§ 10.0 p.m.
§ Mr. Baird (Wolverhampton, East)
I beg to move,That an humble Address be presented to His Majesty, praying that the Regulations, dated 23rd December, 1948, entitled the National Health Service (General Dental Services) Fees (Amendment No. 2) Regulations, 1948, (S.I., 1948, No. 2803), a copy of which was presented on 18th January, be annulled.It is necessary for me to declare my interest as a practising dental surgeon. This regulation was introduced by the Minister on 23rd December as an attempt to curb the very large incomes being made at the present time by dentists. It is an attempt to bring them into some relation with the Spens Committee's Report, which laid down what should be a reasonable remuneration. I wish to make it quite clear that I am not attempting to justify the present high level of dental incomes. I consider that I am in a fairly strong position, because on 5th July when these scales were introduced I warned the Minister that he was paying dentists far too much. My criticism is not that he is making a cut but of the method by which he is making it.
There are one or two generalities about the dental situation of which the House should be informed. The Spens Committee on dental remuneration reported in 1946 that the income of a dentist in his prime, working for 33 hours a week at his chair side, should be £1,600 a year in 1939 values, which is something like £1,750 at present-day values. It is essential also that the House should 1082 recognise that the dentist is not paid like the doctor. He is paid by a scale of fees, with a separate fee for each item of treatment, one fee for a filling, another fee for an extraction, and so on. When this itemised scale was introduced in July last, the Minister made it quite clear that it was purely a temporary scale—it was experimental, and that within the very near future it would have to be modified to bring it into line with practical experience. No one at that time could say how it would work. What then is the meaning of this regulation? It says in the Explanatory Note:The Regulations amend the National Health Service (General Dental Services) Fees Regulations, 1948, by providing for a reduction of the fees payable to dental practitioners when the fees payable under those Regulations exceed a rate of £400 a month. The amount of the reduction is one half of the fees in excess of that figure.This cut operated from 1st February. My criticism is that the method used by the Minister was hasty. The proper method for cutting dentists' incomes should be, as he himself suggested on 5th July might be necessary, by revising the scale of fees rather than the hasty method of chopping down by 50 per cent. anything over a certain amount. In other words, by a revision of the scale of fees the cut would operate not after the dentist had made £400 gross, but would be an immediate cut on all dentists' incomes. Why should the dentist who is working wholeheartedly within the scheme and accepting none but State patients be penalised by this cut when the dentist who is working in the scheme only part time, and doing no more than he need—that is, the dentist who takes up to £400 from State patients—gets off scot-free?
Speaking from a dentist's point of view, I think that there are many anomalies in this hastily drawn regulation. For instance, the cut will operate from 1st February, but the regulation states that money owing to a dentist before 1st February will be taken into consideration when the cut operates. The secretary of the Incorporated Dental Society writes to me:A dentist who is owed £3,400"—and a dentist may be owed three or four months' income at the present moment; and most dentists are owed at least two months— 1083would have the deduction made on reaching his first £1,000 after February 1st. If one is owed £2,400 the deduction would operate at £2,000 after February 1st, and to one owed £1,400 the cut will operate at £3,000 after February 1st.All general practitioners on February 1st except new entrants on or after that date have some amount owing to them, so that none except the new entrants would be able to earn the full gross amount of £4,400 in the eleven month period without deduction.In the different areas dentists are paid by their local executive councils; some areas pay the dentists on one date, some on another, and they may be paid for differing periods. The result is that in some areas dentists' incomes will be cut much more than in others, and I do not think there can be any justification for that. I agree that dentists' incomes must be cut; but if they are to be cut, then they must be cut equally. Under this regulation the cut will be large or small according to the area in which the dentists live.
Those dentists who have come into the scheme because of pressure of public opinion—and there is a large number; some have come in only this month—will not be cut until they reach the full gross income of £4,800, whereas for dentists who have worked sincerely in the scheme and are owed say £2,000 the cut will operate after their income has reached £2,400.
Another anomaly in the scheme concerns what we call existing contracts. A patient may go to a dentist any time up to 23rd December when this regulation was laid, and enter into a contract to have 10 fillings, or to have teeth extracted, dentures fitted, and the Minister guarantees to pay the dentist a certain sum for the work. As far as existing contracts are concerned, there will be no cut. The monthly cheque will still be cut but dentists can claim back on existing contracts at the end of the year. How will this work? First of all, it will be very difficult for dentists, who are very busy today, to keep books and lists of the kind of work which was agreed to prior to and after 1st February. How the cut is to be assessed afterwards I do not know. Apart from that, even according to the Spens Report, out of his gross earnings a dentist has to pay 52 per cent. in expenses, such as salaries to his mechanics, his assistant, and so on; he has to pay the expenses even though his 1084 cheque is being cut. At present, on an average every dentist is owed for about two months' work; in other words, payment is two months in arrear since the Act operated.
