Examination of Witnesses (Questions 120-138)
ROSIE WINTERTON
MP
26 JANUARY 2006
Q120 Dr Taylor: He bent my ear—and
you know how well you can respond when the mouth is full of instruments—with
10 points of exasperation with the new contract. I cannot go through
them all, obviously, but I will pick up on one, the contract with
the PCT and the reference period on which it is decided. You have
already said in answer to several questions that the new contract
frees up time to take on more people; that dentists are able to
increase capacity; that there is scope to take on additional work.
He does not see it like that at all, because he is fixed to exactly
what he earned in that period, yet some of the people who work
with him were off sick during that period and therefore did not
have the same level to which they can work and one person has
been assessed on the amount she did even though she was on maternity
leave. It appears that they are tied to that amount and they can
do that amount in a fraction of the time. In his understanding,
they cannot take on extra work above what they are tied to with
that reference period.
Ms Rosie Winterton: The way that
the new system works is this: there is a reference period where
the earnings are looked at, which matches, at the moment, the
activity undertaken. Under the new system, as I have said, we
have guaranteed three years of the same salary for 5% less work,
so built into that already is that there will be 5% less work.
Q121 Dr Taylor: But if the reference
year was a very low year of income, how do they get around that?
For instance, if somebody is on maternity leave.
Ms Rosie Winterton: If the reference
year was one of very low income, it would be up to them to be
able to talk with the local PCT and discuss the fact that during
that year somebody was on maternity leave. The PCT then absolutely
can have the discretion to say, "We understand that, therefore
we want you to go back to a different level and we can pay you
more." That is the whole idea, if you like, of local commissioning.
There will be instances like that—we cannot help the fact—but
we have tried to take the most recent period, so that we were
saying to dentists, "Don't accuse us of going back two years
and looking at how much activity you undertook or you earned during
that time, this is the most recent year." I accept that,
unfortunately, there may be an occasional incident where, as you
say, somebody was on maternity leave, but the PCT has the discretion
to look at situations like that.
Q122 Dr Taylor: Right. I am relieved
to know about that. If they do carry out more NHS work than specified
in their contracts, will PCTs be able to pay them for that or
are they strictly limited to what is in their contract, even though
you have said the new contract frees up time to take on more people?
Ms Rosie Winterton: The guarantee
is of the earnings minus 5%, which we have said would be a likely
reduction in activity for more preventative care and so on and
so forth. Beyond that, we also know that there is quite a lot
of evidence in terms of the amount of activity undertaken. If
you, for example, as a patient had gone back every six months
and had a check-up and a scale and polish, and under the new system
you only go back every two years—and that similarly applies
across the whole spectrum—then we will be measuring the
units of dental activity that are undertaken by a dentist. If
that shows during the course of the year that the new way of working
has freed up time, then we would expect dentists to be saying,
"Yes, there is scope for us to see more people." If,
over and above that, we said, "We think this is what you
did last year, we think this is what you are going to do this
year, but, additionally, we would like to pay you more to take
on even more people" or the dentist might come forward and
say, "I want to take on another dentist within the practice
and that means that I can take on another 3,000 patients,"
it would be up to the PCT to negotiate that locally with the dentist.
It is a mixture of things. It is the capacity that may be freed
up under the new way of working, combined with the ability of
the PCT to commission over and above that if that is what they
feel is appropriate.
Q123 Dr Taylor: How do units of dental
time match with the new pay scales? Is there a correlation?
Ms Rosie Winterton: Do you mean
the new charges?
Q124 Dr Taylor: Yes, the three bands.
Ms Rosie Winterton: Band 1 is
one unit of dental activity; band 2 is three units of dental activity,
and band 3 is 12 units of dental activity.
Q125 Dr Taylor: Has there been any
assessment of the effect of the new pay bands on the reference
period? The reference period is judged by just the salary. With
the new pay scales, does the same amount of work add up to the
same payment?
Ms Rosie Winterton: With 5% less.
We have discounted 5%. We have said that for the same pay we accept
that there will be a 5% margin where we will say the activity
can be 5% less. Beyond that, I am saying there is very often scope
for that to increase, because, as people move to the new way of
working, it does free up some potential capacity. It may not in
every area—that is for the PCT to be able to say to the
local dentist—but the local dentist may say, "Everybody
in my area has terrible health needs, they come back every week,
so it is unlikely that I would be able to have additional scope."
