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House of Lords Hansard
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NHS: Dentistry Services
25 July 2019
Volume 799

Motion to Take Note

Moved by

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To move that this House takes note of the availability of National Health Service dentistry services.

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My Lords, I declare my interests as a retired dentist and a national health pensioner. It is good that we have this opportunity, on the last sitting day before the Recess, to debate the present situation. The Table Office produced the wording about the “availability” of NHS dentistry. Sadly, a more accurate title would refer to the lack of availability, as whole areas of the country have no dentists offering NHS treatment.

Many Australian dentists came to Britain at the time I did, in the 1950s. That was because there was no work for many new graduates in Australia. At the end of the Second World War, places at university—in my case the University of Sydney—were offered to anyone who had served in the forces. Teaching had to be on a sessional basis, so the laboratories and clinics were in constant use and able to produce many more dentists than if they had just the one session a day.

When many Australians came to Britain in the 1950s, there were about 150 new dental graduates each year, but there was work for only about 50. In Australia, dentists got jobs digging dams or making roads—anything that could provide a job for a living wage. No one seems to know who discovered the need for dentists in the UK, but word spread quickly and hundreds of new Australian dentists arrived by ship at Tilbury—there was no such thing as a quick flight in those days. Colleagues were on hand to explain how to register, obtain dental practice insurance cover and find a job. My knowledge is of the London area: there were plenty of jobs going and lots of children were in desperate need of dental treatment.

It was a shock to discover that a popular 21st birthday gift in the north of England was a full clearance of one’s permanent teeth. That is hard for us to believe now, when we would do anything to save our teeth. While some dental implants are done in the UK, I keep meeting people—even staff who work here—who tell me that they have taken up an offer to go to Budapest to have crowns fitted because it is cheaper there and very well organised. It really is a different world, dentally, from that of the 1950s.

When it was discovered who needed dentists in the UK, people found themselves going to different areas of the country. Their descendants remain in many of those places. I came in the early 1950s and was given a right to stay for six months. I think I asked to stay for a year, but was told, “No, no, we’ll only give you six months”, so I took it. By the end of the six months, they were willing to give us a bit more because, by then, we were involved in the National Health Service.

I served on the local dental committee and the Inner London Executive Council, and I was the first woman ever appointed to the Standing Dental Advisory Committee for England and Wales. That was in 1968.

Kevin, my husband for 50 years, arrived about a year after me. That was because he had won the oral surgery prize. If you had achieved such a special result, you were offered a year on the teaching staff in Sydney. A number of graduates did that and then came over the following year. We eventually bought a dental practice from an elderly Canadian dentist in a poor area on the fringe of the City of London. The houses were all red brick, 200 years old and owned by St Bartholomew’s Hospital. The whole area had quite bad subsidence. As you sat in the dental chair in the surgery premises, you saw that the doorway ran downhill—or uphill, depending on which way you were looking at it. It certainly was not level, and it was pretty worn out by the time we got there.

Many people wanted only a tooth out. We used to charge half a crown, but there was a donation to put in a bottle. That suited a lot of people, because they came in only if they were in trouble with pain. People were not minded to go to the dentist for routine things except, as I mentioned, in the north of England, where things were quite different.

During the years we were there, the area was gradually taken over through compulsory purchase by the GLC, which demolished the lot and rebuilt. It is hard to believe how grim the area was in those days, yet it had a wonderful atmosphere. Patients usually came from their houses in carpet slippers and hair rollers to have whatever was needed done to their teeth. They all went hop picking in Kent, which was how they afforded summer holidays. It is different now; no one goes hop picking because it is all done by machine. Who would have believed that that funny little old area would now be considered so smart? Old Street is the place for high technology; it has come a long way since we were there. A lot of people have been rehoused further out.

It is extraordinary that the number of adults seen by an NHS dentist has fallen in recent years. That surprised me; even if only those who had been going had kept going, the numbers should not have fallen. I do not understand why that is. Perhaps people have moved out; perhaps more people live further out; perhaps they want a dental practice closer to where they live. I was surprised to read that Portsmouth does not have a single dentist offering to take NHS patients; that has not been widely publicised. The numbers seen —in thousands—are set out in the briefing that I know has been sent to most noble Lords.

Also extraordinary was the speech made by Kenneth Clarke, which reversed the situation. In 1988, Kenneth Clarke wanted to introduce national health examination fees. In those days, noble Lords used to go and have a bit of a snooze in the big chairs in the Library after lunch—they are more active now. I went in and said something a bit noisy to wake them up, and then asked them to come into the Chamber and listen to the debate. I did not want to make up their minds for them; I just wanted them to hear what was said. They did, and this House voted to retain free dental examinations. The Bill then went back to the Commons, where Kenneth Clarke made a lengthy speech about why the Commons should agree to reverse the position back to what it had been. He also attached financial privilege so that we could not debate it again. That was a tragic situation; the opportunity had been there, but it was the beginning of the end for national health dentistry.

National health dentistry is now not meeting people’s needs and the biggest worry of all is treatment for children. If they do not get treatment early in life, when they really need it, you can never reverse the damage once the baby teeth are lost. I read in the Manchester Evening News that children are willing and able to have dental treatment under general anaesthetic and huge numbers of clearances are being done, but no one is willing to take on general treatment. There are no general anaesthetic slots available for other operations in Manchester because the clearance of children’s teeth is taking up the full capacity for treatment under general anaesthetic. That is a sad situation and I hope something will be done about it.

I hope today’s debate will send a message that we want NHS treatment to continue. It is very important for those receiving dental care to have that facility available. I beg to move.

