British Dental Association Written evidence to the Health, Wellbeing and Local Government Committee. Workforce planning in Wales. March 2011
Introduction. The British Dental Association (BDA) is the professional association for dentists in the UK. It represents over 23,000 dentists working in general practice, in community and hospital settings, in academia and research, and in the armed forces. BDA reviewed the evidence that was presented to you in 2007. This paper picks out some of the points that were raised then and gives an account of the progress, or not, that has been made in the intervening period. In Wales: The number of undergraduates continues to increase. The two super training practices for Vocational Practitioners are now running in Baglan and Porth. There has been a disappointing uptake of D2 (year 2 of the general professional training programme) training places. Local health boards continue to be unhelpful in respect of offering opportunities for practice expansion. LHBs have also not recognised the importance of facilitating post graduate education in dental practice. Dental nurse training is now a major problem. The Health, Wellbeing and Local Government Committee at the evidence session in 2007 focussed on: The effect that the 2006 dental contract had on recruitment into Wales, in particular, non UK graduates. Training of dental nurses. Dental student numbers. The role of LHBs.
1. The 2006 contract. The 2006 contract has not been an overwhelming success for all practices. Dentists continue to struggle with funding but generally have become used to working with the contract and have, at last, realised that they can neither under nor over perform as the LHBs will be totally inflexible with their funding allocation. The Minister for Health and Social Care in Wales set up a Task and Finish group to look at its effects and to explore alternative methods of working. 1 2. Workforce in 2011. The number of dentists in Wales has risen 2007-10 but we have no figures on whole time equivalents. Number of dentists on the Wales Performer list. March 2007 1186 March 2008 1247 (+61) March 2009 1293 (+46) March 2010 1310 (+17) The gender balance shows a 5% increase in the number of female practitioners from 2007 to 2010 and they now represent 41.3% of the total workforce in general dental practice but for the first time since 2006, the % of dentists who are under 35 and female has dropped below 50%. 2 In the community dental service there are approximately 110 dentists in Wales - 70% are female. We have seen an increase in the number of dentists in Wales who are not UK trained. Currently we estimate that 1 in 4 dentists trained abroad and in the period 2006-2010, of the 752 vocational training numbers issued in Wales, 360 were to dentists who had not trained in the UK.(46%) 1 Task and Finish Group reports 2008, 2009 available on the Assembly website. 2 SDR 124/2010
3. Retirement. In our annual Business Trends survey we ask about retirement. 19% of dentists in Wales planned to retire within the next three years (approx. 250) compared with 15% across the UK and of those over 50, 50% were planning retirement in the same period. The Welsh statistics are banded differently showing that 11.5% of dentists are over 55 (approx. 150) Table 1: % of dentists planning retirement within 3 years Table 2: % of dentists over 50 planning retirement within three years
Some of the reasons given for seeking to retire elicited in the survey: Disillusioned with present dental working with LHB's and compliance with increasing and unnecessary legislation. Far too many hurdles to jump over and dentistry is becoming about ticking boxes instead of caring for and doing right by my patients. I am sixty one years of age and have had enough of silly interfering bureaucrats who know nothing about clinical dentistry As a single-handed practitioner the bureaucracy / health & safety red tape are an issue for me as most are onerous and legal piffle but the new decontamination measures are the final straw and not to mention proposals for re-certification! With the new contract I am very disillusioned with the increased interference and demands placed on me by the LHB and being told that after 25 years of practicing Orthodontics I would now have to have all of my ortho cases treatment planned by a third party. Escalating costs of materials and wages are forcing me into the private sector in an area of real NHS needs (This was not why I became a dentist ) 4. Dentists in training. Undergraduates The number of undergraduates continues to increase and the number of Vocational Training places matches the output of the Cardiff Dental School and is funded by the Assembly. We believe that this year will see an entry of 80 undergraduates which, unsurprisingly, places a lot of pressure on space in the dental hospital and on the teachers. We are told that staffing levels are now critical. A recent question to the Minister about the number of hospital dental staff revealed a reduction in the number over that past four years. 3 Hospital dental staff, as well as providing a service component, also participate in teaching. It remains difficult to recruit dental academic staff and for those who enter an academic career it is difficult to maintain a balance between their commitments of teaching, research, clinical practice and personal development. 3 Assembly Record - 16 February 2011
