Consultation Response – Welsh Government reform of NHS general dental services

KEY MESSAGES:

• Access to dental services is a longstanding issue for many older people.
• The Commissioner will examine older people’s access to dentistry and oral health services in Wales, beginning in autumn 2025.
• The new general dental services arrangements should ensure continuity of care and relationships of trust.
• They should enshrine the NHS Integrated Quality Standard for Older People and People Living with Frailty.
• Automatic “computer says no” responses to older people struggling with access are completely unacceptable and should not be permitted.
• Older people must have non-digital access to dental services and payments for treatment.
• Older people must be engaged in the development of national guidelines on good practice
• There must be robust oversight of implementation at practice level, to ensure that older people receive the treatment and care that they need.

Introduction

The Older People’s Commissioner for Wales welcomes the opportunity to respond to the Welsh Government’s consultation on the reform of NHS general dental services.

During her engagement with older people across Wales in her first nine months in post, the Commissioner has heard from older people about the problems they are experiencing accessing dental services. Further details are below.  The Commissioner has also heard from Healthcare Inspectorate Wales about their serious concerns about some dental practices in Wales.

The Commissioner published her strategy and her work programme for 2025-26 in May.  The work programme includes a commitment to examine older people’s access to dentistry and oral health services in Wales.  The previous Commissioner, Heléna Herklots, submitted written evidence and oral evidence to the Senedd Health and Social Care Committee inquiry into dentistry in 2022.  The present Commissioner, Rhian Bowen-Davies, and her team will be drawing on the Committee’s report and the Welsh Government response, evidence from Healthcare Inspectorate Wales, the current policy environment and intelligence from older people when taking forward her examination.

Heléna Herklots published her report, Access to GP Practices;  older people’s experiences, in March 2024.  The report draws attention to important principles which should underpin older people’s access to GP practices, including continuity of care, developing relationships of trust and addressing practical barriers to access, such as digital exclusion and lack of public transport.  It is essential that these principles also apply to the whole of primary and community-based NHS services, including dentistry and oral health services.

Continuity of care and relationships of trust

Page 9 of the consultation makes a comparison between dental services and other parts of the NHS health care system (“No other part of the NHS health care system prioritises well patients over those with active disease”).  The underlying assumption, that there should be consistency of basic principles across the whole of the NHS, is an important one.

The Access to GP Practices report demonstrated the value which older people place on continuity of care and relationships of trust and their importance for good outcomes, particularly for older, frail and vulnerable people.  As a result, the Welsh Government and the British Medical Association agreed to work towards measures of continuity of care in the General Medical Services contract.

Older people have told the Commissioner that they place a similarly high value on continuity of care and relationships of trust in dental services.  The Commissioner understands that, in legal terms, people are not registered with a dental practice in the same way as they are with a GP practice.  However, in practice, most older people do not experience dental services in this way, returning to the same practice and even the same dentist at every appointment over many years.  It is arguable that the policy environment and dentists themselves have created a legitimate expectation of continuity of care, for example through recalling people for check-ups and through their other communications – the Commissioner has seen written material from a dental practice which itself refers to registration of patients at the practice.  Registration was in fact in place for 16 years from 1990 to 2006 and it is likely that most people would assume it still is.

Under the proposed reform to NHS dental services, people who are assessed to require a recall interval of 18 months or more would be returned to the common waiting list and could be allocated to a different dentist for their next appointment.  This would constitute a major change in their experience of service delivery for older people and it is very worrying for many of them.  Given the outcome of the work on access to GP practices, the Commissioner is surprised that the important principles of continuity of care and relationships of trust seem to be applied inconsistently across different parts of NHS primary care services.  She is concerned about the potential impact of the new arrangements on patient outcomes.

For example:  the previous Commissioner’s response to the Health and Social Care Committee inquiry highlighted cases of older people who had entered into hybrid funding arrangements for partial dentures without realising that they had in effect “gone private” by doing this, moved closer to family as they became older and less mobile, and then could not find a local dentist prepared to maintain their dentures.  The Commissioner is very concerned about how people in this situation would be able to access the dental care they need under the new arrangements.

