated working within the dental services?

Yes. So, we've got two committees that are working jointly on population-needs-driven care. So, Alex, if you'd like to expand on that a little bit.

Thank you, Minister. So, as the Minister described, the Welsh dental committee and the Welsh medical committee are working jointly around population-needs-driven care, to join up some of the thinking in that arena, which is very encouraging. In terms of the accelerated cluster development programme, which is the primary care component around place-based care, that's a programme operating with real pace and momentum. Each contractor area across primary care is at a different stage in terms of its progress, for the right reasons, and the position for dentistry is that health boards are expected to set up professional dental collaboratives by the end of this financial year to set out the groupings of how dental practices will come together to work on various needs. So, some are already in place. Cardiff and Vale have established their dental collaboratives, and Swansea Bay University Health Board have their dental collaborative, bringing together GDS and CDS to look at the urgent care needs for their dental population. 

In terms of the support that's required, we're very mindful that dentists need the time in order to think differently in terms of their patient group, lifting that up to the cluster footprints, which are between about 50,000 and 125,000 people, and that exposes different trends, different patterns in terms of the dental needs and wider needs, which is part of the accelerated cluster development programme. So, we are looking at what support is required to embed that, what we do around the metrics, within the contract, to promote that engagement and create that time for dental professionals to be working together. And, actually, this is something that was positive out of the pandemic for dentistry, as has been noted. Dentistry was one of the most difficult services to run during the pandemic, but, actually, the working together at scale to meet the urgent needs of the population was a really good move forward and something that we're looking to retain as part of the accelerated cluster development programme.

Gareth, sorry, do you mind if I bring—? Do you want to come in now? And I'll come back to you—is that all right, Gareth?

Yes, sure.

Jack.

Thank you, Chair. Just looking at emergency dentist appointments, and, as an example, out-of-hours appointments where the patient is really in significant pain. I think we've all had toothache in the past, but we're talking really significant pain. The example that I've been made aware of—as Jane's rightly said, we've all had this in our in-boxes, and the Minister has as well—over the weekend, and take, for example, in my constituency, in Deeside somewhere, you might phone for an emergency appointment, you've reached that limit where you cannot carry on and wait to hopefully get an appointment as soon as possible. You might end up Dolgellau, if you're lucky. Now, I'm sure everyone will agree that's a lovely drive, but not when you've got significant pain and discomfort there. Minister, you've said today—and we've had plenty of conversations, both in the Chamber and outside the Chamber—that dentistry is one of your top priorities in your role as Minister. Are you looking at emergency services and dental treatment as well as the waiting lists, and I'm sure the other stuff that we'll cover today? And if you are, can you share with us what those plans are and what you expect your officials to scope out?

Absolutely. So, emergency dental care is crucial, and that was never switched off during the pandemic. And it's really important that we underline that—that was always available. Would you mind expanding on that?

Of course. Certainly. This is going back to the first question about a centralised waiting list, and the work that we're doing within the reform is looking at separating out the emergency from those who want an urgent or a routine appointment, and I think that would make—. There's that differentiation, but, at the current time, there is no clear definition of what an emergency, urgent or routine actually means, and that applies to the whole of the UK. And it's a personal issue, as you say. If you're the person experiencing that pain, it's very personal to you at the time. But, at the current time, what we are trying to do is to work with the health boards to look at what they have in terms of that emergency system. Each of the seven health boards does have a process in place that would allow contact for the patient: triage, advice and then onward referral.

Thanks for that. I suppose there are two—. I don't want to go down the digital route, because I think we've spent probably quite a lot of time on that already. Well, there are two things there, I suppose: (1) is there enough capacity in the system to support what you're trying to achieve, then, at the moment? I mean, Deeside to Dolgellau—again, a lovely drive, not ideal when you've got toothache or severe pain on a weekend. And then I suppose, secondly, there's no definition of emergency care throughout the UK. Will there be one in Wales, because we can do that, so are you looking at promoting and—?