Vocational Dental Practitioners (VDPs) Recommendations were made in the Task and Finish group report which concerned Vocational Training. 4 Directing CVT (Wales) to carry out a review of vocational training which also addresses the issue of VT plus 1 and GPT. The review to include an evaluation of the remuneration system for the provision of vocational training in Wales seeking to simplify the process and delineate it from the main payment system for the main contract. This has been done. The two super training practices in Porth and Baglan are now open, sixteen places in total. This has had the effect of reducing the number of places in general dental practices and as a result, a small number of former trainers now do not have VDPs. Each year the BDA surveys VDPs as they finish their vocational year to ask about the future career. The survey in 2010 didn t show any real problems for the VDPs in Wales, all of those surveyed from Wales had found a post by the time of the survey (July), almost half (46%) didn t have to make any applications and 82% made 2 or fewer applications prior to finding a post which is better than average the sample from Wales was quite small though, only 13 (20%) in total Funding for the service component is provided through the Dental Postgraduate Education Department. LHBs therefore derive a benefit from practices with VDPs in that they do not pay from their budget for the treatment provided. Unfortunately many LHBs are still unable or unwilling to fund contracts that allow a VDP to remain in the practice as practice juniors and should the practice lose their training practice status, they lose the service component of VT funding and are unable to continue to see some patients as a result. Specialism training Major problems though exist in training for the dental specialities of oral surgery and orthodontics. The T&F group highlighted the advancing age of the orthodontists and the discrepancy in UK numbers in training v consultant posts, a point picked up in your own report on orthodontics. 4 First report - para 7.2.1u
5. Dental nurses and other Dental Care Professionals (DCPs) There are approximately 2000 dental nurses working in Wales. The problems are: There has always been a high turnover of dental nurses (which are in the majority female) for many reasons and often they did not see this as a long term career. Currently there is no career pathway unless they use their nurse training to assist entry to dental hygiene or therapy courses or become practice managers. In the past, dental nurses were trained in the practice in which they worked (and to the practice requirements). Completion of the examinations was voluntary. Dental nurses must now be either be qualified or on an approved training course in order that they continue to work in dental practice. There are insufficient training places in Wales. A number of courses have recently closed and those that are running currently are in the major urban areas. The privately run NVQ courses have had problems and charge high fees. Practices are unwilling to pay these in case their trainee fail to complete the course, leaves for another type of job or moves on to another practice. Our survey revealed that half of the practices had tried to recruit dental nurses during the year and only 24% had had no difficulties. The main problems appear to be in rural areas where the lack of training facilities compounds the problem. The Welsh Dental Committee has this problem constantly under review and is considering if the training budget, which is currently held within the education portfolio, would be best moved to the health portfolio. In my oral evidence in 2008 I said that I thought that we could do with more dental hygienists and therapists. In the current climate I think I would now say that we have too many which just shows how inaccurate workforce planning is and how much it is influenced by changing circumstances. General practices would rather have a dentist who can do most things rather than a person who is restricted in what they can do. Also, neither of these two groups are cheap labour and opportunities to use them in private practice (non-nhs) are now severely limited by regulation and the general economy. 6. Role of Local Health Boards We had hoped that the mergers of LHBs would result in a more uniform approach to the delivery of dental services. Cross service groups have been established in the new health boards but we have yet to see any beneficial effect on dental services.
