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That this House believes that there is no need to reduce the salary of the Secretary of State for Health at a time when patient satisfaction is increasing, with nine out of ten in-patients saying their care has been good, very good or excellent, waiting times are at their lowest since records began, an extra 200,000 lives have been saved from heart disease and cancer since 1996 and investment in the NHS is being trebled by 2008.
Mr. Eric Martlew (Carlisle) (Lab): I rise to present the petition of the International Fund for Animal Welfare and concerned members of the public regarding Canadas commercial seal hunt. The petition is signed by Brenda King and more than 46,000 other UK citizens, and should be seen in the context of the further 144,000 postcards, text messages and letters presented to the Minister for Trade today, of another non-parliamentary petition by IFAW of 83,000 signatures, and of the more than 31,000 signatures on this matter presented last year by my hon. Friend the Member for Amber Valley (Judy Mallaber) on behalf of Respect for Animals.
That the commercial seal hunt in Canada is unacceptably cruel and notes that all veterinary reports document this. The petitioners are concerned that over 1 million seals were killed in Canada alone between 2003 and 2005; and are further concerned that the UK provides a market for unnecessary seal products.
The petitioners therefore request the House of Commons to pass legislation to ban the trade in all harp and hooded seal products in the UK as a matter of urgency.
And the petitioners remain, etc.
Ms Diana R. Johnson (Kingston upon Hull, North) (Lab): I should like to present a petition from my constituents in the Orchard Park and Greenwood ward in Hull, North, including the lead petitioner, Doreen Gritt, who are fighting for a better shopping centre in their local community. Several of the shops in the area are currently derelict, vandalised or contain very little stock.
To the House of Commons, the Petition of the Residents of the Orchard Park Housing Estate, Kingston upon Hull, declares that the Orchard Park Shopping Centre is in need of redevelopment. The petitioners therefore request that the House of Commons urge the Secretary of State for Local Government and Communities to ensure that a redevelopment or refurbishment of the Centre takes place.
And the petitioners remain, etc.
Sir Paul Beresford (Mole Valley) (Con): I am delighted to have this opportunity to raise this rather complex and minor issue, except in the minds of dentists. That leads me to declare an interest: I am a very, very part-time dentist, but I take a considerable interest in endodontics. The reason for the debate is the letter sent by the chief dental officer for England last month to every dentist in England. I believe that a similar letter has gone out in the other countries of the United Kingdom. The letter stated that its intention was to
clarify the situation with regard to decontamination and reuse of instruments, especially those used in endodontic treatment.
endodontic reamers and files are to be treated as single use.
The advice was intended to stop the transmission of variant Creutzfeldt-Jakob disease from carriers to non-carriers during endodontic treatment. To my surprise, it received a lot of coverage in the national mediait must have been a quiet day. As patients tend to scare easily, especially in relation to dentistry, a little reassurance might help.
Variant CJD is an exceptionally rare but fatal human disease of the brain and nervous system. It was first discovered in 1996 and is considered to have originated in humans through the consumption of cattle infected with bovine spongiform encephalopathy. By mid-2006, 265 people in the UK had either definitely or probably died from the disease. Iatrogenic transmission is considered to be a remote possibility via the prion protein on surgicalespecially stainless steelinstruments. To add to the scare factor, I understand that in the last financial year more than 900,000 root treatments were conducted through the national health service in England alone.
As well as looking at a number of papers dealing with the subject, I discussed the situation with Professor Hugh Pennington, a renowned expert in the field. He pointed out to me, reassuringly, that occurrences of the condition appeared to be diminishing, and said that, at a guess, there were perhaps 200 carriers in the United Kingdom out of a population of 60 million. The chances of being preceded into the dental surgery by one of those 200 are therefore fairly remote.
Professor Pennington made further reassuring points. He said there was no convincing evidence that vCJD had been iatrogenically transmitted to humans by surgical instruments. He thought that surgery was under some suspicion, but that that applied only to surgery on the central nervous system. Moreover, there was no evidence of iatrogenic transmission through dentistry at any time in the United Kingdom or, indeed, the world.
As the Minister will know, the chief dental officer was concerned about the result of research involving
mice and transmission from stainless steel endodontic instruments. That research prompted concern that the protein could be difficult to remove from stainless steel endodontic reamers and files, and hence could be iatrogenically transferred from one mouse to another. Professor Pennington considered that the normal dental wire brush cleaning, followed by autoclaving, would dramatically reduce the already tiny risk to any dental patient. However, the chief dental officer, acting on the precautionary principle, issued a warning.
