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Volume 448: debated on Wednesday 28 June 2006

First, I thank Mr. Speaker for giving me the opportunity to raise the important issue of the availability of dental appliances under the new national health service contract. I look forward to hearing the Minister’s response to the legitimate concern of the dental laboratories profession that the new contract is damaging their industry and, equally importantly, the service provided to patients on the NHS.

I appreciate that my hon. Friend is at an early stage in his comments to the House, but on that point about patient service, does he agree that NHS dentistry is already in great difficulty, with residents in many constituencies such as mine being unable to obtain an NHS dentist, and that any further obstacles are likely to have catastrophic consequences for NHS dentistry in those areas?

I agree. I am well aware of the problems in Cheadle, because a number of my constituents used to access NHS dentists there and are now unable to do so.

I shall focus on three points: first, the impact of the new contract on the availability of certain treatment on the NHS, dentists’ decisions to provide cheaper and less effective treatments, and the knock-on effect on dental laboratories; secondly, the influx of cheaper dental appliances from abroad; and finally, the lack of information given to patients about their entitlement to certain dental work.

There are about 2,700 laboratories in the UK, providing dental appliances to dentists in the NHS and in private dental practices. Seventy per cent. of all dental appliances produced in UK laboratories are made for the NHS, so it is fair to say that any Department of Health decision on dentistry will affect the laboratories and their employees.

The sector employs about 10,000 technicians and a further 11,500 administration and support staff, and the industry operates in one of the few remaining UK manufacturing sectors that still compete against imports. However, the new contract and the threat from overseas competition make the future of the industry look bleak.

The new dental contract aims to simplify the charging system through the use of three bands: diagnosis, treatment and provision of appliances. As such, all work prepared by the dental laboratories falls within band 3. The cost of each appliance to the dentist varies dramatically, but some dentists pick the least expensive items available in band 3, instead of the most appropriate appliance for a patient’s dental needs.

The patient is treated and the dentist gains their required unit of dental activity target, but at a minimum cost. For example, many patients requiring a crown, which perhaps costs £80 from the dental laboratory, are instead being offered single-tooth dentures, which might cost only £20 from the laboratory.

A survey carried out in May of 200 members of the Dental Laboratories Association discovered that orders for single-unit crowns had decreased by 44 per cent. compared with the same month last year, while the amount of one-tooth denture work had increased by 61 per cent.

It is widely accepted that, when feasible, a crown is more appropriate than a single-tooth denture, but there are significant health benefits in avoiding a denture. Although the denture might provide the aesthetic appearance of a natural tooth, it has many more potential complications: the patient may be unable to keep it in their mouth, or it may cause speech problems, compromise other teeth or strip gum tissue away from healthy teeth.

The overall results from the new contract have been startling and prove pretty conclusively, I would argue, that certain dental appliances are not being provided by some dentists under the new contract, and that more people are being forced to go private to receive the treatment that they require.

The May survey showed that NHS denture work had decreased by 79 per cent., and private denture work had increased by 52 per cent. NHS chrome work had decreased by 91 per cent. and private chrome work had increased by 21 per cent. NHS bonded crown work had decreased by 79 per cent. and NHS precious bonded crown work had decreased by 86 per cent. Veneer work had decreased by 73 per cent. and yellow gold metal work had decreased by 38 per cent. in the NHS. Non-precious metal crown work had decreased by 61 per cent. Private bonded crown work had increased by 17 per cent. The number of dentists still providing NHS denture repairs had decreased by 34 per cent.

The Minister cannot argue that she was not warned that that would happen, because in December 2005 she received figures from a survey carried out in the pilot area in September that year. They produced pretty similar results.

One of the core problems with the new contractual arrangements is the significant balancing act that dentists must carry out to ensure that their monthly payment covers the cost of providing a comprehensive NHS dental service while still providing a profit for the practice and a salary for the dentists.

