§ 5.46 p.m.
§ Mr. Baird (Wolverhampton, North-East)
I beg to move,That an humble Address be presented to His Majesty, praying that the Regulations, dated 24th April, 1950, entitled the National Health Service (General Dental Services) Fees (Amendment) Regulations, 1950 (S.I., 1950, No. 663), a copy of which was laid before this House on 25th April, be annulled.It is generally known in the House, and I think all sides of the House will 912 agree, that in relation to the cost of the health services as a whole, the cost of the general dental services are out of proportion. I think that on all sides of the House there will be agreement that there should be some reduction in dentists' remuneration. I, for one, agree entirely with the Minister in regard to some cut for dental remuneration. At the present time the cost of the dental services is running as high as, if not a little higher than, the cost of the general medical services, and while there are some 9,000 dentists on the register there are some 19,000 general practitioners.
My reason for moving this Motion tonight is not because I object to a cut but because I believe that the Minister's method of cutting the remuneration of 913 dentists is wrong. Perhaps I might enlighten the House by recalling that some 12 months ago dentists' remuneration was cut by 20 per cent. The Minister has now arbitrarily imposed a further cut of 10 per cent. in all dentists' remuneration, that is from the monthly cheque which the dentist is paid, 10 per cent. will be deducted each month. As a result of this cut all sections of the dental profession will suffer. The dentist who is slow and a good worker and who is doing a limited amount of work, will suffer just as much as the dentist who is making as much as he can, working as fast as he can to get as big a turnover as he can.
My objection is that the aim of the Government should be not to penalise the good dentist, and that is what the Minister is doing, but to get to the root of the problem and penalise the "spivs" in the dental profession who at present are carrying on a racket and exploiting both the Government and the general public. My objection is that the good and the bad will suffer alike under this Regulation.
§ Sir Hugh Lucas-Tooth (Hendon, South)
The hon. Member has made an allegation against his own profession. I do not wish to engender heat, but he has described certain people as the "spivs of the dental profession." Would the hon. Member indicate what he means by that term—what sort of people are the "spivs"? I think that is important in order to avoid unnecessary altercation.
§ Mr. Baird
I do not wish to begin slandering anyone tonight, or making any accusations even if I know they are true. My main reason in moving this Motion was to see whether I could bring both sides together, and stop what is going on. If the hon. Member wants quotations I will give him one. I heard about it two days ago. The wife of an official of this House went for dental treatment. She was given an appointment two months later. The dentist does both private and public work. She went into the waiting room among a lot of other people. The receptionist said to her, "Come along Mrs. So-and-so, you are one of the charity patients, aren't you?" That is one of the actions of the "spivs," and I could give many more of all types, but I do not want to go into that tonight. The right hon. and gallant Member for Kelvingrove (Lieut.-Colonel Elliot) once 914 accused me of making a filthy speech because I made such accusations, but from the correspondence which he got afterwards he will know that what I said was quite true.
§ Lieut.-Colonel Elliot ( Glasgow, Kelvingrove)
As I have been challenged, I think that the instance given by the hon. Member is singularly inappropriate. What he has described is a piece of gross discourtesy on the part of an assistant, and seems to me to have nothing to do with his main accusation. As for the correspondence I got after the speech, I got many more letters in favour of what I said than against it.
§ Mr. Baird
As I was going on to say, there has been much loose talk recently about the income dentists have been making. It has even been quoted in this House that dentists are making £30,000 a year, and so on. The fact of the matter is that the figures quoted, both in this House and in the Press, have almost always been gross figures and referred to a very small section of the dental profession. Even though they are gross figures, the Ministry has allowed 52 per cent. of that figure to the dentist for his expenses. That figure of 52 per cent. was arrived at in the early days of the Health Act. Since then there has been a cut of 20 per cent. and another cut now of 30 per cent., but the cost of running his practice is still the same. The dentist still has to pay his mechanics—and pay them even a higher wage now—and for his materials. Therefore, while his gross income has been cut by 30 per cent. his expenses are still as high. I would suggest that the amount of percentage which a dentist is allowed for expenses should fee not 52 per cent., but something like 70 per cent., because his income has been cut and his expenses are still as great.
The House should realise that dentists are working very long hours to make these high incomes. I should have declared my interest as a practising dentist. The demand for dental service today is very great indeed. I do a certain amount of dental practice. I start work at 8 o'clock in the morning and I can get as many patients as I want, to come to me at 8 o'clock in the morning. Indeed, if I were willing to start at 7 o'clock, it would be quite possible to get patients to come at 7 o'clock, 7.30 and 8 o'clock.
915 The reason is that there is a much bigger demand now for dental services, especially from the lower income groups, than ever before, and dentists are doing very much more work than before. Therefore I say that whatever cut we do impose, we should see it does not penalise the man who is doing his best to work the Act sincerely and to do good work. We should use any opportunity we have to cut down and discourage—I repeat it again—the "spivs" in the dental profession.
There are various ways in which we could do this and I feel that the Ministry has gone the wrong way about it. There should be more supervision of the work done by the dentists. We have a dental staff in the Ministry of Health whose work is first of all to ensure that the best conservative treatment is being followed by the dental profession. Secondly, it is their duty to ensure that there is every reasonable economy in the working of the Health Act. If this dental staff of the Ministry of Health were at full strength, or even at the strength of its present establishment, we could ensure much better control over expenditure. The establishment is 44 dental officers, but there are only 22. The establishment for the Dental Estimates Board at Eastbourne is 12 dentists but they have only five.
The reason is simple. While we are paying dentists in private practices, a salary at least as high as the Spens Committee report suggested—£1,650, and perhaps a little higher—the dentists employed by the Ministry of Health to carry out the most responsible job of adjudicating on the work of the dentists are being paid a much smaller income. I have previously suggested that the Ministry, by an expenditure of a few thousand pounds in increasing its salary of its inspectorate, and perhaps employing a few more on that work, could save millions of pounds. I wish to ask, and I should like a reply, if any Government inquiry has been made to see if this could be done and what the saving would be in hard cash. I suggest it would fee millions of pounds.
There are other ways in which a saving could be made. The Dental Estimates Board at Eastbourne, to which all cases are referred, can refer the estimates sent 916 to it, back to the Ministry of Health officials, who can inspect the patients before treatment is commenced. I wonder if the House realises how much of this supervision there really is and how many of the estimates sent into the Dental Estimates Board are referred back for inspection? Is it 20 per cent.; 10 per cent.; 5 per cent. or 1 per cent?
I will make an estimate that the number of dental estimates which are sent in to the Dental Estimates Board and referred back for inspection is as low as 0.2 or 0.3 per cent. I believe that in a large proportion of the cases that are referred, the amount of the estimate is curtailed. I believe that on the average the amount of saving on the cases examined by the Ministry officials is 20 per cent. We have already a saving of 20 per cent. on 0.2 per cent. of the estimates referred. If we referred back more for inspection, the saving would amount to millions of pounds a year.
There is another point. The number of cases for treatment which are referred are, as I say, very small. The Minister, I believe, has a right to justify in this House the type and standard of work which is being done by the dental profession. If only.2 per cent. is being examined—and I hope that he will disagree with this figure if he can—how can the Minister possibly get up in the House of Commons and say he is giving value for money? He does not know the type of work being done. He has no way of indicating the type of work being done. Therefore I believe that by bringing up the establishment of the Dental Estimates Board and of the dental officers of the Ministry of Health to full strength and paying them adequate salaries—and it may be by extending the inspectorate a little further—millions of pounds could be saved.
If a cut has to be imposed—and I think it has—there is a much fairer way than the type of cut imposed by the Ministry which is a 10 per cent. overall cut. I believe it would be much better if the cut was on a sliding scale. I would suggest that a dentist whose gross earnings were, say, £450 per month—that is gross earnings, remember—should be cut by 2½ per cent. A dentist who is making £500 per month gross should be cut by 10 per cent. and a dentist making £600 a month gross by 20 per cent.
917 In other words, the cut should be graduated so that the man doing good work and taking his time, should not be penalised. The more a dentist was exploiting the position and working too long hours, the more the cut would be. The danger is that if we impose a cut on the type of man of whom we read in the Press, who is earning £20,000 or £30,000 a year, he will simply work a little harder and the standard of his work will fall lower still. That is what is happening. The best way would be to spread the cut as much as possible so that the "spivs" who are making the big gross incomes would be penalised, but the average dentist doing a good job of work would not.
Hon. Members opposite know that I hold no brief for the dentists, but I believe that the Minister has been arbitrary in the cut which he has made. He did not consider the matter fully before he made it. Something should be done now to break this deadlock between the dental profession and the Minister. I appeal to both sides. I appeal to the dental profession. I believe that there has been a change of heart recently and that the dental profession would like another chance to consider this problem. I appeal to the Minister to give them the opportunity. If they are in favour of the type of cut I suggest—a sliding scale or graduated cut—some gesture from him would go a long way towards reopening negotiations.
