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Session 2005 - 06
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Standing Committee Debates

Draft National Health Service (Dental Charges) Regulations 2005

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Second Standing Committee on Delegated Legislation

The Committee consisted of the following Members:


†Mr. Hywel Williams

†Atkins, Charlotte (Staffordshire, Moorlands) (Lab)
†Balls, Ed (Normanton) (Lab)
Beresford, Sir Paul (Mole Valley) (Con)
†Blunt, Mr. Crispin (Reigate) (Con)
†Crausby, Mr. David (Bolton, North-East) (Lab)
†Goldsworthy, Julia (Falmouth and Camborne) (LD)
†Jenkins, Mr. Brian (Tamworth) (Lab)
MacDougall, Mr. John (Glenrothes) (Lab)
†Mallaber, Judy (Amber Valley) (Lab)
†Morgan, Julie (Cardiff, North) (Lab)
†Murrison, Dr. Andrew (Westbury) (Con)
†Scott, Mr. Lee (Ilford, North) (Con)
†Ward, Claire (Watford) (Lab)
†Webb, Steve (Northavon) (LD)
†Wilson, Mr. Rob (Reading, East) (Con)
†Winterton, Ms Rosie (Minister of State, Department of Health)
†Wright, Mr. Iain (Hartlepool) (Lab)
Frank Cranmer, Committee Clerk

† attended the Committee

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Tuesday 6 December 2005

[Mr. Hywel Williams in the Chair]

Draft National Health Service (Dental Charges) Regulations 2005

4.30 pm

The Minister of State, Department of Health (Ms Rosie Winterton): I beg to move,

    That the Committee has considered the draft National Health Service (Dental Charges) Regulations 2005.

The new dental charging system is important for two reasons: first, it forms an integral part of a wider set of reforms to NHS dental services that will enable primary care trusts to work more closely with dentists to improve local services and patient access; secondly, it will be fairer, simpler and more transparent for patients.

At the moment, patients pay 80 per cent. of the dentist’s treatment fees. However, on implementation of the new system of local contracts from April 2006, the current general dental services system of item-of-service fees will cease. Dentists will instead have an annual contract value agreed in advance, in return for which they agree to carry out a certain number of courses of treatment over the year. A new system of patient charges not related to the fees for the provision of items of treatment is therefore needed.

We asked Harry Cayton, the Department of Health national director for patients and the public, to review the current system of patient charges. His committee had considerable input from representatives of consumer interests and dentists. The review recommended that in future there should be a series of banded charges linked not to individual items of service such as fillings or extractions but to the overall course of treatment that a patient receives, and that there should be three bands related to the level of service provided during the course of treatment. The regulations were drafted on the basis of that report.

The new dental charges system groups dental treatment into easy-to-understand bands, which will make charges fairer and less confusing for patients and less bureaucratic for dentists to administer. Dental patients will know exactly how much they are being charged before they receive their treatment.

We believe that the new dental charging system will be fairer. The maximum cost of NHS dental treatment will be reduced by more than half. The system will also be simpler. We are moving from 400 individual charges for individual treatment items to simple price bands. It will also be clearer. Patients will be sure of knowing how much they are being charged and what treatment they will receive.

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Steve Webb (Northavon) (LD): One thing that is unclear in my mind—perhaps I am the only person in whose mind it is unclear—is the duration of a course of treatment. In respect of earlier versions of the regulations, the point was put to me by dentists that there was an issue about how protracted or otherwise the treatment was. A once-only piece of treatment falls within the band, but if the treatment lasts for a long time—if the dentist is on holiday or there is an appointments backlog—will it be charged for again? Is that a potential ambiguity for consumers?

Ms Winterton: Let me explain how the arrangements will work. When the patient goes along for their initial oral health examination and preventive health check—that is in band 1—they will be prescribed a course of treatment. That course of treatment will last from the first inspection. If, during that treatment, it is found that another filling is needed that was not initially spotted, it will nevertheless fall within the course of treatment.