When there was a dispute between the Government and the dental profession and certain dentists withheld their service, those dentists who were loyal to the Government were promised by the Minister that if the Spens Report was in favour of higher remuneration, he would make retrospective payment to them. The Spens Committee reported 12 months ago, and those loyal dentists have still not been paid what was promised them by the Minister of National Insurance way back in November, 1946, and that is still outstanding. Dentists are now asked to hold back until the end of December before they get their money on existing contracts.
Another minor anomaly relates to anaesthetists' fees. A large number of dentists call in doctors to give anaesthetics for them for the clearance of teeth. The dentists have to pay the doctor's fees, and those fees are included in their monthly cheque. Some dentists, especially those in industrial areas where there are large numbers of extractions, pay the doctors 15 to 20 guineas a week. The dentist has to pay the doctor the full amount but the dentist may have his cheque for that amount cut by 50 per cent. over a month. Will the Minister do anything to remove that anomaly.
There is also the question of the balanced scale of fees. The House should realise that one of the greatest achievements concerning dental aspects of the National Health Service is that in the past a dentist was paid what I consider was an extortionate amount for dentures. He could charge 20 or 30 guineas for a full set, but if the dentist had a sensible patient he was lucky if he got 10s. 6d. or 12s. 6d. for a filling, although the amount of skill required for filling the teeth was much greater than that required for fitting the dentures. The dentist who made three or four full upper and lower dentures a week needed to do little more, but the conscientious man who did fillings had time for little else.
The Minister recognised that the scale of payment was completely unbalanced, and now for the first time the dentists have a balanced scale. The fee for dentures was reduced to ten guineas and the 1085 fees for fillings were increased until they averaged £1 to 30s. a filling. That was good. I can claim that I had something to do with it. However, if anything the balance went too much the other way. At least, the fee for dentures was cut completely to the bone. Today the 50 per cent. cut operates over a certain amount. The dentist who is doing fillings can still make a small profit, but he cannot make a profit on fitting dentures because the 50 per cent. cut operates and he gets five guineas for fitting a full upper and lower denture. I can prove to the House that the cost to a dentist who is doing a good job and putting good quality materials into his dentures is from £5 to £6. I can say from practical experience that it takes £6 to turn out a full upper and lower denture. Yet the dentist will now receive five guineas for doing that job.
§ Sir Hugh Lucas-Tooth (Hendon, South)
Does the hon. Member say that the dentist can make only a small profit on operations other than dentures and no profit on dentures? Is he arguing that the dentists' costs are substantially higher than the 50 per cent. which has usually been accepted?
§ Mr. Baird
Not at all. I do not know the point the hon. Member was trying to put, but I was certainly not arguing that. The point is that the cut operates in such a way that the dentist will be making a loss in certain instances if he produces a high-quality denture, and the conclusion we draw from that is that dentists will be encouraged to put inferior material into dentures in order to clear their expenses. However, those are minor anomalies under the regulations. The most important point relates to the method the Minister has used to cut dentists' fees. This is the point I want to impress on the House. This will create a black market in dentistry. We already see it. We can read about it in the newspapers every day.
The Parliamentary Secretary has not had very much experience at the Ministry of Health—I am not saying that in any slighting way—but his predecessor knows some of the work I have done as far as dentistry is concerned. I think I can claim—I am saying it very modestly—that, apart from the Minister himself, I have done more with regard to the dental aspects of the National Health Service 1086 than anyone else in the House. I think I can claim that I speak here, not on behalf of the wealthy dentists, but on behalf of the poor patients of the wealthy dentists. I have spoken on these lines many times in the House. What is the position? The loyal dentist who has been trying to work the Act, not merely according to the law but according to the spirit of the Act, has been working hard to see as many patients as he could; he has not been turning patients away, and the result is that patients have been flocking to him and he has been making a lot of money.
I do not justify his income. I think it should be cut, and he himself, on the whole, would agree that he is making too much money and wants to be cut—[HON. MEMBERS: "Oh!"]—that is, the majority of the dental profession. We read in the newspapers about dentists who are turning patients away and doing all sorts of unethical things, but they are in the minority; the majority are trying to do a good job of work. There are many trade unionists on this side of the House. Let me tell them that when a dentist works overtime, his rate is cut by 50 per cent. We all know that they are being paid too much and that the method of the Government to cut them is by saying, "Let him carry on at the full rate as long as he works 42 hours a week." Only after he works overtime on behalf of the Government, trying to treat people who need it, is his rate cut by a half, and that is an entirely wrong method. What should be done is to revise the scale of fees for treatment item by item.
There are, however, some dentists in this country at present who are bringing the dental profession into disrepute. The Press have taken it up, hon. Members have asked questions. I want to make it quite clear—and I think I am speaking on behalf of all sides of the House when I say it—that we deplore their attitude. As a result of the Minister's regulation, a dentist can make up to £400 a month gross, which is a net income of £45 per week before his income is cut at all. He works hard until he makes £400 a month, then when a patient comes along wanting further treatment, he says, "No, I have done my quota. If I treat you under the Government scheme I shall have a cut 1087 of 50 per cent. Therefore, I will not treat you unless you come to me as a private patient." The patient who wants dentures can wait a month until the next month starts, but patients in pain cannot wait, and they have to pay on the nail. The Minister's regulation is encouraging these immoral dentists.