The laboratory fee is a substantial element of a dental practice’s budget, so it is in the interest of the dental practice to shop around for the best deal. However, the best deal often means sourcing appliances abroad. In fact, over the past four years, the market for overseas dental appliances has grown substantially. Estimates are that 10 per cent. of UK dental appliances are supplied by overseas laboratories.

In the UK, the Medicines and Healthcare Products Regulatory Agency allows dental appliances made overseas to be supplied to the UK as long as they have come via a laboratory in Europe that is registered to comply with the medical devices directive. The process is not one of proactively seeking to ensure that overseas dental appliances are being made in accordance with the directive. Without assessing the individual laboratory and checking the materials that were used at the time of production, a laboratory that receives dental appliances from an overseas laboratory cannot prove that the device has been made in accordance with the directive, so patients are potentially at risk. They could be supplied with dental appliances on which there was no information about the materials used or who produced and supplied them.

It is imperative that we ensure that patients are aware of what treatment they are entitled to, and what they are receiving. It is important that patients should be made aware that a crown is available instead of a single-tooth denture. If a dentist tells a patient that they need a single-tooth denture, most will assume that that is the most appropriate treatment. I know that if I were to go to the dentist, and if the dentist told me that that was the most appropriate treatment, I would assume that that information was correct. However, some dentists are making decisions based not on clinical need, but on financial considerations.

There is also a lack of awareness about payment for treatment. I have heard of several cases in which patients have had some work done and there have been significant delays in carrying out the rest of the work. Appointments have been made for three months later, so patients have incurred a charge a second time, even though there was a perfectly good reason for doing the work on the first visit or within the three-month time scale.

The new contract encourages dentists to offer cheaper alternatives and to drag out treatment time, rather than to provide the most appropriate treatment as quickly as possible. I therefore hope that I shall receive some assurances from the Minister on raising patient awareness, and some commitment to assessing the impact of the new contract on the provision and availability of dental appliances under the new NHS contract.

I congratulate the hon. Member for Manchester, Withington (Mr. Leech) on raising this significant issue. Dental health is an important part of our public health strategy. There have been major improvements in oral health in recent years. Between 1978 and 1998, the proportion of adults with no natural teeth, who need full dentures, declined from 37 to 11 per cent. However, as the hon. Gentleman pointed out, a reliable supply of well-made dental appliances remains essential to the delivery of high-quality dental care, which is where the dental laboratories can make their contribution.

As the hon. Gentleman said, there are about 2,000 dental laboratories in England, which manufacture dental appliances, including dentures, bridges and crowns, to a dentist’s prescription. Last December, I met members of the Dental Laboratories Association, which represents most of those laboratories, and we discussed the reforms in some detail. Following that, I invited the association to join the implementation group that I have established to review the new commissioning arrangements and to help to ensure that they are achieving their objectives.

The hon. Gentleman talked about the new contract and the result of it. In his constituency, only one contract was rejected, which represented 0.7 per cent. of NHS activity. The point about the new system is that the money that would previously have been given to a dentist who did not take up the contract is now available for recommissioning locally, so his local primary care trust should be using that money to recommission dentistry. We saw from the pilots that over a longer period it is often possible for freed-up capacity, resulting from the new ways of working, to be used to take on extra people, so that more people can see an NHS dentist.

It is a fact that only one contract was not signed, but it is also a fact that constituents of mine still have real difficulty in accessing an NHS dentist. I have had to deal with a number of cases in which, despite following all the normal procedure, people have not been offered a dentist, and it has taken the intervention of their local MP to find them one.

I know that in the past there were big problems with the ability to access NHS dentistry in some parts of the country, but the changes mean that if a dentist leaves the NHS, that money can remain at local level and be used for recommissioning. In the past, the money would have disappeared from the area. Because of the new ways of working, there will be extra capacity so that more people can see an NHS dentist.

