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Westminster Hall

Wednesday 12 January 2005

[Mr. Edward O'Hara in the Chair]

NHS Dentistry

Motion made, and Question proposed, That the sitting be now adjourned.—[James Purnell.]

9.30 am

Mr. Damian Green (Ashford) (Con): I congratulate the newly-appointed Lord Commissioner of Her Majesty's Treasury, the hon. Member for Stalybridge and Hyde (James Purnell), on efficiently carrying out his duties.

I am grateful for the chance to raise this issue, which came to my attention as a constituency matter. Clearly, it also has national implications, and I shall make some general points about the national position shortly. Some problems are, however, specific to my constituency, although their seriousness illustrates the general problem. Indeed, I can see by the number of colleagues from both sides of the House who are present that it affects many constituencies.

To put it straightforwardly, no dentist in my constituency is taking on new national health service patients. In recent weeks, one practice has become so frustrated at the uncertainty surrounding the introduction of the new contract that it has pulled out of NHS work altogether. Inevitably, the effect on local provision has been disastrous.

The problem is illustrated by the primary care trust's figures. Right hon. and hon. Members will be aware that the Government have set targets as part of their commitment to ensuring access to NHS dentistry. When someone living in an urban area phones NHS Direct saying that they need an NHS dentist, they are supposed to be provided with one within 10 km of where they live. A year ago, the Ashford PCT was able to meet that target in 98 per cent. of cases; in the latest quarter for which it has figures, however, that percentage had already fallen to 64 per cent.—well below the Government's target of 90 per cent.—and it is heading downwards at a rate of knots. Clearly, that is not acceptable, although I should make it clear that I have no criticism of my local PCT, which is working extremely hard to do what it can within the severe constraints that it faces. It is trying to extend the hours of emergency cover, but that is simply not enough.

As hon. Members would expect, I have received many letters, e-mails and complaints about the crisis in dentistry in my constituency, but I shall quote only one, which illustrates what is, I am sure, a familiar story to colleagues from all parts of the country. Mrs. Barker writes:

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I am sure that such letters will be familiar throughout the country.

I make a plea to the Minister to see Ashford as a special case precisely because the Government designate it as an area of fast population growth. Already, under the Deputy Prime Minister's sustainable communities plan, 800 new houses a year are being built in Ashford, and the plan is for roughly 1,000 more new houses every year for the next 25 years. We know that about 2,000 more people will be living in Ashford this time next year, and not one of them will be able to find an NHS dentist in the town. For the people of Ashford, easy access to NHS dentistry is a mirage. I know that the Minister will not find that acceptable, so I ask her to suggest to the strategic health authority that the allocation of resources in Kent and Medway this year and in the years ahead needs to reflect an urgent crisis, which will become more acute in years to come.

In my survey of the local situation, I mentioned the new dental contract. The contract negotiations provide the link to the wider national picture. This debate is particularly timely after Monday's announcement of yet another delay in the introduction of the new contract. The Minister will be aware of how frustrated dentists are, and that that frustration and uncertainty have already been reflected in the number of dentists leaving the NHS.

Dr. Nick Palmer (Broxtowe) (Lab): I am grateful to the hon. Gentleman for giving way, and for enabling us to have this debate. Is he aware that the British Dental Association has welcomed the latest delay?

Mr. Green : I am aware that the British Dental Association said that it thought that the situation is entirely unsatisfactory, which is why the talks broke down in December. The association obviously welcomes the fact that the delay has been introduced. However, the proof of the pudding will be in the eating when it comes to whether serious talks can start that resolve the many frustrations that have caused dentists to become so unhappy. Last July the report of the primary care dental work force, the latest work force review, said that in 2003 there was a shortage of 1,850 dentists in England alone, and predicted that by 2011 that shortage is likely to more than double to between 3,640 and 5,100.

The Government have taken notice of that survey and have announced a plan to recruit 1,000 extra whole-time equivalent dentists by October this year through a number of measures, which I am sure the Minister will address at the end of the debate. However, we need to put that in context as a problem that affects different parts of the population in different ways. It is the most vulnerable communities that are least likely to have
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decent access to NHS dentistry, and the community dental service is worse off in terms of vacancies. The BDA has reported that 10 per cent. of posts in the community dental service are vacant, and the average time that those posts remain vacant is 12 months. Clearly that is a worrying situation.

It is also clear that many dentists' frustration is deep-seated. Research carried out towards the end of last year shows that 60 per cent. of high street dentists will either reduce their NHS commitment or quit the NHS altogether. Only 2 per cent. of high street dentists said that they would increase their NHS work on the back of the Government's proposals, while 16 per cent. said that they would stop providing NHS dentistry altogether. Those are worrying findings. To revert to the point made by the hon. Member for Broxtowe (Dr. Palmer) about what is actually happening, I think that the latest figures for those leaving NHS dentistry show a worrying trend.

The figures obviously have to be taken with some caveats because the vast majority of dentists do some private work and some NHS work, but the best guess seems to be that in 2003 about 250 dentists left the NHS, and in 2004 that number increased to more than 300. If we take those figures alone, the Government's plan for an extra 1,000 dentists has to be put into context—more than 500 have left the NHS over the past two years. One of my fears about the Government's proposals to address the crisis is that they are simply pouring water into a bucket that has a large hole in it. Dentists are already leaving in such large numbers that the extra 1,000, even if they can be recruited, will be swallowed up far too quickly.

Lembit Öpik (Montgomeryshire) (LD): Is the hon. Gentleman aware that exactly the problem that he describes is becoming acute in places such as mid-Wales, where almost no NHS dental provision is available to a large proportion of the population? Does he agree that in the long term that will probably cost us more because minor dental ailments will become crises and emergencies, which necessarily cost a great deal more? There is a serious resource issue, which probably will involve higher costs if we do not resolve it in the short term.

Mr. Green : I am sure that that is right. I should make it clear that the idea behind the contract reforms of making dentistry less a problem-solving profession and more a preventive profession seems entirely sensible. The practical effect may be precisely what the hon. Gentleman has just described. I am grateful to him for mentioning mid-Wales because the situation is clearly patchy around the country. I have been struck by the e-mails, letters and phone calls that I have received from different part of the country since this debate was announced. The first came from west Wales and the constituency of Preseli Pembrokeshire where every dentist has now pulled out of the NHS. In an area of high deprivation, in an objective 1 zone, it is no longer possible for an adult to access NHS dentistry.

