Health and Social Care Committee

Okay. My name's Yvonne Jones. I'm a specialist in orthodontics, and I work in the community dental service in Merthyr, and I'm chair of the south-east Wales orthodontic managed clinical network.

Morning, Chair. My name's Russell Gidney. I'm a general dental practitioner, working in Chepstow, and I'm here today as chair of the British Dental Association's Welsh general dental practice committee.

Morning, Chair, morning, everyone. My name's Dan Cook, and I'm a general dental practitioner in Newport, and I'm vice-chair of the Welsh general dental practice committee. As Russell was saying, he's the chair, so I'm here in a supporting role as well.

Good morning. My name's Benjamin Lewis. I'm a consultant orthodontist in north Wales. I'm the chair of the north Wales orthodontic managed clinical network, and representing the British Orthodontic Society today.

Lovely. Thank you, all, for being with us. If I can perhaps ask Russell Gidney and Dan Cook the first question: how long do you think that it's likely to be before we see the backlog issues caused by the pandemic catching up with themselves?

There's a lot to that question, because when you talk about the backlog caused by COVID, you assume that we were in any way without a backlog before we went into COVID. So, the state of play typically within Wales, within the UK, is that about half the population are seen with a dentist at any one time. So, there has always been a large chunk of the population that's not been seen. So, the backlog that's been generated by COVID is really the pause, the hiatus, in treatment for the patients who have been already with a dentist. And the management of that is now being slowed down because we're also then trying to manage some of those patients who have not been seen. So, fundamentally, there's no movement in terms of workforce, there's no movement in terms of budgeting that we're working within. So the amount of treatment that we're providing is still roughly equivalent to about half the population. So, the simple answer to your question is 'never'—we don't have the resources to manage.

And just perhaps give us a view of to what extent the backlog was there before the pandemic, and how the situation has worsened, I suppose, as a result of the pandemic. So, the extent of the backlog before the pandemic.

So, before the pandemic, the BDA did some research at that time, and I believe it was something like 80 per cent of practices were not able to take on patients, pre pandemic. There was a recent bit of research done by the BBC, where they were phoning around practices, trying to register patients, and it was close to 100 per cent that wouldn't take patients on. Now, those practices are taking patients. In my practice, we've got around about 1,000 patients on a waiting list. So we are putting names on a waiting list, but realistically we're telling those patients that we just have no idea when they'll get seen.

Yes.

For me, it's a very similar situation to what Russell was saying earlier. The backlog long predates COVID. Budgets for NHS practices were fixed, certainly in England and Wales, they were capped, from the financial year 2006-07 onwards, which is quite a long time ago now. And the budget has more or less, with some small exceptions, been frozen in aspic since then, and decisions have been made at Welsh Government and Westminster level to retain that cap at half the population having funding for dentistry. And that's something that's been done over and over again. So, by the time COVID came, it certainly wasn't the first nail in the coffin. We were a long way down the river of what I fear is the death of NHS dentistry in Wales and, potentially, in the wider UK as well.

Thank you. I think some of the Members will probably dig into some of your opening comments as they come to ask their questions. And Benjamin Lewis, if I can ask you—in the response from your organisation, you’ve referred to orthodontic provision as being in a dire state. Perhaps you can just expand on that a little.

By all means. I think it's fairly similar to what Russell and Dan have said. As Dan said, orthodontic provision, in essence, was capped in 2006-07 when the units of orthodontic activity were introduced. Although there will have been a number of needs assessments since then, and that that could have resulted in some increased orthodontic commissioning, the problem is that there's already a backlog, and most needs assessments don't take into account, actually, how to address the backlog that has already been created. So, if you’re lucky, it will keep in line with current need, but there's always going to be a waiting time to actually access treatment because of that.

COVID then made everything worse, because treatments ceased, and when treatment did recommence or activity recommended, it was focussed on those with the greatest clinical need, so those ones who would become at risk if they weren't seen, which were those patients in active treatment. So, it meant that new cases weren't started. So, the backlog that was, say, previously two to three years to actually get seen—then you just added the length of COVID on top of that.

In addition to that, when you look at current commissioned activity, we're undercommissioned according to need. So, Wales, generally, is about 76 per cent of need, but that will vary region to region, and that's historic. So, for instance, Cardiff and Swansea will over-commission for the number of 12-year-olds, which is what the need is based on. So, it's usually about a third of 12-year-olds. So, Cardiff and Swansea will over-commission, but that's because of the geography in south Wales where high-population densities would have the location of specialists, and patients from more rural areas would commute into those high-population densities, such as Cardiff and Swansea.

Okay, thank you, Benjamin. Did you want to come in, Yvonne? Don't feel that you have to.

I'd just agree with that. And also, as well, I think we have to take into account the fact that, actually, looking at the commission according to need, populations in areas have actually increased, so that puts extra demand on services as well.

Sure, sure. Thank you. I know that Members will want to dig into some of what you said in your opening comments. Sarah Murphy.

Thank you, Chair. Thank you, all, for being here today. You've all already, I suppose, referred to some of the statistics and data that are available on this, and it does help—it's what we need, really, to get a picture of what is happening across Wales. But, to come to Russell and Dan with this first question, there have been responses to the committee's consultation referring to the lack of data to actually give that clear picture of dental services in Wales. So, can you be more specific in terms of what information is currently available for NHS and private dentistry on the number of people on a waiting list to access a dentist? How many people have access to a dentist at all? And how long do those with access to a dentist have to wait for an appointment?

Russell.

Go on.

There isn't a lot of data available nationally, because most of the waiting lists are held locally by practices. Practices are independent contractors, as you probably all know, and they have to manage their own waiting lists. So, in my practice, we may occasionally be asked for approximate data from the health board regarding how many patients are on our waiting list. I think it's in the region of 300 at the moment for new patients, and we've still got a wait of maybe 1,500 existing patients we haven't seen since COVID. So, there isn't a nationally held waiting list—they're only really estimates. Would you agree with that, Russell?

Yes, absolutely, because a lot of the problem that we face is that we are all independent businesses, and our information is held locally. So, actually, there is no collation of the general dental practice data centrally that can be used. Some of the health boards, as Dan said, have got a waiting list, which could be into tens of thousands of patients looking for care. Our area, as I said, it's held locally, so we both have our own list. But what we don't know, of Dan's 300 patients, they may all be on my list as well. We just don’t have that information.

What's the knock-on effect of this?

In what manner do you mean?

For you, I suppose. For dental practices, what do you see as being the outcome of this? What kind of effect does that have?

And if I can add to that, you talked about there not being any national data—should there be?

I certainly think that locally held within health boards is a better way of processing, because you speak to the patient experience of this, and they'll phone around hundreds of practices trying to get access. They'll end up on the list of multiple practices, so when we then try and phone patients to get them in our practice to be seen, we're wasting time phoning patients who've actually seen someone else, or they've been to Dan for their care and they realise I'm closer, so they'll jump between practices.

So what's the better way of doing this?

I believe that a centrally held waiting list is more efficient for both patients and practices.