Under the National Health scheme the whole of a dentist's income is taxable, and he cannot dodge it, but the House should realise that it is easy for a dentist to do so by treating casual patients and getting cash for it, and very often the Income Tax authorities know nothing about it. Therefore, that is a further encouragement. This Act is a compromise with the doctors and dentists, it is not a Socialist Measure. Under the Act a dentist is legally entitled to refuse to accept a patient. There is nothing illegal about that, but while he is legally entitled to turn away a patient in pain because he cannot pay, I say that all the leaders of the dental profession must condemn that action as ethically wrong, and I hope the House will endorse that view. Furthermore, we should warn those dentists who are doing this that if they continue to turn away patients simply because they have reached their quota, the Government must take action in some way—I do not know how—to see that this immoral practice is stopped immediately.
The Minister may argue that he has made a certain concession to dentists. The Spens Committee reported that dentists should make an income of £1,750 on a 33-hour chair-side week. The Spens Committee said also that dentists working over 33 hours at the chair-side were endangering their health. The Minister of Health went some way towards making a concession by saying that he would not cut their income until they had worked a 42-hour week. He may say that he does not want dentists to work over 42 hours for fear that the standard of their work will decrease. As a practising dentist, however, I do not think that is true. In certain circumstances—if health permits, and with a well organised surgery—a dentist can work over 42 hours a week and still do a good job of work. If this scheme and the National Health Service are to work, with the present-day shortage of dentists and the great demand for legitimate treatment which we are getting, and remembering also that 1088 people visit dentists for necessary treatment, and not simply to get something for nothing, then those dentists whose health will permit must be encouraged to work over these hours.
Hon. Members are aware of the state of the priority services in dentistry and the dental service for schools. Because of the shortsightedness of the Minister the priority dental services have already to a great extent broken down, and I warn the Parliamentary Secretary that if this regulation is allowed to stand, or if he does not introduce an Amendment to effect a more sensible scheme in the near future, the general dental services, in certain districts at least, as with the schools dental service will break down.
I have criticised the Government because they have not gone far enough on Socialist lines. The methods of payment for dentists, by a scale of fees with varying amounts for each item of treatment, and haggling about how much they should get for this or that item—this type of payment for professional men is degrading. The only solution for both doctors and dentists, as far as remuneration is concerned, is a salaried service. We on this side have always believed in a salaried medical service. To please hon. Gentlemen opposite, and to please the professions, we compromised. A considerable number of dentists have been taking advantage of that compromise. They have been misusing our trust in them. I warn the House, and especially dentists, that if they continue degrading their profession, as some of them are doing, the Government can have no alternative to introducing a full salaried service at the first possible opportunity.
§ 10.23 p.m.
§ Mr. Bramall (Bexley)
I beg to second the Motion.
I do not require to take up much of the time of the House or to cover any of the ground which has been so well covered by my hon. Friend the Member for East Wolverhampton (Mr. Baird). Unlike him, I have no direct interest in this matter. It will not make a penny piece of difference to me, except as a taxpayer, whether this Prayer is accepted or not. I have a very great interest, however, in that many of my constituents are already being very gravely harmed by the operation of this regulation which the Minister has laid before the House.
1089 I should like to put before the House the position of dental services in the constituency which I represent. The Borough of Bexley has a population of some 90,000. It has only 11 dentists, of whom three are local authority dentists. In fact, only seven are in the National Health Service, which gives a ratio of one for more than every 11,000 inhabitants, whereas the national ratio, as shown by the figures of the Teviot Committee. is something like one to 4,000 of the population.
I have made comparisons with other areas of similar population. Reading, for instance, has 58 dentists. The borough in which I live, Twickenham, with a population only 10,000 greater than Bexley, has 46 dentists. The Borough of Beckenham, which is about two-thirds the size of Bexley and is not very far from it, has 18 dentists. There are a number of other areas similar to that which I represent. Dagenham is another area with an amazingly low proportion of dentists. It is inevitable, therefore, that every dentist must treat a very large number of patients, otherwise patients must go without treatment.
One can well believe that in an area where there are plenty of dentists of the immoral type mentioned by my hon. Friend, who choose to misuse the regulations and to blackmail their patients in this way, they will say, "We are not going to make so much money out of the Health Service. If you come as Health Service patients, we will only take you in the very distant future, but if you come as paying patients we can take you right away." A patient can exercise his choice and go to a dentist who is differently situated in such an area, but that is not possible in the area which I represent. There every dentist has a crowded waiting-room and could work for 24 hours a day, let alone 42 hours a week, and still not do all the work demanded of him.
Everything possible should be done to help people badly situated in areas of that type to get treatment at least reasonably soon. But what is happening? I will give the waiting list of one typical dentist in my area: next appointments under the Health Service to be made for fillings are in June; next appointments for dentures are in December. Those are for people whose teeth he has extracted. Those who want dentures re- 1090 placed he frankly tells that if they do not wish to come to him as paying patients, they must go to other dentists, as he cannot see them at any time which he can foresee in the future.