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My Lords, I thank the noble Baroness, Lady Gardner, for initiating this debate. I remember a similar debate in the Moses Room about two years ago. I knew nothing about dentists or dentistry, but I was on the subs bench and had to speak on the topic. I learned so much from that debate and I hope that that learning experience continues. I am conscious of the fact that I am among people who have given a lifetime to the profession. I also thank those organisations that sent some stunning briefings; particularly our own House of Lords Library and the Royal College of Paediatrics and Child Health.

The title of the debate concerns the availability of NHS dentistry. If you live in Barrow-in-Furness, it is a 90-mile round trip to see the dentist. It is the same in Whitehaven, Windermere, Bodmin and King’s Lynn. Morecambe is not exactly in a remote part of the country—I declare an interest in that my wife, like Thora Hird, is from Morecambe—yet it is a 61-mile round trip to see a dentist. It is the same in Plymouth. Tim Farron, the MP for Westmorland and Lonsdale, in a debate in the Commons in July this year, said that the situation “has reached breaking point”. For those who have to travel, it is not just the cost of going to the dentist, it is the cost in travel. Will the Minister, in replying, address those difficulties?

It seems to me that whether we are the fifth- or sixth-wealthiest country in the world, it is surely not acceptable that 31% to 41% of five year-olds across the UK have tooth decay. It is particularly unacceptable that those young people are concentrated in the most deprived communities of our country. Of course, we all know that tooth decay is the most common single reason that children aged between five and nine are admitted to hospital. Not only could we do something to sort out decay in children’s teeth—we will come to that in a moment and we will all have contributions to make—we could do something about waiting lists and waiting times in our hospitals. Just imagine the time we could free up if we did something about this, because tooth decay is entirely preventable.

NHS dentists struggle to see even 55% of the population in a one-year period. Lack of access to emergency dentistry is often seen as contributing to overcrowding in hospital accident and emergency departments. The British Dental Association claims that 380,000 patients a year with dental problems are approaching their general practitioner—what? We know that in England dentists are now paid in units of dental activity—UDAs; I learned about this last time, and I spoke to one of my colleagues. Typical values for these units are £20 to £35. They are paid at one unit for a band 1 course of treatment, three units for a band 2 course of treatment, and 12 units for a band 3 course of treatment. For many treatments, the rate of pay is below the cost of providing the treatment to a modern standard and, as a result, many dentists will refer patients for any unprofitable services. I raise this, and I hope the Minister can give more details, because I do not quite understand it.

I asked Adam, my dentist, “How do you ensure that more young people are treated by an NHS dentist?”. He replied, “Ah, Mike, the problem is UDAs”. Each practice is given so many UDAs to treat children, and when they are used up, they cannot treat any more children. The problem is that in affluent areas, dentists will have UDAs left, which will go back to the Treasury, but in deprived areas, the UDAs might finish after six, eight or nine months. Why can we not transfer the surplus UDAs from the affluent areas to those areas? I do not understand that, and I would be grateful if the Minister could explain it, making it simple for me—keep it simple for a simple person—so can I understand how we can use UDAs effectively to treat young people’s teeth.

Poor oral health can profoundly affect an infant or child’s health and well-being. A quarter of adults do not think that it matters if their child develops cavities in their baby teeth, and admit to a lack of knowledge about oral health. There is a common misconception that baby teeth do not matter. However, they are essential for speech, the structure of the space, and for holding space for adult teeth to grow into. Decay can lead to not only infection and discomfort but potential damage to the teeth below. It is therefore essential that parents take their children to the dentist as soon as possible and understand about tooth decay and good dental practices. That is why I regret the closure of Sure Start centres and the reduction in the number of children’s centres. Those were ideal places for parents to learn about the importance of not just dental care but baby teeth, and how parents should be encouraged to look after the child’s baby teeth for the very reasons I have given.

In recent years, although the number of children being seen by NHS dentists in England has increased, as we know, the number of adults has seen a falling- off. This decrease has partly been attributed to labour shortages in the NHS and dental practices, and dentists scaling down their commitment to the NHS or leaving entirely.

On the question of fluoridisation, as we know, fluoride is a mineral that prevents tooth decay and can be added to drinking water, salt or milk as a means to promote oral health. The excellent briefing from the House of Lords Library, which I do not need to repeat, explains how and where that is happening. However, I remember how, as a young head teacher, my progressive local authority—which was in fact Labour-controlled; should I say that?—introduced what was called dental milk, which had the correct amount of fluoride in it. That was a deprived community, with some of the worst dental problems in the region, and parents could choose between the dental milk in a green carton, or ordinary milk in a white carton. Guess what—99% of parents chose the dental milk, and the visiting hygienist said, “Mr Storey, your children’s teeth are improving year by year”.

I regret that for all sorts of reasons—perhaps a fear of fluoridisation—dental milk is not as prevalent in our schools as it used to be. Could the Minister reflect on that issue and say what government might do about it? A study in Scotland—never mind my school in Knowsley—where a similar scheme was in place found that decay rates fell by 48% among five and 10 year-olds who were drinking dental milk. I know that there are legal problems, and so on, but it seems that we are silly not to have developed that opportunity.

Healthwatch produced a fascinating briefing. It states that one theme that has consistently cropped up is that of dentists lacking knowledge or training to be able to treat individuals with learning disabilities, autism or special needs. I had not thought about that, but I should have thought that part of a dentist’s training should be in treating people who are autistic or have a particular special need, or that there were, as there are in America, child-friendly practices and practices which can cope with people with special needs.

We can eradicate tooth decay. It is very simple to improve dental health. It need not be expensive. Most parents can afford to buy a toothbrush and toothpaste. Schools should be willing, particularly in the early years, to work with parents and children to develop good oral hygiene. I remember when the hygienist visited every school up and down the country every year to check the pupils’ teeth. No doubt the Minister will tell us about particular programmes that are operating. That is great, but we want it right across the country, not limited programmes. Why can we not go back to a system where the equivalent of the school nurse, the hygienist or the dentist comes into school and checks young people’s teeth to see what the damage is or what needs to be done and then works with the parents to ensure that children get the treatment they deserve?

