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Nhs Dentistry

Volume 405: debated on Tuesday 20 May 2003

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11 am

Good morning, Mrs. Roe. The Minister knows of my concerns about access to NHS dentistry in Stafford from my correspondence with his Department and the parliamentary questions that I have asked. The problem is not new; it existed when I was elected in 1997. However, given that it has continued for over six years, it is time to grasp the urgency of the situation and do something about it.

The Government have tried to do something by providing the investing in dentistry fund, and Stafford tried to take advantage of it. Several dental practices were identified which might have benefited from investment so that they could provide services to NHS patients. Sadly, many of them dropped out, and only one went forward. It took the public money, set up the NHS dentistry service and provided it for the minimum number of years required under the contract. It then announced that NHS patients were no longer welcome and went private. That exacerbated the pressure in Stafford.

We also took advantage of the dental access centres initiative. Stafford is now the proud owner of a walk-in centre, to which people can go for urgent treatment. An obvious limitation of the service is that it is for urgent treatment only, not for the crucial health care that everybody should be encouraged to undertake. However, because there is no NHS dentist in town, many people go to the centre because it offers the only access to free dental treatment for miles around. That puts the service under great stress; the union representative for the work force at the centre has told me of the pressure that the public put on the staff.

So we have reached the situation in Stafford in which young adults cannot find dentists to take them for NHS work. Staffordshire university students union, which has sites in Stoke-on-Trent and Stafford, contacted me last year to say that many students are unable to find NHS dentists. The student advice centre has received a number of complaints about the fact that facilities in the Stafford area are inadequate.

At the other end of the age range, pensioners cannot find NHS dentists. A well known campaigner in my constituency, Dennis Anslow, found himself put off his dentist's NHS patient list against his wishes. He had such difficulty finding a replacement NHS dentist in Stafford that he is now registered with a practice 20 miles away in Lichfield. He says:

"There must be hundreds of retired people in Stafford in the same situation, judging by the flow of letters in the local press."
I am constantly being contacted by individuals from those two groups, and I shall give three examples from among many cases. Mr. McGrath came to a recent advice surgery to say that he could not find an NHS dentist anywhere that would take him, and Maria Hillman was put off her dentist's list when the dentist went private. She contacted NHS Direct, which is now the way in which people are advised to find a new dentist, and she could not find another in the town of Stafford, population 55,000. The nearest practice was 10 miles away and it quoted a wait of over eight weeks to see a dentist who would require a registration fee up front to take her as an NHS patient. In the end, she felt forced to go back to her original dentist and pay for the private treatment. She is very aggrieved about that.

The same thing happened to Jenny Austin, from the village of Wheaton Aston outside Stafford, whose dentist put her off the list as an NHS patient and said that she would have to pay privately. She contacted me and NHS Direct. As a result of our lengthy correspondence, she says in her last letter to me:
"I have been trying since March to find an NHS dentist from the information you supplied however to no avail, so the information I would like from yourself now is how do I go about getting a reduction on my N.I. contribution to fund private treatment."
That neatly encapsulates the anger and frustration that people feel when they cannot get to an NHS dentist.

I am not alone as a constituency Member of Parliament complaining about these difficulties. Even in the few days after this debate was announced, many hon. Members contacted me to ask what I was going to talk about, in case they wanted to talk about the difficulties in their constituencies. I think that I put them off by explaining that we would focus on dental work force issues, not individual constituency problems. I have described the Stafford experience to show that the problem is serious and urgently needs to be resolved.

To respond to the problem in my constituency, I convened a dental summit in March 2001, at which there was a wide range of participants, including members of the public and the health authority, work force practitioners and individual dentists. We had an exceptionally helpful discussion, in which we considered the obstacles. First, the dentists concentrated on the remuneration differences between NHS dental work and private practice. They explained that too little recognition is given to the rest of the dental team and, as a result, they have immense recruitment problems. They cannot find new dentists coming out of training school or the therapists, hygienists and nurses to go with them. We all identified that as a crucial issue of work force management.

Let me explain what came out of that summit later in the year, locally and nationally. Incidentally, I wrote to the Minister afterwards. We established an ongoing local work force review for dental practices, to try to find ways to attract back into the profession retired dentists and others who have left and to try to identify local places for people from training school. At a national level, Lord Hunt, who was then a Minister, announced in 2001 a dental work force review for the country. That is not yet complete, so it would be helpful if the Minister could say whether it will be finished soon. With my local review, people would like next to establish a dental work force strategy, but clearly there is no point in their finalising that until they know what the national initiative will be.

