§ 1.56 p.m.
§ Mr. Baird (Wolverhampton, East)
I want to raise the question of the unfortunate dispute which has arisen between members of the dental profession and the Government, and, at the outset, I think it is only fair that I should disclose my active interest in this problem. As a practising dentist I want to point out to hon. Members that, during the negotiations and discussions on the National Health Service Bill between the representatives of the dental profession and the Government, and during the Committee stage of the Bill itself, a large amount of good will was evident on the side of the dentists in their attitude to the Government.
As a result of those negotiations and discussions, which have taken place over the last 12 months, I think I am right in saving that dentists have become more and more confident in the attitude of the Minister of Health to the future health services, and, indeed, the Minister himself recognised the good will approach of dentists on the question and actually paid a compliment to the profession on the Third Reading of the Bill. Therefore, it is most unfortunate that this dispute should have arisen at the present time, because it may, if allowed to continue, 209 become a canker and destroy the confidence which at present exists.
First, I should like to deal with the question of dental benefits, and would point out that these are rather different from medical benefits. Medical benefit is compulsory, but dental benefit is paid only by those insurance societies which have surplus profits. Their only obligation is that, if they have any surplus profits, they should pay dental benefit, which must amount to 5o per cent., so that not more than 5o per cent. is to be paid by the patient. The scale of fees—the method by which we pay dentists for their work—has always been accepted reluctantly by the profession as inadequate for the work they are doing. Dental benefit commenced, I think, in 1926, and sometime later, because of the disgruntlement, national negotiating machinery was set up under a Dental Benefit Council, on which there are representatives of the insurance companies and of the dentists, with officials of the Ministry of Health and the Ministry of National Insurance holding a watching brief.
That Dental Benefit Council was set up, I think, in 1929, and it has functioned very well since then, always bearing in mind that there has been reluctance to accept the findings, but they have been accepted, and there has been, on the whole, a very good relationship between the insurance companies and the dental profession. During the war, the Dental Benefit Council itself was in abeyance, and an emergency committee functioned to negotiate between the profession and the Ministry. In 1944, a new scale of fees was agreed on, again reluctantly by the dentists, and became the scale of fees under which dental treatment was carried out. However, during 1945, when the war was drawing to a close, there was a large amount of uneasiness in certain areas of the country among dental surgeons, and unfortunately; in my opinion, in the South of England especially, a large number of dentists withheld their services in regard to National Health Insurance dentistry. As a result of this strike—I will call it a strike—negotiations took place between the Ministry of Health, who were then responsible, and the leaders of the dental profession. The strike was called off, and the Minister gave an undertaking that he would reconstitute the Dental Benefit Council and would set up 210 the Spens Committee to inquire into the future remuneration of dentists.
The Dental Benefit Council was, therefore, reconstituted, with representatives of the Government, the insurance companies, and the dentists, and immediately the dentists submitted an application for an increased scale of fees. The procedure was that the Dental Benefit Council then set up what was called a Scale of Fees Committee to draw up what they considered to be a proper scale of fees. On that Scale of Fees Committee there were representatives of the insurance companies and the dentists, with a Ministry official as chairman. The Scale of Fees Committee met, considered the matter for a very long period, and then reported on a scale of fees. I should point out that the Government officials did not take any part in the voting, and were there as neutral observers, but that, as far as the representatives of the insurance companies and the dentists were concerned, they were unanimous. I would, however, point out that, in drafting the new scale of fees, the Committee had simply to consider what was a just scale of payment to the dentists, and had not the function of finding out from where the money was to come. I would point out also—and I think this is rather important—that while the Ministry officials on the Committee took no part in the voting, they sat in the Committee, and they did not give any hint during the discussions that this scale of fees would be turned down by the Government as being too high.
The Scale of Fees Committee reported to the Dental Benefit Council as a whole. Then, of course, the question was not simply what was to be the scale of fees, but from where the money was to come. There the insurance companies' representatives had a different line of approach. They said that if the higher scale of fees was accepted, the insurance companies could no longer afford to pay 50 per cent. of the cost of dental treatment. However, the question of the scale of fees went to a vote, the twelve dentists voting for the new scale of fees, nine insurance company representatives voting against it and the three representatives of the insurance companies who had been on the Scale of Fees Committee abstaining from voting. The recommendation then went to the Ministry, and, in my opinion very unfortunately, the Minister turned down the recommendations. 211 The point at issue at the present time is not chiefly the scale of fees, but the method of negotiation between the profession and the Government. Here we have a long established machinery of negotiation being turned down by the Minister and the Minister imposing on the profession, without consultation, a scale of fees which he considers to be adequate. The issue is whether we are to have some established machinery, or whether something is simply to be imposed. I want briefly to deal with the Government's arguments, as I see them. The Minister enforced a scale which was considerably lower than that suggested by the Dental Benefit Council. One of the main arguments was that the scale of fees for which the Dental Benefit Council asked showed an increase of 116 per cent. over the 1939 figures. That may be so, but throughout the negotiations the dentists have pointed out that the suggested increase of 116 per cent. is purely an actuarial figure. Many hon. Members will realise that one can prove almost anything from figures. I do not want to go into the details, but as a practising dentist and a Socialist I cannot possibly accept the suggestion that the increase was 116 per cent. The actuarial calculations were made on dental letters submitted way back in 1935. Between 1935 and the present time, the type of treatment has changed considerably. There is much more conservative dentistry, fillings and so on, done today than there was in 1935, and in various ways the type of treatment which people expect is considerably different from what it was in 1935. I make that point in order to show one way in which an actuarial calculation can very often be considerably wrong.