In the interests of an honourable profession which has done good work in the past but which, because of its political attitude over the last three years, has lost all public support, we must make an effort. It is bad for a profession such as this to lose public support, and the time has come when we must try to come together and to get the new scheme working properly from the dental point of view. Some gesture from the Minister would be welcomed both by the dentists and the general public. I hope that as a result of what the Minister has to say, I shall be allowed to withdraw this Motion later.
§ 6.3 p.m.
§ Miss Burton (Coventry, South)
Differently from my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird), I probably speak for most hon. Members of this House irrespective of 918 party in that I speak from the consumer end of the dentist's drill.
§ Mr. Deputy-Speaker (Colonel Sir Charles MacAndrew)
Does the hon. Lady rise to second the Motion?
§ Miss Burton
May I thank you, Sir, and the House for the courtesy shown to a very ignorant new Member. I speak from the consumer end of the drill, rather differently from my hon. Friend the Member for Wolverhampton, North-East. I do not support his Prayer, but I think he has a case when he speaks about the cutting of all dentists' earnings.
I am in the fortunate position of having a dentist who gives service under the National Health Service Act. That dentist has spoken very strongly to me about the inflated earnings of certain members of his profession. He has expressed a wish that it were possible to cut those inflated earnings rather than the earnings of those people who do a solid job. I think we all agree with him. I should imagine that it would be rather difficult to frame a law which would cut earnings in the way suggested by the hon. Member for Wolverhampton, North-East.
Recently in this House in an Adjournment Debate we discussed the scarcity of dentists for the school dental service. Obviously, if there are to be these inflated earnings in the dental profession it will become more difficult than ever to attract dentists to the school dental service. I have tried to get some figures of dentists' earnings at present, but I was not successful. I wanted some general guide showing earnings since the National Health Service Act came into force, so that I could compare them with the position before that date.
I believe that in this country the strongest force is that of public opinion. I am sure that all hon. Members on both sides of the House regularly get complaints from their constituents. I have two letters here from people who are not being treated well by the exceptions who are doing great disservice to the members of the dental profession, most of whom 919 do their job well. We all know that some of these people get inflated salaries. Last week we heard of a dentist in Wales who made £24,000 a year. Cases like that make the headlines, but the dental practitioner who does a good job of work is not mentioned.
If the dentists everywhere and we in this House expressed very strongly our disapproval of these few dentists who are rendering a great disservice and who are being anti-social—using the word "social" in its best sense—perhaps the position would improve. I have here a letter from a constituent and I have confirmed the facts of the case. This constituent had a daughter who came home for five weeks from college. She wanted to go to the dentist whom she had attended for 17 years. She went to that dentist, and the first remark he made was, "Is this a paying case or is it under National Health?" She said that she required treatment under the National Health Service and he replied, "I am sorry. I can do nothing about it."
I took up that case with the Ministry of Health, and I received the answer, which I knew they must give me, that legally that dentist was within his rights, and that there was nothing to compel anyone to join the service or, having joined it, to take people. Nor was there anything to prevent them taking private patients as well. One might imagine that the dentist had so much to do that he could not take on any more work. In that case, his refusal would have been social as well as legitimate.
Three weeks later, the father of the girl went to the dentist. Fortunately, I am not one of those people who have to wear dentures, but I should imagine that it is just as serious if a tooth breaks in ones dentures as it is if a natural tooth breaks. He went to the dentist and asked to have his denture mended. The dentist said, "Is this a paying case?" The man replied, "No," and the dentist answered, "Then, I am very sorry, but I cannot attend to you." The man could not wait for the work to be done later, so he paid 17s. for the repair to be made. I am aware that hon. Members on both sides of the House condemn practices of that kind.
Only last week in my constituency a man came to me and complained that he 920 had been unable to find a dentist who would take him under the National Health Service. I hope that we shall be able to find him a dentist. If the dental profession can do anything to prevent dentists bringing discredit on them in that way, they will do their profession a great deal of good. That is why I raised the matter tonight. I do not support the Prayer, but I am glad that it has given me an opportunity to bring these matters forward.
§ 6.8 p.m.
§ Sir Hugh Lucas-Tooth (Hendon, South)
I am very glad to be able to follow the hon. Lady the Member for Coventry, South (Miss Burton). She and I were opponents in 1945 and, to some extent at any rate, we shall be opponents this evening. I am not certain just how the Debate will go. The purpose of this Prayer is simply to annul the Statutory Instrument which effects a flat rate reduction of 10 per cent. on the gross payments made to dentists under the National Health Service, and nothing else.
I do not deny for a moment that there is need for some action in connection with the dental service. I think that there I can speak for hon. and right hon. Gentleman on this side of the House. Clearly, all is not well with the dental section of the National Health Service. Last year the country spent £48 million and that was wholly divisible between some 10,000 dentists who are now within the scheme. That figure covered dentists in England, Scotland and Wales. It works out at a gross payment of about £4,800, on an average, per dentist per year, and that is ignoring altogether anything which they may have earned outside the scheme. That figure compares with an average of £2,500 a year payable to the doctors within the National Health Service.
It is quite true, of course, that the expenses in the case of the dentist are higher than the expenses in the case of the doctor, but there is something fundamentally wrong when we find that the average dentist is being paid just about twice as much as the average doctor. There must be something wrong with a scheme which produces that result. In the present year, if the Estimate is justified—and the Estimate for the National Health Service has been rather unfortunate 921 in the past—the average dentist will earn £4,500; but that is a gross payment, out of which he has to find his expenses, amounting to something of the order of 50 per cent. The Spens Report proposed, in effect, that the average gross earnings of a dentist should be about £3,800 a year, and that takes into account the difference in the value of money between the time at which the Spens Committee made their recommendations and today, and also takes into account an arbitrary figure, which is probably not a very wild one, of 52 per cent. for expenses.
Therefore, £3,800 would be the average earnings of a dentist under the Spens Report. That is not, of course, a minimum figure, but an average figure. It contemplates that some dentists would get less, and that others would get more. The average dentist, working by himself and giving full service with all reasonable means in his power, should be able to make gross annual earnings of £3,800.
§ Mr. A. Edward Davies (Stoke-on-Trent, North)
The hon. Baronet has raised a most important point. He has said that the Spens Report mentioned £3,800 gross. Has he any comparable information from any other source—I think this is within the ambit of our discussion—concerning the figure which the doctor is supposed to be getting? He has mentioned the allowance of 50 per cent. for overheads. How does this figure compare with the doctors"? It seems to me that the figures have gone completely haywire.
§ Sir H. Lucas-Tooth
It is very difficult to compare the figures, because the ratio of expenses in the case of doctors is different. I think the Spens Committee reported that, on the average, a doctor should get about £200 a year net more than the dentist, but, of course, that does not necessarily mean that the doctor would get anything like that, taking the gross figure. At the moment, if we divide the total amount available to the doctors by the number of doctors in the country on the basis of last year's payments, the doctor is getting about £2,500 gross.
§ The question which I want to put to the Government in the present context is this. We have a Spens recommendation which works out at £3,800, or a total of £38 million for the 10,000 dentists in the 922 scheme, and yet we have an actual figure of £46 million contained in the current year's Estimates. Is the 10 per cent. cut, which is effective under these Regulations, supposed to bring down the estimated figure to the Spens figure, with certain corrections for increasing numbers of dentists, and so on? It seems to me that these two figures clash, and I ask the Government why they picked on the figure of 10 per cent. Was it with a view to bringing down the £46 million into line with the figure of £38 million? If that was not the basis of the calculation, will they say why they think that 10 per cent. is the proper figure, and why it should not be 5 per cent., or even 15 or 20 per cent.? What was the basis on which they arrived at that percentage?
§ Mr. Baird
The hon. Gentleman does not understand me on this point. In 1948, the Ministry recognised 52 per cent. as a legitimate expenses allowance on the gross earnings, but, since then, there have been cuts of something like 40 per cent. in the dentists' gross income, and yet he is still only allowed 52 per cent. for expenses. I say that, despite the cuts, he still has to pay his mechanic, his rent and for the materials he uses. His gross income has been cut by 40 per cent., and we should therefore allow him something like 70 per cent. as the deduction for expenses from his gross earnings.
§ Sir H. Lucas-Tooth
The hon. Gentleman cannot speak for the Government, and I am asking the Government to make perfectly clear what is the figure which they are taking for expenses. It seems to me that we have these two figures—£38 million on the old basis of the Spens Report and £46 million in the current Estimates—and the difference between them is rather more than 10 per cent. It may be that that difference is accounted for by some additional allowances for disproportionate expenses, but I think the Government must give us an answer to that question. How do they know that 10 per cent. is the right figure?