I hope that, by obtaining this debate, I have clearly shown that whatever can be done for Stafford will be done and that this is also a national issue. Let us consider the state that we are in nationally. The number of dentists doing NHS work has risen. Since 1997, the number of dentists who say that they provide NHS dentistry has increased by about 1,700, but the total amount of NHS dental work has decreased. Indeed, about 5 million fewer adults are registered for NHS dental services now than were registered during the peak of 1993–94.

We await the Government's dental work force review, but in the meantime the "Options for Change" working group produced its report last August and has since announced 26 field sites pilots for its work. The review's conclusions were that primary care trusts should commission NHS dental services; we should have a variety of forms of payment, testing them on a pilot basis; we should focus on prevention; a wider range of professionals should be involved in the service; and there should be national standards. Those are all excellent ideas to begin with.

The Audit Commission report, published in September 2002, said that "Options for Change" was a welcome start, but pointed out some of the serious problems that still exist in NHS dentistry. Forty per cent. of dental practices do not accept NHS patients. In some places, no dentists accept NHS patients. Those dentists who do NHS work say that they feel that they are on a treadmill. Piecework pay has in effect remained unchanged for 40 years. The Audit Commission warns, therefore, that the quality of NHS work is at risk. It says that we should move to a new way of working for NHS dental services, emphasise prevention and replace piecework pay.

The latest review of the current situation in dental services is contained in the Laing and Buisson report "UK Dental Care", published in January 2003. The report states that over half of dentists' income comes from private patients, that over a quarter of UK dental patients pay privately and that spending on NHS dental care is still below the peak of 1991–92.

There is, therefore, a need for action, and it is pleasing to see that in the Health and Social Care (Community Health and Standards) Bill provision is made for changing dental services. The debate on that Bill has been overshadowed by the issue of foundation hospitals, but part 4 contains proposals for improving NHS dentistry. It is proposed that primary care trusts should commission services in future and that new kinds of contracts for the service will be possible. The Bill also contains proposals for new ways of remunerating dentists and a clearer system of dental charges, and there is a welcome emphasis on dental public health. Those are all welcome initiatives from the Government. However, the Bill must, of course, pass through both Houses and then be implemented through regulations and commencement orders, so there is still some way to go.

I am grateful to the British Dental Association for its help in preparing for the debate, and I will outline its attitude to the current situation. The BDA complains of chronic under-investment in NHS dental services and says that positive action is needed on work force issues. It says that pay levels and conditions must be attractive enough to recruit and retain dentists working in the NHS, and points out that there is a dearth of training places available for dentists and for professions complementary to dentistry—nurses, therapists and hygienists. Crucially, the BDA welcomes the changes that the Bill presages, but it points out that in the transition from the current situation to that after the Bill's enactment, it is important that fair arrangements are put in place to halt the continued drift of dentists away from the NHS. I agree with that.

I will raise several points, and I hope that the Minister will respond. My first point concerns the new contracts for NHS dental work. Will he assure me that there will be no more piecework pay for NHS dentists? I seek his assurance also that the Government will attempt to stem the shift towards private work by improving the pay and work-life balance of dentists and their teams, and, by establishing better conditions, help them to improve their service to patients. Will the Minister allow dentists access to NHS capital investment, and thereby tempt them to stay in the NHS or to join it? When the Bill has been enacted, will the new contract for NHS dental work focus on NHS list sizes, the quality of the work and health protection—the preventive work that is so important?

I want to see a modern dental team. Will the Minister ensure that there is a wider range of service provision, so that there are salaried dentists as well as those who are privately paid, and that more use is made of the other members of the dental team? With reference to the issues raised at the summit that I held in Stafford in 2001, I know that dentists would also ask the Minister to keep regulation and red tape to a reasonable level in any new scheme that is introduced. Many of my constituents tell me that the complaints procedure, whether for NHS or private work, is unclear, inadequate and ineffective. People would like to see a robust system that they can understand.

To ensure that we have the work force of the future, it is vital that there are adequate numbers of training places in the present. The NHS Modernisation Board, in its most recent report in March 2003, says that capacity is the key factor that holds back modernisation. I wholeheartedly agree—that certainly applies to dentistry. Positive action is needed now to get the right number of training places, and those places must be available to the whole dental team—dentists, therapists, hygienists and nurses.

