Examination of Witnesses (Questions 1
THURSDAY 15 FEBRUARY 2001
1. Good morning. Can I welcome you to this morning's
session of the Committee and particularly welcome our witnesses.
Can I express to you all the appreciation of the Committee for
coming along and for your written evidence. Can I begin by asking
you to briefly introduce yourselves for the record.
(Dr Husband) I am Judith Husband. I am
a General Practitioner in Oxford. I qualified in 1997. I have
worked in Liverpool as well.
(Mr Bosley) My name is Clive Bosley. I am a General
Practitioner from South Oxfordshire, where I was born and bred.
I qualified from UCH in 1967 and have worked in London and Oxford
as a General Dental Practitioner ever since.
(Mr Ross) Alan Ross, Chairman of the General Dental
Practitioners Association, founded in 1954 by dentists. We are
all General Practitioners in the organisation representing High
Street dentists only.
(Mr Renshaw) John Renshaw, I am a General Dental Practitioner
in Scarborough. I qualified in 1969 and I have been working in
Scarborough ever since. I am also Chairman of the Executive Board
of the British Dental Association.
2. Thank you. Obviously the Committee are conducting
this short inquiry because of our concerns over a range of issues
affecting dentistry. It is a matter of regret that this current
inquiry will be very brief. That is not to say the Committee will
not return to the issue in due course after any possible General
Election, so this may just be a marker. We appreciate your co-operation
and we want to look in some detail at some of the issues today
to establish some of the facts behind the current concerns. Can
I begin by asking a general question about your views on the background
to the current difficulties. We all accept that there are problems,
we have got further detailed evidence of what those problems are
that has been sent to the Committee, and a number of issues have
been raised with us as to why we have this current problem, some
going back to the 1990 dental contract issue, which I remember
being discussed, and the fee scale cuts in 1992/93. Can you briefly
start by saying what you feel are the key issues that have resulted
in us having the current problems that we are now facing?
(Mr Renshaw) I think it is a tale of deteriorating
working conditions for many of the practitioners who worked in
the NHS for many, many years, including myself. If you look at
the deterioration that has taken place, the increase in the workload,
the increase in the intensity of the workload, and the diminishing
profits and returns on the amount of effort that is required to
make a living, it is no wonder, in my opinion, that many people
have chosen to leave this particular arena of work and move into
the private sector. I think it is sad for the NHS that they have
failed to keep pace with the aspirations of the profession and
have not been able to keep those people on board. Many of the
people who have left have found a much better working environment
without necessarily making a huge amount of extra money. They
have found a working environment that is much more amenable to
their way of life and the quality of life they seek. I think the
situation has been getting worse. The 1992 fee cut was a major,
major blow to the profession and whenever I go anywhere, no matter
who it is or where I am, it is still mentioned. It is a scar that
is running through this profession that has never been put right.
As a profession I think we have lost our support for the NHS largely
as a result of a succession of moves from the Department of Health
and Government. I am hoping that the current arrangements that
are being brought in, the new strategy, will signal a recognition
of the poor relations that have developed over the years and are
beginning to do something about it.
3. Going back to the issue of 1990 and the contract
and then the fee scale cuts in 1992/93, Mr Ross, how do you feel
that could have been handled differently?
(Mr Ross) That has been and gone, has it not?
4. It has been and gone but it seems to occur
rather regularly in the evidence that we have got about the current
problems, that the difficulties began at that point. If that was
where the difficulties began, I am anxious to look at what might
have been done differently and what lessons we can learn in looking
at what future policy might be.
(Mr Ross) I think the problem was that the profession
was not fully consulted and when the profession was consulted
there was a referendum and the profession voted against the 1990
contract. Unfortunately it was implemented without the full support
of the profession with the inevitable consequence that many practitioners
viewed the 1990 contract as the final straw and they decided to
leave the NHS behind. In 1992 instead of getting a fee increase,
as recommended, we ended up with a seven per cent fee cut and
another batch of dentists then left the NHS. There are these constant
drains and, unfortunately, nothing has been done to rectify those
drains. We are delighted to be here today and that you are actually
listening to us. The Select Committee in 1992 listened to the
GDPA and took on board a lot of our recommendations but, unfortunately,
they gather dust. Further consultation would be appreciated.
5. We have got a good record this week of getting
things changed. We have had a good week. We are hoping to do something
on this issue as well. In practical terms I have mentioned the
background to the particular problems. Dr Husband and Mr Bosley,
what are your views on the fundamental problems that have resulted
in the difficulties that you face now?
(Mr Bosley) I think the fundamental difficulty that
I have always faced is the treadmill: the faster you work, the
less you get paid. I became aware of it in 1964 when I was still
an under-graduate and a Tattersall Commission described it as
being a "hopeless profession" because of this treadmill.