I am not going to talk about sugar in food and drinks—I am sure that other noble Lords will raise that. Children should receive their first check-up as their first teeth come through, recorded on their personal child’s health record. Together, we can eliminate tooth decay from our country.

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My Lords, like my noble friend Lady Gardner, I declare my interest as a fully retired dental surgeon with more than 40 years’ experience. I am a fellow of the British Dental Association and vice-president of the British Fluoridation Society. I thank my noble friend for securing this debate. I also welcome my noble friend Lady Barran, who joins a select group of Peers who understand dental politics. It will only get better, I am sure.

Noble Lords will know that I take every possible opportunity to raise the issues of oral health and dentistry in the House, as these important subjects are all too often overlooked. I am pleased to have another chance to highlight the growing problem of access to NHS dental services today, even though so few colleagues are able to be here on the very last day of the parliamentary Session—and the hottest.

More and more studies now confirm what dentists have always suspected: that a healthy mouth is a gateway to a healthy body and that neglecting oral health can sabotage our long-term overall health. Tooth decay and gum disease are increasingly linked to a heightened risk of serious health problems such as stroke, heart disease and diabetes, yet we continue to treat NHS dentistry as a Cinderella service by not giving it the importance it deserves. Government funding for NHS dentistry per capita in England has fallen by 29% in real terms since 2010. At the same time, patient dental charges have gone up by an inflation-busting 5% in each of the past four years, despite studies showing that rising charges discourage patients from seeking the treatment they need.

Underfunding NHS dentistry might seem tempting at a time of great pressures on the NHS as a whole, but such thinking is short-termist and wholly counterproductive. Patients who cannot find an NHS dentist or delay treatment due to its cost can end up piling huge pressures on other parts of the NHS. Every year, thousands of patients seek free help with dental pain from their GPs or the local accident and emergency department, neither of which is equipped to help them. If you add the cost to the economy of sleepless nights and lost working days caused by tooth pain, it becomes even clearer that cutting dental services is not only bad for patients but a false economy.

It is appalling that only half of adults in England have seen an NHS dentist in the last two years and that more than four in 10 children in England have not seen an NHS dentist for over a year, even though ideally they should have a check-up every six months. We must make sure that we improve access to NHS dental services, so that both children and adults can attend regular check-ups and get a timely diagnosis and appropriate treatment, if required, early on.

Whenever this issue is raised, Ministers assure us that the access rate to NHS primary care dental services remains high. Yet not a week goes by without a new story hitting the press about shocking waiting lists and journey times faced by patients all across England looking for an NHS dentist. We have heard about this already today. Earlier this month we learned that in Cornwall the waiting list for an NHS dentist has topped 22,000, with people waiting 529 days on average. If you live in Windermere in Cumbria, the nearest practice able to accept new NHS patients is now a 104-mile round trip away; this would take over six hours on public transport. Not a single dental practice in the entire city of Portsmouth is able to take on new NHS patients. The list of examples goes on and on. While the Government claim that these are isolated hot spots, it is becoming increasingly clear that this problem affects every part and region of the UK. Something needs to be done, and fast.

Morale among NHS dentists is at an all-time low. According to the British Dental Association’s last member survey, more than two-thirds of dentists with a large NHS commitment are planning to scale down their NHS activity or leave the service altogether in the next five years. Three-quarters of practice owners report struggling to fill vacancies—up from half just two years ago. Practices are closing in large numbers as they struggle to recruit and make ends meet under the current dental contract. Unless there is a change of direction, we will soon be facing an even greater exodus of dentists from the NHS. This brings into sharp focus the urgent need to deliver a reform of the dental contract.

Last April saw the 13th anniversary of the introduction of the current dental contract. This contract is not only widely detested by dentists themselves and discredited by health policy experts, but, equally importantly, is bad for patients as it rewards dentists for carrying out interventions rather than keeping their patients healthy to avoid them. Dentists were promised a new, improved contract back in 2010, but with the fourth wave of so-called prototypes still testing possible new arrangements, it looks as if this badly needed reform is being kicked into the long grass. It is crucial that we stop dragging our feet and finally introduce a new, more preventive, contractual basis for NHS dentistry that would improve access for patients. Both dentists and patients desperately need this. Shifting the focus to preventive treatment would not only yield long-term savings but improve access to NHS dental services and quality of life across the country.

I share the concerns of the British Dental Association that the long-running prototypes remain the tarnished system of payment per unit of dental activity, alongside payments per capitation and quality. With tooth and gum disease linked to many other costly health conditions such as diabetes and heart disease, our health system cannot afford to wait much longer for the NHS to be commissioned in a way that makes a decisive break from activity targets and puts prevention squarely in the centre.

The BDA tells me that dentists want to be paid for keeping their local communities healthy, not for the number of treatments performed. That is what makes the most sense for the long-term sustainability of our NHS, too. We cannot achieve improvements in oral health with a system that continues to offer perverse incentives to treat instead of rewarding dentists for preventing disease.

As an absolute priority we need a new, improved dental contract; a focus on prevention rather than cure; and adequate investment in NHS dental services. These would ensure not only an improvement in access to NHS dentistry for patients but also better oral and general health outcomes for the British people. I hope that our new Minister will take note and I am grateful for her help in this.

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My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for raising this important matter today. She is, and has been over the years, a great campaigner for NHS dentistry services. Many people shy away from the subject, but it needs to be highlighted and I congratulate her on introducing this debate.

There is a shortage of much-needed NHS dentists at the present time, as has been said. Brexit is not helping, and I hope that if we leave the EU we will not lose some of the excellent dentists who come from EU countries. Many people go to Europe for their dentistry treatment because it is good and available.

