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19 May 2009 : Column 389WH—continued
I have been notified of at least three cases, and I believe that the Oxford Mail has more, of people who do not feel that they have been treated appropriately by an NHS dentist who has offered private sector alternatives.
I shall give a couple of case examples of which I have given the Minister notice. The names are invented to preserve anonymity; not even the initials match.
Sally Reynolds is a constituent of mine. She had been a patient at her local dental clinic for many years, attending regularly every six months. She became disillusioned with the clinic last year over an episode involving a visit for root canal treatment. During that visit, she was told that the treatment could not be undertaken by the NHS dentist but that another NHS dentist at the same clinic would perform the treatment, but only if Ms Reynolds came as a private patient.
I do not understand that. The extent of the treatment to be given for certain conditions, even painful ones, may differ between the NHS and the private sector, but if a dentist is an NHS dentist, they cannot say that they can exercise their expertise only in the private sector. In primary care medicine, there are clear rules about that. One cannot try to switch one’s patients between the private sector and the NHS within a consultation. The clinic did not offer any help or advice as to whether or where the treatment might be available on the NHS. As Ms Reynolds was in considerable pain due to her dental condition, she had no option but to accept the offer to go private at that clinic.
There is a specific issue when people are in pain. A range of desired dental interventions are not covered by the NHS because they are deemed to be low priority and/or cosmetic, but, clearly, tooth pain is always covered by the NHS. If the pain is due to root canal problems, I would have thought that it should be capable of being definitively treated on the NHS, usually on a course of treatment that one should not have to wait too long for, even if the initial treatment is merely to deal with the pain. I would like the Minister to confirm that.
Asking someone who is in pain whether they wish to go private and have the treatment, or not be helped at all, is not acceptable, even if the patient is able to go to an emergency NHS access clinic the next day or the next week to sort out the pain in the first instance. It is not acceptable for the prospect of private treatment to be dangled before patients on the day when they are attending a practice as an NHS patient.
I serve on the British Medical Association medical ethics committee, which has given clear guidance about what consultants in an out-patient clinic, for example, should not say, even if it is true. They may say, “I cannot treat you for this because we are not funded to do so”, but they cannot then say at the same session, “But I can see you privately in my rooms next week.” They have to refer the patient back to the general practitioner or ask them to speak to someone else. They can answer only if the question is volunteered by the patient. At the very least, the same should apply in dentistry, especially if someone is particularly vulnerable because they are in pain.
To continue the case study, following the root canal operation, Ms Reynolds was left in excruciating pain once the anaesthetic wore off, and painkillers did not work. That prompted her the next morning to call the clinic, which directed her to the NHS helpline. The helpline arranged an emergency appointment and further treatment at an emergency dental service at a different clinic. She had to take two days off work, and visited the original clinic the following week to have the tooth filled.
Given the circumstances, Ms Reynolds understandably refused to pay the £300 which had been verbally quoted. She did, however, pay what the cost would have been had the treatment been carried out according to the NHS code of practice. The dentist declined her payment.
Ms Reynolds then wrote to the primary care trust to ask why the treatment was not available on the NHS. Apparently it began an investigation and visited the clinic, but could offer no explanation other than that the procedure was difficult, and few NHS dentists undertake molar endodontics. I consider that to be a poor explanation, as there apparently was an NHS dentist at the clinic who could and did undertake the procedure, but only under private terms.
I am engaged in correspondence with the PCT. I am not asking that the Government cut across it—I am capable of having that correspondence—but I would be interested to know whether they recognise this as not simply a local issue in one area. If necessary, I will publicise the case through national consumer programmes to determine whether there is a more common problem.
Clearly, there is a concern that the dentist in question said, “I can’t, but my colleague can, under private terms” to build up the clinic’s private practice at the expense of NHS patients or to boost its financial income. If root canal work is considered so difficult, why is it considered only a band 2 charge under the NHS dental charges regime? My understanding and, indeed, that of my constituent, is that to be an NHS dentist, one must have competence across a range of treatments.
