National Assembly for Wales

Croeso, pawb. Prynhawn da. Welcome to the Health and Social Care Committee this morning. This meeting is bilingual, so witnesses and Members are able to speak in Welsh or English. I don't know if we have done checks with headsets. We might just want to do that, perhaps, right at the beginning of the meeting. Can Members hear? Thank you. Diolch yn fawr.

In that case, I move to item 1, and we have no apologies this morning. And if there are any declarations of interest, please do say now. No.

In that case, I move to item 2, which is our third oral evidence session to inform our inquiry into dentistry, and I'd like to welcome our panel with us this morning, and perhaps you could introduce yourselves for the public record.

My name's Vicki Jones. I'm a consultant in special care dentistry and the clinical director of community dental services for Aneurin Bevan University Health Board.

Good morning. I'm Rob Davies. I'm the associate dental director for Cwm Taf Morgannwg University Health Board.

Bore da, Chair. My name is Manolis Roditakis. I am a community dentist in west Wales and the chair of the British Dental Association's Welsh committee for community dentistry.

Lovely, thank you all for being with us this morning—much appreciated. Perhaps if I can ask the first question to Vicki Jones and Rob Davies. Is there a clear understanding, do you think, of the number of people waiting to access community dental services? And in that question as well, are we aware of the length of time that people are waiting as well? Is there enough data on this? 

I can only speak, obviously, for my own health board; we have a waiting list—. We do have waiting lists. I've been working with our own staff to be able to drill down into what those waiting lists are and dividing them into the different areas: so, for example, domiciliary care for people who require sedation, general anaesthetics, or for children, or for adults, vulnerable adults. So, we're able to do that. So, from my perspective, it also means the different clinics may have different waiting areas as well.

So, unfortunately, for example, the domiciliary waiting list is about two years for routine. So, we are actually, at the moment, seeing all the urgent domiciliary patients that are coming through, simply because of the volume that we weren't able to see during the pandemic, because a lot of those patients were, obviously, living at home and also in care homes, and so, therefore, access to care homes at the time was very difficult. So, we're starting to get through that. So, some of my clinics are managing to get through their waiting lists, whereas others—. So, I always look at the longest waiting list and, at the moment, for example, my Cwmbrân area, the longest waiting list is two years, whereas, in another area, we've managed to get it down to six months. So, we do have, in each area, an understanding of what our waiting times are.  

Okay. Rob Davies.

Just to add to that, really. There is a similar kind of information captured in most health board areas. Vicki is correct; it is categorised into different areas, whether it's special care dentistry, whether it's vulnerable adults, whether it's domiciliary care, whether it's children waiting for general anaesthetic for extractions of teeth. I think one of the challenges with it is those are only the individuals that have actually come forward and have been seen, so I don't feel those waiting times are completely reflective of all the need that is out there at this minute in time. I think that is just the individuals that we are aware of and we know of. Again, because of geography, because of other issues within certain health boards, I think you will see fluctuations in waiting times on that perspective.

Okay, thank you. And really, just to get, perhaps, a view on the length of time it would take to address the backlog in community dental services, and I appreciate it's your own health board you can talk to, but perhaps more broadly, if you have any other wider information as well.

For example, Rob has just mentioned about children requiring general anaesthetics, for example. In Aneurin Bevan, it's two years for routine, and I know, in three other health boards, that's exactly the same. Other health boards have managed to look at those, they’ve got opportunities for general anaesthetics, and so, therefore, they've been able to reduce their waiting times. I think each of our community dental services have different waiting times for different patients. The other thing that we managed to do in Aneurin Bevan was sedation. We were able to put some funding into sedation so that we were able to reduce our sedation waiting list, working with general dental practitioners that actually provide it, so that we could try and reduce those down. So, we've been working with others.

I would say, in answer to your question, that it will probably take another year or 18 months, probably, for us to be able to sit down and say, 'I think we're starting to get to the back of this', possibly two years—but the next 18 months to be able to really see a difference and that we may be getting those waiting times down. That being said, my referrals from general dental practitioners are double what they were in 2019, and given the fact that people are struggling to find general dental services, we can't offload those patients from my service. All I'm getting is lots and lots more patients coming into the community dental services that we have to take on board, and once we've actually provided that care and we know that they're able to go and access general dental services, we're finding that a little bit more of a struggle than we were doing prior to 2019.

Thank you. Perhaps I'll address this question to Manolis. Any comments on the first set of questions, of course, as well, are welcome. But particularly, evidence that we've received makes us aware that there are certain sections of the population that are having more difficulty to access a dentist. I say that, but I know from my own constituency postbag that it doesn't matter what group you're in; a lot of people have difficulties accessing a dentist. But the evidence is saying that it's particularly people with learning disabilities, Gypsy and Traveller communities, asylum seekers, migrants—the evidence is telling us that those groups particularly are having more difficulty accessing a dentist. I wonder if you could perhaps talk to that point.

I think this question directly relates to the previous question about the waiting lists and the backlog, because it is part of the rise in oral health inequalities. There are variations between areas and there are some health boards that have some strong areas and their waiting lists are shorter, but in areas like west Wales, where I work, we do have waiting lists that are so long that I fear that we might never be able to go through these patients. As Vicki rightly said, we do have at the moment an influx of referrals from the general dental service, because it is a broken service at the moment. The capacity that we have in the community services is not enough, by a long shot, in order to deal with these problems. So, maybe two years is an optimistic plan about this. We definitely need much more support.

Thank you. In terms of that last point on needing more support, I think Members will perhaps dig into that in some of their later questions. Just before I come on to Rhun ap Iorwerth, I'd like to welcome Ruwa this morning. Would you like to introduce yourself for the public record? You don't need to touch the microphone at all.

My name is Ruwa Kadenhe. I'm working in Bridgend in the Ogmore valley, and I'm here representing the Bro Taf local dental committee, which covers the Cwm Taf Morgannwg area and the Cardiff and Vale area. Thank you, Chair.

Thank you for being with us this morning. Can I just ask you to check your headset as well? We'll just do a quick translation check. Can you hear that? Lovely. Thank you. Rhun ap Iorwerth.

Do you want me to go first? No worries. I think the service itself is very interlinked, and I think it is difficult to just put community dental services, salaried dental services, general dental services, hospital dental services; it's part of a wider infrastructure, and I think if one area is under pressure, then that has knock-on effects on the other ones. I think that is a fair reflection of where we are at this point in time. I think access to dentistry has been challenging over the past couple of years. Various health boards have had to put in different mitigations, different support in order to deliver that.

I can give you an example within Cwm Taf Morgannwg. Historically, we didn't have within the Cwm Taf area, not so much the Morgannwg area, issues of access to dentistry. There were open lists and people were able to access it. COVID happened and because of the backlog because of that, we are now in a position where a number of the practices do not have the capacity that they used to have to see those patients. So, it relied upon us then setting up urgent dental care, which was delivered and is delivered in a mixed package through salaried services, whether that be the community dental services—a small proportion—or we have taken the opportunity to make some salaried positions and salaried posts that are able to deliver across the piste. I think for a lot of the patients there, the more vulnerable, it's just finding the right avenue as to where we can get that access.

Going forward, where there is pressure there, there is only so much capacity on the other side in order to deliver that. We do have mechanisms in some areas to move resources, but a lot of that is dependent on whether or not it's restricted to general dental services or community dental services. I think there's a finite pot of resources, whether that's money, workforce, those kinds of areas, and it's the challenge to move those across there.

There are pockets where we've been able to do some good practice, such as setting up emergency dental hubs, setting up urgent dental lines, those kinds of things, where we can feed the patients through. But, I am concerned that obviously we're only dealing with the acute elements now. There is still that tsunami, that backlog of care that needs to be delivered on a more ongoing basis. 

There's lots of nodding going on, so I'd like to welcome some of the comments behind those nods. Should there be more clarity on who does what? I appreciate that, obviously, there's going to be flexibility and one part of the dental service will want to take pressure off the other, but actually should there be more clarity?

I'd like too see more integration, to be honest. That's my personal view.  

And Manolis, I think you were indicating. 

Yes, I would like to make a comment, please. I'm here as a community dentist and as a BDA member, and I can only give you my experience from my line of work and from the other members and the discussions that we have. A lot of BDA members in the community dental service have concerns about this new move and about this integration of the general dental service and the community dental service. We feel that this is a reaction to the acute problems of access in the general dental service, but there is a big risk that it will cause further erosion in the community dental service. So, we need to be very careful to focus on the vulnerable groups and make sure that they are not disadvantaged. Any decisions or any resource channeling should be done very carefully and very wisely. My feeling is that, with the current level of resources, we won't be able to do it and we will end up with more inequality than we already have.

We've just had the Welsh Health Circular (2022) 022, and it indicated that health boards have the opportunity now to be able to use the funding that comes in for dentistry not just for general dental services but for community dental services—that we're able to use that funding should there be an area where general dental services funding couldn't be used, and that funding could then be used for the community dental services. I think some of the community dental services are already doing this—myself and Rob, we already have salaried general dental practitioners who are working in what we call 'underdentisted' areas, and I think we have the same with general medical services, where you don't have doctors. And we've had that for a while. So, I would welcome that opportunity, however, we would want to make sure that we had the funding, wouldn't we, Manolis, to support it if you're going to be using the CDS in order to back up areas whereby you haven't got access. That's where I think a lot of us are slightly concerned that we wouldn't be taking the workforce away from our vulnerable adults and children and using them for things where, actually, we could have funding from another source that would support us.

I totally agree with both what Manolis and Vicki have said; the vast majority of care for patients is provided by the GDS. The CDS only provides quite a small proportion of that, and that has historically been targeted to the more vulnerable patients. And so, if we then push more to the CDS to ask them to try to cover deficiencies in the general dental service, then you put at risk the vulnerable people who are already suffering because of backlogs caused by the COVID pandemic.

Back to you, if I can: you welcome co-operation between different sectors as integration; others might call it the clouding of who does what. There was more integration during COVID by turning the community centres into urgent dental care centres, as you said. Is it clear who should be looking after emergency dental cases in a post-COVID world? And are people who are facing dental emergencies able to access wherever that might be?

Just to start on your last point—and I can only speak for our area—individuals who need to access urgent care can do that. We have done that by working with the general dental services and also within the community dental service and setting up other salaried positions to deliver that. The information we're seeing is that we have capacity in the week to see these individuals. We've quadrupled the capacity on weekends to see these individuals, but we're seeing a decrease in the demand during the week and an increase on the weekend. So, there's a little bit of a mixed bag with that one. 

To go back to your first question, access to general dental services, historically, and I'm sure you've heard this from other members, is around about the population and what was funded historically. So, 50 per cent of the population would have historically seen the dentist and that was where the funding was delivered. We're now seeing an increase of different cohorts of patients accessing services, whether that's because of financial constraints on them and they're only choosing to access urgent care because it is the cheaper out of all the different elements, or whether or not there is a backlog where they couldn't get things dealt with for a period of time, which is creating more urgent care.

I think there could be more clarity within the general dental services contractual arrangements. At the minute, we are looking at a contract variation, so there's not a new contract on the table as we speak. But I think there could be more clarity around what the expectations are of numbers of patients to be seen. We don't have dental registration with a dental practice. I'm not sure if the committee is aware of that, but registration stopped in 2006. So, you have a defined population that the practice sees, but they're not registered—not like a GP. And also, patients have the ability to move around as well. So, we're unsure of what cohorts we're being funded to look after, if that makes sense, and I think there could be more clarity around that in registration. But, again, it would depend on how many numbers you're willing to register and what is the capacity within the service.

You asked a question about the emergency dental service and who should actually see these patients. My response would be that the emergency dental service for the community dental patients, the core patients, should be done by the community service. I think that the general dental service has the skills, the efficiency, the fast pace in order to be able to provide the emergency care to the general population.

In the community dental service, and Vicki might correct me if I'm wrong, I think the workforce is about 80 full-time equivalent dentists for the whole of Wales. So, you understand that we're a very small team, and asking us to cover the acute situation in the general dental service is like putting a small plaster on a patient that is heavily bleeding. So, it might provide some comfort for a small period of time, but it's not the solution.

