Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 320 - 339)



  Q320  Dr Stoate: I am surprised that you are so benign about your age of eight because in my experience as a GP, if you do not diagnose strabismus before the age of 18 months you are never going to get binocular vision and that in itself is quite a handicap. Eight is far too late if you are going to diagnose a squint.

  Mrs Hansford: I would agree with you. Eight is the cut-off time.

  Q321  Dr Stoate: It is much too late by eight.

  Mrs Hansford: You could pick them up at four.

  Q322  Dr Stoate: Four is too late.

  Mrs Hansford: It is too late. A child with a strabismus like you are speaking of most parents would be aware of.

  Q323  Dr Stoate: I would like to put on the record that I am a Fellow of the Royal College of GPs and a former College examiner. Dr Baker, we have had a lot of anecdotal evidence that prescription charges put patients off receiving treatment. Is there any concrete evidence that prescription charges affect the way that GPs treat their patients?

  Dr Baker: I am not aware of any literature that would provide that evidence, but that is not to say it is not there. I try to keep up particularly with the health inequalities issues. We can certainly ask our Information Services Department to see if there is anything that relates to that question. I personally am not aware of any studies that have looked at that specifically.

  Q324  Dr Stoate: If your Information Services Department does have any evidence, I would be very grateful if you would submit it to us because we need to have a good evidence base if we are going to make a sensible report to Government.

  Dr Baker: We did have a publication by our health inequalities group called "Hard Lives" which is an overall look at some health inequalities issues. I would certainly be happy to send that on and I can make a specific request around the literature regarding charging and deterring people from treatment.

  Q325  Dr Stoate: Obviously everyone resents paying charges. What we need to know is how much of people's reluctance to pay is just simply resentment at having to pay for what ought to be a free service and how much of it is because they are having a genuine hardship effect. We need to have some evidence for that if possible.

  Dr Baker: The evidence we will find for you if it is there. In my own experience as a GP, I have people say to me, "Don't prescribe me this and this because I cannot afford it".

  Q326  Dr Stoate: I am sure that happens. What we need to try and gauge is a measure of how prevalent that is. I want to move on to non-emergency transport. Do you think that the cost of transport for people to get to hospitals and to clinics can affect the way they access the service?

  Dr Baker: Yes, I do. In fact, the Royal College of GPs is currently writing a paper with colleagues in the Royal College of Physicians and we are looking at the best way in which generalists and specialists can work together so that patients can get the best access to treatment. That is one of the issues that have come up. We have been hearing of cases where people may have a number of chronic conditions and they attend outpatient clinics for that, but because of a number of factors, ie they are more ill, they are poor and they either rely on public transport or it is a question of can they drive, can they park, do they pay parking charges, people default from ongoing treatment for those chronic conditions and that leads to poorer outcomes for important chronic conditions.

  Q327  Dr Stoate: Do you have any evidence you could submit on exactly how prevalent that is?

  Dr Baker: Again, I am not aware of any evidence. We are looking to see what there is in terms of referencing this paper. If we find specific references we can send that to you and I would be also be very happy to send the paper to the Committee once that has been launched.

  Dr Stoate: Thank you very much.

  Q328  Charlotte Atkins: Dr Ellman, what are your main criticisms of the new system of dental charges and what do you think will be the impact on the uptake of treatment?

  Dr Ellman: The impact on patient behaviour is absolutely unknown. This is one of the biggest problems we have. The problem that arises from that is you cannot then model the system to make sure that it brings in the appropriate amount of money. The remit of the Cayton committee[1] that looked at it was that it should bring in the same proportion of money as the current system does. The current system brings in about £487 million out of a total spend of £1.8 billion, so it is about 28%. What we do not know is when you change charging regimes as drastically and dramatically as this particular change is happening what that will do to patient attendance and patterns and nobody else can tell you. The bits that we do not like about the charging are the massive steps which are difficult for patients to get their heads round. For one simple filling they move from a band of £15.50 to £42.40. I do not know what the patient is going to say about that. They may opt to get additional treatment done or they may save it for some time.

  Q329  Charlotte Atkins: What you are saying is that patients may wait until they have more than one pain in their mouth to ensure that they fit nicely into the middle band as opposed to just missing the first band, is it not?

