rose to call attention to the current situation in the provision of National Health Service dental services in England; and to move for Papers.
The noble Lord said: My Lords, in 1946, the Minister of Health, Aneurin Bevan, said:
“The resources of medical skill and the apparatus of healing shall be placed at the disposal of the patient, without charge, when he or she needs them”.
His dream was realised on 5 July 1948 when the NHS was born. In 1999, Prime Minister Blair said that by September 2001 everyone would have access to an NHS dentist, no matter where they lived. His dream is not yet realised.
Now, the NHS exists in a cash-limited system and has a multitude of competing priorities. It is difficult to reach a consensus on expensive drugs and treatments that please everyone. The provision of dental services is a good example. Statistics published by the Information Centre on 28 February show that the number of people in England able to access NHS dentistry continued to decline between 30 June and 30 September 2007.
The purpose of the debate today is not to make political points about the perceived failure of the dental contract, but to discover why the new contract, which was introduced more than two years ago, seems to have failed to meet the Government’s own success criteria for the future of NHS dentistry as set out in the Department of Health report, NHS Dentistry: Options for Change, particularly the need to improve access and to place prevention at the centre of dental care. Why is there such a strong contrast between the view of patient groups, the media and dental professionals, who all believe that the system is in a mess, and that of the Department of Health and its representatives, who assure us that access is acceptable and that reforms are on target? Why did a survey by the Patients Association of Members of Parliament last year find that dentistry topped the poll in the three main concerns about health raised by their constituents? Why has the Health Select Committee in another place found it necessary to conduct an extensive inquiry into how NHS dentistry has been delivered since the reforms? Perhaps the Select Committee will come up with an answer, because one view or the other must be wrong. The Government owe it to the public to provide an answer and to put a stop to claims and counterclaims about NHS dentistry.
I have deep admiration for the Chief Dental Officer, Dr Barry Cockcroft, and his team. He is a very effective presenter and an asset to the department. I declare my interest as a semi-retired dentist with more than 40 years’ experience, of which 20 were in the NHS. Despite this experience and a working knowledge of the NHS treadmill, 10 minutes with Dr Cockcroft usually convinces me that NHS dentistry is working to plan. However, the new contract is complex. In February, Mr Justice Collins, commenting in a High Court challenge involving a dentist and his primary care trust, said:
“I do pity these unfortunate dentists who have to struggle with this”—
legislation. He described the contracts that dentists must sign as being of “inordinate length”, and said that dealing with them was,
“like going through a marsh, trying to leap from tussock to tussock”.
He suggested that if PCTs do not provide terms that encourage dentists to work in the NHS, they are letting everyone down.
Patient groups, dentists and the Government’s own figures show that the number of people in England able to access NHS dentistry has continued to decline. In the 24 months ending in September 2007, 543,000 fewer people were seen than in the 24 months before the reforms were implemented. More than 2.5 million people are now officially recognised as being without access to NHS dentistry, no matter where they live.
Last December, the National Association of Citizens Advice Bureaux found that 34 per cent of respondents to the Omnibus survey of 1,813 adults had not been to an NHS dentist since April 2006. Of the 998 people surveyed who had not been to a dentist in that time, 31 per cent cited lack of availability as the reason why. In an earlier survey in March 2007, the National Association of Citizens Advice Bureaux found huge regional variations in patients’ ability to access dentistry. It spoke of dentistry deserts, observing that people in rural communities who rely on public transport are particularly disadvantaged.
In a survey of more than 5,000 patients and 750 dentists, the Commission for Patient and Public Involvement in Health found that 35 per cent of patients not using dental services said that it was because there was no NHS dentist near to where they lived. It found that people had to pay for private treatment, and that 78 per cent of new private patients left the NHS because their dentist had gone fully private or because they could not find an NHS dentist in the first place. Although it is not a serious problem, noble Lords will have heard of the 6 per cent of patients who are resorting to treating themselves.
The Department of Health acknowledges that 2 million people who wish to receive NHS dentistry could not do so. The British Dental Association believes that this may well be an underestimation of the extent of the unmet need for dental care. To provide some idea of the scale, the Healthcare Commission’s national patient survey in 2005 found that 69 per cent of patients who were not registered with an NHS dentist—this equates to about 15 million people—would like to be. This explains the current increase in hospital admissions for dental treatment. Last year, there were nearly 240,000 hospital admissions for dental treatment. About 18,000 of these were for dental emergencies, of which the majority I assume should have been dealt with by high street dentists. That number has increased by 27,000 patients, and it is clear that regions with a bigger increase in the number of patients without an NHS dentist now show a bigger increase in the number of hospital admissions for NHS dental treatment.
Unfortunately the new contract was not given sufficient time for a proper pilot scheme, and was imposed on the profession. A survey of dentists found that 85 per cent of respondents said that the new contract had not improved access, and that only about 10 per cent of them could take on new patients. Dentists want to provide high quality care for patients in a prevention system, as proposed in NHS Dentistry: Options for Change, but patients’ quality of experience is threatened by the time pressures on dentists generated by the new crude target-driven system.
Under the new contract, dentists must deliver a fixed number of units of dental activity—UDAs—over 12 months. A dentist may be commissioned to deliver, say, 12,000 units annually. The range of treatments provided is assigned to one of three bands that attract a set number of UDAs. Thus if a patient requires one filling, the dentist secures three UDAs, but if the same patient requires 10 fillings during the same course of treatment, the dentist will still gain only three UDAs, even though the work will take much longer. This is just one of the absurd anomalies of a crude target-driven system that was never pilot-tested and is certainly not patient-centred. Yet it is the only measure used to establish whether a dentist has complied with the terms of the contract.
The consequences for a dentist who fails to deliver the requisite number of UDAs can be detrimental. In 2006-07, almost half of dental contractors failed to achieve the required number. This results in practices having to pay back money to the PCT, and can run into thousands of pounds. Deficits of more than 4 per cent can be rolled over into the following year’s contract, adding to the time pressure on dentists to achieve even more targets. Conversely, a dentist will gain no rollover benefit from delivering too many UDAs and will have done this work for free. In some areas, PCTs have taken a constructive and sensitive approach to dentists missing their UDA targets, but others have not. About 40 per cent of practices had money clawed back from them that had already been paid by their PCT, and 35 per cent said that their PCT had insisted that the uncompleted UDAs be performed in the next contract year.
The NHS annual work quotas of some practices have been filled and patients are being turned away, despite the fact that so many people cannot find a dentist. Patients are being told that they must either pay privately or return in the next contractual year. This further explains the increase in hospital admissions for treatment that normally would be carried out in the dental surgery.
The Birmingham Local Dental Committee estimates that up to one-third of dentists in the West Midlands have run out of work or have had to reduce the number of NHS patients that they treat. This arbitrary system of performance measurement fails to promote a more preventive approach to care. When dentists spend additional time with patients to explain oral hygiene, nutrition, smoking cessation and disease prevention, they do so at the risk of missing their UDA requirement or disproportionately increasing their clinical working time.
Despite the Government’s stated aim to allow time for prevention, I fear that most dentists believe that they are still on a treadmill and that the contract in its present form has not worked. Unlike general practitioners, dentists have to buy their own premises, equipment and consumables, and have to pay their own staff. Their business has to be viable. The uncertainty about the new system puts the future of NHS dentistry at risk.
Dentist leaders have long argued that a prevention-based system could be delivered if the NHS contract used a range of quality-based performance indicators, rather than have sole reliance on a single, flawed output measure. They support the Department of Health’s advice to PCTs to include factors such as oral health, access, quality and patient experience in dentists’ contracts. This approach would enable PCTs to develop and agree contracts with dentists and practices that reflect the needs of patients in their area.
If PCTs are to meet the oral health needs of their communities, they must have the right resources to commission dental services successfully in terms of funding and expertise, as well as a commitment to do so. It seems likely that some PCTs with access problems may be adopting a narrow interpretation of their duties, focusing on spending at the level of their historic budgets, rather than on a comprehensive assessment of local need.
For too long, investment in NHS dentistry failed to keep up with funding for other areas of the NHS. Until recently, the proportion of the NHS budget spent on dentistry in England had been lower than it was in 2002-03, at only 2.8 per cent. However, the 11 per cent increase in the dental budget for 2007-09, announced last December, is a welcome development and should ensure improvements in the number of patients accessing primary care NHS dental services. It is also a step in the right direction that the ring-fencing for dental budgets has been extended until April 2001. I hope the Minister might be able to confirm that the income guarantee that dentists were given, which is due to end next April, will also be extended.
