Welsh Government response to the report of the Children and Young People Committee Inquiry into children’s oral health
1. I would like to thank the Committee for their report examining the effectiveness of the Welsh Government’s Designed to Smile programme in improving the oral health of children in Wales, particularly in deprived areas. I would also like to take the opportunity to outline the steps we are taking to help tackle oral health inequalities and improving the oral health of children in our most disadvantaged communities.
2. I am pleased to say many of the Committee’s recommendations support our current policy direction and also recognise the excellent progress made to date on establishing the Designed to Smile programme. The majority of the recommendations are either already in place or planned, and the current development of a National Oral Health Plan will have Designed to Smile as one its key themes.
3. The Welsh Government is determined to tackle oral health inequalities and the gap between the oral health of children from the most deprived and the least deprived families in Wales. Dental decay is a disease of lifestyle with multiple causes. Improvements in oral hygiene and fluoride availability are needed to make progress towards improving oral health and meeting our dental health targets. It is clear more direct and also more innovative methods of delivering preventive care are necessary if advances in child oral health are to be made. In the absence of fluoridation of water supplies in Wales we need to get more teeth in contact with fluoride via alternative methods. The Designed to Smile programme sets out to achieve that objective in Wales by targeting young children in areas of greatest need. The scheme is targeted and priority given to areas on the basis of deprivation and epidemiological data on oral health provided by the Welsh Oral Health Information Unit (WOHIU).
4. Designed to Smile is delivered by the Community Dental Service (CDS) who have significant experience of providing oral health promotion. Their additional role in this initiative focuses on the delivery of fluoride supplementation programmes and improving care for children with chronic tooth decay. It is important to highlight that Designed to Smile is more than simply teaching children how to brush their teeth. The scheme also delivers direct clinical interventions shown to prevent decay – effectively a fluoride delivery programme.
5. As was highlighted in the submissions to the Committee, it is too early to confirm whether the Designed to Smile programme is delivering improved health outcomes for children. We have evidence of good uptake in the targeted schools but we will have to await the outcome of future epidemiological surveys of children to establish if dental decay in children in Wales has reduced. However, the preventative interventions used in the scheme are strong and well established. Designed to Smile is very similar to the Childsmile Programme which has been running in disadvantaged communities across Scotland since 2005. Recent studies in Scotland (2009/10) are showing evidence that the prevalence of caries and decay has reduced over time, and the results are particularly evident in the more deprived communities.
6. Our Programme for Government published in September 2011 includes as a key action the implementation of the Designed to Smile programme to improve the oral health of children. This is supported by the Welsh Government through funding to LHBs of £3.7 million per year.
7. The on-going development of a National Oral Health Plan for Wales will clearly align oral health with public health through links with smoking, alcohol consumption and child nutrition. An integral part of the Plan’s delivery will be the Designed to Smile programme. Oral health is an important part of general health, and the Plan will stress the need for prevention of poor oral health as well as treatment of disease. There will be a particular focus on those groups who have persistently high levels of disease, such as children under 5, and those whose general health makes them more vulnerable to oral ill health.
8. Further development of the programme will continue. Increasing the targeting of children aged 0-3 and strengthening the links with other programmes such as Healthy Schools and Flying Start to ensure consistent action and messages will be part of the on-going action. However, the success of the roll-out of Designed to Smile in deprived areas across Wales is already clear and I am confident the programme will deliver much needed improvements in the oral health of children in our most vulnerable communities.
Detailed Responses to the report’s recommendations are set out below:
Recommendation 1
The Welsh Government should publish the annual monitoring reports of the Designed to Smile programme in addition to the final evaluation report.
I accept this recommendation.
Both the evaluation reports from the Dental Public Health Unit and the activity data reports from the Welsh Oral Health Information Unit at the Cardiff University School of Dentistry will be published on the Chief Dental Officer for Wales’ website.
Financial Implications – None. Any additional costs will be drawn from existing programme budgets.
Recommendation 2
The Welsh Government should ensure that action is taken to better educate parents about Designed to Smile, ensuring consistent messages are given to parents about the importance of getting fluoride onto children’s teeth as part of homebrushing.
I accept this recommendation.
When parents receive the consent form to allow their child to participate in the programme they also receive information about Designed to Smile. As part of the scheme’s evaluation, when parents were asked about the information provided, the overall feeling was that sufficient information was given without burdening the parent. At March 2011, 94% of parents had giving their consent for their children to take part in Designed to Smile. During the same period almost 10,000 parents attended either group oral health promotion or one to one sessions respectively.
