[Relevant Documents: Fifth Report from the Health Committee, Session 2007-08, HC 289, on Dental services, the Government response, Cm 7470, and the Department of Health Departmental Report 2008, Cm 7393.]
Motion made, and Question proposed,
That, for the year ending with 31 March 2010, for expenditure by the Department of Health—
(1) resources, not exceeding £33,990,717,000, be authorised, on account, for use as set out in HC 1039 of Session 2007-08, and
(2) a sum, not exceeding £33,474,467,000, be granted to Her Majesty out of the Consolidated Fund, on account, to meet the costs as so set out.—(Mr. Frank Roy.)
It might be helpful if I give some background to the report that we are now going to debate—sadly for somewhat less than two hours, as a result of the Government statements this afternoon. The Select Committee on Health published its fifth report of 2007-08, on dental services, on 2 July. We took evidence from a range of witnesses, including dentist campaign groups, primary care trusts, commissioners of dental services, public dental health experts, the British Dental Association, the Dental Practitioners Association and the British Orthodontic Society, as well as patient groups and practising dentists. The Under-Secretary of State for Health, my hon. Friend the Member for Brentford and Isleworth (Ann Keen), who sits on the Front Bench tonight, also gave evidence, as did the chief dental officer.
One of the Committee’s findings was that the nation’s oral health has improved significantly since the establishment of the national health service general dental service or GDS in 1948. That is not surprising, given that most other things in society have improved since then. As recently as 1968, the proportion of the adult population in England and Wales who were edentate was 37 per cent. The latest figure is estimated to be about 6 per cent, so there has clearly been a massive improvement in dental health in recent years.
Nevertheless, by the 1990s there was a powerful case for reform of the GDS contract. It was widely agreed that although the provision of NHS dentistry was good in some areas of the country, overall it was patchy. Moreover, the payment system lacked sufficient incentives for the provision of preventive care and advice. In addition, the Department argued that there were too many incentives to provide complex treatments. In April 2006, the Department reformed the GDS contract, making a number of far-reaching changes: primary care trusts were given the power to commission dental services; the patient charging system was simplified; and under the terms of a new dental contact, dentists were remunerated according to the number of units of dental activity—UDAs—completed. The Department issued a number of criteria for success: patient experience; clinical quality; NHS commissioning and improving dentists’ working lives.
Our inquiry found evidence that the new contract had failed to meet the Department’s criteria for success in a number of areas. However, the Committee argued that with more good will from dentists and the Department, the contract could be made to work. The Committee’s main findings were that access to NHS dentistry was not as good as it was said to be, and that the total number of dentists working for the NHS and the number of treatments they provided had fallen slightly since 2006. There are many reasons why dentists moved away from the NHS, one of which was the income available in our society now. This move happened in the parts of the United Kingdom—it certainly happened in England—where one would have thought that there were bigger incomes and more better-off people compared with other parts. In such areas, dentists on some occasions moved wholly into the private sector.
The total number of patients seen by NHS dentists fell by some 900,000 between December 2005 and December 2007. The latest figures for the period from April 2006 to April 2008 show a decline of some 1 million in the number of patients seen. It is possible that patients have good dental health, so it is not necessary for them to be seen. I know that call-backs for people with good dental health are few and far between compared with a few years ago, when there were regular call-backs.
The Committee also found that PCTs had performed patchily in how they commission services. For example, whereas in some areas, such as London, access was good, in others, such as Devon and Kent, it remained difficult for patients to find an NHS dentist.
My constituency borders Devon, and I must report to the right hon. Gentleman that we find exactly the problem that he is describing: a shortage in the availability of NHS dentists. Does he agree that, in many cases, even if the area is relatively well off, there will be people within it who are not and who are suffering?
That is true. We took evidence, which was more than anecdotal, suggesting that some dentists who wanted to move into the private sector were saying to people, “We will take your children as NHS patients, but only as long as you take out private insurance on your cover.” Hon. Members will see what our report said about that, but I must say that not many people defended that practice—I include the professional organisations in that comment. However, unfortunately the practice still goes on.
In addition, the Committee found that strategic health authorities were poor at managing PCTs and gave a dentistry a low priority. We also found that the number of complex treatments, such as extractions and root canal work, has fallen under the new contract by 50 per cent. That was seen to be a consequence of the contract not providing dentists with sufficient incentives to carry out this type of work. That is one of the areas about which we were concerned. I have some views about it, given what the Department has announced in the past few days that it will do to address the situation, as we hope it will.
The Committee found that the new dental contract had also failed to provide dentists with sufficient financial incentives to provide preventive advice, and that the system by which dentists are paid according to the amount of UDAs delivered should be changed. The Department should consider introducing payments based on quality and outcomes frameworks, such as we have in parts—although not all—of general practitioner practice. In those areas, people who have long-term conditions are being managed on the basis that GPs are providing such treatment. We believe that this is something that should be looked at.
The Government’s response to our report was published in October 2008. It accepted some of the Committee’s criticisms, but maintained that the access to NHS dental services would improve over time. The Government response stated that although access was uneven, it was improving and would improve further once the contract had bedded in, and that the Department would investigate whether the number of complex treatments had fallen. The evidence was a bit more than anecdotal. We need to consider issues such as what happens if someone loses one tooth. Although a better way of proceeding would be to put in a crown or something substantial, under the new system dentists could just put in a palate with one tooth on it. That would suffice to get the UDA, and thus the income, into the practice. When we heard such information, we had grave worries about whether the issue of quality was being addressed at all in many senses.
Does the right hon. Gentleman accept that because most dentists are professionals, they will try to do the right thing and provide a quality service? Does he also accept that a system in which an extraction is funded in the same way as complex root canal work, which can take many sessions to carry out properly, is extremely difficult and heavy on consumables, is unlikely to encourage dentists to aspire to quality dentistry, but far more likely to encourage them to do the bare minimum, which is not conducive to good oral health or dentition?
To follow up on the previous intervention, will the right hon. Gentleman also confirm that the statistics appear to demonstrate what was just said—that the number of root canal fillings being carried out has decreased significantly and the number of extractions had increased?
Further to the point made by the hon. Member for Westbury (Dr. Murrison), did the Committee find that the width of the UDA banding—I am told that one extraction counts for the same as four or five—was a disincentive to some dentists to enrol patients who needed substantial work to get them to the start line? Was that one of the reasons for people finding it difficult to get an NHS dentist?
That is the case, and we took evidence to that effect. Some of the more complicated cases were shoved into the acute sector—into hospitals—which was wholly wrong. That is not where such treatment should take place.
The Government also agreed that the historical means of funding PCTs should change and that funding should be based on the needs of the population. That is one of the great difficulties, because the new contract wanted to improve access to NHS dentistry services, but it also had to ensure that we did not lose any more dentists to the private sector. We found that the funding for the activity in question was historically based where NHS activity had been high—and quite right, too. My constituency and the surrounding area are well served, and I would not want to see that diminish. That may sound selfish, but in other parts of the country dentists have walked away from the NHS and we have an obligation to look after the interests not only of the population, but of the dentists who did not walk away but continued to provide a service under the NHS banner.
In my constituency dentists walked away from the NHS. The right hon. Gentleman will welcome the 11 per cent. increase that the Government have put in, but can we be confident that the new formula will distribute that money on the basis of unmet need on this occasion? The key problem with the contract was that the basis of allocation by the PCTs was a historic and restricted view of previous spending.
That is precisely the area in which the Government agreed with the Committee. The contract had to be historic, because we had to defend existing NHS dentistry. The question whether that funding was based on the needs of the population is one of the most difficult when it comes to expenditure on the NHS—I have in mind the debate on improving primary health care. The question is where the disease burdens lie, and answering it is still a problem.
That is not my reading of the situation. Dentists walked away in areas of greater income. We also heard about offers to keep children on as NHS patients provided that the parents took up private insurance. I thought that that was wrong, and the Committee commented on it, but it was part of the same problem. Money gives people the option to make different decisions. My personal view is that in some parts of the country—even in south Yorkshire—dentists decided to walk away from the NHS because they felt that enough people had enough income to sustain private insurance.
My right hon. Friend describes the situation in my constituency. In the south, we have nothing but NHS dentists. They make the contract work, they think that the rewards are perfectly satisfactory and they are great supporters of the NHS. In the town of Stroud and its immediate environs, almost all the dentists are now private. In effect, there are two systems and it is as if the Berlin wall exists between them. Occasionally, people can cross over into the other system, but private dentists do not seem to want to come back into the NHS. If there is a magic bullet that will change that, I hope that someone will tell me, because I would love to get them back.
