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If we are genuinely to look at improving national health service dentistry and to review it, it needs to be reviewed in a comprehensive way that takes into account
many of the issues that I mentioned, and not just vocational training for dentists, although that is important. People will be aware that since the Government have been in office, two new dental schools have opened in the United Kingdom. Vocational training is an important part of getting good dentists working in our health care system. That can only be done if the work is rewarded in a sensible way, and if the reward does not have to be negotiated in the way that I am led to believe it is negotiated at the moment.
8.42 pm
Norman Lamb (North Norfolk) (LD): I start by thanking the Chairman of the Select Committee, the right hon. Member for Rother Valley (Mr. Barron), for a very fair summary of the Select Committee’s conclusions and recommendations. The Committee’s conclusions on how the contract was operated were pretty damning. In paragraph 26, it said:
“The Department asked for the contract to be assessed according to its own criteria for success: patient experience; clinical quality; PCT commissioning; and dentists' working lives. We conclude that the contract is in fact so far failing to improve dental services measured by any of the criteria.”
That is a pretty damning conclusion.
The review announced last week, which, as the Select Committee Chairman fairly said, was mentioned in the Government’s response back in October, seems to be an admission of failure by the Government. For far too long, there has been a sense of denial by the Government that there was any problem with the contract. Back in February, the Secretary of State said:
“Access...is getting better all the time.”—[ Official Report, 5 February 2008; Vol. 471, c. 772.]
“‘It’s getting better all the time’, to quote a line from a track on ‘Sgt. Pepper’.”—[ Official Report, 17 June 2008; Vol. 477, c. 801.]
The Parliamentary Under-Secretary of State for Health (Ann Keen): It is.
Norman Lamb: I hear the Under-Secretary of say that that is true and she repeated the mantra at Health questions today, when she said that access was improving. However, all the evidence points in exactly the opposite direction. I fail to understand how she can continue to assert that access is improving.
I want briefly to highlight some of the failings of the contract that the Health Committee identified, and to refer to the principles that should be applied when we review how the contract works and come up with a better way forward. First, as was highlighted by the Select Committee, the contract was imposed without being trialled. Rather like the Medical Training Application Service—the basis for recruiting junior doctors to specialties—the contracts were imposed by the Government. The right hon. Member for Rother Valley was absolutely right to suggest that we need engagement and ownership by the professionals if we are to ensure that reforms to our health system work to the greatest effect. Without ownership—and that is what happens if we impose a system—the system is unlikely to work effectively.
Access, despite what the Minister continues to say, is worse: 1 million fewer adults and 200,000 fewer children have had access to NHS dentistry since the reforms
came into effect in April 2006. Before the reforms, the Government claimed that 2 million patients wanted access to NHS dentistry, but they could not get it. On the assumption that those 2 million remain, together with an extra 1.2 million people, there are now well over 3 million people, on the Government’s own figures, who want access to NHS dentistry but who are not getting it. As the previous Prime Minister said, the purpose of the new contract was to provide “access for all” who wanted it to NHS dentistry, but it was also to get dentists off the treadmill. The right hon. Member for Rother Valley was absolutely right: the previous contract was not a success, either.
We heard an intervention from the hon. Member for Staffordshire, Moorlands (Charlotte Atkins), in which she made a fair point, and I am certainly not arguing for a return to a better yesterday—the old contract failed miserably in many respects. The new contract, however, continues the failure on access.
Dr. Murrison: The hon. Gentleman is right that the old contract had its faults—most contracts do. However, does he recall the personal dental services pilots that worked quite well and showed great promise? The Government, however, decided to jettison them largely, I suspect, for political reasons. Does he not regret the fact that lessons were not learned from those pilots?
Norman Lamb: I absolutely agree. The failure to pilot schemes or to learn the lessons from pilots that have taken place is desperately frustrating. A system that was introduced without being trialled, in a big-bang approach across the country, was destined to fail. The hon. Gentleman is right to say that the Government should have learned the lessons from those encouraging pilots, which were completely ignored.
The Government’s second assertion when the new contract was introduced was that it would get dentists off the treadmill. However, it appears to have reinforced the treadmill that many dentists believe they are on. We have heard that there is a disincentive to do complex work leading, dentists have told me, to a loss of skills. If they do not do that complex work, they become less skilled, which is worrying. There has been a 45 per cent. fall in root canal work since 2004 and, to confirm the point that I made in an intervention on the right hon. Member for Rother Valley, the number of extractions has risen in the same period.
Charlotte Atkins: Further to the matter that I raised earlier, does the hon. Gentleman accept that the trend for a reduction in complex treatments kicked in before the new contract was introduced in April 2006? It was something that had already been identified as a problem. I should like to establish why that happened, as I do not think that it is automatically clear.
Norman Lamb: That may well be the case, but there is no doubt at all—and I think that the Health Committee report confirms this—that the new contract provides a disincentive to do that work, and the trend has continued with a vengeance since its introduction. In its conclusions, the Select Committee highlighted its concerns, particularly with regard to the loss of complex work, about the quality of dental care that patients who rely on the NHS receive.