Apart from historic under-funding, the PCTs’ ability to deliver dental services has relied on the collection of about one-quarter of the dental budget via payments from patients who must pay for NHS dentistry—nothing free at the point of delivery here. This charge has turned out to be about 20 per cent lower than expected and PCTs are being forced to cover the deficit by a combination of commissioning less dentistry and by implementing inflexible performance targets for dentists. Reliance on patient charge revenue ensures that PCTs’ dental commissioning budgets remain unpredictable for future years. The BDA has called for an allocation of full dental budgets for PCTs, so that they are no longer reliant on patient charge revenue.
In 2004, the National Audit Office warned that PCTs had little experience of high street dentistry and would need to develop new expertise in dentistry. The development of effective working relationships with local dental committees and local dentists is a crucial part of addressing this requirement. The expertise of consultants in dental public health is also vital. The recent loss of a number of consultant posts is therefore of great concern and undermines the Secretary of State’s elevation of public health to the top of the national agenda and his recognition that it is pivotal to reducing health inequalities.
Having drawn on these resources, it is important that PCTs publish plans on how they intend to reduce health inequalities and to improve the oral health standards of their communities. I shall look forward to the publication of the adult dental health survey, which is invaluable for the monitoring of the population’s oral health. I hope that despite the one year delay in publication the Minister can confirm that this report is imminent.
I have tried to be helpful. I am looking forward to the contributions from other noble Lords who are taking part in the debate. I am sure that the Minister has realised that the dental profession and its leaders wish to co-operate, but as an absolute priority the public must be assured by the Government and dental professionals that the NHS dental service is in good order. The noble Lord, Lord Darzi, is leading a wide-ranging review of the NHS and has included a dentist, John Milne, to provide the clinical input and to represent the dental profession. I hope that the review will address this very urgent problem. I beg to move for Papers.
My Lords, from these Benches, we thank the noble Lord, Lord Colwyn, for giving us the opportunity to discuss this critical problem. As he so rightly said, nine years ago the then Prime Minister, Tony Blair, said that within two years every person in the UK would have access to an NHS dentist, which just is not happening. At that time, the picture was pretty bleak and it has not improved. In April 2006, the Government introduced a new dental contract, which promised that dentists would be allowed to take on 2 million new NHS patients. However, figures released in February 2008 show that the opposite has occurred. NHS dental statistics for England, released in February, show that 500,000 fewer patients have access to an NHS dentist since the adoption of the new dental contract.
In February, a Liberal Democrat survey showed that only 29 per cent of dentists were taking on new NHS patients. In March 2007, a British Dental Association poll discovered that 85 per cent of dentists did not think that the reforms had improved access after a year under the new contract. This was shown in the fact that half of all adults and almost one-third of all children still do not have access to an NHS dentist.
For patients who find a dentist, the charging system makes it unaffordable for many of the poor and the elderly. Even the maximum charge for a complex course of treatment under the NHS, which, in England, is £198, and, I am proud to say, in Wales, is only £177, is beyond the reach of many people. For people living just within their income finding this sort of sum is nearly impossible. For those who are unable to find an NHS dentist, the charges are totally beyond them. A week ago, I called at a dentist in the Conwy Valley where an examination costs £60; a routine extraction under local anaesthetic costs £65; a porcelain bonded crown costs £350; and a full set of dentures costs £750. This makes dental treatment very difficult for people to afford.
The noble Lord mentioned the Dentistry Watch survey published in October 2007. It confirmed that more than 10 per cent of people were not registered with a dentist; 35 per cent said that there were no local dentists; and 13 per cent said that they were still on a waiting list. The most shocking thing in the survey was that 6 per cent of the population were treating themselves. They use pliers to remove teeth—one man said that he had removed 14 teeth with pliers—use clove olive and Polyfilla to make fillings and Super Glue to fix a crown. That is not the sort of NHS dentistry we dreamt of for 2008.
A parliamentary Answer that I received in June 2005—the Minister might confirm that the figures are probably near to the mark even today—showed how Wales was missing out. The ratio of dentists in Wales was one per 2,823 patients. Scotland had one dentist per 2,202 patients, while England came in the middle with one dentist per 2,464 patients. The Welsh Assembly, the Scottish Parliament and our own Government need to get together and make sure that there is much wider availability.
The population of Wales stands at around 3 million. In 2005, more than half—1,411,574 people—were unable to register with an NHS dentist. The new contract, as well as failing to improve access, has provided no incentive for dentists to spend time with patients providing, for example, oral health advice such as how to floss and use a toothbrush properly. The contract has been estimated to allocate a mere 90 seconds for oral health advice for each patient. Something is seriously wrong here.
Of course we have known about the disillusionment of the dental profession itself since the contract was introduced. Over 1,500 dentists, 8 per cent of the total, dropped out of NHS provision within three months of the new contract being introduced, and many more signed their contracts in dispute, a situation which has yet to be fully resolved. This issue is too grave for us to make party political points, but we must increase the flexibility of the current contracts. The aim must be to ensure that dentists are properly compensated for completing NHS work and, as has already been mentioned, there must be full co-operation between the dental profession, the Government and patient groups.
I shall not take much more time from the debate. As most dental disease is preventable, charges for check-ups should be scrapped. That would ensure that all patients are able to have their teeth checked regularly, resulting in a massive saving in times ahead. Knowing that the problem is critical, we wish the Government well and look forward to the review in order to find a truly effective answer that fulfils the promise made in 1999: that every person has access to an NHS dentist.
My Lords, I am grateful to my noble friend Lord Colwyn for tabling this Motion. As one of only two dentists in this House, I feel obliged to take part, and I am sorry if noble Lords have heard much of what I have to say before. I was fascinated by the speech of the noble Lord, Lord Roberts, because Wales has always been badly off for dentists. Going back 50 years ago, all the Welsh dentists were driving Rolls-Royces and none of them did any fillings at all. That is a bit of a generalisation, but it was the impression that everyone had. Welsh dentists did nothing except extractions at half a crown a time, but they had so many to do that they could all afford to drive Rolls-Royces. People queued for treatment even then.
Today’s debate looks at NHS dental provision in England and that is what I intend to speak about. I should say first that the position is dire. Last night a paper was presented to a full council meeting of the Royal Borough of Kensington and Chelsea on health inequalities. The review was set up by a sub-group made up of both parties and chaired by a Labour councillor, Judith Blakeman. It identified the lack of National Health Service dental provision in the area and the particular problems arising for people with disabilities. The only provision for these people is at Northwick Park Hospital, if they can get an appointment. It is true that patients with disabilities may not be suitable for treatment in a general dental surgery because they may need a general anaesthetic. Of course now that general anaesthetics cannot be administered in a dental surgery, people have to go to hospitals. There are at least three other hospitals within easy reach of Kensington and Chelsea patients, but none provides any service to help those requiring specialist treatment. One of the suggestions made in the report was that people with special health problems ought to be provided with crisis cards of the type sometimes carried by mental health patients. That might make it easier for them.
But the biggest problem noted in the report is that there is no clearly defined care pathway between community dental services and hospitals, so that communication relies on personal contacts between staff. Just when people have built up good contacts so that one person can phone another saying, “We need someone to see this patient very urgently”, the member of staff at one end or the other leaves their job and the contact is broken. It is important to give thought to this issue.
Surprisingly, the review found that it is difficult for patients in the more deprived northern part of the borough to find National Health Service dentists. Whether that is because those living in the southern part go for private treatment or it is a general problem, I do not know. The report stated that not enough appropriate provision is made or information provided for the black and ethnic-minority communities in the area. The report strongly supported the children’s programme called Brushing for Life and the Cool Kids campaign, but there is still a need for more information.
My noble friend Lord Colwyn told us clearly about the 2 million people unable to access dental care. When the National Health Service was set up in 1948, the leaflet—it was republished 50 years later for us to read—stated that not enough trained people were available to provide dental services, and that is why people like myself came over here. I would love to know who was the first Commonwealth person to discover the need for dentists in this country, but thousands of Commonwealth dentists came over in order to meet that need, and I think they did quite a lot.
I was shocked to hear from my noble friend that dentists have to pay money back to the PCT. I do not understand that. I thought that the new contract meant that dentists would be given guaranteed payments for three years. If the payments are guaranteed, how can dentists be asked to pay them back? I would appreciate a comment on that.
