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Today we already know certain things that have happened to the fortunes of the PCTs arising from the last year or two of operations since the new contracts came in in 2006. First, it appears that the National Health Service got off to a rotten start because it forgot to make any provision for the cost of the contracts. Therefore, the whole cost of the NHS
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All this has occurred against the background of a Statement made to your Lordships to the effect that the new charging system,
- “will not increase the proportion of revenue raised from patients’ charges”.—[Official Report, 7/7/05; col. WS 27.]
This appears to be in conflict with the reality.
I speak on this subject as a humble user of dental services. I have had the same dentist for 45 years. He provides both NHS and private services and I have used him variously in that form during that time. His predecessor, who was an excellent dentist, ran away with his beautiful nurse, went to Easter Island and has never been seen again since. The present dentist certainly did not run away with his nurse, but he did marry her. They have become an absolute pillar of society and are among the most socially provident people, providing for every walk of life in our community.
On the face of it, dentists are asked to be thankful that the Government are saying they are extending their ring-fence over the dentistry budget for a further two years, but, if the top-slicing continues or gets worse, it will be only a matter of time before that budget is again raped and pillaged, as is happening with maternity units and accident and emergency centres. I echo the noble Lord, Lord Colwyn, on this: dentists deserve strong reassurance on this point. If the Government are serious about prioritising preventive dental care, would it not be logical to amend contracts to ensure that dentists were paid on a per capitation basis and not on a per treatment basis? That would at least ensure that patients had the same arrangement with their dentist as they have with their GP.
My friendly neighbourhood dentist has given me what he considers to be eight reasons not to be a National Health Service dentist. Although some of them duplicate those that have been mentioned by other speakers, it is worth going through all eight because their impact is considerable.
His first complaint is that the National Health Service does not recognise that a dental business is a business. It has a fixed income, effectively, but not fixed expenditure. That puts dentists in a place where they have a huge problem in funding and providing, with security, the cash flow to cover their costs. He is particularly concerned about an aspect that has not been mentioned much today: his laboratory bills, which he says are huge.
His further concern is that the UDAs, the units of dental activity payment bands, are seen as covering too wide a spectrum. A dentist is paid the same
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He does not think that dentists wish to take on new patients with an unknown volume of work needed, because of the risk of a large increase in expenses against a fixed-target income. As we have already shown, if a dentist reaches his UDA target without seeing additional patients, he has no extra funding to pay for extra patients and work undertaken.
His other big complaint is that if the dentist falls short of the fixed target in his contract at the end of an NHS financial year, a proportion of his fee can be reclaimed, as we heard from the noble Lord, Lord Colwyn, and that is very painful. In contrast, if the dentist exceeds his target, any further work undertaken by the dentist in that financial year has to be carried out unpaid. According to my dentist—and he says this is a common practice—dentists will sometimes, not surprisingly, opt to close down their business at that point for a month or two and go on an extended holiday. That is surely a huge waste of what could be a valuable resource with which to catch up on waiting lists, and a stupidity in the contractual arrangements that needs to be urgently corrected. He says he can finance his holiday very comfortably, simply because of the amount of material for which he does not have to pay to use in laboratory work for the two months that he might be away.
Preventive work is not carried out fully because dentists are too busy on the UDA treadmill. Although capitation would encourage dentists to carry out preventive work, it is inadequate as the present system seems still to be stuck in the drill-and-fill era.
His age is the same as mine and he is concerned that when a dentist comes to retire, it has become extremely difficult to realise the good-will value of the business by selling it on to a successor dentist, which would be logical and sensible for the community because it would mean that a whole tranche of customers was transferred with adequate dental services being provided. The reason for this is that the PCTs will not provide any transfer undertaking or certification of the UDAs to support a sale to a new dentist coming in. This sounds like a way of seriously diminishing the continuity of the market that is available.