I think at health board level, certainly, the funding can follow the demand, and at national level to health boards as well, then. Because the more granular the data is—to use a real committee term: 'granular'—to use the granular data of areas and health boards, and also localities within health boards, helps to direct the funding. Funding in dentistry in the main has been based upon historical activity from the 1990s and 2000s, really, hasn't it, still? And that doesn't always follow where need is greatest.

The knock-on effect, if I may come in and answer that as well, is that we're constantly turning away patients, and they'll say, 'I bet you could see us if we paid privately', and we have no capacity for that, either. We're really absolutely full with patients. Staff get sick of it, staff are upset because they have to turn patients away and, 'I'm in pain here. You're meant to be caring for us. We've come here because it's the NHS. You should be caring for us.' It's always my staff who have to face patients and tell them, 'I'm sorry, your child can't be seen', and you can think, 'Surely you can squeeze them in.' We've got 30 patients squeezed in already in a session, in a day. We just can't do it, and it's awful. We can't do what we want for all these patients—what they need, more to the point.

Sarah, do you mind if I ask another question on this?

Absolutely, Russell. Yes, of course.

Why is there not a central waiting list within health boards? It sounds like you're saying this is a good idea; it seems a good idea to me, what you've said, so why hasn't that been done in the past? Because if that was done, it would achieve what you said.

It's not in our gift to do that, obviously; it's up to the health boards.

So why aren't they doing it, I suppose? Why haven't they done that?

I honestly don't know.

That's a good answer, then.

Honestly, I'd rather say that than try and give you some waffle about it. The thing is, that's our opinion. I think I'm pretty much on the same page as Russell with this, that it would work better at local level. I think practices have been given the autonomy to decide their own waiting lists, but also, it has been quite convenient, I think, for practices to have to do all the admin. There's no funding available for all the extra work that practices have to do. Funding's less than it was when there wasn't a shortage, and there weren't so many waiting lists. So it's quite convenient, I think, for practices to have to shoulder the burden and the cost of managing waiting lists and turning away the angry parent whose child can't be seen. It's a lot easier for practices to do that than for health boards to have do it. That may give you a clue as to why it has never been done in the past.

Is there any disadvantage to practices of there being a central waiting list? Is any practice going to say, 'Well, I don't really like the health board having a central waiting list'? Is that possible?

The only problem I can see is that practices, as you may know, dentists are—I don't know if we're unique in the NHS, but there aren't many other types of practitioners who are penalised every time a patient misses an appointment. And the amount of penalty, the equivalent of targets missed can vary from in the region of £25 to £250, depending on what appointment was missed, and that's something that the practitioners have to bear out of their own pockets. There may be a concern that practices could be made to see patients again who they know have been poor attendees in the past, and who they know are going to cost them a lot of money, which is going to push practitioners out of the NHS more, potentially. Is that something that you would agree with, Russell?

Yes. If I may, Chair, the one advantage with the practice holding its central list is that it can, to some extent, try and triage those patients. So we can then try and prioritise based on need, although that's obviously difficult to do because, when patients learn that that's what we're doing, they'll give us the answers that they need to give to be seen. But the central waiting list would then give us that demonstration of need, which we don't really have.

Sure. Sarah.

Thank you. And then to Ben and Yvonne, on the information available on orthodontic capacity and the number waiting for services across Wales, and the length of the wait, what is available and is it a similar situation?

If I may start, Yvonne. Orthodontic waiting lists are held locally, as was mentioned previously from a dental point of view. The e-referral system will give you some idea of the number of patients who have been referred, so that gives you some good baseline data. Each region can stipulate how it wants to manage waiting lists, so that will vary between regions in Wales. For instance, down in south Wales, they've got a centrally held waiting list for orthodontics, and patients then are drawn off when capacity occurs. In north Wales, the geography plays an important role. So, we have geographic spread. In primary care, the orthodontic specialist practices are based in high-population densities such as Bangor, central around Rhyl, Deeside and then in Wrexham. We decided as a managed clinical network that it didn't make sense to have a centralised waiting list, because you could, in theory, then have a patient living in Wrexham who was then asked to call down for treatment in Bangor. So, it was more sensible to have a local waiting list that was more appropriate for the geographic needs and the transport infrastructure for that population base.

Waiting times have just increased massively. As I mentioned before, we're currently, across Wales, under-commissioning according to the number of 12-year-olds on the national census in 2021. And waiting times were, say, two years in primary care, even longer in secondary care prior to COVID, and they've just gone up exponentially as a result of COVID. Some units, certainly in secondary care, across Wales aren't even operating at full capacity, because there are still legacy issues within departments, because their departments are still partially with other specialties because of the restructuring of hospital acute sites during the COVID pandemic.

In addition to that, we've actually got delays with patients when they come to the top of the waiting list and are ready to start treatment, when we're making sure that they're actually dentally fit. So, sometimes they might need oral hygiene instruction, some restorative work, or even when they get extractions. So, as part of orthodontic treatment, a proportion of patients will need extractions. We will then see them, refer them off to their general dental practitioner for extractions, and it could be six months before they're actually seen for those extractions. Within that time period, those patients then might lose motivation because they're treatment is dragging out. That motivation might affect their levels of oral hygiene, which ironically then makes them not an orthodontic candidate.

In secondary care services, where all our cases are often multidisciplinary, so we refer on to our maxillofacial colleagues or our restorative colleagues, waiting times within their specialties also affect us. So, again, for instance, in north Wales, just because of the case mix that's there, there's a lot of skin cancer work. Obviously, because it's cancer, that takes priority over dental work. So, the waiting times for, say, exposure of impacted canines, which can cause damage to adjacent teeth, has tripled during the COVID pandemic and beyond.

Thank you very much. Yvonne, did you want to come in as well?

Yes, I just wanted to clarify, actually, with Ben that it's south-west Wales where they have a centrally held waiting list. Here in the Cardiff area, so, south-east Wales, the practices all hold their own waiting lists, so it's not a centrally held one. And also, in the area I work in Cwm Taf, we have one specialist practice in Bridgend, and all the patients from general dental practice in Cwm Taf, a lot of them have to travel all the way down here to Cardiff, and get referred down here to Cardiff. So, it's a long way to travel for a lot of patients.

But, yes, they've all had backlogs. The recent figures for here in Cardiff that I've had is that if they're an urgent case, then the referral to assessment can be from six weeks to 12 months, and then from assessment to treatment, it can be two to 12 weeks. And then for routine, you're looking at 21 months up to four years for the wait, and then again into treatment. But, obviously, treatment is then, if a patient needs treatment, because they can't access general dental care for extractions or healthcare, then they're having to wait even longer before they can start their orthodontic treatment.

Sarah, Ben wanted to come in. Dr Lewis.

Yes. Ben, did you want to come back in?