Yes. Thank you. So, without being too technical on the answer, if we can develop that digital system so that patients can be linked to practices, within the metrics that we are offering to the GDS for 2023-24 is going to incentivise and provide opportunity to see urgent cases. At the current time, we're asking practices to see new and their historic patients. We're changing that so that we are asking them to see more of the urgent and emergency patients. That will give us a more informed idea of how many people are actually looking for that particular service, and we're tentatively looking at where good practice is within practices that are currently using the 'attend anywhere' software, because they find that making that contact and performing a face-to-face over a video link, triaging with the patient, is answering some of the enquiries that are coming in from the patients, and it's also giving them a more informed assessment of the patient when they arrive. 

So, just to go back to the—. Will there be a definition for emergency, of what that looks like? 

So, we already—

Because there isn't in the UK, but we—

There isn't in the UK. We have something on each of the health boards' websites currently, which is the first attempt to try and define what an urgent emergency case is, but I think it links back to the triaging. Just to pick up on my earlier point, if I may, about access, a lot of patients are highly anxious, and this is one of the many reasons why sometimes they present quite late and they've already got an emergency that needs to be addressed. We hear from dental practices that, if they could have the opportunity to triage the patients before they arrive, they'd be better prepared for the more anxious patients, give them more space, give them more time allocated, or maybe even an onward referral into the community service, and that would then mean that the patients will get the quality of the care that they want—not just an appointment to see a dentist, but actually getting that treatment performed. So, we will get that information once we know that the practices are able to see and deliver definitive treatment at that first appointment. 

That's all really welcome, but I'd just take a step back to the—. For example, if I was the patient, or one of us was the patient, the digital solution, whether it's great or not, and hopefully we'll get to the point where that's good and preventing—. But, if you're at that position at that time where you are in severe pain, a digital solution, however good it is, you've still got to go to Dolgellau. That's not the solution they're looking for, is it? So, does it need to increase in—?

So, the point, I think, that Andrew was making was that, at the moment, the contract, that is, the way that we pay dentists from the public purse in Wales, is dependent—. The way we've negotiated that contract means that at the moment we're saying, 'The priority for you at the moment is new patients', okay. In future, we'll negotiate a different contract that will say 'urgent', okay. So, that's where we're heading next, and I think that's certainly something—

So, that might—. That might deal with the issue.

Would deal with your issue. So, at the moment, we're on the 112,000—that's what we're focusing on. Every time—. We'll have to keep the pressure up on that as well, but that's the negotiation, isn't it, that we'll have to get into.

Just one final point, Chair—

We've really got more questions that we can actually get through at the moment, and I want to get through everything. So, ask a question, but a brief question and the briefest answers, if possible.

Yes, really brief question. Maybe I should know this, and I apologise if I should, but that renegotiation of the contract, when will that be?

Briefly.

So, we're in a two-year position where we're embedding dental contract reform. However, we do pick up annual negotiations. So, what I would say to answer that is 'two years', but we need to start teasing that out with the BDA, as the professional body for that.

Okay. Yes, great. Thank you. Diolch.

Thank you, Jack. Gareth Davies.

Thanks. I'll be as quick as I can. It's been suggested to the committee in evidence that dentistry services should be needs-led. So, how will the dental reform programme that I mentioned earlier create a needs-led service and will dental practices be incentivised and rewarded in pay for treating high-needs patients? 

Okay. So, I think it's important to say it's not just needs, it's needs and risk. So, that's a really important distinction there. Under the reform programme, there's modelling to determine funding allocation for specific groups of treatment. So, I don't know if the chief dental officer can give a bit more detail.

Within the new contract, we are looking to drive a more prevention approach rather than a treatment approach, which is the restriction of the current 2006 UDA contract. And because the current contract is activity driven, it means things have got to be done to patients, and it doesn't incentivise prevention. So, we are working with the practices, using a grading system called the assessment of clinical oral risks and needs, which I believe has been discussed at previous evidence, to allow the practices to full understand their patients, the patients' needs, and give them a personalised care plan. This hasn't been possible through the 2006 contract. So, you are quite correct, within the negotiation of the new contract, we're looking at the modelling of the activity as it currently stands and where the barriers are for people to receive their treatment—and, as you already raised, that's the high-needs patients—and, therefore, ensure that we're able to address those concerns by making the contract to allow the practitioner that autonomy to deal with the high-needs patient, whereas, at the current time, they're constrained by the financial boundaries that the UDA has in place.

