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The Committee found that the new dental contract had also failed to provide dentists with sufficient financial incentives to provide preventive advice, and that the system by which dentists are paid according to the amount of UDAs delivered should be changed. The Department should consider introducing payments based on quality and outcomes frameworks, such as we have
in parts—although not all—of general practitioner practice. In those areas, people who have long-term conditions are being managed on the basis that GPs are providing such treatment. We believe that this is something that should be looked at.
The Government’s response to our report was published in October 2008. It accepted some of the Committee’s criticisms, but maintained that the access to NHS dental services would improve over time. The Government response stated that although access was uneven, it was improving and would improve further once the contract had bedded in, and that the Department would investigate whether the number of complex treatments had fallen. The evidence was a bit more than anecdotal. We need to consider issues such as what happens if someone loses one tooth. Although a better way of proceeding would be to put in a crown or something substantial, under the new system dentists could just put in a palate with one tooth on it. That would suffice to get the UDA, and thus the income, into the practice. When we heard such information, we had grave worries about whether the issue of quality was being addressed at all in many senses.
Dr. Andrew Murrison (Westbury) (Con): Does the right hon. Gentleman accept that because most dentists are professionals, they will try to do the right thing and provide a quality service? Does he also accept that a system in which an extraction is funded in the same way as complex root canal work, which can take many sessions to carry out properly, is extremely difficult and heavy on consumables, is unlikely to encourage dentists to aspire to quality dentistry, but far more likely to encourage them to do the bare minimum, which is not conducive to good oral health or dentition?
Mr. Barron: Yes, I do agree. What we have heard in the past few weeks about what is going to happen to NHS dentistry, however, abates a little bit my fears and I suspect those of other members of the Committee.
Norman Lamb (North Norfolk) (LD): To follow up on the previous intervention, will the right hon. Gentleman also confirm that the statistics appear to demonstrate what was just said—that the number of root canal fillings being carried out has decreased significantly and the number of extractions had increased?
Mr. Barron: I am not sure about the extractions side, but I agree in respect of the more complicated work; there was evidence of a shift in that regard, and we could assume that the new contract was what created that.
David Taylor (North-West Leicestershire) (Lab/Co-op): Further to the point made by the hon. Member for Westbury (Dr. Murrison), did the Committee find that the width of the UDA banding—I am told that one extraction counts for the same as four or five—was a disincentive to some dentists to enrol patients who needed substantial work to get them to the start line? Was that one of the reasons for people finding it difficult to get an NHS dentist?
Mr. Barron: That is the case, and we took evidence to that effect. Some of the more complicated cases were shoved into the acute sector—into hospitals—which was wholly wrong. That is not where such treatment should take place.
The Government also agreed that the historical means of funding PCTs should change and that funding should be based on the needs of the population. That is one of the great difficulties, because the new contract wanted to improve access to NHS dentistry services, but it also had to ensure that we did not lose any more dentists to the private sector. We found that the funding for the activity in question was historically based where NHS activity had been high—and quite right, too. My constituency and the surrounding area are well served, and I would not want to see that diminish. That may sound selfish, but in other parts of the country dentists have walked away from the NHS and we have an obligation to look after the interests not only of the population, but of the dentists who did not walk away but continued to provide a service under the NHS banner.
Bob Spink (Castle Point) (Ind): In my constituency dentists walked away from the NHS. The right hon. Gentleman will welcome the 11 per cent. increase that the Government have put in, but can we be confident that the new formula will distribute that money on the basis of unmet need on this occasion? The key problem with the contract was that the basis of allocation by the PCTs was a historic and restricted view of previous spending.
Mr. Barron: That is precisely the area in which the Government agreed with the Committee. The contract had to be historic, because we had to defend existing NHS dentistry. The question whether that funding was based on the needs of the population is one of the most difficult when it comes to expenditure on the NHS—I have in mind the debate on improving primary health care. The question is where the disease burdens lie, and answering it is still a problem.
Mr. Peter Bone (Wellingborough) (Con): It appeared to me from the evidence that we received that dentists did not walk away, but reluctantly left the NHS. They felt that they were forced to leave the NHS because of the contracts.
Mr. Barron: That is not my reading of the situation. Dentists walked away in areas of greater income. We also heard about offers to keep children on as NHS patients provided that the parents took up private insurance. I thought that that was wrong, and the Committee commented on it, but it was part of the same problem. Money gives people the option to make different decisions. My personal view is that in some parts of the country—even in south Yorkshire—dentists decided to walk away from the NHS because they felt that enough people had enough income to sustain private insurance.
Mr. David Drew (Stroud) (Lab/Co-op): My right hon. Friend describes the situation in my constituency. In the south, we have nothing but NHS dentists. They make the contract work, they think that the rewards are perfectly satisfactory and they are great supporters of the NHS. In the town of Stroud and its immediate environs, almost all the dentists are now private. In effect, there are two systems and it is as if the Berlin wall exists between them. Occasionally, people can cross over into the other system, but private dentists do not seem to want to come back into the NHS. If there is a magic bullet that will change that, I hope that someone will tell me, because I would love to get them back.