Thank you. Just following on an excellent point Yvonne made there: as we were coming out of COVID, the Chief Dental Officer for Wales at the time, Dr Bridgman, quite rightly said that, 'Actually, all the capacity we've got should be focused on those with the greatest need.' So, those patients who were coming through were assessed by the referral—information that's on the referral—to say, actually, was there a clinical risk with them waiting a long time. So, those patients have been pushed to the fore when accessing care. The problem was, historically, before COVID, especially in primary care, it was on a time-served basis, unless there was anything really obvious on the referral form. So, you could tell patients, 'Actually, our waiting list is two years. So, you're likely to wait two years until you get seen.' Now, we can't tell patients how long they're going to have to wait, because that is all dependent on the number of urgent patients that comes through, based on evidence of clinical need from the referral. So, it's really hard to give patients any definitive information, which—. Prior to COVID, although not ideal, patients actually were very accepting of, actually, it's a finite amount of resource, if they want treatment on the NHS, then there's inevitably going to be some wait. And they were very understanding when we said, 'Well, it's going to be two years until you can access treatment.' The problem is, now, it's very unsettling for them, because they don't know—is it two years, is it four years? And we know, from the community health council report that came out a couple of years ago, how much impact that has psychologically on these patients, especially young patients in their formative years, when, actually, it can affect education, it can affect their social groupings, it can affect confidence. It has a massive impact on them, and now these patients aren't going to be even seen until they are 16, 17, 18 years old, and, actually, we don't know about the actual long-term psychological effect that has on these patients.

Yes. Thank you, Ben. I just wanted to just as well come back to what you said, Yvonne, because, obviously, we have quite a good comparison there with the data that's available. So, you said that Cardiff and South Wales West do it differently. Do you have an opinion on which system works better, then—centrally held or not?

There are advantages to both, I think, but I think it can be difficult if it's held centrally; it depends on the person who's going to be triaging those referrals, orthodontic referrals, to pick up those who potentially are going to be urgent cases. So, there are swings and roundabouts for both. There can be advantages in the fact that, if one practice is seeing patients quicker, then, obviously, they might be able to see some. But the defining factor, actually, in all of orthodontic treatment is the fact that the practices are commissioned for a certain number of units of orthodontic activity. So, that means that they can only treat a finite number of patients each year. So, there's no capacity to say, 'Okay, we've got capacity'; it's, 'We've taken on all these patients, so we've met our target; we can't treat any more, although we potentially have got the capacity to do it.' So, maybe that's something that needs looking into.

Yes. Did you have any further questions, Sarah?

I was just going to ask, just to everybody, really—I think, Ben, you touched on this—to what extent are there currently inequalities in access to dentistry and orthodontics, and who do you think is most likely to be affected, then, by the current problems? And is there, then—you know, coming back to the data and the evidence, is there any available on which sectors of the population and geographical areas have better access than others?

Did you want to come in first, Dan Cook, on that point?

No. Please answer that first. I just had a little point to come back with in support of what Yvonne was saying, but you can come in now, Yvonne, please. Yes.

Well, I think it is actually those who are of a lower socioeconomical background who are actually going to lose out in all this, because (1) a lot of them will have to travel to access care, whether it be dental treatment or even orthodontic treatment, which impacts on costs for the parents, with all the travelling and days out of work, days out of school, and also, potentially, if they really feel that they don't want to wait and they want to maybe access private treatment, they can't access that treatment; that's denied them.

Just before I bring Dan Cook in, I just want to come back after Dan to you, Dr Lewis, because you've outlined a situation. I just wondered if there's a solution you would recommend as well to what you just outlined, but I'll just bring in Dan Cook first.

Yes, it's just tying together something that I've said in comparison with what Yvonne just said. I believe—and Yvonne can correct me on this if I'm wrong—I believe the orthodontic budget was limited; it was set at the same time that the general dental budget was. And this has been happening since 2006, when COVID was something that was unheard of, in the distant future. If there's a huge area—a huge need rather—in an area for either orthodontics or general dentistry, practices can't respond to that. I had a brilliant graduate—I've had a lot of brilliant graduates working with me, but I had a lady in particular who wanted to stay working in Newport. She was excellent, there was huge local need, the health board was very supportive, but there wasn't any funding. If she'd been an orthodontist and this was an orthodontic practice, it would be exactly the same issue. The budgets are set and have been capped year upon year upon year, whether it's general dentistry or for orthodontics, or other specialist services in primary care in dentistry, and that has been the bottleneck. The problem is that's now set in stone. So, graduates are coming out and thinking, 'Well, the NHS don't want me, why should I really look for a career there? They've limited the budget; I'll have to go and work privately.' It's no wonder that's happening, is it?

Are you going, Russell, to talk about workforce issues?

No, I'm just going to talk within that same point. Just to say, it's something that, if you look at the media side of it, patients don't understand, and I think a lot of people don't understand. If you look at the comments that come repeatedly, it's, 'Well, this practice is telling me they can see me privately. Why are they being allowed to see me privately and not see me on the NHS? They've got an NHS contract.' When, obviously, we're working to that cap that's set, and, actually, the practice staff, over the last few years in particular, have dealt with an awful lot of aggression directed towards the practice because of that.

Worse still now, people are being told in the Senedd, and in other places, that dentists have been bringing everyone back too often and that's the problem, and now that's, 'Hey presto, that's been fixed.' So, all these extra appointments are supposedly available and practices can just see people. We've got people coming in saying, 'Well, they've said there are all these extra appointments. Why won't you see me? You're just looking after existing patients. Why won't you see us?' It's a tough time, isn't it?

Yes. Thank you, Dan. Dr Lewis, did you want to come back in?

So, I think the topography of Wales is significant on access. We're reliant on either personal transport or public transport, and we know that public transport can be a little bit hit and miss in certain small villages around Wales. And patients will travel an hour, an hour and a half, each way to access appointments, and these are every six to eight weeks. So, the effect that that has on education, on work for those that are bringing them, the need for a family support network that actually is going to bring these children to these appointments—it's significant.

There's going to be a publication in the British Dental Journal of an NHS [Correction: 'a Welsh NHS orthodontic'] workforce survey, the first comprehensive one we've done in Wales. And, as part of that, we've created a map of Wales of where all the orthodontic providers are. It's quite stark—these vast swathes of Wales where access to orthodontic providers is just miles and miles and miles away from where they're actually located. And I'll be more than happy—. It's due to be published in the autumn, so, once it's published, I'll be more than happy to forward it to the committee, because, as I say, the map is quite stark and, I say, disproportionate where the providers are placed.

So, in a nutshell, the solution is?

I think—. There's no national solution to these things; I think it has to be done locally, because what would be right in Cardiff is not going to be right up in north Wales. I think it has to be tailored to the population. So, for instance, historically, we'd have a number of different tiers of orthodontic providers. You can have dentists with special interests, who are general dental practitioners with expertise in orthodontics. You could have specialists in primary care, and you can have specialist consultants in secondary care. Each will treat a different cohort of patients, according to their need. Some areas have not really got many dentists with special interests, because they were all very much in high population densities and therefore specialist practices had economies of scale, and that's what worked best for cities such as Cardiff, Newport, Swansea.