It is important brushing in schools and nurseries translates to brushing at home and I accept more needs to be done to accommodate parents at meetings in schools to help publicise more widely the information available about home packs and wider oral health messages that need to be maintained at home. The National Oral Health Plan will also focus on encouraging and enabling individuals to take more responsibility for their own oral health and that of their families.
It is important the process of sending out the free home packs is standardised across schools, to ensure all children receive them at appropriate intervals. At March 2011, 137,898 home packs had been distributed across Wales. On average 2 packs were distributed to each child taking part in the supervised toothbrushing element of Designed to Smile. Evidence suggests they have a very positive effect on children’s homebrushing.
Financial Implications – None. Any additional costs will be drawn from existing programme budgets.
Recommendation 3
The Welsh Government should ensure that data on the number of general anaesthetics administered to children and young people for dental work in Wales is collated and reported as part of the monitoring of Designed to Smile.
I accept this recommendation.
This may be a useful indicator of the success of Designed to Smile but it is important to collect these data on an all-Wales basis in a robust standardised way. Public Health Wales are undertaking an exercise to analyse the available data on the number of general anaesthetics carried out in Wales.
Financial Implications – None. Any additional costs will be drawn from existing programme budgets.
Recommendation 4
The Welsh Government should set out how it plans to ensure the effective implementation of the 0-3 year element of Designed to Smile, and specifically how it intends to involve key agencies in promoting the scheme such as NHS Health Visitor Services, given that there is no additional resource for this.
I accept this recommendation.
The staged implementation of Designed to Smile has meant the programme has been more advanced and developed in some Local Health Board (LHB) areas than others. There is on-going progress being made to engage with 0-3 year olds. This includes:
· Designed to Smile forms part of the NHS Health Visitor Services mainstream health promotion advice and support to parents, working in partnership with key agencies.
· Within public health programmes, the delivery of consistent messages is crucial. School Nursing services have regular contact with Designed to Smile teams in order to receive updates and share information. Whilst school nurses are not directly involved in the delivery of Designed to Smile, they support the initiative by continuing to address oral and dental health as a part of the broader public health work which they are involved in.
The development of the skill mix in the CDS workforce will also help to accelerate the engagement of this age group although we need to ensure the flexibility of the scheme to reflect local circumstance and arrangements is not lost.
I also want to see all local Designed to Smile programmes overseen by local steering groups whose membership bases are broadly drawn to help ensure that the scheme is not delivered in isolation of other health promotion initiatives.
Financial Implications – None. Any additional costs will be drawn from existing programme budgets.
Recommendation 5
The Welsh Government should set out how it intends to improve the oral health of all children in Wales, including those who are not currently targeted by Designed to Smile, and what role the Community Dental Service will play in this.
Dental decay is a disease of lifestyle with multiple causes. As such tooth decay is both more widespread and severe in children from disadvantaged communities. The selection of schools, primarily from Community First areas, ensures Designed to Smile is aimed at those children at greatest risk resulting in a targeted and effective programme.
Not all groups of children need what Designed to Smile has to offer. Children from more affluent areas tend to have good oral health. The flexibility of the programme allows the Designed to Smile team to tackle pockets of deprivation which may occur outside Community First areas including rural areas. Children who have special needs are already being treated by the CDS.
Financial Implications – None. Any additional costs will be drawn from existing programme budgets.
Recommendation 6
The Welsh Government should consider the evidence for incorporating Designed to Smile into the school curriculum to ensure it is better integrated into initiatives such as Healthy Schools.
I reject this recommendation.
Designed to Smile is a preventive programme first and an education programme second. The essential core principle of Designed to Smile is “getting more children’s teeth in contact with fluoride”. That is the evidenced based measure that will reduce dental decay in Wales. It is central to the long term success of the programme to maintain at the forefront of Designed to Smile the clinical intervention and preventive elements of the programme i.e. toothbrushing, preventive varnish application and fissure sealants, particularly given the absence of water fluoridation in Wales.
Incorporating Designed to Smile into the school curriculum is likely to weaken the clinical benefits of the core preventive delivery programme. In addition it would either increase costs significantly or spread resources too thinly. If something is not going to be clinically effective it cannot really be cost effective.
I agree Designed to Smile must continue to integrate in a strategic sense with other health promotion programmes at both national and local levels. The risk factors for dental decay, poor diet, the impact of social and economic deprivation and failure to engage with clinical services are common to other chronic lifestyle diseases. Therefore, it is important a holistic approach is taken to health education, with dental health education integrated with other health messages.
