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National Public Health Service for Wales
A REVIEW OF THE COMMUNITY DENTAL
SERVICE ABMU LHB
A REVIEW OF THE
COMMUNITY DENTAL
SERVICE
ABMU LHB
Status Final - Version 0a
Circulation – Board Directors ABM LHB
Date 18.01.10
Author: Hugh Bennett, Consultant in Dental
Public Health
Version: 0a
Date: 18/01/2010
Page: 1 of 39
Status: Final
AMBU LHB CDS Review
A REVIEW OF THE COMMUNITY DENTAL
SERVICE ABMU LHB
National Public Health Service for Wales
Contents
Page No.
Executive Summary - Key Recommendations
3
1.
Purpose
10
2.
Introduction and Background
10
3.
Oral Health – Assessing the Need
10
4.
The Role of Community Dental Services in Wales
and Services currently provided by the
Abertawe Bro Morgannwg University CDS
10
5.
A Strategic Way Forward
14
6.
Workforce
14
7.
Clinical Activity
17
8.
Funding of CDS
21
9.
CDS Estate
23
10.
Provision of CDS Services into Bridgend
27
11.
Support Systems
29
12.
Clinical Governance
30
13.
Designed to Smile
30
14.
Discussion and Conclusion
31
Annex 1 Institutions Visited by CDS 2008-2009
32
Annex 2 Summary of Activity Data
34
Acknowledgements
38
References
39
Author: Hugh Bennett, Consultant in Dental
Public Health
Version: 0a
Date: 18/01/2010
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Status: Final
AMBU LHB CDS Review
National Public Health Service for Wales
A REVIEW OF THE COMMUNITY DENTAL
SERVICE ABMU LHB
Executive Summary
Purpose
1. This review summarises the current state of the Community Dental Service of the
Abertawe Bro Morgannwg Local Health Board. It also makes recommendations for
stabilising the service and setting a strategic way forward.
Introduction and Background
2. The new ABMU Local Health Board has the responsibility to ensure provision of
primary care dental services to its local population. It will also have the responsibility, as
set out in the Ministerial Letter EH/ML/014/08 Dental Services for Vulnerable People
and the Role of the Community Dental Service, to ensure –


that vulnerable people have access to appropriate dental care through delivery of
comprehensive services
the development of Community Dental Services (CDS) to assist that aim
3. The need to develop CDS services is reiterated in Ministerial Letter EH/ML/032-09
Expansion of Designed to Smile – A National Oral Health Improvement Programme.
This letter builds on WHC 008 (2008) that launched Designed to Smile (D2S). The local
programme now receives £459,000 ring-fenced central funding and must be delivered
by the CDS.
4. Access to primary care dental services has a high public, media and political profile.
The Board of the new LHB will need to view primary, community, and hospital dentistry
as complementary services in order to work towards fulfilling its responsibilities. The
CDS can be described as the managed arm of primary/community dental care.
Discussion
5. If you are a child from a deprived area, have special health needs or are a member
of another vulnerable social group you will probably not be able to access appropriate
dental care as easily as other members of the community. Patients from vulnerable
groups should form the core of those treated by the CDS. It is prudent to point out that
patients from such groups are often disproportionately time consuming to treat (when
compared to those attending general dental practice), not just because the treatment
can take longer, but because overall care management can be more involved.
6. The CDS under-sells itself, it is carrying out an important role delivered by many
committed staff, but that role needs to be better understood by other dental services.
However, there are improvements that can be made in the service.
7. Between the period 2006 and 2009, there has been a gradual reduction in the CDS
clinical workforce. This trend should not be allowed to continue if the service is to fulfil
the role envisaged by the Welsh Assembly Government; the point of minimum critical
Author: Hugh Bennett, Consultant in Dental
Public Health
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Status: Final
AMBU LHB CDS Review
National Public Health Service for Wales
A REVIEW OF THE COMMUNITY DENTAL
SERVICE ABMU LHB
mass has been reached. Issues of long-term sick leave, long standing secondments
out of the service and short term locum contracts affecting several dental officer posts
need to be reviewed, because these have a major impact on a service with such a
small clinical workforce.
8. A recruitment and retention policy is required with its first priority being recruitment of
a Clinical Services Manager. The next priority is to fill vacancies with permanent posts
and if the new Clinical Services Manager is recruited via an internal appointment that
the vacant clinical SDO post created must be retained.
9. The service appears to have been under-funded and under-resourced for many
years. The general state of some clinic facilities is, therefore, poor and the lack of
investment in ICT for the CDS borders on neglect. There is scope for reducing the
number of CDS clinics. However, the purpose of this should not be rationalisation
driven by cost saving, but rather by increasing efficiency in service delivery. The aim
should be to establish a network of clinics fairly distributed across the whole ABMU
area, and a phased programme of clinic improvements. The CDS must remain
accessible to the deprived communities it serves and planners should take this into
consideration.
10. The ABM CDS is drifting into a ‘catch 22’ situation witnessed in the decline of the
CDS in West Wales. The clinical workforce has been reduced and failure to fill
vacancies will further deplete the clinician workforce. Therefore, clinics become less
utilised and come under consideration for closure. However, if clinics are closed or not
made available to the CDS the service will contract further and become even less
attractive to potential recruits.
11. In general, the Mobile Dental Units, when they are in good mechanical order, have
a high usage and a high efficiency, e.g. of the appointments made for Mobile Dental
Units over the past 2 years well over 90% have been kept. Carefully planned Mobile
Dental Units can be an effective way of delivering dental care to isolated populations or
specific institutions.
12. The current NHS reorganisation presents an opportunity to create a stable future for
the ABM CDS. Arresting its decline and developing it would make a positive
contribution to overall dental provision e.g. closer alliance with the Restorative and
Orthodontics Specialities of Hospital Dental Services within the new LHB organisational
arrangements would be the first step to developing the joint working and professional
development opportunities lacking at present.
13. Indeed the impression gained in conducting this review is that, in the past, not
enough has been made of potential complementary contributions the 3 dental services
could make to service provision. This has led to inefficiencies within the whole system.
It beggars belief that so few clinical links between the CDS and the HDS existed under
the old Trust arrangements.
14. Huge opportunities for better coordination of services and for professional
development have been lost over the years. A better balance in the NHS dental
services providing care is possible. There is are knowledge gaps within and between
the 3 services about what the CDS does, should do and is currently able to do.
Author: Hugh Bennett, Consultant in Dental
Public Health
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National Public Health Service for Wales
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SERVICE ABMU LHB
15. The CDS is not as strong as it should be, but it cannot be described as a weak link
in the complementary pattern of dental services because such a pattern does not really
exist. A weak CDS means that patients and the other dental services are losing out on
the added value salaried community/primary care services can bring.
16. Specific mention of the Resource Centre in Neath Port Talbot Locality is warranted.
There is capacity in the new facility for use by the CDS. Recent clinic closures at Water
Street and Dew Road and recommendations on further closures made in this review
were/are, to an extent, dependent on the CDS having a presence within this new
centre. In addition, the new facility is ideal for access by Special Care patients,
something currently lacking at some CDS clinics. Indeed, this environment could
provide an ideal location for developing collaborative working between the CDS and
some parts of the HDS.
17. Many clinical staff display a worthy commitment to the care of vulnerable groups
and a desire to see their service develop. Of particular note are the high motivation,
enthusiasm and professionalism of the majority of the dental nursing staff. However, if
the CDS is to develop into a stronger better fit for purpose service, staff of all grades
need to be flexible in embracing change. That is not to say wholesale revision of their
longstanding clinical/work arrangements, but rather the willingness to accept some
modification that better fits a strategic role for the service.
18. Most CDS clinics do not have basic ICT i.e. modern desktop computer with
internet/intranet access and printer installed. The almost total lack of reliable email
facilities also means that management of services on a day to day basis is archaic.
This is unacceptable and reduces the effectiveness of the service and its management.
In addition, the service is failing to supply the Welsh Assembly Government with robust
annual activity returns. Clinicians are still “shading in boxes with pencils” on cards that
are then “optically read”.
Key Recommendations
19. Recommendations are made throughout the text of the main paper. A summary of
the main recommendations are set out below1. A Strategic Service Plan
It is recommended that a CDS strategic planning group is convened to support the
incoming Clinical Services Manager in developing and delivering a 3–year strategic
plan for the service. The aim of the group being to develop a CDS able to better fulfil
the role envisaged for it by the Welsh Assembly Government and fit into a LHB dental
strategy. An up-dated service specification should form a central component of the 3–
year strategic plan.
The group should be chaired by the new Clinical Services Manager and include, senior
CDS clinicians, appropriate representation from general management, CHC, the local
Consultant in Dental Public Health and representatives from the LDC and HDS.
Author: Hugh Bennett, Consultant in Dental
Public Health
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National Public Health Service for Wales
A REVIEW OF THE COMMUNITY DENTAL
SERVICE ABMU LHB
2. Position within ABM LHB Organisational Structure
As part of Womens and Child Directorate of the old NHS Trust the CDS did not fulfil its
potential. The LHB consultation paper on implementing structures places the CDS
within a Clinical Directorate structure reporting to the Director of Acute Care under
Regional Services to include –