Thank you, Andrew. Sarah Murphy.

Thank you, Chair. Thank you for being here today. So, coming back, we talked a little bit about data earlier on, about the data on patients, but what data does the Welsh Government hold on the dental workforce, including whole-time equivalents and demographics of dentists to establish if the capacity of the dental workforce is appropriate to the level of need and to plan services effectively? And if I can also just tag on to that as well, as we're short on time, how are you then, as well, developing the skill mix within the dental teams and recognising and rewarding the contribution of all dental care professionals?

Okay, thanks. Well, first of all, I think we've got to remember that, many dental practices, they're independent businesses and so we don't hold the aggregated data on them because they don't work for us. But what we've got, in terms of the—. We have a national workforce reporting system that is in progress, and what we'll be doing is we're going to be recording all the dental members of the team. So, you'll have heard us say time and time and time again in the Chamber that it's not just about dentists, it's about the whole team. So, it's really important that, if we're going to develop that, we're developing it, and that will be ready by the summer of next year. So, that's in progress at the moment. And on top of that, HEIW are developing a dental workforce strategy. So, hopefully, we'll know where we are, but we do have quite robust data even now on the trainee workforce, so we're focused on that. Is there anything you'd like to add?

No. It is very important for us to understand what the whole-time equivalent is and that is the model of a contracted profession, that there is a mix between NHS and private, and the vast majority of our practices are mixed—there aren't that many that are purely private and there aren't that many that are purely NHS. So, understanding the whole-time equivalents within the practice, that will then allow us to discuss more about that skill mix, how can we use HEIW, who already have a plan for developing the dental hygienists and therapists, and will give them that opportunity to use scope of practice.

Do you mind, Sarah, if I just come in? What's the timescale on the dental strategy, please?

On the workforce strategy?

Yes, the workforce dental strategy.

The dental workforce strategy.

So, HEIW are working on the details of that with the data they've got. Part of this challenge is that having concrete data helps us with that workforce planning, so, because there's no data held on working-time equivalents, and Andrew's point around the private-public split, it makes it difficult. But what we're looking at is a number of other workforce strategies across primary care to look at this in the round, as well as where are professionals fall into different categories. One of the typical examples that I use is around pharmacists actually working in general medical services, which is starting to blur those boundaries. So, we're not looking in isolation, but HEIW are working that up to give to us. Clearly, there would be a cost point around how we go about affording that, but we'd expect to receive that [Correction: 'a draft workforce plan'] before Christmas.

Okay, thank you.

Okay, thank you. Sorry, Sarah.

No, that's good, because it come on to just my second question then. So, the committee has heard concerns regarding the morale and mental health of the dental workforce, with the mental health of the teams within the general dental service described as being 'in crisis'. And on top of that, there are a lot of questions around what action Welsh Government is taking to recruit and retain dentists, and how it is taking into account the aspirations of dentists, such as the work-life balance, which obviously impacts mental health, and a mix of the roles and development opportunities. And I suppose what we're looking for here is: right now—they're in crisis right now. 

Well, they have access, obviously, through our Canopi programme, and the GP system, so they do have that access. And, also, there are various helplines that professional bodies also have, through the GDC and defence organisations, and the British Denial Association Benevolent Fund—they're a charity. So, there is actually quite a lot of support. I guess part of the challenge is making sure that they know and they are signposted to that support. 

Yes, but the fact that they need mental health support because of their job is different to needing mental health support because maybe you're having a tough time. To say that that's the response—

Well, hang on, we're putting £1 million into this. In a sense, it's the same issue for the broader NHS. We have put £1 million into making sure that they are getting the mental health support, specifically because they're in a practice that is impacting them because of the stress levels linked to their job. 