Mr. Barron: My hon. Friend makes his case.
Norman Lamb: Will the right hon. Gentleman give way?
Mr. Barron: I meant to be very brief, but I will give way.
Norman Lamb: I am very grateful. The right hon. Gentleman argues that it is mostly in wealthier areas that dentists are leaving the NHS, but in rural Norfolk, where we have a low-wage economy, 20 per cent. of dentists left the NHS on the introduction of the new contract. Does he agree that in surveys dentists have expressed overwhelmingly negative views about the contract? The contract as a whole, and the bureaucracy involved, has driven many dentists away, as they believe that they can make an income in the private sector.
Mr. Barron: I would not disagree with that point, but over the past 15 years or more improvement in services in the NHS—be it in dentistry, GP care or hospitals—has been most successful if the professions have had ownership of it. In 1992, when the first new dentistry contract was introduced, large parts of the profession walked away from it and there were divisions in the representative bodies. It is my personal view—it is not articulated in this way in the report—that the new contract, like the 1992 contract, isolated the profession, to the disservice of dentistry in this country. When I said that at the press conference to launch the report, there were nods from some of the representatives of the dentistry profession, although in the press the next day they were reported as attacking the new contract and saying that it was all wrong. However, that is life, and we have all been there.
Charlotte Atkins (Staffordshire, Moorlands) (Lab): My right hon. Friend makes the important point that many dentists walked away from the NHS long before the 2006 contract was introduced. Many towns were NHS-dentist deserts for many years because the PCT had no way of ensuring that NHS dentistry was provided. The dentists could decide, on their own whim, how much NHS work they did and how much private work.
Mr. Barron: I agree. I do not think for one minute that the lack of NHS dentistry is just to do with the new contract. It was happening for many years before that, and in my personal view the lack of professional leadership was one of the main issues. Dentists were not engaged in the process. When we considered NHS charges, I asked a representative of one of the professional bodies what effect the new contract had had, and I cannot remember the exact response but it was along the lines of “We pass comment on it from time to time.” That is not the type of engagement that was envisaged. It is a great pity that we have lost professional leadership at that level, in terms of negotiating contracts for dentistry inside the NHS.
Mike Penning (Hemel Hempstead) (Con): The professional bodies can defend themselves, but one of the reasons for that response is that they felt that the decision was imposed on them. It was not piloted, and the evidence from the previous pilots was ignored. If it had not been imposed on them, they might have stayed around the table to discuss a better contract, but it was imposed without their agreement.
Mr. Barron: Yes, but it was also imposed because they were not engaged in the process. In all the subsequent contracts, such as the hospital doctor contracts or the GP contracts, we have seen what some would call good trade union leadership in the negotiations. I would call it good trade union leadership—it is what I used to do before I came here as a politician—and my reaction is “Well done.” That is what people should do from that side of the table. There has been a lack of such leadership in dentistry, not just in the 2006 contract but for a substantial number of years before that, too.
The Department also said that it would reconsider the unit of dental activity payment system to see whether it could also include quality of treatment. It did not rule out our suggestion of a quality and outcomes framework for style indicators in dentistry. Members will know that an announcement was made about that last Friday. The chief executive of the NHS was giving evidence to the Health Committee on Thursday morning and we asked him a question about dentistry. He replied, “Oh, we are about to make an announcement.” I said, “Great, you normally make an announcement before you come to give evidence to us or before a debate.” To be fair to my hon. Friend the Minister, the Government said in their response to our recommendation 41 that they would review NHS dentistry. Indeed, on 11 December the Secretary of State announced a change to the Department’s line that the reforms to the contract were working and that over time they would deliver improved access. Those are my words, not those of the Department, but I think that there has been a slight change of thinking. The Secretary of State acknowledged that access to NHS dentists remained a problem in many areas of the country and announced the review of the dental contract, which was already contained in the Government’s response to the Committee in October.
The review will be led by Professor Jimmy Steele, who chairs oral health services research at the school of dental sciences in Newcastle. I alluded earlier to the people at our press conference. One of them, Susie Sanderson, who is the executive board chairman of the British Dental Association and who gave evidence to the Committee during our inquiry, said last week:
“The BDA is pleased to see the long overdue announcement of a review of NHS dentistry in England. The announcement recognises the significant problems patients and dentists face and places the Department of Health on a path to addressing those problems.”
I am pleased that the Government have announced that review and will, I hope, address the issues brought up in our report. One of the key aims of the review, contained in the second bullet point in the Secretary of State’s press release, is to:
“Recommend how the Government can best address the issues raised in the Health Select Committee’s 2008 report on dentistry including the suggestion that more treatment bands are introduced.”
That referred to the system of three treatment bands. Under the old contract we had 300 or 400 different treatment bands, and I am not sure that we would want to go back to that, but we took evidence that suggested that introducing a few more bands would make the system a lot fairer than it was.