In the light of the information available to hon. Members, there will probably be no great disposition to cavil at the idea that an average gross figure of between £3,800 and £4,000 is not very wide of the mark of what is desirable for dentists. It seems to me, from such calculations as I am able to make, that some figure of that sort is about right; 923 in other words, there is a case for saying that a deduction from the total amount payable to the dentists should be made, and I do not think that there is any great difference of opinion between the two sides of the House about a deduction of the order of 10 per cent. being a proper one at the present time. I would emphasise, however, that that is a deduction from the average amount payable to a dentist in respect of a fair year's work. It is important to bear in mind, first of all, that the figure is an average one and that it is in respect of a fair year's work. We should therefore disregard any other sums which may have been earned, in view of the very special circumstances existing at the present time.
The hon. Gentleman who moved the Motion spoke of the inflated incomes which are being earned by certain dentists, and I think the House will agree that there is a figure for a dentist's income beyond which it would not be reasonable for us to go. [HON. MEMBERS: "' No."] Some of my hon. Friends appear to disagree with me, but perhaps they will not do so when I finish my argument and say that I do not think there should be a limit to the high earnings of dentists purely for ideological reasons. On the contrary, if a professional man can do twice as much work in a year as the average professional man, then he deserves to get twice the pay. But that is, of course, if he does twice as much work of the same standard. If the dental service were working perfectly and each separate operation were properly rewarded on a basis of merit—which is the assumption that the Parliamentary Secretary is bound to make because that is the assumption on which the whole Health Service, as at present set up, is being run—if, in other words, this system of piece-work is working properly, then the dentist who earns £15,000 a year is doing exactly three times the number of operations as the dentist earning £5,000 a year. If the Minister's machinery is working properly——
§ The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)
I assume that the hon. Gentleman has heard, as we all have, of professional people who work at different rates. They 924 may all do equally good work, but some may work very much faster than others.
§ Sir H. Lucas-Tooth
I quite agree with the hon. Gentleman. I say good luck to the man who works faster if he does equally good work and twice as much of it. I am not concerned with the time he actually spends——
§ Sir H. Lucas-Tooth
The hon. Gentleman seems to forget that these were exactly the questions which we raised time and time again when the National Health Service Bill was going through the House. These were the very questions we put to the Government; we said that the scheme would produce exactly these results.
§ Sir H. Lucas-Tooth
My reason for saying that I think there ought to be a limit to the amount which a dentist is able to earn is not based on ideological grounds—in any case, he will not have much left because our fiscal policy will take care of that—but because the enormous pressure of work on dentists who are making large incomes is beginning to tell on the dentists themselves and on the quality of their work. That is why I think some limit should be set, and that is the fundamental difficulty which this House and the Government have to face. It is the difficulty of the actual shortage of dentists. There are some 10,000 dentists in the National Health Service, and another 1,000 or 2,000 in the service of local authorities or carrying on private practice. That means that there are 12,000 to 13,000, in all, trying to do the work that 15,000 or 16,000 ought to be doing if they are to give the time which we should all like to see them give to their job. That is the problem we have to face.
I hope that today we shall be able to avoid some of the acrimony which has entered past Debates on the dental service, because I think there is a growing appreciation on the other side of the House that some of the things we on this side said in the past are true. We said that the Minister would find that he could not carry out the service he had in mind because there were not the dentists available. We said then, and we say now, 925 that we accept the principle of free dental service as an essentially desirable aim, but the dilemma which we are now facing is that there are not sufficient dentists to provide such a service.
If we are to give those dentists who are available what we consider is a proper amount of pay and insist that they shall not receive heavy rewards for doing overtime, then we shall not get the work done. On the other hand, if we overpay the dentists, we shall get overtime and all the consequences of which the country is only too well aware. We are trying to get a quart out of a pint pot. The result is that, first of all, there is excessive cost. We are trying to bribe the dentists to do more work than they are physically capable of doing. Incidentally, we are sucking the school dental service completely dry, and there is no one on either side of the House who will deny that fact.
If we reduce the fees payable to dentists—as is now proposed—in order to cut down these excessive costs and to ensure that some of them flow back into the school dental service, we shall find that the queues will grow longer, and, what hon. Members opposite never stop complaining about, that the dentists will tend to go back to private practice. The inevitable result of these Regulations will be to encourage dentists to take private patients because there will be less substantial fees payable in the public service. Hon. Members opposite always talk about that as if it were a wicked thing. In either event, the dentist is treating a patient who is suffering, and it is only natural that he should choose the patient who pays him better.
§ Sir H. Lucas-Tooth
If that is the difference between the two sides of the House, it only goes to show that we are living in a real world and that hon. Members are living in a dream world. I can assure the hon. Gentleman that a man who has £5 or £10 in his pocket and is able to pay his dentist feels toothache just as much as the man who has not the money.
§ Sir H. Lucas-Tooth
The position is wholly different in the case of the medical profession, but I would say to the hon. Gentleman that if a doctor is making up his mind whether he will go into the State Health Service or remain outside it and treat private patients, he will say to himself, "Either way I shall be doing good and healing people. In either case their sensations are the same, and, therefore, the question before me is which career will pay me better." Of course, he will take into account such matters as whether the work is congenial, but if the work is the same in either case he will obviously come to that conclusion. It is a question which all ordinary men of ordinary standards and morals ask themselves.
We in this country, at the moment, have not enough dentists to carry out a completely free health service. If I may change the metaphor, we have not enough cloth to make ourselves trousers and a coat. We can either make a pair of trousers or a coat, but we cannot make the whole suit. If we try to make the whole suit we shall find ourselves faced with exactly the sort of disaster which our dental service is facing at present—extremely uncomfortable and a strong tendency to split in various places.
The proposal contained in the Regulations against which the hon. Member is praying is one which must command some degree of assent, for the reasons I have stated earlier in my speech. But, at best, it can be nothing more than a temporary expedient. It may achieve a lower average cost, a lower charge to the State in the immediate future, but it will hit the new entrants into the service harder perhaps than any other section of the dental service and, to that extent, it will tend to dry up recruitment.
In so far as it tends to stop large incomes being earned, it means that, in effect, it will deter dentists from working the present exceedingly long hours. That will lengthen the queues in dentists' waiting rooms. There will be greater inducement to dentists to turn over from the public service to private service. That is the inevitable result and, whatever one's views may be on the morality or otherwise of this question, it is a result 927 which I think we should all deplore on both sides of the House.
That must be the ultimate result. Although some reasonable reduction should be made, I hope the Government will be able to assure us this evening that this is a purely temporary measure, that they recognise the kind of objections I have sought to put before the House and that at the earliest date they will go over this question of dentists' emoluments with the greatest care and produce a new scheme. I believe it will have to be a much more fundamental change than we could discuss on these Regulations. If we cannot get an assurance of that sort, I should wish very much to consider my attitude to the hon. Member's Prayer.
§ 6.34 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)
As I listened to some of the remarks of the hon. Member for Hendon, South (Sir H. Lucas-Tooth) I at first thought we had him with us in desiring some reduction in the cost of the dental services. As he went on with his speech I was beginning to doubt that. I feel that the only logical conclusion to what he was saying was that the dental services section of the Health Service should be withdrawn. I do not know whether he does intend that. It was clearly at the back of his mind when he was saying that, in the earlier days of inauguration of this service, he himself, amongst others, had suggested that this particular element of the Health Service had been introduced too soon. Surely, the deduction from that is that this service was introduced too soon and possibly should now be withdrawn.
§ Sir H. Lucas-Tooth
I said nothing of the sort. What I said was that I think the attempt to have a completely free health service was done much too soon, that it would have been possible to provide for the proper care of all the children in this country, for example, and that that would have been far better than to try to deal with a good many aspects of these services which could have waited until after the children had been dealt with properly.
§ Mr. Blenkinsop
I do not want to carry this forward too far. It is hardly fully applicable to this Prayer, but it is of importance that we should have on 928 record that the hon. Member does feel that apart from priority services—which I agree have suffered severely by the attraction of the other dental services—the rest of the service ought possibly to be withdrawn. I take it that is the intention of what the hon. Member has been saying.
Broadly speaking, there has been agreement on both sides of the House, probably including the hon. Member, that there ought to be further reduction in the cost of the dental services and that the figures now being earned by the dentists are higher on the average than that laid down by the Spens Report and higher than we can reasonably be expected to pay. The figures he quoted were quite accurate but, taking the average, it is true that something like £4,850 gross has been paid over the year 1949–50. As he said, even assuming that the proportion of expenses is at the rate of some 52 per cent., that leaves a figure of some £2,250 as against a figure of approximately £1,800 a year that was recommended in the Spens Report.
