National Health Service (General Dental Services Contracts) Regulations 2005 |
The Chairman: Order. May I gently draw the hon. Gentlemans attention to that fact that other Members might wish to contribute to the debate? I am following closely what he is saying. It is in order, but a third of the time available to the Committee has passed. He might wish to consider that. Dr. Murrison: I am grateful to you, Mr. Pope. The purpose of my not pressing the point about discussing these issues separately was that we could have a holistic debate on GPS and PDS. Inevitably, there is a lot of material to cover, but you will be glad to hear that I am drawing my remarks to a close. I particularly look forward to the Ministers response. I should like to mention briefly the perversities of the banding system, as that is an issue of great concern to dentists. We have three bands, which have been distilled from 400 items of treatment, and it is clear that they will introduce a number of perversities. It is worth pointing out again that this was not Harry Catons original intention. His scheme was very different from the condensed version that the Minister proposes we accept today. It will give an incentive for what one might call the guileful patient or the guileful practitioner, because within band 2 in particular there will be an incentive for dentists to try to go for those items that take less time or involve less expense. The two tend to be one and the same. Dentists will not deliberately do that because they are professionals, but there will be that inbuilt incentive. The cunning patient will work it out that within band 2 they can get lots of treatments. They can probably get 20 fillings for the price of one in band 1 or, more importantly, go for the more sophisticated treatment within band 2 and argue the toss with the dentist in a way that those with less command of the new regulations cannot. The Minister must also address more comprehensively than she did in December the smoothing of UDAs throughout the year. One concern I raised then, which remains with me, is that having negotiated a number of UDAs for the year, there is an incentive for dentists to rattle through those as fast as possible, come to the end of the financial year and say, Well I have done my UDAs, so I can reduce my overheads, put up the shutters and go off on holiday. I doubt whether that will happen much, not least because I suspect that most practitioners have a mixed practice. They have to manage both practices and cannot simply shut down their private practice because they have come towards the end of their NHS commitment. We have seen similar front-loading of treatment in other elements of the health service. PCTs have been unable to fund elective hospital treatments towards the end of the year, and it is possible that that might apply in dentistry. Therefore, some reassurance
That is all I have to saythis is quite brief for meand I look forward to the Ministers comments. Although I have listened with great interest to what she has said, we remain, as she can probably tell, deeply unhappy with the regulations. We hope very much that, even at this late stage, she will put on the brakes and at least consider piloting them. 3.6 pmMr. Philip Hollobone (Kettering) (Con): I want to speak on behalf of my constituents in Kettering, who have been badly let down by the Government on the provision of NHS dentistry. In 1999, the Prime Minister promised that everyone would have access to an NHS dentist within two years. I am afraid that that is simply not the case in Kettering. Indeed, the position is worse than at any time since the Government came to power because, since 2002, almost 7,000 constituents have been thrown off NHS dental lists as a result of the contracts offered to dentists by the NHS. There are now fewer people on NHS dental lists in Kettering than when the Conservatives were in power in 1997, and local people are disgusted. I want to quote a letter from a constituent, which sums up the position well. Katherine Clay, who is very concerned, wrote:
That is the sad situation in the Kettering constituency. People pay their taxes and expect to have access to an NHS dentist. The problem affects not only the current population: under the Governments plans, the population of Kettering is set to grow by between a third and 50 per cent. in the next 15 years. I do not claim to be a statistical expert, but if the population is to increase by a third or a half, we need a third or 50 per cent. more NHS dentists. Local dentists tell me that the sad situation is that the contracts that the Government are introducing will make more of the dentists who currently serve the local population leave NHS dentistry. I want to thank the dentists in Kettering for all their hard work, but, as the constituency Member of Parliament, it is my job to stand up in this place and speak out on behalf of the residents. They are extremely worried that, with the introduction of the new contracts, the Government will make the already difficult situation in Kettering far worse. I urge them, at this late stage, to think again. If they do not, even fewer people in Kettering will have access to an NHS dentist. Column Number: 13 3.9 pmJulia Goldsworthy (Falmouth and Camborne) (LD): I shall keep my remarks brief, as I want to avoid a repetition of our debate early in December and do not want to repeat any of the points made by the hon. Member for Westbury (Dr. Murrison). As other hon. Members have said, we are at a very late stage before the contracts kick in, yet there are still many issues to be resolved and questions to be addressed. I would like to take this opportunity to raise those questions with the Minister. First, how exactly will the new system of units of dental activity get dentists off the treadmill? The UDAs are not like the PDS pilots, in which dentists could work at their own pace. The BDA sent me a document that says:
That is certainly the view that I hear from dentists in my constituency, who are concerned that the UDA output system is untested. That adds further uncertainty, lack of clarity and risk. We do not know what the outcome of the changes will be. Secondly, will the Minister clarify exactly how the new agreements and contract will save on administration? It is true that there will not be the array of hundreds of tariffs that existed in the past, but dentists will still need to give detailed descriptions of the course of treatment for every patient not only to the patient but to those funding the treatment. There will also need to be an assessment of the price band for each treatment. The need for a body to monitor the new contract and agreementsthe Business Services Authoritydoes not fill me with confidence that there will be huge overall administrative savings, although it may mean that neither dentists nor the PCT will bear the brunt of that administration. Let us not forget that the PCTs may have their minds on other things this year, given that many of them will undergo reconfiguration. Thirdly, how will patients understand the new structure, in terms of how the UDAs will work, what the pricing structure will be and what they will be asked to pay? How will that fit with the many dentists who provide a mix of NHS and private services? Perhaps patients will not see the UDAs and the targets as of any direct concern or importance to them, but there will be the new banded pricing structure. How and when will the new information campaign be rolled out, given that the new pricing structure kicks in in April? We are only weeks away from that. I would also be grateful if the Minister could clarify her position on childrens treatment on the NHS. I raise that because the situation is slightly confusing, in that the initial position was to declare an end to dentists being able to hold patients to ransom by saying that they would treat children only if their parents went private. Instead, I understand that there will be a new ransom whereby both parents and children would be forced to choose between private
I was contacted only last week in a surgery by a constituent whose dentist had told her that he could no longer treat her or her husband on the NHS, but that if they went private, their children could still be treated on the NHS. When they sought alternative dentists to provide them all with NHS treatment, they were given three options in Cornwall. They did not live in a 5-mile radius of any of those dental services, and came to me at a total loss about how to find NHS services for themselves or their children. On their behalf, I would be grateful if the Minister could clarify the position. I still cannot see how the new arrangements will keep dentists in the NHS. Does the Minister have evidence to suggest that they will? The evidence from my constituents tends to suggest that the reverse is true. I was contacted last week by a clinic that is probably one of the biggest NHS providers in the constituency, with about 6,000 NHS-registered patients. It is considering leaving the NHS altogether in the new financial year. That will have a massive impact on access to NHS dentistry in my constituency, given the difficulties that I described in the case of my constituent. I have also undertaken a survey of NHS dentists across the county, 75 per cent. of whom responded by saying that they were considering leaving the NHS as a result of the new contract. As has been said, it seems that many are planning to pull out of the NHS altogether or are already doing so. Of course, the new Peninsula dental school recently awarded to the south-west will help bring more dentists to the region. That could reverse the shortages that we have experienced since the previous reconfiguration of dental services in the 1990s, but it will make a difference only if graduating dentists decide to work for NHS dentists rather than private practices. It is not clear whether that will be the case. Given that so much is untested, and given dentists uncertainty about the new contract and the new tariff system, will the Minister undertake at least to assess the impact of the changes and review the system once it is in place? There has been no opportunity to pilot the changes, which means that we cannot predict the impact that they will have on services to patients. Anne Milton: We have talked a lot about patients and dentists, but another group will be affected. Orthodontists are concerned about whether they will have the same protection under the contract as dentists, despite the dentists concerns. Does the hon. Lady agree that orthodontists are engaged in long-term treatment plans with children, and that the terms of the contract are important also for them? Julia Goldsworthy: Orthodontists raised that issue also with me. I hope that the Minister will assure us that a full assessment will be made of how much time dentists spend on preventive work, especially given that it attracts no UDAs. What impact will the changes have on the quality of patient care? How well understood
I hope that the indications in my constituency are wrong and that there will not be a mass exodus on the scale of the early 1990s. The fundamental problem is that we do not know because of a lack of piloting; that makes a full and proper review or piloting before the new contract is introduced even more important. 3.18 pmMs Winterton: May I say what an enormous pleasure it is, Mr. Pope, to serve under your chairmanship? We have had a wide-ranging debate, and a number of questions were asked about the detail of the regulations. I understand that it can be quite daunting to see how much material there can be in such regulations, and translating them into reality sometimes causes a little confusion. I shall therefore explain our overall direction of travel and then answer some of the detailed questions. The hon. Member for Westbury will understand that the regulations were subject to negative resolution. He obviously prayed against them, but I am sorry to say that thereafter we were in the hands of the business managers. I hope that our debate has given him the detailed scrutiny that he wanted and that it will be valuable, given the time scale. I shall start by giving some background. Over the past two yearsthe hon. Gentleman was gracious enough to endorse our approachthe Government have laid the foundations for the most radical reform of NHS dentistry since 1948. At the core of our reform is an improved contractual