Examination of Witnesses (Questions 140-159)
DEPARTMENT OF
HEALTH, CHIEF
DENTAL OFFICER
FOR ENGLAND,
DEPUTY CHIEF
MEDICAL OFFICER
FOR ENGLAND
14 DECEMBER 2004
Q140 Mr Bacon: I would be grateful. Sir
Nigel, you said that your discussions having failed you were now
going to leave it to local negotiation. I take it that you mean
by the PCTS?
Sir Nigel Crisp: I did indeed,
yes.
Q141 Mr Bacon: Given the huge pressure
PCTs are under at the moment with the agenda for change, I was
talking to the financial director of a PCT yesterday who said
that they still do not know what it is going to cost, the GP contract,
which is supposedly fully funded but plainly is not; there are
clear pockets of under-funding or in some senses unfunded commitments,
the consultant contract, and other things like the National Programme
for IT which Professor Halligan knows all about. Given all those
pressures, do you seriously think you are going to get a better
deal for NHS dental patients out of these PCTs who already have
the huge pressure of negotiating locally in terms of retaining
the required number of dentists?
Sir Nigel Crisp: Yes, for two
reasons. This will be the first time that PCTs can determine what
dentistry is provided within their area, so they can go out—and
you have got a rural constituency and I know that there are issues
of access in rural areas—and actually take decisions about
where they want the dentists to be. That is really important;
local issues are fantastically important. The second thing is
that you will be aware that with the primary care contract which
came in this year it was the PCTs who ended up negotiating within
a national framework with 30,000 GPs very smoothly and there is
a lot of overlap between what negotiation they had to do for the
primary care contract, and at this point I will ask Professor
Halligan to describe that, and what they will have to do with
this.
Professor Halligan: I guess a
lot of learning has happened in three areas. First, negotiating
locally with professionals is a real art form and that is about
selling the new GMS contract. Secondly, change management has
been building up, evolving maturing PCTs. Thirdly, for the first
time ever there has been a shift to quality and outcome focus.
Those particular perspectives are now internalised in the developing
PCTs.
Q142 Mr Bacon: You are saying you think
the PCTs—and, Sir Nigel, please comment as well—have
got the skills that are required to do the negotiation? There
has been a lot of criticism of the professionalism of PCTs. Only
one in four, I was reading yesterday, have an IT director. Two-thirds
of them have part-time finance directors. You are seriously suggesting
that the required negotiation skills are there in the PCTs to
negotiate this depth of contract locally?
Sir Nigel Crisp: Let me come back
with two points. The first one is that they have just done it
on primary care.
Q143 Mr Bacon: GPs?
Sir Nigel Crisp: Yes.
Q144 Mr Bacon: As a result of which emergency
admissions have gone through the roof from 3.5 million to 4.6
million because the GPs got the better of the deal.
Sir Nigel Crisp: No. At the last
PAC hearing we went through emergency admissions and that is not
the evidence that we have, that emergency admissions are going
up as a result of that.
Q145 Mr Bacon: They are going up but
not because of that, is that what you just said?
Sir Nigel Crisp: They went up
but actually they are tending to stabilise now. They have got
some good GP contracts working now around the country. The second
point I would make is that of course it is patchy with 300 organisations,
which is precisely why Professor Bedi has an NHS support team
to support PCTs in doing that. This is the right level to do it
in terms of getting the right local deals for people in—
Q146 Mr Bacon: Assuming PCTs have got
the money, but they are already telling us they are hugely overstretched
with all these other initiatives and change, all of which are
costing more than the government thought they would.
Sir Nigel Crisp: In terms of financial
issues, of course there are financial pressures in the system.
There always have been and I am afraid to say there always will
be because the NHS is very ambitious and is trying to do more
and more with the money which has been voted for to do it. Those
need to be managed but in this particular case we have identified
some specific money that is going into the system and we have
safeguards in place to help them to manage these negotiations.
Q147 Mr Bacon: You are talking about
the extra £250 million?
Sir Nigel Crisp: The £250
million, yes.
Q148 Mr Bacon: Can I ask you about that?
That was my next question. Dr Ellman said that £140 million
to £150 million of that would go on the thousand extra dentists.
Assuming roughly a 2%-3% pay rise a further £40 million will
go on that, which takes you up to £190 million or so and
leaves you only about £60 million. Do you broadly agree with
those figures?
Sir Nigel Crisp: I do not know
whether I do or not because I have not seen that breakdown. The
point that I would make is that the thousand extra dentists are
part of the solution and that money will be going through the
PCTs, will it not?