The treadmill is what has destroyed my confidence in my provision,
National Health Service dentistry.
6. Mr Ross referred to the Health Select Committee's
Report in 1992/93 and the recommendations. I just wonder, if not
off the top of your head, whether you could submit to the Committee
your comments on the recommendations in that report which you
consider still to be relevant and should be taken forward?
(Mr Ross) Certainly. There was the direct reimbursement
of expenses and equalisation of expense ratios whereby in places
of real deprivation it takes longer for a dentist to do things.
If there is a large cavity, for example, a large hole in the tooth,
it takes twice as long to fill it. Those areas in the inner cities,
where the most deprivation is, have the highest costs and yet
there is the least reward because of the time it actually takes
to do the work. Those dentists are in the least profitable areas,
there is no incentive for them to go to these areas. The Select
Committee recognised that in 1992 and, indeed, if I am right,
they actually implemented the direct reimbursement of rates, which
is still the only direct reimbursement that we have got.
7. Can I come to you, Dr Husband, specifically
on the points that we have made about the background to the current
difficulties. How far do you feel that the Modernising NHS
Dentistry document addresses some of these problems? What
are your views on the positive and negative aspects of that policy
(Dr Husband) I think it definitely does help dentistry
in some areas and for some people and it has brought dentistry
back to the top of the list, we are discussing it here today,
which I am very glad about. I began dentistry in 1992 and my teachers,
colleagues and people I have worked with since all expressed great
concern. I have grown up in a very pessimistic profession. Even
my own father warned me about going into dentistry.
8. Is your father a dentist?
(Dr Husband) No, he works in a factory. He has never
been to university and he left school at 12 but he stated that
he had great concern that I would be doing merely piecework and
that there were so many other things on offer to me that I should
take those offers and use my abilities elsewhere. I do not regret
doing what I have done. Young dentists are very, very concerned
about the time that they can spend with patients and the current
fee pricing system does not allow that. We open ourselves up to
litigation, we cannot use the talents that our universities taught
us so well and taxpayers paid so much for us to learn.
9. Just out of interest, because you came into
dentistry at around the time of great controversy, and I recall
this because I was a Member of Parliament at the time meeting
local dentists and they were worried about what was happening
at the time, what attracted you specifically to dentistry? What
made you come into dentistry rather than medicine or whatever?
(Dr Husband) I chose dentistry when I was 13 because
I liked the medical base and I thought the course looked very
exciting, I could use my hands, I could have a little go at business,
I could study medicine in depth, anatomy and things like that
and, most importantly, I would be dealing with people, because
I enjoy being with people and learning about them. I think that
is one of our primary roles as dentists, to learn our patients
and their needs to be able to prescribe what they want as well
as what they dentally need and we can build up a relationship.
Unfortunately I do not foresee this occurring in the Access Centres
as they appear to me. I have worked in an emergency situation
in hospital where we just had people turn up in pain and we pulled
teeth out and we did what was necessary. It was highly unrewarding
and I would not want to spend my life like that. If necessary,
I would leave.
10. So you are concerned about the direction
it may be taking in respect of that?
(Dr Husband) Yes.
11. We may come on to that later on. Can I just
pick up one point. You mentioned that one of the things that attracted
you, apart from the actual hands-on involvement of dentistry,
was the business aspect of this. Do you feel that one of the problems
we have with the current arrangements that we may need to look
at is the conflict between the private business interest and service
element of what you do?
(Dr Husband) There can be a conflict there, I do believe,
but if we are running a successful practice for our patients that
will automatically reflect in our business. Good business practices
go hand in hand with providing an excellent service.
12. Our experience as a Select Committee looking
not at dentistry but at other areas has raised very clear conflicts
between private medicine and the wellbeing of the patients. I
am not looking at the wellbeing of the patients in this respect,
I am looking at the wellbeing of the dental service as a community
service. Would you not feel that there are conflicts there that
we may need to address structurally at some point?
(Dr Husband) There are definite limits as to where
we can set up our businesses and do well. I would choose to set
up a business in the South now, having experienced both working
up North and in the South. It makes more business sense to set
up a practice in an area where the demographics suggest that we
have socially got people who will want to come and see us.
13. So the logical consequence for us Northerners
(Dr Husband) There are opportunities up there and
I think the Government really should be focusing their issues
on wider problems other than just access. It is not simply that
there are not enough dentists, which there are not, and it is
not simply that people want to go to dentists and they cannot,
it is that there are lots of dentists in some areas and not in
others. When we have got free choice as individuals, why should
we work in an inner city where we have got junkies shooting up
in the bathroom when we could have a nice life? I am sure we would
all choose to live somewhere that is nice and pleasant, just the
same as where we choose to work.