So, in north Wales, the geography rules. So, actually, we can't really expect patients to travel a three-hour round trip to access care, so, we have maintained a dentist with special interests network to allow, actually, more local treatment to be provided under the support of the specialist. However, the succession planning is there. And I don't know if you're going to come on to retention and recruitment later on, but—

We are. We are about to, actually. So, I might bring in Joyce Watson at this point so we can move on to, perhaps, that area. Joyce Watson.

Yes. I want to talk about workforce and recruitment, and I notice that you're talking about north Wales and south Wales, but I live in west Wales, which is even more remote—so, just saying. You've already mentioned workforce recruitment, because the parameters of earning are so restricted that people think, 'What the heck, I'm not going to bother.' But are there other issues that you want to bring forward? It might be worth asking at this point how long does it take to train a dentist, if those are the people we're relying on.

If I may first, for me, I think the earning issue can be a bit of a red herring and gets focused on too much. A lot of the reason where we're talking about NHS versus private, which I think is what you're alluding to with that—. Sorry, were you—

Not really, I'm talking in general. Because you mentioned it, you said that people were looking at it and thinking—you just said it a few minutes ago—that they might not bother, that the NHS isn't open to them, because—

It was me who said that.

—the budgets—well, somebody said it—were capped.

Yes. It's not in terms of their individual pay packet or their earnings, it is in terms of funding being available for them to make a service. So, if you have a graduate doing dental foundation training after they qualify in an area like Newport, where there is a high need, but provision is less than it needs to be and they want to stay and there's a practice that wants to expand and support them to do that, the funding isn't usually available. Now, that's what I meant, rather—. So, when that's the position in much of Wales, it's little wonder that practitioners choose to advance their career privately. That's the issue rather than, necessarily, their individual earnings. I hope that clarifies what I—.

Yes—[Inaudible.] Anyway, still.

There are a lot of factors that sit within that, and a lot of the motivation can be the ability to take care of their patient, to spend time with their patient, actually to move away from bureaucracy. Typically, for myself, I always have a little bit longer for a private check-up than with an NHS check-up. I've never felt I did different with the patient other than have time to chat and maybe go through advice, or just ask how their day is and build a relationship with them or go through costings and that side. Actually, now I spend longer on my NHS check-ups doing the bureaucracy that has to go with it. It's not adding to the patient care, it's filling in the forms, and a lot of times, as that's always changing, we end up filling those in two or three times because the validation goes through those. So, a lot of our time is taken away from delivering what we want to be able to deliver, which is that care to patients.

Okay. So, do we understand fully, and we have touched on it, the recruitment problems across the area—you've looked at north Wales and south Wales, but, as I said, I'm from west Wales—and what the problems are in terms of the incentives to keep people in priority areas of need?

There's always been a problem with recruiting graduates, I think, to west Wales. West Wales has had a—I wouldn't say acute shortage, but it's a chronic shortage. This has been going on for a long time, and I'm sure you've heard this over and over again from local people and constituents et cetera. Part of the problem, perhaps, stems from that west Wales is quite a long way from a dental hospital and a dental school as well. So, north Wales, certainly north-east Wales, is not far from Liverpool. Perhaps you could argue that north-west Wales and Bangor or Anglesey are a little further away from anywhere as well. It's the west coast, really, isn't it, what we may consider north Wales, the whole west coast of Wales. Cardiff—Newport, Swansea, to a lesser extent, and Bridgend are all reasonably close to Cardiff, so there is that spread of graduates within the area that they qualified in. West Wales has never had that, and that's possibly where this has started from. As a result, many years ago, there's been a—. Long before budgets were capped, there's always been a shortage in west Wales and, unless I'm mistaken, the funding packages that have been agreed when the budget cap was brought in were often based on historic levels of service provision, which in west Wales was quite little, because there was actually a shortage of practitioners, rather than a shortage of need. They mistook funding for need and, actually, the areas that had the most dentists were not always the areas in highest need. West Wales has always suffered from that, as have other rural areas across the UK. It's a big problem. Cornwall and the Isle of Wight spring to mind as areas that have had similar problems.

So, how do we fix it? We know what the problem is.

It's not something we can fix overnight. We're looking at years of underfunding and lack of resources. My personal opinion is that we should try and focus on the training of undergraduates in dentistry across Wales. We need a plan for the long term. Quick fixes aren't going to sort this out. I know there have been successes where undergraduates have spent some time in Wrexham when they've been in north Wales. They possibly need to look at familiarising dental students, undergraduates, with what all of Wales has to offer. Because for a lot of them, it's the M4 into Cardiff out of England, or elsewhere, and they don't get to see what brilliant places some of these places would be to work. And just getting the introduction, making them feel like they know the whole of Wales as a nation, and not just around in Cardiff—that's what would help in west Wales, but that's going to take years to do.

You asked earlier about the training of dentists. It takes five years to do the basic dental training, the academic training, and then at least another year in practice afterwards doing professional training. So, that isn't going to fix things overnight, but, certainly, on a 10 or 15-year forward planning basis, to set something up, looking at expanding dental training into west Wales, as they've done in England in Plymouth and Truro with Peninsula Dental schools, something like that would be a really good idea. And that's not necessarily the opinion of the BDA—I don't know; it's my personal view on it. I don't know what you would think. From an orthodontic point of view as well, would that sort of thing help?

Yes, it would. On top of the general dental training, then they go on and they do the two-year foundation, and then to become an orthodontist, they have to go back and train again in a dental hospital, within a hospital setting. That takes three years, to qualify as a specialist orthodontist, but if you then want to go and be a consultant, that's another two years. But I think maybe as well we ought to concentrate on trying to promote dentistry for local Welsh people, and encourage that. If we take on and train more Welsh students at Cardiff, and try to encourage local recruitment, then we're likely to retain those people here in Wales.

Russell, you wanted to come in.

If I may. I think we can perhaps obsess slightly less about points on the compass and more about rural and urban, because mid Wales has a major issue as well. The modelling that we have within practice generally suits a larger population. When we start talking about the skill mix and using dental professionals, we're talking about practices that have two or three dentists, a therapist and a hygienist—these people working. There's actually quite a large population that's needed to support those, so the whole modelling that we have is actually geared more towards those population centres rather than the rural community.

The issue also, then, is actually getting people into the NHS career pathway. It's not somewhere that people generally want to work. And a lot of the issue is the general motivation in terms of the time that's spent away from patients on admin that's not contributing. There is no career path for a general dental practitioner in NHS dentistry. If you upskill, if you develop new skills, you will get paid less, absolutely, within the NHS. I know it sounds bizarre—I can see the look on your face. At the moment, I'm on the reformed model, Dan's on the units of dental activity model. Fundamentally, there's a very simple credit for that patient. So, I get a credit when I complete the assessment of clinical oral risks and needs, the risk assessment form, and it goes through. Whatever treatment I do on that patient, the more treatment, the less that actually comes in to the practice. So, if I upskill so I can introduce more skills into the practice, I can do more complex treatment on those patients, which means I actually then have to spend more time and be able to see fewer patients towards my target.

Dr Lewis wanted to come in as well on this point.