In June 2019, the Care Quality Commission examined the adequacy of dental support for the elderly in care homes in England. Its findings revealed that 52% of care homes did not have a policy to promote and protect oral health, while 73% of the care plans it reviewed only partially covered oral health or did not cover it at all. In its conclusions, the Care Quality Commission argued that too many people living in care homes were not being supported to maintain and improve their oral health.

One of my part-time secretaries has a mother in a care home in rural north Yorkshire. She has told me that it is very difficult for those in residential care in north Yorkshire to access regular dental care. She noticed that residents with disabilities in the home had difficulties in practising oral hygiene and that overall their oral health is not good.

She tells me that there are long waiting lists at local dentists, some of which are not taking on more NHS patients, and that dentists in north Yorkshire do not routinely visit residential settings. She was told that she would have to arrange a dentist for her mother, but she has not managed to do so over the past seven months because of shortages. Before going into residential care, her mother visited a local dentist every six months, but the home is too far away from her home address to remain with that dentist. When her mother’s dentures were damaged, there was no access to a local dentist for their repair and her mother has had to manage without them. At that home, there does not seem to be a clear policy to protect and promote oral health on a daily basis or to cover residents’ dental health as part of their care plan. It is important for residents to be able to eat a nutritionally balanced diet, but any deterioration in teeth affects the ability to chew fruit, vegetables and meat, so it makes sweet options more attractive, although they are the worst foods for teeth.

Disabled people living in the community can also have problems visiting the dentist. Some time ago, schoolchildren in my part of Yorkshire did a survey of dentist practices and found that many were not accessible. After that, access improved and ramps appeared. The attitude of dentists towards disability can be very varied. Some are helpful, but others just do not want to be involved. How much training in physical and mental disability do dentists and dental nurses have? Understanding disability makes all the difference for people who have so many problems when they come for treatment.

Another vulnerable group where dentistry is concerned is the prison population. Having served for many years on the board of visitors at a young offender institution and having been a member of the parliamentary prison health group—when we had one—I would be interested if the Minister could update us on progress. With the dilemma now facing Feltham young offender institution, where young people are locked up for 22 hours a day, goodness knows what will happen if severe toothache strikes an inmate. There are few published studies on prisoners’ oral health in the United Kingdom, although some national centres have undertaken unpublished work. They have shown increased consumption of sugary drinks and foods, drug abuse and oral neglect in the prison population. The prison population in the UK and the USA is commonly from similar socioeconomic backgrounds but as we know, not all are. Prisoners are mainly socially deprived young males, but the number of older and very young prisoners is on the increase.

Many prison establishments do not have contracts with oral healthcare providers to run sufficient dental care sessions during normal working hours. Out of hours can be impossible. Dental services are generally demand-based, with prisoners requesting to see the dentist or being referred by a prison medical officer. There are services which struggle to meet prisoners’ express demands and have long waiting lists for treatment—that sounds also like the community. The Government’s Strategy for Modernising Dental Services for Prisoners in England needs to be updated as it is out of date. This is particularly important for the section on service provision, which perhaps underestimated the number of dental care sessions required per establishment. Unfortunately, this document is still used by some commissioners when planning dental services. I hope that, if she can, the Minister will update us on how the service is improving.

Three common behaviours among prisoners that have implications for oral health are smoking, excessive alcohol consumption and illegal drug use. There is a great deal of health education that should be promoted throughout the Prison Service. With the Green Paper on public health having just come out, I hope that the section on prevention will include dentistry for vulnerable groups and children’s oral health.

I end by saying that many improvements should and could be made so that the growing elderly population and disabled people living with complex conditions can have good dental care from dentists who understand their special needs, and thus have a better quality of life.

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My Lords, this has been a really interesting debate and—not always unusually for your Lordships’ House—very well informed. The noble Baroness, Lady Gardner of Parkes, who must have been a really inspiring role model as a young dentist, set the tone for the debate and painted a clear picture of dentistry in the past. To add to her point about having all your teeth extracted because it was the cheaper option, I have a friend who got married in 1975—the same year as I did—and for her wedding present, she had all her teeth extracted in her twenties and her father gave her dentures. I cannot get my head around the fact that that happened to a contemporary of mine in 1975, when the NHS was very well established.

My noble friend Lord Storey spoke—with all the understanding that comes with his background not only as a councillor but as a head teacher—about the scandal of tooth decay in children, and he mentioned fluoride in milk. I confess that I was not aware of milk containing fluoride—that was very interesting. He mentioned the closure of Sure Start centres, and I would like to throw in for good measure the reduction in the number of health visitors. Certainly when I had my babies, once the midwife had moved out, the health visitors came in and we were told quite clearly that sugar was not good for our children. Across the country we are several thousand health visitors light—4,000, I think—so this sort of information is not getting to young parents.

The noble Lord, Lord Colwyn, was a practising dentist for many years, so he too really knows what he is talking about. He emphasised the importance of fluoridisation and pointed out that all sorts of health problems are connected to poor dental health. During the time in which he practised, there was a decline in funding and a rise in charges, as well as a decline in children’s access to services. I am a bit puzzled about that. I appreciate that it is not always easy to find a dentist and I can understand why adults might resist going to the dentist because of the charges, but there are no charges for children’s dentistry, so in a sense there is no excuse for that.

The noble Baroness, Lady Masham, has an interest in dentistry going back many years and, like the noble Baroness, Lady Gardner, has spoken several times in debates on the subject. She raised the interesting issue of Brexit. Clearly, many dentists now come from EU countries and they need to stay—we cannot afford to lose them. The other issue that she raised, which I had not even thought about when preparing my notes, was prison dentistry. As people are captive—that is not quite the right expression, but they are in one place—there is an opportunity to sort out their health as well as their dentistry while they are in prison.