§ Mr. Baird
That is right. I would like to see some further calculation made on a more equitable basis. Secondly, we are told, at any rate by some Members of the Government, that one of the reasons the high scale asked for by the Council could not be accepted, was that it would influence the Spens Committee. It may be that the Minister thinks the scale is so high that it would force the Spens Committee to suggest a higher scale than is proper. In my opinion, when the Spens Committee makes its report we shall find 212 that many dentists have been working for very low rates.
However, the point I want to make is that at one time the Minister tells us that the Spens Committee will be influenced by high scales, and then, when the dentists went on strike and refused their service, they were told it was wrong to do so because the Spens Committee had nothing to do with the present dispute. The Minister cannot have it both ways. I believe there is some relationship between the two, although, in practice, not as much as some people would think. The third argument which may be used is that this is only a temporary dispute, and that when the Spens Committee reports the Government will accept the findings and a new scale will be drawn up. In discussions with the Ministry we were told that the Spens Committee expected to report by Christmas of this year. We know now that the Spens Committee cannot possibly report before the summer at the earliest. Therefore, while I, for one, thought that if this dispute were carried on only until Christmas we might be able to tide things over, I think that if we allow it to continue until the summer we shall have a running sore which it will be very difficult to remove.
§ Mr. Baird
In a Debate such as this, on a technical matter, we have to try to think as professional men, as well as supporters of the Government. I hope that in the end my remarks will show that the two are consistent.
Another point that is sometimes made is that some people feel that, because there is a tremendous shortage of dentists at the present time, the dentists are using that position to hold the Government to ransom; in other words, that they are exploiting the shortage. I think that is an unfair accusation to make. During the discussions on the National Health Service Bill, while the doctors' supporters time and again moved Amendments of a 213 nuisance value, and throughout the country tried to make as much capital against the Government as possible, the dental profession were very conciliatory and moved only Amendments which were helpful, and many of which the Government accepted. They could have exploited their shortage value, but they did not do so. These points may be made against the point of view of the dental profession.
I want to give my views as a Socialist and a dentist. First of all, I believe that under a Socialist Government, when we are discussing the terms of service of professional men in the public service, we have to see to it that they are paid adequately for the work they do. As Socialists, that is one principle which we on this side of the House have always advocated. In discussing terms of service, I am not referring merely to dentists or doctors but all health workers, including dental mechanics and nurses. If we are to have an efficient health service we must pay our health workers adequately and see that they are contented in their jobs.
Secondly, I say to the Government that we must try to establish negotiating machinery in which both sides can have confidence. Any imposed scale of remuneration will always be looked upon with suspicion by the people on whom it is imposed. The dentists have always said that the National Insurance scale of fees was a charity scale, in other words, that it was too low, and the dentists who do nothing but insurance dentistry cannot get a proper income. The result is that there has been a large disparity in fees paid by private patients and fees paid through National Health Insurance, and the private patient has been subsidising the insured patient. That is wrong. The dentist who has not subsidised his insured patient from his private patient sometimes did fairly shoddy work. We must have a service by which the poorest of the community have the same dental treatment as the wealthy classes, and the scale of fees must be balanced in such a way that that is possible. It has not been possible in the past under National Health Insurance.
I want to raise also the question of the cost of dentures. I am not suggesting that we should depart from what we call the balanced scale. There is a danger that one type of dental treatment subsidises another. We have to encourage 214 the public to conserve their teeth, to have fillings and preserve them rather than have them out and have dentures instead. While that is what we are trying to achieve, unfortunately because of the lack of education and lack of finance a large proportion of the people have neglected their teeth, so that the only type of treatment which is suitable for them is extraction and the fitting of dentures. That type of treatment, of course, will continue for some years to come. In my opinion, it is impossible for a dentist who provides dentures under National Health Insurance to get a reasonable margin of profit. One of the main reasons for this, which will commend itself to hon. Members on this side of the House, is that before the war the wages paid to dental mechanics in this country were ridiculously low. The average wage was about £2 10s. or £3 10s. a week, and I am proud to think that even though I am a dentist, I was one of the foundation members of the Dental Mechanics' branch of N.U.D.A.W. During the war years we have, at least, put a bottom into dental mechanics' wages, and I think they have gone up by something like 75 per cent. during the war. A point which must be borne in mind is the increased labour cost to the dentist as the result of the trade union activities of dental mechanics.
As a result of the war and the calling up of dental mechanics, more and more dental mechanics' work has been sent out to the dental mechanics' profession, so that one dental mechanic works for a number of dentists, and their charges have increased considerably. Where before the war the cost of processing a vulcanite denture, which was a reasonable standard insurance denture, was six or eight shillings, it is now 25s. or 3os. for an acrilic base. I suggest to the Minister that if he wants further proof he should go to any telephone directory, look up the list of dental mechanics to the profession, telephone any one of them and ask what he will charge for doing the mechanical work for a full upper and lower denture. His reply will be that it will cost at least between £5 and £6. All the dentist receives under the National Health Insurance is £7 15s., so that the balance which is left to the dentist to cover all the work he does in the surgery, including his overhead expenses, is between 3os. and £2. That may not influence the scales to any great ex- 215 tent, but it is a point which must be borne in mind. The most important argument from the dentists' point of view is the fact that the dentists want some negotiating machinery in which they can have confidence.