Following on from the points that have been made, on recruitment and retention, most graduates and professionals will either settle around where they've got a link to the area or where they've trained. So, if we're not providing incentive for them to train in a particular area, we're going to decrease our pool of people who are going to stay. That comes down to job opportunities—if you've got an area that's a renowned area for training, so people go, 'Actually, I'm going to pick that, because it's really, really important.' But because of our national recruitment now, for most dental training jobs, applicants will rank jobs. And that will be ranked on location, but it'll also be ranked on pay. And the pay scale for dental trainees in Wales is significantly less than in England.

As an example, my registrar, who's just finished, when he first started as my registrar in Wales, he was being paid £8,000 a year less than one of his peers in England. So, a person in England who is doing exactly the same job was getting 21 per cent more in his wage than my registrar was. That will affect people, and will affect the current crop of graduates coming through who've just left dental school with £100,000-worth of debt. So, actually, the finance is going to be very important about attracting people into areas. And that's not just dentistry, because, obviously, the pay scales for trainees will affect medicine as well as dentistry. The new graduates are savvy people. They will look at, 'How much did it cost to do my training?' As in, if you have to do a Master's, how much are each of the university fees for that, what are the locations like, what is the wage, and everything like that. Because they have to make ends meet.

We have to be looking at trying to recruit more people from our own localities. We've got the Seren project, which is fantastic. They've just started the Aspire to Care project. These are fantastic initiatives to actually encourage local people to go into medicine, dentistry, but also the other professions, such as physiotherapy, nursing and everything like that. Because a dentist on its own cannot function. We need all the support infrastructure, such as therapists, such as nurses, such as administrative, and to focus on just one aspect is missing the point, to a certain degree. But we have to think about how models are set up. So, when we're looking at increasing the skill mix, from an orthodontic point of view, it's efficient to have a therapy-based model. So, you have a number of therapists, but they need to be supervised by a specialist, so you have a pyramid model.

When we did our Welsh NHS workforce survey, we noticed that, actually, a third—. We had a 70 per cent response rate, so 70 per cent of all orthodontic practitioners [Correction: 'NHS orthodontic practitioners'] within Wales responded to the survey. Out of that, a third of all specialist practitioners in primary care were looking to cease orthodontic activity in the next five years. If you've got a therapy-based model, then that's the linchpin that holds everything together. So, unless you get another specialist to replace that and provide the treatment plans and supervision for the therapist, the whole system falls apart. And, as Yvonne said, to train an orthodontist, it takes a significant amount of time. So, we've got to be thinking about the long-term recruitment and retention. It's not a quick fix, but we need to be thinking about succession planning now.

Can I just check, Joyce, did you have any further questions?

You've answered the second question.

I know Dan Cook wanted to come in, but we're a bit short of time. So, did you have any further questions to ask, Joyce?

No, I think we've got the idea about the morale.

Just quickly, Dan, and I think Yvonne looks like she wants to come in as well.

Really, really quickly, on something that Ben said, which is that dentists can't act alone—you're completely right. Dental nurses are overstretched, the pay isn't great in dental nursing and they don't have access to NHS pensions or any of the other benefits, and they're working hard day in, day out. My nurses work their fingers to the bone so hard, and they're just not recognised. They're not treated as NHS people, and that's wrong. That needs to change.

And the solution? What should change?

There needs to be a mechanism by which dental nurses with NHS commitment, as dentists do, can be somehow recognised and be given access to NHS pensions or other benefits, or something equivalent to it.

Okay. Yvonne Jones.

I agree that we need to look at the pyramid situation, but you need that orthodontist at the top to train it. But also, there are dental nurses. We need more courses that are accessible for dental nurses that don't cost a lot of money to train them up to do other skills as well. So, we have to think about the bigger picture, not just concentrate on dentists and orthodontists.

Thank you. And if you can give me a 10-second answer, or a very short answer, Russell Gidney. You talked about bureaucracy with NHS paperwork for patients, and I think you also talked about admin not contributing. Just to confirm, are you saying that there's too much paperwork associated with NHS patients, and what's the solution?

Less paperwork. [Laughter.]

But presumably there's paperwork there for a reason.

We've been filling in these risk assessment forms, the ACORN form, which I'm going to assume you're aware of, and that data is supposed to be building up profiles of the practices, to look at local commissioning and balancing of funding based on the local need. Well, actually, that data, we're now being told, isn't robust enough to be of any use to that commissioning. We're still putting in those forms. They take about 10 per cent of our time away from providing patient care.

Okay. That's helpful. Gareth Davies.

Thank you, Chair. Good morning, everyone. You've answered a lot in your answers already, but can I just push a little bit more on private provision and the reasons why NHS dentists are going to private? Like I say, you have answered those questions, but are there one or two overwhelming factors? I know pay is a big one, and you've mentioned paperwork as well, but is there a big elephant in the room and one substantial reason why there is such a transition? Do you think that will widen the inequality of access to dental treatment for people?

Why is this happening? Give us the answers—[Inaudible.]

In questions recently, the health Minister was quoted as saying that 14 per cent of contracts have been handed back. That's one in seven contracts that have been handed back, and that's not accounting for reductions in contracts; that's just a full hand-back of contract. The reason, I think, that's contributing to such a high level of hand-back at the moment, is, actually, the changes that are being brought forward. So, we have a new set of targets that were brought in in April 2022. We were given around about three or four weeks' notice to actually adapt our practices to these charges—practices often book in four, five months in advance—which is unfeasible. I'm working within those targets. At a half-year review, I'm on about 25 per cent of my target. Now, we're told that there will be some allowance, but potentially my practice is looking at being at about half of its target; looking at half its money being taken back off it. That may or may not happen, but that level of uncertainty—. Would any of you be happy not knowing what you were getting paid at the end of a year, and carry on working in that job, if you potentially halve your funding? And obviously that affects not just myself, the dentists that work with us, but all the staff that work within there. The uncertainty and pressures that that's bringing in to practice has, I think, a huge effect on practitioners.

What's the difference in pay, then, between an NHS dentist and private, roughly?

I couldn't give you exact figures. There will be outliers, such as practitioners who specialise in, for example, implants, which are not available on the NHS. Typically they would probably earn quite well. For the majority, I think, it's more about workload and work-life balance, and having the reward of being able to upskill, gain new skills, and spend the time they want to with their patients. So, for the majority, I don't think there's actually a huge difference, but I don't have a breakdown of figures that would give you an accurate response.

That data is available. I know the BDA have requested it before, and other groups have, from HMRC. I don't have it to hand either. It's not as big as you might think, but it is available, if you wanted to look it up.

We'll drop a note afterwards—

Yes, please do.

That would be great. Thank you.

I appreciate that. Just finally, how much is known about the number of patients paying for private orthodontic treatment? Does this cause a two-tier system, in effect, then?