I am very grateful. The right hon. Gentleman argues that it is mostly in wealthier areas that dentists are leaving the NHS, but in rural Norfolk, where we have a low-wage economy, 20 per cent. of dentists left the NHS on the introduction of the new contract. Does he agree that in surveys dentists have expressed overwhelmingly negative views about the contract? The contract as a whole, and the bureaucracy involved, has driven many dentists away, as they believe that they can make an income in the private sector.
I would not disagree with that point, but over the past 15 years or more improvement in services in the NHS—be it in dentistry, GP care or hospitals—has been most successful if the professions have had ownership of it. In 1992, when the first new dentistry contract was introduced, large parts of the profession walked away from it and there were divisions in the representative bodies. It is my personal view—it is not articulated in this way in the report—that the new contract, like the 1992 contract, isolated the profession, to the disservice of dentistry in this country. When I said that at the press conference to launch the report, there were nods from some of the representatives of the dentistry profession, although in the press the next day they were reported as attacking the new contract and saying that it was all wrong. However, that is life, and we have all been there.
My right hon. Friend makes the important point that many dentists walked away from the NHS long before the 2006 contract was introduced. Many towns were NHS-dentist deserts for many years because the PCT had no way of ensuring that NHS dentistry was provided. The dentists could decide, on their own whim, how much NHS work they did and how much private work.
I agree. I do not think for one minute that the lack of NHS dentistry is just to do with the new contract. It was happening for many years before that, and in my personal view the lack of professional leadership was one of the main issues. Dentists were not engaged in the process. When we considered NHS charges, I asked a representative of one of the professional bodies what effect the new contract had had, and I cannot remember the exact response but it was along the lines of “We pass comment on it from time to time.” That is not the type of engagement that was envisaged. It is a great pity that we have lost professional leadership at that level, in terms of negotiating contracts for dentistry inside the NHS.
The professional bodies can defend themselves, but one of the reasons for that response is that they felt that the decision was imposed on them. It was not piloted, and the evidence from the previous pilots was ignored. If it had not been imposed on them, they might have stayed around the table to discuss a better contract, but it was imposed without their agreement.
Yes, but it was also imposed because they were not engaged in the process. In all the subsequent contracts, such as the hospital doctor contracts or the GP contracts, we have seen what some would call good trade union leadership in the negotiations. I would call it good trade union leadership—it is what I used to do before I came here as a politician—and my reaction is “Well done.” That is what people should do from that side of the table. There has been a lack of such leadership in dentistry, not just in the 2006 contract but for a substantial number of years before that, too.
The Department also said that it would reconsider the unit of dental activity payment system to see whether it could also include quality of treatment. It did not rule out our suggestion of a quality and outcomes framework for style indicators in dentistry. Members will know that an announcement was made about that last Friday. The chief executive of the NHS was giving evidence to the Health Committee on Thursday morning and we asked him a question about dentistry. He replied, “Oh, we are about to make an announcement.” I said, “Great, you normally make an announcement before you come to give evidence to us or before a debate.” To be fair to my hon. Friend the Minister, the Government said in their response to our recommendation 41 that they would review NHS dentistry. Indeed, on 11 December the Secretary of State announced a change to the Department’s line that the reforms to the contract were working and that over time they would deliver improved access. Those are my words, not those of the Department, but I think that there has been a slight change of thinking. The Secretary of State acknowledged that access to NHS dentists remained a problem in many areas of the country and announced the review of the dental contract, which was already contained in the Government’s response to the Committee in October.
The review will be led by Professor Jimmy Steele, who chairs oral health services research at the school of dental sciences in Newcastle. I alluded earlier to the people at our press conference. One of them, Susie Sanderson, who is the executive board chairman of the British Dental Association and who gave evidence to the Committee during our inquiry, said last week:
“The BDA is pleased to see the long overdue announcement of a review of NHS dentistry in England. The announcement recognises the significant problems patients and dentists face and places the Department of Health on a path to addressing those problems.”
I am pleased that the Government have announced that review and will, I hope, address the issues brought up in our report. One of the key aims of the review, contained in the second bullet point in the Secretary of State’s press release, is to:
“Recommend how the Government can best address the issues raised in the Health Select Committee’s 2008 report on dentistry including the suggestion that more treatment bands are introduced.”
That referred to the system of three treatment bands. Under the old contract we had 300 or 400 different treatment bands, and I am not sure that we would want to go back to that, but we took evidence that suggested that introducing a few more bands would make the system a lot fairer than it was.
The Chairman of the Committee is being very generous with his time. Does he envisage that the change to the quality and outcomes framework will somehow enable dentists in the NHS to provide more preventive care despite a system based on units of dental activity?
Yes, I would hope that it would. That was one of our major criticisms. It was said by my hon. Friend the Minister’s predecessor that the new contract was about prevention. We tried hard to find out whether it was and my personal conclusion was that it was not. In this day and age of public health there are wider issues in relation to dental health and we believe that the contract did not place sufficient emphasis on prevention. Its importance should be recognised. In my view, the advice that health professionals give people should be measured and recognised.
It is probably fair to mention that the chief dental officer said that an element of preventive funding was included in the single UDA, but the evidence we took from dentists suggested that so much was included in the UDA that there simply was not time to do the preventive stuff as well as treating the patient.
The inclusion of more bands for the UDAs might be a way of addressing that problem. The smaller bands, which might not get as much money into the practice, would tackle that issue.
I hope that the review will deal with that. We should not prejudge matters, but the Health Committee will be looking at the outcome of the review to make sure that a preventive agenda is put firmly in place, and that the people who carry it out are properly compensated.
There is one other matter that I want to touch on before I sit down. The review talks about identifying over the next five years how
“developments in workforce planning, training and regulation can best support the provision of high-quality dental services and enhance the working lives of dental professionals”.
In our report, we talked about vocational training and recommended that the fact that some dentists take on students should be recognised. My hon. Friend the Minister attended the session at which the chief dental office gave evidence, and she may remember that he spoke about what is happening in south Yorkshire and about the links with the Sheffield university dental school.
By pure coincidence, I went last Friday to a practice in the seat represented by my hon. Friend the Member for Sheffield, Hillsborough (Ms Smith). I was there for the official opening of an outreach training surgery in a village called High Green. The dentist who runs the surgery also runs one in my constituency, and it so happens that, as a working dentist, he gave evidence to the Committee about the new contract.
We asked the chief dental officer about what was happening with the outreach, on-the-job training of dentists. In answer to question 766 in evidence 98, he said:
“With undergraduate education we have examples of outreach teaching in Sheffield; we have visited two practices in Sheffield where they are working with the PCT and the dental school and a part of their contract is to provide outreach teaching and does not have to be monitored by UDAs.”
My understanding was that the payment of UDAs to such practices was reimbursed by having the students get experience. In other words, the practices get paid for having students on an outreach programme by negotiating more UDAs. If one measures UDAs according to how many patients are getting treatment and then finds that some are being used for student training purposes, the result will be that incorrect figures will be produced. It is not a massive problem, but it is not the best way to proceed.
I asked the chief dental officer whether he thought that that was a right and proper way of reimbursing a dental practice for having students, and he answered:
“I do not think undergraduate training should be directly linked to UDAs”.
As I said, I was at the High Green surgery last Friday to do the official opening of the outreach training surgeries there. The two principal dentists there are Michael and Margaret Naylor, and they said:
“We strongly believe in the provision of good quality dentistry within the NHS and we welcomed this opportunity to have students working within the practice to whom we could pass on our knowledge and enthusiasm and to give the students a window of experience of working within a busy NHS practice.”
One of the students, Rachel Ingle, said:
“I found my confidence increased hugely as a result of my experiences and I feel better prepared to start work as a dentist.”
It was a big gathering, and I asked the commissioners how the outreach programme was being paid for, and how the practice was being rewarded for having the students. The High Green practice takes students from the dental school on six-week work placements, and I was told that it was normal for one dentist to have four students. The process takes time and, although the work involved is obviously not massively complicated, the students do spend time with the dentists who are training them. Inevitably, that slows down the amount of activity that takes place, but the same is true for trainee doctors and surgeons under close supervision in hospitals, where students are obviously not asked to carry out important work. When I spoke to the commissioners, they—not the dentists concerned—said, “Things are still the same.” They said that they were looking into negotiating UDAs, so that they could reward the practice for giving vocational training to students from Sheffield university’s school of clinical dentistry.
