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Standing Committee Debates

National Health Service (General Dental Services Contracts) Regulations 2005

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Fourth Standing Committee on Delegated Legislation

The Committee consisted of the following Members:


Mr. Greg Pope

†Barlow, Ms Celia (Hove) (Lab)
†Blunt, Mr. Crispin (Reigate) (Con)
†Clarke, Mr. Tom (Coatbridge, Chryston and Bellshill) (Lab)
†Crabb, Mr. Stephen (Preseli Pembrokeshire) (Con)
†Creagh, Mary (Wakefield) (Lab)
†Efford, Clive (Eltham) (Lab)
†George, Mr. Bruce (Walsall, South) (Lab)
†Goldsworthy, Julia (Falmouth and Camborne) (LD)
†Hollobone, Mr. Philip (Kettering) (Con)
†Laxton, Mr. Bob (Derby, North) (Lab)
†Merron, Gillian (Lord Commissioner of Her Majesty’s Treasury)
Miliband, Edward (Doncaster, North) (Lab)
†Milton, Anne (Guildford) (Con)
†Murrison, Dr. Andrew (Westbury) (Con)
†Webb, Steve (Northavon) (LD)
†Winterton, Ms Rosie (Minister of State, Department of Health)
†Wright, Mr. Iain (Hartlepool) (Lab)
Geoffrey Farrar, Eliot Wilson, Committee Clerks

† attended the Committee

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Wednesday 8 February 2006

[Mr. Greg Pope in the Chair]

National Health Service (General Dental Services Contracts) Regulations 2005

2.30 pm

Dr. Andrew Murrison (Westbury) (Con): I beg to move,

    That the Committee has the considered the National Health Service (General Dental Services Contracts) Regulations 2005 (S.I. 2005, No. 3361).

The Chairman: With this we may take the National Health Service (Personal Dental Services Agreements) Regulations 2005. Members of the Committee may refer to both proposals.

Dr. Murrison: It is a pleasure to serve under your chairmanship, Mr. Pope.

Today’s debate touches on the lives of a large number of our constituents. I cannot remember an issue in the past five years or so that has prompted so much correspondence in my mailbag as NHS dentistry. It is therefore right and proper to give these measures adequate scrutiny, and it is right that they should be debated together because they are truly intertwined and linked with the National Health Service (Dental Charges) Regulations 2005, which we debated in December. We had a long and fruitful discussion about the vicissitudes of those regulations, and inevitably some material that we shall debate today touches on the substance of that discussion. However, I will do my best not to be repetitive.

It is important to put on the record our objection to the Government’s direction of travel in respect of national health service dentistry. We all want the same thing—to improve dental health and dental public health, and, especially, to focus on preventive measures in oral health—but the question is how we get there. We would probably agree that where we are at the moment is not satisfactory.

For some time, our emphasis has been on capitation, registration and, above all, ensuring that there is a long-term relationship between patient and dentist whenever possible. As with primary medical care, that is the best model for oral health.

There is an extremely strong feeling in the profession, reflected in correspondence to us, that capitation and registration are the best model to deliver health outcomes. The Government’s path is contrary to that and runs the risk not only of not improving the situation, which we can agree is unsatisfactory, but of making it worse. On 1 April, which the profession has begun to call national deregistration day, we will see what the future holds.
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My guess is that many dentists will not sign up to the contract, and many who do will drift away as the months go by.

What is proposed is a leap in the dark. The Minister must accept that there is a large element of risk in what she is embarking on, because she has not tried it out. She will say that we have had personal dental services pilots, which were introduced in March 1997 within the remit of the National Health Service (Primary Care) Act 1997. My hon. Friends can therefore take credit for the success of PDS, which is the model on which it is reasonable to build. However, units of dental activity, which we debated at length in December, have not been piloted. The two models cannot be balkanised, because UDAs are so bound up with the Government’s proposals for the future.

If the Minister’s model for the future is to be properly trialled, the proposed mechanism for dental charges must also be trialled, which has not been done. That is what worries the profession. I hope that the Minister is not kept awake at night, but if anything does that, it should be this proposal. She cannot say, hand on heart, that she is certain that it will be okay come 1 April. The profession thinks that it will not be and we share that view.

