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28 Jun 2006 : Column 116WH—continued
The Forestry Commission and DEFRA are collaborating on research into the use of the immuno-contraception as a method of controlling the grey squirrel population. That is part of a larger DEFRA-led project looking at fertility control methods for a range of problem species. The work on squirrels is based on methods recently
developed in the United States where a single-dose vaccine remains effective for a number of years. For a number of years in the USA, that vaccine has been administered successfully by injection, but of course injection is not an option for squirrels. We are looking therefore at oral delivery systems, which also are being developed in the United States.
Obviously, we need to ensure that drugs are fully tested and trialled before they are put into a context in which UK wild animals might come across them, that they are effective on the target species and that they can be administered safely without adverse effects on other wildlife and of course humans. One problem is that the vaccine is not species-specific so initial work is concentrating on identification of the best carrier bait and the means to prevent access to the bait by other animals, including red squirrels. It is hoped that sufficient progress will be made for enclosure trials between 2006 and 2008. Clearly, however, it is a difficult problem and we would be foolish to act precipitately, before we are absolutely sure of the science.
As I said earlier, our policy for the control of the grey squirrel in woodland prepared by DEFRA and the Forestry Commission was published on 22 January. It sets out a framework for controlling grey squirrels so that populations are held at a level that does not threaten our native woodlands and priority species. The policy articulates a comprehensive policy and action programme, recognises the wider impact of grey squirrels on priority species and woodland habitats, develops a framework and rationale for targeting action where it will be most effective, and promotes new areas of research. Those new research areas are of particular interest. Scientists from DEFRA and the Forestry Commission are following new developments overseas, particularly in the United States where they have been looking at those matters carefully. They are now investigating fertility control agents for managing wild animal populations. Work will continue on that, but we will not see success overnight.
Previous work on immuno-contraception involving the university of Sheffield ended without success, but demonstrated the difficulties of delivering an effective vaccine in sufficient quantities to wild animals. Non-lethal population control measures alone are not guaranteed to be an effective control and most likely we would need lethal control to reduce numbers before non-lethal methods were used to maintain populations at a reduced level.
Looking a little wider, responsibility for red and grey squirrels in Scotland and Wales lies with the relevant Administrations. However, as squirrels can and do move across borders, I can assure the House that experts in the field work in close co-operation. The hon. Member for Hexham spoke about dangers from the north, which have been a feature of life in Hexham for 1,000 years or more, but dangers from the north are very real to the population of red squirrels. A costed action plan is being prepared in Scotland to implement the Scottish squirrels strategy, which aims to maintain viable populations of red squirrels across their current range in Scotland. In Wales, there has been considerable success in saving and expanding the red squirrel population on Anglesey. That has involved the culling of more than 6,500 grey squirrels, but the greys remain and continued vigilance and control will be required to keep them in check.
Preservation of red squirrel populations is not something that the Government can achieve on their own, but we are taking a lead and will continue to do so. Many people love grey squirrels, but the reality is that they are a problem for some of our most threatened native species, such as the red squirrel and the dormouse. It is not realistic, practical or even desirable to eradicate grey squirrels completely, but we must effectively control them if we are to preserve our population of reds and the biodiversity that they represent.
3.41 pm
Dentistry
4 pm
Mr. John Leech (Manchester, Withington) (LD): First, I thank Mr. Speaker for giving me the opportunity to raise the important issue of the availability of dental appliances under the new national health service contract. I look forward to hearing the Minister’s response to the legitimate concern of the dental laboratories profession that the new contract is damaging their industry and, equally importantly, the service provided to patients on the NHS.
Mark Hunter (Cheadle) (LD): I appreciate that my hon. Friend is at an early stage in his comments to the House, but on that point about patient service, does he agree that NHS dentistry is already in great difficulty, with residents in many constituencies such as mine being unable to obtain an NHS dentist, and that any further obstacles are likely to have catastrophic consequences for NHS dentistry in those areas?
Mr. Leech: I agree. I am well aware of the problems in Cheadle, because a number of my constituents used to access NHS dentists there and are now unable to do so.
I shall focus on three points: first, the impact of the new contract on the availability of certain treatment on the NHS, dentists’ decisions to provide cheaper and less effective treatments, and the knock-on effect on dental laboratories; secondly, the influx of cheaper dental appliances from abroad; and finally, the lack of information given to patients about their entitlement to certain dental work.
There are about 2,700 laboratories in the UK, providing dental appliances to dentists in the NHS and in private dental practices. Seventy per cent. of all dental appliances produced in UK laboratories are made for the NHS, so it is fair to say that any Department of Health decision on dentistry will affect the laboratories and their employees.
The sector employs about 10,000 technicians and a further 11,500 administration and support staff, and the industry operates in one of the few remaining UK manufacturing sectors that still compete against imports. However, the new contract and the threat from overseas competition make the future of the industry look bleak.