The NHS Direct advice line is referring people in Pembrokeshire to a dentist in Port Talbot as their nearest NHS dentist, which is 60 miles away. NHS
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Direct fails to mention that the dentist there is refusing to see anyone from outside his area. Even if they wanted to travel 60 miles, the dentist would not help them. Just before Christmas the local health board brought in some extra provision, but that left 40 people who wanted emergency dental treatment queuing for three hours from 7 am at a special clinic, only to be told that the dentist being brought in was in Ireland and had forgotten that he was supposed to be working that day. That is a terrifying snapshot of what is going wrong.

There are similar tales from other parts of the country. In Portsmouth, people make on average 22 calls before they can talk to anyone about the possibility of dental treatment.

Mr. Mark Hoban (Fareham) (Con): I am grateful to my hon. Friend for mentioning Portsmouth. According to the first letter that I received about a dentist going private, my local PCT, Fareham and Gosport, was telling people to go to Portsmouth, Gosport or Lee-on-the-Solent for an NHS dentist. The NHS Direct website today tells them to go to Eastleigh, some 26 miles away. That shows the acuteness of the problem in south-east Hampshire.

Mr. Green : I am grateful to my hon. Friend for expanding my point. Moving further west again, the chairman of the Cornwall local dental committee says that dentists there are already working like machines. Dentists will not put up with the extra work that the contract will impose on them and growing numbers will go private. About 200,000 adults in Cornwall are not registered with a dentist. That is half Cornwall's adult population.

Hugh Bayley (City of York) (Lab): The real principle behind the new contract is whether we should move from the old system of payment for each individual item of treatment, which encourages over-treatment, to a system where dentists seek to promote good oral health for their patients. Surely that is the right way to go and the Government are right to seek to change the contracts. Are not the minority of dentists who resist that wrong?

Mr. Green : As I said, I think that the principle is perfectly sensible. The problem is that there is a huge gap between the rhetoric and the practical reality. The change clearly has not and is not being made in a way that dentists find acceptable. That is why the situation that I am describing, with help from all parts of the House, has come about.

My last port of call is the north-west and a letter from Mr. Tariq Drabu, the chairman of the Bury and Rochdale local dental committee, in response to the Department of Health's chief dental officer, who wrote in The Daily Telegraph about the plan for an extra 1,000 dentists. Mr. Drabu challenged Professor Bedi's statement, saying that he had

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The point about foreign imports is a good one. They are clearly one solution to the problem, but I confess that I feel slightly uncomfortable about the idea of this country trawling the world to attract dentists, for instance from India, where the ratio of dentists to the general population is 1:36,000. I appreciate all the pressures that are on Ministers, but I hope that the Minister agrees that the idea of this country scouring countries that are significantly poorer than the UK for medical staff makes one feel slightly uncomfortable.

Dr. Phyllis Starkey (Milton Keynes, South-West) (Lab): I hesitate to speak anecdotally, but I suspect that the import of dentists from elsewhere is not new. I recollect that when I was taking my own children, who are now young adults, to the dentist, almost every dentist appeared to be from New Zealand. I think that that was because the New Zealand Government had instituted an extremely good preventive health programme, so there was not anywhere near the level of dental caries in New Zealand that would be required to keep all its dentists going, so some came to this country. Given the age of my children, that was happening under a Tory Government.

Mr. Green : The issue is not new, and I can safely say from where I stand that this country has been significantly enriched by the import of New Zealand dentists. As I said, I fully appreciate the pressures on Ministers, but recruiting vital medical staff from countries that are at a much lower level of economic development than we are makes me uncomfortable.

Hugh Bayley : Is the hon. Gentleman arguing against the freedom of dental staff to emigrate and practise in other countries? Would he block British dentists from going to work in the United States, which is a richer country than ours? Does he believe that Poland, Spain or Germany should prevent their dentists from coming to work in this country?

Mr. Green : No, I believe in the free movement of labour and that individuals in all countries should be allowed to work anywhere. That said, I feel uncomfortable about this country, as a rich, developed country, having to solve its recruitment problems by attracting medical staff from countries where they may be even more desperately needed than they are here. That is not an economic but a moral point. Nor is it a partisan point; I agree with the hon. Member for Milton Keynes, South-West (Dr. Starkey) that foreign recruitment has been happening for a long time. However, it should make us uncomfortable that that
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appears to be the routine way in which we attempt to solve problems in all parts of the health service, not just the dental service.

All these problems are happening against what is already a difficult background. A National Audit Office report of last November made pretty stark reading, especially in conjunction with the latest adult dental health survey, which showed that the average Briton has lost eight of his 32 adult teeth by the time he turns 45, and that 44 to 45 per cent. of the population are registered with a dentist. Those figures should worry us.

The NAO asked the right question: will the new contract stem the flow of dentists out of the NHS? So far, the answer has been a clear no. If the situation is not reversed as a matter of great urgency, the crisis, currently patchy, will become universal. I do not underestimate the scale of the problem that the Minister faces. I hope that she can give me some reassurance about the special difficulties in my constituency, and that the uncertainty clouding the future of NHS dentistry can be lifted soon. If it cannot, dental health in this country will become an area of embarrassing national failure. All of us would regret that.

Several hon. Members rose—

Mr. Deputy Speaker : Order. Those hon. Members who catch my eye might care to be aware that the Front Bench contributions must start not later than 10.30 am.

9.51 am

Dr. Phyllis Starkey (Milton Keynes, South-West) (Lab): It will come as no surprise that I intend to draw to the Minister's attention the deficiencies of the dental service in my constituency. However, I also want to talk about the improvements that have started to happen and to touch on the importance of prevention as well as treatment.

The situation in Milton Keynes, so far as I can tell, is that only one dental surgery in the Milton Keynes primary care trust area is accepting new NHS adult patients, and only a small proportion of surgeries are registering children aged 0 to 18 for NHS treatment. Like the hon. Member for Ashford (Mr. Green), I represent an area of housing growth—it has been growing continuously for the past 20 years—which causes problems in that we are continually trying to fill up the bath with the plug out. That adds to our problems as an area of population growth, although we do not have a population that is significantly less healthy than the average for England and Wales.

The story of a constituent in Bletchley highlights a particular problem. He was trying to get new dentures and had been unable to find a dentist who could provide them. It became clear that the laboratory cost for producing dentures was about £10 more than the NHS fee. We finally managed, after a great deal of negotiation, to get him referred to a local practice that had just taken on an extra member of staff to do NHS work, so there was a good outcome to his case. However, that took a great deal of effort.

Another problem is the lack of an out-of-hours service within a 20-mile radius. My understanding is that it is impossible to get treatment after 9 o'clock in Milton Keynes, Luton, Bedford, Northampton and Oxford. That means that people tend to turn up in great
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pain in accident and emergency departments, and have to be given treatment simply for the pain to tide them over until they can be treated for the problem.