I do not want to waste time banging my political drum, but it is worth while putting the matter into context. Since 1998 the number of registrations in this country has dropped 3 million, and the adult registration rate is now 39 per cent. In my region, the south-west, it is about a quarter of the adult population, which is lamentable, yet the Prime Minister famously promised that everybody would have access to an NHS dentist by the end of 2001. I make no apology for repeating that. He said it clearly, and I think the meaning for most people in this country was clear: they would have easy access to a high street NHS dentist by the end of 2001. Manifestly, that has not happened.

This matter will sink or swim on UDAs and on banding. Harry Caton’s report, which introduced UDAs, has been noted by the Government, but what we have today is not what Harry Caton proposed. The detail of UDAs and banding has been substantially revised since the report was delivered, so responsibility for it is in the Minister’s hands—it is her creature.

It seems that more people will pay more under the regulations. The Minister will say that fewer will pay a lot—the top band of NHS charges—and she is right, but more will pay more for lower-grade treatment, and I defy her to suggest otherwise. Dentists will certainly leave; I know that from my constituency experience. Surely other hon. Members are in contact with dentists in their area who say that they will not sign the contract, and we are just days from the deadline at the end of the month. That seems to me to be guaranteed to make a bad situation a jolly sight worse.

It is important to cite evidence from the British Dental Association. It is an excellent organisation in many ways, but traditionally it has probably done what it can to be as helpful as possible to Ministers, so
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we cannot accuse it of being partial to us. What it has said in relation to the new regulations is quite cutting: there is no room for manoeuvre:

    “The situation is a shambles for both patients and the profession . . . the new contract will do nothing to improve access to care for patients or improve the quality of care. The Government claims to be committed to preventive care yet that does not seem to apply to dentistry. We’re now faced with a contract that puts dentists on a new treadmill and means they can’t give the care and time that they want to give to patients. This is bad for patients, bad for dentists and disastrous for NHS dentistry.”

I know that Mr. Lester Ellman, chair of the BDA’s general dental practitioner committee, has, at the eleventh hour, asked the Minister for a meeting to discuss the contract. I am not sure whether he has been given a date and a time, but I urge her to see Mr. Ellman to discuss, even at this late stage, the profession’s concerns about her plans for the future.

We are deeply concerned, as is the BDA and the General Dental Practitioners Association, about the lack of piloting. We are also concerned about the lack of consultation with the profession, which it has complained about, and in this place, where it would have been reasonable, as this is the biggest change to British dentistry in 50 years, to explore the matter more generally in Government time on the Floor of the House of Commons.

We should know why the draft regulations were published for information only and not for consultation. Why did the BDA storm out of negotiations with Ministers early last year? Did it feel that it was being led down the garden path? It is hopeless that such a thing should have happened with the prime negotiating body for that element of health care. I am keen to know why the Minister thinks it happened.

Anne Milton (Guildford) (Con): The Minister looks confused and bemused, but I do not think that the public in Guildford and Cranleigh are wrong. Judging by the expression on her face, she seems to dismiss their concerns, but many dentists in Guildford and Cranleigh are worried. They want to continue to give people NHS dentistry, but they will not be able to do so if they are not adequately rewarded.

Dr. Murrison: My hon. Friend makes a good point. That is a cue for me to refer to some of the many letters e-mailed and posted to me by dentists the length and breadth of the country. Believe me, this is only a small sample of the correspondence that I have received on the subject. I shall quote some of those letters because they exemplify the profession’s concerns.

The Minister of State, Department of Health (Ms Rosie Winterton): I am grateful to the hon. Gentleman for giving way because I want to make it clear that my slight surprise about the statement that the subject has not been debated is due to the fact that hon. Members had plenty of time to debate an entire Bill on the subject. It may have been before the hon. Member for Guildford (Anne Milton) entered the House, but the subject was debated on the Floor on a number of occasions during the passage of that legislation.

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Dr. Murrison: I am grateful to the Minister for that intervention. On reflection, over the past five years, the subject has been debated chiefly when my colleagues brought it to the Floor of the House, largely in Opposition time rather than Government. However, my memory may be somewhat partial.

