Examination of Witnesses (Questions 100-119)
DEPARTMENT OF
HEALTH, CHIEF
DENTAL OFFICER
FOR ENGLAND,
DEPUTY CHIEF
MEDICAL OFFICER
FOR ENGLAND
14 DECEMBER 2004
Q100 Mr Field: You say how new the contract
is and the approach. All that is welcome but earlier you talked
about two groups who are exempt from charges and that was nursing
mothers and young children. Since Mr Attlee brought in the idea
that we should be very concerned about those two groups Britain
has changed significantly. Did you look at whether these were
the two most deserving groups if we were going to exempt groups
en bloc from charges? Was this questioned or does this attitude
come down from Mount Sinai set in stone, not to be questioned?
Are there no more deserving groups like diabetics or others who
perhaps ought to be given free treatment?
Sir Nigel Crisp: May I come back
to you on that as well, which I do think is important?
Q101 Mr Jenkins: It is very interesting
having a witness before you, Sir Nigel, and when I talked to the
previous witness and went through this outline programme I failed
to understand where the difficulty was and why these talks broke
down. As far as I understand it you have both got the same outcome
in mind, and that was not to have an output of fillings but an
output of oral health. The number of patients a dentist had to
look after could be containable plus an element of time for emergencies
in the week, and the reduction of fillings, scale and polish,
examinations, etc, would allow us to increase the number of patients
looked after, if not in the first year, maybe over a three, four
or five year period as the work on his original patient load was
falling. I just do not understand it because to me it is the right
approach; we are moving forward here, rather than talking about
how much dentists earn or not earn, to look, as we have done,
at an agreed formula to make sure they do not fall out of practice
and do not fall out of the NHS. The figures you quoted to us on
the NHS I just find unbelievable, that 75% of dentists' income
and 69% of their work comes from the NHS. It does not bear any
relationship to the real world. About a year ago the Dental Board
wrote to me and said, "Your dentist has now decided that
he is a private-only practice", 100% private, no NHS at all,
because they recognise that they could make more money. The difficulty
to me now is, having trained them and supported them, having a
common accord, we have now got this divergence. Is that the real
reason why there has been this breakdown in talks?
Sir Nigel Crisp: We did not initiate
a breakdown. As you say, there is a lot of commonality. We are
surprised and disappointed but we will move on. On your wider
point what is interesting here is that the NAO has made very clear
that the heading of this report is something like The Risks
To Be Managed, and there are risks and you have just highlighted
one. We have done quite a lot of piloting of this now in that
the first areas started in 1998. We have got quite a lot of evidence
in quite a lot of the country of dentists wanting to move into
this new system, as I say, getting up to 20%. We do need to make
it worthwhile and good for dentists but also we need to be tough
about making sure we secure the benefits for patients.
Q102 Mr Jenkins: One of the things that
surprises me is the amount of work that dentists have. I know
it is difficult to quantify but I was sitting here thinking that
if there are 220 days in a year, taking away 33 days' holiday
and seven days off sick, and there are 23,000 dentists, that is
over 5,060,000 days a year. If there are 50 million people in
the country that means that if a dentist saw ten people in a day
it would cover every person in the country. There must be some
rationale. It takes about 15 minutes to have an examination and
there must be a bolt-on for treatment, so why are we getting so
many treatments when we should be looking at 50 million people?
If we have a programme of oral health in place would that mean
that the amount of work on those 50 million would tumble?
Sir Nigel Crisp: Maybe Professor
Bedi will say this in a bit more detail, but in these pilots we
have actually seen numbers of treatments come down because the
concentration has been precisely on oral health. There is another
thing which to a non-dentist is fascinating, that 30 years ago
40% of the population did not have teeth. We are now down to something
like 10% who do not have teeth, so the needs of the population
for dentistry have changed enormously and there is much more conservation
work now.
Q103 Mr Jenkins: Now I will tell you
another little story which ties in with this. When I went to the
dentist a few years ago, I had a nice dentist, he chatted to me
a lot and did some work on my mouth, and I was grateful to him.
When I went back this year he had left so I had to go to another
dentist. He examined me and he said, "Who has done this?",
and I said, "This practice". He said, "Oh, my word.
It has all got to be redone. It is a mess", because the dentist
who had done the work originally was interested in maximising
earnings and not in maximising my oral health whereas the new
dentist starts off saying, "Come in and this will be put
right", but rather than reporting him to the Dental Board
and tracking him down they said, "They will do it and the
practice will pick the bill up". I am beginning to think
maybe the amount of work they do, fillings and all the rest of
it, is sometimes linked to the amount of income the dentist makes
rather than the oral health of the patient..
Sir Nigel Crisp: Our position
is very clear. We believe that the vast majority of dentists are
concerned about the needs of their patients but there is some
scope for abuse within the system. The new system, which is not
based on treatments but on oral health, will get rid of that perverse
incentive if it is there.
Q104 Mr Jenkins: The answer to that question
is that you still have to monitor and it is this monitoring that
is going to be done with the PCTs?
Sir Nigel Crisp: Yes.
Q105 Mr Jenkins: Do you believe that
the PCT is in a position to monitor the work undertaken by these
dentists to ensure not that we get value for money but that the
patient gets the best oral treatment?
