Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 80-99)

DEPARTMENT OF HEALTH, CHIEF DENTAL OFFICER FOR ENGLAND, DEPUTY CHIEF MEDICAL OFFICER FOR ENGLAND

14 DECEMBER 2004

  Q80 Jim Sheridan: I know this report is restricted to England and Wales. Have you any idea how that situation operates in Scotland?

  Sir Nigel Crisp: They do not have Primary Care Trusts. I am afraid I do not know the exact arrangements.

  Professor Bedi: In preparation for this, as I always do, I spoke to my counterpart, the CDO in Scotland, and they are going through a major consultation, as we did in 2002. They are looking at a new way of systems and that consultation has just finished and they are just going through the responses of how the different sectors, the patient groups, voluntary organisations and the dental professionals, want to change NHS dentistry in Scotland.

  Q81 Jim Sheridan: Again I will focus on anecdotal evidence that I have of speaking to people who have been to the dentist. Where this report is related to England and Wales people who want NHS treatment depend on dentists providing that treatment. I have been told that some dentists use substandard treatment and equipment when treating NHS patients on benefit. Is that off the mark or is that accurate?

  Sir Nigel Crisp: I cannot comment on your individual anecdote but as a matter of principle that must be wrong. They should work to the standards which we have.

  Q82 Jim Sheridan: So in terms of caps or crowns or fillings, whether you are on benefits or whether you are paying for the treatment, everyone in your opinion gets the same treatment?

  Sir Nigel Crisp: Sorry; if you are talking about people receiving NHS treatment, yes. If they are receiving private treatment they may get different materials.

  Q83 Jim Sheridan: If they are in for a filling or a cap—

  Sir Nigel Crisp: If they are having NHS treatment there should not be any discrimination between people whether they are on benefits or not. In private practice they may do different things.

  Q84 Jim Sheridan: So if somebody goes to a private dentist for a filling they will get different treatment from somebody on NHS dental treatment?

  Sir Nigel Crisp: They may do.

  Q85 Jim Sheridan: So there is substandard treatment?

  Sir Nigel Crisp: No, that does not mean to say it is substandard.

  Professor Bedi: There is one type of care. A professional acts professionally and provides one standard of care. There are certain groups—children, pregnant women and nursing mothers and those on low income—whose contribution to the cost of treatment is met by the state. They are exempt from patient charges but the standard that they receive should be universally of the same quality as any other NHS patient.

  Professor Halligan: I think your point is very fair and I never ignore anecdote. I suggest to you that in general terms most dentists are caring and ethical. However, there is always a concern that people will behave less than acceptably. The new contract is measured in two ways: in the complexity of treatment given and the actual course of treatment. Beyond that there are 11 days a year for dentists to understand their duties of accountable care as professionals. One of them would not be to differentiate between private and public patients. That is anathema to everything that we stand for in the NHS and that is something that we need to emphasise more and more. If we invested more and   more in developing quality professionals understanding what best practice is, which is what this is all about; this new contract is evidence based, we would not have the sort of anecdote that you have just described.

  Q86 Jim Sheridan: I am extremely glad to hear that. Going back to the question about salaries, the previous witness suggested that the figures quoted of £140,000 or £150,000 did in fact take into account staff costs, accommodation, that kind of thing. Is there a maximum in the way that Members of Parliament have a maximum amount of allowances that they can claim for staff and accommodation?

  Sir Nigel Crisp: Are you talking about if they are working in the private sector?

  Q87 Jim Sheridan: Yes.

  Professor Bedi: Dentists earn a gross fee and there is an agreement with the Inland Revenue that there is a percentage of that gross fee that they should address for expenses. It is part of an annual discussion we have when we look at the pay of dentists and it usually works, if I am right, at 55% of the gross fees, so when I say that in 2005-06 it is £69,000 for someone working reasonably within the NHS, the gross fees may be in the region of £140,000 but the difference between those figures is to meet practice costs, nurses and other expenses.

  Q88 Mr Field: Sir Nigel, can I ask the basis of this Report? I know after this afternoon's proceedings in the House, when none of us knows what we are voting on, that the pot should not be calling the kettle black, but you are saying that they were not negotiations; they were discussions and that discussions have now been called off, like negotiations used to be in the old days. This document, however, talks about a new contract, does it not?