Therefore, I hope something will be done in that direction as a result of this Debate. I am appealing to the Minister as one of his greatest supporters and admirers. All that the dentists want are the same rights as any other group of workers. Many people feel that because a man is a member of a profession instead of in a trade, he has no right to trade union machinery. I think that once we have our National Health Insurance plans we must have trade unions for the professional men, because they have every right to put their case in the trade union manner. As my right hon. Friend knows, I am in contact with a lot of the leaders of the dental profession, and although there may seem to be 100 per cent. opposition at the moment, I am confident that if my right hon. Friend takes a lead this afternoon to open negotiations in whatever way he thinks best, it will be welcomed by the leaders of the dental profession. I am confident of that, and though there may be some reactionaries, the rank and file and the leaders will welcome any approach he may make.
To the dentists I would say that if we are to rebuild the good will between the dental profession and the Government it is necessary that the dentists themselves should control their own reactionaries, I have noticed that in some areas at least, the dentists—not the leaders, but some of the rank and file with a Tory outlook—are cock-a-hoop because this dispute has arisen, and it is essential for those who lead the dental profession to settle these reactionaries and place before us the reasonable point of view of what I believe is the mass of the dental profession. If this dispute continues much longer, there is a great danger, not from the Government's point of view but from the standpoint of the dentists. For too long have dentists been looked upon not as professional men or doctors to whom one goes for advice, but rather as grocers or someone with whom one haggles over the price. Only recently have we built up confidence in dentistry as a respectable branch of the medical profession. It is essential that nothing is done to undermine that growing confidence of the public in the dentist. If 216 this dispute continues much longer that confidence may be destroyed.
I would also point out—and I think this will be agreed even by supporters of the Conservative Party—that this Government has shown much more sympathy for the professional outlook than any previous Government, and especially as regards the dental profession. During the Committee stage of the National Health Bill, the dental case was listened to and treated sympathetically by the Minister. At the same time, I may mention as well that the Government have already paid in university grants a large payment—I think of 100,000—for re-equipping our dental hospitals. Last week the Minister of Health, replying to me, told us how he intends, in the very near future, to implement the findings of the Teviot Committee for dentistry. In many ways this Government has shown sympathy with the aspirations of the dental profession. I ask the Minister of National Insurance to follow in that tradition, and to be generous this afternoon.
I do not want to make too many concrete suggestions. Perhaps he knows better than I do the best method of approach. But I do feel that there are one or two ways in which he could reopen negotiations. For instance, we believe we could let the dentists charge a higher scale and reduce the insurance companies' proportion still further to something like 3o per cent., at hand, until the Spens Committee reports. Even if the Minister cannot do that, I suggest that he might, at least, give an undertaking that, when the Spens Committee does report, if it shows the present scale is inadequate, he will agree to make retrospective payments from the time of the dispute. It will be difficult to do that, I know, but it may be possible on a compensating scale. I believe it could be done. I am not, personally, tied to any one method of solving the dispute. All I want is to open the door just a little, because I believe that once the handle has been turned both sides will jump in as fast as they can, to get together to resolve this unfortunate trouble. That is my sole reason for raising this matter this afternoon. I have no intention of trying to embarass the Government or of trying to embarass the Minister in any way, but I do believe that this discussion this afternoon will just start the ball rolling a little. If that is done the two sides will come together again, 217 and then we shall be able to look forward to the coming dental service with the good will of the dentists, and we shall have an opportunity, in the years that lie ahead, to build up the status of the dental profession, and to do a very good job in this very important branch of preventative medicine.
§ 2.22 p.m.
§ Mr. Geoffrey Cooper (Middlesbrough, West)
In accordance with the practice of this House, I should also declare my interest in the subject under Debate. I have had and still have relatives in the dental profession as qualified dental surgeons. But I do not think that this would amount to any very substantial interest in expectancy. The hon. Member for East Wolverhampton (Mr. Baird) has covered practically the whole of the ground, but I should like to touch, first, on the point he made relating to the scale of fees. He referred to the anomaly in the price of dentures in the new scale of fees. The price which the Joint Advisory Dental Council is asking for, in this particular item, is nine guineas, compared with the price of £7 15s. which is in the new regulations just issued, which came into force on 3oth September. In 1926 the price for upper and lower dentures was £6. In 1931, however, there was negotiated a reduced price of £5, and it was only in 1944 that the price was again raised to £6 7s. 6d., and the new scale has now increased the amount to £7 15s.