I cannot see how the Minister can face this situation with any degree of equanimity. I know that the situation was bad without this regulation and that there is a great shortage of dentists which unfortunately is largely localised. Areas like that which I represent are largely working-class and have grown up in the last 30 years and not attracted dentists. They are not there and no one can compel them to be there. But the Minister should at least avoid doing the very thing which makes the situation worse.
Only today I received a letter which illustrated the way in which this regulation has already made the situation worse. One of my constituents wanted to replace his dentures and went to a dentist last October. He was told that it would take three months if it was done under the National Health Service, and incidentally he was told that it could be done more quickly if he paid. That is by the way, because he chose to have it done under the Health Service. Four months have now elapsed and the dentist has told him, "I am afraid I cannot see you at all and you will have to find another dentist." That is because the dentist is now limiting his work and instead of taking a given number of appointments in a month, he is spacing them out, as he must see to it that under the Health Service he does not earn more than £400 a month. Therefore, he already had a long waiting list and an overfilled book which are still further protracted in order that in one month he may not receive more than £400 worth of work under the Health Service.
A minority of dentists are doing as my hon. Friend said they have done and will do. They are saying to people, very often to people in great pain, "If you choose to pay you can be seen today or tomorrow or this week or whatever it may be, but if you do not choose to pay but choose to take advantage of the Health Service of which you have every right to take advantage, you must wait until June or December"—or whatever the date is. Undoubtedly that sort of thing has been increased by the advent of this order. Until this order was made I had no complaints of this 1091 kind. Since the order was made in December, I have had a number. The Minister has seen them, because I have passed them on to him. I have talked with the dentists themselves since I have had these complaints and asked them if they were doing the things alleged and, if so, why. They said—and I admit it is a very difficult argument to answer—that the Minister is saying to them, "If you work more than a certain amount of time, you shall be paid half rate for doing it." Therefore, they do not see that that is a reasonable proposition.
As my hon. Friend has said, they are legally entitled to refuse any patient under the National Health Service. I do not think the Minister will be able to do anything about these complaints I have sent him. No action can be taken against any dentist who does this. In areas such as I represent—I speak no wider than that because I know no cases wider than that—the Minister is doing the very thing which is encouraging dentists to do that undesirable thing and to do it under the law as it now stands, and the Minister is powerless to prevent it. That seems to me a very unfortunate situation for a Minister to encourage.
I know that one of the Minister's arguments on this is that he does not want dentists to work more than 42 hours a week. I am convinced that if the Minister were to insist on this position, if he were to limit every dentist to working only 42 hours a week in the Health Service, not only would the Health Service break down, but the whole of my constituency would be in a ferment against a Health Service which they would regard as nothing but a mockery. It is because dentists are working far more than that that the Health Service has worked so successfully, comparatively speaking, up to the present time. I think the Minister is saying that we must accept the position where dentists work this length of time, but we ought not to pay them properly for doing it.
I should like to stress the fact that I have nothing against the basis conception behind this order, that the total remuneration of dentists is too high and should be reduced but I appeal to the Minister in the strongest terms to reconsider a method by which he is penalising those dentists who work most of the time in the Health Service, by which, 1092 without making it impossible for them to work more than a certain amount of time, he is paying them inadequately for doing so, and by which he is preventing dentists, particularly in those areas which have too few dentists, from doing the amount of work that they should do to give people proper treatment, and encouraging dentists to seek more and more the black market way of offering people either an indefinite wait before having treatment in the Health Service or treatment at once for which they pay.
I believe that any scheme which encourages conduct of that type on the part of dentists must be a bad one and I believe that by this order the Minister is making it extremely difficult for anyone to pass any moral rebuke on the dentist who behaves like this because he is being directly encouraged to do it by the whole basis of remuneration being cut away from him. If, instead of working conscientiously to fulfil the needs of patients under the Health Service, he turns aside and insists on their paying, then he can get full remuneration for the work which he does.
§ 10.35 p.m.
§ Sir Hugh Lucas-Tooth (Hendon, South)
The hon. Member for East Wolverhampton (Mr. Baird) is an authority on this subject. I think it is true to say that he knows more about dentistry than any other hon. Member, but when last summer I ventured to move a Prayer to annul a previous order—the order which in fact set up this scheme—I think the hon. Member for East Wolverhampton stigmatised my comments upon it as rubbish. I do not think that I prophesied then that within a year the hon. Member for East Wolverhampton would be coming forward to move another Prayer in similar terms and to use in connection with it—
§ Sir H. Lucas-Tooth
The terms of the Prayer are different in respect of one month. The terms of the comments of the hon. Member for East Wolverhampton are very different indeed from the terms of his speech on that occasion. I should like to explain to the House my attitude to this Prayer, which I believe 1093 is the attitude of a number of my hon. Friends on this side of the House. I am afraid it can be summed up best in the trite words, "We told you so," because when last May we discussed the order setting up the dental scheme under the National Health Service Act, we then said that if the Minister persisted in carrying out the scheme on these lines it would inevitably lead to trouble, and that the trouble would be particularly in the form of bad work on the part of those dentists who would be tempted by the inadequacy of the scheme to do bad work; and that the good dentist to whom the hon. Member for East Wolverhampton referred would be very seriously prejudiced by reason of the scheme.