I shall deal with some comments made by dentists. One says:

    “I believe you are after information about how the government are making a complete shambles of this new NHS dental contract. What tickles me is, after 7 years, they are still trying to blame the previous Tory government. That’s a bit like blaming potholes in the roads on the Romans.”

The letter continues:

    “Nobody knows what . . . is going on, there is no communication to the dentists, and the timescale is unworkable.”

Another dentist writes to me from Bexley, saying:

    “You may be interested to know that the UDA requirements set by the Department of Health have numerous ‘banding’ errors which mean that the dentist is required to do considerably more work for the same contract value, even taking the 5 per cent. reduction into account.”

I shall come back to that point later.

A Birmingham dentist—many have written from there—writes:

    “My staff have gone through the monthly schedules from the base year Oct 2004 until September 2005 and have found discrepancies between the UDA target from the PCT and what my associate and I actually achieved during that period.”

That is a recurring theme.

A dentist from Leicestershire writes:

    “Many GDPs in my area have had enough. They are forced to accept the contract because they have not been in a position to plan to replace the income stream until now but they are making plans.”

I presume he means that they are making plans to leave. That reinforces what I said earlier—many dentists will sign up by the deadline, but will drift away as the weeks and months pass.

A dentist from West Sussex writes:

    “I’m a dentist in W Sussex concerned about the impending new contract. I’ve been promised a 5 per cent. reduction in my work load by Rosie Winterton. My UDA target from the DPB is 128. However, my practice software calculates a UDA target of 71 for the test period 1/10/2004 – 30/9/2005. The software company concerned (Software of Excellence) assures me that the calculation is based on the rules given to them by the DPB/DoH. I’ve mentioned this to my PCT and they agree it’s unfair. They’ve said they’ll reduce the target to my figures but will only confirm this AFTER I’ve signed a contract for 128! I think I’m being stitched up!”

I think he is right.

A dentist from Doncaster wrote to the Minister about the new contract and the miscalculation of UDAs, and sent me a copy of the letter:

    “We will now spend our days on the new treadmill of UDAs and not patient care. The people of Doncaster will suffer from this, and it is unlikely that NHS dentistry will be available in 12 months time.”

The letter concludes:

    “Yours sincerely a very unhappy dentist”.

A dentist from Birmingham writes:

    “I understand you are looking for factual inequities in the New Dental Contract. We are a dental surgery in South Birmingham and we can provide written evidence that our UDAs have been inflated by almost 20 per cent. against last year’s productivity (so much for the 5 per cent. reduction in work load!!)”.

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A little closer to my home, a dentist from Wiltshire—in fact, the secretary of the Wiltshire local dental committee—writes:

    “I have been in contact with many of them”—


    “not least 70+ who were at a meeting we organised on 25 January. I have not yet met a single one who is happy with the new contract.”

Another dentist from Wiltshire, one of my constituents, writes that

    “the adoption of weighted Units of dental activity is a retrograde step and will have the effect of continuing the ‘treadmill and the perverse incentive’”.

A dentist from Chippenham writes:

    “As forecast we can expect another 20 per cent. or so dentists to head for the NHS exit in April.”

Let us hope he is wrong.

A dentist from Birmingham writes about registration rates:

    “A calculation I did with my former employers showed that if you counted all those seen in a 30 month period the numbers ‘registered’ rose by about 50 per cent. Rosie”—

the Minister—

    “is giving notice that she intends to use the 30 month period instead of the current 15 month one to compare the old system with the new. Will opposition politicians cotton on to this I wonder.”

Well, we have cottoned on to it and it is good of that dentist to write to us. The issue is how people are counted as being registered and the possible temptation to massage the registration rates, shall we say, given the difference between a 30-month and a 15-month period. We shall be on the lookout for that.

Another dentist from Doncaster writes:

    “All the good we have achieved in PDS will soon be undone. The emergency access sessions will go as will time spent on prevention and NICE Guidelines. It will be back to very basic drill, fill and extraction, to meet the government targets, because you don’t score points for prevention”.

The Minister commented on that on 6 December and might wish to do so again.