We have to take account of the fact that the Spens Report assumed a period of working which has been falsified by events. That is to say, it assumed a certain period of hours at the chair-side which, as my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird) said, is in fact being exceeded. But making some allowance for that, there is no doubt the figures now being paid must be further reviewed. The main question that has arisen in this short Debate is whether we are reviewing that high remuneration in the proper manner, and whether we are satisfied that the way to do it is by making this overall cut of 10 per cent.
§ Mr. Blenkinsop
The figures submitted by the Spens Report—not by the Minister—assumed that there would be a certain period of time worked but, as is made clear by the Penman Report, and indeed made clear before that, that period of working has been falsified by the actual practice.
§ Sir H. Lucas-Tooth
Before the hon. Gentleman leaves that point, may I say he did imply that the figure of 33 chair-side 929 hours has been thrown overboard by the Government as the proper amount of time. If he does not mean that, would he make it clear?
§ Mr. Blenkinsop
I merely said it is clear from the Penman Report, as well as from other evidence, that 33 chair-side hours are not being worked.
The point arises as to the best method of securing a reasonable reduction in remuneration. As hon. Members know we made an overall cut of some 20 per cent., in effect, last year. It takes some time, of course, for that cut to be effective in actual payments to dentists and we must keep that in mind. One has to consider whether there is any other way of securing a reduction in the amounts being paid out to the dentist that would be fairer both to the dentists themselves and to the general public and would help to bring about a better dental service than we have at the present time.
I must make it clear at the very outset that there is really no question here of what might be called an arbitrary cut such as my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird) suggested. In fact, there have been discussions with the dentists on this matter and we have made it clear that we are most anxious to have alternative proposals as to the way in which reductions could be obtained. But we did feel—and we expressed this quite clearly to them—that although we were anxious to have alternative proposals, this was not a matter which could be left for an indefinite time while alternative proposals were being worked out. We said this in a letter to the British Dental Association:He"—that is the Minister—therefore proposes as interim action to reduce the amount paid on estimates for work undertaken after 30th April by 10 per cent., this reduction to be effected by deducting 10 per cent. from the aggregate total fees in respect of such work, in order to avoid disturbing the present scale of fees. The Minister is, however, prepared to consider substituting for this arrangement a scheme for a sliding scale of reductions applicable to higher earnings which would result in no less a saving, if and when a practicable scheme can be worked out to his satisfaction, with as he hopes the agreement of the profession, and he trusts he can count on the co-operation of the profession to this end.That makes it quite clear that we are not putting forward this scheme as a final 930 proposal. We are most anxious at all times to consider any alternative proposals that may be put forward, but I must remind hon. Members that we have in the past attempted one form or another of ceiling to dental fees. Indeed, my hon. Friend the Member for Wolverhampton, North-East, prayed against that particular method of trying to secure economies in the expense of the dental service early last year.
Therefore, although this proposal for a sliding scale out is slightly different, we have to hear in mind our experiences when we imposed the ceiling last year, namely, that after earnings had reached a certain point there were some dentists who said "After this point in our earnings we are not going to take any more National Health Service patients; we are going to take private patients only." It was largely because of that fact that we agreed to replace that ceiling cut by the 20 per cent. overall cut that we made last year. In any proposals which are submitted to us for a sliding scale revision we have to consider whether or not it would have a similar effect.
§ Mr. Blenkinsop
No detailed scheme has been submitted to us. Negotiations have been broken off by the dental profession. We would ask them most sincerely to come forward and make these alternative proposals to us. The sooner they do so the sooner we shall be able to introduce some other scheme. We are certainly not prepared to await such an alternative sliding scale scheme without taking some interim measures to secure effective reduction.
§ Mr. Geoffrey Cooper (Middlesbrough, West)
In what circumstances were those negotiations broken off by the dentists? The feeling abroad is that although they put forward suggestions, they were met with a flat refusal.
§ Mr. Blenkinsop
No such suggestion has been put forward. It was merely that the dentists said that they felt some sliding scale scheme would be preferable to this overall cut. As I explained in the 931 quotation which I read from the letter which my right hon. Friend sent to the British Dental Association, we accepted that a sliding scale cut might be more effective and more helpful, and we shall certainly be quite willing to consider it, but we were not prepared to await the details of a scheme of that sort before taking action. It is perfectly clear that any proposal for cutting dental fees can only become effective over quite a considerable period of time. Therefore, the door is still open for negotiations and discussion should the dentists come forward with any further proposals.
A good deal has been said about this proportion of 52 per cent. for dentists' expenses. That is the figure that was accepted when the scheme was introduced. We are by no means satisfied that the 52 per cent. is accurate today—but not in the manner that my hon. Friend suggests. We feel that, in fact, 52 per cent. is today too high a figure, and that in considering the expenses ratio one has to keep in mind the volume of work that the dentists are undertaking.
A review is being carried out of the expenses ratio, into the actual amount of these expenses; earlier on it was carried out with the co-operation of the dentists, and now I am not so sure whether they are prepared to co-operate or not, but we are anxious to have their help in getting at the actual facts of what their expenses are. We hope that even now they will be willing to help us in what can only be of assistance to both sides, because we cannot work continuously upon some assumption as to what the figures are. It should be possible to get accurate figures which would help both sides in the negotiations. As I have said, that review is being carried out and should enable us to get more accurate information.
My hon. Friend the Member for Wolverhampton, North-east, very properly suggested that savings might be effected by a more thorough supervision by the Ministry itself, in addition to any other method of cut. He pointed out quite properly that at the moment the Ministry establishment and the staff of examining officers are below the level that we should desire. That is perfectly true. It is also obviously true that the Dental Estimates 932 Board is limited in the amount of effective checking that it can carry out by the size of its staff. We are considering the point that he raised and we are hopeful that we shall be able to improve the effectiveness of the checking in future months.
§ Mr. Blenkinsop
I cannot give the percentage. All I can do is to point out that quite a large number of cases come before the executive councils which originally had been investigated by Ministry of Health inspectors. For example, some 700 cases have been before the executive councils, and there is no doubt that the sort of disciplinary measures which are taken by the Ministry through the executive councils are very effective. All we want is to ensure that that is made still more effective by the improvement of our general staff. We cannot say precisely what saving could be effected by an increase in staff. Obviously that is quite impossible, but we are satisfied that it would be possible to obtain valuable savings in this way.
I do not think any further points were raised. We appreciate the interest of the House, and I think we also appreciate the fact that hon. Members on both sides of the House desire above all to get the dental remuneration into fair balance with other professional bodies within the general Health Service, and also to do what we can to help to develop a proper standard of service for the general public. There is no doubt that there is a big field indeed in which the professional organisation itself can assist in effectively controlling its own members so as to ensure that a proper service is given—as, indeed, we have a right to expect, on the basis of the very adequate remuneration which is being paid.
I ask, therefore, that the Prayer shall be nullified by the House on the grounds that the cut we have imposed is an interim cut and that we are willing at all times to consider alternative proposals, but that immediate action must be taken to ensure more reasonable remuneration for dentists than the extravagant figures which have been paid.
§ 6.51 p.m.
§ Mr. David Eccles (Chippenham)
The Parliamentary Secretary reveals to us the 933 bankruptcy of the Minister, who has no ideas except that of making a flat cut, who admits that that is not satisfactory, admits that the dental service is not being paid in a way which gets the best out of the profession, who supposes it a good introduction to co-operation with the profession, a good piece of democratic planning, to impose this unilateral out and who then expects the dental profession to come back in a good frame of mind.
§ Mr. Blenkinsop
We have had quite a long history of negotiation with the dental profession, and it has not been a very happy one. I should like to know whether the hon. Member for Chippenham (Mr. Eccles) thinks we ought to continue to pay these high fees.
§ Mr. Eccles
I shall tell the Parliamentary Secretary about that very shortly. I hope the hon. Member for Wolverhampton, North-East (Mr. Baird) will not take it personally if I say that dentistry is not an attractive profession. The dental surgeon is in much the same relation to other professional men as is the coalminer at the coal face to his fellow workers above ground in the factories. If we want to expand the labour force in a dirty industry—and spending a lifetime peering and picking in other people's mouths is not a clean job—we have to pay to attract recruits.
The basic fact about this situation, as was mentioned by my hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth), is that 10,000 dentists are nothing like enough to provide the nation-wide service which the Minister created at a stroke of the pen. Supposing that after the war His Majesty's Government had suddenly created a demand for 400 million tons of coal and had said to the coal industry, 'You can supply as much as you can get out of the ground to the customers you choose and the less time and the less trouble it takes no doubt will dictate where the coal goes." What chaos there would have been in the coal industry.
