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A few years ago now, under the old payment regime, I visited an establishment in Cornwall, where I live, called HMS Raleigh. It is a Royal Navy training station. A lot of naval staff go through it in preparation for military service. One of the key issues—this was a few years ago now, but it is by no means ancient history—was that the Navy had to reject a number of people for a service career, particularly careers involved in the nuclear submarine fleet, because of the cost of putting their dental equipment—their teeth—right so that the Navy did not have to bring nuclear submarines back into port or, as my noble friend Lord Roberts said, get out the superglue, the Polyfilla or the pliers. The state of the nation’s teeth was a major problem for recruitment into the services.
In this debate, we can sometimes forget that the system before 2006 was far from perfect and that reform was needed. Some years back, I moved to Bristol and signed up with an NHS dentist there. When I turned up at his practice and sat down, he drilled out the first tooth; I then went back out, whereupon the next patient came in. It was like a production line. I am sure that this occurred with a minority of dentists, but there was an incentive for dentists to give patients treatment that they did not need. That was not good for the Treasury and it was certainly not good for patients. It may have been good for Rolls-Royce orders in certain parts of the United Kingdom, but the system very much needed fixing.
Many speakers have expressed disappointment that the fundamental change with regard to contracts has not been successful. That may be due to a lack of trial runs or pilot studies but it has certainly not delivered what the Government expected or what patients deserve. Further, the third part of the triangle, the dental profession, voted with their bank accounts and their feet and moved out of the NHS.
Having read the relevant literature, I believe that three important areas are involved. One concerns expense, as my noble friend Lord Roberts of Llandudno mentioned. Cost is important, as the noble Baroness, Lady Gardner of Parkes, said. The high-end cost of £194, which can be charged for work that is not necessarily very technical, is a great sum for most people. However, the entry fee even to come in for an inspection is also high.
The noble Lord, Lord Desai, referred to opticians. When you have a problem with your eyes and cannot see, you are aware of that and you try to get it fixed. I speak as someone who wears glasses. There is a public/private option there that seems to work well. However, you can find out about a dental problem too late, when the damage has been done. You can lose teeth or find out that you have serious problems such as cancer or less serious problems such as cavities or broken teeth. However, you may already have lost teeth before preventive work can be carried out. Therefore, price barriers are important in terms of future costs and the population’s overall dental health.
Private practice costs are very high, which has resulted in dental tourism. I am not against that. I approve of the fact that the European Court of Justice, or whoever, permits us to obtain medical treatment
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The second area, which is related to expense, is prevention. The noble Baroness, Lady Gardner, referred to a change in this regard. I never used to mind turning up for a check-up because not only did it not cost me anything but I convinced myself that no dental treatment would take place during a check-up and therefore I could get off scot-free. However, that process got me into the system and I could then be offered dental care. I know that it is free for children, but the same principle applies. I had not previously come across the acronym UDA—unit of dental activity—but it seems to me that UDAs do not cover education and prevention. They are mainly concerned with completed dental work.
The third area is availability, which is much discussed and is certainly a problem in the south-west. I find it difficult to understand how, with the increase in funding over the past few years and the major reduction of 500,000 or 600,000 visits per year—demand going down and funding going up—we still have unavailability for an estimated 1.5 million people. To me, as a small-time economist in my corporate career, compared with the noble Lord, Lord Desai, somehow those figures do not add up. How does the Minister square that triangle of funding going up and demand going down but availability not getting any better at all? Secondly, how do we practically tackle prevention, which, in all medical matters, is what people strive for? We seem to add barriers rather than take them away.
3.45 pm
Earl Howe: My Lords, having listened to the excellent contributions to this debate, I am sure that the Minister will have detected from their tone that most, if not all, of us approach these important matters more in distress and perplexity than in anger. The opening speech from my noble friend Lord Colwyn covered the issues admirably, as one might expect from someone who knows dentistry from the inside. I am sure that the Minister will know him for the professional that he is—a man whose chief aim is always to present a case in a manner that is both balanced and free of unnecessary political brickbats. Making party points is not the object of today’s exercise; the object is to try to expose what is really going on in dentistry and to look for ways in which the situation might be improved.
