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Despite the Government’s stated aim to allow time for prevention, I fear that most dentists believe that they are still on a treadmill and that the contract in its present form has not worked. Unlike general practitioners, dentists have to buy their own premises, equipment and consumables, and have to pay their own staff. Their business has to be viable. The uncertainty about the new system puts the future of NHS dentistry at risk.
Dentist leaders have long argued that a prevention-based system could be delivered if the NHS contract used a range of quality-based performance indicators, rather than have sole reliance on a single, flawed output measure. They support the Department of Health’s advice to PCTs to include factors such as oral health, access, quality and patient experience in
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If PCTs are to meet the oral health needs of their communities, they must have the right resources to commission dental services successfully in terms of funding and expertise, as well as a commitment to do so. It seems likely that some PCTs with access problems may be adopting a narrow interpretation of their duties, focusing on spending at the level of their historic budgets, rather than on a comprehensive assessment of local need.
For too long, investment in NHS dentistry failed to keep up with funding for other areas of the NHS. Until recently, the proportion of the NHS budget spent on dentistry in England had been lower than it was in 2002-03, at only 2.8 per cent. However, the 11 per cent increase in the dental budget for 2007-09, announced last December, is a welcome development and should ensure improvements in the number of patients accessing primary care NHS dental services. It is also a step in the right direction that the ring-fencing for dental budgets has been extended until April 2001. I hope the Minister might be able to confirm that the income guarantee that dentists were given, which is due to end next April, will also be extended.
Apart from historic under-funding, the PCTs’ ability to deliver dental services has relied on the collection of about one-quarter of the dental budget via payments from patients who must pay for NHS dentistry—nothing free at the point of delivery here. This charge has turned out to be about 20 per cent lower than expected and PCTs are being forced to cover the deficit by a combination of commissioning less dentistry and by implementing inflexible performance targets for dentists. Reliance on patient charge revenue ensures that PCTs’ dental commissioning budgets remain unpredictable for future years. The BDA has called for an allocation of full dental budgets for PCTs, so that they are no longer reliant on patient charge revenue.
In 2004, the National Audit Office warned that PCTs had little experience of high street dentistry and would need to develop new expertise in dentistry. The development of effective working relationships with local dental committees and local dentists is a crucial part of addressing this requirement. The expertise of consultants in dental public health is also vital. The recent loss of a number of consultant posts is therefore of great concern and undermines the Secretary of State’s elevation of public health to the top of the national agenda and his recognition that it is pivotal to reducing health inequalities.
Having drawn on these resources, it is important that PCTs publish plans on how they intend to reduce health inequalities and to improve the oral health standards of their communities. I shall look forward to the publication of the adult dental health survey, which is invaluable for the monitoring of the population’s oral health. I hope that despite the one year delay in publication the Minister can confirm that this report is imminent.
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I have tried to be helpful. I am looking forward to the contributions from other noble Lords who are taking part in the debate. I am sure that the Minister has realised that the dental profession and its leaders wish to co-operate, but as an absolute priority the public must be assured by the Government and dental professionals that the NHS dental service is in good order. The noble Lord, Lord Darzi, is leading a wide-ranging review of the NHS and has included a dentist, John Milne, to provide the clinical input and to represent the dental profession. I hope that the review will address this very urgent problem. I beg to move for Papers.
2.45 pm
Lord Roberts of Llandudno: My Lords, from these Benches, we thank the noble Lord, Lord Colwyn, for giving us the opportunity to discuss this critical problem. As he so rightly said, nine years ago the then Prime Minister, Tony Blair, said that within two years every person in the UK would have access to an NHS dentist, which just is not happening. At that time, the picture was pretty bleak and it has not improved. In April 2006, the Government introduced a new dental contract, which promised that dentists would be allowed to take on 2 million new NHS patients. However, figures released in February 2008 show that the opposite has occurred. NHS dental statistics for England, released in February, show that 500,000 fewer patients have access to an NHS dentist since the adoption of the new dental contract.
In February, a Liberal Democrat survey showed that only 29 per cent of dentists were taking on new NHS patients. In March 2007, a British Dental Association poll discovered that 85 per cent of dentists did not think that the reforms had improved access after a year under the new contract. This was shown in the fact that half of all adults and almost one-third of all children still do not have access to an NHS dentist.
For patients who find a dentist, the charging system makes it unaffordable for many of the poor and the elderly. Even the maximum charge for a complex course of treatment under the NHS, which, in England, is £198, and, I am proud to say, in Wales, is only £177, is beyond the reach of many people. For people living just within their income finding this sort of sum is nearly impossible. For those who are unable to find an NHS dentist, the charges are totally beyond them. A week ago, I called at a dentist in the Conwy Valley where an examination costs £60; a routine extraction under local anaesthetic costs £65; a porcelain bonded crown costs £350; and a full set of dentures costs £750. This makes dental treatment very difficult for people to afford.