My hon. Friend has mentioned the costs of making the dentures. I believe that a very large number of the dental surgeons do send the work out to dental laboratories, and do not do the work in their own workrooms. The price charged by the dental mechanics, as has been mentioned, is between £5 and £6. At the new rate of £715s., it leaves only £215s. for the dental surgeon. Now, the work he has to perform for this very small margin, I suggest, is really quite extensive. He has to get his patient to the surgery and has to keep his surgery open long hours, particularly in industrial areas, where people often cannot get along to the surgery until after normal working hours. He has to take an impression. He then takes a bite. That is followed by a try in —it may be one or more—and the work has to be finished with adjustments which may mean further visits from the patient. He undertakes all that work and, at the end of it, there may he, perhaps, a risk 218 of the dentures not being satisfactory, so he may have to make them entirely afresh. He does all that with a margin of only £215s. I suggest that nobody going for a prewar seven guinea suit to some very average tailor, would find that the tailor would expect to get only £215s. for his work. And here are men highly qualified, and expected to do very highly skilled work, for, as I see it, a very small remuneration.
The whole scale of fees is, to some extent, under dispute, but I should just like to emphasise one point. When the dispute took place, the Minister, as has already been said, did agree to a small sub-committee, the Fees Sub-Committee, being set up, with a view to overcoming the disagreement. Since the Minister agreed to that committee being set up, and he did, in point of fact, have on it a representative of the Ministry, surely, both sides to the dispute would be entitled to expect that a decision or, rather the recommendations of this Committee would be acceptable? It was hardly to be thought, surely, that at the end of these negotiations, which extended from January of this year until June, should, at the end of that time, be thrown to the wind? It has, furthermore, been said that the recommendations of this Fees Sub-Committee were accepted by a majority vote of the Dental Benefit Council. Yet when the recommendation was placed before the Minister, he overruled what was, to all intents and purpose's, his own committee's decision. It is the principle that has been raised which is chiefly in dispute—the principle that, when negotiating machinery acceptable to both sides has been used, that then it is cast aside. There, I think is the real point of discontent at the moment. That is the point of discontent, rather than the feeling that the present fees only are inadequate.
These regulations, when they were published, bore the imprint of the Dental Benefit Council. Furthermore, at the back of the regulations the words were given "Published by the Dental Benefit Council," their address was given. Admittedly, these regulations were sent out with a covering letter which did show that there was some disagreement, but, nevertheless, the impression has been created that the fees contained in these regulations were, in fact, supported by the Dental Benefit Council. Many 219 members of the profession feel that that is misleading. They feel that if the regulations with the scale of fees are issued by the Ministry and imposed on the profession, that that should be made perfectly clear to the profession in a way which, because of the imprint on the regulations, it is not clear at the present time. They feel that, in other words, it has rather been "slipped across" them. There is that feeling of suspicion, which, I think, in all the circumstances should have been avoided.
The argument may be used by my right hon. Friend that, since the Spens Committee, which has been appointed to go into the whole question of dental fees, is sitting at the present time, an increase in the scale now may prejudice the findings of the Spens Committee. After all, the reverse argument could also be used, that if a scale of fees materially lower than they should reasonably be is allowed to stand, that again might prejudice the Spens findings in a way which would show some inequality to the dental profession.
Finally, I would ask my right hon. Friend if he would bear this most important point in mind. The National Health Service will in due time come into effect, and it will include dental treatment for the public of this country. The success of the health service obviously depends upon the complete goodwill of the medical and dental professions, so surely this is a time above all others when we should avoid antagonising any sections of those professions. I ask my right hon. Friend if he will take any step that seems possible to allay the suspicions of the dental profession. He has, I understand, received very excellent support from the profession during the time his Bill was being debated. They endeavoured to concede points whenever it seemed necessary, and have in fact given a much more unanimous support to the part they will have to play in the new health service than the medical profession, which has done a considerable amount of lobbying and has tried to stir up public antagonism to the new service. Therein, as I see it, the dental profession have justified, and deserve, fair consideration and fair treatment. Would my right hon. Friend therefore consider the possibility of opening negotiations at the present time to see if the dental profession 220 could not be satisfied in their just claims and at least do everything that can be done to eliminate the sort of suspicion which they seem to be justified in feeling because of the way in which these negotiations have been handled?
§ 2.33 p.m.
§ Mr. Somerville Hastings (Barking)
May I, as a member of a closely allied profession, add my appeal to the Minister to open negotiations, if it is in any way possible, with the dental profession? I agree fully that they have not been too helpful in the past. That only about one-third of them gave the information which was asked for does not suggest a very helpful attitude, but for all that I think that they have been badly paid in the past and have a just claim to some increase in remuneration. The only question is, to what extent should that increase be granted? As one hon. Member has already said, the increase demanded will be 116 per cent. over prewar figures, or, and I should like to put it another way, 109 per cent. over the 1944 figures; that is to say, 109 per cent. above what it was about two years ago. At first that seems, and actually is, a very large increase, but that figure is obtained by taking account of the expenses as well. Let me show what I mean by an example. At present the maximum fee for a set of upper and lower dentures is £67s. 6d. What is claimed is 9 gns. At first that does not seem to be a very considerable increase; we must remember that in that £67s. 6d. a good deal of the cost is made up of fees to mechanics and the cost of materials and so on which have not materially increased since 1944, so this is really a very material increase in the dentists' profits, or in other words, in the money received for actual work done by the dentist himself.
