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Lord Colwyn: My Lords, the gracious Speech contained one small paragraph on health care, which was, coincidentally, very similar to one paragraph this time last year. It stated:
"My Government will continue their reform of the National Health Service offering more information, power and choice to patients, with equal access for all and free at the point of delivery".
The rumour was that there would be no mention of health in the speech this year, but those few words give me the opportunity to declare an interest as a practising dental surgeon and to make a few comments on the current state of dentistry.
The Minister will know by now that nothing upsets me and my dental colleagues more than the reference to the NHS being "free at the point of delivery". It is not true now; it has never been true; and it will not be true when the new improvements in the service come into use in 12 months' time. Unless dental patients are under the age of 18, in full-time education, pregnant or recently pregnant, or on supplementary benefit, they co-pay about 80 per cent of their treatment up to a maximum of £390. It is not free at the point of delivery and it is time that the expression was removed from any connection with dentistry.
The patient charges review is expected radically to change charges for those who pay. Studies consistently show that patients do not understand how the current system works, what they are entitled to, how much is contributed by the NHS, and what does and does not
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qualify for exemption. Details of both the new contract and the patient charges review are not yet published. Perhaps the Minister could provide some further information about a likely announcement date.
In September 1999, the Prime Minister promised that everyone would have the chance to see their dentist. In the July 2000 NHS Plan, the Government said that they were,
"firmly committed to making high quality NHS dentistry available to all who want it by September 2001".
The Government have made huge steps towards changing the system and moving the responsibility for service commissioning to primary care trusts, which may well have difficulty taking on the additional task of managing dentistry as well as general healthcare. A British Dental Association survey earlier this year found great concern among dentists about the ability of trusts to cope with these new responsibilities, with just one in 10 dentists believing that their PCT has the skills and expertise to deal with the complexity of the issues.
The Department of Health's "Options for Change" outlined some of the areas where change was needed—such as workforce, the way dentists are paid, the current emphasis on interventive rather than preventive care, and offered solutions that were to be field tested by individuals and groups of dental practices across England.
There is general concern that the introduction of the dental section within the Health and Social Care (Community Health and Standards) Act 2003, and subsequent decisions, have pre-empted this field testing. It was hoped that a delay in the implementation of the new contract would allow time for proper appraisal and would give more time to the PCTs to gain the knowledge and expertise dentists fear they lack. I hope that the new October 2005 implementation date will give everyone enough time.
The National Audit Office report published last week has also highlighted serious concerns over financial management at PCT level. The BDA agrees with the report, that it is now "make or break" time for NHS dentistry. The chief executive of the BDA, Ian Wylie, has commented that,
and he warned that the Government,
"needs to get these changes right first time if it is not to lose what little confidence the dental profession has left in NHS dentistry".
With less than a year to go before implementation and still without a draft contract, it is no wonder that many dentists are seriously considering whether their future lies within the NHS.
Edward Leigh, chairman of the House of Commons Public Accounts Committee, to which the NAO reports, has called on the Department of Health to "step up its efforts now" to reassure both dentists and patients. Unless it does, it is likely that it will be the Department of Health, not dentists, walking away from the NHS. The department cannot realistically
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expect the profession to sign up to new contracts and ways of working without solid assurances about the exact details of the new contract.
The workforce review published last July stated that in England alone, in 2003, there was a shortage of 1,850 dentists and predicted that it might double to between 3,640 and 5,100 by 2011. In his opening speech the noble Lord, Lord Warner, boasted of more doctors, more nurses and new equipment, but I did not hear anything about dentists. On 14 September, the Secretary of State, John Reid, announced,
"a firm commitment to recruit an extra 1,000 full time equivalent dentists in the health service by next October".—[Official Report, Commons, 14/9/04; col. 1124.]
On 15 November, Andrew Murrison was told that the department is going to,
"check the assumptions upon which our expansion of the dental work force is based",—[Official Report, Commons, 15/11/04; col. 1158W.]
How can this be achieved? The "Returning to Dentistry" recruitment drive has met with mixed results. Perhaps the Minister could bring me up to date with the latest figures. As a result of the "improvements" to the dental contract—as yet unseen—the Government expect existing dentists who have mixed practices to increase their NHS commitment. How many will take this step? How many of the extra 1,000 dentists will come from Poland, Spain or India? While this recruitment is welcomed, surely it offers only a short-term solution to access to NHS dentistry. The real solution to the problem is to train enough dentists in the UK.
The BDA has made an important point about overseas recruitment. The chief executive has said:
"Where dentists are recruited from overseas, it's important that the countries from which we recruit have an adequate dental workforce themselves. India—for example—has one dentist to every 36,000 people. The UK has one for every 2,000. If our ratio improves, theirs just gets worse".
I should be interested to know whether the Minister agrees with that sentiment.
In conclusion, the National Audit Office report warns that the new contracts could be no more effective than the old. Under-treatment by dentists who are paid a salary could replace the over-treatment sometimes caused by the present piecework system.
The current system encourages dentists to recall patients after a fixed period, traditionally six months. The National Institute for Clinical Excellence investigated this recall period and has recommended more flexibility, with routine recall periods being determined for individual patients, structuring the intervals according to risk-assessed clinical need. This is something that I and many of my colleagues have been doing for many years.
Does the department believe that this change—the move away from six-monthly check-ups—will free up more time and enable dentists to take on more patients? I am not convinced that it will have much effect as dentists will be able to allocate more time to their patients, spending time on preventive treatment rather than being reliant on numbers of patients to maintain their income. It may cause an even longer
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queue for dental treatment. At a recent meeting—I cannot remember whether it was six months, one or even a couple of years ago—the noble Baroness, Lady Andrews, thought that the change in recall times would prevent this, freeing up time for more patients, but I have serious doubts that it will make much difference.
The new base contract is fundamental to the introduction and stability of the new system, but the profession needs the details urgently, as well as details of the system for calculation and collection of patient fees.
Five years on from the Prime Minister's pledge, we are still waiting for the latest version of the new contract and the Cayton review of patient charges. At the end of his speech the noble Lord, Lord Warner, said that this is a,
"reforming government who want their public services to continue to improve and to provide even better services to the British people".
The time has come for the Government to confirm that the public have a fundamental right to NHS dental treatment. If they agree, they must commit to providing adequate long-term resources and incentives for the dental profession to work in the NHS.
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