Teeth: 'Why the long wait for orthodontic treatment?'
When Thomas Kendall was 12 he was told he needed an orthodontic brace, but six years later he is still waiting.
Thomas said he was now desperate to receive the treatment he needs as he is due to start university next year.
He has had an initial assessment, but needed to make a 90-mile (145km) round trip from his home in Llanbadarn, near Aberystwyth, to Carmarthen - where the only NHS orthodontist under the Hywel Dda University Health Board is located.
Thomas contacted BBC Wales to ask how many young people in west Wales are in the same position, and why the situation is so much more serious than in the rest of Wales.
"At six years, mine is the longest wait I've heard of, but I know of dozens of friends who have been on the list for three-plus years," he said.
"I'm a member of the UK Youth Parliament, and I've raised this issue several times, but we never seem to get any answers from either Hywel Dda or the Welsh Government.
"Talking to other members of the parliament, it seems like the provision of orthodontic treatment for young people is poor across the UK, but nothing like as bad as in west Wales."
In Wales, under-18s are entitled to free NHS orthodontic treatment.
Historically this was contracted centrally for the entire UK through the Dental Practice Board, but in 2006 responsibility was devolved to the seven Welsh health boards.
At the same time a financial cap was imposed on the amount of orthodontic treatment each board could carry out in a year.
Although this was a decision made by the Welsh Government, it mirrored the cap introduced at the same time by the Department of Health in England.
What went wrong for Hywel Dda?
As far back as 2014, Hywel Dda's provision of orthodontics had run into trouble, with more than 4,000 young people waiting an average of three-and-a-half years to be seen.
At the time, Hywel Dda were warned there was only capacity in west Wales to treat 800 patients a year, and that even if funding was doubled the backlog would take five years to clear.
Dr Stephen Gould, who serves on the Welsh Government's strategic advisory forum for orthodontics, said Hywel Dda faced a particular set of circumstances which created a "perfect storm".
"The cap hit Hywel Dda in two ways: obviously waiting lists went up because they faced restrictions on the amount of young people they were allowed to treat each financial year, but it also acted as a disincentive for orthodontists to set up practices in the area," Dr Gould said.
"It's difficult enough to attract orthodontists into rural areas at the best of times, but when you artificially limit the amount of work they can do then it becomes impossible; it's a situation which would never arise in Swansea or Cardiff.
"And when there are fewer practices offering NHS treatment, then inevitably patients have to travel further in order to access them."
Have things improved since 2014?
Dr Gould said a relaxation on the spending cap, combined with a new tendering process, has begun to make a difference.
Young people in west Wales are now also being treated by orthodontists outside of the Hywel Dda area.
"I'm now able to accept referrals from Hywel Dda at my surgery in Swansea, and whilst it's not ideal from a travel perspective, it is helping to get the waiting times down," he said.
"I really think they're on the right track now. There are still around 4,000 under-18s on the list, but these are mostly legacy cases, and people joining the list now can expect to wait nearer to one-and-a-half rather than three-and-a-half years."
What if I turn 18 before I've been treated?
Dr Gould said not to worry. Anyone referred to an orthodontist while they are under 18 remains entitled to free treatment, regardless of their age when they reach the top of the list.
Also, any cases where delays in treatment may result in pain or permanent damage are automatically fast-tracked through the system, although this means that less serious cosmetic cases have to wait longer.
What does Hywel Dda say?
Jill Paterson, director of primary, community and long-term care, said: "The health board recognises that some patients do have to wait for orthodontic treatment, however waiting list times are based on clinical need with urgent cases prioritised for treatment.
"The current waiting times for an initial assessment for routine orthodontic treatment, from the date the patient is deemed ready for treatment, is approximately three years and six months.
"However, patients categorised as needing urgent treatment will be assessed within 12 weeks.
"The estimated waiting time for starting treatment following assessment can be up to six months, depending on the clinical capacity within the specialist orthodontic practice.
"As at August 2019, there are 4,491 children and young adults waiting for an orthodontic assessment appointment across Hywel Dda."
She added: "Historically the demand for orthodontic services has been greater than the level of services commissioned and this has led to a backlog in the number of patients who can be seen each year compared to the number of treatment starts commissioned.
"The demand for the service would appear to have been compounded by patients being referred too early for treatment, patients who are not orally fit to receive treatment, and patients not entitled to receive treatment.
"As a result, the health board is currently undertaking a full waiting list validation exercise in order to ensure that the number of commissioned treatments started in the future are aligned to demand."
She said the health board was currently in an open procurement exercise for the future commissioning of specialist orthodontic services, based on population need which would increase access to orthodontic services.
"The health board is committed to improving access to orthodontic services for its residents," she said.
"Access to orthodontic services in Hywel Dda showed a significant improvement during 2018-19, with an increase to access of 47%, which was the highest in Wales."
What does the Welsh Government say?
A Welsh Government spokesman pointed out that Hywel Dda have undertaken more treatments in 2018-19 than any of the last five years, adding: "An independent review found the orthodontic resources in Hywel Dda Health Board appear to be sufficient.
"It found past inefficiencies in referrals rather than lack of funding have led to delays in orthodontic provision.
"Wales is now the first country in the UK to operate a fully electronic system for dental referrals in all dental specialities, including orthodontics. We expect the new system to improve the quality of referrals and reduce patient waiting times."
Is Thomas happy with these answers?
"They're nice words aren't they? If it pans out how they've said then great, but they need to know that this isn't something which is trivial to young people. Delayed treatment during teenage years can really affect someone's confidence, and even their future chances.
"Why should people in west Wales receive a poorer service than elsewhere in the country? We're not second-class citizens out here."