It is still difficult to retain a VDP as a practice junior unless the NHS workload / budget is diluted to match the available funding as Local health boards continue to ration dental services by not awarding new contracts or increasing the number of units of dental activity (UDAs) when practices wish to provide more NHS dentistry. 70% of practices in Wales asked for extra UDAs but only a quarter received any with only 6% receiving all they had asked for. 5 The Welsh Assembly Government has issued guidance to LHBs on the transfer and continuation of contracts in February 2010 but still problems arise. 6 Eight per cent of practice owners in England and Wales had tried to sell their practice since March 2009. Of these, two thirds (65 per cent) reported that the PCT/LHB had either refused, or made it difficult for them to transfer their NHS contract to the new owner. Unfortunately, due to the small number of cases, it is not possible to provide further breakdown of these findings. 7 Problems included PCOs refusing to transfer the contract at all, insisting on a renegotiated UDA rate, and a lack of guidance and cooperation. They advised that they will not transfer the contract (NHS) to the new owner. As this practice based on the 1st floor. (Wales) I did consider selling in 2007, and the LHB made it very clear that no guarantee of transfer of NHS Contract was going to be given to any prospective purchaser. Young dentists who would like to stay in Wales are waiting for dead men s shoes so perhaps now is the time to ask if, even with an increasing population, NHS Wales dentistry is virtually full, except maybe in the more rural and remote areas! Fact: since 2006 the Welsh Assembly government have favoured Corporates. I managed to attract two excellent dentists but the Local Health Board would not give us the UDAs for them to provide NHS Care to their income. So they both went elsewhere - in England. 7. Scottish workforce review. 8 Recently published is the Scottish strategic review of the workforce which is a comprehensive document highlighting problems that are mirrored in Wales. Expansion of the undergraduate training places by opening a new (graduate 5 BDA Business Trends Survey 2010. 6 http://new.wales.gov.uk/topics/health/ocmo/professionals/dental/publication/cdoletters/reviewcontract/?lang=en 7 BDA Business Trends survey 2010 8 http://www.scotland.gov.uk/publications/2010/12/24082155/14
entry) school seems to have put Scotland s dentists in balance for the moment. That said, there are not the same funding pressures on practices and much has been invested in dental services in Scotland. 8. The future? The population of Wales is increasing and ageing. Technology is advancing too and we simply do not know what demands will be placed on the dental profession. What we do know is that elderly patients are keeping their teeth. The amalgam generation will continue to need and to seek dental care but, with greater emphasis on prevention and public health measures, we could lessen the need for care in the younger age groups releasing time for treating the seniors in our communities. Do we have sufficient numbers of generalist dentists in Wales at present? Certainly the problems of access seem to have disappeared so perhaps the demand for routine maintenance dentistry has been addressed. Do we have too many dentists? There is little evidence of under employment but still there is much untreated disease. Wales needs to attract or train specialists or generalists with a special interest in orthodontics, special care dentistry and minor oral surgery. The current contract introduced in 2006 has not been well received and dentists relationships with LHBs are sometimes stressful. The Task and Finish Group suggested that there could be alternative ways of working that would better reward good quality in practice and prevention of oral disease. Two pilot projects have been designed for use in Wales and these will start from April 2011. In England, pilots to test new systems are about to commence. Whatever the outcome of the Welsh pilots we will undoubtedly adopt whatever England proposes, be it in a slightly modified form. British Dental Association Wales 4 th Floor, 2 Caspian Point Caspian Way, Cardiff Bay Cardiff, CF10 4DQ T. 029 2049 6174
HWLG(3)-03-11 : Paper 2 Annex A Filling the gaps further improving the oral health of Wales 2011 manifesto www.bda.org/electionwales
Filling the gaps further improving the oral health of Wales 2011 manifesto Despite an improvement in the Welsh population s oral health in the last 30 years, significant challenges remain for the way dental care is delivered in Wales. With limited funding, the Welsh Assembly Government (WAG) must look at the way in which services are designed and delivered to maximise their impact, reduce health inequalities and improve the oral health of the population. www.bda.org/electionwales