Under the new scheme, patients will make a single payment for their course of NHS treatment. For example, a patient requiring a filling will pay a single band 2 payment that will cover the initial examination, preventive advice and the filling. The traditional basic check-up will be replaced with a more comprehensive preventive package which will include any necessary X-rays, scale and polish, and oral health advice. That reflects NHS dentistry’s shift away from invasive treatment to prevention of dental disease through patient education. As many hon. Members will know, one of dentists’ demands has been that more emphasis be placed on preventive care.

Patients who do not currently pay dental charges, such as children, expectant and nursing mothers and those on income-related benefits, will continue to receive free dental care.

The new dental charges system also reflects guidance from the National Institute for Health and Clinical Excellence, which advises that patients should be recalled within between three months and two years, depending on clinical need. I am sure hon. Members know that it is almost traditional that a dentist calls a patient back every six months. The proposed arrangements give them much greater flexibility, reflecting modern dental needs, so that dentists themselves can decide whether a patient should come back once every three months, or, if their oral health is good, after as long as two years.

Dr. Andrew Murrison (Westbury) (Con): Does the Minister agree that a better system might be one of capitation such as that proposed by the General Dental Practitioners Association? Under such a system, a dentist would have a long-term relationship with the patient and therefore an incentive to undertake preventive work to reduce the incidence of dental caries and hence his own work in the longer term?

Ms Winterton: There is no reason why patients should not have a long-term relationship with their dentists under the proposed system. Indeed, it is envisaged that the dentist will have a cohort of
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patients. People will know where they go for their dental treatment. That is the whole idea of a dentist being able to make a judgment as to whether a person needs to come back within three months, or within 24 months if that is what suits them better. If a dentist has 2,000 patients on his or her books, they will remain when new ways of working are introduced, and if time becomes available, the dentist will be able to increase the number of patients whom he or she sees. There is nothing to prevent the development of such a relationship between dentist and patient.

The new dental charges system will enable dentists to give simple answers to patients’ questions about what their NHS treatment will cost and what treatment they will get for their money. That is a much fairer system for patients. Those with low treatment needs will attend less often and those with high treatment needs should find their NHS dental treatment cheaper.

The new dental charges system also reflects the modernisation of NHS dentistry and will promote good oral health. Dentists will be paid for the overall service they provide, rather than for each of the individual treatments they carry out.

A 12-week public consultation on the draft regulations was launched on 7 July 2005 and ended on 30 September. We received 238 responses to the consultation document questionnaire, as well as nearly 200 written responses. We have published our response to the consultation.

Mr. Crispin Blunt (Reigate) (Con): The Minister has spoken about the importance of preventive medicine, but will not someone who requires frequent treatment be better off waiting to have a check-up and 12 fillings than having a check-up and one filling and going back when they need another? Will there not be an incentive for people to wait until their teeth have decayed significantly so that they get a significant amount of treatment for one charge?

Ms Winterton: The hon. Gentleman poses an interesting question about patients’ behaviour. I am not sure that patients would sit around waiting with worsening toothache just so they only had to pay one charge. We should remember that there is a relationship between the patient and the dentist. The dentist may tell the patient that they have good oral health and ought to come back within a year’s or even two years’ time, although they can come back if they have problems in the mean time. One hopes that the patient will trust the dentist to judge whether they are likely to need more treatment. I do not accept that people will sit waiting for months and months for things to get much worse before going back for treatment. It would be difficult for them to gauge that they would need more fillings. How would they do that? Would they think, “Well, I need one filling. Perhaps I will need more in a few months’ time”? I do not believe that patients would think like that. That would be a very perverse way of dealing with one’s oral health.

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Dr. Murrison: My hon. Friend the Member for Reigate (Mr. Blunt) is correct, and his views are shared by the dental profession. Does the Minister not accept that there is an incentive for people to wait until their dental health has deteriorated to such an extent that they need urgent dental treatment, because that will be classified as falling within band 1 and cost £15 or so, whereas elective treatment may well cost more? Furthermore, someone will be able to have as much treatment as they like under the emergency band, whereas that will not be the case if the treatment is elective. There is therefore an in-built incentive to go for emergency treatment rather than preventive treatment.