§ Mr. Baird
In the Prayer last year, when the hon. Member for South Hendon referred to good dentists he was referring to those who charged high fees. When I talk about good dentists, I am talking about the dentists who are wholeheartedly working this scheme, and whom the hon. Member for South Hendon stigmatises as bad dentists.
§ Sir H. Lucas-Tooth
If the hon. Member for East Wolverhampton, on looking up my speech, can find that I described good dentists as those charging high fees, he can make what play with it he likes. There will be time for him in this Debate to do so. The hon. Member for East Wolverhampton said it would be necessary for the Minister to revise the whole scale of pay—I think that was the effect of what he said—but when one listened to his arguments, it was plain that he did not mean revising the whole scale of pay, because that would do nothing at all to cover the kind of difficulty to which he has referred—the difficulty regarding overtime. The hon. Member suggested, in a way which could not have been done better from these benches, that if the Minister wants to get more and better work from the dentists, it is desirable to give an inducement. That is a strange argument to come from that side of the House.
§ Sir H. Lucas-Tooth
It is a general principle with which we would not disagree. On the other hand, there is a limit beyond which I think we would all agree that it is undesirable to induce 1094 anyone to try to work. If one were to revise the scale of fees—and I hope that the Parliamentary Secretary, who is to reply to this Debate tonight, will comment on the point—in such a way as to bring in the dentists who are now earning £6,000, £7,000 or £8,000 a year, down to the kind of level contemplated in this order, it would mean bringing down the less well-paid dentists to a level below anything which the hon. Gentleman opposite, or I think anyone in this House, would tolerate.
This scheme, when first introduced, was the acme of good administration; it was, a boon for which all the people of this country had longed; but tonight, we have a compromise scheme and not what the Socialist Party would have done had they had a free hand. It is not at all what they want but when the hon. Member for East Wolverhampton came to his peroration, he let the cat out of the bag. What he wants is a salaried service—[Interruption]—and I hear hon. Members behind the Parliamentary Secretary apparently supporting that idea. Is that the object? Is it the idea to make the acceptance of such a service inevitable? When we put down a Prayer last year, we did not know what would be the position, but when Statutory Instrument 1297 of 1948 was published, we knew for the first time what was the scale of remuneration intended by the Government; and it was then perfectly obvious that the policy of the Government was to float off this part of the National Health Service in gold, making it completely impossible for the dentists to resist coming in.
§ Sir H. Lucas-Tooth
The plain truth is that that has been the result. The Parliamentary Secretary cannot deny, in the face of his own order, that that is so, and he cannot deny that a large proportion of dentists have come in since the publication of that order. But now we shall have a different story; we are knocking off part of the enticement and there will be, I think further reductions—this is not the end. I cannot say that the Minister has made a breach of public faith, because he stated that this scale of remuneration was liable to review, but it is also true to say that the dentists came in on the basis that 1095 this was to be the general level of remuneration.
§ Mr. Baird
The dentists came in when it was made clear that the basis would be the recommendation of the Spens Report of £1,750 for a 33 hour week. Is the hon. Gentleman in favour of reducing the remuneration below the standards recommended in that Report, or is he not? Will he give me a straight answer?
§ Sir H. Lucas-Tooth
I will give the hon. Gentleman a straight answer. The whole method of remunerating dentists should be revised. I have always said that the original scheme was unworkable, and whatever one does by way of messing about with the remuneration laid down in the original order, against which we put down the Prayer last year, will not clear up the mess in which the Government find themselves. As the two hon. Members opposite have said, this order is very nearly futile in carrying out the purpose which the Government have in mind.
No doubt the Parliamentary Secretary and the Minister are very much concerned about the drift away from the public dental service into private practice. We are all concerned about that development, but what are the facts and the figures that the Government have to face? I have here a copy of the "British Dental Journal" for the month of January, and it will be of interest to the House to hear of the advertisements in this newspaper. There are classified together the advertisements for posts in the public service. They are all very nearly the same and I have not chosen any outstanding ones. Perhaps I may refer to one or two:Montgomeryshire Education Committee—Assistant school dental officer … commencing salary £780 rising by annual increments of £30, and one increment of £20 to £980 per annum.County Borough of Ipswich: Appointment of assistant dental surgeons. … Applicants must be fully qualified and registered dental surgeons. Salary will be at the rate of £750 per annum rising by annual increments of £50 to £900 per annum.and so they go on.