According to my PCT, one of its difficulties, apart from the general shortage of dentists and the fact that more and more have withdrawn from NHS work, is that Milton Keynes, thanks to our Government's stupendous care of the economy, has a hugely dynamic local economy, but that has a negative side as well as a positive one. The negative side is that there are many other employment opportunities, not so much for dentists but for all the other staff whom dentists need to provide a service. In our local employment market, it is difficult to recruit those ancillary staff and retain them.

An additional problem is the high cost of housing in our area, which means that people employed in the public service who would be paid the same wherever they lived in the country find it difficult to move to jobs in Milton Keynes because their effective salary is lower. I ask the Minister to consider that issue, which affects not only the dental services, but the NHS generally. Key worker housing has been made available in Milton Keynes and is helping to deal with the problem, but I ask the Government to keep the situation under review.

From what the hon. Member for Ashford was saying, the situation in Milton Keynes seems to be better, or slightly less worse depending on which way one looks at it, than in his constituency. I am certainly not saying that my constituents have particular and intense problems, but they are suffering like others across the country from general problems affecting the dental service.

Measures have been taken and are starting to improve the situation. There has been a combination of increased Government funding and new innovative ways of delivering the service. I am pleased to have heard recently that the Milton Keynes PCT received Government funding to create 9,000 new NHS registrations. That process is just starting, but I would be grateful if the Minister confirmed the time scale for those new registrations, and what action the strategic health authority will take to monitor progress and ensure that there is no slippage on the delivery of them.

A number of NHS dental access centres have been created in Milton Keynes, which have been extremely helpful in supplementing the normal—if I may describe it that way—conventional dentistry service and enabling people to gain access to dental services when necessary. As well as providing routine care, those centres provide specialist care for priority groups who cannot get to dentists and act as specialist treatment centres for patients referred by other health professionals. Are dental access centres intended as a permanent supplement to the conventional dental service, or are they a stop-gap measure to tide us over during the continuing dental shortages?

A third improvement, which has not yet happened but has been announced, is in the north of my constituency in Wolverton. It is an area of deprivation but a significant amount of extra housing is planned as part of the expansion of Milton Keynes. In November, the Government announced £5 million of funding for a
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new one-stop primary care centre, including dental health services, in Wolverton to care for the current and expected population. I commend such super-health centres, which provide a much wider range of health services than the conventional GP surgery, bring GP and dental health services together, and will also carry out a number of minor operative procedures currently carried out in hospitals. Plans for another such centre in the further growth area on the western side of the city are being consulted on. I commend those initiatives and hope that the Government will monitor their progress when they open so that they can modify how health services are provided if there are lessons to be learned.

On prevention, as in other areas of health, it is important to encourage people to improve dental health so that the need for dental care is reduced. I alluded in my intervention to my children and the influx of dentists from New Zealand, one of whom told me of the effectiveness of fluoridation there, which had drastically reduced the level of dental caries in children, leading to an oversupply of dentists. That is a very happy experience, which I am pleased we are finally building on in this country.

The amendment to the Water Act 2003 requires water companies to increase the concentration of fluoride in water supplies when the strategic health authority requires it. The evidence in favour of fluoridation is extremely strong. It is particularly important for children in deprived areas whose dental health is much poorer than that of children in better-off families. The fluoridation measures will have the greatest effect in improving the dental health of those children in disadvantaged areas. It is important that we continue to point out to parents and to the population at large the health burden of poor dental health, the problems that occur and the need to build good dental health in children. Good dental health will follow children into adult life. It is very difficult to repair in adults the damage done to dental health by a poor diet in childhood.

I wanted to stress the importance of ensuring that fluoridation is extended, but there are other steps that children and adults can take to improve their dental health. It is important to stress the importance of a balanced diet, the need to reduce the sugar level in foods, which has obvious implications for the labelling of foods to ensure that parents and other adults can choose foods with lower sugar levels for themselves, and the importance of reducing the use by parents of fizzy and sugary drinks for children. Parents and children should be encouraged to drink water or milk rather than drinks with high sugar levels that will lead inevitably to poor dental health.

Finally, it is important to encourage people to give up smoking, not only for the more obvious reason that it reduces heart disease and cancer, but because of the effect of smoking on oral health. Smoking discolours teeth and increases the risk of mouth cancer.

For all those reasons, and despite the primary focus of the debate being on the difficulties of gaining access to dental care, I hope that the Minister will not lose sight of the importance of continuing to stress preventive health measures that will reduce the need for people to seek dental care in the first place and immeasurably improve their health.

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Mr. Deputy Speaker : It would be interesting to hear the views of New Zealand dentists.

10.3 am

Sir Paul Beresford (Mole Valley) (Con): You have declared my interest for me, Mr. Deputy Speaker, although it is a little more than that. I have an NHS number and I am a practising dentist, although an extremely part-time one. If someone has toothache on Sundays, there is a chance that they can see me. I am also a member of the British Dental Association, and have dental experience in the NHS and a tiny bit of experience in New Zealand. The comments made by the hon. Member for Milton Keynes, South-West (Dr. Starkey) on fluoride are correct, but she should also mention the school dental services for children in New Zealand, which have also made a dramatic difference.

When I first came to this country, I worked in east London, predominantly in the NHS. Even in those days, however, there was a shift towards private dental care. I also worked in south-west London in mixed practice, and spent a year in the Eastman dental hospital. I have done the rounds, which explains why I am 10 years younger than I look. I have another considerable advantage: I am not on the Opposition Front Bench. I also regularly meet dentists and dental technicians at meetings and conferences.

My constituency has exactly the same problems as the constituencies of everyone who has spoken so far and those who will follow, with perhaps the exception of the Minister, in that we have a shortage of dentists. Most people in my area have the advantage of being able to afford private dentistry, which means that those who cannot afford it have a tough time. There are pockets of quite bad deprivation.

In the past 32 years of my being here, I have been struck by the improvement in dentistry in this country. Several factors are involved, but I know that the reputation of the UK's national health dentistry is not good in other western nations. Dentists in America, Canada, Australia, New Zealand and so on warn their patients who come to this country not to take NHS dental treatment. They advise them to look for a private dentist. However, having said that, things are improving. There have been many changes, but two of the greatest are, first, fluoride in toothpaste and in water supplies—I hope that the Minister takes that seriously, as I will have questions at the end of the debate which I hope that she will be able to answer—and, secondly, the introduction of fees for patients.