But it is much more cost effective to see a patient in the GDS than in the CDS. I think that we all agree. And what patients define as a dental emergency may not actually—by what the Scottish Dental Clinical Effectiveness Programme guidelines say—be what an emergency is. So, patients want to access unscheduled care, where they only come when they have a problem, but that may not actually be an emergency. And so, there is no communication with patients as to what is an actual dental emergency, and what is just unscheduled care, and then there is no provision for unscheduled care, because, historically, the way the commissioning has been done it's been supply led, so they have a supply for 50 per cent of the population, and that's what leads the access. But then, actually, it should be needs led and so,'What does the population actually need?', and not 'What supply do we have?' and then we try to fit everything into what supply we have—it should be what the population needs. And the evidence from the Welsh Government and from Public Health Wales is that the need has gone up post COVID. So, we need to move away from this idea of, 'Okay, we were funding for 50 per cent because that's the supply that we have', and to actually look at what the population need is.

Caries, or perio, which is all of dental disease, is a lifelong disease. If you don't catch it early, if you don't prevent it, it's only going to get worse, and the more you go, the longer in life, the more complex the treatment becomes and the more expensive it becomes, so we really, really need to focus on prevention and different outcomes, and not just focus on trying to fix short-term problems.

Did you want to come back in—?

I just wanted to come back in, because I agree totally with what everybody is saying. I also feel that the system that we have in Aneurin Bevan in our dental helpline is we're able to triage out those patients who should be seen by the community dental services when they phone up for an emergency appointment—for example, domiciliary care, if they have a learning disability, asylum seeker, a person who can't speak English, all those things—we would be able to then channel those into the community dental services to be seen as an emergency. And then those that are your routine emergencies would then go to the general dental services. So, I think it comes to our helpline, really, whereby they're able to channel out to who should be seeing them, and who has the skills to see them, actually, and the time to be able to see them and help them.

But the more pressure there is on the GDS that you are happy to take off, the more—[Inaudible.]

Absolutely, and we're getting so many more referrals from all sorts of non-dental areas—from agencies where they've got vulnerable adults who are struggling to find access. So, therefore, the referrals are coming in to us in the community dental services.

And additional funding would help to—[Inaudible.]

Oh, yes, it would. Yes.

Thank you, Rhun. Sarah Murphy.

Thank you, Chair. Thank you, all, for being here today. I'm just going to ask a question about prevention initiatives, and it has been suggested to the committee that one of these could be that the Welsh Government should resource and support fluoridation of public water supplies, particularly for areas where there is a high prevalence of tooth decay. Also, extending the use of fluoride varnish as a preventative dental care initiative to care homes has been raised. But we would very much today welcome your views on the merits of these suggestions, please. I'm not sure who would like to go first, Chair—I can't see, so if you could let me know, that would be great.

Thank you for the question. You're asking somebody who thinks prevention is key. We've got to move away from a cure service to a care service. We know that, as you quite rightly said, Ruwa, it's lifelong. Once you've got a decayed tooth, it's there forever, until it's possibly removed. So, in terms of fluoridation, I know in England, in their oral health strategy, they're very much in favour of fluoridating the water supply. We did have fluoride in the water up in Anglesey, but that was taken out, and actually we could see the evidence showed that the children's decay rate in their teeth went back up when that fluoride was removed. So, the principle, absolutely, we agree with. I think later on you're actually with the dental public health team, and they would probably have a lot more information about that. But, from our point of view, we know that, as a UK preventive strategy, it is the way forward, if you're able to do that.

In terms of fluoride varnish application in care homes, certainly, with the Gwên am Byth programme, I would agree that would be a very, very good idea if we could do something similar to what we do with Designed to Smile. But, again, that would have to be funded. Therefore, with the Gwên am Byth programme, at the moment, they're just getting back into those care homes and actually providing that, but it would take a lot of workforce to be able to do that. Also, the provision of that fluoride varnish is a little bit more complex because the residents in care homes have much more complex medical histories; children don't seem to have that. Therefore, there is a lot more work to do if you are going to be providing that. But, if you're actually under a dentist, you would be having that fluoride varnish anyway as part of an NHS treatment plan.

That's fine. Thank you, Vicki. Hold back on Gwên am Byth and Designed to Smile because I think there are some specific questions on that later. I can see, Ruwa, you wanted to come in, and then Manolis afterwards.

A lot has been said about reducing inequalities. One of the biggest ways, and this is a personal view, would be to have targeted fluoridation, especially in areas of socioeconomic deprivation, because we know that there is a link between socioeconomic deprivation and the amount of dental disease. There has been so much research on this all over the world, on the safety of it as well, and it's a cheap measure, so I definitely think, if we were looking to target resources and to reduce inequality, that would be one of the biggest ways—. The two population things that reduce decay—if we're talking specifically about decay—would be, on an individual basis, toothpaste available in shops, or, on a population basis, that would be the Government fluoridating water. Definitely, we would support that.

Manolis.

I totally agree with everything that has been said. We are very much in favour of water fluoridation. We, I think, are doing a very good job with the Designed to Smile programme, and there could be scope for expansion for fluoride varnish applications. I just wanted to add to this conversation that, when we're talking about decay and caries, this is something that goes far beyond the dental services and the dental provision. We have to look out and we have to take a very careful look at the sugar consumption—the free sugars—how we can tackle that, how we can maybe provide more taxes and try to reduce the consumption of sugar, because this goes hand in hand with all the other prevention measures. We need more upstream measures of general public health as well.

Do you have any further questions, Sarah?

No, I don't. Thank you very much, Chair. Thank you, everyone.

I'll come to perhaps Jack first and then Gareth, because I think there are some questions that you wanted to ask about some of the topics that have been mentioned, Jack. Jack Sargeant.

Certainly, Chair. Diolch yn fawr. Can you first just outline the dental domiciliary care services that are available in Wales? And there are perhaps two follow-up questions to this: one, whether we are meeting the demands and patients' needs sufficiently—and I can see some head shaking there—and perhaps my further question is do we actually understand the level of demand. What I'm picking up—please correct me if I'm wrong here—from the conversation we've already had is that I believe the answer is, 'We don't understand the level of demand.' So, perhaps my question is: how far away are we from understanding the level of demand, do we know, and then, as we understand it currently, is that level of service being met? Rob, I can see—

I think that question is probably going to be best answered by public health, because that's where most of the information would sit. I think, at a local level, health board level and national level, we do get public health information, but, again, it's dependent on time lags. It needs to be more robust for me and more live data, if that makes sense, in the ability to plan and deliver services. 

As to domiciliary care, dentistry is quite a complicated thing to deliver on occasion, and you do need specific items, specific kit, specific models in order to deliver it. And, as you get older patients, they come with more and more comorbidities, more health issues, so it's getting that balance between the appropriate delivery of care in a community setting and the appropriate delivery of care somewhere where we can best care for them. I think—I can only talk from our health board area—we have some domiciliary care vans. They're rather antiquated, and I think that is a challenge for a lot of other health board areas as well. Having the capital funding and the resources in order to properly invest in the appropriate equipment and facilities in order to deliver quality care I think is something that needs to be looked at and addressed. We are happy to work with Welsh Government on this one, but I think that is something where, if you want to get to that level of care, you need to have the resources and the workforce to do that, because it's a little bit more complex, and I think what Vicki may say in a second—and I don't want to put words into Vicki's mouth—and what we will say is that, a lot of the time, we have to robustly triage which patients need to be cared for in different areas, and how we do it. It'll come down to transportation as well, infrastructure and those kinds of things, so it's quite a complex thing. 

Vicki, and then I know Manolis wants to come in.

Domiciliary care is quite dear to my heart. I still carry out domiciliary care as a consultant, giving it second opinions, because I think, sometimes when you go to a person's home, you're able to assess that person and the situation that they're in. The eligibility criteria for domiciliary care is where it's—. You have to have a robust eligibility criteria. So, if you get that right, and I think a lot of the community dental services do get that right, then you're able—. Because, often, people will think, 'Oh, because I can't get the bus, I might be eligible for domiciliary care.' It costs a lot of money for a dentist and a dental nurse to travel half an hour, 45 minutes, to see somebody in their home. 

The other thing that we've got over in Aneurin Bevan is that we have a model whereby the referrals for domiciliary care come in through a dental helpline, then they go through a triaging process for eligibility, this then goes to me, whereby I decide whether it's the community dental services that sees that person or the general dental services, because we've got five contracts with general dental services. So, if it's less complex, they would go then to the general dental services; more complex, it comes to community. Added to that, using general dental services money, we had an oral health improvement practitioner, who is managed by me—she's a dental nurse—and who goes in and actually provides the oral health education, the fluoride varnish, labelling dentures, speaking with the carers, so that the dentists, when they go out, don't have to do that.

The other thing is dental therapists. We've got nine dental care professional therapists in Aneurin Bevan, and we use our dental therapists to go into care homes and into people's own homes, because they are the people—. Because a lot of the people are end-of-life care, it's palliative dentistry and, actually, what they really need is the prevention side of it, and also very rudimentary dentistry to be provided, to get them comfortable, out of pain and to be able to enjoy, eat and socialise how they want to. So, that would be the model that we would be thinking would be good, but it has to be funded, obviously. 

Just before we bring Manolis in, given that you've only given us the example of your health board, of course, is that the same throughout Wales, would you say? Okay, it's worse.

It's mixed.

It's mixed. Okay. Sorry, mixed.

It is the care pathway for south-east Wales, and so, therefore, it's there because it's part of our managed clinical network. 

And just one final question—I will come to you next. You decide where the patients go when they come through to you. Who sets those criteria? Are they from Welsh Government? Is that the same across Wales or is that mixed again?

The criteria is set on the complexity of the patient that's coming through. So, there are questions that are asked. So, for example, somebody with severe dementia or somebody who has a very complex medical history would go to the community dental services, but somebody who's an older person, very frail, that's not able to go, would then go to the general dental services, yes.

That would be routine across Wales, that wouldn't be mixed—

Yes, it's routine. It is, yes.

Thank you. Manolis, sorry.

I think that Vicki described very well the model as it should work. I provide domiciliary care as well in my health board. I think that in many cases the reality is a little bit more harsh, because of lack of capacity and lack of time. No matter how well and robust the criteria are, the need is there and the need is increasing, because we have an ageing population, we have more people in care homes and we have more people who age with their natural teeth, with advanced prosthetics, with implants nowadays, so their care might become more complex and more needed prevention is the key. But I fear that, in many cases, the care that is provided now is only as an emergency and not routine.

Okay. Thank you for that. Just going specifically on the Gwên am Byth programme, again, we've talked a lot about resources. I think there are two questions here: (1) should it be expanded to places? We've heard from the Welsh NHS Confederation there's been support from members, for example, to care homes and younger vulnerable people and other places. So, could it be and should it be, essentially? I don't know who wants to—maybe Vicki—take this one up?

I think Vicki was one of the main persons who developed the programme, so she's the best to answer.

You've been nominated, Vicki.

Yes. The Gwên am Byth programme actually fell out of the survey that was carried out back in 2011 into care homes. We did a national survey that showed that the actual oral health of residents within care homes was really pretty poor. So, therefore, the funding—we went back to Welsh Government and they provided the funding for us to put in that oral health promotion programme, which has worked really quite well. It changed into what we call an essential Gwên am Byth programme two years ago to make it simpler, to try and speed up the process, because we had a quite sophisticated process of risk assessment to begin with and training and then we decided to make it simpler, so that those care homes that were slightly more reluctant to engage would actually engage, and it's worked really well. So, therefore, we'll be able to use this new essential Gwên am Byth programme—we're doing this in Aneurin Bevan—to go to those agencies that work with people for domiciliary care, for continuing healthcare for those older people that are actually in their own homes. So, we're working with private and NHS and social services and local authority agencies to train them and be able to put together these things. But, also, I would like to add extending that to learning disabilities, to brain injury units, to mental health care homes as well. I would say that we've got everything set up to do that and it would be excellent if we could just extend it to those care homes as well.