On the following page of this journal there are advertisements for practitioners in private practice. I think it is to these that the House should turn its attention. I will quote two or three: 1096West Country.—Old-established middleclass practice.—Assistant dental surgeon required. Early partnership to suitable applicant, meanwhile salary plus share profits. … No late evening appointments. Modern equipment. First year, at least £1,250.Preston, Lancs.—Assistant required with or without view to partnership. £1,250 per annum and bonus. No book-keeping.Assistant required for large practice, Bradford, Yorkshire. Excellent opportunity, salary plus commission. £1,000 to £1,500, 40-hour week. First-class working and living accommodation available.How on earth can the public dental service be maintained when the salaries offered are somewhere about half of what is being offered in private practice? It is physically impossible. That is the situation the Government must face and that is the situation which the order does not touch at all.
§ Sir H. Lucas-Tooth
I am merely saying that it is futile to expect the order to carry out any effective purpose at all, and it cannot be said that limiting dentists' fees to a ceiling of £2,400 a year net will do anything to revive the public dental service. Again, the order must be ineffective in catching what has been called the "dental spiv." There has been some reference to that particular gentleman by the hon. Members who moved and seconded the Motion. Here are two examples of the danger. I am afraid I have to take them both from the Tory Press, but I think these examples have not been noticed so much by the Press which sympathises with the Government. In the "Daily Express" of 21st January there was a report of the West Sussex Health Council that for three hours' work a dentist who claimed to have done 28 fillings was paid £28 8s. 6d. That type of work will be unaffected by this order.
Again, there was a letter in the "Daily Telegraph" on 15th December from a dentist who said that in future he would work two and a half days a week and earn £4,800 a year and then play golf. That type of man is going to be unaffected. He may work for only two and a half days and then play golf, or work for two and a half days in public service and then take up private practice. The order is entirely ineffective in covering that type of practice. The order is ineffective in doing what is essential at this moment—restoring the balance be- 1097 tween the scale of emoluments of dentists and the scale of emoluments of the other professions, in particular the doctors. It does not really touch the problem at all. Merely to limit dentists in the public service to £4,800 a year will do nothing to bring them into general line with the doctors or with any other profession.
The dilemma in which the Government are placed is that either the Minister must reduce the whole scale of dentists' remuneration or he must increase the rate of the doctors' remuneration, in particular, so as to bring him into line with the dentists. That is the dilemma. It is a perfectly simple one. It is not one that we on this side of the House created. We sympathise with the Minister, but it is his own fault. He made this order, and we should like to hear how he thinks this amending order is really going to alter it at all. The present order does something; it is an order in the right direction in that it sets some limit to what is admitted to be in some part, at any rate, a public scandal. Therefore, we do not regard it with disapproval. It is understandable, and the Parliamentary Secretary will no doubt remember that we have not put down a Prayer, and that the Prayer has come from behind his own Benches. We shall listen with the greatest attention to what the Parliamentary Secretary says before making up our minds what line we should take upon this matter.
§ 10.58 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)
I am very glad that we have been given this opportunity of considering this matter tonight and considering it over such a wide field. I should first say that we appreciate the manner in which the hon. Member for East Wolverhampton (Mr. Baird) has raised this matter. We know very well his interest in the whole question and we recognise the assistance he gave to the Department in discussions that we had on the introduction of this scheme. But I do feel that a great deal or the discussion tonight has been rather wide of the mark.
To start with, it must be remembered by hon. Members in all parts of the House that at the outset there was no suggestion that a full dental service could be provided in this country at the begin- 1098 ning of this dental service scheme. It was clearly understood that the shortage of dentists was such that there could be no effective dental service for the whole country, and hon. Members were warned of that position at the time. In fact, as hon. Members have said tonight, it has only been possible to provide the service that has in fact been given because of the serious overworking of many dentists, and it is by no means certain that overworking is satisfactory for the patient or the dentist.
It is quite true that in the first case we based our regulations around the report of the Spens Committee which, as my hon. Friend the Member for East Wolverhampton rightly said, laid down the assumption that there would be a net income of £1,778 a year. When it was found after this scheme had been working for some time that in fact the fees were turning out at a very much higher rate than was supposed, and in fact the incomes being earned were outstandingly higher than those figures, naturally my right hon. Friend had to consider what action should be taken. Discussions were held with the dentists, and suggestions were put before them which they, at the time, regarded as not being the best way of t dealing with the matter, and they suggested that there ought to be more time for discussions and for consideration of the position.
§ Mr. Blenkinsop
It is perfectly true that the suggestions the Minister had in his mind at that time were not precisely the same as those finally decided upon. The regulations finally drafted were discussed with the dental organisations before these regulations were printed or published, and in fact because of those representations certain alterations were made in them.
§ Mr. Baird
My information is that the Minister called the dentists together and gave them an ultimatum that there was going to be a cut placed upon them in this way. It was then announced in the Press, and he then had discussions with the dentists. There were minor amendments made, but there were no discussions at all before the regulations were made.
§ Mr. Blenkinsop
My understanding was that there were discussions before these regulations were made on the date of operation of the regulations, firstly, and secondly, on the actual income to be permitted, which was above the sum contained in the proposals originally put forward. It was originally suggested that there should be a lower standard figure above which there should be this 50 per cent. cut. The figure originally proposed was somewhat lower than that put into the regulations now before the House.