Perhaps when the Minister replies she will assure us that, despite a few initial hiccups—I am avoiding the phrase “teething troubles”—everything will be all right. That seems to be the position taken by our very able and conscientious Chief Dental Officer, to whose efforts I pay tribute. Indeed, I note that only a few weeks ago Dr Cockcroft was quoted as saying:
“All the things that were missing previously—the dental workforce, the money, are now there—and the extra 11 per cent funding we are putting in from April. It will take longer in some areas than in others but certainly all the basics are there now to deliver a really functioning fully comprehensive NHS dental service for anybody who needs it”.
Dr Cockcroft clearly believes those things; his confidence should not be lightly dismissed. The problem, as my noble friend pointed out, is that the profession is
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I believe that my noble friend had the answers. It is for a mixture of reasons. The first one is to do with the dental contract. The contract is perceived by dentists as being fraught with risk. Dentists are professionals who run independent businesses, as a number of noble Lords have emphasised. They are willing to stand up and be judged on the strength of their professional abilities but they do not need the added risk of a contract that can penalise them financially through no fault of their own. Indeed, there is a real sense in which the more conscientious a dentist is, the more likely he is to be financially penalised. That cannot be fair or appropriate.
The UDA is a rather strange animal. It is not like the tariff that operates in NHS secondary care. The UDA does not purport to reflect the amount of work that a dentist actually does, nor is its value the same for all dentists. Certainly, there is a case for flexing the value of a UDA in an area with a shortage of dentists and high dental need, but the variations in value do not always have that sort of logic behind them.
For as long as the dentistry budget of a PCT is based on historic spending levels in that geographic area, which many budgets have been, the total amount of money available may well fail to address unmet patient need. It was very interesting to read the report published last month by the Patients Association, The New Dental Contract—Full of Holes and Causing Pain?. The first question that PCTs were asked was: in 2006-07 is funding designated for dental services ring-fenced or floor-funded? Floor-funding is the minimum spend for a PCT on a particular activity. You might have thought that every PCT would have given the same answer, but they did not—87.7 per cent of PCTs said that the funding was ring-fenced; 12.3 per cent said that it was floor-funded. The result in any given area could be vastly different depending on the way in which the money was treated. It would be helpful to hear from the Minister whether, based on those answers, she believes that some PCTs may be labouring under the misapprehension that the ring-fencing of money precludes or discourages them from topping up their funding for dentistry from their general health budget if they believe that there is unmet dental need.
The other main reason why dentists do not like the contract is that, in their eyes, it does not enable them to do what they want for their patients, which is to take a more preventive approach to care. The noble Lord, Lord Teverson, and others mentioned that. Dentists are not rewarded for prevention. Indeed, for NHS dentists, time taken in giving preventive advice is time lost from doing work that earns them money. The dental contract does not contain any equivalent to the quality and outcomes framework for GPs, under which dentists would be able to earn points for improving the dental health of their patients. The
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If you take those two points together—the difficulty for dentists of expanding their NHS work beyond the envelope dictated by the available UDAs and the lack of incentives for preventive care—you start to question whether the current dental contract is fit for purpose. Its purpose was, of course, to achieve two main things: to widen access to NHS dentistry and to end the treadmill effect of the previous dental contract by enabling dentists to focus on preventive care rather than on interventions. It is true that the new arrangements have greatly simplified the charging structure for patients. I have always applauded the Government for being bold enough to do that. But simplification can be overdone.
From the patients’ point of view, we know from the survey carried out by the Patients Association as well as that carried out by the Commission for Patient and Public Involvement in Health last year that patients are confused by the new contract and how to access regular care. This may well explain, at least partially, the rise in hospital admissions that my noble friend referred to. A priori you would have thought that having the same charge for three fillings as for one would mean that the patients most in need would be seen and attended to, but we know that that is not the way in which the system is working in some places. Dentists are becoming choosy about whom they take on, because, given the choice, it makes financial sense to take on the less complex patients. That perverse incentive is a further drawback to the current arrangements and surely has to be addressed. The latest figures available show the continuation of a worrying trend. We are seeing a steady and significant decline in the number of adults who have seen an NHS dentist within the past two years. In some areas, such as the south-west, the problem seems to be particularly serious.