The recent survey we've done was only looking at NHS providers; that was the reason why I was looking at it. Of the NHS providers that responded, less than 12 per cent of their overall working week was spent providing private care; the rest of it was all NHS. As has previously been mentioned, we're capped for the number of patients we can see. We have to fulfil the NHS obligations, and anything else is obviously up to the individual practitioner, if they've got any more spare capacity to potentially provide private treatment. NHS orthodontic treatment is only accessible to those with a demonstrable need, and, in primary care, under 18 years old. The private aspects will include adults, it includes those that don't qualify for NHS treatment, but it will also include some patients who do qualify for NHS treatment, but, because of the waiting times to access care, have chosen to access that care on a non-NHS basis. But I think we don't have to make the assumption that they can afford to pay privately. They're making a choice to pay privately. Often, the parents are making a choice at the expense of other aspects of their lives. So, just because they are paying privately, it doesn't mean they can, actually, within the family unit, afford that. It's just because they feel the commitment to their own children that, actually, they're going to make sacrifices in other areas to make sure that their children get more timely things. So, potentially, it does create a two-tier system from that perspective.

Thanks for that answer. Just to push a little bit more on that two-tier system in emergency cases. In a worst-case scenario, somebody's in a dire situation. They are in excruciating pain. Dentists are full to capacity. Are there contingency plans in place for those cases happening, so that people aren't in dire pain for days, weeks, months? I get e-mails from constituents, and I'm sure that other Members do here. People are in excruciating pain, and they just have nowhere to turn to. So, what is the plan in those situations?

So, just to come back to your question, and to clarify, 'Are there two tiers?' Yes, absolutely, there are two tiers. There is provision within the health boards for access. So, we've worked with Aneurin Bevan, both of us, and Aneurin Bevan commission sessions with practices to provide care for patients who are struggling to be able to access and register regularly. But that is then seen as just a one-off appointment. They are seen to get them out of pain. Then, temporary work—it might be antibiotics, it might be a temporary filling; it's only really buying them months of time before the problem recurs. And obviously, the burden is just snowballing over time.

It's fire-fighting, isn't it, rather than dealing with the underlying cause. But in the short term, we have to have that. We talked to Joyce just earlier about how we could look at long-term training spread across Wales. But with this, there needs to be that. It is available. It would be interesting to get figures from health boards, actually, on how quickly patients are seen. Some of my emergency patients—. We do emergency sessions as part of my working week, alongside my existing patients. Some of them do have to wait a little while to get through, although the health board, I think, is trying hard to find sessions for them. But there's so much need out there, there's only so much that you can squeeze out of this chronically underfunded system.

Can I just check, before I move on to Joyce and then Rhun—have you got the capacity to stay a little bit longer beyond 10.30 a.m.? I have asked that question to Dr Lewis, especially, because I know that you have got patients to see, and the last thing that we want to do is delay you from that. Are you okay to stay until 10.35 a.m. or 10.40 a.m.?

Yes, that's no problem at all.

Is that okay with the other witnesses?

I'm happy to stay longer.

Yes. I have got patients to see in Newport at 12 p.m.

That's fine.

I should be okay; 10.45 a.m. should be my absolute limit.

I needed to check that, because our inquiry can't stop you from seeing patients, clearly. Joyce, you have got about five minutes, and then I want to just allow 10 minutes for Rhun at the end. Joyce Watson.

Except I wasn't expecting you to come back to me.

Oh, well, I'll come to Rhun first, if you want to, and then come back to you. Rhun ap Iorwerth.

Good morning, all. I see the clock ticking. The question that I wanted to ask is quite a general one. I'd like you to reflect, in a way, on the number of different areas that we have looked at this morning, in order to see whether we can get you to prioritise them, because we are looking to set recommendations in order of priority. So, from all the issues that have been raised, if you had to prioritise the steps that you'd like to be taken in order to deal with the problem of access to dentistry and orthodontics, in order to deal with the inequalities that exist, what would be those priorities? Who wants to go first? Benjamin Lewis, perhaps.

Thank you. I think that we need to be thinking of short, medium and long-term strategies here. There is no quick fix. Because, fundamentally, it is all about capacity, and that capacity will be determined by workforce, unless we address the workforce issues, nothing will alter. When you have got individual courses of treatment, such as an extraction, restoration, and that sort of stuff, they are relatively simple, and so waiting list initiatives will work quite well for those, because they are short courses of treatment and things like that. Orthodontics isn't. You're looking at two years plus-worth of treatment. So, what you have got to think about is actually making sure that you recruit staff, not only to address the shortfall, but actually, that you have got opportunities to make sure that you don't destabilise services by employing someone just to deal with a waiting list initiative over a two-year period, but then not for the long term. Because you're unlikely to recruit the right sort of candidate if they know that it's for a relatively short-term contract.

So I think you've got to be looking at increasing funding to make sure that you're addressing the needs for the current cohort of patients, and as we know, the population has grown, so therefore the need has increased as a percentage, or has maintained the percentage but increased because the population is growing. But then you also need to look at backlogs, and actually, that needs to be brought into the commissioning cycle so that, over time, you are gradually going to reduce those backlogs, but in a sustainable way. Practices in primary care are independent practices. Therefore, they need to be able to have the confidence that any investment is going to be viable, especially if they're taking bank loans. In the current circumstances, banks are extremely prudent in how they're going to invest their money, and if, actually, the business case doesn't add up, then they're not going to get the money to invest anyway. So, in primary care, you've got to have sustainability over a long period of time.

In secondary care, it's about making sure that we're maximising the workforce, making sure they're actually aware, making sure that the support staff are suitably trained and remunerated, because obviously there are potentially banding issues in secondary care for dental nurses, so we can train them up to have additional skills that would free up the specialist. However, then we can't remunerate them appropriately because they're stuck at their current banding, and therefore inevitably will look for a job where they can utilise those skills but get paid appropriately. So, that has a knock-on, and then you end up going through the training cycle over and over again.

We've also got to look at training locally, and make sure that we're encouraging clinicians to come from our local areas so that they're more likely to go back to those local areas. Again, there are lots of good initiatives, but they need to be—. We almost need to ensure that we're promoting that at universities so that we can try and get more local graduates in, and staying around. That goes the same for postgraduate as well. So, that's going from not just orthodontics, but dental foundation training, dental core training, and actually making sure that we're delivering that. And it's not just about pay, it's about training opportunities. As Dan and Russell have mentioned, we want to be professionally satisfied, and we don't want to think that we've come out of dentistry and after five years of training and that's it for the next 40 years. We want to be continually developing our skills to give our best to our patients, and we've got to have an opportunity to do that. It's a waste not to be able to provide those services in the NHS.

On local training, I and colleagues fought hard to get a medical school in Bangor, and I am clear in my mind that we need a dental school there too, for exactly the reasons that you outlined. Is that an ambition that you would share?

The health board, to be fair, has been very proactive. Pete Greensmith, who's the acting dental director, has introduced and helped with the academy [Correction: 'helped with the setting up of the dental academy'] in north Wales, which is very good, and that will help local provision. It will help local provision in the general dental services. It's not necessarily going to help provision in the specialist services, because their training pathway is completely separate for that. And again, I only know about north Wales; there are probably very innovative things happening in south Wales and west Wales as well, but I only know about north Wales.