The noble Lord mentioned the Dentistry Watch survey published in October 2007. It confirmed that more than 10 per cent of people were not registered with a dentist; 35 per cent said that there were no local dentists; and 13 per cent said that they were still on a waiting list. The most shocking thing in the survey was that 6 per cent of the population were treating themselves. They use pliers to remove teeth—one man said that he had removed 14 teeth with pliers—use clove olive and
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A parliamentary Answer that I received in June 2005—the Minister might confirm that the figures are probably near to the mark even today—showed how Wales was missing out. The ratio of dentists in Wales was one per 2,823 patients. Scotland had one dentist per 2,202 patients, while England came in the middle with one dentist per 2,464 patients. The Welsh Assembly, the Scottish Parliament and our own Government need to get together and make sure that there is much wider availability.
The population of Wales stands at around 3 million. In 2005, more than half—1,411,574 people—were unable to register with an NHS dentist. The new contract, as well as failing to improve access, has provided no incentive for dentists to spend time with patients providing, for example, oral health advice such as how to floss and use a toothbrush properly. The contract has been estimated to allocate a mere 90 seconds for oral health advice for each patient. Something is seriously wrong here.
Of course we have known about the disillusionment of the dental profession itself since the contract was introduced. Over 1,500 dentists, 8 per cent of the total, dropped out of NHS provision within three months of the new contract being introduced, and many more signed their contracts in dispute, a situation which has yet to be fully resolved. This issue is too grave for us to make party political points, but we must increase the flexibility of the current contracts. The aim must be to ensure that dentists are properly compensated for completing NHS work and, as has already been mentioned, there must be full co-operation between the dental profession, the Government and patient groups.
I shall not take much more time from the debate. As most dental disease is preventable, charges for check-ups should be scrapped. That would ensure that all patients are able to have their teeth checked regularly, resulting in a massive saving in times ahead. Knowing that the problem is critical, we wish the Government well and look forward to the review in order to find a truly effective answer that fulfils the promise made in 1999: that every person has access to an NHS dentist.
2.52 pm
Baroness Gardner of Parkes: My Lords, I am grateful to my noble friend Lord Colwyn for tabling this Motion. As one of only two dentists in this House, I feel obliged to take part, and I am sorry if noble Lords have heard much of what I have to say before. I was fascinated by the speech of the noble Lord, Lord Roberts, because Wales has always been badly off for dentists. Going back 50 years ago, all the Welsh dentists were driving Rolls-Royces and none of them did any fillings at all. That is a bit of a generalisation, but it was the impression that everyone had. Welsh dentists did nothing except extractions at half a crown a time, but they had so many to do that they could all afford to drive Rolls-Royces. People queued for treatment even then.
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Today’s debate looks at NHS dental provision in England and that is what I intend to speak about. I should say first that the position is dire. Last night a paper was presented to a full council meeting of the Royal Borough of Kensington and Chelsea on health inequalities. The review was set up by a sub-group made up of both parties and chaired by a Labour councillor, Judith Blakeman. It identified the lack of National Health Service dental provision in the area and the particular problems arising for people with disabilities. The only provision for these people is at Northwick Park Hospital, if they can get an appointment. It is true that patients with disabilities may not be suitable for treatment in a general dental surgery because they may need a general anaesthetic. Of course now that general anaesthetics cannot be administered in a dental surgery, people have to go to hospitals. There are at least three other hospitals within easy reach of Kensington and Chelsea patients, but none provides any service to help those requiring specialist treatment. One of the suggestions made in the report was that people with special health problems ought to be provided with crisis cards of the type sometimes carried by mental health patients. That might make it easier for them.
But the biggest problem noted in the report is that there is no clearly defined care pathway between community dental services and hospitals, so that communication relies on personal contacts between staff. Just when people have built up good contacts so that one person can phone another saying, “We need someone to see this patient very urgently”, the member of staff at one end or the other leaves their job and the contact is broken. It is important to give thought to this issue.
Surprisingly, the review found that it is difficult for patients in the more deprived northern part of the borough to find National Health Service dentists. Whether that is because those living in the southern part go for private treatment or it is a general problem, I do not know. The report stated that not enough appropriate provision is made or information provided for the black and ethnic-minority communities in the area. The report strongly supported the children’s programme called Brushing for Life and the Cool Kids campaign, but there is still a need for more information.
My noble friend Lord Colwyn told us clearly about the 2 million people unable to access dental care. When the National Health Service was set up in 1948, the leaflet—it was republished 50 years later for us to read—stated that not enough trained people were available to provide dental services, and that is why people like myself came over here. I would love to know who was the first Commonwealth person to discover the need for dentists in this country, but thousands of Commonwealth dentists came over in order to meet that need, and I think they did quite a lot.
I was shocked to hear from my noble friend that dentists have to pay money back to the PCT. I do not understand that. I thought that the new contract meant that dentists would be given guaranteed payments for
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In the days when I was practising, at one stage dentists’ earnings were limited in the form of a ceiling being placed on the amount they could earn in one year. A lot of dentists did not mind that at all. They would happily do the work in six or nine months and then spend the other months travelling around the world or playing golf in Spain before going back to earn the money all over again. Many of the programmes that are supposedly the answer to everything do not work out in practice.