Ms Winterton: I am not sure how closely the hon. Gentleman has looked at the changes to the arrangements for urgent treatment. The safeguard is that urgent treatment is to be undertaken for the relief of pain. We have removed from the category some of the treatments which were previously available and made the urgent treatment category narrower. It is always possible to identify ways whereby people may buck the system, but we must work on the basis that, by and large, dentists will behave in a professional manner, and patients in a reasonable manner in relation to their oral health. I doubt whether patients will wait for their teeth to fall out before going to the dentist just to save some money.

Julia Goldsworthy (Falmouth and Camborne) (LD): Is not the problem that the banded charges have not been the subject of any piloting, so we do not know how patients or dentists will respond to the new structure?

Ms Winterton: The hon. Lady is right to say that there has been no piloting. There is a simple reason for that, and that is why we are introducing the regulations. Charges cannot be collected in the way we propose without a change in the legislation. We also cannot have two different systems running side by side. That would cause immense problems in collecting the charges, and would create confusion among patients, particularly those who moved from one area to another.

We are making the changes now because dentists have been saying for some years that they want them and because we want to make the system clearer for patients. The work in the pilot sites and the field sites has done much to clarify the different ways of working and enable us to work out the patient charges. I understand what the hon. Lady says, but it would be neither feasible nor practical to try to operate two methods of charging. Were we to try to do that, I think dentists would feel that we were merely delaying introducing changes that were needed.

Dr. Murrison: We have had the personal dental services pilots. The Minister will know that in the National Health Service (Primary Care) Act 1997, the Conservative Administration made provision for them. There is no reason why we cannot have two systems running side by side, as the PDS pilots have shown. Had the Minister introduced legislation
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allowing these charging arrangements within the PDS pilot scheme, we would of course have supported her. I hope that on reflection she will agree that it is not right to moan that we have been unable to legislate for proper charging pilots, since she knows that she would have had our support for that months ago. We all know about the delays in the Cayton report, and the Minister has had plenty of time to take this forward.

Ms Winterton: I hope the hon. Gentleman will not oppose the regulations simply on the grounds that the charging system ought to be piloted. If he does, the Conservative party will be sending dentists and patients the message that long-awaited reforms should be postponed, when all the evidence from the piloting that we have already conducted suggests the reverse. The hon. Gentleman knows that every single pilot has had to be cleared by the Secretary of State because of the way the legislation stands at the moment. I just do not accept that it is feasible to run two systems at the same time. That would make things very difficult both for the Dental Practice Board and its dental reference service. It would also make things even more difficult for primary care trusts.

We need to ensure that we set up a system whereby we can bring in the new patient charges system properly. We set up a review and did detailed work on modelling the charges to ensure that they were fairer. I would be astonished if dentists welcomed the idea of piloting them further. Given that they have been asking for so long for a reduction in bureaucracy to get them off the treadmill, such a delay would not be fair on them. It would also not be fair on patients, because there is another issue which is about consumer input. At the moment, many patients are extremely confused about what they pay privately and what they pay on the NHS. If the hon. Gentleman wants that system to continue, it is up to him to say that that is his party’s position, but I think it would be grossly unfair on patients, who have long been asking for greater clarity.

The Office of Fair Trading report drew attention to the unfairness that patients face, and consumer representatives have been cautiously supportive of the proposals, although I accept that they have expressed concerns about some aspects of them, which is why we put them out for consultation. The Consumers Association said that the proposals would

    “bring real improvements for patients.”

Patients and the public agree that a new dental charges system is needed, and supported many of the aims of the proposals.

It is also important to note that those with the most needs will see the maximum price that they pay under the national health service cut from £384 to £189. I would be amazed if the Conservatives assumed the position of saying that they would vote against such cuts in charges.

Dr. Murrison: Will the Minister give way?

