Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 100 - 119)



  100. I raised that with Mr Renshaw about whether the dental team could be used more effectively, the range of professions allied to dentistry, and his response was that there was no evidence, nobody had done a study. Why is it that we have never looked at how that team might be more effectively used? Where is the evidence?
  (Lord Hunt of Kings Heath) I would like to bring the Chief Dental Officer in on this, but if I can just put the context. We are in discussions with the General Dental Council around the whole issue of regulation, and certainly I think that our experience in other parts of the Health Service is that if you do widen responsibility, if you do accept that professions supplementary to the key professions are able to do an enhanced job, there are real benefits, but perhaps Dame Margaret would like to pick that up.
  (Dame Margaret Seward) There have been studies over the years. The Nuffield Foundation in 1993 looked at the whole contribution of the dental team and, of course, the Service for All Talent that was published subsequent to the deliberations here in the Health Committee in 1999 actually focuses on the need for looking at the skill mix and the future work pattern. Part of the remit of my study, although looking at women and increasing the opportunities for women dentists (who now make up 30 per cent of the Register), was also obviously going to impinge on the therapists and the hygienists and their work patterns because 99 per cent of therapists are women. So all the issues that apply to retaining and bringing back into practice women apply equally to the whole workforce, and that is undoubtedly the way we have to go. In mentioning about women it is really masking things when I say women make up 30 per cent of the Dentists Register because if you look at the age distribution of the sex it is of course now 50 per cent going into dental school and for the first time ever women were ahead of men in the number of graduates who went on the vocational training year which, as you know, is the post-registration year. That has huge implications when we are beginning to see preliminary results. The results of the quantitative analysis are not due for another three or four weeks but from the qualitative analysis, the focus groups, it is huge and GDS figures show that on average women are working two days per week in the GDS. If you extrapolate that into the future that can be huge. So workforce planning is absolutely key. That is raised in the strategy and I think people should be confident that the Government is going to address this.

  101. Can I go back to Lord Hunt's comment about modernising industry and your implication that it was about driving up quality as well. The evidence we had from the general dental practitioners that came before was that dentists want to perform well, they want to do a good professional job, and in terms of accessability what they said we need is general dental practitioners working in the NHS. The evidence they have brought to us is that they are not able to give and provide a quality service under the NHS because of the contract and therefore, in the words of Mr Renshaw, "dentists do not leave the NHS for ideological reasons". The suggestion was that they are leaving it not just because of money remuneration but because the way in which the system was structured meant that dentists could not provide a good, professional service to patients within the framework of the remuneration scheme.
  (Lord Hunt of Kings Heath) There are two comments I would like to make there. The first is I have already said that I understand that the dental profession does have concerns about the pattern of work which they have to undertake under the current GDS contractual arrangements. I have said that we are prepared to sit down with the profession to look at this over the next few months to see if there are any changes that can be made. I do want to say something about quality because I do think it is very important to say that I have yet to see real hard evidence to suggest that the quality of NHS treatment by our dentists is not up to the standard that we would expect. I think part of this whole process is actually taking pride in the quality of the teaching that is done to make people into dentists and the profession as a whole. I think it is also worth making the point that we do have a strong regulatory system, we do have the Dental Reference Service which undertakes sample checks of the work of dentists, we do have a complaints system. Whilst I accept dentists themselves would wish to see changes in the way they work, we must be very careful not to undermine people's perceptions of the overall standard and quality of care that is given by dentists in this country.

Dr Brand

  102. Can I just pick this up, Lord Hunt, because in 1997/98 a series of reports in the Dental Practice Board magazine, Dental Profile, described the low success rates for endodontic treatment, success rates in the order of ten per cent and that is ghastly. It has been suggested to us by an NHS endodontic specialist that these failures of treatment are due to lack of time and the use of ineffective and out-dated techniques and materials. There clearly is evidence that outcomes are not as good and that has been determined by the contractual straitjacket that you put on the practitioners.
  (Lord Hunt of Kings Heath) I will ask the Chief Dental Officer to answer you specifically but my understanding is, first of all, it was not talking about the outcomes of treatment so much as the actual way the treatments were actually carried out. Secondly, the figures for the UK are not out of line with figures in other countries. Perhaps I could ask Dame Margaret to respond to that in some detail.
  (Dame Margaret Seward) Chairman, the report in the Dental Practice Board Magazine actually was saying that the way the filling was put into the root canal failed against European endodontic standards and, as you quite rightly quoted, it was ten per cent. What it did not actually say was that the whole root filling had failed, it was the way that the root canal had been filled with the material, as we call it. In the report it did admit that the technical quality of the root filling does not necessarily affect the outcome. There are a million canals root filled and we do not have great numbers of them failing.

