---

Lord Colwyn: My Lords, I also thank the Minister for the powerful way in which he explained the orders this evening. I remember him taking me aside after the last election and saying how pleased he was that he was not going to have so much to do with dentistry. I am not quite sure where it all went wrong. I also thank the noble Baroness, Lady Neuberger, for her amendment, which I support, and my noble friend Lord Howe for the many aspects of this order he has covered. Your Lordships will be delighted to hear that I have torn up most of what I was going to say, owing to the lateness of the hour, but there are one or two things I should like to clarify this evening.

I commend the Government's intention to change the system by which dentists are paid with a specific fee for a specific item of service, referred to as the "treadmill". I worked within this system from January 1966 for over 20 years. I should remind the House that dental practices are self-employed independent small businesses, and that the dentist is responsible for purchasing or leasing the premises. Highly specialised equipment, typically costing £40,000 for each treatment room, must be provided and maintained. The dentist is personally responsible for staffing the surgery with nurses and receptionists. He or she pays the specialised laboratories that manufacture crowns, bridges and dentures, and all the costs of implementing nationally agreed legislation, such as the Disability Discrimination Act, without any additional funding.

All these costs are increasing year by year at an alarming rate. Implementation of health and safety legislation is a serious cost problem for all practices.
 
15 Dec 2005 : Column 1495
 
NHS dentists do not receive grants or specific funding for equipment, materials or surgeries. Any capital investment is a personal choice, and is funded from the fees per item of service arrangement. With costs representing about 50 per cent of the total turnover, dentists have to work for half of their time to cover costs. I remember seeing between 30 and 60 patients every day. That was a treadmill.

So what is new? The basis of the new system is that the contractor will complete a number of units of dental activity, as set by the local PCT, in return for monthly payments, based for the first three years on past gross turnover. In the transition from the current GDS system, the UDA requirement and contract value will be calculated according to the level of service activity and earnings in the current GDS, minus 5 per cent. The Department of Health claims that this will get dentists off the treadmill, but to me it sounds like another treadmill. Will this new treadmill not become even more onerous as the next three years are monitored and dentists are allocated a new quota for successive years? Will they be penalised financially if the total is not reached?

The noble Baroness, Lady Neuberger, has reminded us that the British Dental Association and consumer groups have expressed concern about the incremental steps in the charge bands, which may well prove a barrier to accessing appropriate dental care. There is no specific encouragement to undertake preventive treatment, and I am concerned that patients may choose to wait for problems and then claim for an emergency course of treatment rather than incur a band 2 payment. The BDA and patient groups have not been informed how this new charging system will be explained to the public. For example, under the current system, an examination with X rays incurs a patient charge of £9.84, compared with £15.50 under the new system. These charges must be made clear to the public and justification given for the perceived increases. It is vital that the public are made aware that these charges are not directly part of the dentist's income. The new system is supposed to be cost-neutral.

I am sorry there is nothing in the regulations to address the issue of missed appointments or late cancellations. During the Standing Committee debate in another place the Minister accepted that this was a key issue for dentists, and suggested that, if there was a sudden and dramatic change in the number of missed appointments, it could be analysed with a six-month review. This is helpful, but the BDA believes that a cancellation charge should be included in the regulations to act as a deterrent, and that dentists should be able to claim UDAs for missed appointments or late cancellations. I should be grateful if the Minister would confirm this.

Neither the regulations nor the Explanatory Notes mention any arrangements for protecting the dentist against patient charge shortfalls. Ever since charging for treatment became part of the system, dentists have had to act as debt collectors for the NHS. PCTs may have a problem with uncollected NHS charges—or
 
15 Dec 2005 : Column 1496
 
"dentists' bad debts", as the DoH describes them. There is a good case for the PCT to assume responsibility for uncollected NHS charges as it does in every other area of the NHS.

I was surprised to see that the Explanatory Notes, in paragraph 7.12, state:

"no dentists' professional representative organisations or patients who responded to the consultation proposed an alternative system of patient charges".

This week I have spoken to Roger Matthews at Denplan and Quentin Skinner at DPAS (Dental Payment Administration Service). Denplan is the largest organiser of insurance-based capitation contracts. Both organisations cover patients for treatment and their average monthly charge is £15 or £16. Many dentists are moving to these and similar organisations to run their patient charging system. Denplan reports a 25 per cent annual increase year on year. The dentists can work at whatever level is preferred and all finances are taken out of their hands. No treatment bands, no UDAs, no money changing hands in the practice, no bad debts. But it is the dentist's choice as to how the practice is run, and many prefer to stay with the NHS.

7.30 pm

I do not understand why the Department of Health did not consider a similar NHS insurance-based system, with free dental check-ups and assessment, identification of exempt patients and monthly payments determined from the total dental budget and an individual's ability to pay. The difference between a capitation scheme and the Government's UDA target system is that under capitation, if the workload is reduced by improving the patient's oral health, the dentist can keep what is saved. This is why modified capitation delivers prevention while UDAs and fees for items do not.