relationship between local primary care trusts and dentists. Beginning in April 2006, PCTs will take over devolved budgets for dentistry and will, for the first time, be able to commission dental services to meet local needs. It is important to understand that they did not like the previous contract, that dental schools were closed and so onthings that I am afraid happened under the previous Administration. What was done under that Administration created difficulties in that if a dentist left the NHS, the money paid to the dentist returned to the centre, which meant that a local area would always lose out if there were difficulties. That situation could easily arise, leaving the local area without any funds to replace the dentist unless another decided to enter the NHS. The regulations change that system, so that the money remains at local level if dentists leave the NHS. I accept that they have left and that that has caused a number of problems, which is why we have had to change the system. When dentists leave, PCTs will now have the power to use the money to commission dentistry from elsewhere. Column Number: 16 Dr. Murrison: The Minister has drifted away from the point on which I wanted to intervene. I wanted to put on the record a response to her slightly partisan point about the closure of dental schools. I hope she will admit that the reason why they were closed was that work done in the 1970s suggested that dental caries would be reduced. Also, nobody could possibly have anticipated the upsurge in cosmetic dentistry, which has done more than anything else to draw people away from NHS dentistry. I hope that she will at least admit to that. Ms Winterton: I hope that the hon. Gentleman will in turn admit that the trend away from NHS dentistry started with the very unpopular contract introduced by the previous Administration and by the cut in dentists fees that followed from the introduction of that contract. It might have been anticipated that closing dental schools was not necessarily a good idea. However, I am pleased to say that we have recently announced the opening of a dental school, which will improve access in the constituency of the hon. Member for Falmouth and Camborne (Julia Goldsworthy). I am upset that she did not thank me for that in her contribution. We should be clear about what we are offering in the contract we are discussing today. I shall come to the remuneration that dentists can expect, but let us be clear that the contract will guarantee an agreed income for three years. We will see a support network for PCTs, and we have seen a lot of additional investment and growth in the past two years. We must correct a long-term problem in NHS dentistry. We are modernising how dentists work but also modernising the overall system of providing NHS dentistry. Lots of comments have been made about patients understanding of the matter, but at the moment, patients are confused about what is offered on the NHS and what is offered privately. I do not know how many hon. Members have had the same experience: people have come up to me and said, Ive just paid £1,000 for NHS dentistry. I have said, No, you havent, because the maximum a person could pay on the NHS, before we introduced the new system, was £384. A mixture of private and NHS work had been done, and patients were not clear about it. The system that I am outlining makes the NHS component much clearer, because there are three simple payments. Someone either pays them or does not. In addition, the NHS maximum that a person can pay under the new system is £189not £384. That is a massive cut in the maximum that NHS patients need to pay. Julia Goldsworthy: If patients did not understand that the current maximum was £384, what efforts will be undertaken to ensure that they understand the banding system and the new upper limit? Surely, the fundamental confusion will remain. People will still receive a mixture of private and NHS work and may not see the exact boundaries clearly. Ms Winterton: A series of leaflets is being used to explain the new system, but, under separate regulations not before the Committee today, which
Anne Milton: Will a public information programme be directed to peoples homesleaflets through peoples doorsor will the leaflets be available only to be picked up at a doctors or dentists surgery? I am slightly concerned because currentlyI see no reason why this should changemany people do not go to the dentist with their children, because they are scared about what it will cost. Unless the Minister intends the information campaign to be very proactive, people will not know what is happening. Ms Winterton: The patient information campaign will involve not only leaflets but posters. I made a mistake earlier: the regulations do contain the requirement to display a poster in the dentists surgerywe are doing even better than I thought. The poster will have to say exactly what is available on the NHS and explain the three-banded system. In addition, leaflets will go to GPs surgeries and to libraries, and primary care trusts will have a role in publicising the information. There is a range of ways in which we shall ensure that patients understand the banding system more clearly than they have understood the information in the past. We spend about £2.3 billion on NHS dentistry, and the new changes will make it much easier for PCTs to have control over their share of the spending. To return to issues that dentists have raised through the hon. Member for Westbury, I understand that people have not found matters as clear as we should have liked. Misleading information has, I am afraid, caused a lot of confusion. However, we have tried, through the Department and through direct communication with dentists, to meet local dental committees. Our acting chief dental officer, Barry Cockcroft, and his team, have been extremely busy going around the country holding meetings that have been as open as possible, to correct some of the misconceptions about what is on offer. PCTs are out there on the front line, and I hope that hon. Members are doing much to support the work of their PCTs. Many are in the middle of a kind of negotiating process, but, even though many queries need to be answered, they believe that the vast majority of dentists will take up the new contracts. Of course, that is up to the dentists, but I assure hon. Members that if an NHS dentist does not want to take up a new NHS contract, the system allows the PCT to commission dentistry elsewhere. There is absolutely no question about that. Mr. Hollobone: On the point about direct contact to explain changes, may I, on behalf of the Northamptonshire Heartlands primary care trust, together with Alisdair McKendrick, who is the