And that's just in terms of more resource available.

It'd be resource. You'd have to resource it, yes. So, yes.

Okay. Rob.

Just to add to that, I agree wholeheartedly with Vicki on what Gwên am Byth is trying and is delivering. I think it's an excellent programme. I think one of the things that needs to be borne in mind is the actual individuals who work within the care setting, so the individuals we are training. I think a lot of us would have seen the high turnover of staff and the challenges around that, so I think that needs to be borne in mind in how we deliver it, how you can manage that service as well, because of the demands on care homes services and domiciliary care. They've got lots of things on their plate to do at this minute in time, so it's that balance as well. So, I just wanted to add that.

Okay. Chair, if I've got time, can I—?

Absolutely.

Thank you. I want to move away from Gwên am Byth and go perhaps to Designed to Smile, looking at our younger generations. Firstly, what are the main challenges, maybe, you could outline for the committee in delivering the oral health services that are required here in Wales? And then, if we look again at the Designed to Smile programme, has that fully resumed since the pandemic, and also—again, a simple question, just as the last one—could it and should it be expanded? I believe the next witness doesn't believe it should be, simply because of the workforce. We have that question later on, but I'd be grateful for your comments there. I don't know who would like to pick that up.

Do you want to take that, Rob?

Yes, I'll take that one, if you want. That's fine. Remind me what was the first bit now, sorry.

So, just an overview of the—.

Okay. So, Designed to Smile is an excellent service. It starts at the real heart of where we need to, and that's prevention, with our children, because, unless we prevent the disease—. We have to remember that the number of general anaesthetics that are taking place in this country, the vast majority for paediatric dentistry is because of decay, which is preventable. So, if we can plug it at the start, or stop it happening at the start, I think there are massive changes for the future. I think fluoridation will be a big step to that, so I'm going to add that in again. Designed to Smile really focuses on that younger cohort when they're in development. I would be supportive of expanding the programme, but I think it needs to be in the context of what is available, what resources are there, and a more targeted approach. As people get older, I don't think it needs to be in the same format, if that makes sense. So, Designed to Smile, as it stands for the under-fives, I think that is key and the essential basis. I think after that, then, we need to look at other ways of educating our children, population, and giving them more resources to do it, rather than just a simple change in the age range. So, there's a little—

Okay. So, there would be a different programme for six to 10-year-olds.

Yes, I think so.

To expand on that, and we can come in then—. A lot of this is prevention. We've heard some of the stuff before to do with the general public health. What action—? If you could give the committee a recommendation of what action needs to be taken to tackle this—. You've mentioned fluoridation, but is there anything else that you'd like to add? Perhaps we could very quickly go through them. I know Ruwa wants to come in as well—[Inaudible.]

In terms of action—. I was just wanting to come in on terms of expansion. It's not my area of expertise, because I'm in general dentistry, but there was a programme, Baby Teeth Do Matter, which is the zero to threes. We know that incidence of disease in the zero to threes is actually the lowest, but, if you don't catch them in the zero-to-three age, it just starts to increase and increase and increase with time. The Baby Teeth Do Matter programme did work very well in the north of England, and so that would be something we would like to see. I don't know if it's going to be in the Designed to Smile programme, or if can be integrated into GDS, which Cwm Taf Morgannwg had done.

I run it.

Yes. [Laughter.] And so, that's something—. Designed to Smile delivered just five basic messages. This is where I would like to see integration within allied professionals, because, if we're going for the future of Wales, this is such a key programme. If we get this right, the Designed to Smile and the Baby Teeth Do Matter, and we set this path, then, in the future of Wales, you will completely change the population, and that has been—. There's lots of evidence. I think Public Health Wales and the previous CDO gave lots of evidence of how it can change oral health on a population basis. So, I think it's one of the most important programmes Welsh Government can focus on. 

Okay. Thank you.

What I would like to add to what everybody else has said is that I believe that, following COVID, children in Wales have been left behind a little bit when it comes to prevention and care provision. The Designed to Smile programme, which is, of course, a fantastic programme, was disrupted for almost two years, and I think only this school year it is starting to recover. But the reports I have from the field is that we still have schools that are a little bit reluctant to participate in the supervised tooth-brushing programme. I think we focus more on the fluoride varnish application, and we're targeting more schools, and I think the way forward is to focus on the same ages, but target as many schools as possible. Right now, the schools are chosen according to the provisional criteria.

I want to say that, before the pandemic, there was never a problem with young children accessing dental services when they needed that. Right now, we are at a crisis point. A few days ago, I was speaking with a mother and she was telling me, 'I understand that I have to wait, but why do my children have to wait so long in order to see a dentist?' So, I think these two things go together. 

Okay, thank you.

Can I just say something about 'Putting the mouth back in the body', and policies? Any prevention policies, like 'Healthy Weight: Healthy Wales', and any sort of policies about prevention, we need to integrate oral health into that as well. That's what I'd like to push for, really.

Okay, thank you. I'm going to put my mouth back in my body there—I think I took quite a lot of time, Chair. 

You're fine. Thank you, Jack. Gareth Davies.

Thank you, Chair. I want to ask about workforce and recruitment issues. Is there clear data on the amount of dental practitioners in each individual health board, and whether numbers are sufficient to need? I suspect that's probably not the case, but could you expand a bit on that and just give us a picture on what the data is like, if there is any, and give a picture across Wales, if you can?

I think workforce data is not where we'd like it to be. I think that's fair to say. I think there is a lack of clarity, not just on the numbers of individuals, but whole-time equivalents, age demographics of the workforce, other dental care professionals as well. Because we are part of a wider service, I think, when you're talking about workforce you need to be thinking about the nursing staff, the actual therapy staff, hygienists, those kinds of things. So, that information is not currently there. I know that it was something that was looked at by Welsh Government, and there was talk on the last contracted element of having a workforce information process, where all practices have to fill that in. It is yet to land, so I don't know what the timing is of that one as yet, but I think that would help with some of the planning. So, if you knew who was working in any given area, the number of committed sessions they have towards the NHS, the number of staff that they have, the number of vacancies, that would help then with planning any future services and resources around that. 

And what do you think health boards can do better, then, to attract dentists into health boards, given those problems?

I think what we've had to do—and I can only talk from my own health board's perspective there—is we've had to be a little bit more creative in the types of roles that we put out and put forward. I think dentists are looking for a mix of roles, and I think dentists are also looking at their work-life balance as well. I think what we're seeing is there are very few individuals that now are working full-time, or they have reduced sessions. So, I think that kind of builds into it.

We had some issues with attracting individuals into our community dental service a few months back, but what we've looked at now is changing the roles so that we have more of a mix of a salaried service, where they do some community dentistry, some special care dentistry, but we also have some development within that as well, where we upskill them and maintain them. I work part-time for Health Education and Improvement Wales as well, as a training programme director for newly qualified dentists, and when you ask them, 'What do you want as a future career?', they're looking for career pathways and development opportunities. I think, if we had the right resources in the right areas to attract these individuals, and support them, whether it's through additional training, additional support, that could support those services as well. So, I think it's that; it's getting that blend. I think the workforce is shrinking. I think the workforce is changing as well. I think the make-up of the workforce as well is split differently, and we're seeing people retire sooner than what they would have historically done as well. 

And Vicki, what about the community dental service, then in terms of recruitment?

It's interesting. I lost all five of my senior community dentists in the last three years to retirement. They went early, because of the situation with the pensions and everything, and also, I think, COVID-19 really did take its toll with some people, as you can imagine, especially clinically. We didn't close in the community dental service—we carried on. We have struggled. However, the last time I put out an advert for a community dentist, I had eight applicants—I haven't had that for years. When I spoke to them—we managed to interview four, and I spoke to the two I had to turn away, which I couldn't believe that I had to turn away, because if I'd have found that funding, I would have kept them, because they were fantastic—they wanted that blended approach now. They wanted a little bit of general dental practice, but they also wanted community dentistry, where they would be supported for development, would be in a role where you've got consultant specialists, you've got dental therapists—all that skill mix. They liked that; they liked that it was different.

But also, and I was talking to Rob about this just now, I only have one community dentist that's full-time now, which is astonishing. If you'd asked me 10 years ago, I would have had probably half my staff at full time. This is the difference. So, it means that—. I have to say part-time workers are excellent, because they usually do more than the days that they actually work, but it does make it much more difficult for us when we're trying to plan things. But also, dental therapy—I'm a big fan of skill mix. I think that, really, we should be looking far more at the education and training of dental care professionals, so that we are able to use them within our services as well. 

What sort of training do you think would promote that in terms of upskilling people for providing a skill mix for professionals? 

At the moment, dentists are five years, and then we have to do that foundation training; dental therapy, three years, and then they may want to do foundation training. But, what we're doing now is when those therapists come to see us, certainly with special care, we're actually training them in aspects of special care, taking them into care homes and teaching them how to—. So, within each of our community dental services, we're upskilling them in order to do that. I could not run my service without our dental therapist going in and looking at a lot of our vulnerable adults who are out there. The other problem that we have, though, is four times now, I think, I've advertised for a dental therapist; there are none out there. Therefore, at the moment, there's a dearth, and we would like more funding to be able to support that training if we could. 

And given the issues that you've spoken about, what's morale like then, generally, amongst dentists? I can't imagine, from what you've described, that it's in the higher echeleons at the moment, but—

I think it's challenged. I think that's the diplomatic way of putting it at this stage. I think there are opportunities, though. I think there are models of training out there, especially when we're talking about an integrated approach. Within Wales, you have three training units. One is an academy that's just been set up in north Wales, but you've got a historic one that is in Cwm Taf Morgannwg, and that was Porth—that was the original—and then you've got one in Port Talbot resource centre. The one in Port Talbot has actually got a great model, in a way, where it has an integrated service with the community dental services at one end, and the hospital dental services specialist care as well. I think, long term, if you're looking to attract, train and retain individuals, you need to be looking at more of a training and development and integrated service environment. Obviously, that comes with resources, capital funding, those kinds of issues, but I think the appetite is out there that individuals will be attracted to that, and retaining them within those posts as well. 

Manolis, did you want to come in? 

Just to answer your question about how many performers we have in Wales, on the NHS digital website, pre pandemic, we had about 1,500. Now, when they say a performer, that's somebody who has just provided a course of treatment for a patient. So, that doesn't tell us, as Rob was saying, whether they're working full-time or part-time. But, there were 1,500 of those. That's gone down, in 2020-21, to 1,100, which is almost 25 per cent of a decrease. So, there is a massive shortage, and speaking to colleagues and speaking to other principals in both our health boards, which are the largest, you find that there is a lack of staff. This is why it tends to end up bleeding into other services. 

And the reason for it, like Vicki was saying, is that people are retiring early. The stress of the amount of paperwork—I believe my colleagues from the Welsh General Dental Practice Committee mentioned—that has to be filled in, and that stress, especially if you were an older dentist and weren't used to computers, and now, you've got all this data to collect. As Wales, we collect more data than anyone else, but we just don't process it very well—I'm not sure why. So, that is a disincentive to work in the NHS, and that's when—. So, general dentists aren't leaving the NHS really for more money, but just for a better work-life balance, because we find that you have to come in at 7 o'clock in the morning, try to do notes, and then you're staying maybe until 6 p.m. to do e-referrals. So, you just don't have that—. You're constantly thinking. And then, there's also litigation and the fact that there's more litigation in the UK than there is in America for dentistry. And so, that makes people not happy to work as much and as fast as the NHS would require them, and they would move to private just to see fewer patients, to be able to do better treatment, to spend more time with their patients, and not really to make more money.

And do NHS dentists have the same access to technology? Because you talk about paperwork; is it actually physical paperwork, or is it e-based, or—?

No, no. It's about a million clicks. [Laughter.] Not a million, but—

But do staff feel like they have the access to that latest technology within the health service? What I'm trying to ask really is: is the NHS keeping up with modern ways of practicing? Is that something that's provided, or not?

Before you answer, did you want to jump in on the back of that as well?

Yes, just very quickly. Thank you, Chair. I may have misheard—did you say that we collect lots of data, we just don't process it very well?

