Why have many dentists in Wales been calling for a change to their contract? Are there problems in accessing orthodontic services? Are young people receiving the dental services they need?
These were some of the issues considered during the Health, Social Care and Sport Committee’s inquiry into dentistry. The Committee’s report (PDF 1MB) published in May 2019 set out its findings and will be debated in Plenary on 2 October 2019.
Current dental contract
The NHS General Dental Services Contract came into force in 2006 in England and Wales. The contract pays dentists an annual amount for their NHS work through a Unit of Dental Activity (UDA) system.
This system consists of three bands that determine how much a patient is charged for their treatment and how much a dental practice is then remunerated:
- Band 1 includes diagnosis, assessment and maintenance;
- Band 2 includes that covered by Band 1 plus additional treatment such as fillings, root canal therapy and extractions; and
- Band 3 includes that covered by Band 1 and 2 plus more complex procedures such as bridges, crowns and dentures.
The payment is the same whether a dentist undertakes one or more similar procedures. The Committee was told there was therefore no incentive for dentists to take on high-needs patients, as they would be paid the same amount for doing more work.
Many dentists have been unhappy with the current contract and the need for a change was clearly expressed by the British Dental Association (BDA) Wales in telling the Committee that “dentists would like the UDA put in the bin”.
Committee Members agreed that that the current UDA system may discourage some dentists from taking on high-needs patients, particularly in areas of deprivation where there is already poorer access to dental services.
Since the Committee’s report was published, BDA Wales has been campaigning to change the way dentists are paid, claiming this has caused an "access crisis".
In June 2019 the BDA published research revealing that just 15.5 per cent of practices across Wales (55 out of 355 practices) were able to offer appointments to new adult NHS patients, and only 27 per cent (96) of practices were taking on new child NHS patients.
Although the Welsh Government has previously made changes to the UDA-based model, the Committee recommended replacing the current UDA targets. The Committee believes that creating a new system would be of benefit to both dentists and patients, as well as boosting morale within the sector.
The Welsh Government accepted the Committee’s recommendation saying it is “moving low value UDAs out of the system and also introducing more meaningful measures based on practice level quality, access, risk and need”.
The Committee requested that the Welsh Government provides a progress report on contract reform in November 2019, six months after its report was published. The Committee will be closely monitoring the Welsh Government’s actions to evaluate how significant the reforms to the contract are and whether they go far enough to meet the Committee’s and stakeholders’ expectations.
Oral health of children and young people
In its report, the Committee recognised the positive impact of Designed to Smile (D2S), the national oral health improvement programme for children in Wales. However, the Committee heard concerns around the Welsh Government’s re-focus of D2S, placing more emphasis on children aged 0-5 years old and a possible shift away from children above that age.
The Committee recommended that the Welsh Government should fund the D2S programme sufficiently to ensure over 5 year olds receive its benefits. In accepting the recommendation, the Welsh Government referred to the “apparent misconception” that children aged 6-7 have been denied the benefits of the programme. It stated this is not the case as schools are offered the opportunity of including children in Year 1 and 2 (5-7 year olds) in the programme.
The Committee also recommended that the Welsh Government build upon existing oral health improvement programmes to address and improve the oral health of older children and young teenagers. The Welsh Government accepted this recommendation and highlighted that resources have been developed to support lessons for older primary school children to reinforce the message of the D2S programme.
An epidemiological study has been commissioned with the aim of assessing and understanding the needs of the 12-21 age group and to help inform future approaches by the Welsh Government to meet the needs of this age group.
The Committee heard that the oral health issues in older children and young teenagers can lead to the loss of permanent teeth. In some cases, many teeth are lost, and the Committee expects effective action to be taken to address this.
Orthodontic services
The Committee also heard that inappropriate referrals to orthodontic services can put a strain on services and exacerbate waiting times issues. The Committee recommended that the Welsh Government work with health boards to develop a clear strategy to ensure that the e-referral system for orthodontic services has a positive impact on ensuring appropriate referrals, prioritising patients and reducing waiting times. The Welsh Government accepted the recommendation, assuring the Committee that it would monitor referrals.
The Welsh Government accepted all six of the Committee’s recommendations. It remains to be seen whether the actions described in the Welsh Government’s response will be enough to remedy the enduring problems of patient access to dental services and the profession’s long-standing dissatisfaction with the contract system.
Article by Rebekah James, Senedd Research, National Assembly for Wales