Ms Winterton: I will in a second.

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The British Dental Association was represented on the review group, and supported the proposal for a charging system based on three bands.

It is true that the BDA has now asked whether the system will enable it to promote a preventive approach to dental health. For all the reasons that I have stated, I believe that it will. In fact, schedule 1—band 1 charges—refers specifically to preventive dentistry.

The regulations set out the charging levels. As I have said, the most expensive charge is to be reduced by half, making dental treatment significantly less expensive for those charge payers with the greatest oral health needs.

We have, however, made some changes to the regulations following the consultation exercise. In response to comments made by the profession and the dental software systems suppliers, an amendment to regulation 8 will enable receipts for NHS charges to be generated electronically, like other till receipts. They will still identify the supplier of the service, the patient, the amount of the charge and the date on which the charge was paid. That will provide reliable information where a refund is to be made under regulation 10.

A number of respondents to the consultation commented that the proposed band 3 charge for an appliance to replace one damaged or lost as a result of the act or omission of the person supplied or, where the person is under 16, the act or omission of the person supplied or the person having charge of him when the act or omission occurred, could have a disproportionate financial impact on patients. What that really means is that if someone loses their brace or dentures and they need replacing, instead of a whole new cost being incurred, the charge will be 30 per cent. of the band 3 charge, rounded down to the nearest 10p.

Arrangements remain unchanged for the Secretary of State to determine that no charge shall be payable, or that the charge should be reduced on grounds of hardship or on the grounds that the loss or damage to the appliance did not entirely result from a lack of reasonable care on the part of the person or supplied or, where the person is under 16, on the part of the under-16-year-old or the person having charge of him when the act or omission occurred.

Adjustments to and easing of dentures has been moved to schedule 1 from schedule 2, and non-surgical periodontal treatment, which is prolonged gum treatment, has been moved from schedule 1 to schedule 2. Schedule 2 covers band 2 charges for treatment, which is where all periodontal treatments logically belong. What all that means is that dentists and others made a number of suggestions about placing different treatments in different bands.

These changes will introduce a much simpler system for patients and for dentists. They will remove a lot of the confusion that there has been surrounding private dentistry and NHS dentistry. This is something that the profession has been asking for for many years. It will reduce bureaucracy, making it easier for those in the profession to do their work and enabling them to
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spend more time on prevention. I believe that this is the right way forward, and I hope that the Committee will support the regulations.

4.54 pm

Dr. Murrison: It is a pleasure to serve under your chairmanship, Mr. Williams, albeit briefly and in this rather miserable Room. No doubt the spotlight will be on this Committee today, notwithstanding political events elsewhere. It is a great pleasure also—[Interruption.] Oh, he has just gone. I was going to be uncharacteristically nice to the hon. Member for Northavon (Steve Webb) and say that he—like me—is supposed to be in two places at once this afternoon. Obviously he has gone to the other one.

The Minister has given a relatively upbeat assessment of the regulations, reflecting the Government’s response to the consultation, which in many ways is a remarkable document that seems to suggest that all in the garden is—

Ms Winterton: Rosie?

Dr. Murrison: That is what I was going to say. But it is not rosy. We know that because of what the dental profession has said. It is important for the Minister to know that, whatever consumer groups may think of the regulations—and, to be honest, consumer groups are now so desperate that they will seize on pretty well anything they can to improve dentistry—the dental profession is crucial in all this. If they walk, there will be no NHS dentistry. We already know that, since 1997—to pluck a year out of the air—registration rates have dropped considerably, and, from what the BDA and the Dental Practitioners Association have been saying to us, all the signs are that more dentists are likely to leave NHS work as a result of the changes from April next year.

The alarm bells should be ringing, but what is still ringing in my ears is the Prime Minister’s pledge that everyone would have access to NHS dentistry. Technically, I guess that that is probably correct, but of course what most people were entitled to believe he was saying was that people would have access to high street NHS dentistry. That was what they understood the right hon. Gentleman to mean, and that has clearly not been delivered.