Yes. I suppose the question then is: what is being done to help make their job more manageable and more pleasant, something that they enjoy going into every day, because that's not what they're telling us? So, instead of putting the mental health support there, what's being done to make the job itself more bearable, more enjoyable so that they don't need the mental health support?

Yes. I'm going to ask Alex to come in. 

Andrew may come in after I've commented, but, actually, some of the way in which the dental reform work is being achieved is about engagement with the profession—there's been an enormous amount of engagement, which has been really pleasing to see—and actually taking on board their feedback. And one of the points that comes out there is moving away from a sort of treadmill of activity—that we're just counting as many times as they can do something—to a more valued job where they have conversations with patients about their risks, their needs and they're giving patients advice and patients were satisfied rather than a tick list. And so, changing the way in which their job operates to move it away from that sort of stressful, volume-based activity. But, as I said, Andrew may wish to add to that. 

Yes, thank you. As CDO, this is something that really worries me about the health of our workforce, and I've spent a lot of time looking at this and looking at the underpinning research on this. And, quite interestingly, there have been a lot of publications over the last decade on this, and I fully appreciate that COVID has magnified, now, this situation. But it was alive, and a worry, pre pandemic. And a lot of the research is saying that there are three elements to it: there is the actual productivity, so the volume of work that Alex has mentioned; there are patient factors as well, because it is a very demanding and complex system for dentists to work in; and then there are regulatory stress sources as well. And I think what is interesting is that, when we look at why practitioners move out of the NHS into the private sector, there is a series of factors, most of which are around quality of professional life, which we've taken and we've built those into the contract reform. But, as you say, it's the here and now, at a time when everybody is working extremely flat out. Our practitioners have done that all the way through COVID, and they're still doing it. And that's why we want to take the reform programme into those final stages, to give them that support. 

Thank you. 

Thank you, Chair. 

Thank you, Sarah. Jane Dodds. 

Thank you. We heard some very powerful evidence this morning from dental therapists and dental hygienists and the union representing them. I think it surprised us all, really, around the restrictions and challenges for dental therapists in particular, working both within the NHS and private dental practices, about what they could and couldn't do. We may or may not have this right or wrong, but I think what we understood is that having the performer number means that they cannot start or even complete a treatment pathway. They also, surprisingly, have no access to an NHS e-mail—that's what they reported. And their working conditions; I appreciate that dentists have challenges, but they are on their feet all day, and they don't seem to have any opportunity to sit down and reflect on what's in front of them. And some of them were being asked to do training in their own time in the evenings. Could you, please, because this could be an opportunity for us to really plug in some of those gaps, since, as we understand it, they can do everything that doesn't touch a nerve—why is it that they can't have a performer number?

It may be a good reason, but explain it to us.

Yes, well, this is something I've been asking my officials as well, so—

And it's a very live conversation at the current time. All of the dental team have a vital role to play in patient care, but the therapists, because of their scope of practice and the skill set that they bring into the dental environment, will not only support the dentist being able to deliver some of the more complex dentistry, but it will also be very good for patients, so—

So, why is it? Can you just—? We haven't got much time, so what's the reason why they can't have a performer number?

It's written into the NHS regulations.

So, can we change it?

Yes.

Yes, that's what I've asked them to—

That is part of the reform.

Brilliant. Result. So, when will that happen in Wales?

That was a question I asked a couple of weeks ago, wasn't it? Come on.

So, it does need regulation change. The way in which contract reform is working is it's done within flexibilities of current legislation, so we need to make wider changes to the dental regulations, and as part of that, we will sweep up this issue around removing those barriers that you heard about this morning, to pick that up. So, as I said, we're in year 1. We want year 2 to embed that, but we're starting to work with lawyers on the legislative changes now.

So, when-ish? Within a year?

So, where are we—2022? So, 2024-25 would be the first year in which we see the new legislation being effective, so clearly, we need to bring that forward in order to go through the process of that and engagement, et cetera. But that is the time at which the dental contract reform will have changed.

