Examination of Witnesses (Questions 60-79)
DEPARTMENT OF
HEALTH, CHIEF
DENTAL OFFICER
FOR ENGLAND,
DEPUTY CHIEF
MEDICAL OFFICER
FOR ENGLAND
14 DECEMBER 2004
Q60 Jon Trickett: On that point, there
was a debate earlier with the previous witness about the differentials
in income to the dentists rather than to the practice because
we understand there is a difference between the NHS dentistry
and private practice. Can you tell us what you believe the ratios
between the two are?
Sir Nigel Crisp: The headline
figure is that 70% of dentists do 70% of their work in the NHS
but that hides quite a lot of variation.
Q61 Jon Trickett: I am thinking about
the income. We were told, for example, that an NHS dentist might
anticipate earning £50,000-£60,000 and then there was
a debate about how much somebody in private practice might earn
and some member said it might be a multiple of that. Can you give
us an idea of the ratios of income to the dentist as an individual
rather than to the practice?
Professor Halligan: A well accepted
practice is that 70% of dentists get their income from the NHS.
Q62 Jon Trickett: No: how much do they
earn? This is the third time I have tried.
Professor Bedi: In the Inland
Revenue figures 2002-03 dentists average, for working full time
in the NHS, about £63,000.
Q63 Jon Trickett: Gross pay, would you
say that was?
Professor Bedi: No, that was the
net figure, take-home pay.
Q64 Jon Trickett: That is rather more
than we were being told.
Professor Bedi: In 2003-04 the
Inland Revenue figure we anticipate is £66,000. We have postulated
that with inflation for 2004-05, and the NAO Report has the figures
there, it is £69,000. On top of that we estimate what an
average dentist may earn within private practice and it seems
to be rounding at the present time to about £90,000. That
is £69,000 from the NHS plus the additional.
Q65 Jon Trickett: If somebody was wholly
in private practice do you have an idea what they might be earning,
because it does seem to me that if it was a significant gradient
between wholly or largely NHS and largely private people are going
to migrate across?
Professor Bedi: It depends to
a large degree on the nature of the private practice. There are
some private practices that specialise in certain things such
as orthodontics, the more complex restorative treatment, and it
depends on location. Those in London and certain other areas will
earn far more. Most dentists have a mixed economy in that 70%
of dentists earn 70% of their income from the NHS. They supplement
that with certain items and it depends very much on the items
that they offer. A lot of dentists do the cosmetic side or the
much more complex side and do it privately or through a different
system.
Q66 Jon Trickett: I just want to try
to focus on the fact that the previous witness was an example
of a dentist who was formerly wholly NHS and he is now doing 90%
private practice. It seems to me therefore that for the 70% who
are NHS, if it is more favourable to do private work, eventually
they will be tilting the balance, will they not, in decreasing
the amount of work they do for the NHS and increasing the amount
of work they do in the private sector? What I am trying to understand
is the gradient between public sector work, if you like, and private
sector work because that seems to be one of the key issues for
dentists if you speak to them, as many of us have done. A lot
of us have spoken to our own dentists in the last few days when
this was coming up. Are you able to help us there?
Professor Bedi: To some degree
because, like you, I speak to an awful lot of dentists, it is
often not how much they earn; it is how they have to earn it.
That is the fundamental issue here and that is what we call the
treadmill. The types of figures you see are very similar for private
dentists in many parts of the country.
Q67 Jon Trickett: So there is no substantive
differential in income per procedure between NHS work and private
work?
Professor Bedi: I think it varies
significantly in different parts of the country. Private fees
are unregulated. We know exactly how much dentists charge for
NHS work. The key thing that we have learned for almost 20% of
practices now in the new system is that they enjoy working under
the new reformed NHS dentistry and we also recognise that there
are certain areas, the cosmetic side such as whitening, etc, where
they do—
Q68 Jon Trickett: Sir Nigel, do you think
there is a degree of resentment within the profession? First of
all, it seems to me that supply and demand mean that it is a seller's
market in a sense, that they are in very powerful position because
we have made some critical errors in the past about the number
of people coming into the profession. There seems to be a degree
of resentment in the profession about decisions made in the past
to do with fee cuts and the 24 months' registration down to 15
months, both of which (and probably other issues as well) affected
dentists' income. Whilst I am not totally convinced that there
is no gradient between private and public dental work, is that
not the problem, that there is now a degree of distrust in the
profession about historic decisions?
Sir Nigel Crisp: Yes, is the short
answer. I also suspect that that might be why the BDA has not
been involved in the negotiation.
Q69 Jon Trickett: Do you accept that
there were effective reductions in dentists' income as a result
of decisions which were made public for the right reasons at the
time?
Sir Nigel Crisp: There was a reduction
in fees. I am not absolutely certain whether that meant individuals'
incomes went down or if they just did not go up as much as people
expected them to.
