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House of Commons Hansard
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NHS Dentists: Cumbria
03 July 2019
Volume 662

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I beg to move,

That this House has considered the provision of NHS dentists in Cumbria.

It is a pleasure to serve under your chairmanship, Sir David. I am grateful for the opportunity to raise an issue of enormous importance to my constituents and many others around Cumbria.

NHS dentistry in Cumbria has reached breaking point. More than half of all adults in our county have not had access to an NHS dentist in the last two years, while one in three of our children does not even have a place with an NHS dentist. In rural areas such as ours, lack of access to an NHS dentist results in families having to make ludicrously long journeys to reach the nearest surgery with an available NHS place. Often, people are not able to make, and simply cannot afford, those journeys for a simple check-up.

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The hon. Gentleman refers to his constituency, but the problems occur across the United Kingdom of Great Britain and Northern Ireland. Does he agree that the lack of dentists in rural areas is incredibly disconcerting? Perhaps we need to look at bigger incentives for those willing to open a rural practice, and incentivise those training in dental surgery, since one in five has to wait three months to have dental surgery. In other words, a rural strategy is needed.

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The hon. Gentleman makes a good point; in a moment I will come to some answers to those problems. The challenge is especially acute in rural communities when it comes to attracting and retaining dentists to work in NHS practices in places that are relatively close to people’s homes.

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I congratulate the hon. Gentleman on securing this debate on all our behalves. The problem affects not just rural areas but more remote urban areas such as Barrow. Does he share my huge concern that people in Barrow face a 90-mile trip to Whitehaven if they want access to a new NHS dentist? That is the longest trip in England, for a town where more a third of young people suffer tooth decay, compared with 5% in more affluent areas.

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The hon. Gentleman makes an excellent point, which I will come to. He is absolutely right that the distance from the nearest available treatment affects urban as well as rural areas. It is a problem across the country that relates specifically to the NHS dental contract, which I will come to in a moment.

According to the most recent data available, taking a child living in Windermere to their nearest NHS dentist will involve a 60-mile round trip to Morecambe in Lancashire. That will mean a three to four-hour journey by public transport, with multiple changes. However, poor signposting by the NHS—it was not easy to decipher—means that that place is not obviously available. The nearest place advertising for new child NHS patients is in Appleby, which is an 87-mile round trip—two hours in the car or a five to six-hour round trip by public transport. It was only with the help of the BDA that we managed to identify availability at the far-distant yet ever so slightly closer practice in Morecambe.

I am sure hon. Members will agree that this is beyond ridiculous. NHS dentistry is a public service. It should not take scouring the internet forensically with a fine-toothed comb and with the expert help of a national professional body to find a space for a child with an NHS dentist. That space has already been paid for through our taxes. Let us imagine for a moment the outrage if it were similarly impossible for people to get access to a GP.

For adults, the situation in Cumbria is even worse. I was appalled to discover that the nearest practice with available NHS provision for a new adult patient in Windermere involves a 98-mile round trip by car to Wigton—a six-hour round trip by public transport, involving three different trains and bus rides. The nearest practice that is adverting is even further away and involves a 104-mile trip, there and back, to Alston, taking over six hours by public transport. After that, the next option listed involved going 123 miles there and back to Blackpool.

Despite those obstacles, families in our communities are still trying to secure places at dental practices but are refused. In Sedbergh, Windermere, Grange, Ambleside and Kendal, dentists are working to their full capacity and even beyond, and are doing a brilliant job, but they simply do not have the numbers or the funding to meet demand. The Government have, cleverly or accidentally, dodged confronting the extent of the problem by doing away with official waiting lists. For the last six years, the NHS has held no waiting lists locally or nationally, and patients cannot depend on their clinical commissioning group or NHS England to support them in their quest to find a dentist who will treat them or their children. Will the Minister rectify that and ensure that reliable and up-to-date waiting lists are kept from now on?

We took the matter into our own hands locally. The Westmorland Gazette and I rang round our local dental surgeries to see whether there was availability, and found that in Kendal, not one of the 10 dental practices in our biggest town had a single space available for an NHS patient. Some 33% of new patients tried and failed to get a dentist appointment in the wider Morecambe bay CCG area last year. That is the equivalent of nearly 16,000 people. When we include those already on the books with a dentist, that figure rises to 18,000 people, and they are just the ones who have tried. That is a disgrace, and the situation is only getting worse.

