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Baroness Neuberger rose to move, as an amendment to the Motion, at end to insert "but this House regrets that the Government have ignored the concerns expressed by the British Dental Association and the National Consumer Council about insufficient forward planning and communication of the new and radical restructuring of the way that the public are to be charged for dental services, which will have a disproportionate effect on those least able to afford the increases, particularly in areas where access to dental services is already restricted".
The noble Baroness said: My Lords, there is no doubt that there will be a general welcome for the simplification of dental charges. None of those who have raised concerns about the regulations has suggested that the Government have been anything
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but brave and sensible in trying to sort out a complex—and, often, incomprehensible to the layperson—system of dental charges. Nor do I wish to detain the House long at this late hour. I am particularly aware of the Minister's rapidly disappearing voice. It would be a great shame if he did not have a chance to reply to the debate.
Let me raise a few objections and explain why I have tabled this Motion of regret. First, the British Dental Association has expressed its concerns about affordability, particularly on the £15.50 entry point. I am grateful to the Minister for sharing with me his reply to the noble Lord, Lord Filkin, as chairman of the Merits of Statutory Instruments Committee, after it drew those regulations to the special attention of the House, on the basis that they might,
The Merits of Statutory Instruments Committee suggested that the House may wish to ask the department about the robustness of its forecasts on how those changes will operate.
The British Dental Association is concerned that, among other things, the banding system will encourage patients to save up their problems to get as much work done as possible for a single charge, which will work against the stated objective of improving preventive care. The Minister's reply to the Merits of Statutory Instruments Committee suggests that government and dentists have learnt a lot from the extensive piloting of personal dental services. He suggests that many patients will attend less frequently than they do now, thanks to new NICE guidelines, but he does not tackle with any conviction the issue of people storing up their dental problems and being dissuaded by charges. His answer is simply:
However concerned people are about their oral health, however reasonable they are and however much they listen to their dentist, if the initial charge is set too high of course people will save up their problems. If they can get urgent treatment at £15.50 rather than have to pay £42.40 for simple treatment, as this system imposes upon them, many of the poorest will do just that: wait, unless they are in agony. They will save their problems and the policy objective of more preventive treatment will not be met.
It is not just the British Dental Association. The Consumers' Association, which was quoted by the Ministers here and in another place as supporting these proposals, has written to me supporting my Motion to amend. It was a member of the NHS dentist patient charges working group that advised the Minister on the new system. It points out that the level of charges that it considered and supported was much lower than those proposed. It is particularly concerned that the Band 3 charge, while significantly lower than the current maximum charge, is significantly higher than the current cost of replacing dentures, particularly partial dentures. It says:
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"It is our view that these new charges will put undue financial pressure on many people, especially the older people. In many cases these charges will make people think again about getting the treatment they need".
Although the Minister tackles the reduction in maximum charges in his letter to the noble Lord, Lord Filkin, he makes no mention of the increase in the cost of replacing dentures, yet he prays in aid how beneficial the reduction will be for older people, even though denture repair is very much an older people's issue.
Equally, the National Consumer Council has raised the issue of the cheapest band, starting at £15.50, being a deterrent for the poorest in our society. The Minister's letter to the noble Lord, Lord Filkin, suggests that the current equivalent of Band 1 treatment, the scale and polish that the Minister has just talked about, would be £15.42 by next year and therefore much the same as now. If they attend less frequently, as new NICE guidelines suggest, the actual costs will be reduced. But that fails to redress the issue that the poorest in our society often have the worst teeth. They will not go less frequently; they will in fact need more Band 2 treatment.
The Minister himself has just admitted that around three-quarters of patients within Band 2 will pay more than previously and only a quarter less. Is that fair to the poorest in our society? In any case, will it encourage them to seek treatment? Others will no doubt address the issue of communication of those changes to the public and to dentists alike. I do not wish to detain the House too long.
I shall end with a quotation from the letter that the National Consumer Council sent to the Committee on the Merits of Statutory Instruments:
"We are not convinced that the current system of exemptions is sufficient to prevent charges becoming a heavy burden on some people. While receiving some state benefits gives automatic exemption from charges, in many cases people on low income have to go through a complex process to apply for full or partial exemption. Those who fall outside the NHS low income scheme, even by a few pounds a week, may still pay the full 80% of the cost of dental work. We believe that the Government should examine the system of exemptions and that the affordability of any changes to the payment system should be reviewed".
"This has particular relevance to improving equity of access to dentistry and improving oral health".
7.15 pm
I hope that the Minister can reassure the House that these new bands will not impact upon the poorest beyond what he has said in his letter to the noble Lord, Lord Filkin. I hope too that the Government will now monitor both dentists' activity and patient access to NHS dentistry to measure the impact of the reforms. Perhaps the Minister will be able to reassure the House by asking the Healthcare Commission to collect information on patients' experiences of the new dental charges, particularly as they affect people on the lowest incomes? If these reforms are found to have a deleterious affect on the poorest, will the Government reduce the charges again by April 2007 so that they are
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in line with the level of charges considered and supported by the NHS Dentistry Patient Charges Working Group? I beg to move.
Moved, as an amendment to the Motion, at end to insert "but this House regrets that the Government have ignored the concerns expressed by the British Dental Association and the National Consumer Council about insufficient forward planning and communication of the new and radical restructuring of the way that the public are to be charged for dental services, which will have a disproportionate effect on those least able to afford the increases, particularly in areas where access to dental services is already restricted".—(Baroness Neuberger.)
