Examination of Witnesses (Questions 65
THURSDAY 15 FEBRUARY 2001
65. Can I welcome our witnesses to the second
part of our session this morning. We do appreciate your willingness
to come before the Committee. Can I briefly ask each of you to
introduce yourselves, starting with Mr Tyas?
(Mr Tyas) Thank you. I am Adrian Tyas.
I am Manager of Operational Services, Cornwall and Isles of Scilly
Health Authority, so I have responsibility for all primary care
services. I have been involved with dentistry for the last ten
years because we have had a dental access problem in Cornwall
for ten years. We set up a dental help line ten years ago and
we had been planning a PDS pilot for a merger of CDS and GDS salaried
dental services in Cornwall. When PDS came along we took advantage
of it. That scheme commenced in 1998 and I have been heavily involved
in it right from its inception.
(Ms Holland) Thelma Holland, Chief Executive of Cornwall
and the Isles of Scilly Health Authority. I am relatively recently
in post and I have had about the most rapid learning curve in
NHS Dentistry. I went to Cornwall eight months ago.
(Mr Scaife) I am Geoff Scaife, I am Chief Executive
of Birmingham Health Authority. I started in October last year.
(Mrs Hamburger) Ros Hamburger, I am the Consultant
in Dental Public Health for Birmingham Health Authority. I have
been a Consultant in Dental Public Health since 1993 working in
66. Perhaps I could start with you and your
background to ask you more or less the question I put at the start
of the previous session, if you were in. What are your thoughts
on why we have got the current problems? Do you more or less concur
with the points that were made by the previous witnesses as to
the background of the current difficulties?
(Mrs Hamburger) Yes, I would concur, although I would
put more emphasis on some of the problems that we had prior to
the 1990 contract and the 1992 dispute because within Birmingham
we have had inequalities in oral health that predate that and
those difficulties have not been affected particularly by those
contractual difficulties. My interest is in oral health, not just
the provision of dentistry, and it concerns me greatly that in
some parts of our inner cities, and my inner city in particular,
we have still nearly half of the children arriving at school at
the age of five with active dental decay and in some parts of
the outer city only ten per cent are arriving with dental decay.
We do quite well in Birmingham, we have fluoride in our water,
we are better than the North of the country
67. Us Northerners are having a tough morning.
(Mrs Hamburger) The North of the country is absolutely
lovely, and it is where I was born, however, unfortunately, there
is a gradient which is outside of socio-economic deprivation,
outside of anything else, whereby oral health gets worse as you
go North. I am afraid that is a fact. Yes, I think the problem
was exacerbated by those difficulties and, as I speak to General
Dental Practitioners, my experience is the same as Mr Renshaw's,
they all mention the 1992 dispute and I can remember them all
working very hard to increase their registrations.
68. Can I put a question to Mr Scaife. Obviously
the Government's strategy on dentistry which came in in September
identified health authorities as the bodies that will "take
the lead in delivering the changes that patients expect".
Clearly in doing that you have got a major task because you are
dealing with a group of individuals who are in private practice,
semi-private practice, scattered all over the place, moving from
the North to the South. Do you feel that this is a role that can
be reasonably expected of you when effectively we have got a market
that perhaps you have only a limited ability to control?
(Mr Scaife) I think you are right in terms of General
Dental Practitioners but, of course, in a city like Birmingham
we have more resource on the ground than self-employed, independent
General Dental Practitioners. We have got a sizeable Community
Dental Service and we are fortunate in that we have a dental hospital
and that also enables us to provide a service. As far as the General
Dental Practitioners are concerned, they are self-employed, they
are independent, many of the rules, if you like, the policies,
are nationally determined, Government decides how many places
there will be on under-graduate dental courses, Government decides
the system for paying dentists both in terms of the operating
of fee scales and, of course, the make-up of those scales as well.