Q126 Dr Stoate: Why did you not consider
bringing in the same sort of contracts as the GP contract, with
a minim practice income guarantee plus quality and outcome framework
points for meetings that were targeted on dental health? That
would have driven up standards. It would have encouraged dentists
to hit particular targets in terms of improvement in dental health
and to prevent dental ill health. There would have been, I would
have thought, more job satisfaction because they would have been
paid for what they were doing to improve dental health rather
than simply the number of people chuntering through their chairs
or the number of people notionally on their lists. I can see why
dentists at the moment feel it is not very professionally rewarding—and
I think that is probably why Richard's dentist is moaning. I would
have thought that a quality and outcome framework type of contract,
like they have with GPs, might have been professionally rewarding
and would genuinely have driven up standards.
Ms Rosie Winterton: When we are
talking about outcomes, we have obviously concentrated on improving
the overall oral health of the population, and building into the
contract the possibility of doing preventative work is an important
part of that. I think we have to be very aware, obviously, that
to a certain extent dentists are independent contractors.
Q127 Dr Stoate: So are GPs.
Ms Rosie Winterton: Yes, but dentists
do more of a mixture of public and private work than GPs tend
to do. With this contract we have tried to respond to the points
that they have made about the drill and fill treadmill. We have
to be quite clear, however, that it is important that we continue
to monitor the work that is done, to make sure that where there
is extra scope we are using that to the benefit of patients. Over
a number of years, we have worked very closely in piloting this
new way of working, and, from all the feedback we have had from
dentists—which is why 30% of dentists wanted to move on
to the new way of working—they clearly like that new way.
I hope the banding system that we are introducing will be much
simpler for them and for patients as well.
Q128 Mr Burstow: If I could come
on to a couple of issues around charges. What assessment has the
Department made or is the Department planning to make of the impact
of the new contract regime and the way it is going to work on
the level of income that will be generated through charges?
Ms Rosie Winterton: The job that
was given to the Cayton Committee was to devise a system that
would be much simpler for patients and for dentists, that also
would raise the same percentage of money through charges as had
been raised previously.
Q129 Mr Burstow: Is there a system
being put in place by the NHS Business Service Authority and yourselves
to monitor that, to make sure that that goal is being achieved
or will be achieved?
Ms Rosie Winterton: Yes, that
will be closely monitored.
Q130 Mr Burstow: From earlier answers
that we have had about the issue of the desire to move to a system
that is more about prevention, if that is achieved, does that
not result in a situation where there will be fewer charges for
activity because the activity will not be chargeable activity?
What will happen then if the income from charges starts to go
down? Will the amount of resource allocated to dentistry still
stay the same or will it be made up from other sources?
Ms Rosie Winterton: If you look
at the banding system that there is, preventative care is specifically
in there. In band 1, for example—and, as you know, band
1 becomes band 2 if there is a filling as well—it does specifically
refer to preventative care. There is a check-up, scale and polish,
preventative care, x-rays all within one band, so it is counted
as a unit of dental activity. But, over and above that, the charges
have been specifically devised and modelled to make sure it can
collect the same amount of income. Obviously that is kept under
review, because we have given a commitment that we would neither
raise more nor less than currently.
Q131 Mr Burstow: In the context of
that commitment, if there were a fall in revenue from charges
the overall amount of resource made available to PCTs to deliver
a dentistry service would be sustained by other sources.
Ms Rosie Winterton: In those circumstances,
we would obviously have to look at the charging system.
Q132 Mr Burstow: You would revisit
in the light of that.
Ms Rosie Winterton: We are pretty
confident that the modelling we have done has been fairly thorough
in ensuring we can raise the same amount of money. That, of course,
is linked. It is important as well that we ensure that the levels
of activity are maintained, which is why we are anxious to make
sure, where there is scope for additional patients to be taken
on to lists, that they are taken on to lists.
Q133 Mr Burstow: Could I ask one
other question on equity around the new charging system. I understand
that patients requiring new dentures due to loss or damage of
those dentures will pay just 30% of the highest band charge, whilst
those who need replacement due to wear and tear will have to pay
the full price, which is going to be £189. Why is there a
difference here between people who have lost or damaged dentures
and people who through long periods of use of dentures are going
to have to pay the full amount? Will this not lead to a situation
where particularly older people will feel unable or unwilling
to replace their dentures, with the consequence possibly of having
poor nutrition through not being able to eat, and those sorts
of things?
Ms Rosie Winterton: It is exactly
the same as the system is at the moment. It is no different. In
terms of replacement and wearing out, the changes that have been
brought in are absolutely no different from what they are at the
moment. I should also say that the maximum charge that can be
paid under the NHS under the new system is a cut from £384,
as it is at the moment, to £189. So there is no change in
the system.
