Examination of Witnesses (Questions 45-59)
DEPARTMENT OF
HEALTH, CHIEF
DENTAL OFFICER
FOR ENGLAND,
DEPUTY CHIEF
MEDICAL OFFICER
FOR ENGLAND
14 DECEMBER 2004
Q45 Chairman: We are now joined
by our witnesses from the Department of Health, Sir Nigel Crisp,
who is the Permanent Secretary and NHS Chief Executive, and we
are sorry that you were ill last week.
Sir Nigel Crisp: Thank you for
the courtesy of holding off the Committee. I had lost my voice
so I would have been an even worse witness than normal!
Q46 Chairman: Professor Raman Bedi, who
is Chief Dental Officer for England and Professor Aidan Halligan,
who is Deputy Chief Medical Officer for England. We are very grateful
to you. I do not know if you heard the evidence of Dr Ellman because
you were outside?
Sir Nigel Crisp: Two of us did
not, no.
Q47 Chairman: Would one of you answer
this question? What Dr Ellman has told us is that he has now broken
off negotiations, and the timetable for reforming NHS dentistry
is on page 39 of the Comptroller and Auditor General's Report,
at figure 19. Clearly this timetable is not now going to be met.
We would like to know what has gone wrong. What Dr Ellman has
said, to paraphrase it, is that it was the hope—and I think
it was the hope of you, Sir Nigel, as well—that dentists
would get off the treadmill, as they call it, and they would have
a more holistic nature to their job and they could look at the
general oral health of their patients, and that it became clear
to them as this contract was going through that that was not going
to be the case, and that is why they have broken off negotiations,
and effectively they would still be on this treadmill. So what
has gone wrong?
Sir Nigel Crisp: Let me pick up
on that point. Firstly, obviously, we were surprised and disappointed
that they decided not to attend the talks this week. I think there
are three relevant points here, which means that this is not absolutely
crucial for us implementing the timetable. The first one is that
they made it clear right from the start that they were not involved
in negotiations; that they were happy to talk to us about the
framework contract but that there were no circumstances, as I
imagine he made clear, in which he would recommend the outcome
of that to his members or take it to a ballot. It was not negotiations,
it was a talk. With all the other negotiations we have had with
people—obviously whether it was the pharmacists or the BMA
or other people—we have always ended up in a position of
having an agreement and them taking it to their members for ballot.
The BDA made it clear to us that that was not their role. So these
were useful discussions, essentially, but not negotiations. The
second point is that, as I understand the difference between the
two sides—
Q48 Chairman: If I may interrupt you
there, because I think this is quite an important point.
Sir Nigel Crisp: It is.
Q49 Chairman: Useful discussions but
not negotiations, but this is a fairly crucial organisation, which
we were just told represents most, if not all, of NHS dentists
in England and Wales. They just walked out of these friendly discussions.
Is there any chance that this timetable is going to be met?
Sir Nigel Crisp: Yes. Shall I
carry on?
Q50 Chairman: Yes.
Sir Nigel Crisp: The point therefore
means that the negotiations actually need to be done at a local
level. So that is the point, that we cannot negotiate at national
level—although we can talk about it and get a framework
we cannot negotiate to a national level, and we will therefore
negotiate locally. The two other very important points, if I may,
are firstly—[1]
Q51 Chairman: Can I just stop you there?
You think that you may have more success locally than you do nationally?
Sir Nigel Crisp: I think the evidence,
as again this report makes clear, is that now we are getting up
to about 20% of dentists who are taking up or applying to take
up what is called the Personal Dental Services, which is essentially
the same framework as the new contract. So we actually have a
number of areas—and it is Mr Field's area, for example—where
most of the dentists are already on the Personal Dental Service
and are very happy to negotiate. So those negotiations are taking
place with that 20% moving in that direction, and we expect that
to increase.
Mr Field: Only 60% of those in Wirral
actually have NHS treatment. So although you say we are a pioneering
place, here in the pioneering area 40% have not got NHS treatment
and part of the Wirral is very rich. I could not get the figures
from the PCT in my area, which is relatively poor.