To conclude, as I said earlier, Michael and Margaret Naylor have a practice in my constituency, quite close to my constituency office in the village of Dinnington. I am an NHS patient there. As I said to the chief dental officer, next door to the dentist’s surgery there is a pharmacy, and next door to that is a doctor’s surgery, run by four or five partners. That doctor’s surgery gets capital allowances, and does not have to negotiate in the way that dentists do. It is a lot more engaged in building up NHS work than dentists are. I understand that dentists can move away from the NHS; we have heard evidence of that. However, there is something wrong if the only way in which income can go into an NHS practice is through UDAs, or what we had before them. That is how I understand the situation; my hon. Friend the Minister may know something different. Dentists do not have the type of capitation fees, or whatever we call them, that are in place in general practice.
If we are genuinely to look at improving national health service dentistry and to review it, it needs to be reviewed in a comprehensive way that takes into account many of the issues that I mentioned, and not just vocational training for dentists, although that is important. People will be aware that since the Government have been in office, two new dental schools have opened in the United Kingdom. Vocational training is an important part of getting good dentists working in our health care system. That can only be done if the work is rewarded in a sensible way, and if the reward does not have to be negotiated in the way that I am led to believe it is negotiated at the moment.
I start by thanking the Chairman of the Select Committee, the right hon. Member for Rother Valley (Mr. Barron), for a very fair summary of the Select Committee’s conclusions and recommendations. The Committee’s conclusions on how the contract was operated were pretty damning. In paragraph 26, it said:
“The Department asked for the contract to be assessed according to its own criteria for success: patient experience; clinical quality; PCT commissioning; and dentists' working lives. We conclude that the contract is in fact so far failing to improve dental services measured by any of the criteria.”
That is a pretty damning conclusion.
The review announced last week, which, as the Select Committee Chairman fairly said, was mentioned in the Government’s response back in October, seems to be an admission of failure by the Government. For far too long, there has been a sense of denial by the Government that there was any problem with the contract. Back in February, the Secretary of State said:
“Access…is getting better all the time.”—[Official Report, 5 February 2008; Vol. 471, c. 772.]
In June, he said:
“‘It’s getting better all the time’, to quote a line from a track on ‘Sgt. Pepper’.”—[Official Report, 17 June 2008; Vol. 477, c. 801.]
I hear the Under-Secretary of say that that is true and she repeated the mantra at Health questions today, when she said that access was improving. However, all the evidence points in exactly the opposite direction. I fail to understand how she can continue to assert that access is improving.
I want briefly to highlight some of the failings of the contract that the Health Committee identified, and to refer to the principles that should be applied when we review how the contract works and come up with a better way forward. First, as was highlighted by the Select Committee, the contract was imposed without being trialled. Rather like the Medical Training Application Service—the basis for recruiting junior doctors to specialties—the contracts were imposed by the Government. The right hon. Member for Rother Valley was absolutely right to suggest that we need engagement and ownership by the professionals if we are to ensure that reforms to our health system work to the greatest effect. Without ownership—and that is what happens if we impose a system—the system is unlikely to work effectively.
Access, despite what the Minister continues to say, is worse: 1 million fewer adults and 200,000 fewer children have had access to NHS dentistry since the reforms came into effect in April 2006. Before the reforms, the Government claimed that 2 million patients wanted access to NHS dentistry, but they could not get it. On the assumption that those 2 million remain, together with an extra 1.2 million people, there are now well over 3 million people, on the Government’s own figures, who want access to NHS dentistry but who are not getting it. As the previous Prime Minister said, the purpose of the new contract was to provide “access for all” who wanted it to NHS dentistry, but it was also to get dentists off the treadmill. The right hon. Member for Rother Valley was absolutely right: the previous contract was not a success, either.
We heard an intervention from the hon. Member for Staffordshire, Moorlands (Charlotte Atkins), in which she made a fair point, and I am certainly not arguing for a return to a better yesterday—the old contract failed miserably in many respects. The new contract, however, continues the failure on access.
The hon. Gentleman is right that the old contract had its faults—most contracts do. However, does he recall the personal dental services pilots that worked quite well and showed great promise? The Government, however, decided to jettison them largely, I suspect, for political reasons. Does he not regret the fact that lessons were not learned from those pilots?
I absolutely agree. The failure to pilot schemes or to learn the lessons from pilots that have taken place is desperately frustrating. A system that was introduced without being trialled, in a big-bang approach across the country, was destined to fail. The hon. Gentleman is right to say that the Government should have learned the lessons from those encouraging pilots, which were completely ignored.
The Government’s second assertion when the new contract was introduced was that it would get dentists off the treadmill. However, it appears to have reinforced the treadmill that many dentists believe they are on. We have heard that there is a disincentive to do complex work leading, dentists have told me, to a loss of skills. If they do not do that complex work, they become less skilled, which is worrying. There has been a 45 per cent. fall in root canal work since 2004 and, to confirm the point that I made in an intervention on the right hon. Member for Rother Valley, the number of extractions has risen in the same period.
Further to the matter that I raised earlier, does the hon. Gentleman accept that the trend for a reduction in complex treatments kicked in before the new contract was introduced in April 2006? It was something that had already been identified as a problem. I should like to establish why that happened, as I do not think that it is automatically clear.
That may well be the case, but there is no doubt at all—and I think that the Health Committee report confirms this—that the new contract provides a disincentive to do that work, and the trend has continued with a vengeance since its introduction. In its conclusions, the Select Committee highlighted its concerns, particularly with regard to the loss of complex work, about the quality of dental care that patients who rely on the NHS receive.
There is a related problem: if someone is referred by their usual dentist—in the past, that work would have been done by that dentist—they have to wait again, perhaps in considerable pain. The Select Committee recognised that that was an unsatisfactory situation and that, more often than not, it is appropriate for the work to be done by someone’s own dentist. The point has been made repeatedly, both in the debate and beforehand, that there is no proper incentive for dentists to do preventive work, and the system does not emphasise quality. As I pointed out in an intervention, it is massively unpopular with dentists.
UDAs are a sort of straitjacket that has been imposed on the profession. There is a great deal of evidence of dentists running out of UDAs before the end of the year, so they are left with no paid work to do under the NHS. If ever there was an incentive for someone to leave a system that imposes such a straitjacket, surely that is it. Even worse, dentists who do not reach their UDA target, perhaps because it has been calculated incorrectly, end up having to repay money that has already been paid to them. I have a dedicated NHS dentist in my area who gave up in disgust after he was required to repay a substantial sum because he had not met his target.
There is clear evidence of a shortage of orthodontic work, leading to long delays in many parts of the country. A further problem is poor-quality commissioning. There is accumulating evidence that primary care trusts are not taking advantage of the powers that they have and using those powers to good effect. By not carrying out dental health needs assessments for their areas, they are commissioning not on the basis of need, but on the basis of where dentists happen, by historical accident, to be. In Norfolk dentists have been allocated additional UDAs for the rest of the financial year, but they are reluctant to invest in new facilities and in bringing in extra dentists if they have no guarantee that that will continue, so the UDAs go unused.
There is, however, some evidence of good quality commissioning taking place in some parts of the country. I refer in particular to the Heart of Birmingham PCT. I heard an extremely interesting presentation from Ros Hamburger, the public dental health specialist there. In that primary care trust, the contract has been manipulated to reduce reliance on the UDA for the payment of dentists. Instead, payments are based on quality thresholds and preventive work, adjusting the contract in a constructive and positive way. Time will tell whether it works and whether that lesson can be learned elsewhere, but it is right to point to the fact that good things are going on in some parts of the country.
Concern has been expressed about the allocation of funding around the country and the importance of moving to a needs-based system for the allocation of funds. Many dentists are expected to leave in 2009. That is the expectation in the profession, and I suspect that that fear is driving the Government to get on with the review announced last week.
All that leads me to ask whether that rather Soviet-style commissioning of care, rationed from the centre by an unelected quango, can ever work effectively. It clearly turns dentists off. Too often, they are left frustrated. The Minister shakes her head, but if she talks to dentists, she will find that that is what they say. They are left frustrated by slow, inefficient responses from the primary care trust. As we know, the PCTs have failed to identify where the need is and to allocate UDAs accordingly. The system is not working and the temptation for dentists all too often, not just because of the money, is to escape to a simpler life where they are their own bosses and where they do not have to deal with such a bureaucratic system.
As the Select Committee also recognised, there is a need for fundamental reform—the Chairman referred to it as a fundamental or comprehensive review—of how the system operates.
The right hon. Gentleman is nodding from a sedentary position.