My early recollection of dentists, in the 1950s, is of a big van pulling up and parking in the car park opposite my primary school. We all trooped over for an inspection and were terrified, lest there be a problem to which the solution would be the pedal-driven dentist drill. It might not have hurt but it made a devil of a clatter, and that experience has stayed with me.

I declare my interest as in the register. When both doctors and dentists are being trained, they are not always told how to treat adults or children who have a learning disability. That is something well worth mentioning, and I am sure others would say the same. Dentistry is now light years away from that 1950s image that prevented me being a regular attender. It was not until I was at university—where, if you went to the dental school for your treatment, it was free, modern and overseen by professional teaching dentists—that I overcame my fear. My teeth were crowded and out came my wisdom teeth; I had a car accident and they were straightened. My student dentist was a rugby player and sang rugby songs to keep me calm.

All this is light years away from the treatment I receive now from my dentist in Horseferry Road. She is a tiny lady who comes up to only my shoulder, but she is absolutely forthright about my care, what I need, what she is going to do and why. We talk through options of NHS or private care for my treatments, and I am not allowed to leave without making an appointment for my next check-up.

I am fortunate: I can afford the treatment. It is worth mentioning that I live in Cornwall, where I have not been able to get an NHS dentist for 15 years. I was chair of a PCT and we tried very hard to attract dentists to come to live in Cornwall. It is a lovely place but it is a long way from everywhere and, very often, if dentists are married, their other half cannot get a job in Cornwall, and so it is not an option. That cuts across a whole load of things, and I suspect the situation is much the same in the Lake District. Areas of outstanding natural beauty are fine, but they are not always an ideal place for professionals of any sort to get jobs.

I shall talk today about the concerns of the dental profession about contracts and add something about the treatment given to old and disabled people living in care settings, and I have just mentioned the shortage of dentists in many parts of the country. A lot of this is linked to the need for a new contract for dentists and is a response to the issue of adults living in poverty and unable to afford treatment, which I shall mention as well. My noble friend Lord Storey has pretty thoroughly covered the issues around children and their oral health.

It is a sad fact that many people in the UK do not access regular dental care. Many homeless and vulnerable people are not registered with a dentist and put up with severe dental pain and infections, often masked by drugs or alcohol. Others who work long and unpredictable hours feel that taking time off work to visit a dentist is unaffordable and impractical; people with a history of mental health problems often face personal barriers to accessing dental care; and those who cannot afford treatment just do not register.

Until preparing for this debate I was not aware of the amazing charity Dentaid. Originally set up to recycle donated dental equipment to charitable dental clinics across the world, it has now set its sights back on the UK. It has equipped a mobile dental unit—I suspect a rather more modern version of the one I visited all those years ago—which visits homeless shelters, day centres and soup kitchens to screen, advise and treat those not registered for NHS care and, it goes without saying, unable to pay NHS fees. Volunteer dentists run the service, and it has been working in Kirklees for nearly five years. Since it began it has visited schools, community centres and Dewsbury town hall, offering free access treatment on a pay-what-you-can-afford basis. Patients just turn up and wait to be seen. It was commended to me by my noble friend Lady Pinnock, herself a councillor on Kirklees Council. This year, Dentaid received funding from the council to run a series of clinics in accessible locations. They are very busy and have treated hundreds of people.

On the one hand, I applaud Dentaid and Kirklees Council for the initiative, but on the other I really despair that these initiatives should be necessary at all. What work has been done to assist those who are unable to pay NHS dental fees? There is an NHS low-income scheme covering prescriptions and dental treatment, but it is not as widely advertised as it might be. Often the retort is, “Well, they can just look on the NHS website”, but it is unlikely that the first point of access for such patients is the website.

I turn to those living in care centres, which the noble Baroness, Lady Masham, mentioned. Has the Minister had an opportunity to read the CQC report on oral health called Smiling Matters? Three years on from when the NICE guidelines on oral health in care homes were published, the CQC carried out an inspection and concluded that poor oral health can affect people’s ability to eat, speak and socialise normally—though I am sure that the noble Lord, Lord Colwyn, will say that he could have told us that anyway. Most care homes had no policy to promote and protect people’s oral health. Nearly half were not training staff to support daily oral healthcare, and nearly three-quarters of care plans reviewed only partly covered oral health or did not mention it at all. As has been mentioned by the noble Baroness, Lady Masham, it can be difficult for residents to access dental care, and 10% of homes had no way to access emergency dental treatment for their residents. Given that most care homes are privately run, what can reasonably be done to turn this situation around? Could the Minister give some thought to that question?

I do not have enough time to adequately express the profession’s concern about its contract, which has been an ongoing issue for several years. My noble friend Lord Storey and the noble Lord, Lord Colwyn, covered this quite well. Why is this issue taking so long to resolve? Will the Government reassess both funding and charges in the new contract? The noble Lord, Lord Colwyn, said that the current contract is detested and discredited. It is all about interventions, not prevention, which sounds terribly old-fashioned in this day and age when everything about health is about promoting prevention. There are also perverse incentives.

How long must dentists wait? Could the Minister give us an indication of a timescale for this? Happy dentists will be less likely to leave the profession, and new dentists will join if there is a contract that is modern and suits not only patients but the profession. That is, after all, something that all of us want.

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My Lords, this has been an excellent and comprehensive debate, made particularly authoritative by contributions from former dentists. I thank the noble Baroness, Lady Gardner, for securing it.

The noble Baroness is quite right that there are many serious problems related to accessing NHS dentistry services that must be urgently addressed. We share her concern that large swathes of the country have been left without a dentist following the closure of multiple NHS dental practices. There are 14 areas where residents have to travel more than 20 miles to get a dentist as they are unable to register as a new adult patient locally. The noble Lord, Lord Storey, is right to stress both the health and personal effects of this, such as the cost of travelling expenses, which many will simply be unable to afford.