  103. Sorry, Dame Margaret, you are telling me now that there is a European standard that is totally a waste of time, we do not have to work to it because you believe our outcomes are satisfactory with a ten per cent success rate. You either have a standard or you do not. Are you saying that the Department will change its standard when it suits them? This really is not satisfactory.
  (Dame Margaret Seward) I accept what you are saying about the standard but I think one has got to be clear that this is a very high standard set by a specialist group who are endodontists, who actually work and are registered in a separate register which is held by the General Dental Council. We are talking about NHS Dentistry which is appropriate, cost-effective and which can be provided for the vast majority of people.

  104. So you are saying that 90 per cent of root canal fillings can be sub-standard and that is satisfactory?
  (Dame Margaret Seward) No, I did not say that. I said that the root canal standard that is used by the Europeans is in relation to the actual material and the way that the filling is put into the root canal. There is no evidence whatsoever in that report that there is a failing in the actual way the tooth functions after it has been root filled.

  105. Has any work been done to see what our eventual failure of teeth is, what number of teeth have had to be extracted after root canal work in the 90 per cent that have not met the standard and in the ten per cent that have?
  (Dame Margaret Seward) No. He did not report that. He reported it on a radiographic—

  106. Have you looked at it because clearly this is of enormous concern? You are trying to reassure us that the outcomes would not have been any different but have you actually looked at the outcomes?
  (Dame Margaret Seward) The guidance to the profession on standards right across the board, not only on endodontics but also in the DPB profiles where they looked at dentures, they looked at crowns and bridges—

  107. I would really like to stick with this particular thing. Ninety per cent of root canal fillings have not met a particular standard which you do not particularly agree with. Your reassurance to me and the Committee is that outcomes for individual patients, and presumably individual teeth, do not rely upon meeting the standard that we only meet for ten per cent of our patients. Have you done any work to substantiate what you have just told us?
  (Dame Margaret Seward) I have not done any work, no, I am not an endodontist.

  108. Do you know of any work that has been done?
  (Dame Margaret Seward) There is work that has been published over the years on various aspects of root canal filling.

  109. The point I am trying to make is I think Mr Austin had a very useful line of questioning because I think the reason for people leaving the National Health Service, from what we have heard, is not to do with the level of fees, although everybody moans about levels of fees, it is the structure of the fees and the fees being based still on an attitude to dentistry which stems back to 1948. It is interventionist dentistry, and repeated interventions, rather than intervention and maintenance. That comes back to this point about how you actually get rewarded for working with a team and using your personnel effectively. I believe that your whole structure of rewarding the GDS service has got to be looked at unless you are prepared to take the other route, which we have explored with the health authorities, which is to put the funding in through the PDS and Dental Access Centres and you try to influence what we all want to see, which is proper long-term care, which is something that certainly the private insurers have recognised as cost-effective.
  (Lord Hunt of Kings Heath) Can I just say on the issue of quality that I do come back to the role of the Dental Reference Service. We do have the ability to do, I think it is, over 50,000 check-ups a year undertaken by the Dental Reference Service looking at the quality of dental treatment and, where they are concerned about it, being able to refer it back to the relevant health authority. I think that, backed up by the introduction of clinical governance in the dental profession and the encouragement towards clinical audit—

  110. It would be very helpful—
  (Lord Hunt of Kings Heath) Those mechanisms will provide an assurance.

  111. It would be very helpful for the Committee if we could have a note specifically on the root canal fillings which indicates that dental quality control has tracked some of these teeth that have been filled and whether the outcomes are different.
  (Lord Hunt of Kings Heath) I am happy to do that.

  112. That would be very helpful.

  (Lord Hunt of Kings Heath) Could I just respond to the other point which comes back to the nature of the contract. I think from what I have said you will understand that we are very willing to engage with the profession—113. And so are they.
  (Lord Hunt of Kings Heath) Indeed so. The strategy has acted as a catalyst for that to happen. I think the fact is that over the last 13 years, and going back to the early 1990s, there has not been a strong enough, confident relationship in order to have a grown-up discussion. I believe we now can do that.