The other point that you picked up is that there were employment issues in some of your comments. Changing the legislation doesn't unlock that. There is work around training the right number of wider dental professionals, which takes time to lead in. So, the legislation is, yes, unlocking part, but it doesn't, tomorrow, change the wider position, so we've got lots in train in that space.

They described this as 'low-hanging fruit'. You know, an NHS e-mail, can they have one? That's one. Two, can they have access to training in the NHS? What are the things that we can work on that are short term, that give some hope for people who are trying to access NHS dentistry? We thought this was one of them. So, we're really keen to see what can happen to really effect this, please.

Just very quickly. So, NHS e-mail—my predecessor put in nearly £90,000 so that all the dental practices had access to NHS e-mail, but, of course, you have got to be somebody who is providing NHS care, you've got to be the contract holder for that. We have had those discussions, but it having been raised again, I will take those away to look at.

Low-hanging fruit—we are and we do utilise the therapists within the community dental service. They are a very important part of the community dental service, in which, similar to private dentistry, they don't have the same restrictions because of the NHS regulations, and that's where there is a disparity. We are already utilising them within the community dental service and encouraging them.

Talking about education, HEIW has set up a foundation therapy programme, so when they come out of their degree, they get a one-year supported programme. At the current time, it's within primary care, but we're looking, for next year's cohort coming out, as to whether we can cross over and they spend some of the time in community and some of it in primary care, so that they develop that skill set, which is the educational ask that you've mentioned.

The issue around the NHS e-mail was in relation to being able to access the NHS training hub. I've forgotten the name, sorry, but that was the—

ERS.

Yes, it was three digits.

ERS.

ERS. So, is it possible for those working in the dental service to access the ERS without having an NHS e-mail? What are the obstacles around that?

Not to my knowledge. I'm not 100 per cent on that, but not to my knowledge. I think it's one that we can take away to understand. As Andrew described the cost to provide NHS e-mails to dentists, we'd have a look at the cost to provide it for the wider dental team and what that unlocks for them. This, as you describe, may be a low-hanging fruit if it is just an e-mail address, but it does come with a small—I appreciate—cost.

Is there any other reason or objection to those that might not be working directly for the NHS to be able to access the ERS system for training purposes? 

Unless it offsets capacity for other health professionals, but to my knowledge it's not a concern. We'll have to look at it. 

No, and what I'm keen to do, if we're training people up, I want them to be working for the NHS. I don't want to be training people up and then they go off to the private sector. So, we've got to just be careful in terms of conditionality. If you're investing in someone—I've laboured this point with people over and over again: if I'm paying, I want something in return for the public of Wales, thank you very much. 

Yes, and I agree with that point and understand it, but it could also help to alleviate pressure as well.

Sure. 

There are two angles to it. Absolutely. 

Yes.

It may be my ignorance. I wonder if they're talking about ESR, the electronic staff record, rather than ERS.

It could have been.

That can be looked at. The other is something called e-Learning for Healthcare, ELFH, which is a resource that all dental teams are able to access. It used to have a requirement that you should input your NHS number so that you can get a validated certificate, which is required by the General Dental Council for continuing professional development, but that was removed just as we went into the pandemic so that everybody can access that with a private e-mail address. 

You're surely right; we're getting all our letters mixed up, but we know what we mean, I think. 

Too many acronyms, I think, going on here. 

Rhun ap Iorwerth.

Is there anything—?

I suppose the point to add to that is the work that Healthcare  Education and Improvement Wales are doing, which we've described. We'd want to take that to look at whether the current capacity is fit for what that modelling and projection suggest, to then make an informed decision both about where and the volume that we would need. 

Lovely. Thank you. We know that we have a capacity issue with staff; we need to train more, we need to create the capacity to train more. 

Would you like to expand on that, Andrew, or is that—?

Yes, thank you. Yes, I totally agree with that and, as I mentioned earlier, one of the major priorities for the CDS is to support the vulnerable groups, and that includes those who are hard to reach. And I think, with the ongoing expansion that we've asked for within the Welsh health circular, we'll start to address some of those issues.

