Motion made, and Question proposed,
That a Supplementary sum, not exceeding £3,007,000, be granted to Her Majesty, to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1956, for the provision of a comprehensive health service for England and Wales and other services connected therewith, including medical services for pensioners, &c., disabled as a result of war, or of service in the Armed Forces after the 2nd day of September, 1939, the treatment abroad of respiratory tuberculosis, certain training arrangements, the purchase of appliances, equipment, stores, &c., necessary for the services, and certain expenses in connection with civil defence.
§ 9.0 p.m.
§ Mr. Iain Macleod
I can explain this Supplementary Estimate in a sentence or two. It comes as a natural consequence of the restoration of the 10 per cent. cut in dentists' remuneration which was made as long ago as 1950. The dentists have been pressing for the restoration since 1952. I felt at the time that an immediate increase was not justified, but I suggested to the British Dental Association that we should have a detailed inquiry. That inquiry was completed in July last year, and as a result there has been this increase, a cancellation of the 10 per cent. cut.
I should make clear that the 10 per cent. increase is an interim measure while I work out the new scale, which is a complicated affair, for the fees of the dental profession. But negotiations for that are going well, and I hope that it will not be long before we have a final decision. The Committee may like to have these figures: under the new arrangement average dentists will receive, including the Exchequer superannuation contribution, about £2,000 net. That compares with the general practitioner's 1855 average net income of rather more than £2,200. But it is calculated that single-handed dentists working without assistants, in the class with which the scale is particularly concerned, the 35–54 years' old age-groups, will receive rather more than £2,400 net, so I think that the relativity between dentists and doctors in general practice has been kept well in mind as these arrangements were made.
I think that the Supplementary Estimate itself is perfectly clear. In a full year the 10 per cent. restoration will cost £3½ million for England and Wales plus, of course, an extra amount for Scotland and as it came into operation on 1st May the gross figure is 11/12ths of that, or £3,200,000, and when we take into account appropriations-in-aid it comes to the amount for which I have asked the Committee, £3,007,000.
§ Dr. Stross
Can the Minister say whether the figures which he has given for remuneration are for a net or gross income?
§ Mr. Macleod
They are net. Under the new arrangement the average dentist should receive, including the Exchequer superannuation contribution, a net income of about £2,000.
§ 9.5 p.m.
§ Mr. Blenkinsop
Unlike the previous Supplementary Estimate that we were considering a moment ago, this one asks Parliament for extra money. It is not merely a transfer, as the other was. We are therefore entitled to inquire rather fully into this demand for something like £3½ million a year extra for this section of the National Health Service.
At the very start, one could say that this is one of the costs made inevitable by the introduction of charges in the Service. That may very well be so. Had the charges not been maintained as they have in the dental service, this revision of remuneration might never have been required. These charges have undoubtedly hit certain sections of the dental profession more severely than others. The Minister talks about the average figures for dentists, but it is more difficult to get a fair average in this field than in other fields in the National Health Service. The position of dentists in industrial areas is often very different from that of dentists in other parts of the country.
1856 I am sorry that the opportunity does not seem to have been taken of a much more thoroughgoing review of the position about the payment of dentists. Many of us take the view that the whole basis of payment of dentists, that of payment for individual services rendered, is open to a good deal of objection, and I should have been glad if some investigation had been made to see whether it is possible to get on to a basis of sessional payment or something of that kind for at least the conservative type of treatment which we are all anxious to encourage, "conservative" again, I must stress, with a small "c." Even if a major change were not possible, we would like to know something more about the construction of the scale payments which the right hon. Gentleman told us is an essential part of this agreement for the revision of the 10 per cent. cut, and which of course has a very real bearing upon the form of our dental services. We can encourage or discourage conservative dental treatment, according to the weight we put upon it, in working out the actual scales of payment. One can discourage the provision of dentures and can encourage the conservative treatment, which, broadly, has been the effort up till now.
I would certainly like to know, before we pass this Supplementary Estimate, what view, at any rate in general terms, the right hon. Gentleman is taking on this matter. I do not necessarily expect detailed scales of fees. Obviously the right hon. Gentleman cannot give them at this time, when matters are under discussion; but he could indicate his view of the sort of emphasis he wants to give in the scale of fees to the different types of treatment that are provided.