The consequences should not be underestimated. Children across Cumbria have some of the worst dental health in England, with one in three suffering tooth decay by the age of five. In some areas, almost 20% of children under three have tooth decay, and a fifth have tooth decay when they are still toddlers. Often, that does long-term damage to their oral health before they even have the opportunity to make decisions for themselves. If children cannot see a dentist in a regular and timely way, preventable conditions become emergency conditions and the pressure is piled on NHS services, along with all their other responsibilities.

Nationally, tooth decay is the leading reason for hospital admissions among young children, despite being almost entirely preventable. In 2017-18, over 45,000 children were admitted to hospital to have multiple teeth extracted under general anaesthetic because of tooth decay. Children face completely unnecessary pain and distress, and the NHS faces a £36 million annual spend for that dental work. Dentistry in Cumbria is understaffed, underfunded and overstretched. Although this a local problem, it is a symptom of a systematic one, the effects of which are felt right across the country.

The primary cause of the increasing problems with dental access in Cumbria and across England is the way that this Government choose to commission dentistry. The NHS dental contract is completely perverse. Based on units of dental activity, it sets quotas on the number of patients an NHS dentist can see and the number of dental procedures they can perform in any given year. If a dentist delivers more than they have been commissioned to do, not only are they not remunerated for the extra work, but they have to bear the cost of any materials used, any necessary laboratory work or other overheads from their own pockets.

That is not the only issue. Last November, I managed to secure the agreement of health bosses to increase the contracts of local NHS dentists in Kendal, so that they could see and treat more patients. It was great news—I thought. However, when NHS England contacted our local dentists, it found that not one of them was able to take up its offer because, as it told me,

“the practices are already working to capacity within the staffing resources they have available, reporting they are having difficulties recruiting additional staff.”

Additional resources were made available, but there were not the dentists to provide the service for local people.

The problem is at least in part the result of the contract, which pays a set amount for particular types of treatment, in some cases regardless of the number of teeth the dentist is treating. In practice, that means that a dentist gets paid an average of £75 for an entire course of treatment, including six fillings, three extractions and a root canal, but that is not enough to cover their overheads. They get paid exactly the same amount of money for a single filling. That acts as a serious disincentive for dentistry, full stop, but especially in more deprived areas, where evidence shows that more significant treatment is often required.

Perhaps the most significant issue with the current dental contract is that it totally fails to provide any serious recognition or budget for preventive work. The work of educating adults, parents and children to maintain good dental health receives no funding, despite the fact that that would significantly ease the burden on dentists and the NHS as a whole further down the line. Indeed, check-ups are the smallest and least-remunerated part of the unit of dental activity worksheet. As a consequence, there is no massive incentive to up the number that a dentist does.

None of that is helped by the Government’s decision to cut £500,000 in the last few months from Cumbria’s public health budget this year, undermining vital preventive work, especially in our schools. Nor does it help that we are currently in limbo when it comes to the future of emergency dental services under the soon to be defunct Cumbria Partnership NHS Foundation Trust. Will the Minister tell me which trust will be responsible for emergency dentistry in south Cumbria after October?

Morale among dentists practising in the NHS is at an all-time low. The latest British Dental Association membership survey shows that nearly three in five dental practitioners in England are planning to scale down or leave NHS work entirely in the next five years. Those with the highest NHS commitments are the most likely to want to leave. In recent months, I have received countless letters at an increasing rate from residents, many of them very elderly, asking where they can go for dental treatment, as their current dentist has gone private and they have effectively been kicked off the list. A lot of parents have contacted me saying that they have been asked to pay now that they have been kicked of their local dentist’s NHS list. If they pay, the dentist might provide NHS provision for their children. It strikes me that that is a form of bribery. Many parents cannot afford to pay for themselves just so their children can get free care. That is not right.

The current system also fails to use the skills of all dental staff to their full potential. The NHS dentist contract restricts the initiation of a course of treatment to dentists alone. I met the British Association of Dental Therapists, which explained that dentists often refer the patient to a therapist to carry out the treatment if it is within the remit of their qualification. The fact that that can be begun only by a dentist creates a bottleneck that prevents patients from receiving the treatment that they need when they need it. The dental therapists made the case to me—and, I believe, to the Government—for reforming the system to allow them to initiate a course of treatment, ease some of the burden on dentists, and enable patients to be seen more quickly. I ask the Minister to action that request, or at least to look into it as a matter of urgency.