Another Doncaster dentist—my word, lots of Doncaster dentists have written to me—says:

    “I thought you might be interested that the Dentists in Doncaster are in uproar at the proposed new dental contract with its iniquitous UDAs, capped ceilings of revenue and reintroduction of the treadmill.”

A husband and wife dental team from the midlands writes:

    “We are now however having to accept a contract that has not been fully piloted in its present form contrary to what the DOH keeps indicating. I could go into details but suffice to say I have never met so many colleagues that are disenchanted with the proposed contract and are considering cutting back or leaving the NHS in all the years since qualifying.”

That couple have been practising for 20-odd years.

A dentist from Widnes, who is apparently a “lifetime labour supporter”, writes:

    “I will sign the new contract but am looking to leave the NHS so I can provide a better service for my patients. I am in despair at this evil contract.”

That is another illustration of my earlier point about dentists possibly being tempted to sign up now, but then drifting away as the months go by.

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A dentist from Stokesley, North Yorkshire, writes that

    “it is a worse treadmill than before”.

Another dentist from Birmingham writes:

    “My figures taken directly from the patient notes show that I will be expected to do 11 per cent. more work for the same money, not 5 per cent. less.”

My last dentist, from Birmingham, says:

    “I have numerous stories from Birmingham of how dentists are being cheated by contract talks.

    One Dentist in South Birmingham extended his practice to 6 Dentists last year from 3 to accommodate the extra patients seeking NHS treatment, he has been told his budget is such that the 6 dentists must work part time or three must leave, as his funding is based on the period when he had 3 dentists. This will leave about 4000 Patients without a Dentist.

    Two Dentists in East Birmingham were promised £145,000 each in PDS to expand a dying practice. They bought the practice based on this promise, only for PDS to be scrapped, and have now been offered £60,000 each to run the practice, as it is how much they earned in the test period. The treatment of about 3000 patients is under threat.

    Another Dentist in North Birmingham was encouraged by her PCT to open a practice, she has now registered about 1500 patients, but because the practice opened after the test period she has been offered no contract value.

    This lack of flexibility with atypical years is accepted by the PCTs as being difficult but they are too cash limited to assist.”

I have some sympathy with that last case and certainly with the point about the dentists in south Birmingham. Although there is a recognised need to expand NHS dentistry—indeed, there is a willingness to do so on the part of many dentists—contractual issues at PCT level are preventing that from happening.

In my area, I have been rather frustrated by the case of a dentist who, because he is altruistic, wishes to expand his NHS dental practice but is unable to do so because the PCT says it does not have the resources, or is at least waiting to see how many dentists will sign up to the new contract before it reallocates UDAs to those who feel able and willing to take them up.

I hope the Minister has enjoyed those contributions, and it is important to read them out. It is all very well politicians going on and on about such things, but it is vital that we get feedback from across the country. I have been struck by the number of dentists from all over the country who have written to voice their concerns. In all candour, I have known nothing like it in my five years in the House, and that really ought to sound alarm bells.

We all have an interest in ensuring that NHS dentistry works. Of course, we have an interest in scoring party political points off one another, but, beyond that, I hope that we are here to ensure that things work and to raise concerns with Ministers. I hope that they will genuinely listen to what we, our constituents and those who lobby have to say and that that will make a difference. They need to listen carefully to the concerns that I have articulated, and I hope, even at this late stage, that they will consider more carefully than they have to date the likely impact of the proposed arrangements on NHS dentistry.

It would be nice to know why it has been left to this very late hour to discuss the regulations. I appreciate that the Minister is in the hands of the House
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authorities to an extent when it comes to programming matters for debate, but I had hoped that we would debate the regulations well before now. The dental charges regulations were debated fairly late—back in December—and here we are debating these regulations just weeks from the closing date before which people must sign up. That point has been raised in a lot of the correspondence that I have received.

I would like to hear from the Minister about IT. Connecting for Health and the national programme for IT in the NHS are among the things that we have discussed at length, but we are not discussing NPfIT in the context of dentistry at the moment. What we must discuss is whether the software is in place and up and running to support the huge change in NHS dentistry. We are really talking about the software that is needed to support accounting in the new set-up, as well as the support required at the Dental Practice Board, at PCT level and in practices to ensure that information is correctly captured and recorded.