Burns & Plastic Surgery
Artificial Limb and Appliance Centre (ALAC)
Nephrology
Maxillofacial
Community Dental Services
The term “Maxillofacial” is understood to include the dental Specialties of Restorative,
Orthodontics and Oral Surgery. This is an important point because the greatest
potential for more effective working lays in better links between the CDS the “dental
Specialties”. That being the case there is much logic in housing the salaried dental
services together, please refer to paragraph 13 above.
However, during the review the impression gained was that the Maxillofacial
Consultants are not keen on this option and their argument is awaited.
Another option is for the CDS to fall under a Locality with the General Dental Services.
However, because the future of the CDS must be about developing it to provide more
specialised services/support e.g. special care and sedation, preference is for the first
option. With either option the financial integrity of the CDS should be respected as a
LHB wide dental services strategy is developed
3. Workforce
It is recommended that
a robust recruitment and retention strategy is developed.

it is agreed precisely what the CDS establishment is, including clarifying any
funded vacancies, long term sick leave, long term outward secondments and
short term locum contracts.

in order to stabilise the service, an immediate effort is made to recruit permanent
posts into any funded vacancies identified.

a CDS Clinical Services Manager is appointed with the authority to work
alongside general managers in the decision making processes. If the Clinical
Services Manager is recruited via an internal appointment the vacancy created
must be filled.

a minimum recruitment of an additional 1.5 to 2.5 WTE * dentists/therapists is
required – i.e. 2.5 would roughly return to 2006 workforce levels.
Author: Hugh Bennett, Consultant in Dental
Public Health
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
a priority for recruitment should be a Specialist in Special Care Dentistry (or a
dentist working towards/close to achieving that status).

the commitment to supporting Dental Foundation 2 training is maintained.
* range offered due to the lack of clarity noted in second bullet point
4. Internal Organisation of the CDS
It is recommended that
a Special Care Team is created with leadership from a senior clinician with a
short to medium term strategy for Special Care Dentistry drawn up as a matter of
priority. This will serve to pull together the various components already being
delivered into a coherent pattern of care, setting a platform for future
development.

a senior clinician should take a lead role for Child Services, the CDS should
retain a strong input into providing services to school children from the most
deprived communities. However, the service must review its acceptance and
discharge policies for children, and this should be done in liaison with LHB
primary care administrators and the Local Dental Committee through the LHB
Dental Advisory structures.

the conclusions of the CDS domiciliary audit are acted upon, as a priority, by the
incoming CDS Clinical Services Manager.

there is scope to develop mobile dental services with perhaps the co-ordination
of the day to day running provided by an experienced dental nurse

the Senior Dental Nurse function should be reviewed to reflect changes in
organisational structure recommended above.
Clinical Governance
The incoming Clinical Services Manager should review Clinical Governance across the
service. It is recommended that



clinical audit/peer review processes involving all staff should be revitalised with
designated clinical officers leading the work.
robust annual appraisal for clinicians must be initiated, covering clinical activity,
quality and professional development.
a senior clinician from another CDS should be involved in this process to support
the Clinical Services Manager in this work.
the role of each dental officer is reviewed and an exercise to log the clinical
interests of individual dental officer is undertaken and built into Continuing
Professional Development Plans.
Author: Hugh Bennett, Consultant in Dental
Public Health
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A REVIEW OF THE COMMUNITY DENTAL
SERVICE ABMU LHB
National Public Health Service for Wales
5. CDS Services into Bridgend Locality
It is recommended that
the current provision into the Bridgend Locality by Cardiff and Vale CDS is
maintained throughout 2010 -11.

the newly appointed CDS Clinical Services Manager sets up the initial formal
dialogue with clinical and general management of the Cardiff and Vale CDS/
LHB, the aim being to scope out precisely how the CDS services are currently
provided and the options for future provision.

a joint paper to be presented to both LHB Boards by November 2010 setting out the
options for future CDS services and the risks and benefits involved in any change.
6. The CDS Estate
Most of the clinic locations are being utilised but some are hardly used at all. The aim
must be for a spine of quality multi-chair clinics with a number of strategically placed
satellite clinics linked to them. The CDS should have a strong presence in the
Resource Centre in Neath Port Talbot Locality, see paragraph 16.
It is recommended that







a spine of high quality multiple chair clinic facilities, such as those offered by
Central Clinic in Swansea, the new Resource Centre, Pontardawe (currently only
one chair) and Neath Dyfed Road Clinics is developed.
greater concentration of clinical time around the central clinics is needed to
improve efficiency, i.e. to reduce clinical down times, travel time and expenses
and the possibilities of professional isolation.
select satellite clinics still have a role in bringing certain services closer to
specific deprived communities
Cwmafon clinic should not be used for clinical purposes with immediate effect.
Ystalyfera and Glynneath clinics be placed high on a list for closure.
the possibility of joint provision with Powys LHB from the Powys CDS clinic at
Ystradgynlais should be explored.
the mobile services in the top of the Afan Valley and the fixed services at
Cymmer Clinic be retained and better resourced.
the CDS retains a strong presence in the Gorseinon area, which represents its
most westerly outreach.
Author: Hugh Bennett, Consultant in Dental
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Mobile Dental Units
It is recommended that
there is a need for targeted mobile dental services,

one unit is decommissioned in 2010-11, reviewing the future of another with a
possibility of decommissioning in 2011-12, and increasing the use of others
would greatly improve the cost effectiveness of the mobile dental service
provision.

Mobile Dental Unit (MDU) 1 is decommissioned.

a replacement tractor unit for MDU 2 is secured to ensure that this unit continues
to function at maximum capacity in the Afan Valley.

MDU 3 is used as a temporary clinic during Gorseinon building works and then
considered for decommissioning.

MDU 4 has a high usage and should stay in commission.

the usage of MDU 5 is increased contributing to Special Care services and
replacing the capacity of the two units advised for decommissioning.

the estimated £5000 costs for repair of MDU 5 are met.
7. Information and Communication Technology
ICT in the CDS has been neglected and requires urgent upgrading.
8. Public Health Programmes
It is recommended that the LHB provides ongoing support to the CDS role in delivering
Designed to Smile. Indeed, it is obliged to do so under Ministerial letter EH/ML/032-09
and report to WAG by 30th July.
Conclusion
20. Set in the context of the above the ABM CDS has unfulfilled potential that if
realised, would allow it to deliver more closely the role defined for it in EH/ML/014/08. It
would also contribute with greater effectiveness to the overall provision of dental
services in the area. The vision is for a CDS that complements GDS and HDS services
and is able to engage at the most appropriate and effective points in the system. It can
become a service that interacts in a coherent manner with a wide range of health and
social care stakeholders to improve the oral health of the population.
Author: Hugh Bennett, Consultant in Dental
Public Health
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A REVIEW OF THE COMMUNITY DENTAL
SERVICE ABMU LHB
National Public Health Service for Wales
A REVIEW OF THE CURRENT ABM LHB COMMUNITY DENTAL SERVICE
STRATEGIC WAY FORWARD FOR A UNIFIED SERVICE
1. Purpose
1. This Review summarises the current state of the Community Dental Service in the
ABM LHB area. It also makes recommendations for stabilising, and setting a platform
for developing the service.
2. Introduction and Background
2. The new ABMU Local Health Board has the responsibility to ensure provision of
primary care dental services. It will also have the responsibility, as set out in the
Ministerial Letter EH/ML/014/08 Dental Services for Vulnerable People and the Role of
the Community Dental Service to ensure –