The dentistry contract that came into existence in April 2006 was supposed to promote better access to NHS dentistry. Clearly, however, not only is it discouraging NHS dentistry from entrenching—indeed, it is reducing it—but it is also scaring patients away due to the confused and unbalanced cost structure. This is all completely in conflict with the Government’s statement that the new contracts are designed to allow more time for preventive advice. As matters stand, this situation is capable of being resolved with a bit of common sense. Someone needs to rethink these contracts, take them away from the idealistic approach that is enshrined in the original drafting and get them back into the real world by providing a cost-effective and easily understood service that supports the continuity of dentists running their own independently viable businesses.
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The Government must rethink this one urgently, and I hope that that will be in the context of allowing this House in the near future to have a definitive statement about the PCT financial status and the current whereabouts, and the future use, of that £800 million that we asked about in November but have still heard nothing more about.
3.15 pm
Lord Desai: My Lords, we are grateful to the noble Lord, Lord Colwyn, for initiating this debate. At the outset I want to discount the rumour that I am speaking here only because the alternative the Whips put to me was to have my teeth extracted by them. I am somewhat puzzled by this debate, but I have learnt a lot.
As the noble Lord was saying at the outset, ever since Nye Bevan inaugurated the National Health Service we have been chased by high expectations and continuous adjustments of resources to meet them. Historically, spectacles and teeth were such a problem that within three years they led to the resignations of various Ministers from the then Labour Government.
Today, we have a peculiar situation. On the one hand, we know that there are about 4,000 more dentists in business than there were in 1997. We have the news that only 30 per cent of children entering school with tooth decay problems used to be seen, but now the figure is 60 per cent. Statistics show that 28 million people have seen a dentist in the past two years. More doctors are being trained and will come on stream by 2009. More spending has been committed—£2.5 billion for the latest fiscal period, which is considerably more than was being spent only four years ago.
At the same time, various people are saying in newspapers and, of course, your Lordships’ debate, that all is doom and gloom. A variety of stories has been told today. The noble Lord, Lord Roberts of Llandudno, said how badly off Wales was in terms of dentists. The noble Baroness, Lady Gardner, assured us that Welsh dentists had Rolls-Royces—perhaps not the latest model, but good enough at least. She said that dentists typically worked for nine months and had a holiday for three months—the noble Lord, Lord James, confirmed it—and long may it continue.
I shall try to put into perspective these complaints and problems and the nature of the business that we are trying to understand. The noble Lord, Lord James, was accurate in saying that dentistry is a business. Unlike general practice, dentistry is a business. Opticians have long since ceased to be a subject for debate in the press, but they, too, are a business. NHS entitlements to optical care are very basic, and the frames that one gets on the NHS are fairly basic. Had John Lennon not made them popular in the mid-1960s, nobody would have chosen a National Health Service frame if they could afford anything better. Opticians are a combination of NHS and private: we get our eyes examined and then we spend our money on buying the frame.
Something similar has happened in dentistry, which we have not yet quite acknowledged. It is interesting to ask whether that is a way to look at dentistry. I am not a dentist, nor a frequent-enough patient of dentists to
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Similarly, we have to ask which dental services are required with high frequency—they might be routine services—and which are required in emergencies. Implanting teeth and decorating them either with Chinese lead or South African gold is not a service that an NHS dentist should provide. I may be speaking completely out of turn and a Minister may tell me once again that I am making a fundamental error. When we go to an optician, we do not expect them to give us the best frame possible. But why are complaints of the kind we hear about dentists being made?
We may need to think about a different structure for payments and charges. Some noble Lords have mentioned dentists’ contracts, the complexity of which I can only guess at. If dentists are a business, and have been given certain amounts of money to spend on certain targets which they have not met, it is perfectly right that the money should be returned. I agree with the noble Lord, Lord James, that if they have done more than that, they should be paid for it—that asymmetry should be corrected—but I certainly do not see why the money should not be asked back from dentists. Dentists are not a class of citizens known for their poverty. They may have complaints, but I have seen few dentists out on the streets on income support. Having sympathy for dentists is like having sympathy for bankers who have just lost a couple of billion pounds. It would be hard for them to bring tears to the eye.