I am anxious to make progress, given that the hon. Member for Manchester, Withington initiated the debate and we have only 30 minutes for it. I want to respond to some key issues that he raised about the impact of the new commissioning arrangements on dental laboratories.

Under the new arrangements, PCTs commission a defined annual level of NHS services from dentists, in return for which dentists receive an agreed annual contract value, paid in monthly instalments. I am sure the hon. Gentleman knows that, previously, a dentist was paid only for each intervention. The new arrangements put the system on a much more stable footing. A dentist is paid to look after the individual needs of his or her patient. The annual level of service that dentists must provide is measured in terms of courses of treatment, rather than individual items.

In recognition of the fact that some courses of treatment are more complex and costly than others, the system divides courses of treatment into three broad bands, each with a different weighting—units of dental activity, as they are called in the regulations. The bands are the same as those that determine a patient’s charge, and the hon. Gentleman will know that there are three such bands: £15.50, £42.40 and £189. The highest band, band 3, covers the most complex procedures involving the prescription of dental appliances such as crowns, bridges or dentures. Such treatment carries 12 units of dental activity to compensate for the additional time and laboratory costs.

Inevitably, in an averaging system, dentists will find that some band 3 courses of treatment are more costly and complex to provide than the average while others are less costly. However, averaged over a year, the cost to dentists should be lower than in the past. There should be no financial deterrent to dentists to provide the full range of dental care required by a patient with complex treatment needs.

Let me make this point. It is important to remember that NHS dentists are contractually obliged to provide all the dental care and treatment that their patients require. We expect the great majority of dentists to behave professionally in that respect and we trust them to provide the proper care to patients. There is remuneration for that care and it is no longer calculated on each individual service provided. Dentists are now paid monthly to look after a set number of patients, and the UDAs that they accrue in complex procedures reflect the fact that those are more costly.

If there were evidence that some dentists were failing to provide the necessary care, patients could complain to their PCT, which should take the matter up with the dentist. We would expect it to do so. PCTs can monitor a dentist’s activity and they have a duty to investigate if it appears that he is providing fewer treatments than his patient profile suggests are necessary.

I thank the Minister for giving way a second time, but does she not agree that the fact that dentists can provide a cheaper alternative is an incentive for them to do so? The figures provided by the Dental Laboratories Association suggest that some dentists are doing just that.

I reiterate that cases such as the hon. Gentleman described, of patients having appliances fitted that fell out or made their gums bleed, are unacceptable. If he and the Dental Laboratories Association have evidence of such cases, they should put it to the local PCT and make a complaint, which is the required course of action.

I do not accept that dentists would give in to an incentive and get a few bob more by providing the wrong appliances. That would be unacceptable, and we would need to be firm about it. As I have said, there are mechanisms for the individual patient to complain and for the PCT to monitor dentists. If treatment patterns change, the PCT should investigate. Dentists are professional people and we expect them to behave professionally.

The hon. Gentleman suggested that unscrupulous dentists are breaking up courses of treatment so that they cover more than the two-month period in which patients can return for corrective treatment without incurring a new patient charge. There is no financial benefit from such bad practice to dentists under the new system. Under the old system, the number of patient charges collected by dentists was one determinant of their income. Under the new system, dentists contract with PCTs to provide the totality of patients’ dental care, with an agreed contractual sum that is not affected by the number of treatment courses that patients undergo.

I hope that patients will become increasingly alert to any attempts at sharp practice. We have gone to great lengths to publicise the new charging arrangements. We have distributed leaflets and posters to dental practices and other health service premises, and to public libraries and citizens advice bureaux. There is also information on the Department’s website and on the websites of bodies such as the British Dental Association and the British Dental Health Foundation.