that vulnerable people have access to appropriate dental care through delivery of
comprehensive services
the development of Community Dental Services (CDS) to assist that aim
3. The need to develop CDS services is reiterated in Ministerial Letter EH/ML/032/09
Expansion of Designed to Smile – A National Oral Health Improvement Programme.
This letter builds on WHC(2008)008 that launched Designed to Smile (D2S). The local
programme now receives £459,000 ring-fenced central funding and must be delivered
by the CDS.
4. Access to primary care dental services has a high public, media and political profile.
The Board of the new LHB will need to view primary, community, and hospital dentistry
as complementary services in order to work towards fulfilling its responsibilities. The
CDS can be described as the managed arm of primary/community dental care.
3. Oral Health – Assessing the Need
5. A Profile of Oral Health in the ABMU LHB area was produced by the NPHS for the
ABMU dental planning workshop held on 18th December 2009 and may be accessed on
the NPHS website.
4. The Role of Community Dental Services in Wales and Services
Currently Provided by the ABM CDS
6. Ministerial Letter EH/ML/014/08 states that all NHS dental services must complement
each other. The general dental service is a lynchpin of primary care dentistry and the
hospital dental service a major provider of specialist services. However, there are
circumstances where the CDS will need to provide an input either as the sole provider,
as the provider of an intermediate service, or in partnership or support of another dental
Author: Hugh Bennett, Consultant in Dental
Public Health
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service. During the past 20 years the role of the CDS in Wales has developed under
Government guidance so that it now should include provision of services under the
headings laid out in EH/ML/014/08.
7. In order to review the services provided by ABM CDS against the role described in
EH/ML/014/08, current CDS provision is commented upon and recommendations made
under each of the categories set out in the Ministerial letter :a. facilities for a full range of treatment to children who have experienced difficulty in
obtaining treatment in the GDS, or for whom there is evidence that they would not
otherwise seek treatment from the GDS
A major part of current CDS provision is to children.
In certain geographical areas, some of the most deprived areas in Wales, there is a
need for the CDS to retain a strong input into caring for school children.
In the Afan Valley, it is recommended that the present Mobile Dental Services to
three local primary schools is maintained and better resourced. The clinic in
Cymmer that provides services to secondary school children should also be
retained. Retaining the Cymmer Clinic is doubly important because it is also the
location for one day per week of General Dental Services.
However, in other parts of the LHB area there may well be children seen on a local basis
who perhaps could be referred to GDS services, but only if appropriate general dental
service practices are available. Such a migration of patients would allow the CDS to
develop more specialised care both in paediatric dentistry and other clinical areas.
It is recommended that a senior clinician should take a lead role for Child services
and that the Service reviews its acceptance and discharge policies for children.
b. facilities for a full range of treatment to children and adults who due to their special
circumstances require special care dentistry, and/or have experienced difficulty in
obtaining treatment from other services or would not have otherwise sought
treatment from other services
Under a broad definition there is a considerable amount of special care provision
including treatment from fixed clinics, domiciliary services, oral health promotion and
treatment at various units e.g. rehabilitation centres, high dependency care for people
with learning disabilities who have mental health and behavioural problems, secure
units and residential homes, see Annex 2. However, there is no defined Special Care
Team and therefore a lack of leadership, planning and coordination.
It is recommended that a Special Care Team is created with leadership from a
senior clinician and a short to medium term strategy for Special Care Dentistry
drawn up as a matter of priority. This will serve to pull together the various
components already being delivered, into a coherent pattern of care setting a
platform for future development.
Author: Hugh Bennett, Consultant in Dental
Public Health
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National Public Health Service for Wales
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SERVICE ABMU LHB
The CDS has recently carried out an audit of domiciliary care. It was noted that some
dental officers spent a high proportion of their clinical time carrying out domiciliaries.
The audit concluded that there was a need for such a service but the requirements for
changes and improvements in overall delivery were identified.
A large number of visits have been necessary to complete a relatively small number of
prosthetic cases for both domiciliary and hospital visits.
Although the domiciliary skills and experience of the clinicians are a valuable resource,
a better overall balance in the role of these dental officers should be struck. In addition,
the costs incurred by these officers is high, and while a domiciliary role will always be
necessary management should ensure that the criteria set for acceptance, review and
discharge are robust.
It is recommended that the conclusions of the domiciliary audit are actively
addressed as a priority by the incoming CDS Clinical Services Manager.
c. health improvement initiatives that include preventive programmes and oral health
education
The scope of oral health promotion is centred on the pilot ‘Designed to Smile’ (D2S)
programme with a few other smaller pre-existing initiatives. The recent expansion of
D2S announced in Ministerial letter EH/ML/032/09 Expansion of Designed to Smile – A
National Oral Health Improvement Programme means that the Local Health Board will
be allocated £459,000 ring-fenced central funding for year 2010/11. This funding is
recurring subject of a specific reporting process to WAG. It will mean a rapid roll out of
the local D2S programme that must be delivered by the CDS. Please see section on
‘Designed to Smile’ page 30.
It is recommended that the LHB Board provides ongoing support to the CDS role
in delivering Designed to Smile. Indeed, it is obliged to do so under Ministerial
letter EH/ML/032/09.
d. timely emergency and interim treatment to those adults who do not require Special
Care dentistry but are temporarily experiencing difficulty accessing GDS;
The Local Health Board has well tested urgent and emergency dental provision in
place, inherited from the 3 “old “LHBs. During normal hours the CDS provides such
treatment to its own patients, and will take ad hoc cases of children and patients with
Special Care needs. Currently, the CDS does not play a role in out of hours provision
and if it ever did, it would require additional resources to do so.
e. treatment under CDS/PDS arrangements in areas that would not normally support a
General Dental Practice by reason of being socially or geographically disadvantaged;
The CDS is a service that could be used to provide services under these circumstances
but can only do so if extra resources are made available to it to allow expansion.
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f. monitoring of the oral health of all age groups in the population through support of
the Welsh Assembly Government funded dental epidemiological Surveys
It is important for general management to recognise and support this vital public health
function of the CDS. The ABM Community Dental Service is well catered for in this
area, certainly over the next 3/4 years, with dental officers skilled and interested in this
area of work.
g. oral health screening, including the screening of children in state funded schools and
other priority groups as appropriate;
There has been a dramatic decline in the number of school children screened over the
last 5 years. This can be explained on two main accounts, evidence against the
effectiveness of blanket screening certain child age groups, general pressures on the
service to deliver treatment and general inefficiencies - all combined with a decline in
the workforce. In addition the effect of positive consent has made it more problematic in
getting consent, especially from children in deprived areas.
It is recommended that school screening is targeted on schools in the most
deprived areas and linked with D2S. Also the screening of vulnerable groups is
to be encouraged including those in Nursing Homes, an area of provision that the
reviewer considers is best suited to the CDS, with its developed public health
skills, rather than general dental services with its focus on treatment and
individuals.
h. support for the provision of general anaesthetic and sedation, restorative,
orthodontics, oral surgery and other specialist services. This may include clinical
support of Consultant outreach dental services in rural areas as appropriate;
There is potential in the new Resource Centre for the CDS to commence the provision
of sedation services. This would contribute to the Local Health Board’s overall policy
towards reducing numbers of dental general anaesthetics.
i.
training e.g. final year dental student’s outreach teaching, dental vocational and
general professional training, training of other dental care professionals and
postgraduate specialist training.
It is most encouraging to report that the CDS is now involved in the training of two
“Dental Foundation - 2” trainees (DF2s). On the back of this, the Local Health Board
has benefited from links with the Postgraduate Dental Department that have contributed
to clinic improvements. An additional benefit may be the recruitment of trainees into the
service from the training scheme.
It is recommended that commitment to involvement in DF2 training is maintained.
NB: The CDS provision into Bridgend Locality has been reviewed separately, see page 27.
Author: Hugh Bennett, Consultant in Dental
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5. A Strategic Way Forward
8. It is recommended that a CDS strategic planning group is convened to support
the incoming Clinical Services Manager in developing and delivering a 3–year
strategic plan for the service. The aim of the group being to develop a CDS able to
better fulfil the role envisaged for it by the Welsh Assembly Government and fit into a LHB
dental strategy. An up-dated service specification should form a central component of the
3–year strategic plan.
9. The group should be chaired by the new Clinical Services Manager and include, senior
CDS clinicians, appropriate representation from general management, CHC, the local
Consultant in Dental Public Health and representatives from the LDC and HDS.
Position within ABM LHB Organisational Structure
10. As part of the Women and Child Directorate of the old NHS Trust the CDS did not fulfil
its potential. The LHB consultation paper on implementing structures places the CDS within
a Clinical Directorate structure reporting to the Director of Acute Care under Regional
Services to include 
Burns & Plastic Surgery