Ms Winterton: I am more than happy to meet in Kettering at some stage, as the hon. Gentleman suggests. However, in the interim, it would be more appropriate for the chief dental officer or one of his staff to visit in order to have a face-to-face discussion about particular aspects of dental provision. At present, I am keen to ensure that PCTs that are carrying out local negotiations are allowed to continue with them. The Government are giving them a lot of support in that. I know that there have been particular difficulties in the hon. Gentlemans constituency, but I also know that his PCT has put together a good local commissioning plan. I understand that a new practice opened in April 2005 and has been able to accommodate some 4,300 patients, and that another one should be opening in April 2006 with four dentists. It will be able to accommodate about 10,000 patients. I hope that those changes will take place. I am not absolutely clear about whether the contracts have been finalised, but the hon. Gentlemans PCT should be congratulated on trying to get to grips with the problem by using money that is now available at local levelan approach that I hope he will endorseto improve the situation for his constituents. Mr. Hollobone: The new dentist in April 2005 set up a new practice, having come from another in Kettering. There was no net gain for the Kettering constituency. Ms Winterton: I believe that that dentist has taken on another dentistthat is part of moving to better practices. Of course I understand that there have been difficulties, but I am glad that things are changing. The basis for the changes that we are making was that dentists complained about being on a drill-and-fill treadmill. They would have to put in a charge every time they made an intervention, and they had to battle with 400 separate charges, or items. The hon. Member for Westbury discussed the new band system. He seems to be under the impression that in some way it moves away from the system devised by Harry Cayton. In fact, it uses exactly the same three bands proposed in Harry Caytons report. There were some who said that they would like to see four bands, but we stuck to Harry Caytons original recommendations for three. If the hon. Gentleman will allow me, I shall come on to the UDA system a little later. There was a lot of dissatisfaction among dentists with the previous system and the red tape, which is why we have moved away from that remuneration system. Mary Creagh (Wakefield) (Lab): I thank my hon. Friend for giving way. For the record, I give my thanks, as the MP for Wakefield, for the new dental practice that has been opened there. I invite her to pop up and visit at a time that is convenient for herthat
I have two questions for the Minister. First, will she keep an eye on the patient line? Part of the debate has been on public information access. We have a patient line in Wakefield, but I have heard from constituents that it is not working all that well. Nevertheless, I do not present anecdotes as evidence and I have not conducted a scientific survey on such matters, unlike the hon. Member for Westbury. There have been teething problems with the linesorry, that was an unintended pun. Secondly, what will a dentists average income be under the new contract, and what capital costs will they receive? Ms Winterton: I thank my hon. Friend for those questions. I think that I will be popping up to the area on 23 MarchI remember looking at the appointment this morning. However, I will make sure that that date is convenient for her because I know that the practice opening in her constituency is rather large. I think that my hon. Friend is right about information available to patients. One of the problems with the current system is that things can change day by day and hour by hour; if a dentist suddenly decides not to stay with the NHS or that they do not want to take more patients, little notice is given to PCTs. The beauty of the new system is that PCTs will know much more about what is happening in their area, and with greater certainty. On my hon. Friends question about the average that a dentist could expect for a good NHS commitment, as John Renshaw from the BDA confirmed the other day, they could expect approximately £80,000 a year, with another £80,000 towards practice expenses. Altogether, that is £160,000, which I think is a good deal given that there will be a three-year guarantee of that amount if that is what an NHS dentist gets at the moment. That would also involve 5 per cent. less work, new maternity and paternity rights and so on. So I think that we are making a fair offer. I will now turn to UDAs. A number of hon. Members have indicated that they feel there is a difficulty with UDAs and the fact that we are asking dentists to work to them. As Members of Parliament, we ought to be responsible and ensure that when we introduce a new system of this sort, we are able to monitor the expenditure of public money. I think that we would be criticised if we did not do that. There has been about five years piloting of the new ways of working; that is, looking after patients treatment for however long they are with a dentist, not just working to a drill-and-fill payment, where dentists were paid only when they did a certain amount of work. What we are talking about now is paying dentists for a cohort of patients to whom they give treatment. Column Number: 20 The idea that patients might save up their fillings for one shot from the dentist seems unrealistic. It would be odd behaviour for patients to go round in pain for a long time, hoping that they might need another filling, so that they could have two done together. |
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