We do not control all of that. Given that we have a strategy and
given that it is entirely right that the Government pays attention
to the need to improve access and to improve services, I think
all of us would say that this is a beginning rather than an end
in itself. Health Authorities are the appropriate agencies because,
of course, they are concerned not only with the provision of service
and with access but they are also concerned with improving dental
health in the round and connecting the two together. I think it
is right that Health Authorities should have been given this overall
69. Can I put to our witnesses from Cornwall
and the Isles of Scilly this general point that we picked up in
the previous session about how we may draw dental provision into
primary care. I think you will probably agree with me that we
are now attempting more and more to bring into primary care a
range of provisions that have been scattered around in Social
Services or wherever, in new Care Trusts etc. Do you see a role
for your authority in that process? Do you see the prospect of
bringing dental provision within the mainstream in a practical
sense as well as just in the National Health Service and, if so,
how would you go about achieving that locally? Particularly, what
does that mean for national policy to assist you in moving in
(Ms Holland) If I can take the last bit first in terms
of national policy. It is about taking the strategy we have got
now a stage further. It is about picking up those issues about
workforce, about distribution, about remuneration, so that we
have got more than the short-term, we have got the medium to long-term
strategy. Within that, as far as the health authorities are concerned,
not only across dentistry, we are now trying to ensure that our
advisory structures and our relationships with staff on the ground
can be mapped to take account of the emerging structures in Primary
Care Groups and Trusts. We have got a very good advisory system,
we have got very good relationships with the local dental practitioners.
Phase 1 of our pilot project was about dealing with some of the
emergency things, getting the access. What we are now moving on
to is to work more closely with family dental practitioners and
to develop plans for a Phase 4 project involving family dental
practitioners. What we are doing is trying to coalesce them around
the patches that will be the Primary Care Trusts. One example
would be the way we are handling out of hours services where we
have got projects and arrangements that match the Primary Care
Trust structure. That is emerging, it is not there yet, because
it is a completely different set-up. That is what we need to work
on over the next few years.
70. How will you ensure that the important functions
the Community Dental Service presently undertakes can be protected?
Indeed, where unmet need is demonstrated, how can you develop
the CDS further, given the new requirements being placed on this
service? I am particularly concerned about the dental care of
elderly people in nursing and residential homes and, of the elderly
people, particularly concerned about those who are demented.
(Mr Tyas) This is an objective that we have set ourselves
in setting up the PDS pilot, that the CDS will not be diminished
in any way through the need to provide general dentistry to the
public of Cornwall. We have been monitoring the activity of the
CDS and monitoring the number of dentists who are employed on
CDS activities. The question that you raise about the elderly
population is a big problem in Cornwall, as you can imagine. Fortunately
the service has grown up around it in Cornwall in that we have
three practices that do mostly domiciliary work in nursing and
residential homes. The CDS part of the PDS does provide that service
where it is required but so far it has not really needed to do
it to any great extent. Our pilot is continuing to complete what
are called KC 64 returns, which are the national returns about
community dentistry, even though with the PDS pilot we do not
need to complete those. In relation to the unmet need we are working
with learning disabilities people to provide a whole service whole
county review, including dentistry.
(Mrs Hamburger) In Birmingham the picture is much
the same. We have undertaken to provide the current level of service
to people with disabilities and the frail and elderly, and in
fact we have plans to develop that service and we want to put
in some outreach specialist services which will not only support
the current Community Dental Service but also general dental practitioners,
so we have plans for a consultant community paediatric dentist
and a consultant community restorative dentist to be established
in the future. I think that will be an important change. It will
help both primary care sets of practitioners in dealing with the
very complex work we heard about earlier, which I do believe to
be a challenge to the profession now.
71. It is a personal hobby horse, Chairman,
if you will just give me a bit of space on this. It seems to me
from personal experience that Community Dental Service provision
for people in residential homes is much better than the dental
service provided for elderly patients in hospital. Certainly in
a hospital not very many yards from here I was shocked at seeing
the number of elderly people in wards where they had been for
months and months desperately needing dental treatment as well
but simply not getting it.
(Mrs Hamburger) We try not to keep elderly people
in hospital for months and months and months in Birmingham. If
they are in hospital for months and months and months which, as
I say, we hope they are not, we have provision within the Community
Dental Service to treat those people which comes out of the auspices
of one of the consultant services. In the old days when we used
to have wards that were full of elderly people, we had an all-singing
all-dancing Dental Service. Fortunately, we have fewer of those
long-stay patients now.