I am assuming, too, that the Minister hopes that this restoration of the 10 per cent. cut will do something to arrest the rather alarming decline in the number of dentists in practice and the expectation that we must have of a very much more serious decline in their numbers in the next few years. I am well aware that a committee was set up by the Minister at the end of last year to investigate this. We shall all be very interested to see its report when available and to read the recommendations.
That it is a really serious matter there is no doubt. The Central Health Services 1857 Advisory Council make it quite clear that there is an overall shortage of about 8,000 dentists as against the total who could and ought to be in practice if we are to have the dental service we need. It is more serious even than that, because about 40 per cent. of the practising dentists are 55 years of age or over. I suggest that that indicates that there will be quite a rapid decline in the numbers in the next few years.
The problem is made much more serious by the fact that if we are to build up a proper dental service we must recruit a large number of new entrants to the dental schools. It has been said that about 900 new dental students are needed each year, but at present we are getting only about 450 new entrants. Does the Minister feel that this restoration of the 10 per cent. cut would improve our prospects of getting new recruits? I am very doubtful whether it will be of very great value in that respect.
It is important to look not only at actual payments but also at what one might almost call professional prestige. Interesting proposals were made by the hospital boards for the development of specialist dental sections. I should like to hear from the Minister that he thinks it of the very greatest importance that dentists should be given a rather better status in the hospitals. They need to feel that there are avenues of advancement, if they wish to take them, into such specialist work as orthodentics.
We must regard the present position as very critical, and we cannot wait long for the information from the expert committee which has been set up by the Minister. In fact, unless something is done rapidly we may face a break-down of our dental services simply because there are not nearly enough dentists to provide the services we need—and none of us can imagine for a moment that our standard of dental care is anything to be particularly proud of.
A very great deal needs to be done, and perhaps the greatest job to be done by the Minister is the encouragement of research and of health education. A great deal can undoubtedly be done by the parent in the home. Were sweets not quite as available as they are, dental health might be a great deal better—although I should certainly get into trouble with my own family were I to 1858 suggest any reduction in sweet production and consumption. Nevertheless, I very much hope that the Minister will say that he has in mind the need for a vigorous campaign for dental health education and will do his best, as I am sure he will, to support the dental profession in this work. I am sure, also, that that profession is only too eager to do what it can to help.
In these circumstances, I do not understand why such valuable work as that done at the Eastman Dental Clinic in training dental oral hygienists has not been supported. My hon. Friend the Member for Wolverhampton, North (Mr. Baird) may take a different view, but, amongst other support for such work, the last Annual Report of the Minister's own Department referred in glowing terms to the work being done by oral hygienists, and I was rather surprised when the training was brought to a sudden stop.
I hope very much indeed that what I regard as a very serious situation will be attacked with vigour by the Minister and that he will not regard this restoration of the 10 per cent. cut as a major means of meeting the difficulties that lie ahead. I should like him to look again at the whole position of dental payments and not to rule out of his consideration the effect of the charges for dental treatment. I feel that these charges have a serious effect in limiting the demand that is made for treatment, and in addition create difficulties for dentists in the proper practice of their profession. I hope the Minister will be able to say more than he has said in introducing the Supplementary Estimate, because it is a matter that we on this side of the Committee take very seriously.
§ 9.16 p.m.
§ Dr. Stross
I am very glad that this sum of money has been restored to the dentists. I agree with my hon. Friend the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) that, as a result of the charges which were imposed some years ago and which still exist, dentists have found their gross remuneration severely affected, and if the restoration of the 10 per cent. will increase the average remuneration to say £2,000 a year net, I regard that as reasonable.
I want to take up one point which was stressed by my hon. Friend the Member for Newcastle-upon-Tyne, East. I 1859 should like to know whether there is any prospect of more recruitment. We hope that within twenty years there will be 20,000 practising dentists. Today the figure is about 9,500. As my hon. Friend has pointed out, the number of students is falling year by year. The peak, which was reached in 1947, was 650. Today, my hon. Friend said, the figure is about 450: actually, I think it is about 470.
Then there is wastage to be considered. If we take the present number of students in the country as about 470, we have to remember that about 10 per cent. come from abroad, and therefore when they qualify they will not practise in this country but will go abroad. Therefore, the situation is desperately serious. I cannot imagine any technique which will render everybody's teeth perfect without the help of the dentist. At least, my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird) hopes that nothing like that will happen in his lifetime. We have to assume that we need the services of these people.