The day to day operation of Designed to Smile relies on close partnership working with schools and the Educational Establishment, support for this at the highest level is important. One of the important elements of the programme is its integration into the wider local and national interventions such as the Welsh Network of Healthy School Schemes and Flying Start. A great deal of work has already been done in terms of diet, nutrition and fitness in schools, and Designed to Smile fits well with these.
As part of the scheme’s evaluation, 91% of head teachers said they felt the scheme fits well or very well with their overall school curriculum; 95% also felt it fitted well or very well with their wider health initiatives. There is no compelling evidence to suggest incorporating Designed to Smile into the school curriculum will result in better integration with wider local and national initiatives.
Financial Implications – None.
Recommendation 7
The Welsh Government should make changes to the NHS dental contract to enable better integration of prevention and treatment across dental practices and to ensure it encourages dentists to undertake preventative work with children.
I accept this recommendation in principle.
We are current piloting new ways of working to deliver NHS dental services. A pilot aimed at Preventive Dental Care for Children and Young People involves changes to how a dentist is paid to treat children. A capitation based payment system has been introduced for 0-18 year olds, underpinned by an additional payment linked to taking on additional children and weighted for local deprivation.
The aims are to give incentive to prevention in care of the primary and mixed dentition, complement our Designed to Smile oral health programme and test the introduction of quality and access indicators. The pilot allows the appropriate referral of children from the CDS to General Dental Services and vice versa.
The pilot will run until March 2013 under independent monitoring and evaluation to help inform the Welsh Government on how the dental contract may look in the future.
Financial Implications – There are none at this stage. The early indication from the monitoring data of the pilots has seen a general trend in the reduction of the level of patient charge revenue. This trend may pose additional financial risks for LHBs and the Welsh Government.
Recommendation 8
Local Health Boards should be required to publish information on their annual expenditure on the Designed to Smile programme, including any extra investment they have provided to the Community Dental Service to support this work. For every Local Health Board it should be possible to see how much money is being spent on improving the oral health of children and the take up of the scheme in their areas in order to assess consistency across Wales and value for money.
I accept this recommendation.
LHBs already report their expenditure on Designed to Smile in their monthly operating expenditure returns and in their annual accounts to the Welsh Government. The funding allocated is specifically for the delivery of Designed to Smile and expenditure incurred must be directly related to its development and delivery and not to other dental services. The expenditure is also monitored externally and is subject to independent evaluation by the WOHIU at Cardiff University (as part of the wider evaluation of the programme).
I have recently announced my decision to extend the ring-fencing of the dental contract budget until March 2015 which includes the resources for Designed to Smile. This sends a strong message to LHBs and the profession about protecting dental provision and supports our Programme for Government commitment to build on Designed to Smile.
Financial Implications – None. Any additional costs will be drawn from existing programme budgets.
Recommendation 9
The Welsh Government should ensure that Designed to Smile is central to its National Oral Health Plan for Wales; it should set out the Welsh Government’s long term commitment to the programme and how this will fit with other Government programmes and initiatives, as well as providing a fuller picture of how dental services for children are currently being accessed across Wales and how this will change in the future. In particular, the role of the Community Dental Service (CDS) needs to be clearer, including how access arrangements to the CDS are set up and what action will be taken to address the inconsistency in CDS service provision across Wales.
I accept this recommendation.
Designed to Smile, children’s dental services and the CDS will all be included in the National Oral Health Plan.
The Welsh Government has already issued clear guidance on the role of the CDS, including the baseline and development of Designed to Smile:
· Welsh Health Circular (2008)008 – Designed to Smile – A National Child Oral Health Improvement Programme Promoting Better Oral Health and Delivering a Fluoride Supplementation Programme. The WHC includes targets for oral health improvement.
· EH/ML/014/08 - Dental Services for Vulnerable People and the Role of the Community Dental Service.
· EH/ML/032/09 - Expansion of Designed to Smile – A National Oral Health Improvement Programme.
At the same time as announcing that ring-fencing of the dental budget would continue, I also reminded LHBs of the Welsh Government’s commitment to the CDS and the guidance already issued (LG/ML/001/12 – ‘Local Health Board ring-fenced dental allocations and the role of the Community Dental Service’ refers).
Financial Implications – None. Any additional costs will be drawn from existing programme budgets.
Recommendation 10
The Welsh Government should keep under review the evidence for fluoridating water supplies in Wales.
I accept this recommendation.
The Welsh Government acknowledges that the scientific evidence supports the case for water fluoridation as having significant health benefits but has no current plans to fluoridate water supplies in Wales. However, the Welsh Government will keep in view the evidence base for fluoridating water supplies in Wales.
Financial Implications – None. Any additional costs will be drawn from existing programme budgets.