72. Listening to what both groups of people
have been saying so far I wondered within the primary care work
that you are doing how you manage to get the dentists on board
on this, given that it is a financial disincentive for them to
treat NHS patients, given that they lose money if they take this
holistic approach, which obviously we are all trying to adopt.
How did you get them working with you?
(Ms Holland) There are a number of things that persuade
people to change, are there not, and I think one is the push of
desperation with the current situation. The plans in Cornwall
were laid on the basis of phased implementation. Our immediate
need was to provide access to a service for people who needed
treatment within the next 24 hours and, by and large, that we
have done and we have managed to recruit people into the county
so we have not pulled people away from the General Dental Service
in Cornwall. We obviously recruited them from somewhere but we
have now got 17 out of 19 in post, new appointments into the county,
so we have increased the level of dentistry. That has had an impact
on everybody. The next phases for us are around beginning to pull
into the pilot project the more routine, the maintenance services
and beginning to address the oral health issues and to involve
the family dental practitioners. We were reflecting coming up
yesterday why it was that we had such a huge turn-out at the meeting
to discuss this and why there was this tremendous interest from
the existing general dental practitioners. There is not one reason.
In many cases it is because it might offer a better alternative
to the treadmill we have heard about earlier this morning. The
other issue is that the perception of the dentists locally is
that the first-wave pilots have been well-run and well-led and
they have been fully consulted and fully involved. Therefore,
if that model is followed then they can see that there are advantages
73. I would like to ask a question about the
plans you have got in each authority for developing the Personal
Dental Service and what sort of liaison arrangements you have
got with the various groups involved and whether you feel that
that is a cost-effective way of using dental resources and whether
the costs of treating patients through that sort of system have
increased in comparison with operating the General Dental Service.
One wonders whether each of you have developed Dental Access Centres
and how far you feel that the costs of developing them and the
revenue costs of running them offset their value and the likely
development of them. You have heard what was said in the last
session about Dental Access Centres.
(Mr Scaife) I will start with Dental Access Centres
and then move into costs and ask Ros to pick up the large Personal
Dental Service pilot which is about to start in Birmingham. We
do not have and do not propose to have at this point one of the
60 or so new Dental Access Centres that are proposed for England.
Frankly, we do not think at this point that we need one. We are
fortunate in that we have a dental hospital and that provides
a service. We are also fortunate in that we have in Birmingham
(probably because of socio-economic reasons) still a very fair
coverage of general dental practitioners providing a service to
NHS patients. Our registration rate is about 48 per cent currently
so we do not propose to have a Dental Access Centre. The point
you make about relative cost is interesting because what we have
heard earlier this morning is a very clear explanation that the
service that is provided by general dental practitioners is paid
for as piece rate, is looking after patients who probably take
an interest in their oral health, and obviously is based upon
what they do, and you have also heard this morning that the Community
Dental Service exists primarily to provide a service to particular
groups, vulnerable groups, whether they are the elderly in hospital,
or children, or children in care, or whatever, often people with
poor dental health and often people who need extended service,
and the pressures are not the same. So I think in terms of cost
there is a danger here of comparing apples and pears. The Community
Dental Service is providing a service to a different constituency
and it is providing a different kind of service to the General
Dental Service, although I accept that the payments system does
impose a pressure upon general dental practitioners to work quickly
and therefore to be less expensive. But I will ask Ros to pick
up the point about the Personal Dental Service pilot.
(Mrs Hamburger) We intend that the Personal Dental
Service pilot extends in the way I have already described in that
we get some more specialist services out there as an outreach.
We also hope that the development of information and management
technology will be a pilot, perhaps for General Dental Practice
in Birmingham, because we see we may be able to improve the effectiveness
of both services if we can get better patient administration systems
at the very least for our general dental practitioners and we
hope that the PDS will act as a focus for that. Our PDS will have
to workand we are very encouraged by the reaction of our
local dental practitionersvery closely with the GDS. My
vision for the future would be that the PDS outlets would form
a focus for primary dental care in the future which will be part
of a primary care network, a locality network, which perhaps will
fit in better with present Primary Care Trusts and Primary Care
Groups to allow dentistry to be a fuller part of the NHS.