The hon. Member who opened this discussion talked of the balanced scale, by which fees which were rather low in one branch, stopping teeth for instance, were made up by rather higher fees in another branch, as for instance the preparation of dentures. I want to suggest that that is highly undesirable. Whatever he is paid the dentist ought to be paid for the work undertaken without any consideration of anything else. I know the dentist is a professional man and I know he does his very best for his patients, but if one branch of his work, for instance the extraction of teeth and the making of den- 221 tures, is to be relatively better paid than, say, the stopping of teeth, a tendency is created for the professional man concerned to undertake what is perhaps easier and simpler, and certainly less fiddling and fatiguing, namely, extractions and the preparation of dentures.
Finally, I feel—I do not know whether you will rule me out of Order, Mr. Deputy-Speaker—but all this business is unfortunate and seems to show how very much better this service would be if the dentists were on a salary and were not paid by piece work. Here I have a list of prices for extractions—
§ Mr. Deputy-Speaker (Sir Robert Young)
The question which is now being raised by the hon. Member would require legislation. It is therefore not in Order.
§ Mr. Hastings
I bow to your Ruling, Mr. Deputy-Speaker. The figures of fees I have here are very variable and indicate, I think, that very great care should be taken in the consideration of these scales. They show that it would be a very good thing if the dentists could be induced to take a reasonable point of view, if some slight concession could be granted and if negotiations could be undertaken once more between the dental surgeon and the Minister
§ 2.38 p.m.
§ Mr. Skinnard (Harrow, East)
It is very valuable in this House to have, on all technical and professional questions, the advice of specialists who are Members of the House, but we are all interested in this subject, no matter what profession or trade we belong to, or even if we belong to none at all We all represent potential dental patients, and even those of us who possess dentures already, and are no longer, perhaps, ourselves personally interested in the fees charged by the dental profession, have, most of us, dependants who are more fortunate and who still possess their natural teeth, and therefore must look forward—if look forward is the right expression—to regular visits to a dentist. The dental surgeon differs from the medical practitioner in that he is paid only on work done. That, I think, is a very important distinction; he has to live on the actual visits of patients to his surgery. The Dental Benefit Council is very rightly concerned, as far as the dental panel is concerned, with the remuneration dentists receive from their practice.
222 The approved society representatives, on the other hand, are naturally very thoughtful about the funds at their disposal. In the middle, like Mr. Pickwick, between the rival editors, are the unfortunate patients, and many of these patients at the moment are suffering pain and anxiety because of this unfortunate dispute. I have received letters, and no doubt other hon. Members have been badgered by their constituents, and quite rightly so, complaining that people have insured themselves according to law, and have paid what they can afford as a regular part of their budget for safeguarding their health and that of their families, and now, when they go to a dentist to receive dental benefits, they are informed that they must pay fees of which they had no idea. According to a circular sent by the Joint Advisory Dental Council to all dentists—You are therefore advised to tell your dental benefit patients forthwith, if you have not already done so, that their dental letters cannot be accepted, but that you are willing to undertake treatment at the costs in accordance with the scale rejected by the Minister.The patients are in the dark about this dispute, and I submit that it is the business of this House to think, and think quickly, on this matter. It is not just a question of professional remuneration, but it is a question of a vital service.
Having listened carefully to the argument presented, I feel that there is a very strong case to be made out for the recommendations of the Dental Council, although the rise in the general prices seems to be very large. As has been said, it is a very large increase due to the introduction of a new principle into dental treatment, and that is allowing dentists to make a charge for examination and report. Examination and report is remedial. I have suffered in my youth from visits to a dentist who was frightfully disappointed if he could find nothing to do. If my teeth were sound, he reported to my father "He has unusually healthy teeth. I am sorry that there is nothing that I can do for him." Jubilantly we left the surgery, for this was a visit for which we had nothing to pay; if it was a waste of time for the dentist, it was no waste of time for us. I belong to the teaching profession, and we have been trying for a long time to make it a general practice that everyone who is still in possession of his teeth shall go regu- 223 larly every six months to the dentist to see whether his teeth need attention. I am sure that this is very much in the mind of the Minister as an important part of the general health service. We want to encourage visits to the dentist, not in a sense of dread and wonder whether anything horrible is going to happen, but with a feeling that the visit is an insurance and that one's teeth will be safeguarded. This can only be done by allowing a fee for examination and report. It has put up the general costs very considerably.
I do not think that the dentists would want to make unnecessary extractions and provide dentures, if there was a rational scheme of fees which the dental profession considered adequate. I think the overall cost of dental treatment would tend to lessen, because the habit of regular visits would lessen the expenditure on dentures and extractions, and dentists would increasingly provide treatment, such as scaling and other treatments designed to preserve the teeth, which are largely practised in America, rather than exchange them for beautiful gold or other artificial teeth. I observed that when I was in the United States, in the schools and among all classes of society of all ages, to possess dentures was regarded as a disgrace and not as an adornment, and persons were accounted wise who preserved their natural teeth to the greatest age. I should like to see, by the cooperation of the dental profession, properly remunerated for preserving teeth, Britain adopting the American attitude. Patients are now waiting, and many of them are in pain, because of this unfortunate dispute. I add my appeal to the Minister to see if he cannot very quickly resolve the difficulties, and try at least to meet the dental profession half way.
§ 2.46 p.m.