Appointments, older people and frailty

The Commissioner is very concerned about the proposal that failure to attend for two consecutive appointments, or three within a treatment plan, will result in someone being returned to the bottom of the list, with no consideration of the barriers to attendance with which many older people struggle. The Equalities Impact Assessment accompanying the consultation document acknowledges that “vulnerable patients may experience disproportionate barriers outside of their control causing them to miss their appointment. These may include transportation issues, work conflicts, or health problems. By allowing for a limited number of missed appointments, we consider the proposed approach is considered (sic) fair and proportionate.”  The assumption is that these barriers are episodic and that overcoming them on the third or fourth occasion is within the patient’s ability.   However, many of the reasons which prevent older people from keeping appointments, such as long term conditions or deprivation, are not episodic but chronic, and for them those barriers persist.  Chronic barriers to access include caring responsibilities which make it almost impossible to leave the house, dementia (the Commissioner is aware of people living with dementia being sent NHS appointment letters they can no longer understand) and sensory loss which makes reading or making phone calls extremely difficult, among other things.

The Commissioner is aware that GP practices record sensory loss and communication preferences on the patient record.  Even so, the Commissioner and her team frequently hear of people whose preferences are ignored in NHS communications.  There is no information in the consultation document about how NHS dental services might be required to tailor the appointments process to older people’s communication needs, to help them to attend appointments.  As one inquirer to the Commissioner’s office has pointed out, the consultation document is framed as a consultation with the profession about a contract for services.  It is not framed as a consultation with the public about a major change in service delivery and therefore does not address the proposed changes from the wider perspective of the patient.  This is disappointing and unhelpful.

The Commissioner is particularly concerned by the existing unsympathetic and rigid response of some dental practices to older people who are struggling with access.  For example, in the case of one couple in their eighties, the husband was trying to resolve a difficult situation constructively by offering his own appointment to his wife.  He was told that giving up his own appointment voluntarily would trigger his own removal from the waiting list.

Withdrawing services from frail older people who are struggling with barriers to access is not acceptable and contrary to the NHS Wales Integrated Quality Standard for Older People and People Living with Frailty.  The purpose of the Quality Standard is to ensure wrap-around preventative support and services to vulnerable older people and people who are frail.  It includes a commitment to “take into account ‘what matters’ to older people in our decision making in improving care”.  The reform of NHS dental services must ensure that the system enshrines it and that dental practices comply with it.  Automatic “computer says no” responses to older people struggling with access are completely unacceptable and should not be permitted.

Page 16 of the consultation document states “There is a need to define good practice in terms of decreasing the failure to attend rate and, as mentioned earlier, there is ongoing work to develop national guidance in this area.”  The failure in the consultation document to address the proposals from the wider public perspective is a major omission.  It is essential that the development of national guidance on good practice on decreasing the failure to attend rate is co-produced with members of the public and with older people in particular, if it is not to reinforce existing rigid and potentially harmful approaches by individual practices.

Charges for treatment

Although it does provide some examples of increases and decreases in the cost of certain treatments, the consultation document does not include an overall assessment of the impact of the new dental charges on older people.  As the 2022 inquiry response points out, the oral health needs of older people are changing and becoming increasingly complex. Many older people now need regular maintenance and restoration of natural teeth and individually designed partial dentures, where previous generations would have needed a full set of dentures to replace all their teeth.

The Commissioner is concerned that the higher costs may fall disproportionately on older people. The Commissioner’s response to the Work and Pensions Committee Consultation on Pensioner poverty – challenges and mitigations provides further information on poverty and older people in Wales.  There does not seem to be any assessment in the consultation document of the impact of changes to treatment costs along with potential mitigations through entitlement to Pension Credit and the NHS Low Income Scheme, which might enable the Commissioner to develop a more informed view of the financial impact on older people.

The 2022 inquiry response supported the Royal College of Surgeons’ recommendation in 2017 that more data is needed both on the oral health of the older population and on older people’s access to dental services, and that data on the older people’s cohort should be further disaggregated by age band in Wales.  This would enable an assessment of financial impact to be made and both data collection and consideration of financial impact on older people should be addressed as matters of urgency.

