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Throughout 2022, 2023 and 2024, Benjamin Lewis, Consultant Orthodontist and Chair of the North Wales & Powys Orthodontic Managed Clinical Network led a variety of research papers into the orthodontic workforce in Wales.1,2,3 Could they provide a snapshot and tell a story of what's happening elsewhere in the UK, or are the problems Wales-specific? BDJ In Practice spoke to Ben to get his perspectives on what implications the research has for the workforce.

In your own words, can you tell us what the trio of papers tells us about the orthodontic workforce situation in Wales?

This research has, for the first time, identified both the quantity and spread of the NHS orthodontic workforce across Wales. The map provided in the first article highlights that the location of the majority of orthodontic services is in high population density areas.1 Although this is not necessarily surprising, it does potentially impact on the rural population's ability to access care. It was noted 30% of all clinicians work across multiple sites.

Orthodontic services in Wales have embraced the wider skill-mix, with orthodontic therapists now comprising around 25% of the orthodontic workforce. Of the respondents to the survey, over 60% worked 10 or more sessions per week, and 80% of those who worked part time, undertook 6-9 sessions per week.2

The survey results indicated that 96% of respondents felt that they had chosen the right career path, with over 88% enjoying going to work. However, the survey also demonstrated the increasing demands being placed on respondents and that over 50% were finding it harder to achieve an effective work/life balance.3 Worryingly 24% of respondents were planning to reduce the clinical time they spent doing orthodontics over the next two years and 25% planned to cease all orthodontic activity over the next five years.

In your first paper you conclude ‘The distribution of the orthodontic providers is predominately in areas of high population density, resulting in some rural communities being a significant distance from any orthodontic provider.' How significant is this for the population, given the ‘dental desert' narrative is one replicated across the UK?

The implementation of the Welsh orthodontic reviews' recommendations over the last 15 years has led to a consolidation of orthodontic providers across Wales.4 This has resulted in greater efficiencies and associated cost reductions. The shift towards economies of scale has inevitably resulted in a reduction in the small volume providers. These tended to be located within general dental practice settings as this was the only way these smaller value contracts were financially viable. As a consequence this has reduced the number of orthodontic providers in rural areas, resulting an increased travelling distance and time burden for the rural population to access care.

Wales, like many areas in the UK, have been reliant on Dentists with Enhanced Skills (DESs), with specialist support, to provide more locally based orthodontic services in rural areas. Unfortunately, the consolidation of orthodontic providers, as well as GDS providers ceasing to provide general NHS services, has resulted in a significant reduction in local services. It is incumbent on Health Boards (HBs) to look at their population spread and associated needs when commissioning services. The re-commissioning of a targeted Tier 2 network would allow re-establishment of these valuable local services. However, to achieve this is easier said than done as it requires significant investment in time and training, along with associated specialist support, to ensure that these services are sustainable in the long term.

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© rbkomar/Moment/Getty Images Plus

You also conclude in the second paper that one in four were planning to cease orthodontic work within five years. Again, how significant is this?

This is potentially very significant, although it must be remembered that 30% of the NHS orthodontic clinicians in Wales did not complete the survey. If we assume that this cohort were not planning to cease providing orthodontic care, it still means that over 15% of the entire Welsh orthodontic workforce planned to cease activity within five years. This includes a disproportionate number of specialists, which causes particular concern as orthodontic therapists make up 25% of the overall orthodontic workforce and they require appropriate levels of supervision.5 Without suitable replacement of this specialist supervision, the new working model, relying on orthodontic therapists for service delivery, becomes extremely vulnerable.

Do these data suggest dentistry has a problem with work/life balance?

In a nutshell, I would say yes. However, the situation is nuanced and likely to be influenced by the attitudes of the different professional generations. Evidence suggests that there is a shift towards more of a part time working pattern,6 especially by the younger members of the team. The reasons for this are likely to be multifactorial, potentially including the importance of a better work/life balance; overall longer practicing life (with increases in the retirement age); financial commitments; family commitments etc. It could be argued that the newer entrants to the profession have a healthier and more sustainable attitude to work/life balance, however, this has significant implications on workforce planning, as more professionals will be required to deliver the commissioned activity (head count versus whole time equivalents).

There is also another element to this, that is often under appreciated. Many individuals perform additional professional roles, outside their clinical work, such as committee members, advisors or examiners, which are often done ‘out of hours' on a voluntary basis. These are often undertaken due to a sense of ‘duty', but also for the rewards of wider professional connections and increased personal satisfaction. However, anecdotally, it is becoming harder and harder to fill these positions which is both an issue for the delivery of these wider professional responsibilities as well reducing the experience and voice of the profession as a whole.