§ The Minister of National Insurance (Mr. James Griffiths)
I am very grateful to my hon. Friend who has raised this subject, and to my other hon. Friends who have spoken on this matter. They have raised it in a temperate manner, in contrast to some of the things which have been said outside this House. They have obviously been seeking a way out of this unfortunate dispute. I hope that anything I shall say will not in any way prejudice whatever 224 settlement is possible. I am bound to put the episode in its proper perspective, because it has been represented that the Labour Government are now refusing to pay the scale of fees which has been adopted by trade union machinery.
It is very essential that the position of the Minister and of the Government should be explained. In order to do that, I must explain what these additional benefits are, the people who are entitled to them, and under what conditions they are entitled to them. Additional benefits which include dental benefit are not statutory or standard benefits provided by the National Health Insurance Acts, and let me make it perfectly clear at the beginning, are only available to a proportion of persons who pay insurance.
The House has heard during past weeks and months my views on the system whereby unequal benefits are paid to insured persons. The system is going, and it ought to go. What it means is that for many years the State and employers have made equal contributions for insured men and women, but all have not been provided with equal benefits. Dental benefit is one of the unequal benefits. It is not available to all insured persons, although they pay the same contributions. It is available only to those who are lucky enough to get into a society which has available surpluses. I happen to be one of those unfortunate people who have been outside. Dental benefits are provided if the approved societies have disposable surpluses, and if they set aside part of their surplus to provide additional benefits.
So far as our figures go, dental benefits are available to about 13 million insured persons, and when provided they consist of cash contributions towards the cost of treatment, at fees not exceeding the scale of payments laid down. The insured person himself has to meet the rest of the cost. The position generally, until this difference arose, was that the approved society provided at least 5o per cent. of the cost, and the insured person the rest. Therefore, no insured person in the country is provided with free dental benefit as such. All that he is provided with is a contribution from his approved society, if they are able to make a contribution, of not less than half the cost of the treatment. This system of providing dental 225 benefit is completely unlike the panel system. For example, medical benefit is provided for insured persons under the National Health Insurance Act, and the patient selects his own panel doctor. There is then a contract between the doctor and the Government, by which the doctor provides medical service, within the prescribed rules, to the patient. That is a public service.
Even when a scale of fees is accepted, there is nothing, under the existing arrangement, by which a dentist must provide treatment. If an insured person wants dental treatment he goes to the secretary of his approved society and he gets a dental letter. He takes the letter. to the dentist. Under the present arrangement, there is nothing to compel the dentist to give him treatment. The dentist may say, "No, I do not want to give you treatment." I do not say that dentists may do that, but I want to make clear that that is the position. If the dentist accepts the patient, he undertakes to provide him with the best treatment and materials possible in accordance with the regulations. The fact that the Dental Benefit Council has accepted certain scales, does not mean that every dentist will accept them. When a scale was adopted on the recommendation of the Dental Benefit Council, there were some dentists who refused to operate it, and they were perfectly within their rights in doing so
§ Major Guy Lloyd (Renfrew, Eastern)
I hope that the Minister is not trying to give the impression that there ought to be a closed shop in the dental profession?
§ Mr. Griffiths
I am not discussing the closed shop question now, but I shall be glad to discuss it with the hon. and gallant Gentleman at some other time. I have a lot of experience of employers making a closed shop against my union, but I will not go into that now. It is essential to remember two things: First, that the approved society system is going very soon. As soon as the National Insurance scheme comes into operation—at the most in 18 months' time—it goes. Whatever settlement is made now can 226 only be for a short time. When the new national health service comes into operation, dental benefit will be provided for everyone, and not a few lucky people, as part of that service. Let me say on behalf of the Government, the supporters of the Government, and, I believe, the nation, that we shall be beginning an entirely new chapter in this field when this scheme comes into operation. As one who has the greatest possible respect for the medical and dental profession, may I say that when the Government's scheme comes into operation, it will give its members a new place in the national life, a new opportunity for service, and a service which is far better than anything we have ever seen before. I approach this matter without prejudice of any kind, but with a desire to see that members of the profession shall have a proper prestige and an opportunity of serving everyone in the nation who needs their service. What my right hon. Friend the Minister of Health and I have had to decide was the action to be taken in this temporary period during which the approved societies are still in existence, and during which time they will have to provide these services out of their surplus funds.
Approved societies are not entitled to provide this service out of any other funds but the funds earmarked for the purpose. It is essential to remember that. My right hon. Friend and I have to decide not what we, as a Government, think the dentist ought to have, but the scale of fees which the approved societies can meet. If they cannot meet it, there is no service; and if there is no service, it is no good trying to make an agreement. When the negotiating committee approached this problem, they did not consider at all—if I understand correctly what the hon. Member said—as being relevant to their purpose, where the money came from. But if there is not the money to meet 5o per cent. of the cost, then there can be no service. There is no purpose in an insured contributor going to his approved society and obtaining a letter for his dentist, if he has to meet the cost himself. He might just as well go direct to the dentist without a letter. I have to take into account what the approved societies can pay and bear in mind that they have only a limited amount of money for this purpose.
§ Sir W. Darling
The Minister must have an aggregate. There is a limited number of societies with surpluses for this purpose. How many societies are there, and what is the total amount of money during the next 18 months for dental benefit?