What principles should apply in shaping that reform? First, a set amount of public money is available for dental care, and I suspect that no political party in the Chamber will advocate at the next election a massive increase in that amount. The challenge is to maximise the effectiveness of the money available for NHS dental care so that it improves the nation’s dental health.
I turn to the second principle. I am sure that we all agree that the objective is to achieve access to high-quality dental care for all. Some people achieve that access by paying for it. Ten years ago, our dentist announced that he was going private. We wanted to stay with him, so we reluctantly ended up on a Denplan scheme. I do not like paying it, but I get used to it and ultimately can afford it. Our concern should be for those who cannot. The right hon. Member for West Dorset (Mr. Letwin) said that there is a real problem with low-income people in areas that are generally affluent; they often find that they have hopeless access to NHS care. In rural Norfolk, which is not a particularly affluent area, there is certainly poor access. Our focus should be on those who cannot afford to go private. We must ensure that they get access to high-quality dental care.
The third principle is that we must focus on children’s dental health, because if we get it right during childhood, the chances are that a substantial amount of work will be avoided later in life. Advances such as the use of fluoride in toothpaste and, in some areas, the fluoridisation of water, have had a significant effect in improving dental health. The fourth principle is that—please—we should involve the profession in shaping any reform. If we fail to do that, the reform will not work. We should trial any reform first and we should not go for a big-bang introduction, because that will end in tears.
Despite the Minister’s denials today, the Government appear tacitly to have accepted that the contract is not working as intended. The clear conclusion of the Select Committee is that the contract has not achieved the objectives set at the start. Now there is the opportunity to get it right, and it is important that we do so because many people on low incomes in our country are not getting access to high-quality dental care. We must focus our attention on them.
I am delighted that the Health Select Committee finally took up my suggestion of holding an inquiry into dental services. For a long time, dentistry has been a much neglected area of UK health care. Perhaps that is because people do not generally die from dental decay, although a meeting of the British Dental Association panel the other day showed some alarming results for oral cancer and how dentists can save lives by ensuring that oral cancer is picked up early and treated effectively.
Dental decay is not a death sentence, so it is not regarded as a top priority, certainly among many primary care trusts. However, we ignore dental health at our peril. Oral health is integral to general health. In 2003, the World Health Organisation’s “World Oral Health” report stated:
“The interrelationship between oral health and general health is particularly pronounced among older people. Poor oral health can increase the risks to general health and, with compromised chewing and eating abilities, affect nutritional intake.”
However, good oral health is a major issue not only for older people but for a range of people of all ages. It is particularly a problem for people from deprived backgrounds in terms of pain control, discomfort, and general self-esteem. Having decayed teeth makes a huge difference to the confidence of young and middle-aged people.
Before the new NHS payments system was introduced in April 2006, there was significant confusion and fear about the burden of dental costs, with up to 400 different charges possible and a maximum payment of some £389. The new system has simplified that charging mechanism to three charging bands, with maximum payments almost halved to £198.
I have not seen the figures to prove that, but there are certainly issues with the three bands, and there are perverse incentives for people to store up dental health problems. The Select Committee on Health, of which I am a member, rightly identified some of those problems. The three bands have not been developed well and they need to be looked at again. Simplification of the charging system is vital because someone on a low income needs to know that if they go to a dentist, they can pay the bill. There was also a lot of confusion over whether people were paying for private or NHS treatment. People must be clear about what they are paying for so that they are not encouraged to take up private treatment when they cannot afford it.
I am also pleased that the legacy of the old system whereby dentists provided NHS treatment to young people under 18 only if they treated their parents under a Denplan or other private care scheme has largely gone. It cannot be right to coerce parents to register as private patients as the only way of ensuring that their children get NHS treatment. The Chairman of the Committee rightly pointed out that our witnesses were clear about the fact that that should not be accepted. I understand that the chief dental officer has made it clear that children-only contracts with dentists have no long-term future in terms of PCT commissioning, but some PCTs have maintained them because they are concerned about the shortfall in treatment for children.
The hon. Lady has touched on something that I was going to say, which is a contrary point. My concern is that dentists who have children-only contracts will pull out of the national health service completely and those children will not get the service.
My argument is that it is right to have dentists choosing either private or NHS care. I was very concerned about the case of a constituent who had been in a contract whereby she and her husband were on a Denplan deal, and their children were being treated under the NHS. Through the new PCT commissioning arrangements, the local dentist had said, “Actually your children now have to be under Denplan.” They reluctantly agreed to that and were amazed when, after one of the children had a filling, they were charged £50 on top of the Denplan rates for it. They were absolutely flabbergasted, because they had assumed that the children would be covered in full for all their treatment, but they were not.
There are lots of concerns and we have to come up with a solution. I hope that the review that the Government are conducting will look into how extensive children-only contracts are, whether they can be avoided and whether stopping them in areas where they are creating problems would cause a shortfall in treatment for children, which we must avoid.
I am listening to the hon. Lady with interest. My experience is that if NHS dentists were available, people would go to them. In the circumstances that she is describing, surely it is better that at least the children are on the NHS than that nobody should be.
My point is that the Government’s priority must be to ensure that everyone who wants it should have access to NHS dentistry. I therefore very much welcome the independent review of NHS dentistry that the Health Secretary announced last week and look forward to the results of the study that is due to be published next spring.
It is clear that there are still huge variations in access throughout the country. We need to learn from areas where good practice has become embedded. Ten years ago, I worked closely with the dental department of North Staffordshire hospital to encourage forward-looking dentists to relocate to north Staffordshire. I was delighted to welcome Jonathan Webb to Leek, where, after quite a struggle, he opened a new NHS dental surgery in Regent street. I was also delighted to perform the opening ceremony and to sign up as his first NHS patient.
I think that Mr. Webb thought, misguidedly, that the practice would be a nice little venture and that he could coast through to retirement. However, 10 years on, and with lots of encouragement from North Staffordshire PCT, Mr. Webb now has more than 20,000 patients. His practice, which is called TLC 4 Smiles, has relocated in Leek and now includes eight surgeries, four full-time dentists, one part-time dentist and three full-time hygienists and therapists. The practice is 96 per cent. NHS, with just a small amount of private cosmetic work.
Mr. Webb was one of the pioneers of working with qualified Polish dentists to help plug the gaps in NHS dentists that we experienced, both in 2006 and before. He has pointed out to me—normally when I have had my mouth wide open so I could not respond—that the training that those Polish dentists have received does not fully equip them for the different culture and tasks that they face in the UK. It is not that they are not properly qualified; it is that things are a bit different in the UK. Mr. Webb needed to put in extra work with those dentists, but the new contract did not compensate him for his efforts—efforts that PCTs should recognise as essential to ensuring that dentists are delivering high-quality dental care in an NHS service that is of the appropriate standard.
In October this year—some 10 years on—in Biddulph, on the other side of my constituency, I was delighted to perform yet another official opening ceremony of an NHS dental surgery. It took me three years to persuade my local primary care trust of the urgent need for such a surgery, because it did not figure as a high priority for the PCT. I believe that that is a problem countrywide. Once it was established that the need was there, however, the PCT was very supportive of the dentists, Mr. and Mrs. Keen—who, as far as I know, are not related to the Under-Secretary of State for Health, my hon. Friend the Member for Brentford and Isleworth (Ann Keen).
The PCT helped to secure the right building for Mr. and Mrs. Keen—just behind the high street—and the right contract, so that Biddulph people, who had been denied access to NHS dentistry for so long, would be prioritised as patients in that surgery. We avoided the long queues around the block by directing applications through the PCT, but that has not halted the expansion of the practice. Although it has been open for just three months, it is already recruiting an additional dentist, and has the capacity to develop three more surgeries.
This is a young dental team who have enthusiastically embraced NHS dentistry and have the passion that will allow them to take on the challenge of huge inequalities in oral health in the town of Biddulph, which is an old mining town. That is not to say, however, that there are not significant issues relating to the NHS dental contract that must be addressed. It is widely recognised that PCTs are not renowned for their commissioning skills. In general, they seem to lack the necessary analytical and planning skills to carry out that role effectively.
With the commissioning of dentistry coming at a time of PCT mergers, dentistry clearly did not receive the priority that it deserved. As a result, access to NHS dentistry has deteriorated rather than improving with the new contract. But at least, through the GDS contract, we can now address the uneven and inequitable distribution of NHS general dental services. In the past, there was no mechanism to allow that. The people of Biddulph either had to travel out of the town, or had to sign up for private dental treatment through Denplan. Most of them—unlike the hon. Member for North Norfolk (Norman Lamb)—could not afford that. They were at the mercy of the decisions made by their local dental practitioners, who could decide for themselves how much NHS and how much private treatment they provided.