Mr. Letwin:
The Chairman of the Committee is being very generous with his time. Does he envisage that the change to the quality and outcomes framework will
somehow enable dentists in the NHS to provide more preventive care despite a system based on units of dental activity?
Mr. Barron: Yes, I would hope that it would. That was one of our major criticisms. It was said by my hon. Friend the Minister’s predecessor that the new contract was about prevention. We tried hard to find out whether it was and my personal conclusion was that it was not. In this day and age of public health there are wider issues in relation to dental health and we believe that the contract did not place sufficient emphasis on prevention. Its importance should be recognised. In my view, the advice that health professionals give people should be measured and recognised.
Sandra Gidley (Romsey) (LD): It is probably fair to mention that the chief dental officer said that an element of preventive funding was included in the single UDA, but the evidence we took from dentists suggested that so much was included in the UDA that there simply was not time to do the preventive stuff as well as treating the patient.
Mr. Barron: The inclusion of more bands for the UDAs might be a way of addressing that problem. The smaller bands, which might not get as much money into the practice, would tackle that issue.
I hope that the review will deal with that. We should not prejudge matters, but the Health Committee will be looking at the outcome of the review to make sure that a preventive agenda is put firmly in place, and that the people who carry it out are properly compensated.
There is one other matter that I want to touch on before I sit down. The review talks about identifying over the next five years how
“developments in workforce planning, training and regulation can best support the provision of high-quality dental services and enhance the working lives of dental professionals”.
In our report, we talked about vocational training and recommended that the fact that some dentists take on students should be recognised. My hon. Friend the Minister attended the session at which the chief dental office gave evidence, and she may remember that he spoke about what is happening in south Yorkshire and about the links with the Sheffield university dental school.
By pure coincidence, I went last Friday to a practice in the seat represented by my hon. Friend the Member for Sheffield, Hillsborough (Ms Smith). I was there for the official opening of an outreach training surgery in a village called High Green. The dentist who runs the surgery also runs one in my constituency, and it so happens that, as a working dentist, he gave evidence to the Committee about the new contract.
We asked the chief dental officer about what was happening with the outreach, on-the-job training of dentists. In answer to question 766 in evidence 98, he said:
“With undergraduate education we have examples of outreach teaching in Sheffield; we have visited two practices in Sheffield where they are working with the PCT and the dental school and a part of their contract is to provide outreach teaching and does not have to be monitored by UDAs.”
My understanding was that the payment of UDAs to such practices was reimbursed by having the students get experience. In other words, the practices get paid for
having students on an outreach programme by negotiating more UDAs. If one measures UDAs according to how many patients are getting treatment and then finds that some are being used for student training purposes, the result will be that incorrect figures will be produced. It is not a massive problem, but it is not the best way to proceed.
I asked the chief dental officer whether he thought that that was a right and proper way of reimbursing a dental practice for having students, and he answered:
“I do not think undergraduate training should be directly linked to UDAs”.
As I said, I was at the High Green surgery last Friday to do the official opening of the outreach training surgeries there. The two principal dentists there are Michael and Margaret Naylor, and they said:
“We strongly believe in the provision of good quality dentistry within the NHS and we welcomed this opportunity to have students working within the practice to whom we could pass on our knowledge and enthusiasm and to give the students a window of experience of working within a busy NHS practice.”
One of the students, Rachel Ingle, said:
“I found my confidence increased hugely as a result of my experiences and I feel better prepared to start work as a dentist.”
It was a big gathering, and I asked the commissioners how the outreach programme was being paid for, and how the practice was being rewarded for having the students. The High Green practice takes students from the dental school on six-week work placements, and I was told that it was normal for one dentist to have four students. The process takes time and, although the work involved is obviously not massively complicated, the students do spend time with the dentists who are training them. Inevitably, that slows down the amount of activity that takes place, but the same is true for trainee doctors and surgeons under close supervision in hospitals, where students are obviously not asked to carry out important work. When I spoke to the commissioners, they—not the dentists concerned—said, “Things are still the same.” They said that they were looking into negotiating UDAs, so that they could reward the practice for giving vocational training to students from Sheffield university’s school of clinical dentistry.
To conclude, as I said earlier, Michael and Margaret Naylor have a practice in my constituency, quite close to my constituency office in the village of Dinnington. I am an NHS patient there. As I said to the chief dental officer, next door to the dentist’s surgery there is a pharmacy, and next door to that is a doctor’s surgery, run by four or five partners. That doctor’s surgery gets capital allowances, and does not have to negotiate in the way that dentists do. It is a lot more engaged in building up NHS work than dentists are. I understand that dentists can move away from the NHS; we have heard evidence of that. However, there is something wrong if the only way in which income can go into an NHS practice is through UDAs, or what we had before them. That is how I understand the situation; my hon. Friend the Minister may know something different. Dentists do not have the type of capitation fees, or whatever we call them, that are in place in general practice.
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