§ Mr. Griffiths
All I can say is, that there are about 13 million insured persons who belong to approved societies which have provided, in the past, this additional benefit.
§ Mr. Cooper
Will the societies which provide these benefits publish their figures, so that they can be checked; and will these figures be available to the dental profession?
§ Mr. Griffiths
There is a most careful check and audit of the accounts of every approved society in the country. It is possible, from the society or, indeed, from the Ministry, to obtain particulars of what disposable surplus any society has and how it is used. The surplus is actually money which is part of the National Insurance Fund. Every society is kept under careful watch and guard, and its accounts are audited, and there has been no suggestion that there is anything wrong with them.
I now come to the question of how this present dispute has arisen. The scale of fees in force before 3oth September, was introduced in March, 1944 This is not a very long time ago. The 1944 settlement allowed an increase of 17 per cent. over the prewar scale. Moreover it contained two new features requested by the dental representatives on the Dental Benefit Council, namely a relative improvement in the fees for conservative treatment and the introduction of a fee for examinations and reports on treatment needed.
That was in 1944. The dental organisations undertook to recommend that scale for acceptance by their members. By and large, the members accepted it loyally but, as I have said already, there were some who refused to operate it. During 1945 some dissatisfaction developed but no responsible suggestion was made until February of this year, when the matter 228 was raised through the Dental Benefit Council that the fees were inadequate. As a result of a demand for a review of the scale that council set up a subcommittee of three dentists and three representatives of the approved societies, to undertake a review of the scale in the light of the existing conditions, and "to make recommendations to the council." My hon. Friend the Member for West Middlesbrough (Mr. Cooper) referred to the fact that there were representatives of the Ministry on the Dental Benefit Council and on the sub-committees. I am sure he will agree that those representatives were completely impartial. They did not take part in discussions, or in voting, or in arriving at decisions.
The sub-committee submitted a report which recommended a scale which, in the words of the report itself, was calculated, on the committee's assumption that expenses were 52½per cent. higher than in prewar days, to yield the dentists an increase of 116 per cent. in net remuneration over the prewar scale, and of 109 per cent. over the then existing scale.
§ Mr. Griffiths
It may be, but I think it was accepted at the meetings that the net increase was 116 per cent. The subcommittee's report was considered by the Dental Benefit Council, which is composed of an equal number of representatives of the approved societies, not only of insurance societies and insurance companies but of approved societies generally, and of the dental profession. After discussion the matter was put to a vote. I want to make this point quite clearly, because it is very important. The impression has been created—I am not saying that my hon. Friend who raised this matter was responsible for it—that what was presented to my hon. Friends and myself was a unanimous recommendation from the Dental Benefit Council. It was nothing of the kind. This is what happened. The reference back of the subcommittee's report was moved by representatives of the approved societies on the Dental Benefit Council. Acceptance was urged by the dentists. There was a definite cleavage between the two sides. When the vote was taken, 12 representatives of the dentists voted for it and nine repre- 229 sentatives of the approved societies voted against it. The voting would have been 12 on each side, but three of the approved society representatives had been members of the sub-committee, and they thought that they ought to remain neutral in the voting. The approved societies were solid on one side, while the dental representatives stood solid on the other. That was the kind of recommendation that was made to us.
What we had then to decide, and remember it relates only to the next 18 months, was whether the scale suggested could be operated by the approved societies. The approved societies made it perfectly clear that the scale should be rejected. There were three reasons. The first is most important. It is that funds were not available to meet the cost of the proposed scale. I put it to the hon. Member for East Wolverhampton (Mr. Baird) that if the approved societies came to me, and said that if we approved the new scale they would not have the funds with which to meet it, would he expect me to make a regulation prescribing that scale? What would be the purpose of that? It would cheat the insured people of this country if I approved a scale giving the dentists an increase in remuneration of 116 per cent. over prewar scales if the approved societies could not meet their obligations. Dental benefit is not a statutory benefit. I cannot compel approved societies to provide it. It is on a sort of voluntary basis, and nothing can compel them—
§ Mr. Baird
Time after time in past years when negotiations have taken place between the dentists and the insurance companies, the insurance companies have used the lever that if a higher scale were paid, the funds to meet it would not be available, but they have always found the money. Can they not find the money for the proposed scale?
§ Mr. Griffiths
The approved societies told me they could not pay the new scale which was recommended. It would be very easy for my right hon. Friends and I to approve the scale, but the insured contributors would be unable to go to their dentists for treatment because the 230 approved societies could not meet the cost.
Until 3oth September the proportion which the insured contributor had to pay was not more than half. The approved societies told me they could not meet the proposed new scale. My hon. Friend suggested that we might accept a scale whereby the proportion payable by the societies reduced from 5o per cent. to 3o per cent. That would mean that the insured contributor would pay 7o per cent. My information is that most of the societies could not pay anything like 5o per cent. on the new scale. They are limited all the time by the money they can provide for the purpose. It must be remembered that there will be a new scale of remuneration for dentists under the new health service which comes into force, not in several years' time, but 18 months hence. The matter of fees is therefore one in which the Minister of Health and the Secretary of State for Scotland are also concerned because they have to provide the new service. In connection with the scheme they have proposed—and the dentists and all have accepted the view—that a Committee should be set up to examine the whole of the problem and report upon what should be the level of remuneration of dentists under the new service. We have, therefore, taken the view—we were entitled to—that apart from the fact that the scale provided would have meant a breakdown of the system and a failure by the approved societies to provide a service, the scale was such a radical departure from the old scale, far more so than any improvements made before, that it would prejudge the very issues the Spens Committee had been appointed to investigate. We therefore suggested that, for these reasons, we could not accept the scale.