In the days when I was practising, at one stage dentists’ earnings were limited in the form of a ceiling being placed on the amount they could earn in one year. A lot of dentists did not mind that at all. They would happily do the work in six or nine months and then spend the other months travelling around the world or playing golf in Spain before going back to earn the money all over again. Many of the programmes that are supposedly the answer to everything do not work out in practice.
On these units of dental activity—the other side of the coin, as my noble friend put it—patients are smart enough to know that they can get a cheaper and better deal if they wait until they need more than three fillings. It is not only dentists who are thinking about that; patients are watching their pennies too. So when the noble Lord, Lord Roberts, told us that a full set of teeth cost £750, I was amazed. I made hundreds of sets of false teeth, for which patients originally paid £2.50. Even private dentures did not cost £750, so the figure is very high for a basic set of teeth.
My Lords, that was the cost with a private dentist, not an NHS one.
My Lords, I am relieved to hear that because it was an unbelievable amount. However, I think the fee for an examination quoted by the noble Lord was for an NHS dentist—
My Lords, that was also with a private dentist.
I understand, my Lords. However, patients have to pay for National Health Service examinations, and I support the view of the noble Lord that they should be free. Indeed, I think that that was the beginning of the rot in NHS dentistry. In 1986 I fought for and defeated the Government in your Lordships’ House on a provision to retain free dental examinations. That was reversed in the Commons and financial privilege attached, so when the proposal came back to this House we did not have the opportunity to play ping-pong or debate it further. Throwing out free dental examinations was the beginning of the end of NHS dentistry. It may be taking a long time to die, and I hope it never does, but it is certainly not good news.
The point I made in that debate is that not only people who have teeth need dental examinations. Many people on all kinds of different chemical therapies and drugs can easily develop a malignancy in their mouth which can clearly be picked up by a dentist carrying out an examination. To now read in the paper that many patients have not seen a dentist for more than two years, since the new contract was introduced, is very disturbing, because who knows what is happening in such mouths?
A dental practice is rather like running a small business. As the noble Lord, Lord Colwyn, said, you have to provide your own equipment and premises and balance the books. As time goes by, more and more paperwork is required and more regulations are introduced. A regulation has already been passed that as from July this year, every person helping you in your surgery will have to be fully qualified. I am all for people getting bigger and better qualifications. In general nursing I am in favour of nurse practitioners and nurses with higher skills, but it was a tragedy when we threw out the state-enrolled nurse who did not have to have A-levels to get into nursing. Some of the best nurses I have known could never have achieved the number of A-levels required. We have lost out by imposing academic qualification standards only. As in other businesses which are bringing back apprenticeships, people can learn so many things simply by working in a surgery.
When I see the questions and answers about dental nurses, it concerns me that if, for example, you need someone to fill in for 10 minutes a day while someone goes off for lunch and so on, that person must also be fully qualified. Apart from the registration fee, which will be about £100 a time, in a national health practice it will be an expensive business to have that many fully qualified staff. There should be a degree of flexibility. If someone is ill or away, there should be some way of finding someone to fill in. It is the same for dentists. On maternity breaks they still have to maintain their full training standards and registration. All these matters are quite difficult for people.
Another matter which is quite damaging arises from the Health and Social Care Bill. It has been announced that under order 2—which I think appears under Section 60 of the Act—the General Dental Council will be fully appointed. There will be 12 lay members and 12 professional, but they will be fully appointed. That is a retrograde step. A regulation was introduced some years ago that a number of general dental practitioners could be elected to the General Dental Council, and I was one of those elected at that time. In my experience of the General Dental Council and since, when I have been following matters, the elected members have been extremely useful. They have represented ordinary dentists, mostly in national health practice, and have been able to bring the council’s attention to the day-to-day real problems that exist. If everyone is to be appointed by the Privy Council—even if they are appointed as ordinary practitioners—they will not necessarily be representative of the practitioners in the way that someone elected to that post would be. When we get back to the Bill I shall have another go at that.
Another regulation is being introduced in July in relation to technicians. All these matters impact on the costings for dentists. All technicians in this country will have to be registered and work to a certain standard. But if you send your work to a technician, there is nothing to stop him sending it off to be done in South Africa or China because it is much cheaper to have it done there. There has been considerable trouble in the United States. People have suffered from lead poisoning caused by crowns produced in China. These have had a deadly amount of lead in them and have been put into people’s mouths. It is quite complicated.
Another interesting feature of dentistry for the private person is dental tourism. I was sitting next to someone at breakfast in the House yesterday who was just off under dental tourism to have seven implants done in Hungary. He told me that to have it done here would cost £20,000 but to have it done in Hungary would cost £7,000, so there is a considerable difference. I recall that at the time of the Hungarian uprising, or perhaps a few years afterwards, a man came over to Britain with 20 jam-pot crowns, as they were called, which were common in eastern Europe. They were tin things that you bought off the shelf, put into the mouth and hammered into position. They did untold damage to the gums—they were dreadful. But that man, who escaped in the uprising and came to this country, was able at that time to have all his crowns done in our surgery under the national health scheme, with a beautiful result.
I am running out of time. I think the National Health Service provides a marvellous dental service. I do not want dentists to be concerned about their futures; I want them to feel confident and I want patients to benefit.
My Lords, I offer my sincere congratulations to the noble Lord, Lord Colwyn, on his timely initiative in introducing the debate today. It is a slightly unusual problem that we are facing because it is not often that one is simultaneously concerned with the creation of a resource and a market to use it, which are really the two halves of the contract issue that we are facing here. What we have heard from the speakers so far suggests that neither side of the equation is finding that the deal is working to its satisfaction. We need to look very carefully at why.
Your Lordships will remember that on 8 November last year we debated the question of the National Health Service in general and the financial aspects of it. A very interesting aspect which emerged on that occasion was the fact that there had been a £800 million deduction made in one year from the cash allocated to the PCTs. This was to be held in deposit for two years hence until it could be released back to them. Questions were asked on that occasion as to how the PCTs were to function in the mean time. Given the fact that we have already had significant recognition today that the PCTs are ultimately responsible for the management of dental services, one has to ask whether any of the problems today in dental services are closely related to the absence of that £800 million from the PCT pot. We have not yet had a definitive response from the Minister—the noble Lord, Lord Darzi—as to the present whereabouts of that £800 million, its future release and its present earning potential and security. I hope that we will in time be informed of that important information.
Today we already know certain things that have happened to the fortunes of the PCTs arising from the last year or two of operations since the new contracts came in in 2006. First, it appears that the National Health Service got off to a rotten start because it forgot to make any provision for the cost of the contracts. Therefore, the whole cost of the NHS dental services for that first year from April 2006 effectively fell straight into and formed the bulk of the black hole in the deficiency of NHS funding for that first year. Things got marginally better in the second year when the patients had to fund a total of £62 million, which was an increase of 15 per cent over the previous year, from their own pockets. In the course of that, 47,000 fewer people used the NHS dental services that year. So it has had a push-pull effect; the more the cost has gone up, the more people have voted with their feet and walked away from using the service.
All this has occurred against the background of a Statement made to your Lordships to the effect that the new charging system,
“will not increase the proportion of revenue raised from patients’ charges”.—[Official Report, 7/7/05; col. WS 27.]
This appears to be in conflict with the reality.
I speak on this subject as a humble user of dental services. I have had the same dentist for 45 years. He provides both NHS and private services and I have used him variously in that form during that time. His predecessor, who was an excellent dentist, ran away with his beautiful nurse, went to Easter Island and has never been seen again since. The present dentist certainly did not run away with his nurse, but he did marry her. They have become an absolute pillar of society and are among the most socially provident people, providing for every walk of life in our community.
On the face of it, dentists are asked to be thankful that the Government are saying they are extending their ring-fence over the dentistry budget for a further two years, but, if the top-slicing continues or gets worse, it will be only a matter of time before that budget is again raped and pillaged, as is happening with maternity units and accident and emergency centres. I echo the noble Lord, Lord Colwyn, on this: dentists deserve strong reassurance on this point. If the Government are serious about prioritising preventive dental care, would it not be logical to amend contracts to ensure that dentists were paid on a per capitation basis and not on a per treatment basis? That would at least ensure that patients had the same arrangement with their dentist as they have with their GP.
My friendly neighbourhood dentist has given me what he considers to be eight reasons not to be a National Health Service dentist. Although some of them duplicate those that have been mentioned by other speakers, it is worth going through all eight because their impact is considerable.