There is exactly the same chaos today in the dental industry. The demand has been probably doubled and, naturally, those who were there to supply the demand are nothing like sufficient, and to make matters worse this is a dirty industry 934 to which it is difficult to attract recruits. All this shows that the Minister was in far too much of a hurry when he brought in the National Health Service.
§ Mr. Blenkinsop
Both the hon. Members for Chippenham and his hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth) have talked about being in too much of a hurry. Does the hon. Gentleman therefore mean that he suggests that this service should be withdrawn?
§ Mr. Eccles
I shall not give way to the Parliamentary Secretary again. He has asked me two very silly questions, both of which I shall deal with in my speech. I say that the Minister was in too much of a hurry in view of the fact that his original estimate for the service in England and Wales was £7 million, was revised to £17 million, was £26 million in 1949, and then had to be revised to £40 million——
§ Mr. Speaker
We must not discuss the Supplementary Estimates of the Ministry of Health or the whole Health Service of the Ministry of Health. We are on a very limited point on this Prayer.
§ Mr. Eccles
I bow to your Ruling, Mr. Speaker. We are on the point of cutting that estimate by 10 per cent., and I thought that perhaps I might mention the size of the figure. Of course, the proposed cut of 10 per cent. will do something to reduce the error of the Minister's financial estimates, but will it do anything to correct the errors in the service itself? By now the experience which we have had of the dental service is quite sufficient to make the Minister confess that the whole basis of his scheme is unworkable, and that he should take it away and produce another scheme.
How could we arrange, instead of cutting all round by 10 per cent.—as is proposed in the Regulations—to pay the 10,000 dentists in such a way as to get the best work out of them, to concentrate that work where it is most needed—which is not happening today—and also to attract an adequate supply of recruits to the profession? Those are the three principles which should determine the shape of the demand on the dental service at a time when the demand is so much greater than the existing profession can meet.
§ Mr. Mellish (Bermondsey)
Does the hon. Member suggest that there should be compulsory powers to deal with the dentists, to direct them into the right places at the right time?
§ Mr. Eccles
Nothing of the kind. Having stated what I believe to be the case, I will, if the hon. Member permits me, now look at this 10 per cent. cut. I suppose it will reduce the quantity of work done by the 10,000 dentists today. That is one of the aims. There will be a larger number of people waiting for treatment, a larger number of people who will never receive treatment, although they might be compensated by the fact that those who do have treatment may receive rather better quality treatment. It will certainly have the effect, however, of reducing the output of the 10,000 dentists. [HON. MEMBERS: "Why?"] Because if it is to be less attractive to work longer hours—and we are told that the people who have to be discouraged are those who put in such long hours that they do slipshod work at the end of the day—then these people will not work such long hours but perhaps they will do rather better work. At least, that will be the case if these Regulations are successful. These people will not treat so many patients.
§ Mr. Blenkinsop
The hon. Member's argument is completely opposite to that of some of his hon. Friends. They have been arguing that as a result of this cut, dentists would be encouraged to work even longer hours and the danger might be that it would reduce the standard of work. That is the argument which we have been hearing.
§ Mr. Eccles
I think that was the argument of the hon. Member for Wolverhampton, North-East (Mr. Baird). It may be so—it may be that there are some dentists who, if the rate is cut, will do more and more work, but I doubt that very much. I think it is more likely that under schemes of this sort, and also under the scheme of a graduated cut which the hon. Member for Wolverhampton, North-East proposed, a good many dentists will say, "A game of golf for me"; and that, when his income reaches a certain point—as happens with certain other highly-taxed persons in other branches of the medical profession—he will not do more 936 work. Such people will choose leisure at the week-ends, when these Regulations do not pay them to work.
Will this cut mean that more of whatever work is done by the 10,000 dentists will be done among the priority classes? It would be of advantage if the children received a little more attention and the adults a little less. I should not like to express an opinion one way or the other; I do not know enough about it. But I suspect that after this cut the hourly rate of earnings of a school dentist, allowing for the fact that he works much shorter hours and receives certain allowances such as, perhaps, a car allowance, may not be very much different from the hourly rate of the average dentist in the service. If we could now make a calculation of what the school dentists earn in a session and compare it with the nett income of a dentist in the service of adults I should doubt if the difference is so enormous as is often thought. It may be that this cut may persuade a certain number of the older men to go back into the school dental service, but I am not satisfied with just saying that it may. Steps ought to be taken to see that that does occur. I do not think the Minister is right to leave to the chance operation of this new scale of payments the bringing about what, I think, the whole House would desire.
§ Mr. Baird
This is a most important point. There are two ways of getting more school dentists. One is to reduce the salaries of dentists in general practice to the level of those in the school dental service, and the other is to raise the salaries of the dentists in the school service to the incomes of the dentists in general practice.
§ Mr. Eccles
A little later I shall say what I would do about that, but I hope the hon. Gentleman will let me approach things in order. The third question to ask is whether or not the cut will attract more recruits. Of course, it will not. As we lower the emoluments of a profession we naturally decrease the number of young men and women willing to enter that profession, in comparison with the numbers entering other professions. Furthermore, when the paymaster, the Minister of Health, is from time to time slamming cuts on a profession, without negotiations, it naturally destroys the confidence of the young people, and 937 deters them from coming into a profession where there is an employer of that—I should say—thoroughly unwelcome type of character.
I wondered whether an hon. Member—I think it was an hon. Friend of mine on this side of the House—was right when he said that the emoluments are "all haywire" compared with the emoluments of other members of the medical profession. I do not see how one can make a judgment like that straight off without asking whether it is more important that more young people should be attracted to be dentists or to be general practitioners. In this world the relative attractions of taking up two different types of medicine will be weighed up by young people. For all I know, from the point of view of the health of the nation—I do not pretend to be an expert—it may be more important to have 1,000 more dentists than 1,000 more general practitioners, but to say that the rewards are all haywire without considerations of that sort does not, to my mind, make much sense.
The hon. Gentleman the Member for Wolverhampton, North-East (Mr. Baird), made two suggestions. First, he said that millions of pounds could be saved if there were more "snoopers"—more inspectors—who went round each day to look at the estimates of the profession. "Millions of pounds," he said. He must have a very low view about his own profession, because, obviously, if millions of pounds are today being wrongly paid out it means that there is fraud on a colossal scale by members of his own profession.
§ Mr. Eccles
In so far as the hon. Gentleman says there would be millions of pounds saved by a closer inspection he is saying that there are millions of pounds fraudulently obtained in the service today.
§ Mr. Baird
This is a most important point. It is a matter of clinical judgment, 938 and not all dentists have the same clinical opinion as the Ministry of Health inspector. This is a way in which money can be saved. Let me give an example. A dentist prescribed two jacket crowns which cost about £20, and the estimate was passed. A fortnight later the dentist put in another estimate for the extraction of teeth and the fitting of a denture. That was passed, too. Since the jacket crowns were unnecessary, £20 would have been saved if there had been prior supervision.
§ Mr. Eccles
What an honourable profession it must be if every single case of treatment has to be inspected by some other dentist—by a man who has for some time enjoyed a secure job in the Ministry of Health. I should prefer to trust to the general standards of the profession rather than call on men who had failed at the chair and went to the Ministry, to go round teaching other people how to do work they could not do themselves.
§ Mr. Blenkinsop
I do not think the hon. Gentleman should be allowed to make statements of that sort, that are quite uncalled for and cannot be replied to by the people on whom he is casting a slur.
§ Mr. Eccles
I am entitled to say that there are now 22 of these inspectors who, presumably, must have been dentists themselves. The proposition of the hon. Member behind the Minister is that that number should be very largely increased. Where from? From the dentists who are now employed in their profession and now turn over to the work of inspection? No, Sir, we had too much of that in the agricultural industry.
The second proposition of the hon. Member was this graduated scale, which, of course, is a kind of Surtax: the more one earns the less one keeps of each succeeding £100. I would leave that to the Chancellor of the Exchequer. I do not think that in medical practice or any other professional occupation we can say, "We do not think it is right that a man should earn more than a certain amount." There are enormous differences between the inefficient and the efficient. I imagine that a dentist can organise himself and have several assistants—six or seven, nine or ten. He may be served by a nurse-secretary who is extremely able at controlling the flow of work. There may be a team 939 —a sort of small clinic. Why should the man at the top who organises that not go on doing that sort of thing, which is greatly to the benefit of the public? "Oh, no," says the hon. Gentleman opposite, "if he earns more than a certain amount, no matter how clever he is, no matter how efficiently he organises his surgery, or how many assistants he has, he must stop."