  Dr Ellman: It is a possibility. I have no handle on this. I have no way of knowing what patients will actually do. Some will progress as they have always progressed but many will be unsure.

  Q330  Charlotte Atkins: Is the new contract going to be profitable for dentists or are a lot of dentists going to go down the completely private route?

  Dr Ellman: There is some evidence from the plan providers particularly, because they are the people who have people signed up, that quite a number of dentists are moving outside the NHS because they do not see the reforms being satisfactory for their particular practice. How workable it is remains to be seen. I know that the Department of Health is fairly confident that they think they have got it right, but a lot of my colleagues are confident they have not. The one really big item that is missing is the drive towards prevention. I think the drive towards prevention is the one that I would really like to have seen in place. That is there as a token more than as a positive driver.

  Q331  Charlotte Atkins: So by going private they think they could do more preventative work, do they?

  Dr Ellman: Most dentists who go private do not go private just for the income. They go private to allow them to spend time to produce the quality of dentistry they think they want to produce and they feel patients deserve. The two things do go together. The new system does not really provide them with that time and it does not provide them with a generation towards a quality of service and a quality of outcome which we all want. The intangible factor is that of job satisfaction and that is one that dentists do not get when they are pushed really hard in terms of a lack of time to deal with patients. So when you get the average dentist out there working on the NHS seeing 40 patients a day, they do not feel that they can form a good working relationship with those patients, they have not got the time to encourage prevention to take place and that is a continual reinforcement process.

  Q332  Charlotte Atkins: If they want to get off the drill-and-fill treadmill, would not the best way of doing that be by increasing the input of fluoridation in terms of particularly young people's health?

  Dr Ellman: The scientific evidence is that fluoridation makes a massive impact particularly on young people's dental health, yes, but this has issues that you know a lot more about in this House than I know about it to do with the resistance to it. That is not in my gift but it is there.

  Q333  Charlotte Atkins: What is your view about the issue of dentists who are requiring parents to go private while they treat their children on the NHS? I understand under the new contract that will not be acceptable.

  Dr Ellman: I have no evidence that this actually happens. I am not denying that it does.

  Q334  Charlotte Atkins: You should see my postbag in that case because I can assure you it does.

  Dr Ellman: I will take your evidence. I think it is wrong that patients are treated in that way. It is not something we do in our own practice. You could say we only treat adults privately and we will happily take your children on the NHS, but I do not think one should be a condition of the other. I find that unacceptable.

  Q335  Charlotte Atkins: Is it not difficult to separate that? You could have a dentist saying, "I don't make it conditional", but we know some say on a nod and a wink, "I will not take your children unless you go on Denplan", or some other private system and it is very difficult to prove one way or the other, is it not?

  Dr Ellman: I would imagine it is.

  Q336  Charlotte Atkins: If you heard that some of your members were going down this route you would condemn them for that, would you?

  Dr Ellman: I think we would want to advise them not to do so.

  Q337  Charlotte Atkins: Mr Cartwright, based on what I hear and see from your own evidence, you are concerned about the cross-subsidy to sight test fees from people who require spectacles, is that right?

  Mr Cartwright: That is correct, yes.

  Q338  Charlotte Atkins: Is that because you think that the present sight fee does not cover the extensive sight test that most optometrists embark on?

  Mr Cartwright: The current sight test paid for by the NHS, which is £18.39, does not cover the real cost of providing that examination, which is around £37. There is this cross-subsidy from the sale of spectacles and contact lenses which in effect is a tax in some ways on the wearer of spectacles who is then paying for part of that examination.

  Q339  Charlotte Atkins: Just because you have a sight test at one particular practice does not mean you cannot take that sight test off and go and buy your spectacles somewhere else, is that right?

  Mr Cartwright: That is correct.

1   Note by witness: In 2003, Harry Cayton, the Director for Patient Involvement at the Department of Health, established a working group to review patient charges. He submitted the group's report to Ministers on 31 March 2004. The report was published on 7 July 2005. The BDA were present on the committee as expert advisors and concentrated on two key issues for dentists of bad debt and missed appointments. Back

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