Professor Bedi: There was a reduction
in fees and dentists did feel very much that they were asked to
make a commitment and that penalised them financially. That was
the scenario that happened 14 years ago in the early nineties.
It still has scars.
Sir Nigel Crisp: It still rankles.
Q70 Jon Trickett: I was interested in
the previous witness with the debate about how we can increase
the amount of money spent on dentists. Surely a little bit of
tender loving care to dentists who feel bruised would also secure
an increased number of outputs? It seems to me that is something
we have to achieve and possibly an increased income to the dentists
but not to the extent that the money goes on increasing pay rather
than increased outputs. Is there no possibility of a meeting of
minds to achieve what does not seem to be too difficult, a virtuous
circle on these matters?
Sir Nigel Crisp: That is exactly
where we were, Mr Trickett, and it is exactly the debate that
all our PCTs are now having on the PDS project with their individual
practices: what is the balance here? Let us move away from an
interventionist system to a more appropriate system and in doing
that free up some time. How much should go to the dentist and
how much should go to the patient—
Q71 Jon Trickett: One final point but
an interesting one: bad debts by patients. Are the dentists going
to be expected to collect bad debts?
Professor Halligan: Where patients
are charged that will no longer be borne by the practice. It will
be borne by the PCT. That is very clear in the new contract. That
is a major source of concern for dentists. You said earlier that
there were rankles from 1992. There most certainly are. There
is a big selling exercise needed here because there is a low grade
anxiety that, for all sorts of unintended reasons, there may not
be engagement. That is why we are guaranteeing gross earnings
for three years and that is why we are making sure that those
earnings are not based on interventional treatment but on appropriate
treatment and we are moving the risk to practices on patient charging
to the PCTs.
Q72 Jon Trickett: If I understand this
issue of bad debts, my dentist feels that he may be required to
take a hit on bad debts whilst the NHS then finds the patient
who owes the dentist money another dentist should they require
further treatment. Can you totally rule that out, that that will
not impact at all on the individual dentist?
Professor Halligan: It is a very
reasonable concern. We have factored that in and as long as they
make real efforts to deal with those debts and are not cavalier
about them that risk will be taken by the PCT, not by the practice.
Q73 Jon Trickett: Is it true that the
NHS would find that person, who perhaps owed significant money
to a dentist or to the NHS, another dentist without first of all
securing the money that they owe?
Sir Nigel Crisp: I do not know
the answer to that question. We will come back to you.[4]
Q74 Jim Sheridan: I apologise if I am
repeating questions that have already been asked previously. Professor
Bedi, if I were to say to you that I have anecdotal evidence of
a Member of Parliament asking a question about dentists and NHS
funding and particularly the training that was given and paid
for by taxpayers, and that Member of Parliament then receiving
an anonymous letter saying that if they continued with this line
of argument then he would withdraw all NHS services in their constituency?
Professor Bedi: Sorry, that they
would withdraw because of—?
Q75 Jim Sheridan: Because of the line
of argument that the taxpayer has already paid for NHS dentists
to train and now they are being asked to pay again by the dentists
going private. This Member of Parliament received an anonymous
letter from a dentist in their constituency saying that if they
continued with this line of argument then he would withdraw those
NHS services. Is that fair?
Professor Bedi: Yes, we spend
a considerable amount of taxpayers' money to train dentists but
there are no plans to tie them into any type of activity over
commitment into the NHS that I am aware of.
Q76 Jim Sheridan: Would you support a
Member of Parliament being blackmailed into diluting that argument
because this dentist is threatening to withdraw NHS services?
Professor Bedi: As a fundamental
principle, irrespective of the issue, I think blackmailing anyone
is not acceptable.
Q77 Jim Sheridan: So if an individual
dentist abdicated all responsibility for NHS treatment would someone
somewhere ask the reason why?
Professor Halligan: Yes, they
would. The current risk in the current system is over-treatment.
20% to 30% is what is postulated within this report. In the new
contract there is a real risk of under-treatment. The only way
this will work is by monitoring it closely. If someone is not
treating, our dental reference officers on the patch will identify
those outliers and they will be asked to account for what they
have not done.
Q78 Jim Sheridan: So if constituents
receive a letter from a dentist saying, "I no longer provide
NHS treatment", someone somewhere in the profession is asking
that particular dentist why?
Professor Halligan: Absolutely.
Sir Nigel Crisp: Locally.
Q79 Jim Sheridan: Who locally?
Sir Nigel Crisp: There is a member
of staff in the Primary Care Trust whose responsibility it is
to manage contracts with dentists. That is where we are going
to be. We will certainly want to know why.
Professor Bedi: An example of
that for me was a dentist who said they were leaving and when
asked by their Primary Care Trust about that they said, "The
premises are not right. I cannot expand", and the Primary
Care Trust came along and provided new premises, new facilities
and engaged in a new contract. This new system, the reforms that
we want to do, allow for that to address some of the frustrations
dentists have about the present system.
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