§ Mr. Blenkinsop
The actual figure of earnings which was discussed with the dentists, as I understand it, was a certain figure. After the dentists had made their representations, that figure was somewhat raised. We have figures now for the standard yearly income, above which there is to be a cut for any earnings in excess of £4,800 gross. The original suggestion was that a somewhat lower figure should be accepted.
§ Mr. Blenkinsop
If the hon. Member cares to put a Question down he can do so. I understand that the dentists themselves suggested that this figure should be altered, and that it was partly as a result of those representations that the figure of £4,800 was included in the regulations. I am not suggesting that the dentists accepted the regulations we have laid, but I am saying that the matter was raised with them. They claimed that a fuller investigation ought to be made before this was done. My right hon. Friend felt, I think rightly, that the position was so serious and urgent that we could not await any further investigation, which could not alter the facts already before us, and that inevitably this decision to make an immediate cut had 1100 to be taken, although that did not in any way rule out the further discussions we desire with the dental profession on the whole question of the rates of their remuneration.
It is clear that even with these cuts, these arrangements we have made, the dentists are earning a great deal more than was envisaged in the original Spens Report. The Minister clearly laid down that we were accepting that Report as the basis of remuneration to dentists. There has been a very wide discussion tonight on the whole position of the dental service and the availability of it, and on the effect of this regulation on the availability of the service for National Health Service patients. It has been suggested that in many cases the result has been that, when a certain number of patients have been taken on by dentists in the service, extra patients are taken only as private patients. That may be, but faced with the fact that the earnings of dentists were proving to be so very much higher than had been suggested in the Spens Report, my right hon. Friend was bound to take certain emergency action.
I am not suggesting that this deals satisfactorily with the problem for the future, but I am suggesting that it was impossible for my right hon. Friend to allow this situation to continue, of this very large increase being earned. I am sure that I have the support of all sides of the House in saying that these increases were far too high and had to be cut in some way. I am not quite sure whether the hon. Member for South Hendon (Sir H. Lucas-Tooth) was proposing cuts down to the figures originally proposed in the Spens Report. I rather gathered from the intervention of my hon. Friend the Member for East Wolverhampton that he hedged a bit, and refused to give us his view on the matter.
§ Sir H. Lucas-Tooth
May I interrupt? If the Spens result could be produced it would be most satisfactory. I did not hedge. I merely told the hon. Member that it was physically impossible to produce the Spens result under the scheme the Minister had made.
§ Mr. Blenkinsop
I am suggesting to the hon. Member that it was absolutely essential to accept the recommendations of the expert Committee which was set up. The Committee made certain recommendations and the Minister very clearly, in introducing those regulations to the House, insisted that those rates did not tie his hands in the future. One hon. Member referred to that fact. The Minister was therefore entirely free to make such changes as he felt necessary.
My right hon. Friend is anxious to discuss the whole question of the rates of pay of the dental profession with their representatives in our common anxiety to get a solution which will be satisfactory and fair to them in the light of the Spens Committee's Report and at the same time fair to the great body of our taxpayers. I am sure that hon. Members opposite are anxious to see the taxpayers protected too.
I want to say something further about the suggestion that the effect of these orders, for there are two, has been to push patients away from the National Health Service into private dental service. It is absolutely vital that we should insist that any service that requires longer working hours for dentists than the actual figure of 42 hours which is provided for is not one which can be regarded as being to the benefit of the Health Service patient or to the dentist. Forty-two hours is nine hours above the figure recommended in the Spens Committee's Report. That Committee was an expert body, and we feel that without a great deal of further experience, we do not want to commit our people to a service which in our view would be wholly unsatisfactory in that way. I hope that my hon. Friend will accept my assurance that we are most anxious to discuss this whole field with the dentists and to arrive at a more final, satisfactory solution. We do not regard the orders that we have placed before the House as more than emergency requirements which I believe everyone in the House would agree were necessary by virtue of the very large sums which were being claimed by dentists.
My hon. Friend raised one or two detailed points which I should mention. The retrospective payments on the old dental letters are under discussion.
§ Mr. Blenkinsop
They are linked up with matters which are now under discussion. I quite agree that we want some settlement as soon as possible. My hon. Friend also raised the question of anaesthetists' fees. They are included in the 52 per cent. of practice expenses which are allowed. I do not think that anyone can suggest that we have any need to weep tears over the position of the dentists on the question of expenses today. Surely the position is quite on the other foot.
We ought to be anxious at the moment, as the Government are anxious, to secure a new agreement which is fair to all parties but which comes very much nearer to the original Spens Committee recommendations. I hope my bon. Friends will therefore withdraw the Motion on the assurances I have given of our anxiety to reach a full and satisfactory conclusion to this matter. I also think the House should agree that in the circumstances in which we find ourselves and particularly, perhaps, with relation to the Debate which will take place in a few days' time, it is vital that every possible method should be tried to cut down any unnecessary extravagance in these services.
§ 11.11 p.m.