That all changed when the PCT awarded the NHS contract to Mr. and Mrs. Keen. Not surprisingly, many Biddulph people are choosing to move to NHS treatment in their state-of-the-art surgery, because they are now empowered to do so. I am pleased that the Department of Health is belatedly offering a programme of work to PCTs to encourage them to commission more effectively, and is reviewing its dental public health work force so that it has the skills to assess the need for better NHS facilities. That should help PCTs to get their act together.
As for the NHS dental contract itself, there is a real need for a review of aspects of the reforms. It should be established, for instance, whether the units of dental activity so hated by dentists can allow a proper focus on preventive care and cosmetic treatment. Now that the dental health of our young people is so much better, there is clearly much less need for the drill-and-fill approach. They demand much better cosmetic and orthodontic treatment, and we should focus on that. We must also look again at the payment bands to ensure that patients are not encouraged to delay visits to their dentists and store up dental problems in order to save money under the new charging system. We must ensure that the UDA system is used flexibly enough to allow dentists to get off the drill-and-fill treadmill and to address the wider public health agenda. That is what primary care trusts were set up to do, and they must do it in the area of dentistry as well as in other areas of public health.
PCTs must make more use of specialists and consultants in dental public health and carry out more effective oral health needs assessments. They must work more closely with their dentists to ensure that they are addressing the real oral health needs of their populations. They have to address the other health needs of their populations; why are they not doing it in relation to oral health? And where are the strategic health authorities in all this? They seem to have completely reneged on their responsibility to manage the dentistry performance of PCTs. The Department of Health needs to investigate with the profession whether the quality and outcomes framework-style system that GPs have would help to improve the dental health of patients.
I welcome the closer working relationship that appears to be emerging between the Department and dentists. I also welcome the top priority that the Government are giving to improving access to dentistry, the increased £2 billion funding for dentistry and the announcement of further action in the new year to improve access. I am sure that the Committee will look carefully at those new measures.
I want to finish by thanking the Health Secretary for the £14 million a year for local health authorities to support fluoridation schemes in areas of poor dental health. That is the single most effective measure to reduce oral health inequalities, and this provision demonstrates that we have a Government who are committed to doing that. I would also like to congratulate the South Central strategic health authority on being the first SHA to undertake a fluoridation consultation under the Water Act 2003. I wish it every success in its initiative, and I hope that the Government will give it all the support that it needs. Dental health in the United Kingdom is improving, but far more needs to be done through fluoridation and through working with the profession to ensure that we make the best of the health professionals working in dentistry.
I am interested that the hon. Lady mentioned fluoridation. Is she aware that most of the evidence is showing a case for fluoride relates to its use in a topical sense, and that the evidence base for adding fluoride to the water supply is very limited? Some countries have actually removed fluoride from the water. I think that her enthusiasm is slightly misplaced, because the improvements in dental health in areas where fluoride has been added to the water have not been as great as had been expected.
That is absolute rubbish, I am afraid. That is not the case at all. I benefited greatly from being brought up in an area where there was a huge amount of fluoride in the water; it made a huge difference to our oral health. If we compare the situation in fluoridated Birmingham with that of Manchester, we see that the evidence demonstrates the benefits of adding fluoride to the water.
I am going to try to rush through my speech, and to add to, rather than repeat, the points that have already been made. In his introduction, the Chairman of the Committee said that there were three drivers or criteria in the original contract and that, from the point of view of the dental patient and of the profession, it had certainly failed. We do not have a more preventive approach now, dentists are on a treadmill as they have never been before, and there has been a transformation, in that many dentists have moved out and many thousands more wish to do so. We really need to find a system that will encourage many of those dentists who have gone totally private to come back, at least in part. The difficulty with that, of course, is the treadmill I mentioned and the avalanche hanging over every dentist with UDAs—units of dental activity—and the UDA contract.
The difficulties of the UDA system—for example, the issue of whether to do root canal treatments or extractions—have already been touched on. A root canal on a molar tooth will take about 90 minutes, if the dentist is practised at it and if they use very expensive nickel-titanium reamers, which must be thrown away. In contrast, an extraction generally takes 15 minutes and the forceps are retained, which provides quite an incentive to the dentist, sadly.
What really worries me is that according to NHS information centres, in excess of 1.2 million people are no longer able to access the national health service. That applies to about a million adults and, even more appallingly, about 200,000 children. That has got to be overcome. The hon. Member for North Norfolk (Norman Lamb) mentioned that it is anticipated that many dentists will leave next year. The only benefit of the credit crunch that I can see is that they might be tempted to stay.
Let me move on to two other issues: the development of dentistry and the patient, who has not really been mentioned so far. Over the last 10 or perhaps 12 years, there have been dramatic changes in dentistry, mostly positive and with most gains predominantly experienced in the western world, by which I mean the United States, Canada, Australia, New Zealand, parts of Europe and to some degree in the UK, but outside the national health service.
Mention was made of fluoridation, and I would like to re-emphasise the point made by the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) and to contradict the intervention from the hon. Member for Romsey (Sandra Gidley). Fluoridation is heavy in many of the countries I mentioned. It has made a huge improvement to the diminution of dental decay and without the detrimental health side-effects that were predicted by a few and were proclaimed by scaremongering detractors. Let me take a few moments to explain more fully.
When I was a kid in New Zealand, dental schools provided dental nurses to work in state schools—New Zealand’s schools are almost entirely state schools—and there were three dental schools. With fluoride in 60, 70 or 80 per cent. of the country’s water supplies, those dental schools have been diminished to one. There are more schools, more children and more teeth, but there is less work. Instead of having three dental schools, as I said, New Zealand now has one, and the girls who come out of it who go to treat the children spend 50 per cent. of their time teaching prevention and 50 per cent. on actual treatment. Only a sixth of the number of children need treatment now, yet the effect of fluoride in the water supply has a lesser effect on children than on adults.
Let me come back to the changes in dentistry. Progress on dental materials and techniques has been dramatic. Dentistry provides very successful implants, new composite fillings, new all-porcelain crowns, porcelain inlays, protective porcelain inlays/overlays and new materials for dentures, many of which can be and often are retained and stabilised by implants. There are beautiful, natural-looking veneers, protective overlay veneers, successful dental bleaching methods, dramatic new orthodontic techniques producing quite superb results and improved oral surgery techniques. Protection against cancer is also better if patients go to the dentist.
We need to recognise that dentists are taught all those techniques in dental schools, but they are not available on the national health. I do not think that they should all be available on the national health. NHS dentistry should be driven predominantly as a health service for oral conditions. I am sorry to disagree somewhat with the hon. Member for Staffordshire, Moorlands, but although cosmetics are vital, the NHS should have no role in paying for them, except in exceptional circumstances, which do arise. A young girl who comes in with stained upper and lower anterior teeth should have bleaching available to her on the national health service. As the system works now, however, she will get six or 12 veneers where the teeth are stripped down via a high-speed burr and damaged for ever. The bleaching, however, would leave her with her natural teeth and make a dramatic change. We need to think about that.
One negative, which I touched on during Question Time earlier and which the hon. Member for Staffordshire, Moorlands also mentioned, is oral cancer. It is distressing to see that the incidence of oral cancer has got much worse. There are more deaths, and the cure and detection rates are diminishing. A large degree of that relates to the fact that patients are no longer being seen.
The chief dental officer was reported in the press as claiming that dentists were milking the system by asking patients to return for annual examinations. I hope that that is wrong, because the prevalence of oral cancer, particularly in deprived areas, means that it is vital that patients are seen and checked for that cancer regularly. I am referring to young people as well as those whom we normally expect to get cancer as they get on. Another point needs to be made: if a decayed molar, for example, needs to be restored, it can be restored by amalgam, composite, gold, porcelain bonded to gold or porcelain bonded to porcelain, but whatever is used, that is one fewer decayed tooth among the national population.
We need to work to a system that introduces the private sector working alongside the NHS. I am a great supporter of NHS dentistry. I spent a lot of my career, in the early days, working in east London. We need NHS dentistry, but we need the dentists to be there for it. Taking away the drive to force them out, which the UDA targets system has introduced, might give us the chance to persuade some of those dentists to come back.
I have a few more points to make. I hope that the Minister will think carefully when she looks at the new review. I shall cut out most of what I wanted to say and put a few basic points to her. We need to move on fluoridation. I have touched on that. Australia, New Zealand, Canada, a number of European countries and most of the states of the United States have dramatically better dental health than the UK, and that is entirely down to fluoride.