That is not the way to make progress in any profession or in any business. We should allow people to have a chance to go as far as their capacity will carry them. If it be said "Oh, but the standards in the dental profession are so low, their morals are not very high, they are not very conscientious, they do slipshod work" one asks: Why do they do it? Because the status of the profession was never high enough in the past. How can we get the status higher but by having some plums at the top so that the man who succeeds can earn as much in that profession as he could, say, in any other branch of surgery? And why not?
§ Mr. Eccles
The proposition of the hon. Gentleman is to put a special tax upon anyone earning more than a few thousand a year, as though we said to the greatest surgeon in Harley Street, "If you do 20 operations you will get so much each, but if you do 21, then for the twenty-first operation you will get less than for the 20." That is a nonsensical way of organising the dental profession.
§ Mr. Eccles
The hon. Gentleman brought this forward as his own proposal and I credited him with having some ideas. I was wrong.
The truth of the matter is that the Minister should confess that he has not got enough dentists for a national service. Therefore, what he ought to do is to take away this system of paying the 10,000 dentists on the piece rate as it is now, and then select carefully the priority classes in the country for whom it is important, in everyone's interest, that 940 treatment should be given—and I assume the House would agree that that was the children, and then expectant mothers—and firm steps should be taken to see that they are the first charge upon the profession as it is today.
Whether that could be done by making the service free up to the age of 18 and for expectant mothers, and then making adults pay something over and above that, I do not know. But it is up to the Minister to make a radical change in the whole dental service, because, at the moment, by his bad administration he is not only over-straining the dentists we have, but by his method of payment he is diverting their services from those who need them most. That really is not in the national interest, and simply to come here with the old bankrupt practice of a 10 per cent. cut for everybody—which, I believe, will do nothing for the expectant mothers, and precious little for the children—only shows what we all know on this side of the House, that we need a new Minister of Health and a recasting of the whole of this service.
§ 7.12 p.m.
§ Mr. Geoffrey Cooper (Middlesbrough, West)
As a rule we listen with interest to the hon. Member for Chippenham (Mr. Eccles) because he usually puts forward a reasoned case which he has, presumably, thought out with some care. This evening, however, he rather destroyed the strength of his own argument by putting forward an unnecessarily exaggerated case. I think, too, that to cast aspersions on the profession in the way he did is not helpful to this Debate, particularly when he pours scorn on some aspects of the scheme which he describes by saying that it is dirty and unattractive work. It may be in some respects restrictive, as viewed by some people, though there is no shadow of doubt that in the main dentists are trying to do an honest job of work, and trying to give a reasonable public service.
We must admit that when any schemes are started difficulties are bound to arise. We should make due allowances for those difficulties and try to be more helpful in the suggestions we make, rather than cast these sorts of aspersions about wildly. The analogy the hon. Gentleman used was particularly unhappy when he suggested that a dentist working on the face of his patient was like a coal miner 941 working at the coal face. I do not think that will be very well received in his constituency.
The Minister's real problem, as I see it, is that he is faced with the rather difficult task of effecting a reasonable balance between the total costs of the service to the public, the quality of the work—which of course, is extremely important—and the quantity of work that is done. If the total costs to the public have seemed excessive it has probably done nothing more than show the enormous amount of blacklog of work that there was under the old rather ineffective system, and we should pay due regard to that fact. On the other hand, we can see the difficulties which confronted the Minister when accounts started to pile up and the newspapers got hold of a few isolated cases where excessive fees seemed to be earned by certain dentists by streamlining their work, so that he probably had to act rather quickly.
I am inclined to think that he acted a little precipitately because there were at that time, I understand, certain negotiations in hand, and I think it would have been better if the Minister could have produced amongst the dentists right from the start the impression that he was trying to co-operate with them to the utmost extent, because by his trying to be cooperative he could have reasonably expected co-operation from the dentists. The description of my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird), of negotiations being broken off, simply indicates that the Minister perhaps did act in a way which was not best calculated to get the co-operation of the dentists that he might have got otherwise.
§ Mr. Blenkinsop
Does my hon. Friend suggest we should wait indefinitely for proposals instead of instituting this interim cut?
§ Mr. Cooper
I do in this respect. I understand—I am subject to correction on this—that negotiations were in hand, and that undue delays were not blamed on the professional negotiators, and I therefore think that if the Minister had held his hand for a short time he would probably have got an answer quite quickly.
The important thing in any negotiations—and this applies whether they are negotiations in industry or in professional 942 matters of this type—is that when a rate has been fixed and later the basis of the rate is found to be inappropriate, suddenly to make cuts is the sort of thing which causes a tremendous amount of bad feeling. That is one of the chief complaints made by trade union officials who negotiate on behalf of workers in industry. When an industrialist suddenly cuts the rate he destroys any confidence that there may be between the workers and the industrialist. I believe that the Minister should try to avoid any suggestion of that sort. Of course, it may not be true. Although my hon. Friend the Parliamentary Secretary has already spoken, it may be that later on with the leave of the House he might perhaps be able to comment on that. If he could destroy that impression which has been created amongst dentists, it might give greater hope for the future of any negotiations undertaken later on.
Undoubtedly, in many cases the earnings were high, and it may be that some of the work was scamped, but I believe that was in only a comparatively few cases. I think that the high rate of earnings has been due, on the whole, to dentists putting in an excessive amount of work. They did it in the public interest, and it is therefore unhelpful if immediately, or at an early date, they are penalised for putting in that extra work. It is an indication of their desire to do the right thing. Their suggestion to look at their Income Tax returns to see what their rates of earnings were was a decent gesture. Moreover, when the question of the expenses ratio was under consideration the method of analysing a number of Income Tax returns would have been a very fair way for the Minister to obtain the essential information he required.
§ Mr. Daines (East Ham, North)
Is my hon. Friend satisfied that the Income Tax returns of dentists, as a whole, are complete and show all their earnings?
§ Mr. Cooper
That is a very interesting point, because the system is so arranged that they cannot be paid out of public funds except against actual certificates which they send in. It is therefore known officially exactly what they are earning.
§ Mr. Daines
I take it that my hon. Friend is supporting the Prayer of the 943 hon. Member for Wolverhampton, North-East (Mr. Baird). Perhaps he would go for further sources of information to the speech of the hon. Member for Wolverhampton, North-East, when we discussed this matter before.
§ Mr. Cooper
I will certainly make reference to that, but as I understand the position now dentists can get no fees from public sources unless they render a return of what they have done, and those returns are also available for the Income Tax officials. At least the money they get from public sources is therefore well known, and that is the principal matter we are considering this evening—the money they are paid out of public funds.
The important thing I wish to refer to is the question of quality. I believe that my hon. Friend the Member for Wolverhampton, North-East, is right when he suggests that there should be a slight increase in the number of inspectors. That is not to say, as the hon. Member for Chippenham said, that every case must go before an inspector; but when there is a sufficient number of inspectors available special cases which are brought to their notice can be examined with a reasonable chance of there being not too much delay. I believe that would tend to encourage throughout the profession a higher standard of work, and would therefore tend to some extent to reduce the total amount of earnings.
I believe that if we try to cut down the expenses ratio to too great an extent, it will tend to discourage the high quality of work being done in the dental workshops, and I believe that the Minister is anxious to avoid any deterioration in the quality of the work. However, may I suggest to the Minister that, at an early date, he looks at the sliding-scales proposed by the British Dental Association, because I think he will find that the suggestions are reasonable and also meet with the general approval of the dental profession.
I think that the arbitrary imposition of a 10 per cent. cut in this way is not going to achieve his purpose. It is bound to go against the effective working of the dental scheme by making the dentists less co-operative. We have to take into account the conditions at long-term which will encourage good men to come forward 944 and take part in the scheme; otherwise it will break down and will be to the public disadvantage.
We have also to prevent, as suggested by the hon. Member for Chippenham, the complete elimination of the possibility of good salaries for exceptionally good work. It is something taken into account in the case of the Health Scheme as applying to doctors, and I do not think that dentists should be excluded from these exceptional prizes if they can justify their claim. I would ask the Minister to have another look at this 10 per cent. to see whether he is justified in making the cut at this time. I think that if he were to delay a little, he would find the dentists completely co-operative.
§ 7.22 p.m.
§ Mr. Iain MacLeod (Enfield, West)
I am afraid that I regard the Regulations before the House tonight as a stride, and a long stride, down the road to utility dentistry which the profession has been forced to enter upon in these last two years. When we look at the background of the Regulations, we have, first, the Spens Committee report. Fortunately, that ground has been adequately covered by Members on both sides of the House and I need not review it again. There are however one or two small points which, I think, should be made.