Q134 Mr Burstow: The fact that there
is no change may be reassuring at one level, but the dilemma still
exists that someone who loses or damages their dentures pays 30%
of the highest charge band, whereas someone who needs new dentures
through wear and tear has to pay £189. There is a huge difference
there, particularly for older people, for whom money often is
tight. That may well be a sufficient disincentive, so that they
do not get themselves a new set of dentures and therefore cannot
eat as well and run a whole series of other health risk as a consequence.
Ms Rosie Winterton: The reason
there has been this system of the 30% charge is because one would
assume that that was happening within a fairly short space of
time and not necessarily when a whole new set were needed. That
has been a safeguard, frankly, that has been in to assist people
who unfortunately do lose them, but it is rather different from
the approach you would take if you were having a whole new set
of dentures because you needed them. Let me stress, we looked
at that third band extremely carefully, because it was an issue
about particularly older people needing more intensive treatment,
and that is why we have cut it, as I have said, from that maximum
of £384 to £189.
Q135 Mr Burstow: Is that gap something
you need to look at, between those who pay only 30% who may have
been quite irresponsible in losing their dentures, through not
looking after them properly, and another group who look after
their dentures perfectly well but find, simply because they have
had them for a long time, that they have worn out?
Ms Rosie Winterton: As I have
said, it is something that has always been the case. I do not
think it is something that happens with enormous frequency. I
do not think people deliberately go round losing their dentures,
if you like, or being careless with them. It is not really what
you would expect people to do.
Q136 Mr Burstow: Some people do not
deliberately go around being careless.
Ms Rosie Winterton: I am not sure
if we have the figures on it. I am more than happy to try to provide
the figures.
Chairman: Minster, as you are probably
aware, we are involved in an inquiry into NHS charges. Whether
you or other ministers will be coming in front of us, we could
follow that up further in the appropriate place.
Q137 Dr Naysmith: One of the suppositions
is that the proposed regulations will encourage dentists to do
more NHS dental work. Is that based on any evidence or research
that you have carried out? Does it surprise you a little bit that
there has been this negative response from quite a large section
of the dental profession?
Ms Rosie Winterton: In terms of
the pilots we have had running for some years; the fact that,
when we invited dentists to move over early if they wished to,
30% of them did move over; and the feedback we have had that not
only is it a better way of working but it has released time in
many instances to be able to see more people, are reasons why
we can be confident that it will lead to increased access. There
are some dentists who have complained that they might have to
take on more people, but I do think it is important that we are
clear that the evidence we have shows that the new way of working
means that it is possible to take on more people and I think that
the public would expect us to use that capacity to treat more
people if it is possible for us to do so. Where some people have
said it is important that there is good value, given the fact
that the offer we are making to dentists, I believe, is a good
one, I think the public expect us to make sure that in return
for what is a good offer we are monitoring very carefully to make
sure when capacity is reached and when there is more capacity
in there. The public will know that they are not going back every
six months any more, and they will say, "If we are not doing
that, does that mean there is an ability to take on more people?"
because children/mother/brother/sister cannot get a dentist. They
would expect us to do that and that is what we should be doing.
Q138 Dr Naysmith: I am a very enthusiastic
supporter of a regulatory reform of various sorts. There is a
very interesting statistic in the evidence you have provided to
us. You have calculated that you are going to save bureaucracy
which will be equivalent to 300 full time dental and practice
staff posts per annum and that is going to stem from being much
more efficient and simple at collecting data and data submissions.
What evidence do you have from the assumptions? You are calculating
that it is 60 seconds per electronic claim and 90 seconds per
paper claim. Regulatory reform is rarely as accurately expressed
as that and I wonder how you arrived at that calculation.
Ms Rosie Winterton: Because we
have such brilliant officials! It is based on a long history of
collecting information. I think this is an area where we have
had a lot of experience, through things like the Dental Practice
Board, which for a long time has been collecting the charges.
It has been able to monitor the activity, so we have been able
to translate what has been an incredibly complicated system. There
were over 400 different charges for dental treatment which we
are replacing with three. The amount of work which, quite honestly,
had to go into doing these calculations, and if we move to a more
effective electronic system as well, mean that it will have been
extremely carefully modelled.
Dr Naysmith: Thank you.
Chairman: Minister, I do recognise that
(a) we have gone on for two and a half hours now but (b) you are
a single witness and have had no respite whatsoever, unlike the
rest of us around this table. I would like to thank you very much
indeed for coming along and helping us this morning.
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