Yes. We collect—

So, answering both questions, then.

—an absurd amount of data. And so, every time a patient comes in, we fill in what we call an FP17, which is a risk and need assessment. And on this, we're going to fill out ethnicity, we're going to fill out NHS numbers, we're going to fill out how many teeth they have in their mouth, what their periodontal disease is, down to the number of appointments when they had an aerosol-generating procedure, which is where you had to use a fast handpiece. So—

Are you saying, though, that this information that you're asked to put in is irrelevant? Should you not—?

No. It's supposed to be feeding into the new contract. And if I speak to dentists, this is probably the biggest reason that all the dentists are leaving sooner, because of the amount of paperwork that they have to click through on a computer. And where an exam might have been 10 minutes before, it has to be 20 minutes now.

It just amazes me, really, that we collect the data and we don't use it. It begs the question: is there a point in doing it? Well, surely, there must be a point in doing it.

That's one for Public Health Wales. They're going to—

I've made a note of Public Health Wales.

They've said that, later on in this year, they will start to process the data and look at it. But, yes, it's a difficult one.

So, the question is—. My first question was about data, and I'm really interested in the point that we take all this data, but we don't process it. So, I'm trying to understand—put it this way: what do you think should happen to make this better?

We need the risk and need. But when you collect data, you're only collecting the patients who actually come into the practice. So, the patient who's at home, and may not access dental care in the way that you want them to, you won't have data on that. So, that data, we can never get. We do need the data, but we need to streamline it. We're in a process of change, we're in a process of transition. They've put all this data into the FP17 and made lots of changes in a very short amount of time, and that's what's caused a lot of angst.

So, what I'm interested in is—Rob wants to come in, and then I'll come to you, Manolis—what needs to change, in your view. Rob.

Two things. I think the information is important to collect, because I think we need to have a better understanding of the needs of the population that we are serving. So, what is the need that is in the system? I think the information needs to be live. The current collection of information is delayed, because, obviously, you don't know that information until a course of treatment has been completed. So you might see them on day 1, but you might not get that information within Welsh Government or down towards a health board level until—if the course of treatment's lasted four or five months, you don't get that until later on.

And what's the obstacle in making it live?

The obstacle in making it live at this moment in time is that independent contractors have to go out and provide their own software systems. So the software systems available within Wales are commercially purchased. There is nothing that's being delivered by Welsh Government to have a—. When I say the software system, every dental practice, or mostly those that are computerised, they use providers, such as Software of Excellence, Carestream, those kinds of big companies that provide a digital solution. A lot of those, then, the changes that have been made by the collection of data, have to be shoehorned on the back of that. So, I think it's—

So, what's the answer?

The answer is to make a more simplistic system that can be rolled out to NHS dentists to collect the information.

And that has to be overseen by Welsh Government.

I would suggest that that would be the best place for this to sit.

Okay.

And to make it simpler for dentists in terms of the amount of data that we're collecting. So—

How do you do that?

Well, there's a lot of unnecessary data on the form, I feel.

What's unnecessary? 

So, the risk and the need—yes. A lot of the other stuff either should be automated, which they haven't managed to do, and it can easily be automated with software, but because the software companies work not just in Wales, they work in England and Australia—

Are you saying that other information could be populated and you wouldn't then have to ask for it each time? Is that what you're saying?

Yes.

Right. Yes. So, if I fill in a chart—if I look at your mouth today and I fill in a chart, it should just automatically take that data and put it into the information that the Welsh Government wants, instead of—

And you all agree. All of you on the panel agree with Ruwa—yes?

Definitely. May I just add that there is a lot of duplication of data insertion in the system as well? And to point to a very simple example: whenever I do an initial examination with a patient, there is what we call the basic periodontal examination, which is a simple chart. I have to insert four times, on four different screens, the same chart, and this takes time. This makes the system slow and inefficient, and it's also a bit frustrating for us, because we could use our time doing something else. So, modernising and simplifying the data collection would take us a long way.

And just for the record here, other panel members were all nodding. So, you're all in agreement with each other on this issue. Rob.

I think there just needs to be a little realisation that, when we're talking about general dental services, they're independent contractors and they don't only provide NHS care; they are commissioned to do it. But the software packages that they have are commercial entities that have been bought, and we utilise them as well. So, it's about making sure that you have a robust system that collects the data, but it actually feeds into the other systems as well. So, I think there's always a—. It would be nice to have one simple system that delivers it simply, but I think we've been here before with NHS electronic systems, and I think that is a challenge in itself.

Okay. If anybody wants to ask any questions on this—. It sounds like a massive challenge, though, because if you've got a dentist that is an independent provider and then doing private as well, it sounds complicated to achieve what you want to achieve. I think you're recognising that.

Yes. And also, there are lead times in making any changes. With any of these software providers, you're talking a six-month lead time.

Right. Okay. And, Manolis, you wanted to come in?

This is about another topic; I think there were many questions that I wanted to come in on. I think Gareth asked the question about morale, and I want to pick it up, because I think it's important. Within the community dental service, the morale is very low, and it has been low for a number of years now. We ran surveys, and we have causes of stress that are: the excessive pressures of the waiting lists, of course, and the backlog; the limited control that we have over the diaries; poor communication sometimes with the management; and again, what we said about dysfunctional IT systems. This was noted by our members. Now, poor morale, if we have pressure for a prolonged period of time, unfortunately, this can cause mental health problems, and this is a very serious issue in the dental profession at the moment. BDA Cymru has done two surveys and the results were stark. We see a huge rise in mental health problems. I was discussing recently with two colleagues and one said, 'I feel abandoned where I work'—those were the words. And the other one said, 'I had to seek mental health support'—I think it was Canopi, the mental health service—'because I felt responsible for the amount of patients waiting on the waiting lists to see me.' I think that's a very serious issue, and it has an impact on our lives, on our families, on our careers, and, of course, it has an impact on service provision as well.

Absolutely, yes. Thank you very much.

I'll bring Gareth in. Do you have any more questions, Gareth? 

No, I'm done, Chair.

Absolutely. Ruwa.

Just on mental health in the GDS—and I've highlighted this several times with Rob and with the Cardiff and Vale team—mental health is incredibly, incredibly—. The mental health of the teams is just in crisis, really. I think you as a committee, last time, put forward that we shouldn't be working to targets, and these targets were putting untold amounts of stress on dentists. Like Vicki said before, move towards care and not targets, and move towards outcomes where we're not bleeding into maybe community dental or accident and emergency, and not just numbers. Because all these targets are the No. 1 reason why contracts—well, in our area—get handed back, because they're not able to hit these unattainable targets.

Okay. Thank you, Ruwa. We'd better move on. The last set of questions, perhaps, from Joyce Watson.

Well, I know the answer before I ask the question. I know the answer is that you'd like more money. So, there's no point in asking, 'Do you want more money?', because it's obvious. So, if you had more money—that's what I'm going to ask instead—where should it be spent, and what should be prioritised?

So, who wants to answer that? We're talking about, if you got a limited amount of additional money, what would be the priority spend.

The priority for me at this minute in time would be an integrated care model. So, resources and facilities to deliver urgent access, ongoing care and an intermediate service, so that you can attract and retain individuals to deliver that. Now, that's a slightly ambitious target because that's capital funding and all those kinds of things, but you asked, and that would be it. And the other thing would be capital funding to deliver on domiciliary vans and care, for me.

Manolis.

If it's a hypothetical question, I would say prevention. First, make sure that we support adequately all the prevention programmes. Prevention is key on all levels. Secondly, I would say supporting the CDS to stabilise and to become as strong as possible, so that we can provide the care that we can to the most vulnerable groups. And, third, I would say engage with the general dental service and improve their contracts, because the general dental service is the backbone and, at the moment, I believe that slowly it is dying. So, I would like a lot of engagement with the good colleagues of the general dental service.

Okay. Because the next part of that question was the priority in tackling the inequality. There's clear inequality in the dental service, according to all the witnesses. So, if there was one thing that you could do to help tackle that inequality, so it's a key message that we give to Government, what would it be?

Ruwa.

When talking about reducing inequality, I wouldn't say there's one thing, but, definitely, we talked about fluoridation before. In terms of accessing the people who have been affected the most, trying to get more people from those communities to get into dentistry. So, people who are, maybe, from rural backgrounds or are from backgrounds that normally don't access services in the way we'd like them to, to get more people into dentistry from those backgrounds, because then they can go back and service their communities.

And then, the contract as it is, even the contract variation and the reform that we had, is not tackling inequality at all. So, they're not targeting resources towards high-need areas or low-need areas. So, we need a very big change in commissioning, where the commissioners, instead of looking for equity betwen providers, look for equity for patients, so that the patients that need the most get the most, and the patients that don't need the most get the least. So, if we can do that, we're—. The contract right now is a one-size-fits-all, and even in contract reform we're still on one-size-fits-all, and that's a very big frustration. So, if we don't get that right, we will continue to increase inequalities.

Okay.

I'd start off with prevention, obviously, but if it wasn't prevention, I'm with everybody, really: it is about access. But it's about access in terms of the right person, seeing the right patient, at the right time, at the right site. Therefore, that integrated-working model would really help. So, therefore, we would be channelling those patients, identifying them, channelling them to the right services. Therefore, it's value for money and the right person would be seeing them. So, it's having that integrated-care-pathway approach whereby we're all talking and working together in order to be able to utilise the funding as best we can. And I think this is an opportunity.

I think one of the good things that COVID did is that community dental services and general dental services all worked together really well. We had to. We had to. We had to. We had urgent dental centres and everything like that. It would really be such a shame to lose that and lose that momentum now. Even now we get people phoning up now, asking for opinions on things, and vice versa. You know now the different general dental practices who can take patients on. We are working that way, and that's the sort of model I would love, and I think that would really help with the inequalities.

Okay. So, if you’re working that way now, and it was forced and necessary, is that happening everywhere? Or is it just in some places?

Around Wales, I think it's working really well. All of us are working really well. But we don't have enough access. At the moment, that's the issue. We don't have the workforce, we don't have that. But if we did, I think that we would have that fantastic—. The way that we used to work with our general medical practices, for example, down the road, who'd suddenly find an ulcer in a mouth and say, 'Will you go and see Rob down the road, Rob can have a little look at it?' We seem to have lost all of that, and I think if we start to bring that back together, that will stop the inequalities that we're seeing at the moment and, therefore, also that integrated working that we all valued. We value what GPs do and they value what we do and how we can all work together.

Okay, thank you.

Thank you. Can I just ask a process question, just to help me understand? If a member of the public—. Maybe they've attempted to register with an NHS dentist for check-ups, but they can't do that. They then get into an element of needing to see a dentist. What should they do?

So, that comes down to access waiting lists and access to services, I suppose, in a way. I think the challenge a lot of the time with patients is that they know where the dentists are, local to them, although I use the word 'local' loosely within Wales, because the geography doesn't help with a lot of things. Practices as well have been placed in historical places. That's where they were and that's where the commissioning is. So, where the service is delivered and where the need is are slightly different. Within our health board, we have taken the decision of setting up a central waiting list. I know that's caused comments that you’ve looked at before. That has come with its challenges. Having a waiting list, obviously, means that you have to have resources in order to send individuals from—

How do you do a central waiting list if each dentist practice is—? Because a member of the public walks in, registers with one and says, 'Can I go on your waiting list?' They say, 'Oh, yes, okay.' Do they then tell you, or do they—?

So, the way we've done it is twofold. Ideally, I think there should be a single, automated waiting list that's managed centrally. And I think there are some—

And that works live with each practice, because they go into a practice. 

Yes, so—

So, it's not that the member of the public contacts the health board and asks to go on a list; they go into the practice and say, 'I want to go on a waiting list', and you're suggesting that waiting list works centrally across the health board area.