It is, first of all, well within our minds that the Spens Committee concentrated their inquiries on the age group 35–54, and that 50 per cent. of that age group were, pre-war, earning less than £700 a year in terms of gross personal income. The recommendation of the Spens Committee was that the figure should be increased to £1,100, and then they recommended the £1,600 which has been the subject of discussion tonight. The most important thing to remember about the Spens Committee Report is that it was never intended, and it was never said in the Report, that every dentist should be able to earn that sum. They were discussing a particular age group and dentists with particular qualifications; it was never in their contemplation that we should be able to read, as we can now almost every day in "The Times" and "Daily Telegraph" advertisements—I saw one the day before yesterday: 945Assistant dental surgeon required. Salary £1,300 a year plus substantial bonus plus car plus residence.That means that the most newly-qualified dental surgeon starts at a figure considerably in excess of the Spens recommendation. We must remember that when we talk about 10,000 dentists taking, on an average, last year, £4,800 in public money, the figures include assistants and also all those who for various reasons, perhaps because of age or other circumstances, did not do the full amount of work. Therefore, the sums that are being earned by the people in that age group are very considerably higher than the Spens estimate.
These Regulations arise because, in the opinion of the Government—and I agree with them—too much public money is being spent on the dental service. It has been the complaint of the Minister or his Parliamentary Secretary, in Debate after Debate, "How could we know that this would be the amount of money that would have to be paid out in the dental service?" I would like to remind him, because it has not arisen today, that we on this side of the House knew, and said, nearly two years ago, what the cost of this scheme would be, and we have been proved right.
I would like to read to the House what was said by my right hon. Friend the Member for Saffron Walden (Mr. R. A. Butler) on 16th September, 1948, which was a few weeks after the scheme started:As for the dental scheme, the Treasury after the Spens award, said that the total annual cost would be £27 million, and we are now told that there are something like 30,000 requests a day being made to the Estimate Board at Eastbourne for dental benefit of one sort or another. So much the better if we can afford it, but the total cost is not, as stated originally, £27 million but likely to be between £50 million and £60 million."—[OFFICIAL REPORT, 16th September, 1948; Vol. 456, c. 242–3.]Taking into account the cuts last year, my right hon. Friend was right. The Government have not yet discovered what the final cost of the scheme is to be.
The Parliamentary Secretary said, quite rightly in my view, that one of the most important points to consider in dental remuneration was the expenses ratio. I agree with him and not with the hon. Member for Wolverhampton, North-East (Mr. Baird). Even today, an expenses ratio of 52 per cent. is too high, and after these cuts it will still be too high. It is 946 obvious that the expenses ratio does not continue to rise rapidly as the number of patients increase. Factors like rent equipment and other things remain stationary, but I believe that when the cut is made, 52 per cent. will still be too high. It has been said over and over again from this side of the House that the basic fact to consider in looking at the dental service is that there are not enough dentists to run the service.
In 1946, when we started this scheme—the beginning of the story which has led to these Regulations—the Minister knew that perfectly well. The Minister told the House:We have not enough dentists and it will therefore be necessary for us, in the meantime, to give priority treatment to certain classes—expectant and nursing mothers, children, school children in particular and later on, we hope, adolescents. Finally, we trust that we shall be able to build up a dental service for the whole population."—[OFFICIAL REPORT, 30th April, 1946; Vol. 422, c. 45.]On the Second Reading, in 1946, the Minister knew where we were going. When this matter of dental costs was discussed in the Committee he used these words:… when the State is making certain things universal and free it has to make up its mind at what point it stops. If it provided everything freely, the answer would at once be that the whole scheme would soon break down."—[OFFICIAL REPORT, Standing Committee C; 26th June; Vol. 46, c. 1793.]I agree. We agreed with him in 1946, and we agree with him today. But he has changed his point of view. These things which I have quoted are two years before the scheme came into effect. They were two years of difficult negotiations with the British Dental Association. The Government "raised the ante" and blinded the profession with gold. If I may change the metaphor, the carrot is being pulled into the wings, now that the dentists are in the profession.
The Minister can come before the House with another cut, and another, with the sweet simplicity of the 10 per cent. This is not the last cut which the dental profession is to suffer. The situation that has been created by dental remuneration will not be profoundly affected by these Regulations. The Minister has created a paradise for the "spiv" dentists who see in this scheme an attractive incentive to quick and shoddy work and the use of shoddy material.
947 The good professional dentist, who is the backbone of the profession and in the vast majority, has welcomed, of course, the financial improvement to his position which this scheme has brought about, but he loathes and detests the contempt in which the public hold this honoured profession. Dentists hate not being able to go to the golf club without someone saying "Here is a man earning £100 a day," and then he turns on the wireless he finds he is the butt of every cheap comedian. Something should be done to remove this impression.
We have had a scheme put forward by the hon. Member for Wolverhampton, North-East, which, in fact, is the British Dental Association's scheme, as an alternative to this 10 per cent. cut. I must say that I find the scheme a little naïve. If I remember rightly, they had another scheme last year to evade the cuts that were then being made. I should have found it much more convincing if they had come forward at their own will with their suggestions and proposals before any cuts were proposed.
I would rather see their efforts concentrated on the ethical side of dentistry. I think a tremendous amount could be done here. When the cuts were made last year, there was a letter in the "Daily Telegraph" from two dental surgeons to the effect that if these cuts went through Parliament, they would earn their Spens maxima in two-and-a-half days and play golf for the rest of the week. I have not the quotation with me, but it is in my personal files. I thought it one of the most disgraceful things I have ever seen in print coming from professional men. However, we are not discussing the ethics of this side of the House or the other side, but those of the dental profession. What matters is how they will regard these cuts, and I have given an example.
Last year, at the Labour Party Conference, which was held at one of the watering places we all go to for our conferences, the Minister of Health said that priorities were a religion to Socialists. But just look at what happens to Socialism in practice. Let us try for a moment to see what has happened. The answer I would give is contained in a first-class report, with which I am sure most of those who have spoken in this Debate will be familiar, namely, "The Practitioner." 948 In reviewing the first year's working of the National Health Act, this is what it has to say about dentistry:The virtual breakdown of the School Dental Service, and with it of the maternity and child welfare dental services, all of which were earmarked as No. I priorities, is regarded by the whole profession as the greatest and most tragic failure of the new Health Service. Although it may be politically expedient, it is nevertheless scientifically wrong, as well as economically unsound, to provide dentures for octogenarians while allowing the teeth of the rising generation to be neglected.That is precisely my view. I believe that we have got thus far with the scheme, because it is politically expedient.
§ Mr. Speaker
I would point out that this is a very limited subject, and that the dental service as a whole is not the question now before us.
§ Mr. MacLeod
Let me conclude, then, by saying this: I believe, as has been said so often, that these Regulations are not setting about this very serious problem in the right way. If we accept the basic fact that there are not enough dentists, and if that was admitted in 1946 by Members opposite, then let us consider the real implications. It merely shows immaturity to suggest a scheme for the whole population with inadequate resources. What we have to do is again to restate the priority classes in dentistry, and to see that they get priority. There are many ways to do this, apart from the over-simplified method suggested tonight We must try to get the co-operation of the dentists, or even make it a condition of service, with regard to the British Dental Association scheme. This sort of miserable tinkering with dental remuneration is not the way to secure a happy profession, nor is it the way to give a good service to the people.
§ 7.35 p.m.
§ Dr. Hill (Luton)
I want briefly to comment on one aspect of the problem. The essence of what we have been discussing tonight is how best and most effectively an economy can be made, bearing in mind that the mode of remuneration, and so the mode of effecting the economy, has, or can have, an effect on the working of the service. Emphasis has been laid on the fact that there are too few dentists to provide a comprehensive service. That being so, it is for the Government to answer the question: Is it desired that dentists should seek to 949 provide a comprehensive service? There being too few dentists, it can be provided only by their working long hours and at considerable speed. I am now speaking of the average picture.
If it be true that there are too few dentists working ordinary hours to provide a comprehensive service, and in the light of the Government's statement that a comprehensive service is available to the community, is it the desire of the Government that the dental profession, with whatever consequences may flow from it, should seek by working longer, harder and speedier to provide the comprehensive service? It seems to me that this difficulty of cost arises because remuneration has been arranged in the past on the assumption of a reasonable week's work at a reasonable pace. In order to deliver the goods to the people, the dental profession has had to work longer and quicker than is reasonable, with here and there a lowering in the quality of the service.