I welcome the Government’s steps to reform the system by beginning to carry out a few pilots and trials in different forms of commissioning, but the pilots have not gone far enough, there are not many of them, and the proposed systems do not provide a complete break from the old “unit of dental activity” system. Rather, they blend it with new systems. In the face of the crisis that we have on our hands, I am afraid that a piecemeal change is simply not enough for the people of Cumbria. We need total system reform. The Government need to sit up, take notice and change the contract so that people get the dental treatment they need. The current system is unjust, not fair to dentists and patients, and not fit for purpose. It is not good enough for Cumbria.

Urgent action is needed to roll out a system that fairly rewards dentists for the work they do, includes incentives for preventive work and allows all dental practitioners to use their skills to their full capacity. If we want our NHS dentists to feel that their vital work is valued and not to feel encouraged to move into working privately or give up the profession altogether, we need to take swift, far-reaching action. We need a funding system that does not feel like a treadmill, that rewards preventive care and that is not riddled with unfairness, idiosyncrasies and perverse incentives.

Those of us living in Cumbria are seeing the colossal impact of the current system on the health of children and adults alike, and we are further affected by the huge distances that we have to travel to get care, if we are lucky enough to stumble across an NHS dentists with available space. My question to the Minister is this: what action will she take to provide my constituents with the NHS dental healthcare that they desperately need and that their taxes have already paid for?

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It is a pleasure to serve under your chairmanship, Sir David. I thank the hon. Member for Westmorland and Lonsdale (Tim Farron) for securing this debate. He raised some important issues about dentistry, some of which are national problems that I have been looking at since I came into this role about three months ago, and some of which are pertinent to both the urban and rural areas of Cumbria—I know that there are problems in the constituency of the hon. Member for Barrow and Furness (John Woodcock) relating to geography and economics. I will talk a bit about what we are doing nationally, but of course there are some distinct issues to do with the geography in Cumbria.

Cumbria has struggled to attract dentists. The hon. Member for Westmorland and Lonsdale has raised that issue, which I take very seriously, on many occasions. National access to NHS dentistry is high, but I know from my conversations with colleagues from across the House that there are notspots, and that in isolated areas it is very difficult to get to a dentist. We are taking steps to address that issue to ensure that everyone has access to an NHS dentist. It is NHS England’s responsibility to commission dentist services to meet the needs of local people, and it has been actively looking into dental access issues in Cumbria. Its regional team covers my constituency, so it is looking at Lancashire and south Cumbria together. It has urgent work in hand to explore and implement schemes to improve local access.

In south Cumbria, NHSE will be working to help practices that are under-delivering on their contracted levels of dental services. If despite that support a practice remains unable to deliver its full contracted level of dental activity, the unused funds will be diverted into other local practices. NHS England believes that that could support care for about 3,000 patients. Alongside that, work is being taken forward across Lancashire and south Cumbria to integrate dental services within primary care networks. It is important that dentists are part of the integrated primary care network team, enabling oral health advice and prevention work to be offered across the primary care network. Oral health needs, including gaps in services access difficulties, must be part of the wider health picture. The hon. Gentleman touched on that when he talked about access to GPs.

That is the local action. I want to touch on what we are doing nationally.

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The Minister made a very interesting point about people who under-deliver on their contract. It is important that we do not misunderstand what that means. A dental surgery can be working flat out, but if it is, for example, spending more of its time doing preventive work or reacting to people who want consultations and so on, it gets only one unit of dental activity for that. It could be absolutely full to the brim but be doing the lower-tier work just because that is how it is, reactively. That dental surgery is not failing or not working hard enough. It is doing the preventive stuff that we want it to do more of, but the UDA system, with its perverse incentives, does not reward that.

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The hon. Gentleman anticipates my speech: I will talk about contract reform later. He knows much better than me that the problem with the previous contract was that it was introduced with perhaps a bit too much haste, and we are now living with the consequences. We are mindful that we need a contract that works well and is sustainable for the future.