14. I choose to live in the West Riding of Yorkshire,
which is very pleasant and very nice, but the logic of your comments
for people in the North of England is that there will be some
sort of rampant private market in the South and those in the North
will be left with some sort of state level. Scarborough is one
of the nicer parts of Yorkshire.
(Mr Renshaw) That is exactly why I moved there.
15. I am a little concerned that the logic of
what you are saying is that you appear to be arguing for a two-tier
system and the market will provide where the market can flourish
and the rest of us in the North in particular will have what?
What is the picture for us Northerners, dentures?
(Dr Husband) Dentures are too expensive. I am only
giving my opinion. I am only a dentist making my decisions for
my future. I very much enjoyed working up North, it is a different
world up there in many ways. Costs are lower, laboratory bills
are lower, there are different opportunities up there that can
be used to the good, and the Government could also utilise its
16. I am interested in your thoughts because
obviously you are a young dentist and you have got your career
future ahead of you. Mr Renshaw, right of reply from the North
(Mr Renshaw) Yes, absolutely. The tragedy, of course,
is that Judith is right, she is absolutely right. The current
system is driving dentists in that direction. We have a major
mismatch between disease incidence, which tends to be the further
North and the further West you go the worse it gets, and the distribution
of the profession, which seems to be the further South and the
further East you go the greater the concentration of the professional
workforce. What we have to do is go back to square one and have
a look at what this service is supposed to be providing and try
to make sure that it does provide it. What has been true in the
last 40 years is that we have not really sensibly looked at what
the distribution of manpower is. We have got to get back to that.
Nobody has tackled it because it is too difficult and, as usual,
it is left to find its own way. It is finding its own way now
and if somebody does not do something about it we have got even
worse problems in front of us. This is not a situation which is
static, it is actually deteriorating rapidly right now.
Chairman: I will bring in Peter Brand who, by
the way, represents the Isle of Wight.
Dr Brand: You cannot get much further south
than that. It is a jolly nice place but we have got the second
lowest GDP in the country.
John Austin: It is full of retired Northern
Chairman: With dentures.
17. I think Dr Husband's father was an extremely
astute and wise man describing it as piecework. I think I have
called it bob-a-job work and in one of your submissions it talks
about "drill and fill". I am very concerned at what
you are highlighting which is this North/South divide and this
acceptance in some parts of the country that the only thing you
appear to be entitled to is emergency work and sorting out acute
problems, whereas in the South I think a lot of dentists left
the National Health Service because they believe in restorative
work and then maintaining that, using much more the skills of
oral health professionals generally in addition to dentists. In
your submission you talk about the inadequate fee level, but do
you not think that the real problem is the fee structure? NHS
Dentistry is well rewarded if you are prepared to be nimble with
your piecework, but it is not what people professionally want
to do, which is to maintain good oral health. Are there meaningful
discussions going on? I have great concern that the Government
is addressing an emergency in the wrong direction, that they are
putting in these phone and go clinics and emergency alternatives
to NHS Dentistry but I do not get the feedback from my dental
colleagues that they are talking in a meaningful way or actually
recognising the sorts of patterns of contract that the private
insurers appear to be quite good at. I would really like your
feedback on that.
(Mr Ross) We think that the strategy as it is just
sets about the whole thing in completely the wrong way. It is
a long awaited strategy admittedly, but it is a huge missed opportunity.
It tinkers at the edges. As you say, it is going towards a relief
of pain service for unregistered patients. As we were saying earlier,
dentists are not trained for that, we take pride in our work,
we take pride in the quality of our work and we want to take our
time to do the work. Overall I have some problems with the level
of remuneration but by and large it is the method by which we
have to arrive at that remuneration, it is the treadmill. Successive
governments over 30-odd years have realised that dentists will
work harder and harder and faster and faster for the same income
and we are fed up with it.
18. Is there a perverse incentive? If you actually
do your job maintaining oral health does your pay go down?
(Mr Ross) You will earn less. The trouble is that
successive governments, as they squeeze tighter financially, actually
take things out of the NHS that we are allowed to do. We are no
longer allowed to do what other people would consider basic crown
work, we are just not allowed under the regulations to do it.
If it is basic crown work, it is so poorly paid that we just have
to turn it out so quickly. The morale in the profession has been
devastated in the last ten or 20 years and it is getting worse
19. The whole profession or those remaining
in the National Health Service?
(Mr Ross) Those remaining in the National Health Service
because those who have gone into private dentistry have realised
that there is another way, that they can take time in their work.
They do not necessarily earn a great deal more, they might be
earning the same or even less, but there is pride in their work.
They can take time and produce quality work in their patients.
I am afraid the strategy really does not address those problems
(Mr Bosley) I agree with Alan there, that the quality
issue is at the basis of perhaps one's withdrawal. I am sorry,
I have dried up.