Examination of Witnesses (Questions 100
- 119)
THURSDAY 15 FEBRUARY 2001
LORD HUNT
OF KINGS
HEATH, DAME
MARGARET SEWARD
AND MISS
HELEN ROBINSON
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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