As we have heard, this is not a rural phenomenon confined to a handful of small villages; on the contrary, it is also true of large towns. The city of Portsmouth, which, I remind the House, has a population of nearly 400,000, is without a single NHS dentist accepting new patients, leaving over 1 million NHS patients with the option to travel or to miss out on the care that they need. That is simply unacceptable.

Regular dental checks, recommended at least every six months, are key to good oral health, disease prevention and early diagnosis of routine or complex conditions affecting the mouth, jaw and other parts of the body, given that dentists are able to spot early warning signs in the mouth that may indicate systemic conditions such as AIDS, cancer and diabetes. I liked the description from the noble Lord, Lord Colwyn, that a healthy mouth is the gateway to a healthy body. I think we would all agree with that.

Not being able to visit the dentist can potentially be very harmful to your health. It is imperative that the Government take urgent action to ensure that everyone has access to an NHS dentist locally. NHS England is responsible for helping people find a dentist locally through its customer contact centre. Can the Minister tell the House how many dental cases the centre deals with annually, what analysis is made of this information in terms of gender, age, ethnicity and location, and how the information is used to improve patient services and outcomes?

The sheer cost involved in accessing NHS services is another huge barrier. Free universal healthcare is a source of national pride but, despite falling under the banner of the NHS, dental treatment is not free at the point of need for the vast majority of adults, who do not meet the increasingly narrow exceptions criteria. NHS dental prices have risen by 5% this year—the fifth annual price increase. As a result, a check-up in England and Wales now costs £22.70, a filling or extraction costs £62.10, and a crown or false tooth costs £269.30. These are significant outlays, which are of course much higher in many surgeries.

We echo the British Dental Association’s concern about the increase in so-called DIY dentistry. While accurate figures on the extent of this are hard to find, there are alarming anecdotal accounts of people being forced to pull out their own teeth, resorting to long-term use of painkillers to delay going to a dentist, visiting their GP, as the noble Baroness, Lady Jolly, said, or going to A&E for emergency treatment. Such A&E visits form 1% of all hospital attendances in England.

Even adults who are NHS-exempt experience considerable administrative barriers to accessing NHS dentistry services. Every year, more than 40,000 people in England receive fines of £100 from their dentists through the automated system designed to stop people fraudulently receiving free treatment. The fines are applied by a random screening process to check eligibility and amount to approximately £4 million a year. Many vulnerable people who we have heard about today, including dementia sufferers and those with learning disabilities, are inadvertently falling foul of this system and being unfairly fined. Fines have been levied for minor misdemeanours such as ticking the wrong box or confusion about the forms that had to be filled in. Even when patients are eligible for free treatment, an incorrect identification of specific benefit payments or a failure to renew documents can trigger the £100 penalty, which rises to £150 if there is a delay in payment.

Many vulnerable patients such as those with dementia, learning difficulties or other health conditions will be brought to the dentist by a carer, who might not have detailed information about types of benefit and exemption certificates, or may be overwhelmed by the complexity of a patient being migrated from one benefit to another under the universal credit rollout. The noble Baroness, Lady Jolly, rightly highlighted the dental care problems experienced by homeless people. I was very interested to hear what she said about the work of Dentaid.

It is clear that the system has become a significant barrier to vulnerable people accessing care, through lack of awareness as to eligibility, inability to provide required documentation or the fear of being wrongly accused of fraud. Even when patients—or, more likely, a carer or someone on their behalf—have been able to navigate the equally complicated and confusing appeals process, about 90% of appeals are overturned as having been incorrectly applied for. Does the Minister agree that the system is not fit for purpose and needs urgent review? Will she undertake to work with dentists, GPs and the Department for Work and Pensions on this?

The noble Baronesses, Lady Masham and Lady Jolly, referred to the Care Quality Commission’s recent report Smiling Matters: Oral Health in Care Homes, which is of particular concern. As we have heard, on 100 routine inspections the CQC found that most homes had no policy to promote or protect people’s health; nearly half were not training staff to support daily oral healthcare; 73% of care plans reviewed only partly covered or did not cover oral health; and 10% of homes had no way to access emergency dental treatment for patients. As both noble Baronesses stressed, residents in care homes may have difficulty brushing their teeth due to poor manual dexterity, limited mobility, vision problems or cognitive difficulties, and long-term conditions such as Parkinson’s disease or dementia exacerbate those difficulties. Residents may be left unable to eat, drink or communicate. As the Alzheimer’s Society says:

“Mouth pain can have a huge impact on people with dementia, and can lead people to stop eating completely. Looking after a person with dementia’s oral health is vital”.

Can the Minister tell the House what action is being taken to address this very serious problem? The noble Baroness, Lady Blackwood, told the House on 11 July that dental care in care homes is being considered in the social care Green Paper—our old friend. Can the Minister tell us what areas are being addressed and what actions will be taken to ensure that NICE standards for oral health in care homes are being adhered to? Does she support the CQC’s call for mandatory staff training in oral care and check-ups for all residents upon admission? Does she have any insight as to when the Green Paper will finally be published?

For far too long the Government have treated NHS dentistry as an optional extra, with patients throughout the country ultimately paying the price of failed contracts and year-on-year budget cuts. Despite high-profile announcements and repeated pledges to put prevention at the heart of NHS strategy, the Government have failed to invest or make any tangible commitment to dentistry, while the long-awaited NHS Long Term Plan, published in January, largely ignored oral health. Indeed, there was no dedicated chapter or even a heading on oral health, while dental care is mentioned only twice in its 136 pages.

Access to an NHS dentist remains a key challenge. I hope the Minister will be able to assure the House that the new Prime Minister intends to make access to NHS dental services a domestic policy priority. It is vital that he commits to reviewing the level of NHS dentistry funding, and to working with the sector and stakeholders to remove the barriers faced by vulnerable patients in particular.