§ Mr. John Baird (Wolverhampton, North-East)
Would my hon. Friend tell me whether he is referring to the income from the National Health Service or to the overall income?
§ Dr. Stross
What I had in mind was the income after payment of overhead charges. One can say that the average gross income of the family doctor is about £3,250. If £1,000 is allowed for overhead charges, that leaves roughly the £2,200 which the Minister mentioned.
I want to know what is the difficulty about recruitment. Why cannot we get more young people to go to the dental schools? Obviously there are places available for them now. It is not that we need more schools to accommodate them.
I want to bring particularly to the Minister's attention the fact that only six women out of a hundred——
§ The Deputy-Chairman (Sir Rhys Hopkin Morris)
I think the hon. Member is going beyond the Vote, which deals with salaries and not recruitment.
§ Dr. Stross
I assume that the Minister will agree that one of the reasons for the increase in salaries is to obtain better recruitment for the sake of the service as 1860 a whole, and that he is not so much concerned with the 10 per cent. increase in salary as with the effect on the service. I wish to put only one question to the right hon. Gentleman. Has he noticed the wonderful field for recruitment to the profession among women? Only six dentists out of every hundred are women, both in the schools and in practice. I see no reason for assuming that women cannot be as good dentists as men. For all I know they might even be better. There must be some strange reason why they are not entering the profession, and it may well be financial.
Has the Minister considered that local authorities vary greatly in respect of the assistance which they offer to young people who are accepted into the dental schools? Some are much more generous than others. Will the Minister therefore consider whether young people who wish to become dentists ought not to have, in addition to any other source of income, opportunities to receive assistance from the Ministry by way of loans to be repaid? There is a similar provision in the medical profession for certain types of assistance. The Minister knows the fund to which I refer. Only a small sum would be needed; £50,000 might easily cover it. They could draw on that fund, and it would be replenished by repayments after they had qualified.
If the Minister would introduce such a fund I am sure that in the long term we could solve the problem of getting enough dentists to serve our needs. Today we have not enough. I am sure we are all disturbed about that.
§ 9.23 p.m.
§ Mr. John Baird (Wolverhampton, North-East)
I must disclose my interest because, as a practising dental surgeon, I am one of the two Members of the House who will benefit if this Vote is passed.
The decline in the number of dental students is very serious and, if it continues, within a short time we shall not have enough dentists in the country even to carry out the ordinary routine dental practice. If I thought the main reason for this was that a dentist's income was too low, I should welcome the Vote with open arms. I am not saying, of course, that we should vote it down, but if I thought it would solve the problem of 1861 recruitment I would welcome it with open arms.
I do not think remuneration is the main reason for the lack of dentists at present. I believe that a net income of £2,000 is an adequate income for a professional man. We are told that the average income of dentists today ranges from £1,800 to £2,200. With this increase the average will be about £2,000. For the dentist in his most virile years the income will be at least £2,400. I do not want to tread on anybody's toes, but in some professions there is some undisclosed income and I do not know whether there is any such undisclosed income in dentistry. If there is, a dentist may be making a little extra on the side.
In my opinion, the major reason for the lack of recruitment to the dental profession has been the vacillation of both sides in the House. First, there was the chopping and changing of dentists' incomes, and then the imposition of charges, both by my hon. Friends and by hon. Members opposite. Dentists did not know where they were from one day to another until a few years ago.
The second reason is that dentists are very bad publicists. In order to try to increase their incomes, they tried to tell everyone how hard up they were. It was a lot of baloney, because dentists were never hard up but were doing well all the time. By carrying on that type of propaganda they did the profession very much harm. I believe that openings for young people in the dental profession are very attractive today. It is a profession where a man with ability and agility with his hands and certain academic propensities can make a very attractive income in fairly comfortable surroundings. The sooner we start publicising the attractiveness of dentistry the better it will be for the profession and the country as a whole.
There is, however, something wrong with our sense of values. A few months ago we agreed to the Danckwerts Award for doctors whereby we gave doctors between £9 million and £10 million a year. Tonight, without any ripple of opposition and with the benches almost empty, we are agreeing to pay another £31 million to 9,500 dentists. As a practising dentist, I can tell the Committee that to a dentist now making £2,000 a year that means an increase of £5 to £8 a week in personal net income, not gross.
§ Dr. Stross
Will not my hon. Friend agree that there is a little difference as this is restitution of a cut and the Danckwerts Award was not restitution of a cut?