His first complaint is that the National Health Service does not recognise that a dental business is a business. It has a fixed income, effectively, but not fixed expenditure. That puts dentists in a place where they have a huge problem in funding and providing, with security, the cash flow to cover their costs. He is particularly concerned about an aspect that has not been mentioned much today: his laboratory bills, which he says are huge.
His further concern is that the UDAs, the units of dental activity payment bands, are seen as covering too wide a spectrum. A dentist is paid the same amount for performing one filling as for 10 fillings, despite the material expenses and laboratory costs that have to come out of his own pocket and which are disproportionately much higher than for one single filling.
He does not think that dentists wish to take on new patients with an unknown volume of work needed, because of the risk of a large increase in expenses against a fixed-target income. As we have already shown, if a dentist reaches his UDA target without seeing additional patients, he has no extra funding to pay for extra patients and work undertaken.
His other big complaint is that if the dentist falls short of the fixed target in his contract at the end of an NHS financial year, a proportion of his fee can be reclaimed, as we heard from the noble Lord, Lord Colwyn, and that is very painful. In contrast, if the dentist exceeds his target, any further work undertaken by the dentist in that financial year has to be carried out unpaid. According to my dentist—and he says this is a common practice—dentists will sometimes, not surprisingly, opt to close down their business at that point for a month or two and go on an extended holiday. That is surely a huge waste of what could be a valuable resource with which to catch up on waiting lists, and a stupidity in the contractual arrangements that needs to be urgently corrected. He says he can finance his holiday very comfortably, simply because of the amount of material for which he does not have to pay to use in laboratory work for the two months that he might be away.
Preventive work is not carried out fully because dentists are too busy on the UDA treadmill. Although capitation would encourage dentists to carry out preventive work, it is inadequate as the present system seems still to be stuck in the drill-and-fill era.
His age is the same as mine and he is concerned that when a dentist comes to retire, it has become extremely difficult to realise the good-will value of the business by selling it on to a successor dentist, which would be logical and sensible for the community because it would mean that a whole tranche of customers was transferred with adequate dental services being provided. The reason for this is that the PCTs will not provide any transfer undertaking or certification of the UDAs to support a sale to a new dentist coming in. This sounds like a way of seriously diminishing the continuity of the market that is available.
The dentistry contract that came into existence in April 2006 was supposed to promote better access to NHS dentistry. Clearly, however, not only is it discouraging NHS dentistry from entrenching—indeed, it is reducing it—but it is also scaring patients away due to the confused and unbalanced cost structure. This is all completely in conflict with the Government’s statement that the new contracts are designed to allow more time for preventive advice. As matters stand, this situation is capable of being resolved with a bit of common sense. Someone needs to rethink these contracts, take them away from the idealistic approach that is enshrined in the original drafting and get them back into the real world by providing a cost-effective and easily understood service that supports the continuity of dentists running their own independently viable businesses.
The Government must rethink this one urgently, and I hope that that will be in the context of allowing this House in the near future to have a definitive statement about the PCT financial status and the current whereabouts, and the future use, of that £800 million that we asked about in November but have still heard nothing more about.
My Lords, we are grateful to the noble Lord, Lord Colwyn, for initiating this debate. At the outset I want to discount the rumour that I am speaking here only because the alternative the Whips put to me was to have my teeth extracted by them. I am somewhat puzzled by this debate, but I have learnt a lot.
As the noble Lord was saying at the outset, ever since Nye Bevan inaugurated the National Health Service we have been chased by high expectations and continuous adjustments of resources to meet them. Historically, spectacles and teeth were such a problem that within three years they led to the resignations of various Ministers from the then Labour Government.
Today, we have a peculiar situation. On the one hand, we know that there are about 4,000 more dentists in business than there were in 1997. We have the news that only 30 per cent of children entering school with tooth decay problems used to be seen, but now the figure is 60 per cent. Statistics show that 28 million people have seen a dentist in the past two years. More doctors are being trained and will come on stream by 2009. More spending has been committed—£2.5 billion for the latest fiscal period, which is considerably more than was being spent only four years ago.
At the same time, various people are saying in newspapers and, of course, your Lordships’ debate, that all is doom and gloom. A variety of stories has been told today. The noble Lord, Lord Roberts of Llandudno, said how badly off Wales was in terms of dentists. The noble Baroness, Lady Gardner, assured us that Welsh dentists had Rolls-Royces—perhaps not the latest model, but good enough at least. She said that dentists typically worked for nine months and had a holiday for three months—the noble Lord, Lord James, confirmed it—and long may it continue.
I shall try to put into perspective these complaints and problems and the nature of the business that we are trying to understand. The noble Lord, Lord James, was accurate in saying that dentistry is a business. Unlike general practice, dentistry is a business. Opticians have long since ceased to be a subject for debate in the press, but they, too, are a business. NHS entitlements to optical care are very basic, and the frames that one gets on the NHS are fairly basic. Had John Lennon not made them popular in the mid-1960s, nobody would have chosen a National Health Service frame if they could afford anything better. Opticians are a combination of NHS and private: we get our eyes examined and then we spend our money on buying the frame.
Something similar has happened in dentistry, which we have not yet quite acknowledged. It is interesting to ask whether that is a way to look at dentistry. I am not a dentist, nor a frequent-enough patient of dentists to be able to answer; I speak more as an economist. People say that not everybody has access to dentists, which may be true. Apparently, around 60 per cent of the population has access to dentists. Perhaps that has been the case for the past 60 years. The question that I put is: does everybody need immediate access to a dentist all the time? A dentist is someone you visit frequently at certain ages in your life: when you are a child, you need them; when you are very old, you need them. In between, you need them only for emergencies. If children in school can be seen by a dentist, especially if they have tooth decay, that is a good cover on the surface. The fact that the 40 per cent of the children who did not have tooth decay did not see the dentist may be worrying but it is not serious.
Similarly, we have to ask which dental services are required with high frequency—they might be routine services—and which are required in emergencies. Implanting teeth and decorating them either with Chinese lead or South African gold is not a service that an NHS dentist should provide. I may be speaking completely out of turn and a Minister may tell me once again that I am making a fundamental error. When we go to an optician, we do not expect them to give us the best frame possible. But why are complaints of the kind we hear about dentists being made?
We may need to think about a different structure for payments and charges. Some noble Lords have mentioned dentists’ contracts, the complexity of which I can only guess at. If dentists are a business, and have been given certain amounts of money to spend on certain targets which they have not met, it is perfectly right that the money should be returned. I agree with the noble Lord, Lord James, that if they have done more than that, they should be paid for it—that asymmetry should be corrected—but I certainly do not see why the money should not be asked back from dentists. Dentists are not a class of citizens known for their poverty. They may have complaints, but I have seen few dentists out on the streets on income support. Having sympathy for dentists is like having sympathy for bankers who have just lost a couple of billion pounds. It would be hard for them to bring tears to the eye.
We need a redefinition of the nature of the business, in which such things are made clear. Although there are complaints, citizens understand that when they go to a dentist, what they can expect from the National Health Service are certain basic, essential services. Luxuries are not delivered as part of the NHS. Additionally, not only does advice on dental care not need to be given by a fully qualified, first-rate dentist but it should be available in schools. It should be much more widely available, on a paramedical level, with trained people. But we also have the problem that, given the kind of foodstuffs that children are eating and have been encouraged to eat, the story of teeth is much more tragic today than it was, say, 50 years ago. We have created a much bigger problem by not taxing properly sugar and salt in foods. We have allowed that sort of laissez-faire regime in food consumption to encourage tooth decay.
Many of those issues should be considered. Debates like this are very good. Rightly, we may never be fully satisfied with any part of the NHS. However, I am confident from what I know that more money is being put into the NHS and more people are seeing dentists. If the people of this country are not yet 100 per cent fully satisfied, let us make sure that we get there. If the contracts are difficult, let us try to look at them. The time has come to understand why the service provided by dentists, along with the testing of eyes and getting spectacles, is in a different class from the general service provided by the health service. When we understand that we may be able to devise better contracts and financing of dental care.
My Lords, I thank the noble Lord, Lord Colwyn, for introducing this debate. I declare an interest as president of the Royal Society of Medicine, whose fellowship includes dentists as well as doctors, for which we are best known, and vets. It includes allied professionals and managers who work with dentists. In the light of the comments of the noble Baroness, Lady Gardner of Parkes, I feel that I should also declare that I come from Wales, where I have friends who are dentists who drive small, second-hand cars. My dentist, my own Mr Jenkins, does only private work now, because he has also abandoned NHS dentistry.