Mrs Gordon

  114. I want to go back to the issue of access and ask about the problems of access for particular groups, the elderly or disabled, and how you see pulling all this together to actually improve that access and to lessen the health inequalities?
  (Lord Hunt of Kings Heath) First of all, I think we need to deal with access generally and clearly the Dental Access Centres, the commitment payment which is rewarding those dentists who do a lot of NHS work, and also the Modernisation Fund this year, £35 million, which again is designed to invest in those dental practices which do a lot of NHS work, those enable us to tackle the general access issue. Alongside that, I think that health authorities in their role as developing dental strategies within the Health Improvement Programme do need to focus on inequalities and develop strategies to meet them and, of course, a Community Dental Service at local level is the way in which we would expect particular pockets of difficulty to be met. In the whole process of the strategy, just as we are engaging with the profession nationally, one of the most important developments is to get health authorities to take dentistry seriously again. Through the access issue, through the deprivation issue we do expect them to come up with an action plan that details out how they are going to do that.

  115. We have heard this morning that for dentists working in GDS there is no incentive to look at the wider agenda of public health, oral health. How can you build that in so there will be that incentive to do that work?
  (Lord Hunt of Kings Heath) I think that the more the Health Service engages with the profession, the more the profession will get round the table to talk about the wider issues. It is very, very important that when the health authority is developing its health improvement programme that the dental profession and local dental committee are fully engaged in discussions about how the dental input can be made. We will certainly be encouraging health authorities to do that. Alongside that I would expect the community dental service to, equally, have constructive and positive relationships with the profession so that when it comes to tackling some of these very difficult areas what we want in the end is team work. We want to go to the profession at local level and say, "We do have a problem here. Can you help us solve it?" At the moment there is far too much division between the profession and the local health service.

  116. When they are small businesses obviously financial issues are important and there is no financial incentive to do preventative health.
  (Lord Hunt of Kings Heath) There are two issues on that. First of all, there is the issue of the contract and, as I have suggested, we are willing and keen to talk to the profession about whether there are changes that could be made that will reflect both the issue of what are the incentives in terms of treatment as opposed to prevention, but also looking at the issue of whether at the moment there are the wrong financial incentives, perhaps over-egged. Equally, we must make sure that in any contractual change there are not perverse incentives the other way that can lead to neglect of patients. The experience in 1990 suggests that can also be a problem. In terms of dentists' involvement in wider NHS issues that is an issue that we are looking at in relation to the commitment payments. Commitment payments were introduced a few months ago to enable us to reward NHS dentists. One of the issues we have been exploring with the profession is that if a dentist is involved in some of those wider issues that they perhaps could qualify for commitment payments in respect of that.

Dr Brand

  117. We have gone through the bits I was most concerned about except perhaps to tease out with the Minister the direction that the Government is taking. There could be two ways of trying to influence the way dentistry is delivered. One is directly through the service, and you have got this paradox of having Dental Access Centres, having employed dentists doing piece work, and the GDS doing piecework and trying to achieve continuity. Is there any evidence in the Department that the effects of PDS and Dental Access Centres are reducing the viability and further reducing access to NHS Dentistry through the GDS?
  (Lord Hunt of Kings Heath) I will ask Miss Robinson to answer any specifics on that but the general point to be made is that we see Dental Access Centres as being complementary to the GDS.

  118. You would restrict them to emergency treatment, one-off treatment?
  (Lord Hunt of Kings Heath) No, I think some Dental Access Centres are enabled to provide follow-up treatment although, equally, we would be delighted if when someone had gone for a one-off treatment to a DAC, We were able to ensure that they then went on to a NHS dentist for regular treatment. It is very important for me to say that Dental Access Centres have not been established to compete with GDS; they are there to complement the GDS.

  119. At the moment very often people turn up at the Dental Access Centre, they have their emergency treatment, and then they are left struggling to find someone else to follow it up.
  (Lord Hunt of Kings Heath) It varies from Dental Access Centre to Dental Access Centre. Clearly when they start inevitably there is a huge backlog of people who require treatment and that has then meant the DACs have had to focus on those people who need urgent treatment. As they settle down we hope DACs will be able to provide regular treatment but, as I have said, the game plan here is to encourage more GDS dentists to take on more NHS patients for regular treatment.

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