There is a related problem: if someone is referred by their usual dentist—in the past, that work would have been done by that dentist—they have to wait again, perhaps in considerable pain. The Select Committee recognised that that was an unsatisfactory situation and that, more often than not, it is appropriate for the work to be done by someone’s own dentist. The point has been made repeatedly, both in the debate and beforehand, that there is no proper incentive for dentists to do preventive work, and the system does not emphasise quality. As I pointed out in an intervention, it is massively unpopular with dentists.
UDAs are a sort of straitjacket that has been imposed on the profession. There is a great deal of evidence of dentists running out of UDAs before the end of the year, so they are left with no paid work to do under the NHS. If ever there was an incentive for someone to leave a system that imposes such a straitjacket, surely that is it. Even worse, dentists who do not reach their UDA target, perhaps because it has been calculated incorrectly, end up having to repay money that has already been paid to them. I have a dedicated NHS dentist in my area who gave up in disgust after he was required to repay a substantial sum because he had not met his target.
There is clear evidence of a shortage of orthodontic work, leading to long delays in many parts of the country. A further problem is poor-quality commissioning. There is accumulating evidence that primary care trusts are not taking advantage of the powers that they have and using those powers to good effect. By not carrying out dental health needs assessments for their areas, they are commissioning not on the basis of need, but on the basis of where dentists happen, by historical accident, to be. In Norfolk dentists have been allocated additional UDAs for the rest of the financial year, but they are reluctant to invest in new facilities and in bringing in extra dentists if they have no guarantee that that will continue, so the UDAs go unused.
There is, however, some evidence of good quality commissioning taking place in some parts of the country. I refer in particular to the Heart of Birmingham PCT. I heard an extremely interesting presentation from Ros Hamburger, the public dental health specialist there. In that primary care trust, the contract has been manipulated to reduce reliance on the UDA for the payment of dentists. Instead, payments are based on quality thresholds and preventive work, adjusting the contract in a constructive and positive way. Time will tell whether it works and whether that lesson can be learned elsewhere, but it is right to point to the fact that good things are going on in some parts of the country.
Concern has been expressed about the allocation of funding around the country and the importance of moving to a needs-based system for the allocation of funds. Many dentists are expected to leave in 2009. That is the expectation in the profession, and I suspect that that fear is driving the Government to get on with the review announced last week.
All that leads me to ask whether that rather Soviet-style commissioning of care, rationed from the centre by an unelected quango, can ever work effectively. It clearly turns dentists off. Too often, they are left frustrated. The Minister shakes her head, but if she talks to dentists, she will find that that is what they say. They are left frustrated by slow, inefficient responses from the primary
care trust. As we know, the PCTs have failed to identify where the need is and to allocate UDAs accordingly. The system is not working and the temptation for dentists all too often, not just because of the money, is to escape to a simpler life where they are their own bosses and where they do not have to deal with such a bureaucratic system.
As the Select Committee also recognised, there is a need for fundamental reform—the Chairman referred to it as a fundamental or comprehensive review—of how the system operates.
Norman Lamb: The right hon. Gentleman is nodding from a sedentary position.
What principles should apply in shaping that reform? First, a set amount of public money is available for dental care, and I suspect that no political party in the Chamber will advocate at the next election a massive increase in that amount. The challenge is to maximise the effectiveness of the money available for NHS dental care so that it improves the nation’s dental health.
I turn to the second principle. I am sure that we all agree that the objective is to achieve access to high-quality dental care for all. Some people achieve that access by paying for it. Ten years ago, our dentist announced that he was going private. We wanted to stay with him, so we reluctantly ended up on a Denplan scheme. I do not like paying it, but I get used to it and ultimately can afford it. Our concern should be for those who cannot. The right hon. Member for West Dorset (Mr. Letwin) said that there is a real problem with low-income people in areas that are generally affluent; they often find that they have hopeless access to NHS care. In rural Norfolk, which is not a particularly affluent area, there is certainly poor access. Our focus should be on those who cannot afford to go private. We must ensure that they get access to high-quality dental care.
The third principle is that we must focus on children’s dental health, because if we get it right during childhood, the chances are that a substantial amount of work will be avoided later in life. Advances such as the use of fluoride in toothpaste and, in some areas, the fluoridisation of water, have had a significant effect in improving dental health. The fourth principle is that—please—we should involve the profession in shaping any reform. If we fail to do that, the reform will not work. We should trial any reform first and we should not go for a big-bang introduction, because that will end in tears.
Despite the Minister’s denials today, the Government appear tacitly to have accepted that the contract is not working as intended. The clear conclusion of the Select Committee is that the contract has not achieved the objectives set at the start. Now there is the opportunity to get it right, and it is important that we do so because many people on low incomes in our country are not getting access to high-quality dental care. We must focus our attention on them.