  Sir Nigel Crisp: Yes indeed. That will be between the PCTs and individual practices. It is exactly the same as with GPs where the NHS Confederation negotiated a contract with the BMA around primary care and then the BMA organised a vote of their members as to whether or not they would accept it, but the actual negotiation had to be done by the PCT.

  Q89 Mr Field: So when will this come into operation?

  Sir Nigel Crisp: October.

  Q90 Mr Field: But if you look at paragraph 2.30 of the Report, it says, "Primary Care Trusts will therefore need to establish effective arrangements for monitoring access, oral health and patient satisfaction", but it is all going to come in in October?

  Sir Nigel Crisp: We are bringing in the new contract in October.[5]

  Q91 Mr Field: Of next year?

  Sir Nigel Crisp: Of next year.[6]

  Q92 Mr Field: So they have almost a year to run?

  Sir Nigel Crisp: Yes. Part of the reason for having a delay was listening to the profession about how much work they believed needed to be done in order to do that because the original date was April, so we have put it back to October.

  Q93 Mr Field: But you talk in the document, Sir Nigel, about guaranteeing the fee income and that somehow dentists should not be on this treadmill. We are on a treadmill, you are on a treadmill, my constituents are on a treadmill. Why should dentists not be on a treadmill? We want them to deliver some outputs, do we not, tangible ones which we can measure?

  Sir Nigel Crisp: We do indeed, and that is why we are going for a framework contract which basically says that by moving to this new arrangement which is more preventative and more appropriate so that you do not have to have a check-up every six months; you can stop having unnecessary check-ups and that is the treadmill bit, that will release the benefit of a certain amount of time. We are saying that part of that time we want dentists to use for their professional development in quality and part of that time we want to secure more access for patients.

  Q94 Mr Field: If we go back to one of the Chairman's first questions, it was about whether we do not now provide an NHS dentist service throughout the country and you rather skilfully said that the aim is still to do that although we will not deliver that. Do you not think it is more difficult to deliver that if, for example, my constituents cannot get onto the books of a local NHS dentist if you are bringing in a contract which is telling dentists that they should spend quite a lot of their time doing things other than what my constituents most need, and that is not just in cases of emergency when we are beside ourselves with pain but that we have a general service like we do with the doctor?

  Sir Nigel Crisp: If I may literally take your constituency as an example, as it happens your constituency went live on 1 January with a pilot for this, a field site. Forty-four practices joined. They went onto this new system and as a result at the end of October 4,600 new NHS patients have been able to get onto the lists.

  Q95 Mr Field: You say "my constituency". It is four constituencies, is it not?

  Sir Nigel Crisp: This is The Wirral field sites.

  Q96 Mr Field: The Wirral has some very different areas in it. I pushed the PCT to give me the breakdown for the four constituencies because I guessed there might be differences where these new patients were picked up but they could not provide that. Might you push them for the figures?

  Sir Nigel Crisp: I will absolutely push them because part of what we are trying to do is to deal with inequalities.[7]

  Q97 Mr Field: Although we cannot break down the figure we have still only got 60% of residents in Wirral who feel they have got the service that the Chairman was asking about and that is that they know who their dentist is. Because of this special effort we have managed to get over half. It is an achievement. I am really pleased that they have done it, but it shows the mountain to climb, does it not?

  Sir Nigel Crisp: I think it does but you also deal with another point here which is that because we are changing the nature of the service some people will still be saying, "Do we not need to have six-month check-ups and is this not just the government saving money by not doing that?", whereas my colleagues argue that you need check-ups when you need check-ups.

  Q98 Mr Field: I am happy with that. I have two other points. Under this new robust system we are going to get do you think bad debts will rise or fall? They will rise, will they not?

  Sir Nigel Crisp: I do not know. It is not something I have considered but I will now consider and I do not know whether colleagues know that, whether the PCTs will be better debt collectors than individual dentists.

  Professor Bedi: With this new system we have looked at some of our field sites and pilots where there is bad debt and how charges are being collected and we are getting mixed results with regard to that, but it is new both for the patient and for the dentist. We are learning through the field sites about bad debts and about patient charges. One thing for certain is that we need to make patient charges simpler.

  Q99 Mr Field: Is not collecting bad debts part of the treadmill you are trying to get dentists off? It is part of the job they do not want to do. Doctors do not want to sign sick notes. Everybody wants somebody else to do the nasty side of their job and they just want to pick up the nice side of the job. Can I just leave that with you?

  Sir Nigel Crisp: Please, and I can come back to you, because I do not know the answer.[8]


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