Artificial Limb and Appliance Centre (ALAC)

Nephrology

Maxillofacial

Community Dental Services
11. The term “Maxillofacial” is understood to include the dental Specialties of Restorative,
Orthodontics and Oral Surgery. This is an important point because the greatest potential
for more effective working lays in better links between the CDS the “dental Specialties”.
That being the case there is much logic in housing the salaried dental services together,
please refer to paragraph 13 above.
12. However, during the review the impression gained was that the Maxillofacial
Consultants are not keen on this option and their argument is awaited.
13. Another option is for the CDS to fall under a Locality with the General Dental Services.
However, because the future of the CDS must be about developing it to provide more
specialised services/support e.g. special care and sedation, preference is for the first
option. With either option the financial integrity of the CDS should be respected as the LHB
wide dental services strategy is developed.
6. Workforce
14. There has been a slow decline in numbers of the CDS clinical workforce at a time
when the demands upon the service have increased, and the full potential for utilising the
service to address inequalities in access to care has not been realised. There are currently
8.3 WTE clinicians and this figure includes a short term locum post, see tables 1 and 2.
Over the past 4 years the clinical workforce (dentists and dental therapists) has been
reduced by between 2–3 WTE, (a range is presented because of the lack of clarity around
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long-term sick leave, long standing secondments out of the service and short term locum
contracts affecting several dental officer posts).
Table 1. Community Dental Service Workforce as at October 2009
Full time
Part time
5
3
7.3
2
1.6
Dentists
DF2s
Locum
WTE as at
October 2009
1
Comments
1
Therapists
1
0.6
Senior Nurse
1
1
Nurses
9
D2S
2
2
DHPO
1
1
7
Receptionist
19
2.1 wte “seconded” to D2S
13.5
2
1 .3
15
29.3
0.3 wte for “waiting list” admin
Source: Acting CDS Clinical Services Manger
Table 2. Comparison of Workforce 2006 to 2009
Staff
2006
2009
Dentists
9
7.3
DF2`s (training grade)
0
1.6
+1.6
Therapists/hygienists
2
0.6
-1.4
Senior nurse
1
1
15.3
13.5
D2S
0
2
+2
DHPO
2
1
-1
Receptionist
1
1.3
Nurses
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15. There has been no recent workforce modelling for community dental services in
Wales; the history of dental workforce modelling is one fraught with pitfalls. There is little
evidence to back any methodology for calculating an optimum CDS workforce. However,
an estimate is made in this paper based on population and acceptance that the ABM LHB
area is comparatively well off in terms of general dental practitioner (GDP) numbers. CDS
services into the Bridgend locality are provided by the Cardiff and Vale CDS, see,
“Provision of CDS Services into Bridgend (and Llantwit Major areas)”, see page 27.
16. Therefore, the ABM CDS currently provides services to Swansea and Neath Port
Talbot (NPT) Localities. The number of WTE dental officers/dental therapists is used as a
crude indicator for the size of a CDS service. Based on other areas in Wales where CDS
services are generally accepted as fulfilling their role across a similar geographical area
and population base as Swansea & NPT a ratio 1 WTE clinician 30,000 population would
seem reasonable, indicating the need for around 11 - 12 CDS clinicians to service the total
population.
17. That would mean recruiting an extra 2.7 to 3.7 WTE clinicians. However, the existing
Dental Foundation posts also need to be factored in because they do contribute to
treatment services. Given this, it would be reasonable to recommend recruitment of an
additional 1.5 to 2.5 WTE clinicians, i.e. 2.5 would a return the workforce close to roughly
2006 levels
18. Approximately 40% of the clinical workforce will be reaching retirement age within the
next 5 years and it is important that advance plans are in place for the recruitment of
replacements. A long-term recruitment and retention policy is required, the first priority
being recruitment of a Clinical Services Manager. The next priority is to fill vacancies with
permanent posts If the Clinical Services Manager is recruited via an internal appointment
then the vacant clinical SDO post created must be retained.
19. Between the period 2006 and 2009, there has been a gradual reduction in the CDS
clinical workforce. This trend should not be allowed to continue if the service is to fulfil the
role envisaged by the Welsh Assembly Government. Issues of long-term sick leave, long
standing secondments out of the service, and short term contracts affecting several dental
officer posts need to be addressed because these have a major impact on a service with
such a small workforce. The current pressure distributing dental nursing staff between
chair-side duties and D2S will be relieved by recruitment of extra DCP staff into the D2S
programme with the new WAG funding.
It is recommended that –

a robust recruitment and retention strategy is developed.

it is agreed precisely what the CDS establishment is, including clarifying any
funded vacancies, long term sick leave, long term outward secondments and
short term locum contracts.

in order to stabilise the service an immediate effort is made to recruit
permanent posts into any funded vacancies identified.
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
a CDS Clinical Services Manager is appointed with the authority to work
alongside general managers in the decision making processes. If the Clinical
Services Manager is recruited via an internal appointment then the vacancy
created must be filled.

a minimum recruitment of an additional 1.5 to 2.5 WTE * dentists/therapists is
required – i.e. 2.5 would roughly return to 2006 workforce levels.

a priority for recruitment should be a Specialist in Special Care dentistry (or a
dentist working towards/close to achieving that status).

the commitment to supporting Dental Foundation 2 training is maintained.
* range offered due to the lack of clarity noted in second bullet point.
20. Specialist skills and training – The ABMU CDS does not employ any clinicians who are
on the General Dental Council’s Specialist Lists. However, there are Senior and Clinical
Dental Officers who have developed interests in specific types of clinical treatments such
as Special Care (including sedation) and Orthodontics.
It is recommended that an exercise to log the clinical interests of individual Dental
Officer is undertaken and built into Continuing Professional Development Plans.
21. It is often the case that CDS officers deal with patients who have complex medical
histories and social backgrounds which can entail considerable additional case
management. Therefore, some administration time may be required but the time must be
in proportion with “active” clinical treatment time and the specific role of the officer. The
impression gained is that the administrative time some officers receive appears higher
than the reviewer’s experience in other CDSs.
It is recommended that the amount of administration received by all clinicians is
reviewed by the incoming Clinical Services Manager with support from general
management.
7. Clinical Activity
22. The robustness of activity data collected by the CDS across Wales has declined due to
lack of national and local policies to develop and invest in a national ICT strategy for the
CDS. All CDSs must make an annual activity return to the WAG. There have been several
revisions of the KC64 activity return form over the past 5-6 years. A new form CDSWR is
being piloted this year by WAG with the North Wales and Gwent CDSs, which have
recently invested in comprehensive IT systems. The other CDSs are being asked to
populate the form as best as possible for 2009-10.
23. The data analysed in this review is sourced from WAG published statistical briefs up to
2006-7 and more recent data provided by the Acting Clinical Services Managers. The
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robustness of this data is open to conjecture but if interpreted carefully it does provide a
reasonable picture of the services activity. The following observations and conclusions
were drawn from data summarised in Annex 2.
Total and First Contacts
24. The total contacts per year has generally remained stable but data was not available
for some years and past year data was used in some annual returns. Likewise, the
numbers of first contacts have remained fairly stable with recent annual figures not far off
that of those at the beginning of the decade.
The data shows that most of the contacts are with 5 -15 year olds.
25. However, in other parts of the LHB area, there may well be children seen on a recall
basis who perhaps could be referred to GDS services, but only if appropriate general dental
service practices are available. Such a migration of patients would allow the CDS to
develop more specialised care both in paediatric dentistry and other clinical areas but
should be carefully planned and phased.
Screening
26. The numbers of the population screened has fallen from a high in 2001 of 27,100 to a
low of 2,529 in 2007/8. This may be explained by several factors
as a result of guidance from the UK Screening Committee around the
ineffectiveness of the outcomes of screening of children of certain age categories