As the Minister probably knows, endodonticstooth root filling or, in laymans terms, taking out the nerveare used as a means of preserving a tooth in its place in the jaw when it is dead or dying, or as a means of retaining or restoring a badly broken-down tooth. If the Minister does not follow that, the Chancellor will be able to explain, according to recent reports in the newspapers. The dentist locates the so-called nerve or pulp through the occlusal surface of the tooth using instruments such as diamond or tungsten carbide burs, often followed by stainless steel burs to locate the main pulp chamber. Further instruments, especially in the case of premolars and molars, are frequently used for location and opening of root canals.
Locating of the openings of the canals may be difficult and may involve specialist instruments, particularly endodontic Piezo ultrasound diamond and nickel titanium instruments. Traditionally, the cleaning of the canals is undertaken with stainless steel endodontic reamers and files. More recently, the profession has moved to the use of much improved rotary nickel titanium reamers. The manufacturers suggest that they should be used on up to 10 root canalswhich is just as well, as they are expensive. The advised limit is intended to reduce the risk of file separation in the canal. The alternative treatment of teeth clinically requiring root canal treatment because of disease is, of course, extraction.
Interestingly, a report in the British Dental Journal at the end of last month about a research programme on dental treatment and the risk of vCJD, involving examination of patients carrying the disease, concluded
We did not find a statistically significant excess of vCJD associated with dental treatments with the exception of extractions.
Most instruments used for extractions are stainless steel. Incidentally, so are most dental instruments, all of which at some time or other will be contaminated with blood and potentially, in some cases of dental surgery or scaling, with oral tissue.
To give the Department of Health its due, I understand that it has been funding a research programme seeking a new method of prion decontamination. Last weekthe timing was brilliantthe research produced, through a collaboration between D-Gen & DuPont, a new prion disinfectant called Rely+On Prion Inactivator. Only DuPont could have come up with a name like that.
All those issues raise a number of questions. First, in the research on mice, was hypochlorite used, as in normal human etidodontics, as a lubricant and remover of protein tissue from instruments? Secondly, bearing in mind that stainless steel instruments are increasingly being replaced with nickel titanium, does the research on mice indicate that they as hard to clean of protein tissue as stainless steel? Thirdly, has use of the new prion inactivator been taken into account in
the decision, or can it be now? Fourthly, in view of other research, why have endodontic files been specifically selected when many other surgical instruments, including other endodontic instruments, could technically be just as vulnerable?
Fifthly, as national health service dentists keep asking, who will pay? Stainless steel reamers cost probably less than £10 a pack. The cost of nickel titanium kits varies between £35 and £60 a kit. We must also consider endodontic instruments that enter and touch vital pulp tissue. A dentist who frequently searches for root canals might use one, two or three ultrasonic cutters in doing so, and they cost between £70 and £85 each. Endo-access kitsto use the dental slangwhich have stainless steel burs as well as tungsten carbide ones and which frequently hit the pulp because they have to go through to find the chamber, cost £40.
Finally, as Professor Pennington agreed, the risks are infinitesimal. There are very few carriers. Sterilization techniques massively reduce what is already a very tiny risk to virtually no risk, especially if the new prion inactivator is used. Hence questions have to be asked about risk assessment and whether proportionality should be applied to the precautionary principle. In essence what I am asking is, can we have another think?
The Minister of State, Department of Health (Ms Rosie Winterton): I congratulate the hon. Member for Mole Valley (Sir Paul Beresford) on securing the debate, and I pay tribute to all the dentists for their co-operation in implementing what is an important measure as part of the Governments precautionary actions to ensure the reduction of variant Creutzfeldt-Jakob disease infection risks. The hon. Gentleman asked a number of questions on the research, and I hope he will accept that I do not know all the answers, but I would be happy to write to him with details on the procedures used in identifying the risk and other matters.
I can assure the hon. Gentleman that in April the chief dental officer and colleagues in devolved Administrations looked carefully into what action needed to be taken. That was informed by the preliminary findings of research that was in progress at the Health Protection Agency, and it was also based on precautionary advice from the Spongiform Encephalopathy Advisory Committee, which provides the Government with independent expert scientific advice on such matters as bovine spongiform encephalopathy, CJD and scrapie.