I met the dentists and suggested to them that for the interim period a new scale calculated to give an increase of 50 cent. in the net remuneration above prewar figures should be brought into operation. I realised, and I also made it clear to the dentists, that in agreeing to a scale which would give a net remuneration increase of 50 per cent., I would still have to explain the increase to the approved societies and suggest that the proportion they had to pay should be reduced from 50 per cent. to 40 per cent. This meant 231 that the proportion the patient would have to pay could be increased from 50 per cent. to 60 per cent., in order to make it possible for a scale of 50 per cent. above prewar to come into operation. In short, in order to operate a scale 50 per cent. above prewar levels I would have to make the man pay proportionately more, and the society less. What would be the effect if I accepted the present proposal of my hon. Friend to make it a great deal more? I made that proposal of a 50 per cent. increase accompanied with a suggestion. I asked that this should be accepted for the moment, and that the allocation of the increase amongst the various forms of treatment could be worked out. In the meantime, there was the Spens Committee which we believed would be able to report with the turn of the year, round about Christmas. It would report upon what should be the level of remuneration in the service in the future. I said, without any committal on either side, bearing in mind the fact that I was limited all the time by what the approved societies could pay, that we should be quite prepared to look at the scales again in the light of the Spens Committee Report. Unfortunately, the work of the Spens Committee, which could very well get on with its task, has now been held up, because the dentists have refused to serve on the Committee because of this unfortunate dispute.
§ Mr. Baird
I have a letter from Sir Will Spens, and its contents are rather different from what the right hon. Gentleman is saying. The dentists are at present collecting evidence for the Spens Committee, and in this letter Sir Will Spens tells us that the work of that Committee will not be held back, because it will take two or three months to collect the evidence. So this will not finally hold back the Spens Committee Report.
§ Mr. Griffiths
It is no good the Committee collecting evidence, unless the Committee is constituted, and the dentists are represented on the Committee. I appeal to them to reconsider the matter. Whatever happens about the dispute, there is no question of anybody winning or losing. Whatever happens, in 18 months the whole system goes. I shall be glad to be one who pushes it out. The new health service, with a new place and opportunity for dentists and everyone else, is a permanent scheme, and the Spens Commit- 232 tee's big job is to investigate and report on what ought to be the level of remuneration in the new public service. I appeal to the dentists to reconsider their decision not to sit on the Committee, and to rejoin it, for it is in their interests, and in the interests of the whole community, that the Spens Committee should be able to go on with its work, and report quickly.
I have met the approved societies, and gone into this matter very carefully with them. For the next 18 months I have the responsibility of seeing that the system of the approved societies is carried on. I am in the unfortunate position of standing between two sides. I do not want to see the approved societies break down. They have to be absorbed into the new national insurance service, and their personnel has to be absorbed. In the next 18 months I do not want to see the breakdown in the provision of the dental benefits, but I want to see them carried on and sustained. I know perfectly well, and this is beyond any question, that, if I accepted this new scale, and imposed it on the approved societies, they would tell me, "We cannot meet it out of the funds we have at our disposal." Therefore, I believe it would be dishonest for me to approve and impose a scale under which the approved societies would not be able to provide the benefit required of them.
My hon. Friend the Member for East Wolverhampton is a very temperate man, and in his constructive speech he asked, "Is there a way out?" I hope there is. Perhaps he knows that when I met the dentists I appealed to them not to push their suggested scale. My hon. Friend the Parliamentary Secretary to the Ministry of Health was with us. I said, "Do not push this scale because, quite honestly, I cannot accept it," for the reasons I have made clear to the House and on which I believe I have carried the House with me. I urged them, "Do not insist on that scale. Let us get together." I still say that if the dentists and their representatives have any suggestions to make, I am prepared to consider them. I wish to make it clear beyond any question of doubt that anything I accept is of no value unless the approved societies can work it. If a useful suggestion is made, if it appeals to me and I accept it, and if the approved societies accept it, and can work it, and it is reasonably fair to the insured contributor, then all will be 233 well. If it places the whole burden on the insured contributor I cannot accept it, as it would be unjust and dishonest. If there is another way out, I am prepared to consider it. If my hon. Friend's approach is an olive branch of the profession, if they come to me with any suggestions for breaking the deadlock, and arriving at a settlement to carry on the service for this next 18 months, and which will maintain the best relationship between the Government and the dental profession, I am, as I say, prepared to consider it. I can only consider it in the light of the fact that the service has to be provided by the approved societies in the way I have described. I hope that this afternoon's discussion will not have created any more bitterness, but that it will have swept away some of the misunderstandings. If there is a new approach, I, speaking for my right hon. Friends as well as myself, subject to the reservation I am bound to make, am quite prepared to consider it.