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Standing Committee E
Thursday 19 June 2003
[Mr. Peter Atkinson in the Chair]
Provision of primary dental services
Dr. Evan Harris (Oxford, West and Abingdon): I beg to move amendment No. 635, in clause 157 page 74 line 21 leave out
'to the extent that it considers it reasonable to do so'.
The Chairman: With this it will be convenient to discuss the following amendments: No. 629, in clause 157 page 74 line 22 after 'provide', insert
'and promote the development of'.
No. 636, in clause 157 page 74 line 23 at end insert
'in accordance with identified local need'.
No. 639, in clause 157 page 74 line 26 at end insert
'and will ensure that provision that is currently available under the existing system, including the care of those with special needs, and services such as orthodontics and oral surgery, will be secured.'.
Dr. Harris: I am delighted that we are finally, at least in this clause, discussing the role of commissioning. The Minister is aware of earlier exchanges during which regret was expressed at the fact that a great deal of this piece of legislation is designed to change structures and systems relating to the provision of service. This generally very welcome clause recognises the importance of commissioning, particularly local commissioning according to local decisions.
The amendments seek to examine more carefully the basis upon which commissioning decisions will be made. Proposed new section 16CA(1) does not give enough priority to the importance of first assessing local need and then commissioning services designed to meet it. Instead, it simply allows primary care trusts to judge what it is reasonable to commission. I should be grateful if the Minister would explain how that qualification, and the basis on which local commissioners have a duty to commission dental services, compare to the commissioning of other services by health authorities or their replacements under the National Health Service Act 1977. The comparison seems to be a fairly loose one, and it may be more appropriate to place a requirement in the Bill to deal with local need.
Dentistry, the provision of dental services and the level of public dental health vary considerably across the country. That variation is too great, which implies that there are pockets of great need. Commissioners may decide to increase the level of provision to a degree that they consider reasonable given all the circumstances. However, if that level comes nowhere near meeting the identified need, or if they do not take
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steps to identify the needs of public dental health, health promotion, access to dental care, access to screening services and access to emergency and elective treatment, the commissioners may fall short.
In tabling amendment No. 635, the Liberal Democrats have the support of the Consumers Association, which requested that we raise the issue with the Government. It too recognises that access to dentistry is poor and that dental services are under great pressure in many areas. We have also heard from the British Dental Association that the share of funding for dentistry under the national arrangements has fallen from about 5 per cent. to nearer 3 per cent. of NHS spend. That constrains the ability of dental services to obtain sufficient resources to keep up with the level of need or demand, which is why the Committee and the Government have faced the problem of poor access to NHS dentistry.
Providing the ability for local commissioners to commission services and to be responsible for making contractual arrangements with providers—a matter to be dealt with in later clauses—is a sensible move away from a nationally negotiated and nationally organised system of contracting with dentists, and I support the Government in their intention. However, reference to need will be important.
We are concerned at the continuing failure to provide the ability for people to register with an NHS dentist. The Government made a limited pledge to ensure universal access to dentistry as much as possible. However, that really meant access in emergencies and did not result in people registering with dentists, as was the case before the drift away from NHS dentistry to private dentistry.
Primary care trusts should be required to identify the need for people to be registered with a dental practitioner, just as they register with a medical practitioner in primary care. Without that, there will not be the holistic and preventive care provided by dental practitioners that is an important part of dental health care, but simply a dental sickness service that deals with problems as they arise. There will not be the continuity of care that registration with an identified dental practitioner gives, and patients will not receive the advice that regular check-ups provide. Whether the practitioner is salaried or on a contract is immaterial; the question is whether that holistic care will exist.
If the Government were minded to look kindly on amendments Nos. 635 and 636 and consider the necessity to identify and cater for need, they would find that there was more pressure on local commissioners to ensure that they provided not just a holistic and preventive service, but one that was actually cost effective. If more dental disease were prevented by advice and appropriate evidence-based, effective screening techniques, and by dealing with problems early rather than in an emergency, the cost of dental care would ultimately be lower than if people were allowed to drift into problems that a firefighting system would rectify.