The introduction of fees had a dramatic effect on standards, because patients started to take notice of what was being done. They asked the dentist why something was being done a second time when it had been done last year or the year before and so on. If they had to pay for the filling, they asked whether they could have a white one. That brought in change quite quickly, which was stimulated by magazines and the Daily Mail Femail pages—it seemed that everyone had to have a "Hollywood smile", although I should be desperately upset if we ever reached that stage. Dentists started to lift their standards, particularly in the past decade, and to examine the available equipment and materials. There has been a huge improvement in that respect, but also a huge change in costs.
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When I was at the Eastman dental hospital I spent quite a bit of my time undoing botched work done on patients who came in with toothache. One of the primary areas was in endodontics—root canal treatment. In those days dental schools taught students to use Dr. Sargenti's N2. I said to the professor at Guy's, "Why are you teaching students to use that stuff, which is banned by most western nations?" He replied, "They will have to do national health dentistry and that is the only way to do it quickly." When I pointed out that it had a 60 per cent. failure rate, he just shrugged his shoulders. That was depressing, but even more depressing is that the national health dentist gets about £75 or £80 for doing molar root canal treatment, which will be reflected in the income under the new system. It should take a dentist and one or two assistants between one and one and a half hours to do the work properly, and the capital cost of the equipment—microscope, digital X-rays, fancy nickel titanium files and so on—is more than £20,000. There is also a continual heavy revenue cost because the nickel titanium files can be used only a few times or they break and have to be discarded. If they break at the end of a tooth, the dentist is worried and has to phone his protection society to make sure that he is all right.

The only way to respond to such matters would be to make a large investment. Dentists are asking for £4 billion-plus and, realistically, that is not to be expected, so the question is where we are going. At present, we are going backwards. Dentists are disappointed and upset. We have heard how they are moving out, and I assure the Minister that what they say behind the scenes is unprintable. They have had enough, and if they could get out, they would. They would go into private dentistry because there are more incentives and more opportunities for dentists to produce work that they are proud of and to respond to patients and their demands. That worries me, because although there is a need for that, as I know from my time in east London there is also a desperate need for a basic health service that is oriented towards dental health, rather than fixing things with new private cosmetic treatment.

The hon. Member for Milton Keynes, South-West spoke about the difficulty of getting a full upper and lower denture for a constituent, the cost of which is £100, £200 or £300 from the NHS. Even privately it is not much more than that, but more exotic dentistry, such as full implant replacements, costs £40,000 or £50,000 per patient, which is out of the question. There is a definite health need, but the demand for cosmetics need not and should not be met to that degree by the NHS.

I was astonished when the Secretary of State, responding to a question from a BDA representative at a press conference on the last White Paper, announced that "dentistry was sorted". I have not heard a more incorrect statement for years. The dentists have had enough. The dentists' organisations have had enough—they have ended up walking out. Patients are finding the situation impossible. They believed that, by the end of 2001, they would have the opportunity—according to the Prime Minister—to have access to national health dental services. They probably have that access if they are prepared to drive to it, but they have to drive a long way.
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The new contract was intended to solve the problem, but there are some major problems with it. In an intervention, the hon. Member for City of York (Hugh Bayley) mentioned that there was a fee system that tended to make dentists rush more and do more—I think that "treadmill" was the word that he used. The problem is that one treadmill has gone, but we are bringing back another.

There is pressure from the Government for dentists to meet figures—they will have to meet the agreement on producing sufficient turnover for the finances that they have been promised. That will have two effects: first, it will speed up treatment but reduce the standard of treatment; secondly, it will make the dentist choose a quicker, cheaper option, particularly when laboratory costs and fees are involved. If an elderly patient comes in with a denture that they need to eat with—a genuine health need—which is linked to a key tooth that has suddenly developed an abscess, will the dentist, when he is under pressure, spend two and a half, three or four hours carrying out root-canal treatment, building up the tooth, putting a crown on it and then making a denture to attach to it? I suspect that he will be tempted to say no to that work, although I hope that he will not, and to extract the tooth, which is a poorer treatment for that patient. However, the new treadmill will induce the dentist to do that.

The idea that we will rush undergraduates into the profession and that within five, six or seven years they will all be pouring out of the dental schools to solve our problems is not on. That will not work. To begin with, we do not have the staff to deal with them.

We have also touched on the matter of overseas recruitment. In that context—a point that has not been mentioned—I have deep concern over standards. I was recently horrified to discover that the pass mark required for dentists in the UK, when they sit the international English language test system, has been lowered. Perhaps that has been done for current convenience.

I recognise that the Minister will not be able to answer all our questions today. However, I ask her to write to us all with the answers to those questions that she does not deal with. I shall pose only a few questions, but there are many more. One question that I have asked repeatedly in written form concerns when dentists and their professional organisations can expect sight of a draft base contract. There have been repeated delays. There have been responses to questions, but no answers.

Does the Minister accept that the drive to increase the number of NHS dental patients is seen as a transference from one treadmill to another, and how will she overcome that? The paper-based tick-box system of monitoring, which we as dentists anticipate, will impose pressure throughout dentistry and will, as I mentioned earlier, lead to poorer treatment. However, in the case of one or two dentists—although I do not know any of that sort—it will mean that their golf handicaps will improve.

Does the Minister recognise that the increase in demand for private dentistry with those new materials brings greater patient satisfaction, and that it is a
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contribution to the dental health of the nation? We think that we have a problem now, but if everyone dropped private dentistry and rushed to the NHS, the overload would be phenomenal.

Can we be assured that the new base contract and the NHS link with dentists will enable dentists to tackle health care in a mixed practice, and that there will not be pressure to cease mixed practice? I want the Minister to recognise that any restriction on private dentistry will have a bad effect on standards and cause an increase in demand on the NHS. Many dentists need that mixture because they undertake a core service on behalf of the NHS, which they are willing to do because they can top it up with the private health service. If they do not have that, many will go straight across to being private. We need to recognise that, under the contract, capital investment is welcome, meagre though it is. There needs to be more recognition that with modern dentistry—with changes and the increased costs of modern equipment—day-to-day revenue costs are increasing faster than inflation. I am deeply concerned that the PCTs are so overburdened and so ignorant of dentistry that it has become just a little hole-in-the corner job, of no particular interest unless there happens to be local Members—like the two we have heard from today—who will jump up and down on their necks.

Finally, as the hon. Member for Milton Keynes, South-West mentioned, there is the vital issue of fluoridation. We took a teetering step during consideration of the Water Act 2003. Members on both sides of the House supported an amendment, but we are still waiting for the regulations. Can the Minister hurry up the process and tell us when the regulations can be implemented? I am a dentist who, in my tiny part-time work, engages almost entirely in private dentistry. However, NHS dentistry is an important part of the health of this nation. It is oral health against oral cancer, as was mentioned, and agonising toothache with the pain which that gives not only to those suffering from it, but to the employers and the economy of this country.