§ Mr. David Renton (Huntingdon)
I feel very sorry indeed for the Parliamentary Secretary. In the circumstances, he made his answer exceedingly well, but his position has not been a very easy one. He is new to the job. He had a very able predecessor and if he does as well as his predecessor did in the past, he will not be doing so badly. I warn him that he may very often have to "hold the buck" for his Minister, as he has had to do this evening. This is not the first time we have had to complain on these very important occasions of the Minister not being present. [Interruption.] I will give two previous instances.
§ Mr. Blenkinsop
As a matter of mere courtesy, surely the hon. Member realises that the Minister has been here taking the Debate the whole day. I think the hon. Member has been a bit discourteous.
§ Mr. Renton
As I have been challenged on that, may I say that when the order which is amended by this order came up, the Minister was not here and we complained. When my hon. Friend the 1103 Member for Denbigh (Sir H. Morris-Jones) initiated a Debate on the Adjournment about three weeks ago, the Minister was not here; very important matters of the Health Service were raised, and I understand that the Minister was given notice. It is apparently becoming a habit. I accept the explanation which has been given. No doubt in future, when the Minister has not been in the House all day, we shall see him when important points concerning his Department are being raised.
The hon. Member for East Wolverhampton (Mr. Baird) described the Minister's regulation as a hasty one. I should be more inclined to describe it as a panacea and a somewhat vindictive one. He will not overcome the difficulties, which he has himself created, by this sudden chopping down, as the hon. Member for East Wolverhampton so rightly pointed out, in a manner which results in cutting rates after a certain amount has been earned. That applies most particularly when one bears in mind—as I do not think the hon. Member for East Wolverhampton did bear in mind—that there are also Income Tax and Surtax to reckon with, the result being that rates which might be earned after the minimum amounts earned by this order have been reached, might be negligible. I am sure it is not the Minister's desire, although it is the result of this order, that he should get highly skilled work done virtually for nothing, in circumstances in which he very much wants to get it done, in order to sustain his political reputation.
May I make special reference to the effect of this order in rural areas? Of course, a large part of present-day legislation is based on the assumption that those in Whitehall know better what is going on elsewhere than the people on the spot, but apparently those in Whitehall in this instance have overlooked the fact that a dentist's work in a rural area, among agricultural patients of all classes, is to a great extent seasonal. People working on farms have not time to go to the dentist during busy times, during harvest or haymaking or fruit picking, whatever the seasonal operation may be. Therefore, the dentist finds that in rural areas his work is crowded into those months of the year in which there is not quite so much work to be done on the 1104 farms—in other words, into the winter months. A dentist in my constituency who has considered very carefully this order and its application to himself, as he is entitled to do, assures me that the effect of the order is going to be this: he is going to suffer very considerably because of the seasonal nature of the work coming in, while set off against that is the constant nature of his overhead charges, including his need to pay a mechanic all the year round. A dental mechanic is not usually employed on piece-work terms; he is employed on a salary, unless he is in a large urban centre, where he may be working as an independent man.
§ Mr. Blenkinsop
I want to ask the hon. Member whether he realises that the regulations, as drafted, provide for the carryover of earnings from month to month, so that, in effect, at the end of each month there is a new reckoning so as to ensure that if he has a lower rate of earnings in one month he can reclaim part of the excess in the previous month.
§ Mr. Renton
I am much obliged to the Parliamentary Secretary. May I assure him that the constituent who referred the matter to me, and I myself, had carefully considered that point. It so happens that the first months which come into reckoning are, for my dentist, the busy months, and the later months are the slack months. That is true of nearly all dentists in the rural areas. It must be so. It seems to me that what has happened is—and I hope that the hon. Member for East Wolverhampton will take good notice of this; I do not wish to be unkind to him, as I know his motives are sincere, but he has fluctuated from time to time—that the Government have undertaken to do a great deal in the provision of dental services without having the manpower to do it. If they wish to produce the goods, they must make it worth while for people to work overtime and to work hard, at some risk to their health. It seems to me that the Government have bitten off more than they can chew, and that this order does not in any way help the matter.
§ 11.18 p.m.
§ Mr. Assheton (City of London)
I have no desire to intervene in this Debate except to offer congratulations to the Parliamentary Secretary, who is new to 1105 the post, upon the gallant effort he has made to defend a difficult position. I am sure that the hon. Member for Huntingdon (Mr. Renton) was not aware, as I am, that the Minister whose absence tonight we deplore, has suffered a domestic bereavement. If he had been aware of that, I am sure he would not have said what he did.
§ Mr. Renton
I am obliged to the right hon. Member for pointing that out. Had I known that earlier, I would not have made the remarks that I did.
§ Mr. Baird
May I also congratulate the Parliamentary Secretary? I know what a difficult and technical subject this is. The hon. Gentleman has done very well; he has not satisfied me, but his offer to the dentists of an opportunity to meet the Minister and to get together with a view to solving this problem in the way which I suggest is the only way, satisfies me to some extent at least; and I therefore beg to ask leave to withdraw the Motion.
§ Motion, by leave, withdrawn.