by pressure upon the service such as the need to respond to access problems to
GDS

the requirement to provide services to more vulnerable groups with Special Care
needs

a decrease in the workforce and issues around positive consent
Orthodontics
27. This Review has brought to light that orthodontics is carried out by a dental officer
pursuing a personal interest in this type of treatment. The officer carries out 2 sessions
weekly within the hospital dental service in Neath hospital as well as providing
orthodontics with the CDS. The CDS is reimbursed for only one hospital session.
However, the dental officer is not pursuing any formal training and currently cannot be
described as a Dentist with a Special Interest (DwSI), but the fact that the officer does
have a close association with a consultant-led service is reassuring in terms of
governance.
Given the problems with access to orthodontics in primary dental care in the region
it is strongly recommended that this provision is maintained and developed further
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28. The Dental Officer currently providing this should have an appropriate CPD
programme mapped out fitted to his clinical interest, and the formal links with consultantled hospital services re-affirmed, including involvement in PAR exercises.
Patient Appointments
29. In 2008/9 approximately 22,000 appointments were made, but only 14,000
appointments were kept. This can partially be explained by the category of patient that the
CDS treats who tend to be from more deprived backgrounds and vulnerable groups e.g.
they may have greater dependency on public transport.
However, it is recommended that a closer analysis is carried out on failed
appointments. This will help to show good practice by some dental officers/clinics
that may be adopted to reduce the number of failed appointments. Simple
measures such as telephone, text or postal communications prior to recall
appointments could be considered.
30. Of the 14,000 appointments kept, 1055 were with elderly and other vulnerable patients
but the vast majority of the rest were children. There was also about 10-12 % that fell into
an “other” category. This seems to confirm the long standing trend of the service in
treating school children. An effort should be made to identify the category of patients that
are currently recorded as ‘other’ as this may increase the identifiable numbers of
vulnerable patients that are actually being treated within the CDS.
Interventions
31. The most recent analysis carried out by the CDS itself confirms that of the 14,000
appointments kept, about half resulted in interventions and that some 3,600 interventions
were restorative, 900 for scaling, some 80 for periodontal treatment, 500 for extractions
and 150 for prosthetics. The vast majority of clinical interventions were made by Dental
Officers although Dental Therapists also contributed, but in very small proportion. There
seems to be potential to use a broader skill mix.
Reasons for Referral to CDS
32. There is a high child recall rate. A considerable proportion of patients seem to find
their way to the CDS attending initially as an emergency. Many new referrals appear to be
self referrals and these could equate with the emergency attendances. This is not unusual
for the category of patient the CDS serves.
33. Historically, a high proportion of referrals have also been categorised under the
heading “unable to treat in the GDS.” Referrals from screening, hospital and other health
professionals represent a small percentage. What is surprising is the low number of
referrals from GDPs and this may confirm the lack of a co-ordinated strategy towards the
provision of dental services. The numbers recorded under “other” category are high and
confirm that more effort should be made to identify these sources.
It is recommended that the CDS tightens up on its recording of “reasons for
referral” because it would be expected that a higher number of referrals should be
coming from Healthcare and Social Services stakeholders.
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Domiciliary Dental Care (DDC)
34. DDC has been defined as a service that reaches out to care for those people who
cannot reach a service themselves. It includes dental care carried out in a location where
a person is either permanently or temporarily resident as opposed to care delivered in
dental clinics or mobile units. The aim of DDC is to deliver appropriate oral healthcare to
people whose circumstances make it impossible, unreasonable or otherwise impracticable
for them to secure care in a fixed clinic, hospital or dental mobile unit.
35. The demand for DDC is increasing and is likely to continue to do so as advances in
medical science and increased life expectancy mean that more people are surviving with
illness and disability. Mobility and/or ability for self-care is often reduced by physical
disability, mental disability or chronic disease and a combination of functional limitation,
multiple drug use and limited access to dental care puts these vulnerable people at greater
risk of poor oral health. Their oral health needs will be unmet unless they receive DDC.
Recent guidance from the Welsh Assembly has clarified the role of the Community Dental
Service (CDS) in Wales in the provision of dental care for vulnerable people. This role
includes the provision of DDC, see references page 39.
Domiciliary Visits CDS 2008- 09
36. The old Swansea Local Health Board had a strategy for the provision of DDC and this
defined the roles for both the GDS and CDS. One of the Acting Clinical Services Managers
has carried out an audit of DDC provided by the CDS from which the following points have
been drawn.
Key Points

A total of 1174 appointments were made for domiciliary visits by CDS staff in the
audit of these 1070 were kept.

Poor recording of activity data by some dental officers.

Most visits were to domiciliary residences or patients’ own homes, the split being
roughly even.

It is not possible to determine the clinical outcomes from the data available.

The greatest part of the DDC provided involved the provision of prosthetic and
restorative interventions followed by scaling and polishing and extractions.

The remaining treatments involved items such as examination, preventive
counselling and issue of prescription or fluoride.

Considerable overlap occurred in terms of the geographical areas visited by CDS
clinicians and there seems to be a case for a more refined booking system to better
organise DDC and increase efficiencies.