I have already raised concerns about the software model that is used to calculate UDAs, but that is not what I am talking about in this context. I am concerned that practices and PCTs do not have the software necessary to support changes in how we account for NHS dentistry. The Minister has presumably considered the issue, and I hope that there will not be another public sector IT disaster and that things run smoothly. It would be good to have her assurance that that is the case.

Several dentists have written to say that they are concerned that training packages in the new system have been discussed at length, but nothing has been delivered. That is part of their general concern that they have not been kept in the picture; they have not been adequately consulted or informed about the new arrangements. It is important to stress that we are talking about not a slight change to the arrangements, but the most fundamental change in NHS dentistry for half a century. It is remarkable that dentists are not being adequately informed, and that dentists and their staff are not being offered the training that they need to be happy and comfortable with what is happening.

There is a look of incredulity on the Minister’s face. No doubt she will say why when she responds to the debate. The dentists have expressed their views to us and the litmus test is the correspondence we have received—not from a small group of disaffected dentists, but from dentists throughout the country who say, “We have not been kept informed. We do not know what is going on, we are panicking and we need more information.” The Minister needs to understand that, get to grips with it and do what she can to rectify matters at the eleventh hour.

I am interested to know what the arrangements will be for out-of-hours cover, as the issue has been raised with me locally, where I live. Clearly, PCTs will have responsibility for that element of NHS dentistry. I lied ever so slightly when I said earlier that I had given my last quote from a dentist, but the following is short and it relates specifically to out-of-hours cover:

    “Virtually every practice on the on-call rota has or will have turned private for adults by April 1”.

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That implies that there will be no emergency cover in the area. The letter goes on:

    “The local situation, we have been told, is that bleeding and swelling involving an airway are the only emergencies that are admissible, dental pain is not an emergency.”

That is what the dentists have been told. We covered the matter very briefly on 6 December when the Minister said that dental pain is an emergency, and I agree with that. In a previous incarnation, I was required to do a bit of dentistry in the absence of a dentist, although I am not trained specifically in dentistry. I consider dental pain an acute emergency, especially having experienced it myself.

Will the Minister say what is to be regarded as an emergency by PCTs? I would include protection of the airways, bleeding and swelling, and dental pain, which is by far the most common dental emergency. The dentist I quoted is fearful that there will not be any dentists on the rota come April 1, so there will be no emergency service in primary dental care in his area. I suspect that the Minister will have looked specifically at that concern and will have some idea of how prevalent such a situation is likely to be after 1 April. Will the only out-of-hours emergency dental cover to which we have recourse be an accident and emergency department? That would be a serious deterioration in the service that we enjoy now.

On 6 December, we briefly covered the tolerance limit for UDAs, and I am pleased that in the revised regulations it has gone up from 2 per cent. to 4, which is a move in the right direction. That limit is still rather fine, however, and dentists are worried that towards the end of the year there will be an overshoot. They will not want to go under their UDA allocation for the year because that involves penalties.

I am worried about dental public health and oral health research, and so are a number of people who have written to me. Currently, 400-odd treatments that are listed for payment are recorded separately. That will obviously be reduced to three bands, plus a few other bits and bobs under the new regulations. What assessment has the Minister made of the impact of that on dental epidemiology?

It may seem quite a small point, and I suppose that in the great scheme of things it is, but advances in dentistry, as elsewhere in health care, are informed by research, often epidemiological research. Unless there is an alternative means for capturing individual items, as we can currently with the recording mechanism available to us, that recourse to dental epidemiology will be lost, or at least severely damaged. It would be nice to know what thoughts the Minister has had on that and whether she intends to do anything to remedy it.

What does the Minister have in her regulations that will incentivise preventive oral health? In December, she went some way to convince us that preventive oral health would be encompassed within band 1. The hope is that dentists will use band 1 to practise prevention. Other than that, it is difficult to see what effort has gone into focusing on preventive oral health within these regulations and, other than allowing dentists to charge for preventive oral health within band 1, it is
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not clear how the Government will carry forward their stated intention of focusing on preventive health in respect of dentistry.

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Prepared 9 February 2006