8.58 pm
Charlotte Atkins (Staffordshire, Moorlands) (Lab):
I am delighted that the Health Select Committee finally took up my suggestion of holding an inquiry into dental services. For a long time, dentistry has been a
much neglected area of UK health care. Perhaps that is because people do not generally die from dental decay, although a meeting of the British Dental Association panel the other day showed some alarming results for oral cancer and how dentists can save lives by ensuring that oral cancer is picked up early and treated effectively.
Dental decay is not a death sentence, so it is not regarded as a top priority, certainly among many primary care trusts. However, we ignore dental health at our peril. Oral health is integral to general health. In 2003, the World Health Organisation’s “World Oral Health” report stated:
“The interrelationship between oral health and general health is particularly pronounced among older people. Poor oral health can increase the risks to general health and, with compromised chewing and eating abilities, affect nutritional intake.”
However, good oral health is a major issue not only for older people but for a range of people of all ages. It is particularly a problem for people from deprived backgrounds in terms of pain control, discomfort, and general self-esteem. Having decayed teeth makes a huge difference to the confidence of young and middle-aged people.
Before the new NHS payments system was introduced in April 2006, there was significant confusion and fear about the burden of dental costs, with up to 400 different charges possible and a maximum payment of some £389. The new system has simplified that charging mechanism to three charging bands, with maximum payments almost halved to £198.
Dr. Murrison: Does the hon. Lady accept the central truth that more people pay more under this scheme than under the previous one?
Charlotte Atkins: I have not seen the figures to prove that, but there are certainly issues with the three bands, and there are perverse incentives for people to store up dental health problems. The Select Committee on Health, of which I am a member, rightly identified some of those problems. The three bands have not been developed well and they need to be looked at again. Simplification of the charging system is vital because someone on a low income needs to know that if they go to a dentist, they can pay the bill. There was also a lot of confusion over whether people were paying for private or NHS treatment. People must be clear about what they are paying for so that they are not encouraged to take up private treatment when they cannot afford it.
I am also pleased that the legacy of the old system whereby dentists provided NHS treatment to young people under 18 only if they treated their parents under a Denplan or other private care scheme has largely gone. It cannot be right to coerce parents to register as private patients as the only way of ensuring that their children get NHS treatment. The Chairman of the Committee rightly pointed out that our witnesses were clear about the fact that that should not be accepted. I understand that the chief dental officer has made it clear that children-only contracts with dentists have no long-term future in terms of PCT commissioning, but some PCTs have maintained them because they are concerned about the shortfall in treatment for children.
Sir Paul Beresford (Mole Valley) (Con):
The hon. Lady has touched on something that I was going to say, which is a contrary point. My concern is that dentists
who have children-only contracts will pull out of the national health service completely and those children will not get the service.
Charlotte Atkins: My argument is that it is right to have dentists choosing either private or NHS care. I was very concerned about the case of a constituent who had been in a contract whereby she and her husband were on a Denplan deal, and their children were being treated under the NHS. Through the new PCT commissioning arrangements, the local dentist had said, “Actually your children now have to be under Denplan.” They reluctantly agreed to that and were amazed when, after one of the children had a filling, they were charged £50 on top of the Denplan rates for it. They were absolutely flabbergasted, because they had assumed that the children would be covered in full for all their treatment, but they were not.
There are lots of concerns and we have to come up with a solution. I hope that the review that the Government are conducting will look into how extensive children-only contracts are, whether they can be avoided and whether stopping them in areas where they are creating problems would cause a shortfall in treatment for children, which we must avoid.
Mr. Bone: I am listening to the hon. Lady with interest. My experience is that if NHS dentists were available, people would go to them. In the circumstances that she is describing, surely it is better that at least the children are on the NHS than that nobody should be.
Charlotte Atkins: My point is that the Government’s priority must be to ensure that everyone who wants it should have access to NHS dentistry. I therefore very much welcome the independent review of NHS dentistry that the Health Secretary announced last week and look forward to the results of the study that is due to be published next spring.
It is clear that there are still huge variations in access throughout the country. We need to learn from areas where good practice has become embedded. Ten years ago, I worked closely with the dental department of North Staffordshire hospital to encourage forward-looking dentists to relocate to north Staffordshire. I was delighted to welcome Jonathan Webb to Leek, where, after quite a struggle, he opened a new NHS dental surgery in Regent street. I was also delighted to perform the opening ceremony and to sign up as his first NHS patient.
I think that Mr. Webb thought, misguidedly, that the practice would be a nice little venture and that he could coast through to retirement. However, 10 years on, and with lots of encouragement from North Staffordshire PCT, Mr. Webb now has more than 20,000 patients. His practice, which is called TLC 4 Smiles, has relocated in Leek and now includes eight surgeries, four full-time dentists, one part-time dentist and three full-time hygienists and therapists. The practice is 96 per cent. NHS, with just a small amount of private cosmetic work.
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