Earl Howe: My Lords, the House will be grateful to the Minister for introducing the order which was described by the Government Whip's Office as being of "medium controversy". To my mind, and especially after listening to the noble Baroness, it carries with it a considerable degree of controversy. I should like to set out for the Minister some of the reasons why it causes me as well as the dental profession a good deal of concern. My noble friend Lord Colwyn will be supplementing my remarks from his own perspective as a dentist.
The new price bandings provided for in the regulations represent, as the Minister said, a radical departure from what we have had up to now. Like the noble Baroness, I am the first to acknowledge that a simplification of the current system is a thoroughly desirable thing. I have no quarrel with the general concept of what the Government are seeking to do. The problem I have is with the detail. The first thing that strikes you when you examine the new charging structure is that, for a very significant group of patients, the cost of going to the dentist will be a great deal higher than it is now. The entry point for having anything done to you at all will now be £15.50. At the next tier of the scale, for treatment, you will be charged £42.40, and by the Government's own admission, three-quarters of patients falling into Band 2 will pay more than previously. The noble Baroness rightly mentioned the cost of denture repair, which is a further concern. It is no doubt true that, under the NICE guidelines, a lot of patients will not be visiting the dentist as often as they used to, but a lot will be. For many, £15.50 and £42.40 are significant sums. The first issue, then, is the affordability of the charges for those on fixed or low incomes, particularly the elderly. I cannot believe that the new bands will not have a very pronounced effect on the uptake of dental treatment among these groups, and that is a considerable worry.
That is why, if we change the remuneration structure for dentists in this fundamental way, we ought to have some clear idea about how it will affect patient behaviour. Will it increase demand for dental services and, if so, from which segments of the population? Will it reduce demand and, if so, in what respects? I suspect that the Government, if they are honest, have no idea either way. That is a profoundly unsatisfactory state of affairs. If the new charges had been piloted in a few selected PDS practices—and I understand why
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that idea presented insuperable difficulties—we might have had quite good answers to those questions. But we do not. So, we must surely ask the Minister to institute some means of measuring the impact of these reforms in terms not only of dentists' activity but also of improving access to dentistry. Will primary care trusts be obliged to collect this kind of data?
The second thing that hits you when you look at the charging structure is the element of perverse incentive. One of the things that I had hoped to find in it was a recognition of the importance of preventive care. It has been a criticism of the dentists' remuneration structure over many years that they have had an incentive to treat but no incentive to encourage patients to look after their own dental health in such a way as to make treatment unnecessary. How do the regulations recognise that concern? While the inevitable consequence of moving to a very much simpler pricing structure is that you move away from a strict fee-per-item approach, it is obvious that if patients realise that it will cost them the same to have three teeth filled as it will to have one tooth filled, they will be likely to want to cram in as many treatments as they can to a single visit. If that happens, the idea of dentists being able to spend time with patients talking about oral health promotion goes out of the window—the time will have gone.
Similarly, if you say to patients that they can have emergency treatment for £15.50, which would normally cost them £42.40, what is that but a message to them not to bother to make regular appointments with their dentists or look after their teeth as carefully as they should? The Minister may say that he would not behave in that way and nor for that matter would I, but if you are of limited means and did not understand the importance of maintaining good oral health, which a lot of people do not, that is exactly what you might do. Personally, I can see a strong case for making the emergency charge band more expensive than is now proposed and the charge in band 1 slightly less expensive. As it is, I simply do not begin to see how the new charges will encourage people to adopt a preventive approach to oral healthcare. Perhaps the Minister will enlighten me on that.
One of the other avowed aims of these arrangements is to improve clarity for both the public and dentists about the costs of NHS dental care. To be pedantic about it, I do not think that the costs of dentistry will be made any clearer to either side. The thing one hopes for is that there will be greater clarity on the price of dental treatment, but how will that happen? The one positive thing that you can say about the current system—complexity aside—is that it is at least transparent, but you can hardly say that about the proposed system, which needs explaining. Dentists have got to have an easy and effective way of communicating the tariffs to their patients. However, the BDA tells me that it is baffled by several elements of them even now. For example, the Minister in another place implied in Standing Committee that under band 1 the dentist is obliged to provide a set package of services for every single patient. Is that correct? If it is, it is not self-evident.
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That is why it is incumbent on the Department of Health to promulgate the details of these changes to patients and the public. I would be grateful if the Minister could give us further and better particulars of how they plan to do that because the Minister in another place was pretty vague on the question. The noble Lord, Lord Warner, has helpfully expanded on the Government's plans in the letter to the noble Lord, Lord Filkin, which he circulated today, but it would be useful to have the main points on the record.
For all these reasons, I find myself in sympathy with the terms of the amendment tabled by the noble Baroness, Lady Neuberger. She is perfectly right that even if the new charging structure were not controversial in any particular and even if everyone agreed on it, it would still be necessary to have an effective communication strategy for patients because the new tariffs represent such a marked departure from the system in place at the moment. Patients need to understand that.
I know that the Government believe in all sincerity that they have responded to the concerns of dentists constructively and that they have got the formula right. Despite that, I hope that, at the very least, the Minister will recognise that there are legitimate doubts out there that the formula is right, and in the light of those doubts we need his assurance that the effect of these regulations will be closely monitored and the new arrangements within them will be subject to review after an appropriate interval.
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