BDA Wales urges the Welsh Assembly Government that is elected in 2011 to: 1. Take further steps to eradicate oral health inequalities 2. Continue to pilot and evaluate a new general dental services contract which benefits patients and dentists alike 3. Support Health Boards 4. Plan for the future. www.bda.org/electionwales
1. Take further steps to eradicate oral health inequalities BDA Wales believes that further improvements to oral health can be made by rolling out the successful Designed to Smile programme. To reduce stark oral health inequalities and improve the oral health of the nation, BDA Wales calls on the WAG to develop a national oral health strategy. The dental health of children in Wales is amongst the worst in the UK. Over 50 per cent of five-year-olds have experienced tooth decay 1. The inequalities gap is increasing with a three-fold rise in tooth decay in children living in areas of deprivation compared to more affluent communities. BDA Wales therefore welcomes the introduction of the Designed to Smile programme. Launched across Wales in 2009, following pilots in 2007, it is a community-based programme of supervised tooth brushing and fluoride varnish application for children led by local community dental services. The BDA calls for an extension of the programme throughout Wales. If advances in child oral health are to be made, direct, innovative and targeted methods such as this are necessary. The BDA also calls for the new WAG to develop a comprehensive oral health strategy which can be reflected in the Health Boards local plans. The NHS dental service provided for the people of Wales will fail to meet local needs without a strategy to reduce oral disease. The strategy should have a focus on rural areas and the needs of vulnerable patients including those with disabilities and should take account of the resources required by practices if they are to continue to provide NHS care across Wales. The WAG should implement recommendations from the June 2010 Special Care Dentistry in Wales report, that highlight the need for integrated planning. 1 A National Oral Health Improvement Programme Promoting Better Oral Health and Delivering a Fluoride Supplementation Programme, Designed to Smile 2008. www.bda.org/electionwales
2. A new dental contract for Wales BDA Wales welcomes the new contract pilots for dentistry focusing on access, quality and prevention. BDA Wales calls for the pilots to continue. To ensure the new contract works for patients and dentists, they must retain clear aims, be fully funded and be robustly evaluated. April 2006 saw the implementation of far-reaching reforms to NHS dentistry in Wales. Those reforms were criticised by patients, dentists and politicians alike. I just want a contract that allows dentists to meet the needs of patients in an open manner that everybody is comfortable with the local health board, the patient and the dentist all three parties have got to be happy. NHS dentist in Wales BDA general practice focus groups, Practice owner report June 2010 Consequently, a Task and Finish Group was convened in 2007 to look at how the contract might be improved. A number of recommendations were made and the group concluded that Units of Dental Activity (UDAs) as the sole outcome measure were inadequate and did not allow for time to be spent with patients for preventive care. Some recommendations have already been implemented including the extension of the ring-fencing of the dental budget until 2012, and issuing guidance to Health Boards on the termination and transfer of contracts. Heeding the group s conclusions, the WAG has set up two pilots which aim to deliver a preventive approach to oral healthcare. They will start in April 2011. BDA Wales welcomes the pilots. In order to succeed however, the pilots must be properly funded, have clear aims and be comprehensively evaluated before any decision is made to extend them. To tackle health inequalities, BDA Wales also calls for the pilots to assess weighted funding for areas of deprivation and high disease levels. www.bda.org/electionwales
3. Support Health Boards BDA Wales calls for Health Boards to receive robust central guidance and support. Health Boards should have the opportunity to plan NHS dental services based on the oral needs of their population. Health Boards have little direction under the current system. BDA Wales is concerned that some approaches to contractual issues are inconsistent and sometimes difficult to work within. Indeed, some locality units have not adopted a partnership approach to their dental contractors, preferring to behave as managers. Due to these ever-changing and differing approaches, morale amongst dentists in Wales is low. A recent BDA survey of dentists found that 31.7 per cent of respondents reported low or very low morale 2. To enable dentists to dedicate their time to patients, the new WAG must address these inconsistencies and inefficiencies by providing strong central guidance and support and sharing best practice. In addition, in order to develop strategies and to plan