Q52 Chairman: Let Sir Nigel Crisp carry
on.
Sir Nigel Crisp: The third point
I would want to make is that, as I understand it, the basic difference
is that with the new contract what we are doing is moving to a
more appropriate way of treating people, which is more preventative
orientated, which will see less intervention. That will release
a dividend in terms of dentists' time. What we have said throughout
the process is that the first 11 days of that we would leave with
the dentists for their professional development, for ensuring
that we have got quality, clinical governance and so on, but over
and above that we would expect to use the rest of that dividend,
as we have done with the Personal Dental Service pilots, to treat
more patients and have more access. I think what Dr Ellman is
suggesting is that we want the whole of that area for treating
more patients. We do not. We want to make sure that there is good
quality treatment, professional time, 11 days we think is pretty
generous, and in addition to that we want, as the NAO says in
its Report, to make sure that in this change we get some benefit
for patients in terms of additional patients having access as
a result of this process, which is what we are getting through
the PDS pilots. I am disappointed that the BDA have decided not
to continue talking to us but, as it was not a negotiation, we
can carry on and we will have negotiations with people locally
and we would not expect the timetable to slip.
Q53 Chairman: Can I ask you about patient
charging as referred to in paragraph 2.17 of the Report on page
32? Would you explain why you delayed announcing the details of
these new charges?
Sir Nigel Crisp: We are still
considering the new charges and we will be making sure that before
October 2005, which was the deadline that you referred to earlier,
we have the new patient charges out and the framework contract
that we want PCTs to negotiate within.[2]
Q54 Chairman: Would it be a fair criticism
of you that you have effectively removed yourself from providing
NHS treatment to new patients in some deprived areas of this country,
that it is no longer possible for the NHS to guarantee treatment
for new patients coming to the NHS in some deprived areas of the
country? There is a reference to this in paragraph 1.33 which
you can find on page 19.
Sir Nigel Crisp: No, I do not
think that is right.[3]
Q55 Chairman: You are telling us that
it is possible in all areas of the country for new patients who
wish to access NHS dental treatment to achieve it, because I am
sure you are not claiming that?
Sir Nigel Crisp: Let me make the
distinction, which is that if a patient rings up NHS Direct they
will be told of where they can get urgent or emergency dental
treatment. That is not the same as registering with an NHS dentist.
Q56 Chairman: Emergency treatment, not
routine dental treatment?
Sir Nigel Crisp: Emergency or
urgent treatment.
Q57 Chairman: But not routine treatment?
We have given up in this country now guaranteeing NHS routine
treatment to people in many areas of this country? That is right,
is it not?
Sir Nigel Crisp: No. We are failing
to deliver that, which is a slightly different point. Urgent and
emergency treatment is accessible through NHS Direct but I do
know that in parts of this country it is difficult to get registered
with an NHS dentist and that is precisely why we are changing
the contract and employing more dentists.
Professor Bedi: You are right
that access is difficult in certain areas of this country and
it will increasingly get difficult and the NAO Report will say
that the reforms we are doing are to address that very issue.
The risks are much greater if we do nothing. We are doing three
things. We are increasing the investment that we announced back
in July. We are increasing the workforce tremendously and also
the system of reforms we are putting into place will address the
very issues which you raise.
Q58 Chairman: Are you finding 1,000 new
dentists here?
Professor Bedi: The short term
measure is 1,000 equivalent dentists to address the immediate
term. We have a long term strategy of increasing the number of
students in our undergraduate dental schools.
Q59 Chairman: How can you guarantee that
these 1,000 new dentists will not simply transfer from areas of
greatest deprivation in the NHS into more lucrative private practice,
like many of the others?
Sir Nigel Crisp: Because the process
we are going through is to sign them up onto the contracts and
target on the areas that need them so that we will sign them up
as dentists to deliver that service. The supplementary question
is, in the long term could they then shift to do more private
work? Part of what we are trying to do is make sure that NHS dentistry
is attractive to people. As I said, we are approaching now 20%
of dentists that have signed up or are wanting to sign up to the
PDS do indicate that there are a lot of people who are finding
it attractive, but we have to make it attractive.
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