At the end of last year, following a question on the Floor of the House from the noble Baroness, Lady Gardner of Parkes, I wrote to 214 English acute care NHS trusts to survey their services on the subject of the new dental contract and how it had affected cancer services. I intended to find out the experience of cancer centres, but it was not possible to disaggregate cancer centres and units from trusts not providing cancer services, although it was easy to exclude mental health trusts and community trusts from my survey. Of the 214 trusts mailed, I received responses from 110, of which 81 said that they provided cancer services.
Twenty-nine of the trusts that responded—that is over one-quarter—answered yes to the question, “Has the dental contract adversely affected your clinical service?”, and many wrote comments about negative effects experienced through the new contract. Of the 29 that answered yes, by far the most common reason given was a significant increase in referrals. For example, Salisbury District Hospital reported a 30 per cent increase in referrals. Mayday Healthcare Trust reported a 100 per cent increase and the Royal Wolverhampton Hospital Trust reported a threefold increase. Although 66—or 60 per cent—of respondent trusts had emergency dental services available before the new contract, only 50 per cent of the trusts now have such services. Comments from those with current services included that there had been a,
“sharp increase in heavy local referrals … less availability of community dentists”,
“an increase in inappropriate referrals to maxillo-facial services”.
Several commented that routine dentistry is difficult to access and that patients either do not have a dentist or have less regular dental check-ups.
Sadly, those figures simply add weight to the stories from accident and emergency departments reporting a steep increase in patients with toothache and dental abscesses. The immune system of patients undergoing other treatments such as cancer therapy may be compromised, making them particularly prone to infection and in need of good dentistry.
I turn to the importance of dental hygiene in patients with systemic disease. Those with scleroderma and muscular diseases can find cleaning their teeth particularly difficult because they cannot open their mouth adequately, and they may have limb weakness which makes cleaning their teeth difficult. For those with heart disease, the NICE guidelines do not recommend antibiotic cover for routine dental work because the evidence shows that many more bacteria are showered off into the bloodstream at other times. That guideline has been very carefully looked at and seems eminently sensible. However, when the mouth is dirty all the time and a particularly large bacterial lobe is around the gum margins, the risk of high bloodstream infection obviously increases.
Quite apart from that, patients who have lost weight, particularly those with cancers, often find that their dentures do not fit, so to maintain nutrition they need rapid access to community dental services. Without such services their dentures swing around in their mouths, clunk and cause erosion of the gum margins. My own hospice unit has for many years enjoyed good community dental services from a local dentist. I have seen first hand how bedside relining of dentures and emergency management of caries can dramatically improve eating, talking, comfort, quality of life and social interaction. It cannot be overestimated how rapidly these patients get relief and how rapidly they need the service.
Another small area of NHS dentistry which I should like to address is one that may not be on noble Lords’ radar today—forensic dentistry, which is crucial to the criminal courts. There are only four such centres in the UK: one in Cardiff, one at the Royal London, one in Glasgow and one in Sheffield. With such a small number of training posts these services could be viewed as an endangered species. Once the number of these dentists has dwindled they will be greatly missed by those wishing to bring prosecutions for heinous crimes. I am sure they will be greatly missed by the Ministry of Justice. I am delighted to see the Minister in his place.
Routine dentistry consists not only of dentists but of dental therapists, dental nurses and dental hygienists, as well as dental technicians who work behind the scenes but with leadership from dentists. As the noble Baroness, Lady Gardner of Parkes, pointed out, early detection of oral cancers in this day and age is due primarily to dentistry, and the management of ulcers and infections are core competencies of dentistry. In addition, facial pain clinics and even some smoking cessation clinics are run by good dental teams. Sadly, those are not a ubiquitous resource.
Orthodontics, another area not addressed, is a very specific field whose methodology to measure tooth crowding determines eligibility for NHS treatment. If the criteria are tightened by stealth, fewer children will qualify for NHS orthodontics. We must be aware of the damage to body image, as well as of the poor functioning of all aspects of the mouth, that can occur as a result of grossly misaligned teeth. Let us face it, a teenager is less likely to be or feel kissable behind the bike shed if they truly have buck teeth. That may sound trivial but it is not. Body image problems are horribly apparent in our society and undermine many other aspects of young people’s functioning.
Before this debate I read an interesting article in the Daily Telegraph that stated that almost half of Britons, 23.1 million people, have not seen an NHS dentist—or a hygienist or anyone else in the dental team—in the past two years. Apparently the figure has increased by 4 per cent, almost 850,000 people, since the Government introduced the new contract in 2006. I also noted with interest the response by the Minister in another place to a Question tabled by Tim Farron. The Minister stated:
“The Department estimates that there are some two million people in England who would like to access national health service dental services but are unable to do so. This estimate predates the dental reforms introduced in April 2006”.—[Official Report, Commons 13/3/07; col. 309W.]
I wonder what that figure would be now. The increase in referrals to acute trusts seems to be putting pressure on efforts to meet the new national waiting-target time of 18 weeks from referral to start of treatment. I was interested to learn that London has more NHS dentists than most other areas of the country, yet only half of Londoners regularly visit the dentist, and children in London are less likely to visit a dentist than children anywhere else in the country.
There seems to be hard evidence of a gap between the theoretical standard that should be attained and practice on the ground. That needs urgent examination. While listening to this debate, I was wondering whether there needs to be a cross-party working group to look at dental services in the long term with forward planning for 20 or 25 years. The danger of overpoliticising dentistry is that it will become a political football subject to elections and so on, whereas new dental graduates coming in to establish their careers need to know where they are going in the very long term. This has been an important and timely debate. I hope we will eventually see an upturn in the provision of dentistry with high-quality dental care across the whole population.
My Lords, I thank the noble Lord, Lord Colwyn, not so much for calling this debate but for the masterclass that he gave in his opening remarks. I do not have great knowledge in this area and I found what he said good and useful for the parliamentary record and for other organisations outside the House. When I walked into the Chamber for this debate, I wondered why I felt a particular fear; of course, the reason is that there are two dentists present. This is an area of high emotion. Dentistry is a medical or technical practice that we want an excuse not to use. Psychologically, that lies behind a number of the statistics that the noble Baroness, Lady Finlay, mentioned. Later, I shall come on to how we can reduce some of the barriers.
A few years ago now, under the old payment regime, I visited an establishment in Cornwall, where I live, called HMS Raleigh. It is a Royal Navy training station. A lot of naval staff go through it in preparation for military service. One of the key issues—this was a few years ago now, but it is by no means ancient history—was that the Navy had to reject a number of people for a service career, particularly careers involved in the nuclear submarine fleet, because of the cost of putting their dental equipment—their teeth—right so that the Navy did not have to bring nuclear submarines back into port or, as my noble friend Lord Roberts said, get out the superglue, the Polyfilla or the pliers. The state of the nation’s teeth was a major problem for recruitment into the services.
In this debate, we can sometimes forget that the system before 2006 was far from perfect and that reform was needed. Some years back, I moved to Bristol and signed up with an NHS dentist there. When I turned up at his practice and sat down, he drilled out the first tooth; I then went back out, whereupon the next patient came in. It was like a production line. I am sure that this occurred with a minority of dentists, but there was an incentive for dentists to give patients treatment that they did not need. That was not good for the Treasury and it was certainly not good for patients. It may have been good for Rolls-Royce orders in certain parts of the United Kingdom, but the system very much needed fixing.
Many speakers have expressed disappointment that the fundamental change with regard to contracts has not been successful. That may be due to a lack of trial runs or pilot studies but it has certainly not delivered what the Government expected or what patients deserve. Further, the third part of the triangle, the dental profession, voted with their bank accounts and their feet and moved out of the NHS.
Having read the relevant literature, I believe that three important areas are involved. One concerns expense, as my noble friend Lord Roberts of Llandudno mentioned. Cost is important, as the noble Baroness, Lady Gardner of Parkes, said. The high-end cost of £194, which can be charged for work that is not necessarily very technical, is a great sum for most people. However, the entry fee even to come in for an inspection is also high.
The noble Lord, Lord Desai, referred to opticians. When you have a problem with your eyes and cannot see, you are aware of that and you try to get it fixed. I speak as someone who wears glasses. There is a public/private option there that seems to work well. However, you can find out about a dental problem too late, when the damage has been done. You can lose teeth or find out that you have serious problems such as cancer or less serious problems such as cavities or broken teeth. However, you may already have lost teeth before preventive work can be carried out. Therefore, price barriers are important in terms of future costs and the population’s overall dental health.