May I suggest to the Minister that she needs to recognise a few basics? Patients need choice and they need that choice presented to them by well-trained dentists. The dentists need the appropriate equipment and materials. They need the time to produce quality work, including prevention, which the UDA targets system does not allow them. The measure of success should be the number of dentists prepared to offer core dental health treatment on the national health, not necessarily the number of people using the NHS, because that choice must be the patient’s choice.
I am delighted to take part in the debate. My remarks will be brief, because they have to be brief. I do not want to have a coughing fit. Like most Members who are present, I wish to keep my sanity and my health for the Christmas period.
As always, it is a delight to follow the hon. Member for Mole Valley (Sir Paul Beresford), who knows much more about dentistry than I could ever want to know about it. My impression of dentistry is one of a profession going through quite dramatic change—structural change, changes to training and changes in how the profession is funded.
My views have been formed in two particular ways. First, I have two quite close friends who are former dentists and are horrified at some of the changes that have taken place in the profession. They see themselves as good, old-fashioned NHS dentists and not in their wildest imagination could they think that, once they had left the profession, it would go from being almost comprehensively NHS to being much more dependent on the private sector.
My second point of impact was a meeting with dentists in the Stroud area some years ago. It is the only meeting that I have had with dentists collectively because it was such a shocking experience; it is seared on my memory. This meeting pre-empted the new contract, and virtually to a person, the dentists made it absolutely clear that whatever was in the new contract introduced by the Government, it would be the baseline, and that they would negotiate on top of it. They did not see the British Dental Association as representing them; they saw themselves, more or less, as private contractors in a marketplace who would charge whatever the patient would be prepared to spend.
That was a pretty depressing experience, because I went to the meeting to try to bring those people back into the NHS, and I learned very quickly that they were not very interested in coming back to the NHS, whatever was in the contract. This is why my constituency is so unusual, as I said when I intervened on my right hon. Friend the Member for Rother Valley (Mr. Barron) earlier. In the south of my constituency, all the dentists are NHS dentists. I have to explain to my constituents that if they live in the Stroud area, they ain’t going to get an NHS dentist, but if they live in the south of the constituency, they will—unless they choose to cross over. It is a bizarre situation, and it is just like having the Berlin wall. I wish we could overcome that problem.
It is grossly unfair that those in the north of my constituency do not have access to NHS dentistry, and dentists who operate in the south, such as Steve Clarke, who runs a big training practice, are able to make money out of the NHS. He is supportive of the NHS, and provides quality care on the NHS. I know that because I send to his practice a lot of constituents who moan to me about not being able to access an NHS dentists. Something peculiar is going on, perhaps because of the wider changes in dentistry.
The problem with the PCT is that it measures access to NHS dentistry across my whole area, so the picture looks quite good. Of course, it depends which part of the area people live in, and those in the northern part of my constituency are strongly disadvantaged. I had that argument with the PCT, which is now putting resources into Cheltenham, Tewkesbury and the Forest of Dean, having previously put resources into Gloucester. I keep asking for resources to be put into Stroud, and it looks at the figures and says, “You’ve got a good number of NHS dentists in Stroud”. However, that is the case only on a locational basis.
I shall end on the issue of fairness and equity. I hope that the Government will consider that issue in the investigation that they have launched. I could go into all sorts of questions of fairness and equity with regard to orthodontistry, where those who seem to be in the right place at the right time get free treatment and other people do not. I also feel strongly about the question of what people get for what they pay. We have all dealt with difficult constituency issues where people have felt that they paid money when they were not sure what treatment they would receive. That is one of the problems of not underpinning dentistry more widely. I could speak about fluoridation, but I am clearly not among friends because I am a long-time opponent of fluoridation of the water supply, so I will say no more about it.
In conclusion, I hope that there is a comprehensive investigation of dentistry in this country. I accept that we have not got it right, but that has been true for a long time, and we owe it to people in those deserts where there is no NHS treatment to provide greater fairness and equity. If this investigation can do that, it will have come not a second too early; too many people have lost out, and continue to lose out, which is completely unfair in this day and age.
It has been a short, but excellent debate, and I apologise to hon. Members who have not had the time that they deserved— perhaps having three statements at the start of the day did not help. I know that the Chairman of the Select Committee raised that during a point of order earlier.
I shall try to touch on some of the points raised by hon. Members this evening, starting with the Chairman of the Select Committee. I was a very proud member of the Select Committee, and we heard earlier that there were calls for an inquiry into dentistry some time ago. I agree that there were such calls, and I praise Committee members for calling for that. I also praise the Committee for the quality of the recent report, which was very fair. It is scathing in places, but it also offers forward-thinking and innovative ideas on how the contract could be progressed. I do not agree with parts of the report, however, and Her Majesty’s Opposition also have some ideas on how we could make progress, to which I will return shortly.
I was interested to hear the Chairman of the Select Committee, the right hon. Member for Rother Valley (Mr. Barron), refer to his dentist, because unless he is having treatment at the moment, he has not got a dentist as this contract does not involve registration. Therefore, unless someone is undergoing treatment, they do not have a dentist. I would have liked that to have been made clear in the report; I do not think it is generally known by the public, but it is a fundamental point of the contract, which was imposed on dentists in 2006, that people are not registered unless they are actually having treatment. That is a very important issue, because if we were to go out on to the high streets of this country and ask members of the public who rely on NHS dentistry whether or not they are registered with a dentist, the vast majority would still say they were even though they are not. They might turn up at the dentist and say, “I need treatment”, but that dentist might have already run out of UDAs; that dentist might already have said, “I can’t treat any more patients this year.” Those are the circumstances when some of the problems are occurring.
Does my hon. Friend not agree that one of the most powerful ways of incentivising dentists is to register patients, as they would then have an incentive to build up a list of people with good oral health, which would ultimately reduce their work load? That aspect of incentivisation has been completely missed in this new contract.
I completely agree with my hon. Friend and I will come on to that point later. I do not see how we can have preventive dentistry without having some form of capitation and registration. I think the right hon. Member for Rother Valley alluded to that in his speech.
The report digs deeply into what NHS dentistry is capable of doing in this country today. Should we actually give up on parts of the country that rely on NHS dentistry? There is a postcode lottery; it is a fact that in some parts of the country that I have visited there is a plethora of NHS dentistry. In Newcastle and the north-east there is almost no private dentistry, whereas in other parts of this country—I am referring to England now—there is almost no NHS dentistry. This is a national health service, however, and that is partly—although not completely—why this contract was created. It was already in difficulties before, which is why the Government, in good faith, tried to bring in a contract that would help, but instead it has made the situation worse.
When the Select Committee took its evidence, about 900,000 people who had had NHS dentistry had lost it. The latest figure is 1.2 million. That means there are now 3 million people in this country who need to rely on NHS dentistry but cannot access it. As the economic climate becomes increasingly difficult, more people will need to rely on NHS dentistry. I listened carefully to the comments of the hon. Member for North Norfolk (Norman Lamb) when he said he is in Denplan. A lot of people who are in Denplan will not be able to continue to afford to make those monthly payments should they lose or change their job. The demands on NHS dentistry will, therefore, increase.
We must look at what the Government might propose in the review. My personal view is that this contract is a damaged brand, with its language of UDAs. From meeting dentists around the country, it is clear that they are not confident that the contract can provide for the British people the sort of dentistry we expect in the 21st century. I therefore look forward to the review with a degree of scepticism in terms of where the contract can go.
The panel undertaking the review has been welcomed, but I note that it contains no community dentist and so some dentists will be wondering about its composition. It seems to be made up of a couple of academics, somebody who apparently wants to be the chief dental officer one day and a failed commissioner who commissioned dental services without doing a needs assessment. Does that augur well for the future?
No, it does not. In fact, it resembles something similar to what happened when this contract was imposed in 2006.
Lots of hon. Members have discussed the importance of proper continuity and discussion with the professionals in the dentistry profession. As has been mentioned, no one body represents the whole of dentistry and the dentistry profession—perhaps it would be better for the dentists if they did have one body that could stand up and fight their corner. I am very concerned that there appears to be a lack of engagement between Ministers and the professionals.