It should do and it should be validated as well, because I think one of the challenges that we've had is we had no choice but to set up the waiting list, especially for the Bridgend area, which is challenging for us. We've set that up in a way to allow patients not to have to ring around every practice. But that still doesn't stop some patients, actually, ringing the practices and sitting on a waiting list there. At this minute in time, we are unsure whether or not all the patients are sat on about five different practice waiting lists, or whether they're sat on ours. For me, I would like to see a simple automated system. There are software providers out there that can do that. The e-referral system does have some capacity in doing that—

But you're saying you've got a central waiting list now.

We have a central waiting list that we've had to set up ourselves within the health board, which is administrative and resource person heavy at this minute in time. We've brought in QR codes, we've brought in phone lines, we've brought in e-mails. But, again, that's quite burdensome for patients and burdensome for the administration of it, and also the validation of those lists. I think that's the biggest challenge. I might tell you that I've got 3,000 patients waiting on that list, but I don't know whether or not they've already accessed somewhere else at this minute in time. So, I think, if you're looking at that system, it needs to be central, it needs to be integrated, and it needs to be automated.

So, you think there should be a central waiting list, by health board, across Wales.

Yes. There's a caveat with that—

Yes.

—because obviously if there is a central waiting list then we've got to have the resources in order to where we can send those patients.

Yes. But the waiting list is separate, isn't it? It's still a waiting list, but—.

A waiting list will define the needs of those individuals who are looking for the care. Whether we have the resources or the capacity to deliver that care, or we're just going to have a growing waiting list, that's the balance that you look at there.

And why is it that you think other health boards in Wales, perhaps, are not having a central waiting list?

I can't answer that.

Well, I'm asking you to, I suppose, speculate on what the obstacles are for them, I suppose.

I can say for Aneurin Bevan it's that we don't have the resources to actually manage that list. They take a lot of managing, central lists: patients ringing up, 'Where am I? Where am I on that list?' and all sorts of people phoning back. They don't turn up at a practice, so therefore they then phone up and say, 'Oh, well, I want to go back on that waiting list.' It's a lot, and if you've got 10,000 or 20,000 people on a waiting list, that's a huge number of calls coming through.

So, you're all saying on this panel that you're all in agreement that there should be central waiting lists by health board area, but you need the resource to do it. You all agree with that point, yes?

The appropriate resource.

Yes, right. Ruwa, you wanted to come in.

I'd just say that in Cardiff and Vale and Cwm Taf Morgannwg they do have a central waiting list. The practices will still have their own waiting lists, because historically practices had their own waiting lists. Then, through COVID, these two health boards hired people in, dental nurses in, to manage waiting lists. So, they've hired people to come in and manage their waiting lists. Cardiff and Vale has 14,000 on there. Rob knows his numbers, but last time I checked with them it was about 1,000. What happens is, if we were just to do something simple like what we're trying to do now, which is to collect an NHS number, if the data was live when the NHS number links up to a course of treatment, it should just automatically take them off. 'This patient has had a course of treatment at practice X, Y, Z,' and it would automatically take them off, but that would require joined-up thinking. At the moment, because everyone is independent and everyone is using different software, health boards are only just starting the central waiting lists, which is helping. And we take patients from the health board in my own practice, but I have to ring them up on a Saturday or a Sunday, and on a Saturday or a Sunday in my free time, because we're not paid for the admin of trying to get in touch with these patients. When I ring them up they say, 'Oh, I found another dentist.' There are numbers to access urgent care with the health board and a central waiting list in those two health boards.

Okay. We're over time so it's quick-fire questions and answers, so very short. Jack.

Mine's just for the record, really. This seems to me like the community pharmacy fax machine issue. It's just—.

The fax machines, yes.

It needs to be on the record. It does.

Yes. We recently had a debate about access to—. Access to—

It's the joined-up approach, isn't it?

Fax machines—using fax machines. The NHS is still buying fax machines. Not only using them, but they're still buying them. Sorry, Manolis, you wanted to come in.

A very quick comment to add regarding the waiting lists and the data available. Of course, I am in favour of locally held waiting lists by health boards, but this information should be open and should be open for scrutiny, because if we don't have transparency on the data, we don't have accountability, and I think this is an important issue. In the BDA, we have asked in the past and we have not had the responses that we wanted.

Sure, thank you.

Community dental services know their waiting lists. We know how many patients are waiting. We know that. We know, and we're constantly trying our best, aren't we, to identify those very vulnerable patients who need to be seen first, et cetera. So, it's different for community dental services than for the general dental practitioners.

It could be made simpler for you as well, with IT solutions and so on. 

It could be, yes. 

Okay. And just another process question: at the moment, for someone who needs treatment but they're not registered with a dentist, they phone up their health board; at that point, then, do you see that patient as a community dentist, or do you then triage that out to a general dentist? 

It will vary from health board to health board. If we look at our own waiting list, and I'm talking about Cwm Taf Morgannwg now, we utilise the contract variation, and we've had agreement with certain practices that they will work with us and take some of our patients off the waiting list on a quarterly basis. 

So, you pay them for that service, for that emergency treatment element.

It's part and parcel of their metrics anyway, so there's not an additional payment. We are sourcing patients for them in order for them to meet their targets, and they are supporting the health board in order to manage the waiting lists. In some areas, we clear the waiting list on a quarterly basis; in other areas, where there are fewer dental services, we're unable to clear those waiting lists. So, that's the challenge with any waiting list: yes, we can collect it, but we've got to have somewhere for these individuals to go and the resource to do it. 

And just to get this straight in my mind, if somebody needs urgent treatment on a Saturday morning—

There's a separate urgent line, so they can access urgent care within 48 hours.

But sometimes they get seen by the community dentist and some health boards across Wales have got agreements with general dentists. 

Some within it, but within our health board the vast majority are seen within the general dental services. 

Right, okay. Got it. 

At weekends in Aneurin Bevan, for example, it's the community dental service that runs the out-of-hours. So, that's something extra that's been given to us with GDS funding. 

Okay, that's helpful. Just looking around the room, has anyone got any last-minute questions? No. Thank you for your time this morning, it's been a really helpful and fascinating session. Diolch yn fawr iawn. Thank you very much for your time. We'll take a 10-minute break and come back just after 11:00.

Welcome back to the Health and Social Care Committee. I move to item 3, and we continue with our fourth session now with regard to our inquiry into dentistry. I'll ask the witnesses to introduce themselves for the public record.

I'm Angela Jones. I'm interim director of health and well-being with Public Health Wales.

Hi, I'm Anup Karki, consultant in dental public health within Public Health Wales.

Bore da. I'm Ivor Chestnutt. I'm the professor of dental public health at Cardiff University.

Thank you ever so much for being with us and for your papers ahead of the session as well—thank you very much for those.

We've just had some information in regard to the current state of oral health of the Welsh population and also in terms of access to dentistry as well. I'm just wondering if you've got any opening comments in regard to that.

Perhaps I could start on levels of oral health, Chairman. I would refer the committee to figure 2 on page 9 of my written evidence, which sets out the improvements that we've seen in oral health in five-year-olds over the last 10 years, in the period between 2008 and 2016. So, oral health in young children, prior to the pandemic, was improving.

If we think about teenage children, I think it's important that we remember the significant improvements that we've seen in oral health in Wales over the last 30 or 40 years. In 1973, the average 15-year-old had eight decayed permanent teeth—

And just for committee members, it's in our committee pack on page 48—just to make sure we've got the right information in front of us.

Thank you. So, the point really is that since the introduction of fluoridated toothpaste in the early 1970s, we've seen a very significant improvement in oral health in Wales. 

As far as the adult population is concerned, to summarise oral health there, the adults are in three cohorts. There is an ever-diminishing number of older people who have lost all of their teeth. Those were the people who grew up in the early and middle part of the twentieth century. There then are the people who grew up prior to the introduction of fluoridated toothpaste—those who are my age and older, who retain most of their teeth, but have that because of significant intervention in fillings and crowns and bridges. And then we have the younger cohort who are growing up largely free of dental disease unless they grew up in a deprived area, because the disease has gone from being normally distributed in the population to becoming concentrated in those who come from the most disadvantaged areas. Dental disease is a disease of poverty, and that's where the problems are concentrated.

We discuss mainly dental caries; that's the major problem. There are of course issues with people's gums, and there's a proportion of the population who are at a high risk, 10 to 20 per cent, and will lose a significant number of their teeth over their lifetime due to periodontal disease. And then of course, the most serious and life-threatening condition that affects the oral cavity is oral cancer, and that affects about 50 [Correction: '250'] new cases in Wales every year.

Thank you. If I could just widen the question—. There's quite a bit of what you said there, Professor, that other Members will want to have specific questions on later, so I'll let them dig into that. But I suppose the question I'm asking is do we have a clear picture of access to dentistry. I'm wondering if you want to comment on that aspect.

On access to dentistry, general dental services collect quite a bit of data, and that goes to an organisation called the NHS Business Services Authority. There's a form called an FP17 form for each course of treatment a dental practitioner does under a GDS contract. They fill in that form and send it. The population overall varies between children and adults in different health boards—it varies between areas—but overall, 50 to 55 per cent of the population over a 24-month period accessed dental services before the pandemic. Obviously, the pandemic has had an impact during those two years, and the access has dipped.

Surveys of the public we've done before show that there'll be a proportion of the population who will just access private care, and there'll be a proportion of the population who just access urgent dental care, regardless of what their need is. There'll be a proportion of the population who will just access on and off for a course of treatment, and they think they have got good enough oral health and don't access for a while. But that 50 to 55 per cent of the population used to access on a regular basis, although that also includes urgent dental care as well. So, that's the level of broad access, but again, there are variations based on deprivation, variations based on geographical areas, and other variables that change the access.

And in terms of oral health, which population groups would you be most concerned about in terms of access?

I think Professor Chestnutt highlighted that disease in the population is going down, but most of the risk factors are on those highly deprived areas. Most of the risk factors for dental disease—periodontal health as well as dental caries as well as oral cancer and everything—are concentrated on those deprived areas. But the access under the UDA system—at least with the current units of dental activity system—isn't based on need quite. So, there is that 50 to 55 per cent of the population who access dental services, but within that cohort, there'll be those who need less and others who'll need more, and at the same time, there'll be a cohort who couldn't get to that dental service.

We may come to this later, but if you design a service based on need and reorientate the whole system towards those who need the treatment first and prioritise them, then I think a lot of that access problem will probably improve. But obviously, there'll be a trade-off, because a significant proportion of the population are used to going every six months—they want that, they value that. If you want to reprioritise within the limited pot of money, then you'll probably have to reprioritise towards those with the greatest need first, and the vulnerable groups.

Angela, if I can bring you in, but perhaps widen the question out as well in terms of how much do we know about people accessing private dentistry as well.

If we widen out the question of inequalities first of all, bear in mind that we don't just look at oral health and dental health in isolation, because the people who are most in need, or where that need is, are also the communities with the highest levels of obesity, the highest levels of consumption of sugary and high-energy foods, the highest levels of smoking and smoking-related diseases—we've heard about the oral cancer, which is correlated as well—and other related conditions such as obesity. So, we end up with communities that have multiple inequalities and the health impacts multiply for those, so they're compounded, really, in communities and in vulnerable groups in particular. Often, they're the groups that find it harder to access the services, to get there, to take time off work, to take time off work to take children there; those communities where you might have people with a high level of mental health need, substance misuse, a whole range of factors, really, that contribute and would need us to have a different approach to addressing those.

So, if you look at, potentially, 55 per cent of the population, rolling population, generally using NHS dentistry, roughly about 20 per cent of the population using private dental services, then you're still left with about 25 per cent of the population that are not regularly using dental services and having that dental support. So, going back to what my colleagues have said here, really, if we were to reorient services towards a needs-based service where you provide greater service, greater prevention in the areas and in the communities that need them most, then that would begin to address some of that inequality.

It doesn't exist just on its own. As I said with the other elements that contribute to poor oral health and poor health generally, other initiatives such as 'Healthy Weight: Healthy Wales' and the tobacco control strategy and the whole reorientation of primary care to look at a more prevention, early intervention focus with the community, making every contact count across health professionals—all those contribute, really, as well in terms of the wider impact.

And perhaps just a view on whether there's a two-tiered system being created in terms of people accessing a private dentist simply because they can't register with an NHS dentist.