A large number of visits seemed to have been necessary to complete a relatively
small number of completed prosthetic cases for both domiciliary and hospital visits.
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This is a cause for concern due to the cost implications involved in travelling
expenses and loss of clinical time.
It is strongly recommended that a booking system linking specific clinicians with
specific geographical areas nearer to their base is introduced. Guidelines for case
selection treatment planning and discharge need to reviewed, agreed and adhered
to. These must be an integral part of an overall Special Care Strategy.
37. Appropriate training could be offered to care staff in elderly long-stay centres and
hospital staff regarding oral care, including measures to prevent denture loss and reduce
costs incurred in their replacement.
Hospital Visits
38. Hospital visits are made by the CDS, very few staff are involved in this provision. 589
visits were made that involved mostly prosthetic treatment. Patients from the acute
hospitals may leave to take up places in the other outlying hospitals until they return home
or other arrangements are made for their care. This patient group can prove challenging
in terms of providing dental care. Prosthetic treatment was the main intervention provided
during the care provided (83%), but once again, as with domiciliaries, the number of visits
carried out appears disproportionate in terms of the actual numbers of prosthetic cases
apparently completed.
This is another area that requires a policy review.
8. Funding of CDS Services
39. Until recently the 3 Local Health Boards Swansea, Neath Port Talbot and Bridgend
were the commissioners of CDS services. These LHBs were only just beginning to get a
handle on CDS, having been heavily involved in introducing and learning to work the new
general dental services contract, when the recent NHS reorganisation took place. It
seems that in the past the CDS budget was drawn from the block allocations that were
made to the provider NHS Trust.
40. In addition, the CDS also shares facilities and support with some other services and so
it is perhaps impossible to tease out the full cost of the service, but Table 3 gives a
reasonably accurate figure.
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Table 3. Community Dental Service Budgets
Forecast
2008/09
Budget
2009-10
£
£
AMB for services into Swansea and NPT
Localities
1,390,000
Pay
115,000
Non pay
1,505,000
total
Cardiff and Vale for services into Bridgend
£
Unavailable *
Source: LHB General Management
* this will form part of future work see recommendations page 29
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9. The CDS Estate
41. The majority of patient care is provided from 13 fixed clinic locations that are currently
LHB owned Health Centres/Clinics with a total of 17 dental chairs, see Figure 1. Efficiency
and effectiveness of provision is hampered by the lower than ideal clinical workforce
numbers and the wide geographical spread of clinic locations. There are 5 Mobile Dental
Units.
Figure 1. CDS Locations in Swansea and NPT Localities
42. The clinics were not formally inspected but most were visited to gain a general
impression of their status. Information on sessional use and patient numbers were
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(i)
(ii)
(iii)
(iv)
(v)
(vi)
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General patient facilities including access
Equipment, including decontamination facilities
Clinical Usage of clinic
Geographical location
Information Communication Technology (ICT)
Staff facilities
General state of decoration
43. Most of the clinic locations are being utilised but some are hardly used at all.
The aim must be for a spine of quality multi-chair clinics with a number of
strategically placed satellite clinics linked to them.
44. The service appears to have been under-funded and under-resourced for many
years. The general state of some clinic facilities is therefore poor and the lack of
investment in ICT for the CDS borders on neglect. There is scope for reducing the
number of CDS clinics. However, the purpose of this should not be rationalisation
driven by cost saving, but rather by increasing efficiency in service delivery. The aim
should be to establish a network of clinics fairly distributed across the whole ABMU
area, and a phased programme of clinic improvements. It is understood that a
phased re-equipment programme is being considered. The CDS must remain
accessible to the deprived communities it serves and planners should take this into
consideration.
45. CDS clinics at Water Road and Dew Street have already been closed and the
provision and patients transferred the new Resource Centre. The Cwmavon clinic is
unacceptable on all counts and should also be closed.
46. The Ystalyfera and Glynneath clinics are poorly utilised both in terms of clinic
time and patient throughput. Patients attending these clinics could access better
clinical facilities further down the valley, and there is good public transport.
It is recommended that Cwmafon clinic should not be used for clinical
purposes with immediate effect.
Ystalyfera clinic would be next on a list for closure followed by Glynneath.
The feasibility of a joint provision from the Powys CDS clinic at Ystradgynlais
should be considered.
47. In the rest of the Afan Valley a Mobile Dental Unit provides services to three
local primary schools. The clinic in Cymmer provides services to secondary school
children, and is also the location for one day of GDS. This provides a pragmatic
model for providing dental services into a deprived and “isolated” geographical area.
It is recommended that the mobile services in the top of the Afan Valley and the
fixed services at Cymmer Clinic are retained and better resourced.
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48. Recommendations on closure of CDS clinics made in this review are dependent
on the CDS having a strong presence within the new centre. There is capacity
available in the new facility understood to be available for use by the CDS. Recent
clinic closures at Water Street and Dew Road and recommendations on further
closures made in this review were/are, to an extent, dependent on the CDS having a
presence within this new centre. In addition the new facility is ideal for access by
Special Care patients, something currently lacking in some CDS clinics. Indeed, this
environment could provide an ideal location for developing collaborative working
between the CDS and some parts of the HDS.
It is recommended that CDS has a strong presence in the Resource Centre,
even if this means sharing with HDS services. Indeed, this environment could
provide an ideal location for developing collaborative working between the two
services.
49. The clinic at Gorseinon represents most westerly outreach the ABM CDS. The
facility is just about adequate in terms of continuing provision from it in the short
term. It requires investment to bring it up to an improved standard and would then
offer the potential to treat a wider range of vulnerable patients. It is understood that
new build is planned for this area and that a dental facility within the proposed
development is agreed.
It is recommended that the CDS retains a presence in the Gorseinon area.
50. It is important to retain a spine of high quality multipurpose surgery facilities
such as those provided by Central Clinic in Swansea, the new Resource Centre
and the Pontardawe (currently only single chair) and Neath Dyfed Road Clinics.
This will allow some of the peripheral clinics to be closed but specific satellite clinics
will continue to have an important role in bringing certain services closer to certain
deprived communities e.g. Bonymaen Clinic and Morriston. Bonymaen Clinic
does need some refurbishment but for the moment should be kept open for the
moment to maintain a service in this deprived location. Morriston does offer good
access for wheelchair patients and for this reason alone should not be part of any
closure programme in 2100-11. A disability access audit carried out in 2008
identified areas of concern in several CDS clinics.
It is generally recommended and accepted that concentration of clinical time
around the central clinics will improve efficiencies, by reducing clinical down
time, travel time and expenses. Such a policy would also reduce the
possibilities of professional isolation.
It is recommended that if the CDS is to operate from a central spine of clinics,
then some work is needed to ensure that these clinics are be accessible for all
groups of patients.
51. The Hillside Clinic is located in a secure school and should remain open to serve
the pupils that represent a vulnerable group.
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52. The only CDS clinic with a dental panoramic radiographic facility is Dyfed Road.
The Resource centre in Port Talbot should have one very shortly but there are none
in CDS clinics in Swansea. This is a major diagnostic limitation.
Mobile Dental Units
53. In general, the Mobile Dental Units, when they are in good mechanical order
have a high usage and a high efficiency, e.g. of the appointments made for
Mobile Dental Units over the past 2 years, well over 90% have been kept.
Carefully planned Mobile Dental Units can be an effective way of delivering dental
care to isolated populations or specific institutions. The ABM CDS has five Mobile
Dental Units, of which two are currently out of use. In general there is scope for the
utilisation of mobile services.
54. Locations visited by MDUs:

Cadle, Clwyd and Portmead Primary Schools in Swansea

Abergwynfi, Croeserw and Glyncorrwg Primary Schools in the Port Talbot
area

Ysgol Crug Glas, Maes y Coed and Pen y Bryn / Maytree Special Schools in
Swansea.
55. Commissioning two units and increasing the usage of Mobile Dental Unit 5 would
greatly improve the cost effectiveness of the Mobile Dental service provision. In
addition some of the equipment from these two units might be salvaged and possibly
installed in clinics were the equipment needs improvement.
It is recommended that 
there is a need for targeted mobile services.

one unit(MDU 1) is decommissioned in 10-11, the future of MDU 3 is
reviewed with a possibility of decommissioning in 11-12, ( this and
increasing the use of other units would greatly improve cost
effectiveness )

a replacement tractor unit for MDU 2 is secured to ensure that this unit
continues to function at maximum capacity in the Afan Valley or it
remains fixed on site at Croeserw School with another unit visiting the
other primary schools in the valley

MDU 3 is used as a temporary clinic during Gorseinon building works
and then considered for decommissioning

MDU 4 has a high usage and should stay in commission.

use of MDU 5 is increased contributing to Special Care services and
replacing the capacity of the two units advised for decommissioning.
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the estimated costs of £5000 for repair of MDU 5 are met.
10. Provision of CDS Services into Bridgend (and Llantwit Major
areas)
56. CDS services into Bridgend (and Lantwit Major) are currently provided by the
Cardiff and Vale University LHB. This is a continuation of a longstanding historical
arrangement that stretches back several decades. Workforce, activity and types of
provision are summarised in Figure 2.
57. Services are currently provided from three key sites in the Bridgend Unitary
Authority area. These are Bridgend Clinic in Quarella Road, Maesteg Clinic (which is
on the Community Hospital site), and Pontycymmer Clinic. In general the facilities
are good but those at Pontycymmer do require some improvement. The range of
services provided from each site are as follows:58. Bridgend. There is 1 WTE dental officer resource at Bridgend clinic, providing
the following range of services
Routine care for children with special care requirements and those who are
from socially disadvantaged backgrounds.

Oral health care for adults with a wide range of Special Care needs, including
learning disability, medically compromised, mental health problems etc.

Domiciliary dental care for people of all ages who are housebound through
age or disability.

Inhalation sedation for anxious patients (one session per month).
59. Maesteg and Pontycymmer. There is 0.4 WTE dental officer both at Maesteg
and Pontycymmer (totalling 0.8 WTE), providing routine dental care for children and
adults with Special Care needs.
60. This service is managed as part of a wider CDS locality group, ensuring that the
local group of clinical staff benefit from networking within the larger group of dental
colleagues. A training programme is provided in paediatric dentistry by a Specialist
from the Merthyr area, as well as Special Care training by an SDO in Special Care
Dentistry. All clinical staff in the locality have the opportunity to benefit from this, and
it involves both observation and supervised clinical practice.
61. In addition to the above, there is a Designed to Smile (D2S) team which is
delivering the programme into this area. This is part of the wider D2S initiative,
involving a combination of Dental Health Educators and Dental Health Support
Workers. Also, a fissure sealant programme targets 4 schools in the Bridgend area
and regular mobile dental treatment services to 4 primary schools in the area. There
is liaison with the AMB LHB D2S Implementation Group.
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Figure 2. Summary of the Cardiff & Vale University Local Health Board CDS
Workforce, Activity and types of provision into Bridgend Locality.
Source Cardiff & Vale University Local Health Board CDS
62. The Cardiff & Vale University Local Health Board CDS also visits a Special
School in Bridgend as well as two Adult Day Centres. This provision is currently
being reviewed because many of the people attending such centres are now being
integrated into the wider community, and require a revised approach in order to
ensure that they do continue to receive dental care.
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63. This CDS also provides the workforce for the national dental epidemiological
surveys in the area carried out within the Bridgend area.
64. It should be recognised that the current ABM CDS cannot take over provision
Bridgend area at the drop of a hat. It does not have the workforce capacity and
cannot match the input from Specialist clinicians the Cardiff and Vale CDS has
working there.
In addition it would be unfair to patients not to recognise the long-term relationships
built up between the Cardiff and Vale CDS and the vulnerable groups it cares for in
the Bridgend area.
It is recommended that
the current provision into the Bridgend Locality by Cardiff and Vale CDS is
maintained throughout 2010-11