I did not intend to upset the Minister at Health questions earlier today, but I clearly did so. Let me therefore go back for a second to where we were. I asked why no Minister went to the British Dental Association conference in Manchester this year to speak on behalf of the Government, given that the contract is so controversial within the profession. The Liberal Democrat spokesman was there, I was there and so, too, was the chief dental officer. He is a civil servant—he is not a Minister of the Crown and he is not elected; he is appointed by the Secretary of State for Health—and it is fundamentally unfair that a civil servant is there to represent the mistakes and problems that the Government have got themselves into on dentistry. Both the Liberal Democrat spokesman and I refused to debate with him in public, although I would have been more than happy to have debated with a Minister.
I understand that the Minister was busy that day, but I was with a Health Minister on the train to Manchester—the hon. Member for Bury, South (Mr. Lewis) was a Health Minister at the time. I said to him, “Fantastic, you are obviously coming to the BDA conference to represent the Government.” He replied, “No, I am going home.” The only person who was representing the Government was the chief dental officer, and that was fundamentally unfair on him, because he was put in a position that only an elected Minister should be put in.
As the process goes on and as this contract is reviewed, I am very concerned about whether the Government will have the courage to admit how much of the contract they have got wrong and how much of it has affected people in this country. We see reports in the press of people extracting their teeth with pliers and people going to the pharmacists to get do-it-yourself fillings, which are available in most pharmacists in this country, because of the lack of NHS dentistry. That might be down to fear; it may not be fact, but the perception of a lack of such dentistry exists.
We have discussed the UDAs at length today. It cannot be right that in band 2 up to six fillings or one root canal or an extraction can be carried out. The obvious situation to consider is that of a dentist who is under pressure. What is such a dentist going to do? I hope that all dentists do what is right for the patient, but given that they are looking at the UDA rather than at the outcomes, it is obvious that, at times, real problems will arise. Many dentists have said that they are not willing to work under this contract and they have walked away, and we have to encourage them to come back.
One area of the report that concerned me—this issue came up when I was on the Select Committee and we were examining charging—was the bit dealing with dentists who say “I will keep your children on only if you take me on as a private dentist.” Such an approach is fundamentally wrong, because it is blackmailing people by saying that they can have NHS dentistry only if they pay for a private insurance plan or they pay as they go. I think that we have to accept the fact that, there is nothing because so few dentists have been working in some parts of this country, at this stage wrong with a dentist who is willing to take on a child, with no strings attached, under an NHS contract. That is better than nothing, and we need to examine such an approach. I know that the Select Committee was concerned about people being pressurised into certain things. That is fundamentally wrong, but if we can encourage private dentists to come back into NHS dentistry and take children on without any strings attached, that has to be good. On average, children have 1.5 fillings or extractions by the age of five, so the oral hygiene of our youngsters is going in the wrong direction. If we do not address children’s oral health problems, that will have an effect as they get older. It is therefore vital to address the issue of oral health in the young.
We have to encourage more dentists to come back into NHS dentistry. We have to look seriously at the court case earlier this week, which the Government lost on appeal when a dentist objected to the fact that, whether he had performed well or poorly, the PCT could remove his contract at any time. The courts ruled that that was wrong. We should extend the length of contracts, so that dentists can invest in their practices. PCTs do not pay for surgeries or equipment: the investment has to be made by the dentists themselves. There must also be a presumption that should a dentist want to move on or retire, they have the right to sell on the goodwill in their contract. If we want dentists to come back into the NHS, or young dentists coming out of training schools—I have visited them and they are fantastic—to come into the NHS, we must give them the confidence to do so, especially in this difficult economic climate.
I agree completely with the Committee: if we want to understand what is happening to dental hygiene in this country, we have to have registration and a per capita system; otherwise, we will not have a national health service. Instead, we will have the postcode lottery that has put NHS dentistry into crisis today. I welcome the report and I congratulate the Committee on it.
I welcome the opportunity to speak on the important subject of dental services. I will do my best in the time available to respond to the points made in the debate. I start with my right hon. Friend the Member for Rother Valley (Mr. Barron), who made his contribution as Chairman of the Committee. He mentioned training and how it affects dentists in practice. The review by Professor Jimmy Steele, which we welcome, will cover those areas.
My hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) was an absolute trouper during her speech, and we certainly witnessed her commitment to dentistry this evening. I congratulate TLC 4 Smiles, which obviously gave her the courage and commitment to continue. I thank her for her contribution and the work that she and other hon. Members have done to push dentistry to the forefront.
Many hon. Members talked about the importance of oral health care, and the hon. Member for Mole Valley (Sir Paul Beresford) raised the important issue of oral cancer. I am sure that he would agree that the Government’s approach to children and the purchase of tobacco, and the discouragement of cigarette smoking, is important, because reducing smoking is one of the most important elements of addressing oral cancer.
We should consider all aspects of smoking cessation.
People’s oral health has changed, and dentistry needed to change to reflect that. Dentists themselves recognised that the old contract was a so-called “drill and fill treadmill”. Under that contract, dentists themselves chose where to set up in practice, they chose how much NHS work to do, and if they chose to leave the NHS, there was nothing that the local NHS could do to protect local access. As the Committee and many Members have pointed out, it is access that is important. Our new contracts give local primary care trusts the power to decide what services they need. Local PCTs contract with dentists to provide those services.
If the hon. Gentleman will let me proceed with the points that I want to make, he will see that some aspects of the contract have without question improved things for patients. There are difficulties, which we have recognised.
If a dentist decides to leave the NHS, the PCT can commission new services to maintain and grow NHS access. The fundamental principles of the new dental contract are right. It allows prevention as well as traditional dental treatment and allows the local NHS to commission local services to meet local needs.
Will the Minister explain why it takes so long to commission new services? It takes more than a year to do so locally. At the beginning of the process, the commissioners did not even know how many dentists the UDAs would commission. The level of knowledge was that low. What is being done to address that and to speed up the process so that people do not lose out?
The hon. Lady will be aware that those on her Front Bench have said how good the situation is in certain parts of the country, and particularly in Birmingham. There are many good practices that can be considered and we want to encourage the commissioners to do that.
The new contract was a radical change. In its report, the Health Committee identified concerns about the way in which it works. That is why we have asked an independent team, led by Professor Jimmy Steele of Newcastle university, to carry out the review. The review will help us to determine how we can use local commissioning to increase access to NHS dentists and improve the quality of services.
If the hon. Gentleman would like to give me information about where that is happening, I would be very happy to look at it. PCTs have the money ring-fenced until 2011 and they are encouraged. We have to congratulate many dentists and PCTs on the work that they have done to see that the contract works to the benefit of all our constituents and all patients who require dental services.
The review will help us to determine how we can use local commissioning to increase access to NHS dentists and to improve the quality of services. It will investigate whether the decline in complex treatment is consistent with the needs of patients. It will help us to understand what more we can do to encourage prevention and reduce inequalities in oral health. The review will look forward to help us begin to plan the dental services we will need to meet peoples’ needs in the future.
Will the Minister consider putting a dentist on the review panel? May I also briefly bring her back to the key issue of access, which I am not sure that she has quite covered? I remind her that, in 2007, the Department said that the key test of its reforms would be
“their ability to support improved patient access”.
Despite that, 20,000 fewer patients are accessing NHS dentistry in Leeds, and 900,000 fewer have done so across the country in the past two years. How can the Minister possibly defend the contract in terms of access? When will she accept that it has failed in that aim and that the review must fundamentally address that point?
I will not accept that at all. Many Members have said to me, both inside and outside the Chamber, that dental care has improved. In fairness, hon. Members need to recognise that the problems of dental access date back to the early 1990s. The problem had been growing for many years and culminated in the famous queue in Scarborough. That was probably the first time that the nation’s attention was focused on a system that was badly in need of reform.
I ask the House to remember that the queue in Scarborough occurred in January 2004, more than two years before we introduced our contract reforms. Indeed, it demonstrated the need for them. On top of the problems with the old contract that I have already described, we had a shortage of dentists. We have now opened two new dental schools and increased the total number of dental undergraduates in training by 25 per cent. The first of those new graduates will leave dental school next year, and the recurring increase in dental graduates will transform the availability of dentists. I hope that hon. Members of all parties will listen to what I am saying and be honest enough to accept that, although a decision was taken under the previous Administration to close two dental schools, we have now put that right. Does the hon. Member for Hemel Hempstead (Mike Penning) want to intervene to accept that the Conservatives closed the schools, and that we have put that right?
Does the Minister accept that those closures were predicated on projections about the reduction in dental care made by the profession at the time? I am sure that she likes to adhere to the evidence base, so she will know that many dentists, because of the changes to dentistry, have been drawn to cosmetic dental surgery. That was not expected, and she should acknowledge that both those factors are part of the problem that we face today. Will she acknowledge that it is wrong of her to lay into previous Governments for adhering to the evidence base that underpinned those closures?