I'm sure that may happen. If I could just return to the point before we address that, Mr Chairman, of need, I think it's crucially important, and the reforms that are being implemented under the new chief dental officer are starting to address the issue of people attending the dentist when they need to. The model worked on a high volume of low-need patients attending more frequently than was necessary. That was the situation prior to the pandemic, in spite of guidance from the National Institute for Clinical Excellence 20 years ago that patients should be recalled in relation to need. The steps that have been taken by the centre over the summer to restrict check-ups to one per 12 months for those who are in low need is a good step in making available additional resource.

I think there is no doubt that people who, prior to the current situation, would have accessed their care through the NHS may well be forced to have their care privately. I know that last week you discussed the question of central waiting lists, and I think that's something that I could give you some further information on, in that, in Cardiff and Vale health board, we have a central waiting list, and we currently have 15,500 patients on that waiting list. If you join today, then it's about 26 months before you could expect to have an NHS dental appointment.

But the reason why we went down that line, and why I think it's a good idea, is that until now we haven't had a good handle on what the demand for NHS dentistry is, and it hasn't therefore been possible to do an accurate needs assessment in terms of what the demand is, or the need is, out there. So, by having a centralised waiting list, we've been able to heat map where the demand is and therefore allocate resources within the board to those in greatest need. It also provides somewhere definite that we can refer patients to. I think that we are, at the moment, able to provide emergency dental care for most patients, but it's, having sorted the immediate emergency, where do we direct them, and I know that that was discussed in some detail in your session last week.

So, on the central waiting list, just ever so briefly, tell me what the main obstacles are, and how to overcome them.

The waiting list allows us to capture what the need is to then be able to direct patients to practitioners who have spaces available. We can also use that, when we have additional resources, to direct where those are given towards the most need. It also makes the need explicit. It's quite a leaky waiting list in that it requires a lot of administration to run it, because, when patients have been on a waiting list for a time, when they get towards the top, about 30 per cent don't actually need to have dental care at that stage because they've either accessed it elsewhere or they've changed their mind or they've moved away or whatever.

But you've got a central waiting list, and we heard from the last set of witnesses this morning how, for them to move forward with a well-working central waiting list, there would need to be more resource for IT to support that. But you're suggesting that your waiting list is already operating well now.

If we had better IT, we could make it run more efficiently than we do at the moment. But we can make it work.

Okay, that's interesting. How do we get to the point where we have a service based on need?

I think we have to define what need is and what the state can afford to provide, and that requires that being made explicit. We haven't been able to provide comprehensive dental care for everyone in the population since 1952. That's when patient charges were introduced. So, there need to be—and I guess this is on your side of the table rather than ours—explicitly stated criteria for what can be and can't be provided via NHS dentistry.

What should that be in your view? How would you define—how would you define 'need'?

It would depend on individual circumstances that would be needed to render an individual free from pain and to be able to eat, speak and socialise without undue discomfort or embarrassment—that is what you would want to be able to provide for everyone. But that probably wouldn't—. Currently, it doesn't provide for the provision of implants. It certainly doesn't include whitening your teeth. It would probably, unless there was a massive increase in funding, remain the provision of plastic dentures rather than metal dentures on the NHS. So, it's that level of detail as to what exactly the state is able to afford and able to provide, and that would provide clarity for the practitioners and for the patients as to what they can expect.

Rhun, do you want to come in at this point?

Who would like to take that? 

Do you want to me to start?

Yes, go ahead.

I can start. Thank you for that question. I think prevention has to be multifaceted. A lot of prevention needs to happen outside dental practice. Obviously, in all clinical settings, not just dentistry, but wider primary care, as Angela mentioned, everyone has got a role to play in improving oral health. A simple question around oral health and oral hygiene can trigger that oral health conversation in various settings. So, clinical settings have a big role, but I think the ideal system overall—a lot of prevention has to happen outside the dental practice setting, because there are limitations in terms of what can be done within the clinical setting as well. So, when you're talk about 'wider in the community', we've already got the Designed to Smile programme, and that obviously needs to be recovered on the back of the impact from the pandemic. In our submission, we talked about—and Angela touched on—all the other risk factors that are prevalent in highly deprived areas, as well as the vulnerable groups. So, how do you make sure that they get all the prevention they need? For the vulnerable groups, for example, all the care plans—. If they need support in care, their care plan has to have an oral health element in it, but so many care plans do not contain oral health and oral hygiene in there. Care homes are one of the examples. At the community level, I think, somehow, we need to have intervention to reduce the consumption of sugar in the population. Overall, we call it an upstream, downstream, midstream approach in public health, but I think a lot of upstream approaches are required to reduce our overall population's sugar consumption, and most of that in the most vulnerable in society and the deprived areas; they consume more of those risk factors for dental disease, as well as wider communicable diseases. So, I think it has to be multifaceted, multimodal and a multi-agency effort.

It's interesting that you put it in the wider context, and not focusing on dentistry. Who else wants to describe, again, the importance of early intervention and how preventative dental healthcare looks in an ideal world? 

I think, like many chronic common diseases, oral diseases are influenced by people's lifestyles and life circumstances, and that's got to be where we tackle. And the interventions to prevent obesity—reduce the amount of sugar that people are having in their diet, the tax on sugary drinks, the removal of vending machines in schools, which the Senedd achieved many years ago—all of these types of things are clearly important. But, in households that are disadvantaged, it's an issue of initiating the personal habits. I've referred already to the key role played in preventing tooth decay by, twice a day, brushing with fluoride toothpaste, and what the Designed to Smile programme does is socialise that habit in households where it might not otherwise happen, and there's not only the tooth brushing in the schools, there's the provision of home packs, which sets up the precedent and makes available the resource for the children to then be able to—. It then becomes a habit. The personalised aspects of looking after your health need to be ingrained and become a habit, and that's the real issue behind Designed to Smile, and that's what it's designed to do. And that's why we don't provide, I don't think—. One of your questions was, 'Does it need to be extended to six to 10-year olds?' It doesn't, because that wouldn't—. You can achieve it in the early stages, as the evidence that we've looked at earlier shows.

There'll be other questions, I know, on Designed to Smile specifically.

So, it's a combination of health education, health prevention and health protection. They're the three things that go together to promote people's health. It's very important that we don't see oral health in isolation from the rest of the body; it's a joined-up approach, and that's the battle. Anup and I are fighting the case for, if there is a smoking cessation campaign, to remind people that smoking contributes to oral cancer and to periodontal disease—we need to keep that on the agenda. It's not about just purely oral health; it's about people's overall health.

Anything else to add on the general preventative picture?

Yes. I think we need to look at the wider environment, certainly, and the life course as well, so that we're doing prevention right from the beginning, from pregnant women, to breastfeeding, healthy weaning of children, regular attendance at dentists, and targeting those groups particularly that we know are not regularly attending, and having that education and support. Designed to Smile is meant to pick up a lot of those children, because it's targeted, obviously, but it needs to be reinforced at home as well. So, it on its own is not—. It will help, but it is not the answer on its own. We have to look at that wider environment and through the life course around smoking and diet and so on; the food environment more generally that we're exposed to from schools, in our workplaces and our communities as well. So, it is much broader, and making sure that all our contacts with people—making every contact count, whether it's a GP or a nurse or a health visitor, all those contacts count, and support.

So, where are we falling short? Because the long lists of people waiting for treatment suggest that the preventative, you know, isn't working. Messages aren't getting through, or is it that cohort of the population affected by poverty in particular that is more heavily affected? Identify those gaps. 

So, I would say that many of the people seeing their dentist are there for a check-up, and we know that, somewhere between 30 and 40 per cent of them have good oral health. They're judged on the assessment of clinical oral risks and need risk assessment sheet as green across dental caries, periodontal disease and mucosal disease. So, three quarters of the people—. So the challenge is that lots of people on the waiting list to see a dentist don't actually have disease as such; they're just in the good habit of going to the dentist regularly. It's the people who fall through the gaps, and vulnerable groups, and I think we need to be thinking about how we provide access for them, and they get access to care—those who are less able to negotiate the system.

If I could just add also, going back to the wider population, if you have children and you try to find a healthy food in the supermarket, you can just look at the supermarket and what's available there, trying to find a healthy snack, and if you're talking about people living on a minimum income, trying to afford healthy food is a challenge as well. So, you go to the supermarket and all the 'buy one, get one free' and all that sort of food is all unhealthy. They have lots of sugar in them. So the natural instinct is to buy them if you've got less money. So we have to also make the healthy food affordable for those families. 

This is difficult for us as a committee, because these are population-wide issues that affect everything from dental care to cancer and all that. It's difficult for us to make recommendations other than the very, very obvious ones. So, if we had to try to bring it down to recommendations that we can make as a committee around strengthening preventative, where would the focus be?

The first one is to recover the Designed to Smile programme we had, because the pandemic has had a serious impact on the Designed to Smile children. The target is towards those three most deprived—[Inaudible.]—areas through the nursery and primary school setting. So we have to recover that programme. We've still got a long wait before we can recover that programme. We have to be focused on that, and because it relies on the schools and the nurseries to participate, some of them may not feel ready to start that programme again, so we need to make sure that that's not diluted, and we focus on that. 

Beyond that, as Professor Chestnutt said, we need to make sure that all the healthcare settings contribute to our oral health agenda, and not just the dental practices, obviously. And the dental service model has to be preventative as well, because you can't treat your way out of this level of disease we have in the population, as Professor Chestnutt suggested. Most of the disease is double—. In the most deprived areas, the diseases double the diseases in less deprived areas. So, all the effort has to be not just through the dental, but also programmes like Flying Start, the Healthy Child programme, and all those sorts of programmes have to include an oral health element in them.

And on the other end of the life course approach, as Angela suggested, on the older population we have got the Gwên am Byth programme for the care home population, but most of the disease in that population happens before they enter into care homes. So, unless every care package for the older generation has got that oral hygiene and prevention element in it then you're just firefighting when they get to the care home, because you've got lots of disease. When we did the care home survey almost 10 years ago, almost 73 per cent of those living in care homes had tooth decay, but there's no difference between those who are living there for longer or for the short term, within a year. So that means a lot of disease probably happens before they got in.

So, it's always about making sure that, as we call it in dental public health, we are putting the mouth back into the body, so that the care plan for all the vulnerable groups has got oral health in it. 

I think if we return to the issue of people who are on waiting lists, or who aren't seeing a dentist at the moment, prevention is one thing, but we do need to make sure that the system, and then the reform of the system, is set up in such a way that the practitioners are willing to take on and treat the higher needs patients. And there's a disincentive to do that at the moment, and there certainly has been under the 2006 contract. And so, I would strongly argue that, as the system is reformed, we certainly don't want to go back to fee pricing of treatment, but we need to have a system where the reward for the practitioner is proportionate to the need of the patient. It doesn't make sense to be paying someone the same money for treating one filling as they get for doing six, and that needs to be addressed. But it's how that gets worked out and the balance between a capitation system, which we're going towards, and a fee-per-item system. And it's getting the balance between those two that's the issue.

Thank you.

Thank you. Sarah Murphy.

Thank you, Chair. Thank you for being here today. You've touched on this in some of your previous answers, but I'd just like to drill down a little bit more into the oral health of children and older people. So, Designed to Smile aims to improve the oral health of young children in Wales. But do you think that there is a gap in provision for older children—so, say, between six and seven—who fall outside the scope of this programme?

So, when Designed to Smile was initiated, it didn't go up to age six, seven, and to year 1, year 2. That is an important age, because the first adult teeth are emerging at around age six or seven. So, I would see scope for Designed to Smile being extended to that age, because that's the age when fluoride varnish or fissure sealants can be applied to newly erupting first permanent molars, which are the teeth that are most likely to decay in that section of the population that are prone to dental disease and dental caries. But I wouldn't see any need for it to be extended beyond that, because I think, given the limited resources that we have, we've got to direct them to the areas of greatest need. And in Wales, we've taken a proportionate universalism approach, where the Designed to Smile programme is targeted in relation to need. So, it's about 53 per cent of schools, or nursery schools and pre-schools, that are involved in the programme. To expand further will just dilute your effort, and we haven't got the workforce to do that.