74. Thank you. Cornwall?
(Mr Tyas) Our position is that we have got a network
of 20 clinics which are all Dental Access Clinics around the county.
Our first objective was to be able to provide emergency treatment
at the least for anyone who required it and the figures show that
we are doing that within 24 hours for 94 per cent of patients.
We set ourselves a target of people not having to travel further
than 20 miles to access a dentist and the statistics show that
70 per cent travel less than ten miles. We have available advice
or triage every day 24-hours a day, either through the Dental
Health Line or NHS Direct. We are trying to achieve an end to
inequalities in access to dental care in Cornwall. Not everyone
wishes to be registered, therefore the kind of service that the
PDS 1 in Cornwall is providing will supplement what the GDS can
provide and what we aspire to for a fourth wave of practice based
PDS schemes. The costings, as we have already heard, are not directly
comparable. We have looked at them very closely. The figures that
we have got show that in the PDS in Cornwall the cost is £65.50
per patient which relates to 1,010 claims per dentist, but they
all involve intervention. PDS includes general anaesthetics, special
needs and orthodontic treatment. The GDS, on the other hand, is
less cost, £42.10 per patient, an average of 1,786 claims
per dentist, 916 of those are for no intervention, 870 therefore
with an intervention. Looking at the statistics in GDS in Cornwall,
there is relatively little complex dentistry being carried out
in the General Dental Service.
(Ms Holland) I think the other thing that we have
found over the years that we have had the Personal Dental Service
pilot is that there is an economy of scale. In the first year
it was more expensive, it came down in the second year, and as
we have expanded and developed it it is going to come down again
in this year.
Chairman: Any further questions?
Mr Gunnell: No, I think that was adequately
covered. When I look back at the statistics you have given us
it is obvious that you have got tabs on it all.
75. Do you think there is a paradox that you
are supplying emergency one-off care in Dental Access Centres
where you have an employed service so people do not work on piece
rate for doing piecework, and you are trying to develop a wider
public health agenda through your General Dental Service, which
is on piecework?
(Ms Holland) The short answer is yes. The health authority
has responsibility to try to make sure that we can provide a long-term
objective of oral health and, at the other end, we can deal with
those people in immediate need.
76. But your means of influencing events, oral
health, are largely restricted to what monies you can give out
direct and national contracts. As health authorities, and Dr Hamburger
especially as a Consultant in Dental Public Health, do you get
frustrated about the structure that we currently have which, to
me, does not seem to encourage either team work between dentists
and other professionals within oral health and a bit of a long-term
commitment to dental health?
(Mrs Hamburger) I have been frustrated because General
Dental Practitioners are independent and there have been very
few levers that the Health Authority has been able to use to
77. There are lots of levers but you cannot
use them. The levers are with Central Government through their
(Mrs Hamburger) That is right. The strategy, which
does have its weaknesses , does signal that the Health Authority
has more levers than it has had in the past. For instance, we
can take out
78. Does that include NHS contracts?
(Mrs Hamburger) Yes.
79. What levers should there be? You have got
this enhanced role and I am worried that your ability to address
these concerns has not been enhanced in any way by the plan. What
are the levers that you need? We need to be looking ahead at the
strategy that we will suggest from this inquiry, the proposals
that we make. What do you feel would help you to bring about what
you obviously desire to achieve and establish in Birmingham?
(Mrs Hamburger) Some of the levers are coming and
we know that the Modernisation Fund is there waiting to be used
and the Dental Care Development Fund is there. I would like to
be able to pursue that further. I think dentists, particularly
in socio-economically deprived areas, have considerable difficulty
in making adequate investment into their practices, there are
a lot of disincentives to those investments. I would like to be
able to redress those disincentives locally. The other options
which are really open to us now, which I think we could pursue
with the current strategy, are some of the softer options of working
more closely with the profession, looking at some of those things
that cause them stress outside of the treadmill, how to cope with
the treadmill, helping with their patient administration, bringing
them up to date with IM&T, which sadly they are behind on
because there has been a lack of investment there. It is accepting
that dentists are there, not thinking that they are some other
place on Mars, and working with the group, asking locally what
would help them and being able to provide some of that.