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My Lords, I congratulate my noble friend Lady Gardner on securing time for this important debate and all noble Lords who have contributed, although I feel, like the noble Lord, Lord Storey, that I am also on the subs bench. I have certainly learned a great deal from all today’s contributions.

I am genuinely pleased to have the opportunity to talk about NHS dentistry in England, but before I do I also thank my noble friends Lord Colwyn and Lady Gardner for their contributions to the NHS. I am delighted that our immigration services were enlightened enough to extend my noble friend Lady Gardner’s six-month visa many years ago.

This is a very serious and important area, and I know it is one that my noble friend is concerned about and has raised on several occasions. As we have heard put very eloquently across the House, poor oral health can have a devastating impact on an individual’s quality of life and an even greater impact on that of a child. We know that the two main dental diseases—dental caries or decay and periodontal or gum disease—can be almost eliminated by good tooth brushing, backed up by regular examinations by a dentist. As the noble Lord, Lord Storey, said, this is one of the most preventable areas of healthcare.

Noble Lords did not refer to—and I hope your Lordships will permit me briefly to comment on—the prevention Green Paper published on Monday, which included two important commitments on oral health. We will be consulting on two initiatives: water fluoridation and supervised toothbrushing. My noble friend Lord Colwyn referred to fluoridation. We aim to address the unwarranted variation in children’s oral health across the country.

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I am grateful to the Minister for giving way. Can she remind us how many years have gone by since the Government began to examine the issue of fluoridisation?

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I am happy to write a response to that later.

Next year, we will consult on rolling out a school toothbrushing scheme in pre-school settings and primary schools in England. This would allow us to reach the most deprived children in the country aged between three and five, with the aim of reaching 30% of children in that age group by 2022. We will also be exploring ways of removing any funding barriers to fluoridating water, to encourage more areas that are interested to come forward with proposals.

Many noble Lords, including my noble friend Lady Gardner, talked about children’s oral health. We know that overall our children’s oral health has improved significantly, with the most recent data from 2015 showing that 75% of five year-olds in England are now decay free. Several noble Lords talked about children’s tooth extractions in hospitals due to decay. For children under 10, they have fallen slightly, by 2% between 2016-17 and 2017-18, but, encouragingly, for the under-fives extractions have fallen by 22% over the past five years, and there has been a steady decline over those five years. I am by no means denying that problems remain but am just trying to set a perspective. We want to keep that trend going.

Looking at some of the things that we are doing to address this, NHS England has developed schemes focused specifically on children in areas of high dental need. The Starting Well programme is aiming to improve the oral health outcomes for children in the most deprived areas, and is focusing on 13 high-priority areas, with the aim of increasing the provision of advice and interventions to all children under the age of five, particularly those who do not regularly visit a dentist. This will include outreach to children not currently in touch with dental practices. That is the focus in the most deprived areas. Also, to complement this, NHS England is developing the Starting Well Core, which aims to reach children between the ages of nought and two and is being offered to children anywhere in the country where commissioners decide that it is needed.

My noble friends Lord Colwyn and Lady Gardner and the noble Lord, Lord Storey, and the noble Baroness, Lady Jolly—perhaps everybody who has spoken—talked about challenges around access to NHS dentistry. Over 22 million adults were seen by a dentist in the two-year period ending in 2018, and 7 million children were seen by an NHS dentist in the 12-month period ending in 2018. Although those overall numbers are good, as noble Lords have pointed out, there are specific areas of the country known as “hot spots”—although I think they might be called “cold spots”—and it is vital that steps are taken to address these issues. NHS England is taking a number of actions to improve dental access nationally. These include, first, flexible commissioning to allow NHS commissioners to deliver a wider range of services from dental practices. That would include not just basic dental services but orthodontic services, which we think in turn will make NHS dentistry more attractive to new dentists.

That leads me on to the challenge of recruitment and retention. Again, if one looks at the numbers, there has been an increase in the dental workforce over the past five years. The noble Baroness, Lady Jolly, asked a question about the impact of Brexit on the workforce. In March 2019, we put in place legislation which ensures the continued recognition of European qualifications by all the professional regulators in the field. This means that EU staff who currently practise in the UK can continue to do so and that professionals qualified in the EEA and Switzerland can continue to apply for registration after exit day, deal or no deal.

NHS England is also working closely with Health Education England and a wide range of stakeholders to improve the career profile for dental professionals, allowing them greater flexibility to move between specialties. We are aware that some practices are handing back their contracts, and we recognise that there are stresses in the system. That underlines the importance of reforming the dental contract, as well as the measures we are taking to support professionals.

The noble Lord, Lord Storey, asked about the transfer of UDAs—units of dental activity. The ability to transfer regionally is currently very limited, given the way they are set up, but the introduction of more flexible contracts and the new dental contracts being piloted will allow much greater emphasis on prevention, which many noble Lords have rightly raised. To pause on the new dental contract, it has now been evaluated and shown positive results. We have just taken on 28 more practices. I absolutely appreciate that there is frustration that the new contract has not been rolled out more quickly, but we are awaiting ministerial and NHS England sign-off on that.

The noble Baroness, Lady Masham, and the noble Lord, Lord Storey, talked about dental treatment for people with disabilities. Wherever possible, people with a disability who live in the community should be treated within a high-street dental practice. There is also a legal obligation for dental services to make reasonable adjustments to ensure that patients with a disability can use their services, in the same way as other people do. Where practices cannot make those adjustments, they have a duty to make arrangements for the patient to be referred to a more appropriate place to be treated.

The noble Baronesses, Lady Masham and Lady Wheeler, asked about clinical skills when treating citizens with a learning disability. NHS England has made a commitment in the long-term plan for the provision of dental services for those with a learning disability and autism. Part of that provision will ensure that clinicians have access to skills training, which many noble Lords also rightly raised.