This year, Ms Reynolds attended the clinic for her next six-monthly appointment and was confronted by the same dentist who undertook her root canal work. The dentist informed her that unless she paid in full for the previous treatment, the clinic would no longer treat her as an NHS patient. She left without receiving treatment, and has told me that she considers such conduct to be equivalent to blackmail.
I question whether such actions are appropriate. Cost recovery procedures may have to be undertaken, but they should not be a matter between an NHS dentist and a patient, or even a private dentist and a patient. The patient should come first. Bills can be chased through other means rather than by refusing treatment. I should like to hear the Minister’s view on whether refusing to see someone as an NHS patient because there is a dispute is acceptable. At the very least, in the instance that I am talking about, there was a dispute and a complaint.
Sally Reynolds has since been able to source another NHS dentist, but understands that others may not be so lucky. I share her concern. I wonder whether there is a trend among some dentists to try to deter people from registering as NHS patients so that they can concentrate on private patients, either for their own reasons or because the NHS dental contract does not permit them, in many cases, as I said earlier—and as many dentists and their association claim—to make a living with a high volume of under-remunerated, under-reimbursed dental work.
The second case involves someone who I am calling Anne Cowley, who was refused root canal treatment by an NHS dentist on the alleged grounds that she was a
new patient, because she had registered as a new patient. When she enquired how long she would have had to be a patient before she was entitled to treatment, the reason was changed and she was then told that the tooth was too far back in her mouth. She was faced with the prospect of going private for the treatment, which she could not afford. The dentist at the clinic offered to do the treatment himself privately for nearly £500, but this did not solve her problem, because she had registered as an NHS patient to avoid having to go to a private dentist to have her painful condition dealt with.
Anne Cowley has a further complaint, which is that she was treated rudely by the dentist and the practice—I am asking the PCT to investigate this—despite having been in considerable pain due to her condition for three weeks. Apparently, the dentist first said to her when finding out that she was a new patient, “Tell me about your teeth. Please tell me there’s nothing wrong with them.” That may show that there is a general problem in dentistry, with dentists dreading new NHS patients with major problems, because they lose income owing to the remuneration available from the dental contract. That is what has been said to me, although I do not exclude the possibility of this being a local problem with a particular dentist or practice. The PCT has told me that it is looking at what action can be taken in respect of this case and I will be engaging with it.
I have set out for the Minister two examples—there are others—and mentioned the ethical concerns, aside from rudeness and putting people in a difficult position with respect to money when they are in pain, about NHS dentists seeking to advertise their private practice to a patient in the chair who has come to see them as an NHS patient. Perhaps there is a role for guidance, at the very least, to be given to dentists by the Government through PCTs, which says, “If you’re faced with this problem, you cannot have that conversation with the patient in the chair,” and, maybe, “You are constrained from recommending your own practice as the provider of that private treatment.” There has to be some constraint.
Not having heard both sides, I do not have enough information to condemn the dentists complained about in these cases. It would not be appropriate for me to identify them or the patient, even if the patient were willing, without having heard their side. There is due process to go through in respect of complaints through the PCT. But my receiving three such complaints in the short space of a few weeks suggests that there is an underlying problem here, and I would be extremely surprised if it were confined to my constituency or to Oxfordshire. I should be grateful if the Minister responded to these cases in respect of the information that we have, which I accept is only from one side, and for any general points that she can make about both the ethical position and the position relating to the contract. I look forward to her response.
1.14 pm
The Parliamentary Under-Secretary of State for Health (Ann Keen):
It is a pleasure to serve under your chairmanship today, Mr. Bercow. I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on securing this debate on a matter that I know is of great concern to him and his constituents. I am sure that this debate will cover the concerns of other Members of
Parliament, and I appreciate his comments. I also want to take this opportunity to pay tribute to all NHS staff in Oxfordshire for their hard work and for the dedication that they show in providing high-quality health care for local patients every day.
There has been good progress in improving access to routine NHS dental care, with NHS dentists delivering more courses of treatment in England in 2008-09—an increase of more than 400,000—compared with the same period last year. Of course, we want to go further to ensure that every person who wants access to an NHS dentist can have it. We have invested a record £2 billion in dentistry and the 10 strategic health authorities in England, with the 152 primary care trusts, have set themselves the aim of delivering access for all who seek it by March 2011.
