Childhood tooth decay declines as Health Committee calls for a more flexible dental contract

(Title Image: National Assembly of Wales)

Health & Social Care Committee
Dentistry in Wales (pdf)
Published: 22nd May 2019

“Paying someone the same amount to deliver a course of treatment on a patient regardless of the amount of work involved makes little sense.

 

“Therefore this Committee believes it is time to end the current arrangements and find a new way of making sure everyone in Wales has access to quality dental services regardless of where they are.”
– Committee Chair, Dr Dai Lloyd AM (Plaid, South Wales West)

1. The current dental contract needs to be replaced with a more flexible system

Since 2006, NHS patients in Wales have been charged for dental treatment by three bands and local health boards reimburse dental practices based on the number of units of treatment (UDA) they undertake. The lowest band (check up) is 1 UDA, while the highest band (bridges, dentures etc.) count as 12 UDAs.

Health boards set a UDA allowance for each practice and each practice has to hit 95% of its UDA allowance before being reimbursed in full. The UDA value is usually between £23-30 depending on the health board and dentists can’t take on any more work than the allowance.

Under the UDA system, a patient who needs one filling pays the same as a patient who needs 10 – but in both cases, it only counts as 3 UDAs. This doesn’t properly reflect the cost of treating complex patients, disincentivising dentists from taking on patients with the greatest need.

Health boards claw back money in cases of underperformance by dental practices against UDA allowances and in 2017-18 £6.5million (3.8%) of the £180million primary dental care budget was clawed back. There were assurances this money was being re-invested in dentistry, but the Committee recommended close monitoring by the Welsh Government.

2. A prototype new contract has boosted dentists’ morale and enables better long-term treatment planning

The Welsh Government are trialling a new dental contract at a number of practices. The UDA system is relaxed and instead of trying to undertake work in as quick a time as possible, dentists are encouraged to improve the oral health of their patients and prevent problems before they start.

Higher cost treatments are reserved for people who can maintain their oral health, while high-need patients are helped by a wider range of oral health professional; they go through a “care pathway” similar to that you might get at a GP or over a course of hospital treatment.

The Committee agrees that moving away from the UDA system would benefit dentists and patients, but warned the Welsh Government to prevent “unintended consequences” of introducing a new contract without full and proper field testing. Also, any new contract has to incentivise treating high-need patients.

3. There are no recruitment problems, but there are issues in retaining dentists after foundation training and orthodontists

Dental recruitment is now done on an England-Wales-Northern Ireland basis, though Swansea Bay Health Board said this was counter-productive as English recruits in Wales may stay a year but move back to where they have roots. The retention rate of Welsh-domiciled dental postgraduates and foundation dentists is around 50-65% in any given year. Also, English trainees earn up to £4,000 a year more than in Wales.

While there’s no struggle to fill dental school places, just 15% of applications to study dentistry at Cardiff University are from Wales – though this could be simple geography as prospective dentists from north Wales may prefer to study at Manchester or Liverpool. Witnesses supported introducing a “pre-year” to attract Welsh-speaking students and students from less well-off backgrounds.

There’s also a backlog for orthodontic treatment (braces etc.), with a fall in the number of orthodontic service providers since 2012. A new electronic referral management system has been introduced to triage patients based on clinical need and give a better idea of how long orthodontic waiting lists actually are.

4. Dental decay amongst children is at its lowest rate since records began

Since the introduction of the “Designed to Smile” initiative, the proportion of children with at least one decayed tooth fell from 45.1% in 2011-12 to 29.6% in 2016-17. The programme targets schools in deprived areas, but tooth decay rates amongst children in these areas remain higher than average. People living in deprived areas also have reduced access to dental services.

Designed to Smile has stopped applying fluoride varnish to children at school after their permanent teeth have erupted and instead left it to high-street dentists – something the Committee said needs to be reconsidered. Witnesses called for oral health programmes to be introduced for older children as many won’t have benefited from Designed to Smile.

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