Professor Bedi: We are introducing
a system which is not new. In 1998 we were piloting this and the
NAO commissioned a report from the University of Birmingham to
look at the difference between those working in the new way as
opposed to the present system. They did not find any major differences.
The fears that we had were not realised in that study. The NAO
recognises this is a risk. We have put into place a reference
system, checking, peer group support. There are fewer risks in
the new system with the reforms than there were in the old system.
Q106 Mr Jenkins: In the Report the Barnsley
field study looks like an excellent scheme. Since we have got
this are we going to reinvent the wheel or are we going to send
this out as the pattern to be replicated up and down the country?
Sir Nigel Crisp: This is the point
of the framework contract, that we want to introduce a few contract
and best practice examples. Raman has got a dental support team—I
cannot remember how many—whose aim is to help PCTs to do
just that, learn the lessons.
Q107 Mr Jenkins: How much does it cost
to train a dentist?
Professor Bedi: The present figures
vary but at the moment if we include the five years that they
train, plus the one year vocational training it is about a quarter
of a million.
Q108 Mr Jenkins: It costs the NHS a quarter
of a million pounds to train a person who can walk away and set
up in private practice the next day?
Professor Bedi: During that period
they are working in NHS facilities providing patient care in their
training.
Q109 Mr Field: Even worse.
Professor Bedi: In their vocational
training they are working within NHS practices.
Professor Halligan: So you get
some service out of them.
Chairman: While they are students.
Mr Williams: They are practising on their
patients and not going on the books.
Q110 Mr Jenkins: They have an opportunity
to develop that skill and practise within the NHS. If we did not
have an NHS training regime, if they had to go away and pay to
train in a private training college, bringing people into practice,
it would cost them individually at least a quarter of a million
pounds?
Professor Bedi: 70% of the income
of dentists comes from doing NHS treatment.
Mr Jenkins: You keep saying that like
a mantra. It is wrong, it is out of place, please do not believe
it. There are NHS dentists out there doing 100% of their work
on the NHS and others have walked away from the NHS on day one.
They are making up to £150,000 a year and pocketing it on
the misery of people and they have been trained and financed by
the NHS, the taxpayers of this country. That is the only point
I was making.
Q111 Chairman: National Audit Office,
do 70% of dentists do 70% of their work on the NHS?
Mrs Taylor: I cannot answer that
from the information that I have at the moment here. I can find
out for you.
Chairman: That would be very useful.
Q112 Mr Field: Chairman, is it 70% of
all dentists or 70% of those dentists who undertake some NHS work,
because the point that has just been made is that you could have
a group who train and practise on us and then set up in private
practice who would not be part of the base 100% from which that
70% is calculated.
Mrs Taylor: I will check with
my colleague but my understanding from the information that we
got to do the analysis we have is that because dentists can come
in and out of NHS treatment it is not a static position at all,
and because they can change the proportion of NHS treatment to
private that they give at any one time, coming up with a figure
is very difficult. I am interested in seeing the source of the
figure and we will work that out as far as we are able to.[9]
Q113 Mr Steinberg: This meeting is totally
surreal. I cannot believe what I have been listening to because
the story that you are giving me is totally different from the
story that I get in my constituency, from the rest of the country,
from people I have talked to. I have never known such complacency
in all my life. The fact of the matter is that dentistry in this
country is in meltdown, absolute meltdown. You cannot get an NHS
dentist. It is all right for the Prime Minister to say, "Ring
NHS Direct and you will get a dentist". How many people have
rung NHS Direct?
Sir Nigel Crisp: 19,000 a month.
Mr Steinberg: Do they all get dentists?
Q114 Chairman: Emergency.
Sir Nigel Crisp: Emergency and
urgent.
Q115 Mr Steinberg: Did they get a dentist?
Sir Nigel Crisp: For emergency
and urgent. The figures we have got are something of the order
of 94% get it within a short distance. I cannot remember the distance
but they are able to access emergency or urgent treatment—
Q116 Mr Steinberg: What is "a short
distance", Sir Nigel?
Sir Nigel Crisp: I need to come
back to you on that.
Q117 Mr Steinberg: You had better because
I was talking to a Member of Parliament this afternoon and he
told me that in his constituency they have to travel 70 miles
to get an NHS dentist. Is that a short distance?
Sir Nigel Crisp: No, that is not.
The point that I made earlier, which was not remotely complacent,
in response to your Chairman was that we are not doing as well
as we want to.[10]
Q118 Mr Steinberg: That is complacent,
you are not doing it as well as you want. I had three people last
week who could not get a dentist.
Sir Nigel Crisp: Did they try
NHS Direct?
Q119 Mr Steinberg: They came to me and
I told them to go to NHS Direct. I also mentioned it to the PCT.
We have not got one dentist in my constituency who is taking new
NHS patients, not one. My dentist told me a fortnight ago that
he is no longer going to take NHS patients, so for you to come
along and say that everything seems to be okay and this damn new
contract is going to solve everything, that is not right. People
cannot get a dentist.
Sir Nigel Crisp: I am not remotely
saying that everything is okay today. I said earlier that people
are not getting a dentist, which is why we are recruiting a thousand—
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