On these units of dental activity—the other side of the coin, as my noble friend put it—patients are smart enough to know that they can get a cheaper and better deal if they wait until they need more than three fillings. It is not only dentists who are thinking about that; patients are watching their pennies too. So when the noble Lord, Lord Roberts, told us that a full set of teeth cost £750, I was amazed. I made hundreds of sets of false teeth, for which patients originally paid £2.50. Even private dentures did not cost £750, so the figure is very high for a basic set of teeth.
Lord Roberts of Llandudno: My Lords, that was the cost with a private dentist, not an NHS one.
Baroness Gardner of Parkes: My Lords, I am relieved to hear that because it was an unbelievable amount. However, I think the fee for an examination quoted by the noble Lord was for an NHS dentist—
Lord Roberts of Llandudno: My Lords, that was also with a private dentist.
Baroness Gardner of Parkes: I understand, my Lords. However, patients have to pay for National Health Service examinations, and I support the view of the noble Lord that they should be free. Indeed, I think that that was the beginning of the rot in NHS dentistry. In 1986 I fought for and defeated the Government in your Lordships’ House on a provision to retain free dental examinations. That was reversed in the Commons and financial privilege attached, so when the proposal came back to this House we did not have the opportunity to play ping-pong or debate it further. Throwing out free dental examinations was the beginning of the end of NHS dentistry. It may be taking a long time to die, and I hope it never does, but it is certainly not good news.
The point I made in that debate is that not only people who have teeth need dental examinations. Many people on all kinds of different chemical therapies and drugs can easily develop a malignancy in their mouth which can clearly be picked up by a dentist carrying out an examination. To now read in the paper that many patients have not seen a dentist for more than two years, since the new contract was introduced, is very disturbing, because who knows what is happening in such mouths?
A dental practice is rather like running a small business. As the noble Lord, Lord Colwyn, said, you have to provide your own equipment and premises and balance the books. As time goes by, more and more
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When I see the questions and answers about dental nurses, it concerns me that if, for example, you need someone to fill in for 10 minutes a day while someone goes off for lunch and so on, that person must also be fully qualified. Apart from the registration fee, which will be about £100 a time, in a national health practice it will be an expensive business to have that many fully qualified staff. There should be a degree of flexibility. If someone is ill or away, there should be some way of finding someone to fill in. It is the same for dentists. On maternity breaks they still have to maintain their full training standards and registration. All these matters are quite difficult for people.
Another matter which is quite damaging arises from the Health and Social Care Bill. It has been announced that under order 2—which I think appears under Section 60 of the Act—the General Dental Council will be fully appointed. There will be 12 lay members and 12 professional, but they will be fully appointed. That is a retrograde step. A regulation was introduced some years ago that a number of general dental practitioners could be elected to the General Dental Council, and I was one of those elected at that time. In my experience of the General Dental Council and since, when I have been following matters, the elected members have been extremely useful. They have represented ordinary dentists, mostly in national health practice, and have been able to bring the council’s attention to the day-to-day real problems that exist. If everyone is to be appointed by the Privy Council—even if they are appointed as ordinary practitioners—they will not necessarily be representative of the practitioners in the way that someone elected to that post would be. When we get back to the Bill I shall have another go at that.
Another regulation is being introduced in July in relation to technicians. All these matters impact on the costings for dentists. All technicians in this country will have to be registered and work to a certain standard. But if you send your work to a technician, there is nothing to stop him sending it off to be done in South Africa or China because it is much cheaper to have it done there. There has been considerable trouble in the United States. People have suffered from lead poisoning caused by crowns produced in China. These have had a deadly amount of lead in them and have been put into people’s mouths. It is quite complicated.
Another interesting feature of dentistry for the private person is dental tourism. I was sitting next to someone at breakfast in the House yesterday who was
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I am running out of time. I think the National Health Service provides a marvellous dental service. I do not want dentists to be concerned about their futures; I want them to feel confident and I want patients to benefit.
3.05 pm
Lord James of Blackheath: My Lords, I offer my sincere congratulations to the noble Lord, Lord Colwyn, on his timely initiative in introducing the debate today. It is a slightly unusual problem that we are facing because it is not often that one is simultaneously concerned with the creation of a resource and a market to use it, which are really the two halves of the contract issue that we are facing here. What we have heard from the speakers so far suggests that neither side of the equation is finding that the deal is working to its satisfaction. We need to look very carefully at why.
Your Lordships will remember that on 8 November last year we debated the question of the National Health Service in general and the financial aspects of it. A very interesting aspect which emerged on that occasion was the fact that there had been a £800 million deduction made in one year from the cash allocated to the PCTs. This was to be held in deposit for two years hence until it could be released back to them. Questions were asked on that occasion as to how the PCTs were to function in the mean time. Given the fact that we have already had significant recognition today that the PCTs are ultimately responsible for the management of dental services, one has to ask whether any of the problems today in dental services are closely related to the absence of that £800 million from the PCT pot. We have not yet had a definitive response from the Minister—the noble Lord, Lord Darzi—as to the present whereabouts of that £800 million, its future release and its present earning potential and security. I hope that we will in time be informed of that important information.
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