Genuinely, I wish the Government every success with their new system. Dentists want it to work. The dental organisations want it to work. But the way that it is intended to work must be clarified and explained to contractors and to their patients.

Lord Warner: My Lords, we have had an interesting short debate, with many useful points raised. On the issue of communication, the proposals have been and will continue to be well advertised. They will have been in the public domain for nine months prior to the introduction of the new system in April 2006. During this time we have listened to the public response. We considered carefully the merits of reducing the band 2 and particularly the band 3 charge, as the consumer organisations asked. However, if such a reduction had been made, it would have had a disproportionate impact on the charges for other bands. We have reduced the cost of replacement orthodontic appliances to 30 per cent of the £189 band 3 charge—a substantial reduction.

For the first time, we have new powers in regulations to communicate and advertise a fairer, simpler system. Schedule 3, Part 5 of Regulation 34 of the contract regulations states that a dentist,
 
15 Dec 2005 : Column 1497
 

"must display in a prominent position in its premises in a part to which patients have access information relating to patient charges, as supplied by the PCT, for the purposes of providing information to patients".

Noble Lords may be interested that in the early road testing of three key messages with users, one which contrasted the current 400 charges with the new charging regime, most people were shocked that there were over 400 charges and believed that this was not something that the NHS should be advertising—their words, not mine. And in response to this debate we will redouble our efforts to make clear to patients that information on charges is now guaranteed by robust regulations. I would be happy for the noble Baroness, Lady Neuberger, and other noble Lords to write to me with any key points which she or they would like the new information leaflet for patients to incorporate.

As I explained in my opening remarks and the letter to the Committee on the Merits of Statutory Instruments, in devising the new charging regime we have learned from the experience of the PDS scheme, but could not pilot a parallel system of charges, because it would have been unlawful to do so. The noble Earl, Lord Howe, recognised that. Section 26 of the National Health Service (Primary Care) Act 1997 allowed for PDS pilots, but said that the charging regime had to be the same as GDS.

I turn to the issue of whether we backed away from Cayton. I repeat that members who now criticise signed up to the Cayton group report. Whatever aspersions that some members of the Cayton group, such as the BDA, may wish to cast on the conclusions of that report now, they did sign up to it when it was published and we have kept faith with it in these regulations.

As I said in my opening remarks, the Cayton report was frank in stating that there may be winners and losers. We acknowledge that. The report stated that its proposals for banded charges would improve affordability and equity. We have stuck with banded charges. The cost of the most expensive treatment has been cut in half, and up to two thirds of people may pay less in charges overall.

The alternative would have been to keep the current 400 charges; maintain confusion for patients; operate a system that patients do not want; and fly in the face of what the Cayton group recommended. It is considerably easier to criticise reform of patient charges than it is to think up new arrangements and to enact them. Our proposals are faithful to those of Cayton.

I dealt with the issue of why we did not pilot the new system of charging, but we drew on the experience of the personal dental services arrangements which now cover more 30 per cent of dentists. Those have shown a considerable drop in the number of item-of-service payments involving a dentist using that new system.

A number of noble Lords asked why we claim to have changed the ratio for the three bands. The figures in the report were only illustrative, based on the Dental Practice Board's classification of treatments, and the
 
15 Dec 2005 : Column 1498
 
new ratios reflect the grouping of treatments into three units of dental activity. The Cayton report recommended that the relative weighting of the bands should be maintained. In relative terms, there is still a much greater difference between band 3 charges and bands 1 and 2. The band 1 charge, which most people will pay, has simply moved over time from the £12 to £15 banding that was suggested, to £15.50, which, as I said in my opening remarks, includes a provision for inflation next year.

A number of noble Lords suggested that the combination of the new charges and the new contract will not provide incentives for the promotion of oral health among patients, because it is still based on units of dental activity. One of the objections to the item-of-service remuneration system, on which the current charges are based, is that it rewards dentists only for treating dental decay—drilling and filling. The need to pay dentists for advising people on how to maintain good oral health by preventing dental disease is fundamental to the new contract. Preventive work is included in the list of mandatory services, and an exhaustive list of these services is included in the description of the band 1 courses of treatment. By taking dentists off the drill-and-fill treadmill and allowing them to spend more time with patients, we have allowed them time to give oral health promotion messages. As I said on several occasions and in the letter to the merits committee, the number of items of service in the PDS pilots was reduced by about 30 per cent, and that has provided dentists with much more time to carry out health promotion and preventive work. A combination of the changes of approach that we are introducing gets dentists off the drill-and-fill treadmill and provides opportunities for preventive work with patients.

I may not have responded in as much detail as a number of noble Lords would have liked, but the hour is late and I am about to lose my voice. I recognise the anxieties that a number of noble Lords have expressed. We will of course keep all these arrangements under review and we will no doubt return to this issue at some later stage when we have more experience.

---