The new dental contract aims to simplify the charging system through the use of three bands: diagnosis, treatment and provision of appliances. As such, all work prepared by the dental laboratories falls within band 3. The cost of each appliance to the dentist varies dramatically, but some dentists pick the least expensive items available in band 3, instead of the most appropriate appliance for a patient’s dental needs.
The patient is treated and the dentist gains their required unit of dental activity target, but at a minimum cost. For example, many patients requiring a crown, which perhaps costs £80 from the dental laboratory, are instead being offered single-tooth dentures, which might cost only £20 from the laboratory.
A survey carried out in May of 200 members of the Dental Laboratories Association discovered that orders for single-unit crowns had decreased by 44 per cent. compared with the same month last year, while the amount of one-tooth denture work had increased by 61 per cent.
It is widely accepted that, when feasible, a crown is more appropriate than a single-tooth denture, but there are significant health benefits in avoiding a denture. Although the denture might provide the aesthetic appearance of a natural tooth, it has many more potential complications: the patient may be unable to keep it in their mouth, or it may cause speech problems, compromise other teeth or strip gum tissue away from healthy teeth.
The overall results from the new contract have been startling and prove pretty conclusively, I would argue, that certain dental appliances are not being provided by some dentists under the new contract, and that more people are being forced to go private to receive the treatment that they require.
The May survey showed that NHS denture work had decreased by 79 per cent., and private denture work had increased by 52 per cent. NHS chrome work had decreased by 91 per cent. and private chrome work had increased by 21 per cent. NHS bonded crown work had decreased by 79 per cent. and NHS precious bonded crown work had decreased by 86 per cent. Veneer work had decreased by 73 per cent. and yellow gold metal work had decreased by 38 per cent. in the NHS. Non-precious metal crown work had decreased by 61 per cent. Private bonded crown work had increased by 17 per cent. The number of dentists still providing NHS denture repairs had decreased by 34 per cent.
The Minister cannot argue that she was not warned that that would happen, because in December 2005 she received figures from a survey carried out in the pilot area in September that year. They produced pretty similar results.
One of the core problems with the new contractual arrangements is the significant balancing act that dentists must carry out to ensure that their monthly payment covers the cost of providing a comprehensive NHS dental service while still providing a profit for the practice and a salary for the dentists.
The laboratory fee is a substantial element of a dental practice’s budget, so it is in the interest of the dental practice to shop around for the best deal. However, the best deal often means sourcing appliances abroad. In fact, over the past four years, the market for overseas dental appliances has grown substantially. Estimates are that 10 per cent. of UK dental appliances are supplied by overseas laboratories.
In the UK, the Medicines and Healthcare Products Regulatory Agency allows dental appliances made overseas to be supplied to the UK as long as they have come via a laboratory in Europe that is registered to comply with the medical devices directive. The process is not one of proactively seeking to ensure that overseas dental appliances are being made in accordance with the directive. Without assessing the individual laboratory and checking the materials that were used at the time of production, a laboratory that receives dental appliances from an overseas laboratory cannot prove that the device has been made
in accordance with the directive, so patients are potentially at risk. They could be supplied with dental appliances on which there was no information about the materials used or who produced and supplied them.
It is imperative that we ensure that patients are aware of what treatment they are entitled to, and what they are receiving. It is important that patients should be made aware that a crown is available instead of a single-tooth denture. If a dentist tells a patient that they need a single-tooth denture, most will assume that that is the most appropriate treatment. I know that if I were to go to the dentist, and if the dentist told me that that was the most appropriate treatment, I would assume that that information was correct. However, some dentists are making decisions based not on clinical need, but on financial considerations.
There is also a lack of awareness about payment for treatment. I have heard of several cases in which patients have had some work done and there have been significant delays in carrying out the rest of the work. Appointments have been made for three months later, so patients have incurred a charge a second time, even though there was a perfectly good reason for doing the work on the first visit or within the three-month time scale.
The new contract encourages dentists to offer cheaper alternatives and to drag out treatment time, rather than to provide the most appropriate treatment as quickly as possible. I therefore hope that I shall receive some assurances from the Minister on raising patient awareness, and some commitment to assessing the impact of the new contract on the provision and availability of dental appliances under the new NHS contract.
4.9 pm
The Minister of State, Department of Health (Ms Rosie Winterton): I congratulate the hon. Member for Manchester, Withington (Mr. Leech) on raising this significant issue. Dental health is an important part of our public health strategy. There have been major improvements in oral health in recent years. Between 1978 and 1998, the proportion of adults with no natural teeth, who need full dentures, declined from 37 to 11 per cent. However, as the hon. Gentleman pointed out, a reliable supply of well-made dental appliances remains essential to the delivery of high-quality dental care, which is where the dental laboratories can make their contribution.
As the hon. Gentleman said, there are about 2,000 dental laboratories in England, which manufacture dental appliances, including dentures, bridges and crowns, to a dentist’s prescription. Last December, I met members of the Dental Laboratories Association, which represents most of those laboratories, and we discussed the reforms in some detail. Following that, I invited the association to join the implementation group that I have established to review the new commissioning arrangements and to help to ensure that they are achieving their objectives.