Rhun, I think Joyce has got some questions around that area.

Yes, of course.

Have you got any further questions?

No, that's okay.

Do you want to come in now, Joyce?

Yes. Designed to Smile, obviously, was closed down through the pandemic—schools were closed—and we have to now restart it, and, of course, we now have two years of children who didn't take part in it at all. And so, if we're looking at gains for potentially some of the most disadvantaged, this has been a success story in terms of those gains. So, do we know when we're going to restart it? Have we restarted it and how is that going? And we've heard evidence saying that, whilst it's good where it's in operation, there's the eight-to-11 age group as well, and of course, some of these will have transitioned into those groups because they missed those two years.

I think it's really important that, first of all, we make sure you're aware that the distribution of toothbrushing home packs continued throughout the pandemic. So, those were still available to people. What happened, of course, is that we didn't have the opportunities to do the kind of staff training and the updating of protocols and resources. So, that's been one of the challenges. So, we never switched it off as such. It’s just trying to get people to re-engage after quite a difficult period. That’s been hard for us. But can I ask Andrew to—?

Yes, certainly. In answer to your question, it has restarted, but it's very slow, and again there are complex reasons behind it. A lot of the staff moved on to vaccination programmes and supporting other COVID responses, and some of those have moved into different careers now, and we’re having to slowly bring the staff back into the programme. We’re rebuilding the confidence with the schools, because they’ve had significant disruption, particularly on education, so this year has been a very gradual reintroduction but, again, the community dental service are prioritising that as a function. As the Minister said, we kept the toothbrushing packs being sent out, and, with the current cost-of-living crisis, that is being maintained.

And just the question around the eight to 11-year-olds, the underlying principle of Designed to Smile is to socialise a behaviour change. And you’re absolutely correct, we’re not reaching out to every child under the age of seven, but we are hoping—and there is evidence emerging—that, because they’re getting the benefits of the Designed to Smile programme, the supervised toothbrushing with fluoride toothpaste, and the signposting—if they have dental needs, they’re being signposted to a dental facility—that that will socialise their behaviour as they start to progress through the senior years of their junior education.

But we do have, two years later, eight-year-olds who were six and haven’t had the benefit of that. And I know that budgets are extremely tight and about to get tighter, but is there any opportunity along the way to capture just that particular eight-year-old?

Just to pick up on the other discussions, at the current time, the workforce is fully engaged, so we would need to be expanding the workforce if we were to expand that programme, but, at the present time, they are heavily engaged in the restoration of services. So, that would be an aspiration, rather than something that would fit the reform programme at the current time.

Okay, and then just finally from me, then, can we be assured, then, because you’ve said that the 'toothbrush in the post', I suppose I should call it, because I can’t remember what you called it, has happened? So, that age group would have received that, anyway.

Yes. It carried on throughout the pandemic.

That's great. Lovely, thank you.

Do you want to—?

Yes, one more question on the preventative. I was brought up on Ynys Môn in the late 1970s and 1980s, and the chief dental officer will no doubt know the significance of that in that these teeth of mine were looked after by fluoridated water. I know it works. You all know it works. Are you ready to take on that challenge of trying to win the support needed to implement fluoridation in Wales?

Nice easy question for you.

Oh, my gosh. [Laughter.] Well, my first answer is that this is a problem for Julie James. So, it's a public health [Correction: 'water policy'] responsibility and the policy sits with the climate change Minister. So, it's got to be seen—

Surely it's both of you.

Yes.

I'm not taking that brushing off.

No, no, no, don't worry, I was going to go further.

I suppose that the question could be directed at the chief dental officer, I suppose.

No, it's the—. No—

All right, we'll stick to the Minister. We'll stick to the Minister.

The chief dental officer will tell me no doubt that he believes that it is a very effective prevention measure. The question, then, is: politically, are you willing to take on the challenge?

Look, one of the things that we think is important, one of the things that’s happening at the moment and part of the contract reform is the fluoridation—. What’s it called?