10.16 am

Linda Gilroy (Plymouth, Sutton) (Lab/Co-op): I congratulate the hon. Member for Ashford (Mr. Green) on introducing a very important debate. I will try to speak briefly, as I had the opportunity of speaking in a debate in May 2004 on dental provision in Devon. I do not propose to go over the issues I raised then, describing how our part of the country is one of the hot spots where some problems emerged early. In that debate, other hon. Members and I raised issues to do with the supply of dentists in Plymouth and the wider dental health community in Devon and, indeed, Cornwall. In particular, we were concerned about the importance and future security of the vocational dental health service. That plays a significant role in providing dental care, especially in the poorer areas of my constituency. We talked of the need to establish dental training, at least as an outpost of Bristol—the nearest dental school to Devon and Cornwall—because, as with medical care, dentists tend to go into practice where they were in training, and, vice versa, more people come into training in such a locality. That has certainly been found to be the case with the new Peninsula medical school.
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We also talked a lot of the expectation that we might be able to recruit dentists, particularly from within the EU. If the hon. Gentleman feels uncomfortable about that recruitment, I hope the Minister will be able to offer some reassurances. I certainly think from what I know of the progress that has been made that there is no need to feel uncomfortable. I look forward to my hon. Friend's comments, but the hon. Gentleman, and perhaps other hon. Members, should reflect on the fact that the haemorrhage of dentists from the NHS has been going on since the early 1990s, when a deeply unpopular contract was introduced. Indeed, two medical schools also closed then. I will not dwell on that particular political point, but is important to make it, and I urge the Minister to continue to give serious consideration to the training of new dentists, particularly in our part of the south-west peninsula.

I know that there has been progress and look forward to what the Minister has to say about that. Like most hon. Members, I am in regular contact with my local PCT, and have been over a range of recruitment issues since that earlier debate. I thank her Department for its speedy attention, helping us in trying to resolve some issues in finding new ways forward. Plymouth primary care trust is continuing to work hard to stabilise the situation and plan ahead. Some dentists have entered into early contracts. We were an "Options for Change" field site and those contracts appear to be working successfully. Plymouth primary care trust continues to try to maintain those dentists working in the NHS and to improve access where possible, bringing them back into personal dental service local contracts. I hope that the Minister, in responding to the questions raised, will say what the Department is doing to ensure that PCTs such as Plymouth can build with confidence on what they have already achieved. For that, it needs a PCT budget for dentistry and clear guidance, with swift clarification on contracts where such guidance is unclear.

I want to illustrate the point briefly in relation to a practice of five dentists in my constituency, where there seems to be some lack of clarity over both the ability to enter into individual contracts and the need to do so. The point was highlighted by a somewhat frustrated dentist who wrote to me:

One of the dentists is even likely to return to his own country. The dentist continued:

by the inability to come to a conclusion over individual contracts. I hope that that can be resolved.

Finally, I want to comment on one or two points arising from the Plymouth city council scrutiny committee. All last year it worked alone and with other scrutiny committees in Devon and Cornwall to try to bring some sense to the difficult situation in the far south-west, of which I know the Minister is aware. A copy of the scrutiny report has been sent to her and I hope that she will pay particular attention to its recommendations about children.

The report recommends conducting a national review of dental health care for children and not giving practitioners of NHS dentistry an automatic right to
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deregister an NHS child patient, although I do not know whether that is practical, because they are individual contractors and business people. Also, as the hon. Member for Ashford said, children who have been registered with an NHS dental practitioner should be permitted to remain on that practitioner's list, irrespective of whether their parents have registered as private patients following a change in practice by that dentist.

Finally, the report also recommends establishing a south-west peninsula school of dentistry, as part of our new Peninsula medical school, which is establishing such first-class representation in other medical fields.


10.23 am

Mr. Elfyn Llwyd (Meirionnydd Nant Conwy) (PC): I will not pretend that the problem can be laid entirely at the Government's door. I remember debating the very same point under the Major Administration with the then Secretary of State for Wales, the right hon. Member for Wokingham (Mr. Redwood). In a debate in 1993, he agreed to provide a grant for Welsh dentists to set up in NHS practices, which partly alleviated the problem. However, I live in one of the most rural parts of Wales. My constituency is 100 miles north to south and 100 miles east to west, but we have only two NHS dentists in the entire area. The out-of-hours emergency provision is two hours on a Sunday morning and a 150-mile round trip—a three-hour drive—which is absolutely third-world stuff.

A proud elderly lady from Bala came to see me recently and said that she had to see her GP more often because her oral health was suffering owing to the fact that she cannot access reasonable treatment. We face a crisis. I have a list from the Gwynedd local health board of 30 dentists in the county, 29 of whom will not accept adults on the NHS and one of whom will do so from April 2005. The situation is extremely disturbing.

There is of course an uneven distribution of dentists. Many dentists have told me that students often train in dental schools and then get attached to urban practices, where high-paid cosmetic work is undertaken. They are attracted to that work rather than to rural areas. There is no doubt that it is placing considerable pressure on GPs. As I mentioned, the lady from Bala gave such evidence. As has been said, dentists are frustrated by the lack of time available to spend with patients to offer proper preventive advice. None of this is new; it has been happening for some 10 years, but it is now even more urgent that something be done.

The Prime Minister promised at the 1999 Labour party conference that anybody wishing to access NHS dental provision would be able to do so by 2001. However, the position in Wales is probably far worse than in 1999. Overall, there are 0.36 NHS dentists per 1,000 population in Wales, according to a study undertaken by Bath university that was published in May 2004. That compares, for example, with 0.6 in the Czech Republic, 0.7 in Belgium and Germany and 0.8 in Norway—so we are lagging behind. Worse still, only 46 per cent. of adults in Wales are registered with an NHS dentist, and that figure has not improved since 2000.As was recently acknowledged by the Minister responsible
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in the Welsh Assembly, that figure has remained constant, with 40 per cent. of children in Wales not registered with an NHS dentist. The overall result, according to the Joseph Rowntree Foundation, is that five-year-olds in Wales have, on average, twice as many missing, decayed or filled teeth as youngsters in the west midlands or south-east England. That is a serious position and, obviously, something needs to be done.

The report of the Select Committee on Health in 2001 said:

It went on to say:

It is far worse in rural areas. Perhaps the Minister will consider the fact that the Ceredigion local health board is offering bursaries of £12,000 for students who train in dentistry and come back to practise in the Ceredigion area for five years after graduation. I do not know whether that scheme commends itself to her, but it might be a way of dealing with the problem.