§ Mr. Baird
I am not distinguishing between the Danckwerts Award and the payment to dentists. Let me finish my argument. The doctors have £9 million to £10 million a year and dentists £5 or £6 a week more, yet this Chamber is nearly empty, but when railwaymen or engineers ask for a few bob a week more, we have a discussion in the House and the benches are full, and hon. Members opposite say that they are holding the country to ransom. There is surely something wrong with our sense of values. During the last few years in the House I have seen judges' salaries raised by £5,000 a year, town clerks and various other local government officials have had their salaries raised by £500 a year and doctors and dentists have had increases of many pounds per week, yet a few weeks ago when engine drivers asked for an increase a judge was asked to decide whether they should have it. I suggest that before we grant this increase of £3½ million to dentists it might be a good thing if we set an engine driver to adjudicate and decide whether the dentists deserve it. I believe that would be a much better way of dealing with the matter.
§ Mr. Baird
Someone suggests that the job might be given to our former colleague, Archie Manuel. He would decide as fairly as Lord Justice Morris decided the claim of the engine drivers. I am not arguing against the restoration of this 10 per cent. cut—[HON. MEMBERS: "Oh."] I have not yet finished my argument. I quite agree that when the cut was introduced it was said that it was a temporary cut until a new scale of fees could be negotiated with the dentists. I want to indict the hon. Lady the Parliamentary Secretary, who is laughing, and her right hon. Friend. Why has it taken all this time to negotiate a new scale of fees with the dentists? We have gone on year after year and dentists have been grumbling and complaining. They did not want just the 10 per cent. cut restored but a new scale of fees, and year after 1863 year they have been put off. Now we have the 10 per cent. restored on condition that a new scale of fees is negotiated. Why was that not done three or four years ago, as it could have been done? There is hardship in certain parts of the dental profession. Some people are today suffering financial hardship, but I do not believe that the restoration of the 10 per cent. cut will solve the problem. By giving back the 10 per cent. to the dentists, we are giving a 10 per cent. increase to all dentists.
There is no hardship among all dentists. There is hardship only among dentists in certain pockets of the country. Those pockets are in the industrial areas. This hardship is not due to the imposition of a 10 per cent. cut in the overall income of dentists a few years ago but is because my hon. Friend the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) and his right hon. Friend the Member for Middlesbrough East (Mr. Marquand), and the Minister opposite, have imposed charges in the Health Service. As a result of imposing those charges, a large number of people who were getting free dental service could not afford to pay the £1 or the fee for dentures. That is why today in the industrial and poorer areas the dentists are hard up.
If we are to make an improvement in the areas where dentists are suffering hardship, the way to go about it is to remove the charges in the Health Service. I do not expect to achieve that result, neither do I expect that the Minister will accept the advice of my hon. Friend, advice which some of us wanted to tender to my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) ten years ago, that the only way to tackle the problem was to pay the dentists a salary instead of a scale of fees. I believe that in the long run the only way to get an equitable health service is by a real National Health Service in which dentists do not compete against each other to make a little more but work in a salaried service in health centres. In the long run, the country will be forced to come to that as the only way in which we can build up a really Socialist—in the best sense of the term—health service.
May I make one or two practical suggestions to the Minister? He is now 1864 entering negotiations with the dentists on the scale of fees. Some years ago, he and I crossed swords more than once on the question of the school dental service. At that time, I said that he would never get an efficient school dental service because he wanted two or three thousand dentists to operate it. I still say that. I believe that the future of children's dentistry lies with the general practitioner until we get our health centres. The ordinary general practitioner as a whole will not be encouraged to develop the children's side of his practice until he is paid a decent fee.
If any hon. Member came to me to have a filling done, I would receive a fee varying from 15s. to £1 2s. 6d. per filling. It would take me perhaps 20 minutes to do the filling. A young child between, say, the ages of five and eight —that is when we need to start treating children's teeth—who comes to me for treatment is nervous. He is afraid of the dentist, of the dental chair and of the engine, as he calls it, and the noises it makes. I have to spend five minutes talking to him, preparing him, and very often I have to spend twice as long in doing the filling, for which I receive 7s. 6d. The average fee for grown-ups varies between 15s. and £1 2s. 6d. We can say that the average is £1 a filling, whereas for filling a child's tooth the fee is 7s. 6d.