The fact remains that two dental schools were closed under the previous Administration, and that they have been opened by the present Government.
As I said, the new contract is based on dental services locally commissioned by PCTs to meet the needs of people seeking care in their areas. We have shown our commitment to increasing access to NHS dental services by increased investment of 11 per cent. in the current year. Next year, we will invest a further 8.5 per cent., for a total increase of £385 million over the two years.
We have reinforced that commitment in the NHS operating framework for 2009 by stating that PCTs should aim to provide access for anyone who seeks help in accessing NHS dentistry. In 2006, a significant number of dentists chose not to accept their new contracts. The level of service that they represented was 3.6 per cent. and, in patient terms, that was the equivalent of services for around 1 million patients. This loss is still reflected in the 24-month access data published by the information centre.
The number of dentists providing NHS treatment in 2007-08 increased by 655. So although the dentists who refused the new contracts in 2006 were lost, the number of dentists has started to grow again. The number of courses of treatment delivered in 2007-08 was 2.7 per cent. higher than in 2006-07, and the figures that the information centre published in November show that courses of treatment delivered in the first quarter of the current year are on course to be 3 per cent. higher.
Looking forward, the figures show that PCTs this year have commissioned more dental services than ever. This increase in activity will show in the access data very soon, but locally it is already visible in the form of new practices opening and of existing contracts being grown.
Despite the national figures, many PCTs are already ahead of the game. Some 30 per cent. of PCTs have actually increased dental access from March 2006. Some have done very well. The Isle of Wight, for example, has increased dental access by 24 per cent., while both the Medway and the Telford and Wrekin PCTs have increased it by 17 per cent. Those figures hardly support the view that the new contract somehow causes access to reduce, but I accept that other PCTs need to move further and faster on access. The new commitment in the operating framework gives PCTs a clear signal as to the priority that we place on access.
In my constituency, dentists have developed and run an outreach project to apply fluoride varnishes to children’s teeth to protect them from decay. At the same time, they have put the parents in touch with local dental services. There are many other examples around the country of similar initiatives that can be carried out as part of the contract.
The Select Committee was told to expect a mass exodus from the NHS in April 2009. We do not see any sign of that, although some practices that previously have employed a restricted contract approach to their NHS commitment may find that the PCT proposes a contract value that more properly reflects its commitment to the NHS. Such practices tend to offer child-only contracts, or contracts for exempt patients only.
In conclusion, the past three or four years have been turbulent and unsettling. We now need to move forward with the profession, using the increased investment and larger work force as part of a greater focus on providing NHS dental services that we can be proud of.
I am proud of our NHS dentists; they work hard. They have worked hard for all of us, with a difficult contract. We will make sure that the evidence from our review, and the evidence in the Health Committee report, which my Department welcomes, will continue to strengthen access to dentistry in all our constituencies.
Debate interrupted, and Question deferred (Standing Order No. 54(4)).
The Speaker put the deferred Questions (Standing Order No. 54(5)).
Vote on account, 2009-10
Office of Gas and Electricity Markets
That, for the year ending with 31 March 2010, for expenditure by the Office of Gas and Electricity Markets—
(1) resources, not exceeding £315,000, be authorised, on account, for use as set out in HC 1039 of Session 2007-08, and
(2) a sum, not exceeding £700,000, be granted to Her Majesty out of the Consolidated Fund, on account, to meet the costs as so set out.
Department of Health
That, for the year ending with 31 March 2010, for expenditure by the Department of Health—
(1) resources, not exceeding £33,990,717,000, be authorised, on account, for use as set out in HC 1039 of Session 2007-08, and
(2) a sum, not exceeding £33,474,467,000, be granted to Her Majesty out of theConsolidated Fund, on account, to meet the costs as so set out.
The Speaker then put the Questions on the outstanding Estimates (Standing Order No. 55).
Supplementary Estimates, 2008-09
That, for the year ending with 31 March 2009—
(1) further resources, not exceeding £7,425,726,000, be authorised for use for defence and civil services as set out in HC 1163 of Session 2007-08,
(2) a further sum, not exceeding £32,112,484,000, be granted to Her Majesty out of the Consolidated Fund, to meet the costs of defence and civil services as so set out, and
(3) limits as so set out be set on appropriations in aid.— (Ian Lucas.)
Estimates, 2009-10 (Vote on Account)
That, for the year ending with 31 March 2010—
(1) resources, not exceeding £168,435,164,000, be authorised, on account, for use for defence and civil services as set out in HC 1039, HC 1136, HC 1160 and HC 1171, of Session 2007-08, and
(2) a sum, not exceeding £160,963,839,000, be granted to Her Majesty out of the Consolidated Fund, on account, to meet the costs of defence and civil services as so set out.—(Ian Lucas.)
Ordered, That a Bill be brought in upon the foregoing Resolutions;
That the Chairman of Ways and Means, Mr. Chancellor of the Exchequer, Yvette Cooper, Mr. Stephen Timms Angela Eagle, Ian Pearson and introduce the Bill.
Consolidated Fund Bill
Presentation and First Reading
Mr. Stephen Timms accordingly presented a Bill to authorise the use of resources for the service of the years ending with 31 March 2009 and 31 March 2010 and to apply certain sums out of the Consolidated Fund to the service of the years ending with 31 March 2009 and 31 March 2010.
Bill read the First time; to be read a Second time tomorrow, and to be printed (Bill 5).
On a point of order, Mr. Speaker, regarding the statement made by Assistant Commissioner Mr. Bob Quick on the entry into the House of Commons and the arrest of my hon. Friend the Member for Ashford (Damian Green). The statement, we are told, recognises parliamentary rights and freedoms, but we are also told that a report exists. I have written to you, asking whether you would be kind enough to demand and/or ask the person who produced the report—Chief Constable Johnston of the British Transport police—to make it available and put it in the House of Commons.
The statement that we have been provided with welcomes the assurance of Chief Constable Ian Johnston
“that the arrests and searches were lawful.”
Irrespective of whether the arrest was lawful, on which I make no comment, the question of whether the searches were lawful is a matter of privilege for the House. The statement asserts that they were lawful, but that is a matter of grave dispute. It is well established that the question of whether a privilege exists is one for the courts. It is for the House to decide whether there has been an infringement. I therefore regard the matter as being within the framework of the complaint of privilege that I have already made to you. I would be grateful if you considered the matter and made appropriate representations, so that we can have a copy of the report; otherwise, there would, I believe, be a breach of privilege.
Perhaps I might reply to the hon. Member for Stone (Mr. Cash). As I came downstairs this evening to take the Chair, I learned of the statement that was made. It is my understanding that the Johnston report will not be published until criminal proceedings are dealt with. Therefore, there has been no publication of the report, and the situation is as it stood this afternoon, when I replied to the hon. Gentleman to say that I was not going to allow a debate.
Further to that statement, if I may, Mr. Speaker. This is very important. The question of whether article 9 of the Bill of Rights provides for the Police and Criminal Evidence Act 1984 to be overridden by that article in proceedings in Parliament is the question before the House. The complaint of privilege that I have made effectively states, as you know, Mr. Speaker, that article 9 overrides PACE in respect of the precincts of the House. That is a matter on which the Standards and Privileges Committee must adjudicate in due course if a motion is passed. I believe that that is the position, if I may say so with respect, Mr. Speaker.
I am grateful, Mr. Speaker. Further to the point of order from my hon. Friend the Member for Stone (Mr. Cash). The final review document by Chief Constable Ian Johnston is a review of the behaviour of the police, contrary to the statement of Assistant Commissioner Quick published this evening, which says:
“As is normal with such reviews, it cannot be published at this time as it relates to an ongoing criminal investigation”.
It does not relate to such an investigation, but to the behaviour of police officers. May I therefore ask you, Mr. Speaker, to reflect—overnight, perhaps—on whether you could consider later in the week, before the House rises for the recess, insisting to the police that the review document, which is now in its final form, be made available to hon. Members?
The hon. Gentleman has almost taken the words out of my mouth. He has raised an important matter, and the hon. Member for Stone has raised a point of order, too. As I have stated, I have just come down to chair proceedings, as is traditional for me, to see the last piece of business out before the evening is over. It is best that I take the points of order that both hon. Gentlemen have raised, consider them overnight, and take advice from my advisers and allow the night’s business to proceed. I promise that I will come back to the House as soon as I possibly can on this matter, and of course that will be before the week is out. I thank the hon. Gentlemen for raising their points of order.