NHS dentistry should be available to everyone in Wales

Mike Hedges – MS for Swansea East

I continually get concerns expressed to me about the difficulty in getting an NHS dentist in Swansea. Some practices that used to have a mix of private and NHS patients have either moved wholly to private patients or are only accepting children as NHS patients.

There are problems with getting an NHS Dentist and Dental Practices are reducing and, in some cases, terminating their NHS contracts, including for children. I along with many other people would like NHS Dentistry to be available to everyone who wants it.

Most dentists work in small private practices although I am aware of some large practices across several locations that do exist. Also, a large number of dentists from the European union have returned home with many fewer new dentists coming into Wales from the European union.

There is a need for a new Dental School in Wales, and I have suggested Swansea University as a possible site, though I am sure people in the north will suggest Bangor.

I think it is important that we have another Dental Teaching Centre at a site where we already have a Medical School. If we do not have enough Dentists, I support training more to fill the vacancies.

Smile

Fortunately, we have the designed to smile initiative that works with families and young children by encouraging good oral hygiene by:

• giving advice to families and providing toothbrushes and fluoride toothpaste
• Encouraging a visit to the dentist before a child’s first birthday.
• A dental health programme for nursery and primary school children that includes daily tooth-brushing usually in school and twice-yearly fluoride varnish application.

Issues

One of the best visits that I have made was to a primary school where I was talking about the importance of design to smile ad brushing teeth and said it will stop you having fillings. I then asked were there any questions and one eleven-year-old girl asked what a filling is. I can think of no better endorsement of this scheme.

Along with other Members of the Senedd, I met with Morgannwg Local Dental Committee which represents Dentists and Dental Practices in the Swansea Bay University Health Board area.

Those dentists carrying out NHS work are committed to the principles of the national health service. They raised concerns including the new contract issues that have emerged which are affecting Dental Care and may mean that many Dentists exit their contract.

Around 75 per cent of dentists surveyed by the British Dental Association said that the contract was not working for them. The co-production meetings on the contract have increasingly lacked co-production.

Worry

In 1948, NHS Dentistry was introduced as part of the newly formed National Health Service. There were three fundamental principles: no-one should ever have to worry about being unable to afford necessary medical care; care would be provided free at the point of delivery, and care would be based upon clinical need.

The Dental Contract has gone through many changes. The original payment system was fee per item, where Dentists were paid for each treatment, they provided and this was used between 1951, when Patient Charges were introduced, and 1990, and the system worked well for both Patients, Dentists, and the Government.

The system was changed in 1990, involving Dentists being paid a fee for each treatment, as well as an allowance for registration of adult and child patients. The Units of Dental Activity (UDA) were introduced in 2006.

Flawed

The contract involved dentists being paid for a set number of UDAs per year, with each band of treatment assigned a certain number of units. This was not trialled and was flawed from the start.

This meant that a treatment containing one filling was paid the same as a treatment that required ten fillings — what retail outlet would charge the same for one lightbulb as ten lightbulbs? Surely a recipe for financial disaster.

Furthermore, the value of a UDA was different for different practices, sometimes by more than £10. The system worked against both Dentists and Patients — patients with high needs (lots of fillings needed) were finding it difficult to get treatments done. It has been recognised from the outset of this contract that it was not fit for purpose which resulted in the trialling of alternative contracts.

The prototype A B system was introduced in 2011 as a trial for a new contract system. There were two prototypes in Wales. One was the quality and outcome pilot, and the second, a children and young people’s pilot. Both removed the unit of dental activity and gave clinical freedom to make clinical judgment on what is best for the patient.

Costs

The UDA system introduced in 2006 aimed to control costs, making high-needs patients and certain treatments financially unviable. Since 2021/22, NHS dental contracts have shifted focus to patient numbers rather than treatment activities. New targets, such as fluoride varnish applications and counts of historic, new, and urgent patients, have been introduced annually.

These targets, often announced with minimal notice, are experimental, leading to retrospective assessments and financial clawbacks if targets are not met. The constant adjustments, along with clawbacks, have created business planning challenges and low morale in dental teams, prompting a rise in NHS contract hand backs and many associate dentists moving to private practice.

Currently, about a quarter of General Dental Service (GDS) contracts in Wales still operate under the original UDA system, despite its criticisms. However, this system will be fully replaced when the new GDS contract is introduced.

Wish list

I asked local dentists for a wish list of what would make the working conditions of Practice Staff better in the time running up to the inception of the new contract. Following consultation with LDC executive members they proposed the following:

1. Immediate complete removal of the requirement to achieve 75% of the Historic Patient metric before full interchangeability of that metric with the New and New Urgent Patient metric.

2. Return to the WG contract variation offer of December 2023 until the inception of the new contract, whenever that might be.

3. No amendments to this variation without a full 3 months of notice, and only after full consultation with BDA Wales. This will ensure no last-minute changes to metrics which happened in March 2024 and on a number of previous occasions.

4. The Welsh Government should advise LHBs to seriously consider and be sensitive to practices that claim that a metric is unfair to that practice, recognising that practices have different rudimentary structures, patient bases and skill sets. It must also demonstrate appreciation of the differences between LHBs. A practice covering a university can have less historical patients living in Swansea than the number they need to achieve

Stress

We believe that this will considerably improve the working conditions and reduce the stress on practice staff.

While the current conditions remain they are advising practices that if they are struggling to achieve the 75% Historic Patient metric they immediately stop seeing New Patients and New Urgent Patients once they have achieved the target for that metric, and concentrate on their Historic Patient targets until financial year end to minimise clawback.

Everyone, patients, dentists, and politicians, wants NHS dentistry to work for patients and dentists.