SEAC issued its position statement on dentistry and endodontic treatment in May 2006. At that point, it concluded that it was unclear whether vCJD infectivity could be transmitted via endodontic files and reamers, but that given the plausibility of such a scenario and the large number of endodontic procedures undertaken annually, it would be prudent to consider restricting these instruments to single use as a precautionary measure. In addition, previous Department of Health advice on minimising the risk of vCJD transmission that was published in 1999 stated that where instruments are difficult to clean, consideration should be given to replacing them with single-use instruments. Owing to the difficulty in decontaminating endodontic files and reamers, making those instruments single use
would eliminate any potential risk. A number of dentists were already using single-use instruments for that reason.
The SEAC position statement in May 2006 also noted that there were uncertainties in respect of the scientific data and the assumptions underpinning the assessment of risk. The committee therefore recommended:
Once the research is complete and/or other data become available, the risks should be reassessed.
Sir Paul Beresford: What concerns dentists is that although stainless steel endodontic instruments have been specifically picked out, other endodontic instruments are involved and once one goes to single use of those the cost goes through the roof.
The Department has now received some early findings from the Health Protection Agency from research on mice, which is still in progress. I will write to the hon. Gentleman with some of the details that he requested. The early findings suggest that infectivity can be found in several dental tissues and support the possibility that endodontic files and reamers could pose an effective route for transmission of vCJD. Therefore, the findings at this stage support SEACs view that these instruments should be restricted to single use on a precautionary basis in order to reduce any potential risk of transmission.
After we had obtained the advice from the HPA, we considered that it would be prudent to act immediately on SEACs precautionary advice to make endodontic files and reamers single use. That decision was supported by both the HPA and SEAC. The studies are ongoing and I will give the hon. Gentleman as much information as I can, but I have to say that some of the studies will be subject to peer review before publication. I am sure that he will appreciate the need for that added check.
The hon. Gentleman mentioned some of the concerns about cost implications for those dentists who were not already using single-use instruments. That is a complex area and one that we could not address fully when the announcement was made. The paramount concern at that point was to act swiftly and responsibly in terms of safeguarding public health. However, we have now analysed the cost implications in more detail and we will issue advice to primary care trusts this week on how to recognise some of those additional costs.
I am sure that the hon. Gentleman will accept that the data show that the incidence of root canal treatments is variable. Our figures show that a typical dentist carries out only about 25 root canal treatments a year. For those dentists, the additional costs, which I will detail later, will be marginal and could well be offset by other expenses moving in the opposite direction. We have to be clear about how to approach the issue of expenses that are paid to dentists. We cannot make adjustments every time for different costs that might occur for one instrument as opposed to another. It would be difficult to do that on a yearly basis, so there will be swings and roundabouts in the costs.
However, a minority of dentists carry out more treatments. About 10 per cent. of dentists carry out an average of 180 treatments a year. Even for those dentists, it is important not to exaggerate the additional costs. As the hon. Gentleman suggested, some of the cost estimates have tended to focus on the use of the more expensive nickel titanium instruments, but the evidence from suppliers is that stainless steel instruments make up some 70 to 80 per cent. of the market. Many cost estimates have also ignored the extent to which the previous multi-use instruments had to be replaced; and, importantly, following the announcement dental suppliers have responded swiftly by making single-use instruments available at much lower prices than before.
The Department of Health is also working with NHS Supply Chainan NHS-based purchasing initiativeto enable NHS dentists to take advantage of the significant buying power of the NHS, which should also result in lower expenses across the board. Information from dental suppliers indicates that dentists have responded in a very professional manner to the announcement and are now ordering sufficient quantity of these instruments to enable them to be treated as single use.
Taking all those factors into account, our best estimate is that practitioners undertaking 25 treatments a year are likely to incur additional costs of about £80 on average per year. Practitioners undertaking 180 treatments a year will, we think, incur additional costs of about £1,000 per year. As I said, this week we will issue PCTs with advice that will recognise that the NHS
needs to make arrangements to discuss those higher costs with contract holders.
Sir Paul Beresford: The key point is where we draw the line on what an endodontic instrument is. If we restrict the definition to reamers and files, the figures seem right. However, if we include other instruments involved in endodontics, including those that touch the potentially infected pulp, the prices are much higher.
Ms Winterton: We are preparing an expert risk assessment, involving those in dentistry decontamination and public health, on the potential risks associated with a range of different procedures. However, until that work is completed it will not be possible to be specific about what other measures we may need to consider. However, I have taken on board the hon. Gentlemans points, and it is important that we conduct that slightly wider risk assessment.
In conclusion, our primary concern in making the announcement was always to safeguard the health of patients undergoing treatment and to reassure patients that we would continue to place their safety at the heart of services commissioned by the NHS. As I said, we are now also working to ensure not only that we consider any further risks, but that there is a fair recognition of any significant additional costs faced by the profession.