But they've introduced a sort of—. They've tried to do dental fellowships, so they've introduced areas such as oral surgery where the health board has paid for someone to do a diploma and hopefully a Master's in a particular speciality, but with that, they come and work in areas such as Anglesey, and they then are meeting a local need from a general NHS [Correction: 'general NHS dental'] point of view, but they're also increasing their own skills, which will hopefully then deliver that to a local population afterwards. Well, because that's over a three, four, or five-year time frame, they're more likely to have set down roots, they're more likely to have moved their family there, they're more likely to have invested in the community, in schooling and everything like that, and therefore they're more likely to stay in the area.

Yes, and potentially have the full undergraduate experience in years to come as well, linked to the medical school. Thank you very much for that. So, again, to you in the room in Cardiff, a list of the priorities, then—the things that we really need to focus on doing as a matter of priority. And that may well mean those are the financial, standing priorities, too, or maybe not. Maybe you could comment on that.

I would fully agree with Ben that workforce is a big issue, but we have to be mindful that we're working within that capped budget, and when we talk about workforce we talk about funding. So, just to reiterate what we said before, the budget for general dental services is for roughly about half the population, and every time that we are giving somewhere else, we are taking away from something. So, at the moment we're looking this year within Wales at about 100,000 new patients being seen, and there are some questions around that as a genuine metric. But, that is only being seen by removing our access from the patients that we would have seen historically, and actually, for the 100,000 that we're seeing, it might be 150,000, 200,000 that we're losing because they're the more stable patients, for the guide. Everything within that is give and take.

But, for us, from a general practice point of view, and obviously the point of view of the orthodontics as well, the priority has to be prevention. The majority of our time is spent treating what is an entirely preventable disease—decay and gum disease are preventable diseases—and that feeds into patient education and motivation, and things like the Designed to Smile programme, which showed fantastic success rates. The BDA has argued repeatedly that that should be expanded to actually reduce that burden. Every filling that we can reduce now, that filling will need replacing in 10 years' time, 20 years' time. That effect is cumulative, going through the years.

But, to introduce that prevention will produce a real reduction in what we do day to day. The use of dental care professionals, that skill mix, is rightly spoken about as the way to introduce that, but the maths within that has to be very carefully considered. If we employ a therapist in the practice, a therapist might have a salary probably around about two thirds of that of a dentist. That's probably questionable as a figure, but that's only a small proportion of that cost of the provision of the service. The majority of the cost actually comes in the surgery expenses—the materials, the employing of a nurse, the employing of receptionists, the lighting, the energy bills—all of those things that come with it.

So, if we were to take a dentist and replace them with a therapist, the cost saving may actually only be around about a sixth. And obviously, that dentist then is not working; they haven't got funding to work. We're not then able to give them another job to do without bringing in more funding. So, fundamentally, the asks are very clear and very easy, but until we can actually have honest conversations about what we can do with the budgeting that's there, rather than masking what we're losing to provide that new access or that new service, then realistically, I don't think we're ever going to get anywhere. It's actually honesty that is my biggest ask of what we need—an honest conversation about what we can do with the funding we have available.

Thank you. I have one other specific question, but just to give our other witnesses an opportunity, is there anything that you would like to add to what we've heard already in terms of priorities?

I'd like to add that I really do think we need to concentrate on oral health, promoting that, and getting parents involved in looking after their children's teeth, because there are still far too many children now who have general anaesthetic for extractions. And then, the long-term impact of that is that they lose space as their adult teeth come through, and then the impact is I then see them to take out further teeth and straighten their teeth. So, if we can get parents on board looking after their teeth, then not only does it reduce the burden on general dental services, it reduces the burden on orthodontic services as well. So, I think that is where a lot of money and time needs to be concentrated.

And general medical and other services as well.

Yes, general medical services as well, because also, if the general diet is good, we're going to have less obesity and other health problems.

I'll bring Ben in in a moment. Doesn't Designed to Smile, though, help with that, Yvonne?

It has, but I don't think it's—. I don't know how much of an impact it's made. I haven't got the figures for it.

Designed to Smile was a 15 per cent reduction in decay in the ones who were seen, but it's currently, I think, only just being reintroduced, and it's quite limited within its remit. We've argued repeatedly that that should be expanded to offer more.

And does it need to be expanded because the certain age groups that it was covering were being missed during the course of the pandemic?

That whole age group was being missed. So, Designed to Smile was looking at bridging the gap between deprivation areas, and it did a very, very good job of that. But, what we can see is that, up to the age that it was treating, it has reduced that deprivation. But, we have no idea if those trajectories still say the same after that, or if they'll then spread out. The deprivation still exists, and hasn't changed.

Sure. Ben, you want to come in. It will have to be brief because we're coming to an end now. Dr Ben.

Yes. Just two very brief points. The first one is: people aren't going to be able to access orthodontic treatment unless they've got an adequate dental foundation. So, if they haven't got adequate oral hygiene, they won't be able to access orthodontic treatment. That can be a very good motivating factor for people to get up to a satisfactory level of oral hygiene, which hopefully they'll maintain for the rest of their lives with all good habits. But, it also does tie into those who don't get access to dentists and dental advice, which often is lower socioeconomic groups, who can be disproportionately affected from not accessing orthodontic treatment.

And the second is not my area of expertise at all, but when we're looking at the skill mix in general dentistry, as Russell said, when you're looking at the cost-effectiveness of providing a certain treatment element in primary care—we, obviously, moved away from fee-per-item back in 2006—I think it's got to be recognised that, if you're wanting to employ dental therapists, they can provide a certain cohort of treatment. That's usually the simpler treatment. So, if you're using them for the simpler treatment, it means the dentist doing the more complex treatment, which, per unit cost, is more expensive. So, in contract reform, from my point of view, looking from the outside, it is irrational not to actually make sure that those more complex treatments are remunerated appropriately, because, otherwise, you will get a massive shift of people not wanting to do the more complex treatments, which denies NHS patients the care, or they move into other provision mechanisms that will allow for that to be done.

Thank you. Right. It's a very quick question, to Russell, perhaps, that'll help us with the next session that we have this morning. The Gwên am Byth services for older people: give us a top line of where you think we're at and where the main challenges are to make sure that that Gwên am Byth programme is working well.

Do you want to take that, Dan? Do you know more about Gwên am Byth than I do?

Yes. It'd be quite a good one to ask to the community dental service representatives as well, wouldn't it, who I think you spoke to earlier in the week. It's not really my area of expertise, I'm going to be honest with you, Rhun—I'd rather not speak on their behalf.

It has again been severely affected through COVID. So, it was the outreach, the support, the education, the whole preventative side that sits within the elderly community. But it's had to stop through COVID; the access has not been there to do so. Any benefits that have been gained over the previous years will be lost and, again, need to double down.

Yes. We're told it's restarted pretty well, actually, but I was just wondering if there were some comments this morning. That's perfectly fine if you don't want to add anything in particular there. Thank you. Thank you, Chair.

Joyce, any brief questions to finish?

I was going to ask that question, so that's been answered. I think we've got the answer to the backlog. The current situation in hospital dentistry, which is a question for Ben, probably, so I think we've covered everything.