Q149 Mr Bacon: Professor Halligan, I
know that Sir Nigel said that you may have mis-spoken on the question
of debt recovery but you did say that as long as they made real
efforts then the risk would be borne by the NHS. That set me wondering
what constitutes "real efforts", how you measure whether
there are real efforts, and are you proposing to set up an NHS
dental recovery performance management agency, run by Capita perhaps?
You are not?
Professor Halligan: If you like
I will send you a note clarifying the issues around that.
The Committee suspended from 6.01 pm to 6.09
pm for a division in the House
Q150 Mr Jenkins: Sir Nigel, in response
to Mr Steinberg you said, "We are not short of dentists".
I know you were referring to the new programme, but obviously
we are short of dentists.
Sir Nigel Crisp: We are short
of dentists today, yes.
Q151 Mr Jenkins: How many dentists have
your department estimated we need today in Britain, bearing in
mind the rising demand, bearing in mind the inability to provide
dentists in socially deprived areas? I suggest that if we compare
ourselves internationally that is 33,000, but since we have dental
nurses and hygienists it might be a lower figure, it might be
down as far as 30,000 or 29,000. What is your estimate for the
number we need and what are you doing to secure that number in
my lifetime, shall we say?
Sir Nigel Crisp: Professor Bedi
published this document in July, which has the workforce estimates
in it. We say increasing the NHS workforce capacity by the equivalent
of a thousand dentists, and I recognise that some of them are
part-time, so it is the equivalent of a thousand whole time dentists,
by October next year will allow an extra two million people to
register with an NHS dentist. That is a thousand equivalent who
we intend to secure by October next year and we have got an advance
programme on that. Would you like me to ask Professor Halligan
to—
Q152 Mr Jenkins: I would like you to
answer the question: how many dentists? What is the figure we
need?
Sir Nigel Crisp: A thousand.
Q153 Mr Jenkins: You are telling me that
if we have 23,000 now 24,000 will meet the needs of the country?
Sir Nigel Crisp: This was a pretty
exhaustive piece of work looking at the workforce needs and this
is the figure—
Q154 Mr Jenkins: Who is going to stake
their reputation that with these thousand extra dentists—I
could have Mr Steinberg or any other member coming here and saying,
"I have no NHS dentists in my constituency", because
that is what you are telling me. I have given it out here: how
many dentists do we need to do the same as the European countries
with 33,000? I am not interested in the income of dentists. I
am interested in the treatment of people. You tell me why we need
less and what is the figure?
Sir Nigel Crisp: I understand
that, which is why Professor Bedi led a working party to try and
address precisely that question.
Professor Bedi: Yes, we did, and
it is not just the number of dentists we need; it is the twin
needs: the investment which we have announced and the reforms,
which are very important because there is no point pouring dentists
into a system when there is a haemorrhage at the other end. We
have said that we estimate that there are approximately two million
people that we need to address.
Q155 Mr Jenkins: So the total number
is 24,000?
Sir Nigel Crisp: We need to increase
it by 1,000.
Mr Jenkins: I would not put my reputation
on it.
Q156 Mr Williams: While you are waiting
for us to come back from this division will you get your statisticians
to work out how many extra dentists we would have had now if we
had not closed down the places in 1987?
Sir Nigel Crisp: Is that the dental
student places?
Q157 Mr Williams: Yes.
Sir Nigel Crisp: If we had not
closed the dental student places in 1989. Okay.
The Committee suspended from 6.12 pm to 6.20
pm for a division in the House
Q158 Mr Williams: Did you work it out
for me?
Sir Nigel Crisp: Our best estimate
is 550 in England and 550 who would have graduated in Scotland.
Jim Sheridan: Oh, a thousand.
Q159 Mr Williams: Can I for a moment
turn to page 54, tables 23, 24 and 25? It is rather puzzling that
England with such a high population for dentists emerges from
table 23 as having the best figures of all the countries in that
list for 12-year olds. How do you explain that?
Professor Bedi: We have significant
improvements, which is a credit to a lot of groups—dental
professionals, health educationalists, but also to the general
nutrition that is happening. We have for our 12-year olds undoubtedly
the best oral health among our European colleagues, but when we
have a look at the number of dentists per population ratio that
can only be understood when you look on the other page at the
members of the dental team to population. I think it is archaic
to look at the number of dentists per population. We should look
at the members of the dental team to population. We have more
dental hygienists and therapists than most of our European colleagues
and we are increasing that and that I feel is good news and the
way we should be providing dental care.
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