Private practice costs are very high, which has resulted in dental tourism. I am not against that. I approve of the fact that the European Court of Justice, or whoever, permits us to obtain medical treatment abroad that is not provided under the National Health Service. However, our dental service is high cost in both the public and private sectors.
The second area, which is related to expense, is prevention. The noble Baroness, Lady Gardner, referred to a change in this regard. I never used to mind turning up for a check-up because not only did it not cost me anything but I convinced myself that no dental treatment would take place during a check-up and therefore I could get off scot-free. However, that process got me into the system and I could then be offered dental care. I know that it is free for children, but the same principle applies. I had not previously come across the acronym UDA—unit of dental activity—but it seems to me that UDAs do not cover education and prevention. They are mainly concerned with completed dental work.
The third area is availability, which is much discussed and is certainly a problem in the south-west. I find it difficult to understand how, with the increase in funding over the past few years and the major reduction of 500,000 or 600,000 visits per year—demand going down and funding going up—we still have unavailability for an estimated 1.5 million people. To me, as a small-time economist in my corporate career, compared with the noble Lord, Lord Desai, somehow those figures do not add up. How does the Minister square that triangle of funding going up and demand going down but availability not getting any better at all? Secondly, how do we practically tackle prevention, which, in all medical matters, is what people strive for? We seem to add barriers rather than take them away.
My Lords, having listened to the excellent contributions to this debate, I am sure that the Minister will have detected from their tone that most, if not all, of us approach these important matters more in distress and perplexity than in anger. The opening speech from my noble friend Lord Colwyn covered the issues admirably, as one might expect from someone who knows dentistry from the inside. I am sure that the Minister will know him for the professional that he is—a man whose chief aim is always to present a case in a manner that is both balanced and free of unnecessary political brickbats. Making party points is not the object of today’s exercise; the object is to try to expose what is really going on in dentistry and to look for ways in which the situation might be improved.
Perhaps when the Minister replies she will assure us that, despite a few initial hiccups—I am avoiding the phrase “teething troubles”—everything will be all right. That seems to be the position taken by our very able and conscientious Chief Dental Officer, to whose efforts I pay tribute. Indeed, I note that only a few weeks ago Dr Cockcroft was quoted as saying:
“All the things that were missing previously—the dental workforce, the money, are now there—and the extra 11 per cent funding we are putting in from April. It will take longer in some areas than in others but certainly all the basics are there now to deliver a really functioning fully comprehensive NHS dental service for anybody who needs it”.
Dr Cockcroft clearly believes those things; his confidence should not be lightly dismissed. The problem, as my noble friend pointed out, is that the profession is saying something quite different. I happen not to believe that this is scaremongering or dog-in-the-manger behaviour. Most dentists, in my opinion, are supporters of the NHS and would dearly love to be able to deliver NHS dental care. But the fact is that we are not yet seeing the necessary numbers of dentists coming forward and signing up, or the necessary increase in the number of patients. Why is that?
I believe that my noble friend had the answers. It is for a mixture of reasons. The first one is to do with the dental contract. The contract is perceived by dentists as being fraught with risk. Dentists are professionals who run independent businesses, as a number of noble Lords have emphasised. They are willing to stand up and be judged on the strength of their professional abilities but they do not need the added risk of a contract that can penalise them financially through no fault of their own. Indeed, there is a real sense in which the more conscientious a dentist is, the more likely he is to be financially penalised. That cannot be fair or appropriate.
The UDA is a rather strange animal. It is not like the tariff that operates in NHS secondary care. The UDA does not purport to reflect the amount of work that a dentist actually does, nor is its value the same for all dentists. Certainly, there is a case for flexing the value of a UDA in an area with a shortage of dentists and high dental need, but the variations in value do not always have that sort of logic behind them.
For as long as the dentistry budget of a PCT is based on historic spending levels in that geographic area, which many budgets have been, the total amount of money available may well fail to address unmet patient need. It was very interesting to read the report published last month by the Patients Association, The New Dental Contract—Full of Holes and Causing Pain?. The first question that PCTs were asked was: in 2006-07 is funding designated for dental services ring-fenced or floor-funded? Floor-funding is the minimum spend for a PCT on a particular activity. You might have thought that every PCT would have given the same answer, but they did not—87.7 per cent of PCTs said that the funding was ring-fenced; 12.3 per cent said that it was floor-funded. The result in any given area could be vastly different depending on the way in which the money was treated. It would be helpful to hear from the Minister whether, based on those answers, she believes that some PCTs may be labouring under the misapprehension that the ring-fencing of money precludes or discourages them from topping up their funding for dentistry from their general health budget if they believe that there is unmet dental need.
The other main reason why dentists do not like the contract is that, in their eyes, it does not enable them to do what they want for their patients, which is to take a more preventive approach to care. The noble Lord, Lord Teverson, and others mentioned that. Dentists are not rewarded for prevention. Indeed, for NHS dentists, time taken in giving preventive advice is time lost from doing work that earns them money. The dental contract does not contain any equivalent to the quality and outcomes framework for GPs, under which dentists would be able to earn points for improving the dental health of their patients. The only measure used to determine whether or not a dentist has fulfilled the terms of his contract is the number of UDAs that he has worked.
If you take those two points together—the difficulty for dentists of expanding their NHS work beyond the envelope dictated by the available UDAs and the lack of incentives for preventive care—you start to question whether the current dental contract is fit for purpose. Its purpose was, of course, to achieve two main things: to widen access to NHS dentistry and to end the treadmill effect of the previous dental contract by enabling dentists to focus on preventive care rather than on interventions. It is true that the new arrangements have greatly simplified the charging structure for patients. I have always applauded the Government for being bold enough to do that. But simplification can be overdone.
From the patients’ point of view, we know from the survey carried out by the Patients Association as well as that carried out by the Commission for Patient and Public Involvement in Health last year that patients are confused by the new contract and how to access regular care. This may well explain, at least partially, the rise in hospital admissions that my noble friend referred to. A priori you would have thought that having the same charge for three fillings as for one would mean that the patients most in need would be seen and attended to, but we know that that is not the way in which the system is working in some places. Dentists are becoming choosy about whom they take on, because, given the choice, it makes financial sense to take on the less complex patients. That perverse incentive is a further drawback to the current arrangements and surely has to be addressed. The latest figures available show the continuation of a worrying trend. We are seeing a steady and significant decline in the number of adults who have seen an NHS dentist within the past two years. In some areas, such as the south-west, the problem seems to be particularly serious.
From this year, the dentistry budget will go up by 11 per cent. That is an important step and I welcome it. But I say what I suspect the Minister knows: by itself the money will not do the trick. Two years ago, when the new contract came in, we and many others said that PCTs were woefully ill equipped to commission NHS dentistry. In some PCTs, I am sorry to say, those commissioning skills are still absent. The Chief Dental Officer more than hinted as much the other day and the Minister, Ann Keen, in her evidence last month to the Health Select Committee, conceded that,
“some PCTs need much more support”.
That is certainly right. It is not just a matter of throwing money at the problem and hoping that it will resolve itself. PCTs need to start commissioning much more smartly. To begin with, they need to look carefully at the guidance on successful procurement issued by the department last month. Among other things, the guidance urges PCTs to learn about best practice from other areas. There are success stories around, such as Sandwell PCT, where the number of NHS patients has gone up. Meanwhile, the Government have taken what I believe is the necessary step of continuing the ring-fencing of funds for dental services for another couple of years. It would have been risky in the extreme to do anything less.
However, we come back to that contract, in which the faith of the Chief Dental Officer continues to reside. I am really doubtful about it. The BDA believes that as many as 1,000 dentists have been lost to the NHS since April 2006 and, contrary to the recent pronouncement by the Secretary of State, it is younger dentists who are proving less enthusiastic about doing NHS work than older ones. If we cannot attract the young professionals, where as a nation will we be in five or 10 years’ time? The Government do not have long to rescue the situation. For all our sakes, I hope that they can do so.
My Lords, I thank the noble Lord, Lord Colwyn, for initiating this debate. It has been an interesting discussion featuring our two dental experts, including the noble Lord, Lord Roberts, who seems to be working very hard today. I thank all noble Lords who have participated for their informed, interesting and varied contributions. I shall attempt to address the questions that have been raised but, should I fail to do so, I will write to noble Lords.