In your third paper you assert respondents said ‘increasing demands being placed upon them by patients/parents, employers, the Regulators, the Government and Health Boards' was a factor in their unhappiness. What can be done to improve these five areas?

The most frequent concern raised by patients/parents is the waiting time to access treatment.7 This is usually related to the levels of commissioned activity in primary care or workforce capacity within secondary care. Both of which are not in the control of the individual clinicians, who, all too frequently, unfortunately bear the brunt of the frustrations of those waiting to access care.

This sense of ‘lack of control' also seems to be having a significant impact on respondents' levels of satisfaction in the other areas mentioned above. However, another aspect was a ‘target driven culture'. Targets which have been implemented for perfectly logical reasons to monitor service delivery, efficiencies, clinical outcomes, and professional standards, have also resulted in a significant administrative burden, especially on the clinical leadership, which increases the likelihood of burnout.

As with many aspects of life, communication is key. Service users need to have their expectations managed, by being provided with realistic timeframes in which they will be able to access care and that these timelines are often outside the control of the clinicians providing the services. With regard to the targets which are set, I feel that the clinical teams need to be more actively engaged, so that the rationale behind the targets are communicated effectively. This will also allow the ‘target setters' to be made aware of the wider implications to the clinical teams and the time burden that the associated data collection results in, as this may influence the rollout.

The National Assembly for Wales Health, Wellbeing and Local Government Committee's Review into orthodontic services in Wales produced a number of recommendations. Does your research suggest there is still a long way to go before these recommendations have been implemented, or given the changing nature of the profession, are they somewhat obsolete and could be reviewed?

Following the numerous inquiries into orthodontic and dental services across Wales, along with the implementation of some of their recommendations, there have been improvements in efficiency, delivery and cost effectiveness of NHS orthodontic care across Wales.

However, there still needs to be progress. For example, the first recommendation from the 2011 report was ‘We recommend that the Welsh Government commissions further research to assess the orthodontic treatment need, ensuring that contracts for orthodontic treatment are adequate to meet demand.'8 However, this research has revealed that, despite numerous rounds of commissioning across Wales, the level of annual commission activity is only 76% of that required to address the normative annualised orthodontic need (based on a third of 12 year olds). It is not clear if HBs have produced comprehensive Orthodontic Needs Assessments, to provide accurate estimates of the orthodontic need within their region, prior to commissioning rounds as would be considered best practice.9

The changing landscape of service provision across Wales, along with the lingering impact of COVID-19 mean that some recommendations may now not be valid. For example, ‘Recommendation 4. We recommend that the Welsh Government discusses with the Welsh Consultant Orthodontic Group how to introduce standardised UOA rate to address the disparity in UOA value and volume of treatment provided.' - Although an equitable ambition, it would not necessarily be fare, as it is recognised that the cost of delivering a service will vary depending on the location and the scale of the operation. As such the UOA rate may be best determined by the commissioning process, but with a minimum UOA rate embedded within the process to ensure that the successful bids are both sustainable and able to attract a suitable workforce for their delivery.

It is hoped that the re-introduction of the Welsh Strategic Advisory Forum in Orthodontics, will be able to act as an effective conduit to provide advice to the Welsh Chief Dental Officer and Welsh Government on orthodontic related matters, as well as helping standardise approaches across Wales.

Finally, what impact will these reports and data have on the patient?

The research was designed to allow comparisons between different HBs to be made, as well as providing data on Wales as a whole. The data gathered will inform decision makers, helping them with strategic planning both at a HB level and nationally.

At a local level within North Wales, the information provided has prompted the commissioning of a comprehensive Orthodontic Needs Assessment. This Needs Assessment has articulated the changing demographics over the last 10 years; demonstrated the current annualised orthodontic needs across North Wales; and also the likely trends for the future. In contrast to many Needs Assessments, this one has also addressed the “elephant in the room”, which is the existing groups of patients who have already been referred and are already on waiting lists to access orthodontic care. This is allowing a more comprehensive strategic policy to be formulated, to manage, not only the annualised orthodontic treatment need, but also help address the significant waiting list backlog for the initial assessment in a sustainable way.

At a national level, Health Education and Improvement Wales (HEIW) are responsible for the training and transformation of the NHS workforce in Wales. The research data obtained provided evidence to HEIW to help secure funding from Welsh Government for additional orthodontic specialty training places. This is a crucial element of workforce planning to ensure that we generate sufficient specialists to provide NHS funded treatment within Wales in the long term. ◆