We are here today to discuss the regulations, Mr. Williams, and I know that if I stray too far, you will call me to order, so I will try to stick to the subject before us. I received quite a few representations from dentists, both corporately and individually, and, as is the case with most constituency MPs, the ones that bear most heavily upon me are those from my own constituents. A couple of practices have been kind enough to write to me about the regulations. They have contributed to the consultation exercise, and have copied me in to their contribution. One practice in Trowbridge, which had better remain anonymous, e-mailed me on Thursday:

    “We are three months away from the biggest change to dentistry in 50 years and we the providers not only don’t have the detail but we have no confidence that it will work or if it will be ready in time. These changes will not get dentists off the treadmill and are unlikely to retain dentists in the NHS let alone increase the
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    number of dentists. The only way the system is being propped up is with the promise of dentists from India. We are unable to engage with the NHS and can get no response from policy makers. The PCT is a failed organisation. It is in turmoil, unable to engage with providers and unable to work collectively.”

The Federation of London Local Dental Committees says:

    “The 2006 dental contract will cause more toothache.”

It seems to me that the upbeat assessment given in the Government’s response to the consultation is really well short of the mark in terms of representing the true views of the dental profession, and if dentists do not sign up to the changes from February next year, the whole thing will descend into chaos.

We have waited a long time for the Cayton review, which feeds into the regulations. The Minister will remember the lengthy correspondence that we had, trying to extract that document, which we understand was in her in-tray for many months. The new contract was originally to be published in April last year. It was delayed to October 2005, and now the target date is April 2006. We have had an unseemly last-minute rush, with dentists not really understanding what is happening. Very few to whom I speak really understand what system will be in place. Only last Friday did they understand what a UDA would be. It was only last Friday that they understood that no specific value would be attached to a UDA, but that in fact its value would be assigned by the primary care trust. I will come back to what that actually means later, but it seems to me extraordinary to leave dentists so long before they can make a proper assessment of their financial future. That is hardly the way to encourage dentists back into the NHS, and hardly the way to encourage them to sign up to the NHS dental contract.

Everything points to a Government who have not taken the profession’s concerns on board adequately and who have failed to understand that providers are central to their plans. I hope that we all want NHS dentistry to be reinvigorated, but it seems to me that Ministers do not fully understand that it is the providers who are crucial. They are independent contractors, and if they walk, we shall not get an improvement in NHS dentistry.

We at last heard from the acting chief dental officer last Friday that the value of a unit of dental activity would be set locally by a PCT. I am not quite sure why that should be. It seems to me sensible to award a value for a UDA. Talking about pilots, the Minister referred to the difficulty of running parallel systems. We were assuming that UDAs would have a value that would be set. That was what we were waiting for, because that was the implication of what we were told. Given that the information has been published at the last moment, I wonder whether there has been a cop-out. It looks as though the problem has become too difficult and has been shifted on to primary care trusts. If that is so, I assume that there will be margins within which UDAs will operate. I cannot believe that Ministers will not give PCTs an indicative value, and if that is the case, as I expect it is, it would be nice if the Minister would let me know what that value is.

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It would be useful to know why Cayton’s recommended charges and the Government’s are significantly different. I wonder whether it is because activity in PDS pilots has been depressed. We understand that the whole exercise is to be revenue-neutral, so some clarification on that point would be useful. I would also like confirmation that the proposals will indeed be revenue-neutral. The Minister said that if the Opposition opposed the measure, we would be voting against cuts in charges to patients. How she can make that accusation if the proposals are really revenue-neutral, I do not know. She might like to reflect—

Ms Winterton: Does the hon. Gentleman not accept that at the moment the maximum NHS charge is £384—that is for people with very bad oral health who need a lot of treatment—whereas under the new system it will be £189, or half the current figure? That means that if the Conservatives oppose the regulations, they will be voting against cutting the maximum that an individual pays under the NHS from £384 to £189. I should have thought that that was a simple proposition.

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Prepared 12 December 2005