From the outset, it is important to say that our record on dentistry is strong, so I refute the suggestion from noble Lords that the system is failing, and I shall say something in support of that. England is a leader within Europe in improving oral health. According to the World Health Organisation database, our 12 year-olds have the best oral health in Europe, measured by decayed, missing or filled teeth.
Through the 11 per cent increase over the current year, our dental funding allocation for the NHS in 2008-09 will be £2,081 million, net of patient charge income. Therefore, this Government are demonstrating their commitment to improving access to dental services. That figure is 56 per cent higher than the net spend on dentistry in 2003-04, and more than double the equivalent spend in 1997-98— an increase of 117 per cent.
We are increasing our dental workforce. In July 2004, we launched Project 1000 with a commitment to recruit the equivalent of 1,000 more dentists. In fact, we exceeded that target. By October 2005, we had recruited the equivalent of 1,453 new whole-time dentists, including those returning from employment breaks and overseas dentists. We have also raised the number of dentists in training by 25 per cent. The first new cohort of additional students will graduate next year. We have established two new dental schools. We now have more than 4,000 more dentists than there were in 1997 and 300 per cent more dental care professionals. To ensure that the additional dental students will be able to pursue their careers in the NHS, last month we announced that new funding of £32 million will be made available to fund more vocational places. I hope that that addresses some of the concerns expressed by the noble Baroness, Lady Gardner.
The Government’s starting point is to begin to rectify the longstanding access issues caused by the previous system, described so ably by the noble Lord, Lord Teverson. Thus, through the changes introduced in April 2006, we have given the local NHS the power to control its local services. Under the 1990 contract, if a dentist reduced or stopped his or her NHS work, there was very little that the local PCT could do to replace the lost services. Under the new system, the funding for that service remains with the local NHS, enabling it to build and plan a sustainable service to meet the local needs of the population, rather than the piecemeal system we had before.
We have radically simplified the patient charging system, to which reference has already been made, scrapping the confusing tariff of 400 charges under the old system. Now patients’ treatment falls into one of three clear payment bands for courses of treatment, on which noble Lords have expressed some doubts, rather than fees for each item of service. We have reduced the maximum charge from £384 to £198, directly benefiting those with poor oral health. The reforms have also allowed us to remove the exclusive focus on active treatment and allowed dentists to concentrate more on preventive treatment.
The noble Lords, Lord James and Lord Teverson, both raised the issue that the new system has merely swapped dentists from one treadmill to another. This misrepresents the nature of the reforms. In fact, the noble Lord, Lord Teverson, did not make that criticism. For many years, dentists had complained that the old fee-per-item system created a treadmill effect and gave no time for preventive care. The new system, which we developed in close consultation with the British Dental Association and other stakeholders, guaranteed dentists the same income for delivering 5 per cent less activity than they did during the reference period. That enabled dentists, without any financial penalty, to spend more time on preventive care.
The noble Lord, Lord Colwyn, asked why the Government’s view of the reforms appears to be out of step with some of our stakeholders. I am not going to pretend that everyone is happy—clearly, that is not the case—but with any major reform there will be people who will be unhappy and for whom it will take time to recognise the benefits of the new system. However, the citizens advice bureaux have stated publicly and repeatedly that they welcome the reforms and regard them as a sound basis on which to build dental services.
I suggest that lots of committed NHS dentists have realised, as the reforms have bedded down, that this is a workable system. The commitment that the reforms represented to NHS dental services is something that mainly private dentists may be uncomfortable with because if they have business models based on a local shortage of NHS services the resurgence of the NHS on dental services will, rightly, challenge them.
The general welcome for the 11 per cent funding uplift, the clear upsurge of interest from corporates in providing NHS services, and the fact that PCTs generally report no difficulty in attracting dentists to provide new services suggest a rather different picture from the one in the headlines. Tackling the problems that began in the early 1990s will not be an overnight job, but the Government are very serious about getting NHS dentistry back on track.
As I have mentioned, we appreciate just how big a change the reforms were for PCTs and the dental profession alike, and we have continuously offered support during this process. The noble Lord, Lord Colwyn, is correct to say that those local relationships lie at the heart of the improvements that need to take place.
As well as making year-on-year increases in the funding available to PCTs to commission dental services, we have made increasing access to dentistry a national priority in the 2008 operating framework. We have also extended the ring fencing, mentioned by several noble Lords, of dental funding to 2011. I will address the issue raised by the noble Earl, but I shall take some time to explore what seems to be a misunderstanding by some PCTs on the position. I promise to get back to him on that. We are seeking to offer commissioners further stability when planning their dental services over the next period.
I hear the concerns raised by the noble Lord, Lord Colwyn, and others about PCT funding. Dental budgets are now allocated net of patient charge income for good reason. The reforms give local control and management of NHS dentistry to PCTs so that they can determine what dental services are commissioned in their area. But as the amount of patient charge income is largely determined by what services are commissioned and how those services are delivered, it makes sense for the local body to oversee the whole dental budget. We cannot plan centrally for the effects of such local decisions. For example, a local decision to prioritise orthodontics or other services for children will directly affect patient charge income and needs to be based on local priorities and assessment of needs.
Patient charge revenue was reduced in the first year of the new system. It is too early to measure the settled-state level of patient charge income under the new system but the indications are that 2007-08 will see patient charge levels closer to those predicted. We have provided guidance and data to PCTs to help them and their dentists understand the local factors affecting levels of charge income and to help them correct any problems that may have arisen as the new system was bedding down. We have also provided, and continue to provide, practical support and guidance to PCTs on commissioning appropriate dental services. These have been both direct from Department of Health officials, including the chief dental officer, and through the primary care contracting team, who are experienced NHS managers providing hands-on, tailored support to PCTs as well as a whole suite of guidance available to all dental commissioners through the website. For example, we will shortly be issuing updated guidance to PCTs on handling end-of-year issues with their contract holders, which I know is an issue of particular interest, as has been mentioned by noble Lords several times during the debate.
Annual service levels are agreed between the PCT and the dentists at the beginning of the year for all existing dentists and will be based on the actual patterns of service the dentist provided under the old contract. Ninety-seven per cent of contracted activity was delivered in the first year of reforms. Indeed, Suzie Sanderson, chair of the British Dental Association’s executive board acknowledged that in the press release issued on the subject. She said:
“We know from our own research that many primary care trusts have shown understanding when examining end of year issues.”
The BDA’s own research showed that in 25 per cent of underdelivered contracts, PCTs had written off the shortfall entirely. However, PCTs have the responsibility, as the local commissioners of dental services, to use flexibility and choice within the new contract to handle such end of year issues as they feel appropriate. If they feel that necessary resources are not being used effectively they can re-invest them in other local dental services to help ensure that patient demand is met.
On the flipside, I heard the noble Lords, Lord Colwyn and Lord James, describing practitioners with the reverse problem of delivering all their contracted activity before the end of the year. The only reason that they would have to shut up shop early and head for the golf course, as the media have recently reported, and which the noble Lord, Lord James, mentioned, would be if they were spending less time with their patients than they had done previously. PCTs have the flexibility to increase contracts where this is appropriate and have guidance on providing alternative care to any patients affected by a dentist meeting his contract too early. While we are not content when even a single patient remains affected, we are pleased to say that anecdotal reports suggest that this has been far less of an issue this year than it was last year. PCTs have used the support I have just outlined greatly to improve the provision of services across the country.
For example, the community dental access project set up by Tower Hamlets PCT in 2003 brings the dentists to the community through a range of dental services. Tower Hamlets has historically been an area of poor oral health and low uptake of dental care. The project, which has been developed at every step with the local community, uses a fleet of mobile dental surgeries to travel out into the heart of the community to locations selected by the local community. Both screening and treatment services are offered and the project uses link workers to help local people understand their dental treatment and how to access care.
The project has brought dentistry much closer to patients and the mobile services are very popular, with sometimes 100 people being screened in a day at a community event. However, I can assure noble Lords that the Government are not looking through rose-tinted spectacles, and we know that we still have work to do to ensure that everyone in this country who wants to see an NHS dentist can do so quickly and easily.
Several noble Lords said that the number of patients accessing NHS dental care has dropped by 0.5 million in the 24-month period ending September 2007 compared to the 24 months ending March 2006. I need to make it clear that these figures do not reflect the current situation. The noble Earl referred to the figures. The most recently published figures cover September 2005 to September 2007. Around 4 per cent of services had to be replaced during 2006 when the reforms were introduced, equating to around 960,000 patients. The statistics show that drop.