I think you're asking about hospital dentistry specifically, I suppose.

So, again, there are just massive backlogs. Hospitals have been affected because they're on acute sites, so therefore, during COVID, many staff were redeployed onto the wards, or their departments were remodified to provide different types of services. Some departments haven't got their full surgery space back, so that limits, automatically, the capacity that they can provide in that service. I think there's a sense that, often, things are crisis driven rather than forward planned. So, for instance, if you've got a need for x number of specialists, whether that be orthodontics or restorative, for instance, sometimes, you employ one, even if there was a case of need that said, for instance, 'In north Wales, there's a benefit where, actually, when we looked at the numbers of the patients and the age demographics, then we need at least 1.5 if not two full-time restorative consultants'. We employ one, because that meets the target for the oral cancer multidisciplinary teams, and therefore the pressure is off, then, to employ anyone further. And I think the recruitment and retention systems in a lot of organisations isn't as effective as it should be. So, we're missing out on opportunities. When someone becomes available, we want to snap those people up and get them, because it is harder to recruit in Wales, and the further west we go, the harder it is to recruit as well.

I think we also need to be looking at symbiotic relationships as well. So, if someone's come in, often by the time they come to consultant level and specialist level, they've got other commitments. They've got a family, they've got a partner who has a job, and I think we need to be looking in totality at these individuals, because we want them to settle in Wales and become part of the fabric of society. Therefore, we should be saying, 'Actually, such and such has got this job, so chances are their partner will have a job that we need as well.' So, we need to be looking far more holistically at that and promoting the benefits of Wales, not just on the professional side, but the social side, the cultural side and things like that, but making sure that, actually, when we're comparing against the other home nations, the headline figures are understandable. For instance, if you employ a consultant in whatever specialty in Wales, it appears on the advert that you get paid less to start with and you get paid less at the end. Now, actually, the progression through the pay scale is better in Wales than it is in England, but people, unless they're interested in that particular job, will not look at the nitty-gritty. They will just take the headline fact, and if, actually, they've got two places to move to, one that may be more geographically convenient and appears, on the face of it, to have a higher, better remuneration, well, actually, they're obviously going to choose that job unless there's a desperate pull to that other area. So, I think we've got to be better, from a Welsh point of view, at marketing all the many benefits that we have in Wales to try and attract people not just to come for the short term, but to actually stay, for them, for their kids, and hopefully that will propagate through.

Can you just clarify something in terms of hospital treatment? When you get patients who have cancer of the mouth, who would be dealing with that, and would those people be seen with the urgent need that is required?

Just briefly, if you can, Ben.

They're seen by the maxillofacial facial team, but any reconstruction is seen by the maxillofacial facial team, possibly orthodontics, but very rarely for that cohort, but mainly by the restorative team. So, it's having adequate access to both the initial treatment, which is obviously the removal of cancer and any radiotherapy, but just as important is the rehabilitation, because that's where patients are going to need to get their lives back, and that's with the restorative team. They're seen as urgent priorities, so they're seen within a two-week time frame, and that will displace other activity, which has a knock-on effect on other disciplines.

And, Russell, you wanted to come in, but can I ask you about domiciliary care as well—if you can comment on that?

Yes, okay. Just briefly, on the hospital care, Ben alluded to it before, but, actually, a lot of the pressure could be taken off hospital care by fixing the GDS contract and the problems within there. Ben spoke about special interest contracts, but, even below that, allowing dentists to expand their skills and manage more of those patients. There are patients I refer that I could quite ably manage if I was supported to do so.

Domiciliary care, unfortunately, is falling largely short. Again, community dental services provide a lot of domiciliary care, but, within practices, within the pressures that we're working with within our contract, the vast majority of practices that have been engaged in domiciliary care are stepping away from that now to try and manage their own local business pressures. So, it is an issue and, again, the fix, I think, is the fix of the general contract to allow people the freedom to do those things.

And a very final question, if I can, to Russell and Dan: who do you think are the most impacted by problems with access, both in terms of sectors of society and geographical areas, and the solutions, the answer to that?

Go on, Dan.

I think there are those who can't afford private dentistry. There's that, isn't there? There are people in rural areas, and we've talked about west Wales as an example—north-west Wales, amongst other areas. There are people new to Wales who can't get on lists because they've maybe come in to Wales, or people who haven't had an historic relationship with an existing practice. We know that people in lower socioeconomic groups tend to visit less often. I think there's data on that. So, the health inequality and inequity is amplified by any capping and any restriction in funding, such as that which we have in Wales.

I think, anywhere, that deprivation is going to get amplified as we go forward, and particularly for the children who aren't getting the chance to get those early interventions. The filling they have now will be treatment that they'll need for the rest of their lives, but they're not even getting the chance to build the same relationships with dentists that they have in the past, because they're just not getting opportunities to see them.

One more thing about what Ben said, and I can finish on that, if I may. I know I'm being quite verbose today about this, but when we're talking about oral cancer provision, when there's such a focus on—. Certainly, if we'd gone into contract reform, I wouldn't have been able to make my targets; I would have had to have seen patients who are high risk for oral cancer less often than I think they safely can be seen. That's one of the reasons I didn't go for contract reform. So, unless you've got the patients coming in to general dentists to be diagnosed, you could have the best multidisciplinary team, and you've got excellent ones in Wales, but if the cancer isn't diagnosed—and it's often a cancer without symptoms in the early stages—they're not going to get seen. So, they're one of the patients who suffer massively from bringing it all together—the high-cancer-risk patients—where practices may end up, if this trajectory continues, with a policy forcing them to see these patients less often.

Yes, thank you. We've really come to the end of our time now. You were looking like you might want to say something briefly, Yvonne Jones.

I was just going to say that, previously to all this, we actually took part in the orthodontic managed clinical networks. We're engaged with the Welsh Government through the strategic advisory forum in orthodontics, and I think that's a worthwhile forum for us to get together, and we discuss with the chief dental officer and we come together to provide national guidelines—

Does that not happen now?

No, we've not had any for quite a while, and I think—

Why is that?

—there are moves for it to maybe be disbanded. Well, it stopped during COVID, and then we've not met again since, and obviously now we've got a new chief dental officer. So, I think—

Okay. Just briefly, what were the benefits of that forum?

Well, we helped put together national guidelines, and helped steer the national agenda on orthodontics, because we can't do that locally through our MCNs.

Okay, that's interesting. Thank you. Maybe we can pick up on that. Thank you ever so much for your time this morning, and thank you to you all for agreeing to go a little bit over as well. It was a fascinating session. Both organisations gave very comprehensive consultation responses, which is really helpful for our inquiry. We'll send you a transcript of proceedings of this morning's session. If you feel you want to add to something, then please do, but this is the first session of many, so, if you do have time to listen in and you feel you want to come back on any point that others contribute towards the inquiry, then we'd welcome it for you to drop us a note on that. Thank you very much for your time this morning. It's been a fascinating session.

Thank you.

Thank you very much.

Thank you.

We'll take a 10-minute break and we'll back at 10:55.