With regard to dentists, the BDA estimates that a 25 per cent. increase in the number of new dental students is needed. The Department is funding 40 training places for therapists this year, but it has a target of 150 places within two years, so—my goodness—it must get its skates on to meet its own target. Such a step change in the number of training places is exactly what I am calling for in this debate.

At present, there are only 13 training centres in the whole of the United Kingdom. As part of the 2001 summit, we volunteered staff for a new training school if the Government were interested. Nothing came of volunteering ourselves then, but if the Minister were interested in expanding the number of training places, Stafford would step forward and offer its services.

We need urgent action now. The work force review is a very serious issue. There is uncertainty about the transition from the present system to the PCT commissioning of the future, and people are worried that that uncertainty may hasten the shift from NHS to private dentistry. We need to give reassurances about funding and clarity. I hope that the Government will issue template contracts for use by PCTs and dentists, so that they can see clearly what is being discussed. I hope that the Government will announce an adequate floor funding level for PCTs when they take over the commissioning of the service. I ask the Minister to show the Government's good intentions with announcements on training places and funding now.

So it comes to this. We are rebuilding the NHS as a whole, with vision and determination. There have been recent signs of success. Let us do the same with NHS dentistry and create a service in which we, the staff and our constituents can take pride.

11.16 am

I begin by congratulating my hon. Friend the Member for Stafford (Mr. Kidney) on securing this debate and on the persistent way in which he continues to take up the cause of NHS dentistry in his constituency. I stress at the outset that we are committed to ensuring that NHS dentistry is available for all who need and seek it. The future of NHS dentistry is as a service that better addresses health inequalities, the prevention work about which my hon. Friend talked and the different needs of different communities by securing a better balance between prevention and treatment. I counted seven questions in my hon. Friend's speech, and I can say yes to all of them. I hope that my response will illustrate what we are doing on this important aspect of policy.

Although we should be proud of the major improvements in the oral health of the population over the last 20 years, due in the main to the fluoridation of toothpaste in the 1970s and 1980s and, in some areas, to the fluoridation of water, there remain some areas in which tooth decay, especially among children, is too high.

The Minister touched on fluoridation, a subject in which I have an interest. In countries such as New Zealand—that might suggest the reason for my interest—70 per cent. or even 80 per cent. of the water supplies have been fluoridated. That has been a success: none of the difficulties that the anti-fluoridationists suggested have ever manifested themselves and the All Blacks still win most of the time. Therefore, will the Government create the opportunity for fluoridation to take place nationwide?

On a point of order, Mrs. Roe. My point is not that the hon. Gentleman has not asked my permission to take part in this debate—that it is naughty of him, but I shall overlook it because of his great experience—but I am worried that we shall be diverted down the road of debating the fluoridation of drinking water. That is a controversial issue, but it is not related to the dental work force.

That point has no doubt been taken by the Minister, but he gave way to the hon. Member for Mole Valley (Sir Paul Beresford), so it was incumbent on me to call the hon. Gentleman.

I shall move swiftly on, but I remind the hon. Gentleman that we have asked the chief medical officer and the chief dental officer to commission further work on the subject. It is important that local people take these decisions—we do not believe in universal fluoridation—but they should do so on the basis of proper evidence and without fear. That is especially so of the water companies, given their fear of being sued.

I will now answer my hon. Friend's points. We were successful in meeting the Prime Minister's pledge that everyone should have access to an NHS dentist. People have difficulty registering in some areas, but my hon. Friend will know the history up to the late 1990s after the contract was introduced in 1990. He will be aware of the lack of funds to support it and realise that the lack of piloting brought us to a frightful place. It was important, through the Prime Minister's pledge, to give people access to an NHS dentist.

I am aware that my hon. Friend's constituents face difficulties with access and problems that relate to oral health and to the prevention of oral problems. There are significant variations in the levels of tooth decay throughout the country. Residents in the south-east enjoy a lower incidence of tooth decay, thanks to the fluoridation of the water supply, but residents in other parts of the country have nearly average or above average levels of tooth decay.

There are also problems in obtaining registration with NHS dentists. The south Staffordshire area relies on dental access centres in Stafford, Burton, Cannock and Tamworth to provide a safety net for people who do not have access to an NHS dentist. That is why we are undertaking one of the most radical programmes of reform of NHS dentistry since its inception. My hon. Friend is right: NHS dentistry has more or less remained the same since 1948. Only the programme of action— the legislation currently before Parliament—will change that paradigm once and for all and begin to address the serious needs of his constituents.