I fully appreciate that there is no single answer, but I have spoken recently with several dentists about the subject. One in my constituency, Dr. John Swain of Dolgellau, told me that the position is far worse in rural areas, as we know, but that one of the problems is that smaller practices need financial assistance to take in trainees. That might also assist. I have spoken with the Secretary of State for Wales, also the Leader of the House, who thinks that that is a good idea, so I ask the Minister to take it further. If the right hon. Gentleman has not spoken with her, would she be prepared to discuss it with him? I have tried to be as brief as possible in the light of the time constraints, and I am grateful for this opportunity to raise this important matter.

10.29 am

Dr. Nick Palmer (Broxtowe) (Lab): I shall be brief. Most dentists are happy to work for the NHS if they can do so with reasonable terms and conditions, and most patients are not really too concerned with the detail. As virtually every speaker has said, they simply want the access. During periods of uncertainty, dentists are open to approaches from private groups, which pursue them with somewhat predatory zeal. Once they are signed up, they turn their ruthless marketing on to the patients. At least two of my constituents say that they were told in the surgery by Denplan salesmen that unless they signed up at once, they would find that not one dentist in Greater Nottingham was taking on NHS patients. That is, frankly, a fat lie. It is therefore important that dentists who are keen to stay with the NHS should be able to negotiate their arrangements as quickly as possible. I have been corresponding with the Minister on behalf of my constituent Andrew Keetley. In the last exchange I said that discussions with him were continuing, but he says that he has not heard anything for quite a long time.
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I appreciate that not every application can be granted or considered, but it would be good if those matters could be brought to a conclusion as quickly as possible.

10.30 am

Mr. Paul Burstow (Sutton and Cheam) (LD): I congratulate the hon. Member for Ashford (Mr. Green) on securing the debate. It is useful for the House periodically to review progress on the issue. The progress has been rather depressing; the figures suggest that it is still in reverse rather than going forward. I want to comment on two or three points that have been raised in the debate, which is timely in view of the written statement that was made on Monday, with its remarkable closing words:

Surely the best measure of how the Government are doing is the number of people with access to an NHS dentist.

Reference has been made to the Prime Minister's promise of 1999. Back in 1997, 51.8 per cent. of adults were registered with an NHS dentist. According to new figures that I obtained from a written answer in December, the figure for 2004 had fallen to 38.8 per cent. The number of children registered has fallen alarmingly from 65.7 per cent. in 1997 to 54.6 per cent. in 2004. The hon. Member for Milton Keynes, South-West (Dr. Starkey) referred to the aspiration—I think that that is how it must be described at the moment—of 9,000 new NHS registrations. On the basis of answers that I have received, I would suggest that only one in five NHS dentists is registering children at the moment, and that only 14 per cent. are registering charge-exempt adults.

The most vulnerable are struggling to find an NHS dentist anywhere with a book that is open and to which they can be added. In my constituency, I found from a survey that I undertook last year that 30 of the 69 practices were not taking NHS work. Some people might uncharitably claim that the Government's two-pillar approach to dental reform—the local commissioning of dental services by primary care trusts and the new contract—is fundamentally undermined by what the Government said in their written statement on Monday; they might say that those pillars are crumbling.

Mr. David Drew (Stroud) (Lab/Co-op): Does the hon. Gentleman agree that part of the problem is the extent to which dentists have ceased to believe that the British Dental Association speaks for them? Dentists in my area feel that the negotiations are problematic because of uncertainty about whether they are truly represented.

Mr. Burstow : I am not here to speak for the BDA, which will speak for itself. I am sure that dentists will make representations through hon. Members such as the hon. Member for Stroud (Mr. Drew).

Hugh Bayley : Will the hon. Gentleman give way?

Mr. Burstow : No. I am trying to make progress in a very short time, and the hon. Gentleman has made several interventions.
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The PCTs were found by the National Audit Office to have had little experience of high street dentistry, as the hon. Member for Mole Valley (Sir Paul Beresford) said. They are already absorbing a huge agenda of change, not least of which is the GP contract. Monday's written statement explained that the delay is needed to give PCTs the time to prepare for their new role. It also explained that a longer lead-in time is necessary to allow public consultation on key aspects of the matter, and so that the parliamentary process can be fully observed.

How on earth can we be presented with a statement at the beginning of this year telling us that the parliamentary process needs fully to be observed? Why was the Department unaware of the need to do that when it was programming the implementation of the reform years ago? Why on earth has the Department only now woken up to the fact that the National Audit Office warns that PCTs are not ready? Why did it not make its own assessment and reach the same conclusion, so that it could have put in place the measures to provide PCTs with the necessary capacity?

The dental work force review was commissioned by the Department in July 2001, and was the first since 1987—it was very welcome for that reason—but it was not published until July 2004. It had sat in the Department from autumn 2003. We have heard that shortages of up to 5,100 dentists are forecast for 2011 and that the number going through training in the next few years will not fill the gap. Surely, that will necessitate substantial overseas recruitment, and regardless of whether one supports the idea of open access and the free movement of labour, there must be serious questions about safeguarding the ethics of overseas recruitment to ensure that we do not poach resources from countries that can ill afford to lose them.

The hon. Member for Ashford referred to NHS Direct, and it is worth noting that calls to it about dental matters have increased by 77 per cent. over the past two years, against an overall increase in calls of 10 per cent. So, there is a huge underlying problem, with people failing to gain access to NHS dentistry services and seeking emergency access.

The second pillar is the new contract. We need the details of that contract, and it would be helpful if the Minister said when they will be shared with those in the BDA, with whom the Government are negotiating, so that things can begin to move forward.

Will the Minister also say something about how the new charging regime will interact? There is a question about the extent to which it will generate a financial shortfall in funding for NHS dentistry. Given that the NHS health economy has a £500 million deficit, which is growing, according to the Health Service Journal, how will that shortfall be met?

The hon. Members for Milton Keynes, South-West and for Mole Valley referred eloquently to prevention, and the absence of a reference to it in the White Paper on public health gives cause for concern. I hope that the Minister can clear up an issue arising from the written statement. It would be useful if she clarified the Government's attitude and intentions towards the National Institute for Clinical Excellence guidance on the call-up for checks by saying when they will be rolled out and implemented.
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There is no magic solution to fixing NHS dentistry. The current direction of travel—local commissioning through PCTs, provided that they have the necessary capacity and skills, the long overdue reconstruction of the work force, and the new contract, which will, I hope, move us to a system that is about prevention, not drill and fill—has to be the right way forward.