The hon. Gentleman has raised the matter of dental access in Oxfordshire.
Dr. Harris: Before the Minister moves on to the general picture, I accept the figure that she has given, which indicates that the number of treatments has increased, but the British Dental Association tells me that the latest statistics from the NHS information centre on people’s access to the NHS, rather than to procedures, shows that 27 million patients—nearly 53 per cent. of the population in England—were seen by an NHS dentist in the 24 months ending 31 September 2008, which is a decrease of 1.1 million patients compared with the period ending 31 March 2006, when the new contract was introduced. So it seems that, procedures aside, individuals are finding it ever more difficult to get NHS treatment, and the number of patients—the proportion—getting access to NHS treatment has fallen over the past two years since the new contract was introduced.
Ann Keen: I understand that the figures are given retrospectively and that they have improved in the past year. I am happy to write to the hon. Gentleman about the figures.
In Oxfordshire, there are areas where people are unable to see an NHS dentist as quickly as they would like. The hon. Gentleman may be aware that in the Oxfordshire primary care trust area the latest figures show fewer patients were seen in the past two years than the national average—46 per cent. against 53 per cent. I have been advised by Oxfordshire PCT that that reflects recent retirements and a reduction by some practices of delivery of NHS dentistry in the transition to the new contract, which was in place in 2006. But the PCT has not been idle. It agreed a dental commissioning strategy in July 2008, which will support improvements in access to NHS dentistry in Oxfordshire and lead to improved oral health for the local population. That is backed by increased funding. The PCT has received a 13 per cent. increase in its dental allocation, which is an additional £2.6 million.
The hon. Gentleman has raised the matter of access to root canal treatment. I am concerned to hear that some of his constituents may have been misled about the availability of root canal treatment on the NHS. It is important that individual patients receive all the treatments that they need and that NHS dentistry can meet all clinical needs. Patients should be able to trust their dentist to provide a comprehensive, high-quality service
that reflects their needs and preferences. That is reflected in the principles and values set out in the NHS constitution, which was launched in January this year.
NHS dentists have both a contractual and an ethical obligation to deliver all treatment that is clinically required, including root canal treatment. Indeed, they are paid to deliver such care. Although the vast majority of dentists provide excellent care for their patients, it is unacceptable for patients to be told that root canal treatment is not available on the NHS. Where that happens, it is important that the PCT takes decisive action.
This morning, in view of this debate, I discussed one of the cases that the hon. Gentleman has mentioned with the PCT. The PCT informed me that the case was raised last week; that a remedial notice was sent yesterday to the practice, which was given 28 days to provide reassurance that it will not happen again; and that if the concerns continue, the PCT can terminate the contract. It has said that it will keep me informed. I feel confident that the hon. Gentleman will be interested in any communication that I receive, which I am happy to share with him. As he has said, it is difficult to comment on individual examples, but Oxfordshire PCT assures me that it has investigated the complaints and taken action.
Pain is pain, wherever it happens in the body. Acute pain requiring root canal work is extremely distressing, and the ethics of how the patient is treated will always be of great concern to us all. Health professionals must, wherever they serve, behave as ethically as possible. I am disturbed to hear what the hon. Gentleman has said. If those concerns continue, the PCT will take action.
Sometimes, a dentist is unable to provide a treatment because of its complexity. In such circumstances, they should refer the patient to a suitable NHS service that can provide the treatment. Those services are available, and many clinicians are renowned for root canal work. The PCT has worked with local dentists to improve guidelines and advice when patients need to be referred for more specialist NHS dental care.
In the past year, the PCT has successfully improved access to NHS dental services in Oxfordshire by supporting practices to expand their surgery capacity, bringing in new dentists, making capital grants to support expansion and extending contracts. New providers have been established in Banbury, Wallingford and Oxford in the past 18 months, and 8,000 more people have been seen in the past year. The PCT is also targeting children in areas of deprivation with high levels of dental decay by providing topical fluoride varnishes in Sure Start centres. The hon. Gentleman referred to the inequalities in health and dental care, and it is important that the mum has good antenatal care, because teeth are formed before we are born. Fluoride is the most effective and cost-effective remedy for tooth decay, and Sure Start centres, not only in Oxford, but around the country, are starting to address the serious inequalities in health. Those projects will expand next year.