The programme will involve considerable changes to the current dental service. The problem with the current system is that the distribution of NHS dentistry is determined by the dental practitioners choosing to deliver it, not by the NHS choosing to commission it. There is little patient choice, which is why we are legislating for far-reaching reform of NHS dental services. It is proposed that the primary care trusts will be given a duty to commission dental services within their boundaries to meet reasonable needs. In doing so, the different oral health needs of different communities can be met, and dentists who sign a contract with a PCT will have a secure income in return for making a longer-term commitment to the NHS. I cannot emphasise too strongly what a transformation that will be: the local community will commission its dental services and will be able to plan for local people and to prevent oral decay in a way in which it has never done before.

As my hon. Friend says, it is also proposed that the way in which dentists are paid is changed once and for all so that we move away from the current "item of service" system. We hope that that will reduce the treadmill effect about which some dentists complain and that it will make NHS dentistry a more attractive option. My hon. Friend is right: the old system was appropriate after the war when oral health was pretty bad, and it was important to get people through the door, do the drillings, sort out the decay and get them out of the door and back in again in a few months to continue the job. We are no longer at that stage because of toothpaste and other things. The picture throughout the country is patchy: patients have different expectations of dentists, and we should incentivise dentists by paying them to treat people in a way that is appropriate for the 21st century. The proposed system will not, of course, automatically improve delivery, but it will lay the foundation for long-term change and will create the framework for proper contracting and a degree of certainty between the NHS and dentists that currently does not exist.

To meet the new responsibilities for dental services proposed in the forthcoming legislation, PCTs will need to assess local oral health needs, including health inequalities. Moreover, for the first time since the foundation of the NHS, primary care dentists will have the opportunity to undertake what is essentially a public health role.

However, that is only half the story. Although we need to modernise the NHS dental service, we also need, as my hon. Friend suggests, a twin-track approach to recruit and retain dentists. We must also make the best use of the trained staff who are already part of the dental team. We are taking action on all these fronts.

I apologise for not being here earlier. Although I tried to arrive in time, my scurrying was not enough. One of the key questions is the removal of the piecework system. Assuming that that is one of the seven questions that the Minister mentioned, his answer was yes and he has hinted at that now. The legislation is short and difficult to assess. Will the PCTs have an enormous choice in how they pay dentists because, if they cannot attract dentists, there will be no service?

Yes, they will. The primary legislation lays the framework and we must continue to work with the BDA, dentists and others to put that into context and to meet the differing needs of local areas.

I want to make progress.

There has been a significant increase in the number of dentists on the UK dental register. Numbers working in NHS general dental services are up since 1997, with 18,400 dentists working in England at the end of September 2002 as against 16,728 dentists in 1997. However, as I have said, in some areas access to NHS dentistry remains a problem. When my hon. Friend talks about private dentistry, he illustrates part of that problem. He will know about the recent Office of Fair Trading report into private dentistry. The Government have a 90-day period in which to respond. I must not pre-empt that response, but I suspect that I will be dealing with some of the issues that he illustrates. In a sense, the report has a bearing on the whole dentistry family, both NHS and private. It also raises some important issues about transparency and understanding of what private and NHS treatment provide.

As I was reminded last Thursday, when giving evidence to the Health Select Committee, the Government undertook to carry out the first dental work force review since 1987 in our response to the Health Select Committee's report on access to dentistry published in July 2001. We are undertaking the review in consultation with the dental profession, professional bodies, dental academics, as well as the BDA. Again, I cannot pre-empt the report, but I can confirm that matters under consideration include the age structure of the dental profession; the increasing number of women dentists; and our commitment to develop team-working in dentistry and a skill mix generally. I recognise that the review is taking longer than the timetable originally envisaged because the relationship between access to dental care and the number of dentists in practice is not straightforward. I hope that we can publish that work force review later in the year.

Access depends on the numbers of dentists. Dentists will be attracted by pay. The Minister has carefully not said what form of payment is proposed to replace piecework.

In short, I see a future in which there is local commissioning. We have learned a considerable amount from our access centres, from the personal dental services—salaried dentists, in short—and the ability of dentists to drill down, if that is not an inappropriate phrase, on oral health problems locally. I see a future in which PCTs can do that. We must continue to look at the work force issues to ensure that we have dentists in the right place. At the core of that are health inequalities. I suspect that we will shortly come forward with plans on that issue.

11.30 am

Sitting suspended until Two o 'clock.