If I can come in. I think that also links to the dental service access we talked about. So, if the rest of the population, and that child population, had regular access to the dental service, what they get from the dental service with the ongoing reform is fluoride varnish twice a year, and that—. Again, Designed to Smile offers that, but, also, practices are increasingly offering that fluoride varnish in practice as well. So, it's a combination of those two together. But I think it comes down to the—. If we were to expand without recovering the existing programme first, that may dilute the effort. So, we need to make sure that the programme is recovered sufficiently. And then, at that point in time, you probably need to review what can be done more.

Thank you, that's very helpful. And looking at another cohort then of people, do you think that there is sufficient understanding of the oral health needs of people aged 12 to 21 in Wales?

We carried out a survey of people aged 18 to 25, so we do have evidence on what they perceive their oral health to be. If I can just find what was said. Fifty-eight per cent of 18 to 25-year-olds are classified—there's a self-classification—as oral health as 'good' or 'very good'; 30 per cent reckoned that their oral health was 'fair'; and 12 per cent reckoned that it was 'bad' or 'very bad'. So I think, as I said at the very beginning, oral health in teenagers has very, very significantly improved over what it was, going back over the years, and the disease has become concentrated into a smaller group of children from disadvantaged communities. So, for the age group that you're asking about just now, the answer has got to be getting them into the habit of regularly attending a dentist in relation to their need, and that's—

So—. Sorry. You said there that—. The information that you just gave us, the statistics at 18 to 25, do we have any of those for 12 to 21? I suppose what we're trying to identify is is there actually a gap there, then. Has any research or consultation been done with that specific age group?

We have, other than the five-year-old survey we previously mentioned, we also do a 12-year-olds survey, to look at the permanent—. Because disease level at 12 years old is quite important, because if you've got lots of disease in permanent teeth that accumulates over a lifetime, and then when you're older, that's got a lot of cost for the individual, as well as the society, as well as the NHS. And 12-year-olds, I think, will give enough—[Inaudible.]—because if you think about most of the diseases being in those in the most deprived areas and vulnerable groups, the information I think is sufficient to understand where the disease is, and it's all about what do you do about that, after that. So, most of the disease, dental disease, correlates well with deprivation as well as socioeconomic status. So, we may not know the exact percentages of the tooth decay in that population, but we know where it is.

But just to clarify here, we've got a survey at 12, and we've got information from 18 to 25. So, the 12 to 18 age group, though, there isn't really any information from them.

No. Again, I suppose, doing this population-level survey is quite costly as well, so it depends on how much added value you get by doing that survey as well. And you can—

[Inaudible.]—added value from doing that survey.

I don't think there is, because there are lots of other groups you can look at as well—all the vulnerable groups you could look at.

Yes. I suppose, why is that age group perhaps not such a priority?

We used to do five—. So, the programme was, annually, five, 12, five, 14, five, 12, five, 14. We abandoned doing the 14-year-olds because, logistically, it just became too difficult in the secondary schools to get the children and take them out of class, and so, there were practical reasons. Plus, as Anup has said, we're not going to gain much more from surveying people in between 12 and 18. The information that we get at 12 lets us know where the problems are and where the resources need to be directed. So, we think that that's sufficient.

Yes. Thank you. Sarah.

Yes, of course. So, then, moving on, the Royal College of Paediatrics and Child Health has suggested that the Welsh Government should resource and support  the fluoridation of public water supplies, particularly for areas where there is a high prevalence of tooth decay. So, what are your views on the benefits of what this could be, and do you have any concerns or barriers to implementation too?

Professor Chestnutt, you mentioned this in your opening comments, I think. Do you want to make a comment on this first?

About water fluoridation? Okay. So, we could spend the remainder of this session, we could spend the remainder of the day, Chairman, talking about water fluoridation. So, I spent the first half of my career pursuing water fluoridation. I'll try and summarise what the situation is: water fluoridation is effective in preventing dental caries and would help address inequalities in oral health, if the level of fluoride in the public water supply was adjusted to the optimum level. Technically it's possible, although the capital costs in setting up a fluoridation scheme would be very substantial. The issue is that there is a small but very vocal anti-fluoridation lobby who, over the last 40 years, have prevented the implementation of any new fluoridation schemes anywhere in the United Kingdom. They have, on two occasions in England, within the last 10 years, made very significant efforts to try and implement fluoridation—in the area around Newcastle and around Southampton. And they got right to the level, went through a judicial review, and still the water there isn't fluoridated. So, water fluoridation is a political issue; it's for your side of the table rather than ours, I would suggest.

When I came to Wales 23 years ago, we looked seriously at implementing water fluoridation, and, at that stage, the then First Minister explained to us that he didn't think they could get consensus on fluoridation in the Senedd. So, my concern is, if we had water fluoridation tomorrow, that would be of benefit to the people of Wales. It would be safe. The problem is these people who are opposed to fluoridation—there isn't a disease under the sun, hardly, that they haven't linked with water fluoridation. When the evidence is reviewed, there's no evidence to suggest that fluoridation has any adverse effects other than increasing the level of fluorosis, which is white mottling on the teeth, which people are usually quite happy to live with. But, I think that if you were to make a recommendation of water fluoridation, that would end up in a lot of resources being devoted to that—your e-mail bag would be absolutely full, as would ours. I think that, at this point in time, it's very much more important that we be pragmatic, as we were in 2008, and have a scheme that gets fluoride into contact with the teeth of the deprived children in Wales, which is Designed to Smile, rather than pursuing the dream of water fluoridation. Because, my position is, having spent 20 years trying to pursue water fluoridation, it is a dream, and I think, as I've said, from your side of the table, on that one, it would be very difficult to make it happen.

That's a very pragmatic and helpful response, I think—a very honest response. Thank you. Sarah.

Thank you very much. Just my final question, then: it's also been suggested to the committee that extending the use of fluoride varnish as a preventative dental care initiative could be extended to care homes, so what are your thoughts on this?

The Gwên am Byth programme at the moment is, in a way, plugging the gap. If the care package of all vulnerable groups, including those in care homes, had an oral health element and an oral hygiene element in it, we'd probably need less of an effort from the NHS side of things. So, that's plugging that social care gap, if you like. On fluoride varnish, again, the evidence base mostly on fluoride varnish comes from children. I don't know how effective it will be on that care home population. But, if you extrapolate that evidence base from children, it should work, but, again, we have to evaluate. Any scheme like that has to be evaluated—how much it costs, and where the staff come from—because, ultimately, there are big workforce constraints in everything we've discussed just now. 

So, we're running a large National Institute for Health and Care Research-funded clinical trial looking at prevention in care homes. It's led by Professor Paul Brocklehurst from Public Health Wales and Bangor University. It's across Wales, Northern Ireland and London, looking at what works in terms of prevention in care homes. The average time that an individual spends in a care home is 18 months, so we have to look at what is important in that 18-month period, and what is important is keeping the mouth comfortable, having the teeth cleaned, making the mouth feel fresh, preventing them getting fungal infections. They're the immediate things that are important, and that's what Gwên am Byth is about; it's about training the care home staff to not be scared. We've done some work looking into this, and the care home staff, who do all sorts of intimate care for patients, are scared when it comes to cleaning their teeth; they're scared of hurting the patients. That's the issue, and it drops down their agenda. So, what's important in care homes is comfort, and we have to remember the time horizon in which we're working with patients who are resident in care homes.

Thank you very much. Thank you, Chair.

Thank you, Sarah. Joyce Watson.

Good morning. I want to talk about the dental workforce. We know that there are problems with retention and recruitment. So, we'd like to hear your views on how we could improve either or both.

Do you want to take that?

I can start. It's multifaceted and quite complex. We've got challenges from the supply side of things, with the impact of the loss of flow from European dentists and overseas dentists coming to work in Wales. That has been impacted. We've got the impact of the pandemic on the workforce itself, and then them reassessing how they want to work, going forward. We've also got different cohorts of dentists wanting to work in different types of services. Fewer and fewer younger dentists want to work in and own a dental practice. Some of them want to work as a salaried dentist as well. But, overall, we do not have sufficient situational analysis, if you like, to say what is the situation. But I think there is plan to do a workforce survey to understand that because, at the moment, you can say, by a head count, how many are there and there, but we don't know what proportion of them work part time, how many sessions are done in NHS, how many sessions are private. So, it's quite complex. But, having said that, I think we can't wait for all that big, long-term planning to be done. So, the intervention has to be there to attract more dentists and dental therapists and other dental care team members to work in NHS dentistry. For the dental care professional, as we're calling it in dentistry—the dental therapist, hygienist, dental nurses and dental technicians—part of the challenge for the NHS is they don't get—. There is a barrier within the dental legislation for them to work in the GDS, so they can't direct a treatment plan and provide that service; dentists have to do the examination and do that technical planning for them, and it doesn't become as efficient. So, it's not used widely. But, again, even if every dental practice in Wales wanted them, the supply side isn't there.

Other elements dental therapists and hygienists mention is there's no NHS pension provision for them, so it's more attractive for them to work as a hygienist in the private sector. So, it's quite complex, but I think it's all about testing and being innovative, and different areas in Wales will need to use different incentives to attract them. Hywel Dda to Powys to Cardiff will have different incentives that will work, so one intervention may not work for all areas.

Okay. We did hear from the previous witnesses about retention and recruitment, and they did mention, particularly, lifestyle changes, and I think people have made those decisions through the pandemic, particularly, as a consequence of it. So, that being the case, if it is that people want more time to themselves and family, and why shouldn't they, and better places to live—there are particularly better places to live, because I represent Mid and West Wales—we would expect to see an uplift in Mid and West Wales because people moved out of cities. That was one of the big factors. But we're not seeing that; we're actually seeing the reverse. So, what is it that we could do, or do you have an opinion on what it is we could usefully do to help attract people under those terms—the terms people themselves have recognised as important to them?

We know that young dentists like to practise near where they qualify because, having been there for five years, they've developed some kind of social network and circle, although they do have to then move for their foundation year. Dentists in rural and remote areas, to use those terms, which I don't like, but you know where I mean—the nice parts of Wales—has always been an issue, and has been an issue all the time I've been here. Cardiff University is making strident efforts to attract to dental school those who might not otherwise have thought of dentistry as a career for them, and we have what's called contextual admissions whereby additional points to get you to the point of having an interview for dental school is given to students who are resident in Wales. So, we're certainly working with schools in Ceredigion and Pembrokeshire and up north to make sure that the students do think about dentistry as a career in the hope that they, having qualified, will think about returning home. So, that's certainly one thing that we can do.

I think the previous witnesses this morning did refer to the career path for practitioners. Just in advance of today, I did ask the students when I was teaching them over the last couple of weeks what their ambitions were. Did they want to own an NHS dental practice? Some of them did. The concept is that NHS dentistry is dead; it's not. We're having an acute problem at the moment because of access. It's because of two things, or three things, really. There was the pandemic, and the disruption there. There were the issues that need sorting out with the funding model, and there are the issues round about workforce. I don't think we want anybody to be pessimistic about the future of NHS dentistry. We spend a lot of taxpayers' money providing NHS dental services in Wales, and it's about reform of the system to make it attractive for people to work in, through the kinds of things that you're hearing and we've just talked about, like incentivising people in relation to the needs of the patients, the guidance for the year ahead being very clear to people who are wanting to provide an NHS contract. One of the things that has compounded issues this year is that, for understandable reasons that we don't need to go into here, there was very late notice both to health boards and to the practitioners as to what the contract would look like. Now, none of you would enter into a contract for your business where you didn't know what the finishing line was, and in essence that's what the practitioners were being asked to do in this current financial year, and that kind of system needs to be sorted out with a central system.

To just come back to the issue of skill mix, dentistry hasn't pursued skill mix to the extent that medicine has, and that's something that has had some resistance from the profession, as there always is in these things, but also the system is not set up to maximise the use of dental therapists, for example. They can make more money going off and doing scaling and polishing as a hygienist in the private sector than, perhaps, a set-up for a practice in Ceredigion. The scope and the range of skills that both hygienists and dental therapists can do now has been expanded enormously by the GDC, and there's a great deal of treatment that they could actually do if a practice was sufficiently well organised to do that and the regulations were set up in such a way to make that financially viable.