for patients, the BDA calls for Health Boards to observe their statutory requirement to consult and work with Local Dental Committees, also taking into account other professional advisory structures being established across Wales 3. Health Boards also need further guidance and assistance to help them plan services for vulnerable groups, to enable further collaborative working between family and community dentists. It would be nice to work with the health authority, rather than pulling against them. NHS dentist in Wales BDA general practice focus groups, Practice owner report June 2010 2 In addition, 48.5 per cent of dentists said that their morale had decreased somewhat or substantially in the last year. BDA, Business Trends Survey, Morale and motivation report. May-July 2010. 3 The Task and Finish Group recommended that Health Boards should have a statutory obligation to consult with Local Dental Committees and have clear guidance on the transfer and termination of contracts. Whilst some of these recommendations have been implemented, others have not. www.bda.org/electionwales
4. Plan for the future Population changes, shifting workforce patterns, changing technologies and an increase in regulation will all affect demand for dental services. BDA Wales calls for a workforce review and the development of an All Wales ICT Strategy for dentistry. If the WAG is going to make best use of its limited resources to deliver good quality, preventive dentistry for patients, planning is required. In particular, overcoming the challenges associated with an ageing population is crucial. More adults in Wales are keeping their natural teeth. In 2009, one in ten adults over 16 had no natural teeth, compared to around one third in 1978 4. This means that this group will have a high level of disease which has been treated by fillings and other restorations. As they age they will increasingly have high and complex maintenance needs. Planning is also needed for care homes and domiciliary care. There are currently weaknesses in arrangements for accessing both routine and emergency dental care, as well as little staff training for those assisting residents with their oral hygiene 5. The new WAG should conduct an urgent workforce review to consider whether the right mix of people is being trained to deliver the right care to the population. This must take into account student and vocational training, retirement and the skill mix of the whole dental team including dental nurses, dental hygienists and dental therapists as well as orthodontists and minor oral surgery specialists. The BDA fears that patient care could be adversely affected by poor graduate support and planning. Cardiff University School of Dentistry continues to increase its undergraduate intake and the WAG has shown its commitment to funding sufficient vocational training places to match the school s output. The way the current contract is funded through Health Boards fails to allow these new graduates to establish themselves in Wales in the long term, however, with many finding employment elsewhere. 4 Adult Dental Health Survey 2009, NHS Information Centre. Published 8 December 2010. 5 Nursing and residential care home oral health policy and access to dental care survey, 2006-7, Cardiff University School of Dentistry. www.bda.org/electionwales
Patient care may also suffer due to a large cohort of experienced practitioners retiring. A recent BDA survey has found that 50 per cent of dentists who are 50 years old or over plan to retire or leave the dental (clinical) profession within the next three years. Reasons for this include increasing bureaucracy and regulation. Accompanying these demographic and workforce changes are huge challenges for technology and quality improvements. Information Technology (IT) plays a crucial role in disseminating information to dentists, patients and in education, and there is a pressing need to bring dental teams into closer contact with the wider NHS family. The BDA supports the recommendation by the Task and Finish Group that an All Wales ICT strategy for dentistry needs to be developed to ensure that practices operate within the NHSnet. This could be delivered as part of the Public Service ICT programme. The new WAG must also consider the impact of increasing regulation and changes to decontamination requirements, ensuring that they do not take money away from the delivery of quality frontline services. Contact BDA Wales: Stuart Geddes Director BDA Wales s.geddes@bda.org 2 Caspian Point, Cardiff Bay, CF10 4DQ For further information about the BDA s public affairs activity please contact Laura Brandon, Public Affairs Officer on laura.brandon@bda.org The British Dental Association (BDA) is the professional association for dentists in the UK. It represents 23,000 members working in general practice, in community and hospital settings, in academia and research, and in the armed forces. It also includes dental students. www.bda.org/electionwales