The British Dental Association (BDA) is the professional association for dentists in the UK. It represents 18,000 dentists working in general practice, in community and hospital settings, in academia and research, and in the armed forces, and includes dental students.

We welcome the opportunity to provide written evidence and comment on the Health and Social Care Committee’s inquiry into the provision of orthodontic services in Wales.

Throughout our paper reference will be made to the work done by Professor Stephen Richmond who, in 2010, looked at the provision of orthodontic treatment in Wales in great detail and made a large number of recommendations.[i]

The terms of reference are to inquire into the provision of appropriate orthodontic care in Wales including:

- Access for patients to appropriate orthodontic treatment, covering both primary and secondary care orthodontic services, and whether there is regional variation in access to orthodontic services across Wales.

1. There still appears to be long waiting lists in parts of Wales. We feel that this may be due in part to the number of inappropriate or early referrals.

2. The Index of orthodontic treatment need (IOTN)[ii] which is used as a guide to eligibility for NHS orthodontic care is not well understood by general practitioners. This results in children being referred for the correction of minor irregularities, sometimes as a result too, of parental pressure.

3. Consequences of long waiting lists:

· Children who need to be seen and who will need treatment may wait so long that they will have passed to optimal time for treatment.

· Long waiting lists reduce the ‘enthusiasm’ for treatment. There are more failed appointments and less patient co-operation.

· Minor irregularities may self correct and the patient/parent may no longer wish treatment but, in the meantime they have occupied a waiting list space.

- The effectiveness of working relationships between orthodontic practices and Local Health Boards in the management of local orthodontic provision, and the role of Managed Clinical Networks in helping to deliver more effective orthodontic services in Wales (e.g. effective planning and management, improvement in the appropriateness of referrals and performance management, workforce arrangements).

4. Where managed clinical networks are in place our members report that they work well.

5. One difficulty has been that the introduction of the 2006 contract put orthodontics into the Personal Dental Services (PDS) group of contracts. These are usually fixed term and because of their value, health boards have put them, on renewal, out to tender.

6. Orthodontic treatment takes some time so practices are never certain that they will be able to complete treatment. But, practices receive full payment for the course of treatment once it has started.

- Whether the current level of funding for orthodontic services is sustainable with spending pressures facing the NHS, including whether the current provision of orthodontic care is adequate, affordable and provides value for money.

7. This is difficult!

· Orthodontic treatment accounts for approximately 50% of spending on the oral/ dental care of children.

· Wales has the highest level of dental disease of all of the UK countries.

· More funding is being put into preventive dental care in Wales but it will be some time before we see vast improvements in levels of dental disease (all of which are preventable) although early trends are encouraging.

· There is little, if any evidence underpinning long term outcomes and the impact of orthodontic treatment.

· Can we argue for more funding, or even retaining existing funding for orthodontics when there is greater need in other areas of health care?

- Whether orthodontic services is given sufficient priority within the Welsh Government’s broader national oral health plan, including arrangements for monitoring standards of delivery and outcomes of care within the NHS and the independent sector.

10. Whilst there are some groups of individuals who will need orthodontic corrections we have to accept that the vast majority of treatment is to correct cosmetic irregularities.

11. Children who are born with a cleft palate, other facial deformities and dental problems such as hypodontia, congenital abnormalities of tooth tissue etc will need the care of specialist orthodontists – usually in secondary care and they should receive that.

12. Gross dental irregularities should also be corrected as a decent smile is, these days, the accepted norm and children can be cruel to their contemporaries resulting in loss of confidence and subsequent educational issues.

- The impact of the dental contract on the provision of orthodontic care.

13. The 2006 contract change put most of the orthodontic contracts into the PDS group – fixed term - usually for three but sometimes five years and introduced the Unit of Orthodontic Activity (UOA). In England, the value of the UOA was fixed, not so in Wales.

14. We feel that mistakes were made:

· The UOA value should have been fixed

· and that, subject to satisfactory completions of treatment - with appropriate peer review, contracts should have been ‘rolling contracts’.

15. There are other issues:

· Payment for a course of treatment is made on commencement rather than staged through to completion. Professor Richmond highlighted this as being a reason why there is no reliable data on satisfactory completion of treatment.

· Waiting lists are a catalyst for early (and inappropriate) referral which heightens the problem.

· There were a few practitioners who had existing patients undergoing orthodontic care and they were able to incorporate into their practice contracts a number of UOAs. Many of these GDPs had an interest in providing some of the simple orthodontic treatments for children in their practices – this saved a referral to a specialist and in many cases the treatment would have been completed quite quickly. The pre-2006 contract included fees for treatment of these simple cases – usually paid on completion and after submission of models showing ‘before’ and ‘after’ treatment.

· It is now almost impossible for a dentist who has not undergone post graduate training in orthodontics / orthognathics to take on and treat simple cases.