The question, however, is whether the Government have prosecuted things in an aggressive way that shows that they recognise that there is a serious problem. I do not think that they have, in their eight years in office, prosecuted the reform and improvement of NHS dentistry with anything like the pace that was necessary. That is why things have become worse over the past few years, not better. Indeed, that is why I fear that they will get much worse and why, for some years to come, many of our constituents will continue to suffer the anxiety of being unable to find an NHS dentist. Although the Government inherited a very poor legacy from the Conservatives, they have not done enough to put things right.

10.38 am

Dr. Andrew Murrison (Westbury) (Con): I congratulate my hon. Friend the Member for Ashford (Mr. Green) on his success in securing this timely debate. At the heart of it lies the famous pledge made at the Labour party conference in September 1999 that everybody who wanted it would have access to NHS dentistry within two years. I think that the Chancellor would bear testimony to the fact that one should not necessarily take prime ministerial pledges at face value, but we were perhaps entitled to expect that we would have something rather different from what we have now. Although dental access centres provide theoretical access, we have heard ample testimony today to the fact that most of our constituents have great difficulty accessing NHS dental care.

Mr. Hoban : Is my hon. Friend aware of the recent survey that indicated that only 40 dentists in Hampshire, Dorset and the Isle of Wight are taking on new adult NHS patients? No wonder people feel angry and bitter that the Prime Minister's pledge has been broken.

Dr. Murrison : My hon. Friend is absolutely right. I used to be a dental patient in Hampshire, and his comments come as no great surprise. They will, of course, be reflected throughout the country.

The proportion of adults registered with a dentist has steadily fallen from 55 per cent. to 46 per cent. today. There might be some dispute about those figures, and I have heard different ones bandied about, but I believe that those are the official figures. However, we can all agree that things are bad and getting worse. Worse still, dentists are leaving the NHS in droves so the debate is timely.

Hugh Bayley : I agree. There are big problems in my area. However, does the hon. Gentleman not agree that there are things that we can do in our localities to make things better? I convened a meeting of the strategic health authority, the primary care trust and the local dental committee in York. As a result, we have got through personal dental services contracts for seven
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practices, which will take on an additional 5,000 patients, and we have established an open-access urgent treatment centre. There are problems in my neighbourhood, but if we work with our local health bodies we can get them to address such problems, using the tools that the Government are making available.

Dr. Murrison : I am grateful for the hon. Gentleman's intervention. From what he has said, the picture in his constituency seems to be somewhat better than that in mine. In my constituency—I suspect that it is typical—the PCT that is being encouraged to run such things is struggling. I believe that it will continue to do so, for reasons that I shall explain. Can the Minister tell us why, according to Monday's announcement, the Cayton report will not be given a full airing until the summer? I shall be grateful if the hon. Lady confirms that she has it, and I would gently suggest to her that this might be a good opportunity to share its contents, which will be crucial as we pick up the pieces of Monday's announcement.

The Consumers Association would also like to see the report. It says that the fear must be that the Government are running scared in the run-up to the election. It suspects that they want to delay publishing their proposals to set charges that are higher than the public can stomach. Others have suggested that the extraordinary delay is because the Government know that the anticipated three-banded system will not work. It will be interesting if the Minister can say which of those two possibilities is correct. We have to accept that progress since the beginning of December has been something of a dog's breakfast. We began with a very poor backdrop: the dental work force review, which was delayed by two years and published early last year.

The sorry saga has, I am sad to say, gone from bad to worse, with the most recent chronology going something like this: on 7 December, hours after the Minister of State, Department of Health, the hon. Member for Doncaster, Central (Ms Winterton), confirmed at the Dispatch Box that arrangements on dentistry were proceeding on time, the British Dental Association walked out of contract negotiations. Lester Ellman, chair of the BDA general practice committee, said:

Earlier that day, the Minister had told us, in a fairly upbeat way:

The following day, I raised the Minister's assurances on a point of order. On 14 December, Sir Nigel Crisp, reflecting on the BDA walk-out, told the Public Accounts Committee, surprisingly perhaps, that the association's involvement was

and that

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Confirming that on 21 December, the Health Secretary wrote to my hon. Friend the Member for South Cambridgeshire (Mr. Lansley):

Yet in an official ministerial statement published on Monday, the Health Secretary announced plans to delay the introduction of the new dental contract until April 2006. Further consultation has been deferred until the summer; I have to ask the Minister why.

Cynics would say—heaven forbid—that in the intervening period we are highly likely to have a general election, and that there is, perhaps, an attempt to delay dealing with what has become an extremely difficult subject until after that general election. As others have said, it is not for want of warning. The BDA, the NAO and PCTs have indicated all along that PCTs do not have the capacity to take on responsibility for commissioning dentistry. It is hardly surprising that things now have to be delayed, and I am not surprised that, as the hon. Member for Broxtowe (Dr. Palmer) said, the BDA welcomed Monday's announcement. It has said all along that things are simply not right for PCTs to take on responsibility for dental commissioning.

Monday's ministerial statement claimed that there has been progress with recruiting dentists from overseas. We are told that the Government intend to recruit 230 dentists from Poland and that they have engaged a recruitment agency to do the job at a cost of £3.8 million, which is £16,500 per dentist going directly to the agency if my mathematics is correct. We also understand that a £10,000 golden hello will be provided to dentists from Poland who wish to work in this country.

Can the Minister offer a justification for spending £16,500 per dentist, given that EU practitioners do not need to take the international qualifying exam and could go straight on to the UK register? While she is about it, can she explain why we no longer have mutual recognition with dental schools of other Commonwealth countries? We have corresponded on this subject before, because it seems to me that there is potential for recruiting dentists in a fairly trouble free way, as we used to do.

In response to the points made by the hon. Member for Milton Keynes, South-West, there is a real ethical difference between recruiting surplus dentists from countries such as New Zealand and recruiting them from those countries where they are desperately needed. I would be grateful if the Minister told us the true cost of the Government's recruitment exercise and how many dentists have started to work here as a result. How long will practitioners, so expensively recruited to the NHS, be tied to the NHS?

A little while ago some representatives from the Dental Laboratories Association came to see me and we had a fruitful meeting. They pointed out that in dental pilot areas their members' work had fallen by 70 per cent. Has the Minister reflected on that and drawn any conclusions? Does she, like me, suspect that one of the factors in pilot areas is that dentists are much less likely to refer expensive work to dental laboratories because of
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the perverse incentive that is acting there? I do not want for one moment to decry the pilots that are being carried out, but it is important to take note of concerns that have been expressed by organisations such as the DLA and ascertain whether the quality of work in those areas has fallen off as a result of the pilots.