That is just the beginning. Proposals for 2009-10 include an additional £4 million to continue improving access to dentistry until 55 per cent. of the population are covered. That funding will increase by another £2 million the following year, as services become fully established, with the aim of reaching 64 per cent. of the population. New services opening this year include the Leys health centre in Oxford, which is due to open
in July 2009, and will provide access for an additional 7,000 patients. That is an increase in provision for a population in an area of high deprivation, where people are currently high users of emergency dental services. There will also be new services in Bridge street, Banbury, which is another area with high oral health needs, and in Witney and Wantage.
It is expected that those measures will enable a further 20,000 patients to be seen by an NHS dentist in Oxfordshire during 2009 and 2010. It is, of course, important that patients know where the new services are, and the PCT’s dental helpline helps 40 to 50 Oxfordshire residents every week to find dentists who accept new NHS patients. The PCT is working with patient groups on ways to raise public awareness of that useful source of advice about local dental services.
Oxfordshire PCT is being helped in its work to implement its dental strategy through the expanded national dental access programme that the Government have set up. The programme is being led by Dr. Mike Warburton, an experienced clinician and manager, and supports the NHS in rapidly expanding dental services where needed. The programme will work closely with Professor Jimmy Steele’s independent review of NHS dentistry. That will also help us to understand how we can ensure that NHS dentists deliver consistently high-quality care while providing the right level of preventive work, as well as considering how we can further reduce inequalities in oral health.
The core of our dentistry reforms—the NHS holds the dental budget locally and commissions dentists directly to deliver NHS care—is here to stay. There is no shortage of dentists wanting to deliver such care. In Oxfordshire PCT, the number of dentists increased from 262 in March 2007 to 289 in March 2008. If an individual chooses to leave, the local PCT can simply commission alternative care from another practice. Our NHS is confident that it can achieve its aim of delivering access to a dentist for all who seek it by March 2011. We strongly welcome the level of commitment to tackle dental access that that time frame demonstrates.
Dr. Harris: I am grateful for the Minister’s comments. I have listened carefully, and I look forward to hearing from her and the PCT about the specific problem that I have raised.
The Minister has said that it is never appropriate for a dentist, even if they feel that it is not within their competence to carry out, for example, root canal treatment, to recommend private treatment to an NHS patient, but that such patients should be referred to another NHS dentist who can do the work. Will she confirm that my understanding is correct?
Ann Keen: I have no problem in saying that if an NHS dentist believes that root canal treatment is too complex for them to undertake in their own practice, NHS consultants and clinicians are available to undertake such work. It is important that the hon. Gentleman accepts that, and that patients in his constituency understand that the NHS exists to provide that.
Dr. Harris: As a few minutes remain, does the Minister agree that it is inappropriate for any dentist, as for doctors in the health service, to discriminate because of their religious views against patients by, for example, refusing to treat a female patient unless they wear a hijab? It was recently reported in the press that that had happened, and it cannot be right for a dentist to set dress codes for patients.
Ann Keen: The hon. Gentleman’s style is sometimes to ask unexpected questions, and as I have known him for some years in the House I was expecting the unexpected. I have no wish to comment on that, because I know not the source.
I urge the hon. Gentleman and his fellow MPs to work constructively with Oxfordshire PCT and the South Central SHA to ensure that Oxfordshire residents are provided with the very best NHS services now and in the future. I know from the commitment that I was given this morning that Oxfordshire PCT is committed to improving oral health in its population, and the development of dental services in Oxfordshire is an integral part of the PCT’s priorities for local health services. I hope that today’s debate has sent out a strong message to dentists to adapt their conversations. The overwhelming majority of dentists in the NHS do amazing and brilliant work, which is difficult, as we all recognise. Not everyone looks forward to visiting the dentist and for dentists to know that before their patients arrive must create even more anxiety for them, but they do an excellent job and I congratulate them all, particularly those in Oxford.
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