Digital exclusion

The previous Commissioner’s 2024 report Access Denied on the digital exclusion of older people highlighted a range of problems which older people encounter due to not being online or having limited digital skills, including difficulties booking healthcare appointments.

The Commissioner understands that the new dental access portal will be run by Digital Health and Care Wales.  There is no information in the consultation document about how older people who are not online or not digitally confident will access dental services if the single point of entry is through a digital portal.  People who are not online and unable to access the Dental Access Portal must not be disadvantaged in terms of access to dental services.  The Commissioner wishes to receive early information and reassurance on this point.  More importantly, the Welsh Government should provide early information and reassurance to the public and to older people in particular.

The consultation document also states (page 16) “Patient responsibilities and consequences of D[id] N[ot] A[ttend] to be clearly displayed in practice, on websites and in patient information leaflets.”  There is no information about how a patient who is not online and not actually in the practice premises when making an appointment or an enquiry will access this information.  In addition, the Commissioner is aware that many older people regard generalised public information as not intended for them.  The Commissioner wishes to be assured that there will be a comprehensive public information campaign, including information specifically aimed at older people, about this and other important aspects of the reform of dental services.

Finally, page 18 proposes that the Patient Charge Revenue is collected via an “online payment system where patients receive an invoice via text or email after treatment and can pay online”.  There is no information about how older people who are not online or not confident about digital banking, can pay for dental services.  It is essential that older people are able to make offline payments if they prefer to do so.

Transport

The Access to GP Practices report identified that transport problems are a significant barrier to access and a frequent cause of missed NHS appointments.  The Commissioner receives many other inquiries and stories about the difficulty frail older people have in finding transport to primary care appointments, through her engagement visits, through her Advice and Assistance Team and via concerned Members of the Senedd and Members of Parliament.   Problems include limited services (or in some cases, especially in rural areas, no services), routes and /or scheduling, a lack of reliability, and inaccessible vehicles.

The consultation document states that one of the intended effects of the reform of dental services is to increase patient accountability for their own oral health.  In the Commissioner’s view, it would be unjust to place responsibility on older people for overcoming problems with access which they cannot resolve themselves, and inhumane not to take those problems into account when considering the reasons for missed appointments.  The Access to GP Practices report recommended that the Welsh Government, NHS bodies and Pan-Cluster Planning Groups should improve public transport to GP practices.  This recommendation applies equally to public transport to dental practices.

Implementation and monitoring

Work to follow up the Access to GP Practices report has revealed that barriers to access are sometimes created by individual practice staff imposing requirements on patients which are contrary to the General Medical Services Contract, such as requiring patients to book appointments online. The Commissioner greatly appreciates the help of the NHS Wales Strategic Programme for Primary Care in resolving these issues when they arise.  The Commissioner is concerned that local governance arrangements for dental services, which provide the channels through which to address these issues, are less well developed than for general medical services.  She welcomes the proposal to develop area-based cluster arrangements for dental services as a means of disseminating and upscaling good practice.

The Commissioner is however concerned about the risk of poor patient experience in practice, in the absence of adequate data collection, the lack of patient focus in the consultation document, and her experience with some GP practices.  The Commissioner will pay particular attention to this in her examination of older people’s experience of dental and oral health services, and will if necessary make recommendations for improvement.  In the meantime, it is essential that the Welsh Government and Health Boards monitor implementation of the new arrangements closely, for their impact on the health and wellbeing of older people.

Conclusion 

The Commissioner is conscious that the vast majority of patient contacts take place in primary and community care.  She has therefore continued to progress her predecessor’s work to encourage stakeholders to implement the recommendations in the Access to GP Practices report and believes they are transferrable to dentistry and oral health services.

While the new general dental services contract offers opportunities to improve dental practice systems, it is essential that dental practices operate in line with the Integrated Quality Standard on Older People and Frailty and that older people are engaged in developing guidance on best practice.

The Commissioner and her team would be happy to provide further information if that would be helpful.