From this year, the dentistry budget will go up by 11 per cent. That is an important step and I welcome it. But I say what I suspect the Minister knows: by itself the money will not do the trick. Two years ago, when the new contract came in, we and many others said that PCTs were woefully ill equipped to commission NHS dentistry. In some PCTs, I am sorry to say, those commissioning skills are still absent. The Chief Dental Officer more than hinted as much the other day and the Minister, Ann Keen, in her evidence last month to the Health Select Committee, conceded that,
That is certainly right. It is not just a matter of throwing money at the problem and hoping that it will resolve itself. PCTs need to start commissioning much more smartly. To begin with, they need to look carefully at the guidance on successful procurement issued by the department last month. Among other things, the guidance urges PCTs to learn about best practice from other areas. There are success stories around, such as Sandwell PCT, where the number of NHS patients has gone up. Meanwhile, the Government have taken what I believe is the necessary step of continuing the ring-fencing
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However, we come back to that contract, in which the faith of the Chief Dental Officer continues to reside. I am really doubtful about it. The BDA believes that as many as 1,000 dentists have been lost to the NHS since April 2006 and, contrary to the recent pronouncement by the Secretary of State, it is younger dentists who are proving less enthusiastic about doing NHS work than older ones. If we cannot attract the young professionals, where as a nation will we be in five or 10 years’ time? The Government do not have long to rescue the situation. For all our sakes, I hope that they can do so.
3.56 pm
Baroness Thornton: My Lords, I thank the noble Lord, Lord Colwyn, for initiating this debate. It has been an interesting discussion featuring our two dental experts, including the noble Lord, Lord Roberts, who seems to be working very hard today. I thank all noble Lords who have participated for their informed, interesting and varied contributions. I shall attempt to address the questions that have been raised but, should I fail to do so, I will write to noble Lords.
From the outset, it is important to say that our record on dentistry is strong, so I refute the suggestion from noble Lords that the system is failing, and I shall say something in support of that. England is a leader within Europe in improving oral health. According to the World Health Organisation database, our 12 year-olds have the best oral health in Europe, measured by decayed, missing or filled teeth.
Through the 11 per cent increase over the current year, our dental funding allocation for the NHS in 2008-09 will be £2,081 million, net of patient charge income. Therefore, this Government are demonstrating their commitment to improving access to dental services. That figure is 56 per cent higher than the net spend on dentistry in 2003-04, and more than double the equivalent spend in 1997-98— an increase of 117 per cent.
We are increasing our dental workforce. In July 2004, we launched Project 1000 with a commitment to recruit the equivalent of 1,000 more dentists. In fact, we exceeded that target. By October 2005, we had recruited the equivalent of 1,453 new whole-time dentists, including those returning from employment breaks and overseas dentists. We have also raised the number of dentists in training by 25 per cent. The first new cohort of additional students will graduate next year. We have established two new dental schools. We now have more than 4,000 more dentists than there were in 1997 and 300 per cent more dental care professionals. To ensure that the additional dental students will be able to pursue their careers in the NHS, last month we announced that new funding of £32 million will be made available to fund more vocational places. I hope that that addresses some of the concerns expressed by the noble Baroness, Lady Gardner.
The Government’s starting point is to begin to rectify the longstanding access issues caused by the previous system, described so ably by the noble Lord,
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We have radically simplified the patient charging system, to which reference has already been made, scrapping the confusing tariff of 400 charges under the old system. Now patients’ treatment falls into one of three clear payment bands for courses of treatment, on which noble Lords have expressed some doubts, rather than fees for each item of service. We have reduced the maximum charge from £384 to £198, directly benefiting those with poor oral health. The reforms have also allowed us to remove the exclusive focus on active treatment and allowed dentists to concentrate more on preventive treatment.