The wording of the clause is far too loose, because a PCT might consider it reasonable to maintain the current level of services and registrations. After all, the
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Government consider that level to be adequate because they claim to have met their access pledge to dentistry. Members on both sides of the House know from their constituencies that current dental provision is simply inadequate, especially the levels of holistic and preventive work that I mentioned. The Government are running the risk of ensuring that commissioners continue to view dentistry and related care as a lower priority than other areas, and it is unreasonable to allow that to continue.
Dr. Andrew Murrison (Westbury): The Government have lived up to their 1999 pledge on dentistry, but does the hon. Gentleman agree that they have only partly done so, as they have fulfilled their pledge on emergency dentistry and but not on the bulk of dentistry care?
Dr. Harris: Yes, the hon. Gentleman is agreeing with my earlier point that their pledge was limited in that it ensured greater access to only emergency treatment. Registration with dentists continues to fall, yet most people consider that good dental care involves the ability to register with a dentist, as one does with a GP, to ensure access to joined-up services, preventive work and advice on screening. The Government seem to want to provoke a firefighting mechanism by ensuring that there is a requirement only to provide access to emergency treatment or treatment when the patient deems it necessary, rather than encouraging the normal teamwork relationship between a patient and their registered dentist.
I hope that the Government have heard that point. I also hope that they recognise that the current wording is insufficient to safeguard the need to increase dentistry care. If PCTs argue that the current dental provision that the Government consider adequate—for which the access pledge has already been met—is acceptable, it would be reasonable not to seek to increase the degree of registration.
The clause does not recognise the degree of variation in dental services and in need. There is huge dental need in certain areas. It is important to debate whether other preventive measures, such as fluoridation, may be appropriate, but it is probably not fitting to do so during debates on this Bill. That whole debate is predicated on the unevenness of treatment.
The British Dental Association advised my colleagues and I on amendment No. 639, regarding the provision of specialist services. It is rather surprising that the British Dental Association, which has been involved closely with the Government in the negotiation of the contract and which, like us, generally supports these clauses, still has concerns. In tabling the amendment, I seek to clarify what specialist and special needs services will be available under the new system, because the Bill makes no specific provision for securing services for patients with special needs, who are among the most vulnerable people in our society. Dentists working in the community dental services have considerable experience in that area: they, and we, need assurance
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that such care will continue to be provided and commissioned by primary care trusts under the new arrangements.
Similarly, patients who need orthodontic treatment and oral surgery must be assured that such services will be available in the future within a primary care setting. The General Dental Council, which regulates the profession, has recently set up specialist registers of those qualified to provide such services, and primary care trusts need to recognise the contribution that such specialists can make.
The Department of Health, through a supplement of the chief dental officer's digest from May 2003, states:
''There will also be an opportunity to ensure that developing dental specialities are given the right incentives to contribute to patient care''.
Amendment No. 639 would seek to secure that. The Minister will know that access to orthodontics and oral surgery is poor. Waiting times for orthodontics were traditionally not measured under the Government's waiting time statistics inherited from the Conservatives, and, therefore, there were particularly long waiting times in that service, as there were for a few other services such as chiropody. Indeed, the term foot and mouth disease might well apply to the failure of the system to measure the waiting times in those specialities. Therefore, due to the priority given to meeting waiting time targets, dentistry, chiropody and some other areas have fallen through the net, and waiting times have become too long.
There are people with complex needs who often have significant other health needs of which oral health is a component. In particular, some patients with congenital disease require effective access to these services both in secondary care and in primary care settings, especially as more expertise develops in primary care and the Government seek rightly to shift services into primary care for reasons of quality and access. If the Government are going to be consistent in that, they must give an assurance that primary care trusts will have a duty not only to commission and secure the services that are currently available for these groups of people with special needs, but to improve those services.
We may be able to cover access to dentistry in other areas, so I will not go into detail on that because you, Mr. Chairman, may see fit to have a clause stand part debate. However, there are issues concerning access to dentistry for other parts of the population, and I hope that we will have an opportunity to debate at some point, though perhaps not under these detailed amendments, what the Government intend to do to secure better access to dentistry in prisons and detention centres, and for some other groups.
I hope that the Government will look kindly on this group of amendments. They are tabled in a constructive manner to seek to ensure that primary care trusts are given the incentives that they need to ensure that dentistry is no longer the Cinderella service that it has been under the current arrangements.
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