We need a redefinition of the nature of the business, in which such things are made clear. Although there are complaints, citizens understand that when they go to a dentist, what they can expect from the National Health Service are certain basic, essential services. Luxuries are not delivered as part of the NHS. Additionally, not only does advice on dental care not need to be given by a fully qualified, first-rate dentist but it should be available in schools. It should be much more widely available, on a paramedical level, with trained people. But we also have the problem that, given the kind of foodstuffs that children are eating and have been encouraged to eat, the story of teeth is much more tragic today than it was, say, 50 years ago. We have created a much bigger problem by not taxing properly sugar and salt in foods. We have allowed that sort of laissez-faire regime in food consumption to encourage tooth decay.
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Many of those issues should be considered. Debates like this are very good. Rightly, we may never be fully satisfied with any part of the NHS. However, I am confident from what I know that more money is being put into the NHS and more people are seeing dentists. If the people of this country are not yet 100 per cent fully satisfied, let us make sure that we get there. If the contracts are difficult, let us try to look at them. The time has come to understand why the service provided by dentists, along with the testing of eyes and getting spectacles, is in a different class from the general service provided by the health service. When we understand that we may be able to devise better contracts and financing of dental care.
3.26 pm
Baroness Finlay of Llandaff: My Lords, I thank the noble Lord, Lord Colwyn, for introducing this debate. I declare an interest as president of the Royal Society of Medicine, whose fellowship includes dentists as well as doctors, for which we are best known, and vets. It includes allied professionals and managers who work with dentists. In the light of the comments of the noble Baroness, Lady Gardner of Parkes, I feel that I should also declare that I come from Wales, where I have friends who are dentists who drive small, second-hand cars. My dentist, my own Mr Jenkins, does only private work now, because he has also abandoned NHS dentistry.
At the end of last year, following a question on the Floor of the House from the noble Baroness, Lady Gardner of Parkes, I wrote to 214 English acute care NHS trusts to survey their services on the subject of the new dental contract and how it had affected cancer services. I intended to find out the experience of cancer centres, but it was not possible to disaggregate cancer centres and units from trusts not providing cancer services, although it was easy to exclude mental health trusts and community trusts from my survey. Of the 214 trusts mailed, I received responses from 110, of which 81 said that they provided cancer services.
Twenty-nine of the trusts that responded—that is over one-quarter—answered yes to the question, “Has the dental contract adversely affected your clinical service?”, and many wrote comments about negative effects experienced through the new contract. Of the 29 that answered yes, by far the most common reason given was a significant increase in referrals. For example, Salisbury District Hospital reported a 30 per cent increase in referrals. Mayday Healthcare Trust reported a 100 per cent increase and the Royal Wolverhampton Hospital Trust reported a threefold increase. Although 66—or 60 per cent—of respondent trusts had emergency dental services available before the new contract, only 50 per cent of the trusts now have such services. Comments from those with current services included that there had been a,
Several commented that routine dentistry is difficult to access and that patients either do not have a dentist or have less regular dental check-ups.
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Sadly, those figures simply add weight to the stories from accident and emergency departments reporting a steep increase in patients with toothache and dental abscesses. The immune system of patients undergoing other treatments such as cancer therapy may be compromised, making them particularly prone to infection and in need of good dentistry.
I turn to the importance of dental hygiene in patients with systemic disease. Those with scleroderma and muscular diseases can find cleaning their teeth particularly difficult because they cannot open their mouth adequately, and they may have limb weakness which makes cleaning their teeth difficult. For those with heart disease, the NICE guidelines do not recommend antibiotic cover for routine dental work because the evidence shows that many more bacteria are showered off into the bloodstream at other times. That guideline has been very carefully looked at and seems eminently sensible. However, when the mouth is dirty all the time and a particularly large bacterial lobe is around the gum margins, the risk of high bloodstream infection obviously increases.