Joyce, do you mind if Rhun just comes in on that point? Rhun.

Just on the expansion of medical training, giving more people the opportunity—dental, I should say—to train to become dentists, you can study to become a doctor in Bangor now, and there will be a medical school pretty soon. There has been the development, or there is the development, of the academy in Bangor. What are your thoughts on introducing a dental school in Bangor? Given that Cardiff University medical school was instrumental in facilitating the development of the medical school, will Cardiff dental school do the same with dentistry?

So, there are two things there, Mr ap Iorwerth. The idea of a dental school in north Wales has, again, been around in the 20 and more years that I've been in Wales. We run outreach centres from the dental school in Cardiff very successfully. There's one in St David's in the city centre, there's one at Ysbyty Cwm Cynon in Mountain Ash, and a similar unit could be set up in north Wales. The issues are, in training medical students, they just go to patients that are already there and are trained by people who are already in the healthcare system. To train dental students, you need a very substantial infrastructure set up to do that, because they see patients that wouldn't otherwise be being seen. They wouldn't be being seen in primary care, for example. So, it's the capital costs and the infrastructure that's needed to run a unit. The other issue is, in a unit that is more than commuting distance from the student central base, that becomes a problem, but probably not insurmountable. In Scotland, they have very much gone down the line of setting up outreach centres like you would envisage having in Bangor or elsewhere in the north. So, that model can be there, but of course you need to then attract the academic staff to teach the students, so that becomes another issue. So, I would say, if that was what was deemed to be needed, it's technically feasible. It just would be a matter of cost, resource and people putting their minds to it.

And it would be a reasonable recommendation for us to make for Government to explore the establishment of more undergraduate dental training in the north of Wales.

I think it would be reasonable to explore that. Yes.

Do you have any further questions, Joyce? No. Jack, Gareth, we've got about five minutes for each of your sections. If the witnesses could just be as succinct as possible, so we can finish by about 12:05, if that's all right. Jack Sargeant.

Diolch, Chair. I'll be quick, really, in terms of—. We know from evidence, don't we, that the dental problems and dental hygiene problems are in the most deprived areas. We're living in a devastating cost-of-living crisis, where families and individuals are changing their lives, the way they heat their homes and the way they eat, et cetera. You can envisage this, can't you, going into how they look after their dental hygiene, particularly affording dental charges and even things as simple as getting toothpaste, and so on. I'm just looking for very simple recommendations that we could make that would have an impact, where we could mitigate the impact of the cost-of-living crisis, particularly for dental hygiene. I don't know whether you want to—.

It's a challenge when, ultimately, it depends on the social welfare system we have and whether that's sufficient for people on the most vulnerable end of society and can they afford all of the things you just mentioned. Obviously, dentistry is free for—. Not everyone pays dental charges, and the dental charges in Wales are well below England. In terms of supporting those families, I suppose so many families are relying on foodbanks as well, so the foodbanks could also include toothpaste and toothbrush packs as well. But, I think it ultimately depends on how the social welfare system supports those families. In the twenty-first century, I think they should be able to afford a toothpaste and toothbrush pack if the social welfare system worked well. 

Any other comments?

I had a child who came to see me once when I was a very junior dentist and she hadn't brushed her teeth in spite of my having had a discussion with her the previous time. She said to me, 'Sir, I haven't brushed my teeth because my brother went to stay with my dad last night and he took the toothbrush.' I recite that story to every year of dental students that I teach. That's the reality of things sometimes.

Designed to Smile provides home packs for disadvantaged children, and of course the charges that patients do have to pay if they are not exempt for NHS treatment, if they can find a dentist, in Wales have been held much lower than is the case in England. They started off the same in 2008, but they've been held here. So, that will help as well. But, as always in these things, it's the people who are—. If you're on benefits, then you'll qualify for free care, if you can find a dentist, but it is the people, as always, who are on the margin, they don't quite qualify because they're not on benefits and then they don't have the disposable income to do it. 

The issue of cost for dental care for people is often not the cost but not knowing the cost. It's being in the dental chair and not knowing what the cost is going to be. And so for that reason, dentists are required to provide an estimate of costs and have a list of charges, but that still is difficult for patients sometimes to work out in advance what the cost is going to be.

Yes, I can understand that. 

And just being aware that there are lots of barriers before they could even get to the dentist, like time off work, transport, access to a dentist. So, I think we need to look at what those barriers are for our most vulnerable people, really.

I think that, again, that's an excellent recommendation, isn't it, because if we're relying on foodbanks for toothpaste, we're in a pretty bad state, aren't we? Thank you, Chair.

Thank you, Jack. Gareth Davies. 

Thank you, Chair. I want to talk about funding, and I'm not going to ask whether there's sufficient funding for improving access to dental services because, on the basis of the evidence that we've taken as a committee on dentistry already, it suggests that that's not the case. But, if further funding was provided, then how should spending be prioritised in your opinion? 

In my opinion, it would be targeting on a needs basis: targeting the additional resources at those who need the service the most, and if that means taking services out to specific groups—. Most of the people who don't access the services or are in vulnerable groups already access some services: mental health services, substance misuse services, domestic abuse services or social care services. So, we know where people are; it's a question of reaching out in the right way to get people the right care and the right access to services. So, I would certainly target it on a needs basis.

And I think, even within the current envelope, if we looked at the skill mix and did some proper workforce planning over a period of five to 10 years, training people to the level and having supervision from dentists, we could do quite a lot with the workforce planning within the cost envelope, I think, going forward.

If I can add to that, the most immediate service people want from dental services is urgent dental care. So, we need to make sure that at least an urgent dental care system and an out-of-hours dental care system are there for the people when they really, really need it: they have got an abscess in their mouth and they don't have to wait for that service. 

And going back to this, it's all about reorientating the service towards need and making sure that each and every service focuses towards the population who need the most first, and the dental contract obviously has to work for that, so that the practices can easily take on the high-need patients. That may mean seeing fewer patients than we used to do under the previous system, but it would be focused and provide more value for money to look after those patients who actually need it the most.

And obviously, we talked about the workforce as well, and I think the workforce itself needs an incentive to recruit and retain. So, the funding itself is not going to solve the problem if the workforce isn't there to do it. Any additional capacity has to go hand in hand with the workforce planning.

I don't have much to add in terms of the priorities that colleagues have outlined and, as I say, the new chief dental officer is working on reforms to the system and the funding needs to come to those. The one thing that we do need to make sure doesn't happen has happened recently—it's where a substantial amount of money was made available in relation to the crisis, but the money comes in October and you've got to have it spent by March, and that's just impossible. So, we need to have a planned approach. Sure, additional investment is required, is necessary, but we've got to be pragmatic about the circumstances in which we're in at this point in time. But it's planning and a horizon that allow the health boards and the independent contractors that provide the majority of dental care to be able to plan their business in advance. That's an important fact: you can't just have the money and expect things to happen like that.

Thank you.

And in regards to how you define need—it was one of the earlier questions as well—given that you mentioned that surveys on oral health in children can be quite costly, we've got a conversation about that and where priorities lie. Is it feasible to try and look into the oral health of other groups? I'm thinking of vulnerable groups as well.

Yes, so we have the resource for doing those surveys and I explained that they used to run annually and we decided that that was too much. So, what we have done is, we're doing five-year-olds in this school year, because that's a priority to see what's happened there and what the next stage is in the very first graph we looked at this morning, in terms of what damage the pandemic has done to oral health in five-year-olds. Next year, we're doing 12-year-olds and then there will be two years after that, which, at this stage, we still can plan in terms of what we want to do and what should be surveyed.

In the past, as Anup has mentioned, we have surveyed care homes, we have surveyed three-year-olds, we have surveyed 18-to-25-year-olds. And so, we'll need to make a decision as to what age group would be most appropriate. I suspect at this stage, we would probably be veering towards another survey of five-year-olds, because we want to be able to see what's happening there because that is the foundation for the next generation. 

What about, just beyond children and young people, other vulnerable groups as well, I suppose?

Sure. The issue always is the more vulnerable groups, so, homeless people, for example, prisoners, people with mental health problems, people with drug problems, Gypsy and Traveller communities. They're all on our radar, but whether you need to go and do a survey of their teeth or whether it's just an easier matter of understanding what the access issues are for these vulnerable groups and for the community dental service to have sufficient resources—. You heard from colleagues in the community dental service this morning, but I think if there is additional resource, that needs to be thought about towards the service that's best set up to provide for the vulnerable groups. And that may, in some instances, mean contracting with interested practitioners to provide care for a particular group. In the past, under the old NHS system, we used to have practitioners who were contracted to provide care for specific care homes and look after care homes, and that still happens, but at the minute, that happens on a private basis, largely. So, planning for vulnerable groups needs to be—. And to have some mechanism for making health boards recognise that that needs—. Because across Wales, the community dental service in some health boards is much stronger than in others.

I'll just bring Sarah in in a moment, but what I'm extracting from what you're saying is that perhaps the priority is more about what are the barriers to access for some vulnerable groups, rather than surveying oral health in those groups.

Yes, just understanding where we can organise the service for them, rather than what their oral health needs are, because we know what their oral health needs are likely to be: high.

Yes, I understood that point. Yes. Sarah Murphy.

Thank you. Just some really quick questions. Do you know when the last time a survey was done of looked-after children in Wales?

We've never done a looked-after children survey at all, as far as I know.

Yes, I have—

—[Inaudible.]—age group, I would assume.

It would be. We've done some work with Sally Holland, the outgoing children's commissioner, on looked-after children and their oral health needs in the past. In fact, their oral health needs often tend—they're no different from the population as a whole. And in some ways, because of the safeguarding system and so forth, they tend to be looked after pretty well, so I wouldn't be overly concerned that looked-after children are out of the system in the way that some other vulnerable groups in the population are.

Thank you. And you've answered my next question, but my last question, then, is: we've also taken evidence about children having access to orthodontic care, so if they're being surveyed at 12, sometimes, and then not again until they're 18, is there anything done to capture whether or not they're actually able to access that service?

Again, similar to the general dental service, there is a backlog of treatment, and orthodontists always have had that backlog of treatment. There are clear criteria as to who qualifies for NHS dentistry; they're based on clinical need. It comes back to prioritisation, I suppose, if you've got a limited pot of money, because it's the same pot of money that the orthodontic service comes from as for the general dental service overall, and the community dentist service also comes from that bigger pot of dental money, if you like, from the health boards. So, it's a difficult prioritisation within each of the health boards: where do you want to prioritise that money, within dentistry even?

Thank you very much. It's more just to understand, I suppose, the decision process, but I really appreciate you being so—like we've said—honest about the challenges, and very pragmatic as well. Thank you.

Thank you. Any Members got any last questions at all? No. And just to the panel: is there anything you want to add that will help us in our inquiry into dentistry that's not been drawn out through questions? Anything you want to, not repeat, but add to what's been said?

I'd like to say thank you for your interest in dentistry and for ensuring that it gets the torch shone on it in the way that's necessary.

Thank you for that. I know our predecessor committee did work on dentistry, and we're keen to do the same, and we'll certainly supply you all with a transcript of proceedings, and if you want to review that and add anything to what you said, and if you follow the rest of the inquiry and you want to come back with any further evidence, then we'd very much welcome that. But thank you very much for your time this morning. Diolch yn fawr iawn.

Thank you very much. Thank you.

I move to item 4, and we have two papers to note, some correspondence with the UK Parliament's Joint Committee on the Draft Mental Health Bill, and a letter from the Professional Standards Authority for Health and Social Care, if we're happy to note those papers. Thank you.

And we move to item 5, and in accordance with Standing Order 17.42, I propose that we exclude the public from the remainder of this meeting today, and for all items other than items 1 and 2 at the meeting on 26 October 2022, if Members are content. There we are, and that brings our public session to an end today. Diolch yn fawr iawn.