I am pleased to say that the current picture is far healthier with access improving as new services open across the country. We know that PCTs across the country are commissioning new and expanded services and that there is no shortage of dentists putting themselves forward for these new contracts. Furthermore, the majority of PCTs now run dental access helplines quickly to match up patients seeking NHS care with the services available. However, because the data available are retrospective and look back over the previous two years, it will take a little more time for the current growth in access to work its way into the figures for the loss of service immediately after the 2006 introduction of the new system.
Several noble Lords mentioned surveys that show a bleak picture. Without going into too much detail, there are surveys and surveys; it is a mixed picture. The Citizens Advice/MORI survey indeed showed a need to improve access, but in publishing the survey, Citizens Advice also welcomed the extra investment that we are making precisely to that end.
The Greater London Authority survey published in November concluded that London is well served by NHS dentists and found that, although the majority of dentists said that they were willing and able to take on new NHS patients, there was a problem in persuading some groups in society to come forward for treatment, which is why I so warmly commended the Tower Hamlets outreach service. In other surveys, the Commission for Patient and Public Involvement in Health survey was based on a self-selecting sample. As a result, those findings must be open to question. For example, the claim that six per cent of the population has resorted to self-treatment would mean that 3 million people had done so, making DIY dentistry marginally more popular as a pastime than freshwater angling. I suggest that that is probably not the case.
My key point is that primary health care trusts are commissioning new services now. We are starting to see reports in local newspapers that reflect that from places as far afield as Gainsborough, Wantage, Newquay, Plymouth, Norwich and west Essex—the sort of places where access problems have been most acute.
The noble Baroness, Lady Finlay, and others, raised the issue of hospital admissions for dental problems. I will not repeat myself by talking about the new services being commissioned, but I am sure that noble Lords will be interested to hear that the proportion of all dental admissions that were emergency admissions has dropped from 8.1 per cent in 2005-06 to 7.4 per cent in 2006-07. The article used the overall rise in emergency admissions, while omitting the fact that, as a proportion, dental admissions were down.
However, dealing with access is only one part of reforming the NHS. We need a quality service. The noble Lord, Lord Colwyn, raised the issue of the NHS next stage review and how dentistry fits into it. In 2007, my noble friend Lord Darzi invited stakeholders, including the British Dental Association and the General Dental Council, to submit their policy ideas to the review. They responded to that invitation and attended the national stakeholder forum to discuss their concerns.
The noble Lord, Lord Colwyn, also asked why the Patients Association poll of MPs showed that dentistry topped the concerns in correspondence. I acknowledge that there are concerns about access to dentistry; that is what this debate is about. In fairness, there are some long-running problems. As I said, our increased spending on dentistry and the inclusion of dentistry in the NHS operating framework is starting to address that issue.
The noble Lord, Lord Roberts, raised the issue for Wales. As he will be well aware, dentistry in Wales is a matter devolved to the Welsh Assembly, so I have confined myself to issues concerned with English dentistry. The noble Baronesses, Lady Finlay and Lady Gardner, and the noble Lord, Lord Roberts, raised the issue of the proportion of adults and children who have no access. There has never been a time when more than 60 per cent of the population was in regular touch with an NHS dentist. My noble friend Lord Desai explained why that may be the case. That is almost certainly not a satisfactory position, but back in 1993, when there was no access problem, 40 per cent of the population chose either to go private or to go less regularly than every two years. We are determined to increase access: that is now an NHS priority. We need to be clear about the number of people who are using NHS dentistry.
The noble Lord, Lord Roberts, talked about charges and whether they should be scrapped. We think that it is better to have a system that exempts people in hardship from payment while charging those who can afford to pay. I should make it clear that half of all NHS patients in England are exempt from charges.
The noble Lord, Lord Roberts, and the noble Baroness, Lady Gardner, raised the issue of dentists needing to be adequately compensated for NHS work. The figures from specialist dentists’ accountants show that NHS dentists’ earnings have increased since 2005-06. Single-handed dentists now earn more than £100,000 a year. Indeed, dentists’ expenses have fallen because the proportion of complex treatments has fallen, as we expected, under the new contract.
The noble Lord, Lord Colwyn, and the noble Baroness, Lady Gardner, raised the issue of income guarantee for dentists. Existing dentists’ gross income was guaranteed for the first three years of the new system, but where practice has changed and dentists’ costs have gone down, it is right that the PCT can renegotiate. The extension of the budget ring-fence shows the Government’s commitment. Within this, the NHS is entitled to expect a fair price for a quality service.
The noble Baroness, Lady Gardner, raised the issue of the claw-back of funds because of the income guarantee. Dentists were guaranteed no less income than they earned under the old system. Activity is set at a level delivered under the old system, so if they do less work now—in other words, if they do not do the work that they have agreed to do—the NHS rightly reserves the right to ask for funds to be given back.
The noble Baroness, Lady Gardner, also raised the issue of dental products and lead in imported fillings. I recognise her concern, but I should add that dentists are responsible for the quality of the materials that they use and, as she will know, they must satisfy themselves that the products they use are of the required standard.
My noble friend Lord Desai was the one person who mentioned school dentists. In 2006, the National Screening Committee considered research into school dentistry and discovered, unsurprisingly, that middle class children were generally registered with a dentist, and that the parents of children in more deprived circumstances often failed to act on the advice that had been sent from schools and those children remained untreated. On the basis of this advice, we believe that the most effective method of improving the oral health of children is not the re-establishment of the school dental service but a combination of population-based inventions, such as water fluoridation—I am pleased that no one mentioned that today, although I have two pages on it—toothpaste schemes that build on the Brushing for Life initiative, improving access to NHS dentistry generally, and running campaigns that encourage families with children to visit their dentist regularly.
The noble Baroness, Lady Finlay of Llandaff, in her usual erudite and informed contribution to the debate, raised a number of important clinical matters, including patients with muscular dystrophy and cancer and the detection of oral cancer. With her permission, I will explore those and come back to her.
The noble Earl, Lord Howe, talked about the number of dentists and the fact that not enough are coming forward to do NHS work. In fact, PCTs at present report no shortage of dentists seeking to expand their NHS activity. For the first time in decades, dentists are competing to provide NHS care. It will take time for the new money to feed through to the new services, but it is not true that recruiting is the problem. The noble Earl highlighted the need to ensure that the money is effective, that it is going to the right places and that we are monitoring it in the right way. We all need to watch that.
The noble Lord, Lord Teverson, said that he felt fear coming into the Chamber, given that two dentists are present. I did not, because I have always had very good experiences with my dentist. The hygienist is a different matter, but it is probably better that we do not go there at this point.
I conclude our discussion today by reinforcing the point that the dental reforms of 2006 were an essential step towards solving the problems created by a previous treatment-focused, provider-led scheme. The reforms for the first time put the power into the hands of the local NHS to plan and to provide dental services to meet the local needs of the population. I reiterate our commitment to improving access to NHS dentistry. I thank the noble Lord, Lord Colwyn, again for bringing this subject to our attention and I thank all noble Lords for contributing to today’s debate.
My Lords, it remains for me to thank all noble Lords who have taken part in this debate. I am grateful for their input. It has been an interesting afternoon. I have written one or two witty remarks about each speech, but in view of the two items of business we have yet to do, I will not say them, except to say to the noble Lord, Lord Roberts, that I regularly used Super Glue when I was in practice and if you want to pull your own teeth out, a screwdriver is far more effective than a pair of pliers.
I thank the noble Lord, Lord James, for mentioning laboratory bills. The problem that technicians have is something the Government have also got to keep a very careful eye on. Finally, the noble Lord, Lord Teverson, talked about dental tourism, which is fine as long as nothing goes wrong. I thank the noble Baroness, Lady Thornton, who covered all the items beautifully and I look forward to reading her speech in Hansard. She commented briefly, I think, on The NHS in England: The Operating Framework for 2008/9, published in December 2007, and the document, Commissioning NHS Primary Care Dental Services: Meeting the NHS Operating Framework Objectives, published in January 2008. I hope that the introduction of those documents will be thoroughly discussed with the profession and its leaders before being imposed.
Many dentists think that the contracts are unfair and unworkable. The shift towards private practice is not to earn more money. It is to create a stable, long-term environment to enable adequate investment in premises and modern equipment, and to spend greater time providing prevention-based care for patients. I beg leave to withdraw the Motion for Papers.
Motion for Papers, by leave, withdrawn.