Quite apart from that, patients who have lost weight, particularly those with cancers, often find that their dentures do not fit, so to maintain nutrition they need rapid access to community dental services. Without such services their dentures swing around in their mouths, clunk and cause erosion of the gum margins. My own hospice unit has for many years enjoyed good community dental services from a local dentist. I have seen first hand how bedside relining of dentures and emergency management of caries can dramatically improve eating, talking, comfort, quality of life and social interaction. It cannot be overestimated how rapidly these patients get relief and how rapidly they need the service.
Another small area of NHS dentistry which I should like to address is one that may not be on noble Lords’ radar today—forensic dentistry, which is crucial to the criminal courts. There are only four such centres in the UK: one in Cardiff, one at the Royal London, one in Glasgow and one in Sheffield. With such a small number of training posts these services could be viewed as an endangered species. Once the number of these dentists has dwindled they will be greatly missed by those wishing to bring prosecutions for heinous crimes. I am sure they will be greatly missed by the Ministry of Justice. I am delighted to see the Minister in his place.
Routine dentistry consists not only of dentists but of dental therapists, dental nurses and dental hygienists, as well as dental technicians who work behind the scenes but with leadership from dentists. As the noble Baroness, Lady Gardner of Parkes, pointed out, early detection of oral cancers in this day and age is due primarily to dentistry, and the management of ulcers and infections are core competencies of dentistry. In addition, facial pain clinics and even some smoking cessation clinics are run by good dental teams. Sadly, those are not a ubiquitous resource.
Orthodontics, another area not addressed, is a very specific field whose methodology to measure tooth crowding determines eligibility for NHS treatment. If the criteria are tightened by stealth, fewer children will
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Before this debate I read an interesting article in the Daily Telegraph that stated that almost half of Britons, 23.1 million people, have not seen an NHS dentist—or a hygienist or anyone else in the dental team—in the past two years. Apparently the figure has increased by 4 per cent, almost 850,000 people, since the Government introduced the new contract in 2006. I also noted with interest the response by the Minister in another place to a Question tabled by Tim Farron. The Minister stated:
“The Department estimates that there are some two million people in England who would like to access national health service dental services but are unable to do so. This estimate predates the dental reforms introduced in April 2006”.—[Official Report, Commons 13/3/07; col. 309W.]
I wonder what that figure would be now. The increase in referrals to acute trusts seems to be putting pressure on efforts to meet the new national waiting-target time of 18 weeks from referral to start of treatment. I was interested to learn that London has more NHS dentists than most other areas of the country, yet only half of Londoners regularly visit the dentist, and children in London are less likely to visit a dentist than children anywhere else in the country.
There seems to be hard evidence of a gap between the theoretical standard that should be attained and practice on the ground. That needs urgent examination. While listening to this debate, I was wondering whether there needs to be a cross-party working group to look at dental services in the long term with forward planning for 20 or 25 years. The danger of overpoliticising dentistry is that it will become a political football subject to elections and so on, whereas new dental graduates coming in to establish their careers need to know where they are going in the very long term. This has been an important and timely debate. I hope we will eventually see an upturn in the provision of dentistry with high-quality dental care across the whole population.
3.37 pm
Lord Teverson: My Lords, I thank the noble Lord, Lord Colwyn, not so much for calling this debate but for the masterclass that he gave in his opening remarks. I do not have great knowledge in this area and I found what he said good and useful for the parliamentary record and for other organisations outside the House. When I walked into the Chamber for this debate, I wondered why I felt a particular fear; of course, the reason is that there are two dentists present. This is an area of high emotion. Dentistry is a medical or technical practice that we want an excuse not to use. Psychologically, that lies behind a number of the statistics that the noble Baroness, Lady Finlay, mentioned. Later, I shall come on to how we can reduce some of the barriers.
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