Our consultation document, "NHS dentistry—proposals for modern oral health", is based on five pillars, not two like the Government's. They are: registration, capitation, a low-cost voluntary monthly payment scheme for non-exempt adults, oral health promotion focused on children and a greater role for the National Institute for Clinical Excellence in determining an evidence-based schedule for NHS dentistry.

Almost all the responses have been positive. One described the review as refreshing and a clear step in the right direction. Another said that the document was impressive, showed a great understanding of the issues that had allowed dentistry to be sidelined, and offered good solutions to many of the issues pertinent today. Other respondents said that they broadly supported many of the underpinning five pillars of the Conservative party's action plan, adding that the plan was cogent and well constructed.

Those positive responses give us good grounds to hope that our solutions, when they are announced very soon by those higher up the food chain, will be well received both by the profession and, more importantly, by patients. In the meantime, I hope that the Minister will use the opportunity provided by my hon. Friend the Member for Ashford to explain why the Government have given up on dentistry.

10.49 am

The Minister of State, Department of Health (Ms Rosie Winterton) : I congratulate the hon. Member for Ashford (Mr. Green) on securing the debate. I am well aware that there are big challenges for NHS dentistry. We have seen from the number of Members on both sides of the House who are present in Westminster Hall that the matter is of concern to their constituents. I hope that I will be able to give some reassurances about the action that the Government are taking.

I take on board many of the points that have been made, but as my hon. Friend the Member for Plymouth, Sutton (Linda Gilroy) said, Conservative Members have to take some responsibility for the very unpopular contract that was introduced in the 1990s, the resulting cuts in fees and the closure of two dental schools. I do not say that we immediately have all the answers, but let us be honest about where some problems arose. That is why we are dealing with the situation today by introducing radical reforms to NHS dentistry. As hon. Members know, we have a drill-and-fill system under the current contract in which dentists are paid for the work that they do, which in a sense is invasive. The problem is that the money reverts to the centre if dentists decide to leave the NHS, and it is not possible for that money to be replaced at local level. By radically changing the system of commissioning at local level, we are enabling PCTs to carry on using their money to commission at local level rather than losing it from the area, as happens at the moment. We are backing up the changes to local commissioning with a 20 per cent. increase in the amount of money that we are investing in NHS dentistry. We are also putting massive extra resources into NHS dentistry.
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Those are key changes. We are also introducing a new contract for dentistry that will enable the changes in preventive care to which my hon. Friend the Member for Milton Keynes, South-West (Dr. Starkey) and the hon. Member for Mole Valley (Sir Paul Beresford) referred. That is exactly what dentists have been saying. They do not like the way that the contract works and want it to change so that it will reflect modern ways of working. That is why we are making the changes. Over and above that, we are also thinking about how we can introduce a new system for charges and for gathering remuneration from dentists that will make things simpler. That will not replace one treadmill with another.

The hon. Member for Westbury (Dr. Murrison) talked about the report on patient charges. We are keen to ensure that we get that right, and I want to do more work on that system before we finally decide exactly how it will work. Various options are available to us, and I want to ensure that there is the least bureaucratic system for dentists and one that enables us properly to monitor public money.

So, we are spending about £368 million more on NHS dentistry in the long term. We will be training more undergraduates, as my right hon. Friend the Secretary of State for Health announced recently. In the short term, we have allocated £59 million in the past year to address some real and immediate access problems. We will recruit an extra 1,000 dentists in two ways. First, we are allowing many dentists to move to the new personal dental services system. About 3,500 dentists now say that they like the new ways of working. We also have several PDS applications in the pipeline, which we want to ensure that we can process. Again, we want to give PCTs more time to move dentists over to the new system, because those dentists are voting with their feet and showing that they like the new ways of working. That gives us the opportunity to ensure that we have learned lessons from some new PDS sites when we bring in full implementation.

There are several points to make about international recruitment. First, we do not recruit dentists from countries that have no surplus of dentists and that do not want us to take dentists from them. We are making good progress. Polish dentists have begun work in the constituencies of the hon. Member for Westbury and my hon. Friend the Member for Plymouth, Sutton. Problems remain in my hon. Friend's constituency, but extra money has been allocated and international recruits are going into her area. I invite Members to meet some recruits from India whom I met at the Eastman dental institute, where the hon. Member for Mole Valley trained. There is a high level of expertise, and it is vital that we use it.

Changes are taking place at a local level with the extra money that we have allocated to PCTs. I met my hon. Friend the Member for City of York (Hugh Bayley) and representatives of the PCTs in his area, and he is right that plans have been formulated and extra money has been allocated. I congratulate him on working closely with his PCTs to that end.

Hugh Bayley : The new PDS contract is making a big contribution in York, but the largest and longest-established NHS practice in York is concerned that a contract currently being negotiated may not be
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approved. Will the Minister give an assurance that any practice that wants to transfer to PDS will be able to do so and that it is just a matter of agreeing the terms?

Ms Winterton : It is certainly a matter of agreeing terms. The Department of Health has set up a support team and increased the number of people dealing with PDS applications. I will take up the point made by my hon. Friend the Member for Broxtowe (Dr. Palmer), and I can also tell my hon. Friend the Member for Milton Keynes, South-West that 9,000 registrations are expected over a three-year period. One new dental practice is starting this spring, followed by four later this year.

In Ashford, £65,000 has been allocated to the local PCT to improve immediate access problems, and I will write to the hon. Member for Ashford about the various dental practices to which that money has been allocated. In the immediate term, there are plans for some 2,500 extra registrations.

I have addressed the points made by the hon. Member for Sutton and Cheam (Mr. Burstow) about the new contract—discussions have taken place and will continue to take place. As I said, I shall pursue the points made by my hon. Friend the Member for Broxtowe, and I will pass on the comments of the hon. Member for Meirionnydd Nant Conwy (Mr. Llwyd) to my right hon. Friend the Secretary of State for Wales.

Nationally, plans to change the system of commissioning dentistry are proceeding, but at local level changes are already being made. Dentists are telling us that they like the new ways of working, and we have also made £59 million available to address some immediate problems.

To address the point made by my hon. Friend the Member for Milton Keynes, South-West, there will always be people who do not register with a dentist, so there will always be a role for dental access centres. I am aware that colleagues, such as my hon. Friend the Member for Plymouth, Sutton, continue to experience difficulties, but the field site in the south-west peninsula has provided opportunities for us to examine new ways of working, and I congratulate her local health authorities on that.

The changes will make a difference to NHS dentistry. I know that there are immediate access problems, but I hope that I have given some reassurance that we have a vision for the future and radical reform, which is backed up by a massive increase in investment in NHS dentistry, both in the short and longer terms.

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