The hon. Gentleman mentioned imported dental appliances. I agree that proper regulation is needed—that is something that we have considered before. The European Community medical devices directive is enforced in the UK by the Medicines and Healthcare products Regulatory Agency, and it meets that requirement. Under the directive, appliances prescribed by UK dentists from a laboratory outside the European Community must be approved by an authorised representative working in the UK. That representative could be a dental technician working in a laboratory registered under the directive or a registered dentist who—if satisfied with the quality of the appliance—is required to issue a certificate of compliance with the directive.

However, to strengthen the requirement further, we have ensured that the new general dental service regulations require the contractor’s patient records to include the certificate of compliance for any dental appliance provided. That means that all the information about an appliance will be readily available for inspection by the PCT. So, if there are complaints, the mechanism exists to ensure that the PCT can examine what has been supplied and satisfy itself that the appliance meets the correct standards.

I intend that the effects of the reforms should be monitored. The hon. Gentleman mentioned the previous personal dental services pilots. The evidence from them was that, in some areas, overall activity lessened, which is why we have introduced measurement by UDA. That will allow us to ensure that any spare capacity is used to allow more people to have access to an NHS dentist and that activity is maintained. The evidence from the pilots showed a certain drop in activity at first, but as they progressed, activity increased, as I have described.

That is true, but activity levelled out over the period of the pilots, and over the full period of the pilots there was a significant overall decrease. Does the Minister agree that the figures from the recent May 2006 survey suggest that the new contract has not resolved the problems that appeared in the first few months of the pilot?

I do not agree. I do not believe that, as the new system to monitor activity beds down, there will be a vast falling off over time, because there is the ability to look at both the prescribing of appliances and the patient profile.

It is important to put all those things together and say that we should pay the dentist to look after the holistic needs of the patients, not just for each filling and so on. Dentists should look at the patient and decide what is best. If what is not clinically appropriate is prescribed, that is wrong. We should be prescribing what is clinically appropriate, including appliances. That, combined with the monitoring, through the UDA system, of the work that dentists are carrying out should ensure that the same number of appliances are prescribed.

However, I have been keen to monitor the effect of the reforms. That is why we have established an implementation group to ensure that the new commissioning objectives that we have set out are met. The Dental Laboratories Association is on that review group, which will be given information on prescribing patterns since 1 April as soon as we have sufficient data to establish any trends. I am not sure what the hon. Gentleman was referring to in relation to May—with the new contract coming in, there would not have been enough time to notice any difference by then—but we expect to have something by September.

If the data show that dentists are not prescribing all the dental appliances for which their patients have a clinical need, we will be able to obtain further information from patient inspections conducted by the dental reference service, which is an important part of the protections that the hon. Gentleman seeks. The DRS is a team of experienced dentists who are charged with ensuring that NHS dental treatment is necessary and carried out to satisfactory standards.

Each year, DRS dentists examine more than 80,000 randomly selected patients. The DRS might be asked to target patients who have undergone extensive courses of treatment under band 2 to see whether an appliance such as a bridge or crown has been clinically indicated but not given, or patients in band 3 to ensure that an appliance has been appropriately prescribed.

That gives a measure whereby we can say whether there are any indications that the prescribing of appliances is not taking place as we think it should be. That is another measure—this time at the national level—to ensure a check. So, there is a check at the patient level, the PCT level and the national level.

I understand the points that the hon. Gentleman made. I hope that I have reassured him that we have not taken the representations from the dental laboratories lightly.

Will the Minister briefly address my comments on the lack of access to NHS dentists, which is an increasing problem in many constituencies?

As the hon. Gentleman will remember, I addressed that issue when I said that, overall, the reforms that we have put in place mean that, whereas previously there was no money left at the local level to replace dentists who left the NHS, that situation has been turned round. Investment in dentistry in the hon. Gentleman’s constituency has increased by 23 per cent. over the past few years.

I hope that I have set out the safeguards that we have put in place, which the implementation review group will want to monitor closely. If there is any evidence of an inappropriate decline in the prescribing of dental appliances, we have the resources to investigate the problem and a forum for devising remedial action.