the newly appointed CDS Clinical Director for the ABM CDS sets up the
initial formal dialogue with clinical and general management of the Cardiff
and Vale CDS/LHB. The aim being to scope out precisely how the CDS
services are currently provided and the options for future provision

a joint paper to be presented to both LHB Boards by November 2010
setting out the options for future CDS services and the risks and benefits
involved in any change.
11. Support Systems
Information and Communication Technology
65. Many clinics do not have basic ICT i.e. modern desktop computer with
internet/intranet access and printer installed. This is unacceptable and reduces the
effectiveness of the service and its management. In addition the service is failing to
supply the Welsh Assembly Government with completed annual activity returns.
It is not acceptable that clinicians employed by the Local Health Board, do not
have access to basic ICT provision such as email facilities and internet
access.
66. Examples were provided where this has prejudiced the care of patients e.g. a
Special Needs patient with a very complex medical history requiring urgent
treatment but the clinician was unable to quickly check the relevance to the dental
diagnosis of a patient’s change in medication.
67. The almost total lack of reliable email facilities also means that management of
services on a day to day basis is archaic. In addition, the recording, collation and
analysis of base activity data for both local management and national returns to the
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Welsh Assembly Government are severely compromised. Clinicians are still
“shading in boxes with pencils” on cards that are then “optically read”.
One of the strongest recommendations to be made in this review is that the
ICT of the CDS needs urgent upgrading.
12. Clinical Governance
68. There are Clinical Governance policies in place.
However it is recommended that



clinical audit/peer review processes involving all staff should be
revitalised with designated clinical officers leading the work
robust annual appraisal for clinicians must be initiated covering clinical
activity, quality and professional development
a Senior Clinician from another CDS should be involved in this process
to support the Clinical Services Manager in this work
the role of each dental officer is reviewed and an exercise to log the
clinical interests of individual Dental Officer is undertaken and built into
Continuing Professional Development Plans.
13. Designed to Smile
69. Ministerial letter EH/ML/032-09 Expansion of Designed to Smile – A National
Oral Health Improvement Programme announced expansion of the programme
launched with the publication of WHC 008 2008 that launched Designed to Smile
(D2S). The two documents provide comprehensive guidance.
70. WAG envisage Designed to Smile developing into a sustainable national
programme to improve the dental health of children in Wales but one that is
delivered locally by the CDS to best fit local needs. There is a strong evidence base
for this type of programme and WAG commissioned evidenced based technical
documents to support the programme that are available on the Chief Dental Officer
of Wales webpage.
http://wales.gov.uk/topics/health/ocmo/professionals/dental/?lang=en
71. The Programme will be co-ordinated and monitored locally and evaluated at a
national level. Long-term monitoring of children's oral health will be carried out
through the national surveys of child dental health.
72. A great deal of work has already been done in terms of diet and nutrition and
fitness in schools and Designed to Smile fits well with these. One of the important
elements of the Designed to Smile programme is its integration into wider local and
national health promotional initiatives such as the Healthy Schools Scheme, Flying
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Start, and with others involved in delivering the general health promotional
messages to children and schools.
73. Chief Executives of Local Health Boards (LHBs) are asked in the letter to ensure
that arrangements are put in place to implement the guidance. In doing so it should
be noted that One Wales – A progressive agenda for the government of Wales,
reinforces the Welsh Assembly Government’s commitment to refocus provision of
dental services to provide a public health focus.
74. In 2008 Swansea / NPT LHBs designated themselves as a D2S pilot area and
achieved efficient first year delivery by the CDS overseen by the work of a D2S
Implementation and Steering Group. A specific D2S Team was created within the
CDS. This was achieved through joint working between the Consultants in Dental
Public Health, clinical leads of the CDS, LHB Executives and local health promotion
specialists.
75. The funding for the local programme is
2009-10 – £ 385,400