The hon. Gentleman talked about the new contract and the result of it. In his constituency, only one contract was rejected, which represented 0.7 per cent. of NHS activity. The point about the new system is
that the money that would previously have been given to a dentist who did not take up the contract is now available for recommissioning locally, so his local primary care trust should be using that money to recommission dentistry. We saw from the pilots that over a longer period it is often possible for freed-up capacity, resulting from the new ways of working, to be used to take on extra people, so that more people can see an NHS dentist.
Mr. Leech: It is a fact that only one contract was not signed, but it is also a fact that constituents of mine still have real difficulty in accessing an NHS dentist. I have had to deal with a number of cases in which, despite following all the normal procedure, people have not been offered a dentist, and it has taken the intervention of their local MP to find them one.
Ms Winterton: I know that in the past there were big problems with the ability to access NHS dentistry in some parts of the country, but the changes mean that if a dentist leaves the NHS, that money can remain at local level and be used for recommissioning. In the past, the money would have disappeared from the area. Because of the new ways of working, there will be extra capacity so that more people can see an NHS dentist.
Ms Winterton: I am anxious to make progress, given that the hon. Member for Manchester, Withington initiated the debate and we have only 30 minutes for it. I want to respond to some key issues that he raised about the impact of the new commissioning arrangements on dental laboratories.
Under the new arrangements, PCTs commission a defined annual level of NHS services from dentists, in return for which dentists receive an agreed annual contract value, paid in monthly instalments. I am sure the hon. Gentleman knows that, previously, a dentist was paid only for each intervention. The new arrangements put the system on a much more stable footing. A dentist is paid to look after the individual needs of his or her patient. The annual level of service that dentists must provide is measured in terms of courses of treatment, rather than individual items.
In recognition of the fact that some courses of treatment are more complex and costly than others, the system divides courses of treatment into three broad bands, each with a different weighting—units of dental activity, as they are called in the regulations. The bands are the same as those that determine a patient’s charge, and the hon. Gentleman will know that there are three such bands: £15.50, £42.40 and £189. The highest band, band 3, covers the most complex procedures involving the prescription of dental appliances such as crowns, bridges or dentures. Such treatment carries 12 units of dental activity to compensate for the additional time and laboratory costs.
Inevitably, in an averaging system, dentists will find that some band 3 courses of treatment are more costly and complex to provide than the average while others are less costly. However, averaged over a year, the cost to dentists should be lower than in the past. There should be no financial deterrent to dentists to provide the full range of dental care required by a patient with complex treatment needs.
Mr. Leech: Will the Minister give way?
Ms Winterton: Let me make this point. It is important to remember that NHS dentists are contractually obliged to provide all the dental care and treatment that their patients require. We expect the great majority of dentists to behave professionally in that respect and we trust them to provide the proper care to patients. There is remuneration for that care and it is no longer calculated on each individual service provided. Dentists are now paid monthly to look after a set number of patients, and the UDAs that they accrue in complex procedures reflect the fact that those are more costly.
If there were evidence that some dentists were failing to provide the necessary care, patients could complain to their PCT, which should take the matter up with the dentist. We would expect it to do so. PCTs can monitor a dentist’s activity and they have a duty to investigate if it appears that he is providing fewer treatments than his patient profile suggests are necessary.
Mr. Leech: I thank the Minister for giving way a second time, but does she not agree that the fact that dentists can provide a cheaper alternative is an incentive for them to do so? The figures provided by the Dental Laboratories Association suggest that some dentists are doing just that.
Ms Winterton: I reiterate that cases such as the hon. Gentleman described, of patients having appliances fitted that fell out or made their gums bleed, are unacceptable. If he and the Dental Laboratories Association have evidence of such cases, they should put it to the local PCT and make a complaint, which is the required course of action.
I do not accept that dentists would give in to an incentive and get a few bob more by providing the wrong appliances. That would be unacceptable, and we would need to be firm about it. As I have said, there are mechanisms for the individual patient to complain and for the PCT to monitor dentists. If treatment patterns change, the PCT should investigate. Dentists are professional people and we expect them to behave professionally.
The hon. Gentleman suggested that unscrupulous dentists are breaking up courses of treatment so that they cover more than the two-month period in which patients can return for corrective treatment without incurring a new patient charge. There is no financial benefit from such bad practice to dentists under the new system. Under the old system, the number of patient charges collected by dentists was one determinant of their income. Under the new system, dentists contract with PCTs to provide the totality of patients’ dental care, with an agreed contractual sum that is not affected by the number of treatment courses that patients undergo.
I hope that patients will become increasingly alert to any attempts at sharp practice. We have gone to great lengths to publicise the new charging arrangements. We have distributed leaflets and posters to dental practices and other health service premises, and to public libraries and citizens advice bureaux. There is also information on the Department’s website and on the websites of bodies such as the British Dental Association and the British Dental Health Foundation.
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