If it is the Government's policy that the dentists should seek to provide a comprehensive service, then that factor must be taken into account in relation to the proposal to cut the remuneration. What will be the effect of the 10 per cent. cut? It may well be, as the hon. Member for Wolverhampton, North-East (Mr. Baird) has suggested, in many cases to speed up the pace of the work to earn the same money. What is it the Government want? Do they want an attempt made, whatever may happen here and there by way of excessive work and to provide the promised comprehensive service for the whole of the community? If not, if the Government are seeking to maintain, as I believe they are, a good quality of dental work, the question has to be answered: Which group is to be left out, and which group is not to have the comprehensive dental service that was promised?
My hon. Friend the Member for Enfield, West (Mr. Ian MacLeod) has pointed out that in fact there has been no priority policy. There has been no attempt to answer the question of which group shall be left out or which group shall come first, with the result that the groups which were promised priority are the last of all to get it, notably children and mothers. The method the Government adopt will have a bearing on the character of the service which results. A 950 suggestion has been made that the full rate of remuneration should continue on a certain level with proportionate reductions in it above that level.
My main criticism of that is that it does nothing to deal with the priority problem—to decide who shall come first within this limited service. It might not be impossible, if that be the method followed to exempt remuneration received from local health authorities for school dental work from the operation of the maximum or by separating from a maximum limitation scheme certain kinds of work which is done for priority groups like school children and nursing and expectant mothers.
I urge the Government in the reconstruction of this scheme, which they appear willing to make if the proposals are forthcoming from the dentists as I know they will be, to do their best to utilise the scheme of remuneration in any modified form in order to do something to meet the priority position. As it stands at the moment, the proposed method will penalise the dentist who has been working at his usual pace and with reasonable efficiency. It might have the effect of quickening his pace. But I believe that the Government have sooner or later to face up to the fact that if there are too few dentists to provide this service then they must themselves decide who is to come last or at least who has to come first.
What I think is to be most regretted about the Regulation is that it does nothing to meet what is the real position, and that it ignores the possibility of a mode of remuneration directing the attention of the profession to the work which in the public interest most needs to be done. I hope the Government will not seek to continue to put off this main issue. If, on the other hand, the Government prefer the work to be done well, let them as an act of deliberate policy, determine who is to come first, and secure that priority groups and genuine cases shall have priority.
§ Dr. Morgan (Warrington)
It seems to me that throughout the whole of his speech, the hon. Member for Luton (Dr. Hill) was moving towards the theory that priority work as laid down should be paid at a higher rate than ordinary treatment to ordinary people. Would he say whether that is so or not?
§ Dr. Hill
I had in mind that if there are to be rates of remuneration which are different above and below a particular line, as was outlined by the hon. Member for Wolverhampton, North-East, it would not be unreasonable to exempt work done for defined priority classes from the operation of that maximum. All I am anxious to secure is that somehow or other those priority groups will receive the priority they need.
§ 7.45 p.m.
§ Mr. Emrys Hughes (South Ayrshire)
I have learned a lot from this Debate. For example, I learned from the hon. Member for Enfield, West (Mr. Iain MacLeod), that the most sensitive profession in the world is that if the dentists. The main lesson to be learned from this Debate is that the Government did not go the whole hog at the beginning and nationalise the profession completely. I do not for one moment subscribe to the professional syndicalism that has been advocated in this Debate by the hon. Member for Luton (Dr. Hill). We have heard too much about remuneration and to little about real service to the public, which should be the dominating object of every one in this profession. The hon. Member for Chippenham (Mr. Eccles) came out with a long and elaborate piece of casuistry in which he asked us to support the theory that the dental profession were justified in holding up the community to ransom. One of the arguments he used was that the dentists deserved more for what he called "dirty work." If that argument is to prevail it should apply to all branches of the medical profession——
§ Mr. Emrys Hughes
The point should be cleared up. The hon. Member for Chippenham argued that this 10 per cent. reduction was unjustified because of the "dirty work" perpetrated by the dentists. It was only my purpose to ask the hon. Member for Chippenham or some other Members of the Opposition to justify the argument opposing the 10 per cent. reduction.
Objection has been taken to the dentists being pilloried on the wireless and in the music hall, and we have heard a request tonight to make dentists a privileged profession. The profession 952 I represent here, that of coal mining, has to put up with all sorts of cracks and jokes about dirty coal, which are a slander on the mining profession. Not only are these music hall jokes, but at Question time in this House the matter of dirty coal has become a common joke. The dentists, therefore, ought not to be so sensitive, but ought to be prepared to take their share of social criticism as well as other people who do dirty work in the country. If we are to base the argument for a 10 per cent. cut in remuneration on the grounds that a certain profession is a "dirty" profession, where are we going to end? We can immediately blackball the medical profession as a dirty profession, and I do not know what epithet should be applied to the legal profession. All the professions could say to this House, "We are entitled to increased remuneration, because we are the dirtiest of the lot."
We have had too much special pleading for a particular profession during this Debate. The hairdressers might as well argue that they are entitled to as much remuneration as the dentists. The professions could come here and say that they would accept this idea instead of the idea of social service, which should be the ethical basis of all professions. I believe the opinion is widely held that dentists have done very well out of this Act. I hope that the time will come when the Minister will do the necessary extraction and grasp the nettle, and will nationalise the profession, in the interests of the general public and of the dentists themselves.
§ 7.51 p.m.
§ Mr. Baird
I believe that, as the mover of the Motion, I have the privilege of replying. I want to speak only for a few minutes. There has been a dearth of ideas on both sides of the House today about how to solve the problem. I think that we shall not solve it until we have a fully salaried dental profession. The sooner that both sides of the House realise the truth of that statement the better it will be for the public and for the profession—but that has nothing to do with the 10 per cent. cut.
The proposed cut will not solve the problem of the school and other priority dental services. The British Dental Association have put forward proposals and they have argued about them. They are 953 divided about 50–50 on them. The school dentists say that their branch of the profession is specialised and that the general dental practitioner is not always qualified to treat young children. It would be wrong for the House to get the idea from the speeches that have been made that the question of the priority classes can be easily answered.
Another point which has been raised is that there are too few dentists. It is true that, just before the Act was passed, hon. Members opposite and the British Dental Association argued that there were not enough, but there were not too few dentists in 1938, at which time a patient could go from one dentist to another if he failed to get satisfactory treatment. If there are too few dentists today, what do hon. Gentlemen suggest? That we should abolish free dental treatment for the general public and concentrate upon school dentistry? There was a shortage of dentists before the National Health Act was passed, when only those who could afford to pay for conservative dentistry could get it.
§ Dr. Hill
Is it not a fact that before the war, in the dental profession alone among all professions, the wastage exceeded the entrants? I only desire to make the point that for some years there has been a most unusual position in the profession of dentistry, in that before the war there were fewer entrants to the profession than there were of people who left it.
§ Mr. Baird
I agree that before the war the profession was as remunerative as it is today, but many people could not afford to pay for dental treatment. Today there is a much bigger demand for dental treatment, and that is the reason for the shortage. If we were to institute a grant-in-aid system, as hon. Members have suggested, we should simply go back to the bad old days when people who could afford to get the treatment would have it and the working-class people would be unable to get it. The Health Service Act has raised the general health of the people. Young people who were in the Forces got to know the value of conservative treatment there, where they got it free. They are now coming into our surgeries. I start at 8 o'clock in the morning, and young people come in before they go to the office. A retrograde step such as is suggested 954 by hon. Members opposite, would undo much of the good work that has been done.
I suggested that we might save more money by more supervision. I am sorry that the Minister did not reply to me on that point. I have raised that point three time now in this House. I believe it is a method whereby we could save three, four, or five million pounds. I cannot calculate the exact amount, but it would be millions. I have had no indication that the Minister has even looked at the suggestion. The hon. Member for Chippenham (Mr. Eccles) said that more supervision would mean more "snoopers," but it would also mean that the people of this country would have a guarantee of getting value for their money.
§ Mr. Blenkinsop
I thought I had made it clear that we are very sympathetic indeed to the point regarding adequate supervision and that we are taking steps to overcome the difficulty.
§ Mr. Baird
If we are to do it, we must have some control over public expenditure and we can only get that by supervision. The public dental officers soon get to know who are the "spivs" in the profession. If we had more supervision we could concentrate on those dentists who we knew were acting in a "spivish" manner. The House must look at this question of supervision as a method of saving public money.
I believe there is a change of heart in the dental profession today. For a long while their attitude to the question was political. They were trying to exploit the situation for political ends. That stage in their history has gone. I believe dentists realise the error of their ways and I believe that if we had a gesture from the Ministry today the dental profession would welcome the opportunity of entering into negotiations again. I am speaking purely for myself. I have no brief for the British Dental Association. I believe that the time has come to try to break the deadlock; in that effort the profession and the Ministry both have a part to play. We shall not do that simply by imposing arbitrary cuts. I beg to ask leave to withdraw the Motion.
§ Motion, by leave, withdrawn.