2010-11 – £469,500
76. The Welsh Assembly Government (WAG) has confirmed that the D2S funding
announced in the recent Ministerial Letter is ring fenced and specifically for
expansion of D2S programme. WAG wrote to the CEOs of all LHBs stating, “Each
LHB is required to take appropriate action in relation to the attached guidance. I
expect an annual progress report from each participating LHB using the services of
the Welsh Oral Health Information Unit. This needs to be submitted by the 30 July,
following the end of each financial year, including details of programme expenditure”.
77. The AMB LHB D2S Implementation and Steering Group will oversee the rollout
of the programme across the Swansea Locality area over the next 3 years. WAG
require this to be delivered by the CDS and it will be the key oral health improvement
initiative within the Locality’s Health and Wellbeing Strategies.
It is recommended that the LHB provides ongoing support to the CDS role in
delivering Designed to Smile. Indeed, it is obliged to do so under Ministerial
letter EH/ML/032-09 and report to WAG by 30th July.
14. Discussion and Conclusion
See Executive Summary
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Annex 1 .
Institutions Visited by ABM HB Community Dental Service 20082009
This paper presents a summary of units/institutions visited by the CDS in 2008-2009
and the interventions provided.
Awel-y-Mor Care Centre
This is a rehabilitation centre providing high dependency care, active and slowstream rehabilitation and respite care. Residents include young physically disabled
adults who have disabilities. These include:
 traumatic or acquired brain injury
 spinal injury
 other physical disabilities such as multiple sclerosis
 people who suffer from congenital illnesses
 people who have learning disabilities
 minimally conscious patients
 people requiring palliative care.
There are approximately 50 residents at this centre. A senior dental officer within the
CDS provides care for the residents on a domiciliary basis and at Central Clinic,
Swansea. The CDS visits this centre at monthly intervals.
Llwyneryr Unit
This unit provides help and support for people with learning disabilities who have
mental health and behavioural problems. There are approximately 20 residents. A
senior dental officer within the CDS provides care for the residents on a domiciliary
basis and at Sway Road Clinic in Morriston. Treatment sessions are provided
several times a year.
Hillside Secure Unit
This centre provides accommodation for 13-17 year olds who need secure care
because of the risk they present to themselves or to the community. Hillside is a
purpose built secure residential children's home with education provided on the
premises. The unit is staffed 24 hours a day. A dental officer within the CDS provides
dental care for the residents on request using facilities at the centre.
Percutaneous endoscopic gastrostomy (PEG) clinic
A CDS dental officer visits this clinic which is held at Singleton Hospital and Ysgol
Crug Glas once a month (total of 4 visits to special school and 8 hospital clinics a
year) for PEG fed children and adolescents. These are multidisciplinary clinics held
in conjunction with a paediatric consultant, a specialist nurse, a senior dietician, and
sometimes a speech therapist. The children are fully assessed for their dental needs
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in conjunction with their complicated medical needs, and referred into appropriate
care if necessary.
Local Authority Residential Homes City in Swansea/ Neath Port Talbot
A CDS dental officer visits several homes for annual oral cancer screenings,
cleaning of dentures and writing of care plans. Increasingly residents require dental
treatment due to an inability to access appropriate care via the GDS. The homes
visited are Ty Waunarlwydd, Arwelfa, Bonymaen House, Hafod, Morfa Afon, Rose
Cross, St Johns, Trem-y-Glyn and Min yr Afon.
Elderly residential hospitals
Patients that are resident at these institutions are elderly and have physical and
mental health problems. They are Tonna (Long Stay), Hill House, Cimla (Long Stay),
Gorseinon and Gellinudd. A CDS dental officer provides dental care on a domiciliary
basis (details for 2008 have already been provided).
Domiciliary dental care (DDC)
DDC is provided mainly by three CDS officers in the Swansea, Neath and Port
Talbot areas (details for 2008 have already been provided).
Adult Oral Health Promotion
A CDS dental officer and an oral health promotion officer provide teaching on oral
health for degree nurses in conjunction with Swansea University. Teaching is held in
the School of Health Science, Swansea University. One day’s teaching per academic
year is provided on oral health. The CDS oral health promotion officer is also active
within the field of adult oral health promotion. With the help of a senior dental officer,
this role has been developed since September 2008. Oral health promotional
interventions are provided at several institutions that care for adults with physical and
learning disabilities.
List of locations for Oral Health Promotion
Adults with a learning disability The oral health promotion team has also
developed an intervention designed to improve the oral health knowledge of the
carers of people with disabilities. In the Swansea Locality- Day Centres visited
include: Glan Dwr, Longfields, West Cross , Fforestfach ,White Thorns ,Beeches,
Abergelli, Parkway, Swansea Vale, MaesGlas and Trewarren. Respite Centres
visited include- Acacia House, Alexandra, Glan Y Afona and Llwynera. In the Neath
Port Talbot Locality - Cadaxton Rd, Rhodes Ave, Beacons View, Glyncorrwg Ponds,
Pen Y Cae ,Monastery Road ,Neath Abbey, Bryn Catwg Rhodes Ave Herbert St.
------------------------------------------------------------------------------------------------
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Annex 2.
Summary of Activity Data ABMU CDS Swansea / Neath Port Talbot
Localities
Sources of data- WAG KC64, Welsh Health Stats, Internal CDS records
Total contacts per financial year: “Swansea / NPT” CDS
Trust
Swansea
Swansea
Swansea
Swansea
Swansea
Swansea
Swansea
Year
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
2006-07
All
Ages
17128
19887
15258
13770
13770
18912
18912
0-4 yrs
1217
1183
897
729
729
0
0
5-15
yrs
12179
13487
10619
9756
9756
0
0
16-64
yrs
2686
3225
2444
2101
2101
0
0
65 yrs and
over
1046
1992
1298
1184
1184
0
0
Age not
known
.
.
.
.
.
18912
18912
First Contacts per financial year: “Swansea / Neath Port Talbot” CDS
Year
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
Swansea
5705
7140
4472
4845
4845
4736
4736
6162
Wales
67340
69932
79228
74761
73174
75439
72336
67026
Analysis of Appointments
Clinician
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Appointments made
904
823
2943
1128
682
693
2535
26
1518
222
871
1586
27
1532
955
103
1098
2413
1781
21840
Appointments kept
536
491
1877
807
410
470
1572
15
1025
138
544
958
13
880
615
70
824
1971
1105
14321
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% kept
59%
60%
64%
72%
60%
68%
62%
58%
68%
62%
62%
60%
48%
57%
64%
68%
75%
82%
62%
PROVISIONALDATA
Status: Final
AMBU LHB CDS Review
A REVIEW OF THE COMMUNITY DENTAL
SERVICE ABMU LHB
National Public Health Service for Wales
Reason for referrals to Swansea CDS
3500
3321
Number of referrals in a financial year
3000
2500
2288
2288
2001-02
2000
2002-03
2003-04
1545
1461
1500
2004-05
1053
1000
894
847
1053
527
500
506
480
527
304
263
460
480
228
131
228
0
All Initial
Contacts
Unable to
obtain Tx in
GDS
Emergency
Orthodontic
Care
Other
Referral reasons
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Oral Health Profile Abertawe Bro Morgannwg
Local Health Board Area
Number of individuals screened per financial year by the CDS (Swansea)
Other
Children
(special
schools)
(split not
available)
0
0
20735
0
2890
21765
20016
2316
2004-05
20016
2005-06
All
Children
Preschool
children
Primary
school
children
2000-01
26057
3249
22808
2001-02
23926
3191
2002-03
24655
2003-04
Other
groups
All
Adults
Elderly in
residential
accommodation
0
521
521
0
27099
0
0
603
0
603
25132
0
0
0
519
519
0
25693
17700
0
0
0
342
342
0
20700
2316
17700
0
0
0
342
342
0
20700**
8918
1498
7420
0
0
0
230
230
0
9378
2006-07
3666
0
3666
0
0
0
3269
218
3051
2007-08
1993
0
1849
0
144
0
268
218
50
Year
Secondary
school
children
Total
(split not
available)
10204
2529
Appointments (provisional data)
Appointments kept
Patient Group
14321
Appointments
kept Interventions
Elderly/handicapped
1055
Total Interventions
6902
Author: Hugh Bennett, Consultant in Dental
Public Health, in collaboration with Maria
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Schoolchild
11608
Scaling
898
Other
1203
Restorations
3558
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Uncategorised
455
Prosthetics
147
Orthodonti
cs
1683
Periodontal
84
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AMBU LHB Oral Health / Dental Services
Workshop
Extractions
532
National Public Health Service for Wales
Oral Health Profile Abertawe Bro Morgannwg
Local Health Board Area
Interventions 2008-09
Other
Uncategorised
Scaling
69
101
291
4
11
17
125
3
75
9
0
87
2
147
71
0
80
28
83
1203
13
8
46
2
201
2
35
0
27
4
1
45
0
23
6
0
30
6
6
455
25
17
129
156
24
9
14
0
131
0
50
80
1
31
27
7
51
119
27
898
Author: Hugh Bennett, Consultant in Dental
Public Health, in collaboration with Maria
Morgan, Welsh Oral Health Information Unit
Version: 0a
Periodontal
treatment
1
1
0
0
0
1
79
0
1
0
0
0
0
0
1
0
0
0
0
84
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Extractions
Restorations
Prosthetics
Orthodontics
23
8
82
89
7
19
115
0
60
11
4
9
2
15
24
0
4
16
44
532
162
37
435
209
81
133
338
3
413
26
301
347
4
138
139
48
257
171
316
3558
0
22
6
83
0
1
3
0
5
0
0
2
1
6
1
0
13
3
1
147
2
9
15
0
0
1
184
3
2
0
1
1
0
1
0
0
1
1453
10
1683
Status: Final
AMBU LHB Oral Health / Dental Services
Workshop
Total
Interventions
213
94
667
537
112
164
733
6
612
37
356
439
8
191
192
55
326
1762
398
6902
provisional data
National Public Health Service for Wales
Oral Health Profile Abertawe Bro Morgannwg
Local Health Board Area
Acknowledgements
The Review was conducted through a series of meetings with senior clinical and
general management stakeholders. All clinicians and Dental Care Professionals
were given the opportunity to pass comments to the Reviewer, with the assurance
that their comments would be treated anonymously.
Particular thanks to:
David Davies, Acting Clinical Services Manager ABM CDS
Susan Payne, Acting Clinical Services Manager ABM CDS
Menna Lloyd, Clinical Director CDS, Cardiff and Vale Local Health Board
Cheryl Evans, General Managements, Cardiff and Vale Local Health Board
Carl Verrecchia, Women and Child Health Directorate
Karl Bishop, Chair of Welsh Dental Committee
All attendees of the ABMU Dental Workshop held on the 18th December 2009, the
outcome of which helped inform the Reviewer.
CDS staff who responded to the opportunity to comment.
Author: Hugh Bennett, Consultant in Dental
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Morgan, Welsh Oral Health Information Unit
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Oral Health Profile Abertawe Bro Morgannwg
Local Health Board Area
References: Domiciliary Dental Care
Fiske J and Lewis D. Domiciliary Dental Care. Dental Update 1999; 26: 396-404.
Guidelines for the delivery of a Domiciliary Dental Service. All Wales Special Interest
Group in Special Clinical Needs 1997.
Fiske J and Lewis D. The Development of Standards for Domiciliary Dental Care
Services: Guidelines and Recommendations. BSDH 2000.
Fiske J, Gelbier S, Watson RM. Barriers to dental care in an elderly population
resident in an inner city area. J Dent 1990; 18: 236-242.
Strayer MS, Ibrahim MF. Dental treatment needs of homebound and nursing home
patients. Community Dent Oral Epidemiol 1991; 19: 176-177.
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