The noble Baronesses, Lady Jolly, Lady Masham and Lady Wheeler, all talked about the CQC report and oral healthcare in care homes. The Government welcome the recent report, Smiling Matters. We are obviously concerned by its findings, which highlight the high percentage of people living in care homes, particularly those with dementia, who are just not getting the oral healthcare that they need. We are carefully considering the recommendations made in the report, together with Public Health England, NHS England and Health Education England. We will respond to the report later this year. The noble Baroness, Lady Jolly, asked about private care homes. I assume that a reflection on the status of private care homes will be part of our response.

The noble Baroness, Lady Masham, asked about dental treatment in prison services. NHS England remains committed to ensuring that oral health services for people in prisons are of the highest standard and that the availability of care is appropriate and timely. As part of that, NHS England is working with the British Dental Association and the National Association of Prison Dentistry UK to review the prison dentistry specification, which the noble Baroness asked about. It is expected that the revised specification will be ready for use from April 2020, after a period of consultation and the completion of the NHS England approval processes. We hope this will address some of the issues of inconsistency of care highlighted in the recent survey of prison dental services by Public Health England. As the noble Baroness rightly pointed out, this is part of wider health issues on the prison estate.

My noble friend Lord Colwyn and the noble Baroness, Lady Wheeler, asked about funding and dental charges. NHS England is required to commission services to meet local need so, for dentistry, decisions on priorities are made within the overall NHS budget, just as with other areas that NHS England commissions. Patient charges are an important contribution to the overall costs of the NHS. The above-inflation increases, referred to by the noble Baroness, Lady Wheeler, were driven by wider austerity measures and difficult financial circumstances. It is critical that no one is deterred from seeking care by cost and, as part of this year’s uplift, the department has committed to look further for evidence on whether patients have been adversely impacted, so that this can be considered next year and in any future decisions. The existing exemptions on charges, referred to by the noble Baroness, Lady Jolly, remain in place.

The noble Baroness, Lady Wheeler, also referred to penalty charge notices. She is aware that the Public Accounts Committee met on 1 July to discuss the use of penalty charge notices in healthcare. The Government announced then our intention to revise our current process for dealing with unpaid prescription and dental treatment charges. We are now introducing a three-stage process for penalty charge notices, and doing so as quickly as possible. This means that, in the first communication people receive from us telling them that they have not paid when we think they should have, we will invite them to get in touch and let us know if our information is wrong. A penalty charge notice would not be issued at this stage, but would if the person either is confirmed as ineligible for free treatment or does not respond to the initial communication.

This has been a fascinating debate for me. The noble Baroness, Lady Wheeler, asked about the commitment of the incoming Prime Minister. These are early days—I think he has quite a long to-do list—but I share her wish that addressing the issues that noble Lords have debated on the availability of dental services should be high on that to-do list. The noble Baroness also asked about the cross-government commitment to respond to vulnerable people as effectively as possible. We are clear that that continues.

I hope my responses have, in some way, reassured noble Lords that the Government remain committed to improving oral health in this country. Of those three strands, in prevention there will now be a renewed focus on tooth brushing and, I hope, flossing, given the amount of time my dentist spends talking to me about it. The others are fluoridation of water, our efforts to give more flexible contracts and improve education opportunities for the workforce, and our commissioning work, with greater emphasis on prevention in the dental contract and greater flexibility, so that local areas can respond to needs, particularly of the most vulnerable in their community. Shakespeare wrote in “Much Ado About Nothing”:

“For there was never yet philosopher

That could endure the toothache patiently”.

We do not want philosophers to have to endure toothache patiently. We do not want prisoners, the elderly, disabled or children to have to endure it patiently.

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Could the Minister drop me a note about dental milk, which I do not think she referred to, and how it might be developed in schools?

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I am happy to do that. I intended to cover that through the fluoridation of water, which we hope is a universal response, rather than milk. If that is not sufficient, I will write to the noble Lord.

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My Lords, it has been fascinating listening to the debate—so many interesting points have been raised. I thank all noble Lords who have spoken and very much appreciate the points the Minister made.

There are a few things I should point out. A noble Lord said that there should be a form to fill out to get extra financial help. I remember those forms. They came from people only a few times and had 25 questions on them. The patients had no hope of understanding them. It took 15 minutes or more of my time to go through the questions, one by one, filling out yes, no or whatever it was. It should be clear who should get help, so something much simpler could handle that issue.

A noble Lord referred to patients pulling out their own teeth. I never felt sympathetic about that because, to pull out your own teeth, they have to be loose. It can be a hard job getting out teeth; that last little bit hangs on. I think it is someone whose teeth are probably just about ready to fall out who would be taking out their own teeth.

There is a very important issue about six year-old molars. Lots of parents are keen to be sure that their children have no bad baby teeth, and others think they do not matter because they will be replaced by other teeth, but six year-old molars come through behind baby teeth. Because of that, people tend to miss it and not check that point for the child.

What the Minister said on fluoridation was very good; she gave us some hope. As an Australian, I must say that Australians have had it for 60 years now, almost everywhere, except for those on a local river or rainwater tank. But it is important to keep it at the optimal level, not the maximum or anything else. That is why there has to be a good water authority that can take fluoride out, as well as put it in. That is essential; you do not want it to be uncontrolled.

I have repeatedly asked questions in the House about Manchester and Birmingham. The answer has always come back that there is no difference in the health pattern for cancer or any other condition, but the big difference is that Manchester has no fluoridated water and the worst possible teeth, and Birmingham has very good teeth, because it has had a fluoridation scheme for so long. People need to be aware of those few things. Interesting and relevant points have been made. I could not speak more highly of what my colleague said on that contract set-up. I ceased to have that a long time ago. I again thank all noble Lords who have contributed.

Motion agreed.