Nationally, we are introducing so-called flexible commissioning, which allows local NHS commissioners to commission a wider range of services from dental practices. That is expected to make NHS dentistry more attractive to new performers. Another key recruitment and retention challenge—of course, this is not confined to dentists; it applies to a whole range of healthcare and other professionals—is the growing demand among younger dentists for more varied portfolio careers. NHSE is working closely with Health Education England and a wide range of stakeholders to make portfolio careers a reality for dental professionals, allowing dentists to move between specialities such as prevention, restorative work, oral health and special care dentistry.

We want UK-trained dentists in the NHS, and we want them to stay in those careers, but dentists from overseas also play an important part in delivering NHS care. I am pleased that the NHS and the Government have taken steps through the launch of the EU settlement scheme to maintain that essential supply of dedicated and skilled workers, including European economic area-trained dentists, when we leave the EU. Last summer, doctors and nurses were removed from the tier 2 cap, leaving more places for other highly skilled professionals, including dentists.

The interim NHS people plan, which was published early last month, commits to creating a capable and motivated multidisciplinary dental workforce of a sufficient size to meet population health needs. The full people plan will be published later this year.

We are working closely with NHSE to reform the current dental contract. Feedback from dentists who are testing the prototype contract suggests it is a more satisfying way of delivering care. It supports a better skills mix, allowing dental care to be supported by a wider range of staff, such as therapists and hygienists. At a meeting a couple of weeks ago with a wide range of dental stakeholders, I announced that a further 28 dental practices had joined the programme, bringing to 102 the number of practices that are testing the new prevention-focused way of delivering care. NHSE is considering carefully when that approach can be rolled out more widely across the NHS. It is important that we get the new contract right, but I am hopeful that the roll-out will happen as soon as possible.

I want to touch briefly on three questions hon. Members asked. The first and most important was about children’s oral health. I heartily agree with the hon. Member for Westmorland and Lonsdale about the importance of children’s oral health and all the preventive measures the Department can take to protect children’s teeth. He rightly pointed out something that not all hon. Members are aware of: the biggest cause of emergency admission for children is poor oral health. Of course, that is entirely preventable. The Government are committed to that, particularly among deprived children. We have made the Starting Well approach available to other NHS England commissioners, and that is promoting increased access and early preventive care for very young children.

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That more a third of children under five in Barrow have tooth decay is truly appalling. The Government need to make faster progress. I assume the Minister would vigorously oppose any attempt to weaken the sugar tax, which is designed to move people away from that harmful substance towards a healthier lifestyle.

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The hon. Gentleman makes a very timely intervention. We can see how successful the soft drinks industry levy has been in how it has helped to reformulate sugary drinks, the amount of money it has raised that has been recycled into school sports, and the fact that it is changing people’s tastes and behaviour. The prevention Green Paper is in train; let us hope that he is pleased with what is announced in it.

The hon. Member for Westmorland and Lonsdale mentioned emergency dentistry and I will have to write to him with specifics about the commissioning of services.

On the public health budget, I know from conversations with Members across the House that there are pressures on local government budgets. The ring-fenced public health budget will be a matter for the forthcoming spending review, when it will be assessed using all available evidence. The hon. Gentleman can be assured that I will take away all the evidence I gather from meetings with Members across the House and in my ministerial position to feed into the spending review process.

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Just so the Minister is fully aware of the facts—I know this predates her time in this role—the NHS talked in its long-term plan about its vision for early identification of conditions of all sorts, and about preventive care, and then literally a fortnight later, just before Christmas, the settlement for public health spending for Cumbria was reduced by £500,000. I would be grateful if the Minister intervened to ensure that that does not happen again, because it has a huge impact on our ability to keep children in good practice in their early years so they have good dental health.

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Of course, part of prevention comes from the public health budget. That now sits back with local authorities, which is where it was historically, and of course—the hon. Gentleman knows my constituency well, having grown up there—there are different needs in different areas. What the NHS does through the immunisation and screening programmes is also part of that aspect of preventive health, but I take on board his comments about the specific public health situation in south Cumbria.

I hope the hon. Gentleman is reassured that significant action is being taken locally in Cumbria and nationally, both now and for the future, to improve access to NHS dental services. The new prevention-focused dental contract in particular, which is a key part of our reforms, should attract people to and keep people in the dental profession, and make dentistry a more varied and rewarding career. It will ensure better access to dentistry in places such as Cumbria and across the country for all our constituents.

Question put and agreed to.

Sitting suspended.