The noble Lords, Lord James and Lord Teverson, both raised the issue that the new system has merely swapped dentists from one treadmill to another. This misrepresents the nature of the reforms. In fact, the noble Lord, Lord Teverson, did not make that criticism. For many years, dentists had complained that the old fee-per-item system created a treadmill effect and gave no time for preventive care. The new system, which we developed in close consultation with the British Dental Association and other stakeholders, guaranteed dentists the same income for delivering 5 per cent less activity than they did during the reference period. That enabled dentists, without any financial penalty, to spend more time on preventive care.
The noble Lord, Lord Colwyn, asked why the Government’s view of the reforms appears to be out of step with some of our stakeholders. I am not going to pretend that everyone is happy—clearly, that is not the case—but with any major reform there will be people who will be unhappy and for whom it will take time to recognise the benefits of the new system. However, the citizens advice bureaux have stated publicly and repeatedly that they welcome the reforms and regard them as a sound basis on which to build dental services.
I suggest that lots of committed NHS dentists have realised, as the reforms have bedded down, that this is a workable system. The commitment that the reforms represented to NHS dental services is something that mainly private dentists may be uncomfortable with because if they have business models based on a local shortage of NHS services the resurgence of the NHS on dental services will, rightly, challenge them.
The general welcome for the 11 per cent funding uplift, the clear upsurge of interest from corporates in providing NHS services, and the fact that PCTs generally report no difficulty in attracting dentists to provide new services suggest a rather different picture from the one in the headlines. Tackling the problems that began in the early 1990s will not be an overnight job, but the Government are very serious about getting NHS dentistry back on track.
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As I have mentioned, we appreciate just how big a change the reforms were for PCTs and the dental profession alike, and we have continuously offered support during this process. The noble Lord, Lord Colwyn, is correct to say that those local relationships lie at the heart of the improvements that need to take place.
As well as making year-on-year increases in the funding available to PCTs to commission dental services, we have made increasing access to dentistry a national priority in the 2008 operating framework. We have also extended the ring fencing, mentioned by several noble Lords, of dental funding to 2011. I will address the issue raised by the noble Earl, but I shall take some time to explore what seems to be a misunderstanding by some PCTs on the position. I promise to get back to him on that. We are seeking to offer commissioners further stability when planning their dental services over the next period.
I hear the concerns raised by the noble Lord, Lord Colwyn, and others about PCT funding. Dental budgets are now allocated net of patient charge income for good reason. The reforms give local control and management of NHS dentistry to PCTs so that they can determine what dental services are commissioned in their area. But as the amount of patient charge income is largely determined by what services are commissioned and how those services are delivered, it makes sense for the local body to oversee the whole dental budget. We cannot plan centrally for the effects of such local decisions. For example, a local decision to prioritise orthodontics or other services for children will directly affect patient charge income and needs to be based on local priorities and assessment of needs.
Patient charge revenue was reduced in the first year of the new system. It is too early to measure the settled-state level of patient charge income under the new system but the indications are that 2007-08 will see patient charge levels closer to those predicted. We have provided guidance and data to PCTs to help them and their dentists understand the local factors affecting levels of charge income and to help them correct any problems that may have arisen as the new system was bedding down. We have also provided, and continue to provide, practical support and guidance to PCTs on commissioning appropriate dental services. These have been both direct from Department of Health officials, including the chief dental officer, and through the primary care contracting team, who are experienced NHS managers providing hands-on, tailored support to PCTs as well as a whole suite of guidance available to all dental commissioners through the website. For example, we will shortly be issuing updated guidance to PCTs on handling end-of-year issues with their contract holders, which I know is an issue of particular interest, as has been mentioned by noble Lords several times during the debate.
Annual service levels are agreed between the PCT and the dentists at the beginning of the year for all existing dentists and will be based on the actual patterns of service the dentist provided under the old contract. Ninety-seven per cent of contracted activity was delivered in the first year of reforms. Indeed, Suzie Sanderson,
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“We know from our own research that many primary care trusts have shown understanding when examining end of year issues.”
The BDA’s own research showed that in 25 per cent of underdelivered contracts, PCTs had written off the shortfall entirely. However, PCTs have the responsibility, as the local commissioners of dental services, to use flexibility and choice within the new contract to handle such end of year issues as they feel appropriate. If they feel that necessary resources are not being used effectively they can re-invest them in other local dental services to help ensure that patient demand is met.
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