We made a lot of mistakes in our first scale of fees. If the right hon. Gentleman wants the dentist in his practice to treat children's teeth, he must ensure in the negotiations that the fees for children's dentistry are raised even though this means reducing the fees for adult conservations.
I was one of those people who were on the Committee which discussed the National Health Service Bill ten years ago. At that time, there were far too many dentists in this country extracting teeth en masse and fitting dentures, because at that time under private enterprise it paid. The dentist got about 20 guineas for a full set of teeth; it was done in a very short time and was quick money, whereas we got only 7s. 6d. to 10s. for a filling. We had to stop that, and perhaps under the National Health Service we went too far, inasmuch as we paid fees which were too high for conservative treatment, such as fillings, and we 1865 reduced the fees for dentures until we were getting 9 guineas for full dentures.
The result is that today it does not pay dentists to do denture work, and it is in the industrial areas, where there is much more denture work than in the middleclass areas, that they are really hard up. In the negotiations which will take place, we hope that, now that the National Health Service is on its feet, the Government will look at this again and bring the balance over a little the other way. Those are the two points which the Minister might bear in mind when he goes into negotiations with the dental profession.
Finally, I want to say again that this 10 per cent. cut was a temporary one, and that the promise was made that it would be restored when the new scale of fees was negotiated. Therefore, I do not propose to oppose these Estimates here tonight. I myself will benefit, I agree, but, at the same time. I would say that this House has a very queer sense of values if it passes this tremendous increase in income to dentists at the same time as there is a terrible hullabaloo when we say that we should increase the income of engine drivers on the railways by 3s. or 4s. a week.
§ 9.36 p.m.
§ Mr. Iain Macleod
Perhaps I can reply briefly to the speeches that have been made. It will surprise nobody to hear that I am not going to make any pronouncement on charges or professional payments tonight, and indeed the whole essence of this Supplementary Estimate is that it is regarded, as I told the Committee earlier, as an interim measure pending a settlement of this new scale of fees.
The hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) asked me about the new scale and how it was being worked out. It is very complicated to explain to the Committee, but what we have done is to take the year 1952–53, because that year was used for our detailed investigation, and we have so arranged matters from our investigation that the total fees that would have been paid in that year if the 10 per cent. cut had not been in operation shall be redistributed by the new scale of fees for the amount of work that was actually completed in that year. It requires a very detailed calculation, and if the hon. 1866 Gentleman would like me to do so, perhaps I could write to him and give it to him in some detail.
The hon. Gentleman also asked what was done about weighting the scale with more of a slant towards conservative work. The old scale was intended to be balanced; that is to say, it was based on actual chair-side timing, so that, in theory anyway, dentists did not spend an undue amount of time on one kind of treatment, but it did emerge that perhaps they spent too much time, and therefore too much money, attending to certain parts of their work. We are hoping in the new scale to give greater weight to dealing with children's teeth, and I am sure that we have the co-operation of the profession in working that matter out.
The hon. Gentleman also asked me if the restoration of the 10 per cent. cut will help. Personally, I believe it will and mainly for this reason. Whether rightly or wrongly, this cut has been regarded by dentists as a five-year breach of faith by Ministers of Health of the parties on both sides of this House. The fact that it has now been restored will remove a very deeply felt grievance, and to that extent it is bound to help.
Research and education are matters which I have very much at heart, and the Committee will know that very recently I issued a circular which achieved the distinction of a fourth leader in "The Times" for its reference to lollipops. I have had the particular point made in this debate exactly in mind. I should like to join with hon. Members in coalition against their hon. Friend the Member for Wolverhampton, North-East (Mr. Baird) in his views on oral hygienists; and perhaps a certain legal Measure which has pursued a strange career in recent years might in future reappear.
§ Mr. Macleod
If the hon. Member for Wolverhampton, North-East (Mr. Baird) reads in HANSARD the record of what I have said, I do not think that he will find much difficulty in interpreting it.
1867 The hon. Member for Stoke-on-Trent, Central (Dr. Stross), and indeed all hon. Members who spoke referred to recruitment. It is very much in our minds, and that is why we set up the very distinguished McNair Committee. It is worth noting that entrants in England, Wales and Scotland last year numbered 478, a figure rather higher than that in previous years. I do not know whether that trend will continue. There were tendencies in the schools after the First World War very similar to the one which we have seen in recent years.
I will not comment on the suggestions made in the debate about women and the possible help by payments, which the hon. Member for Stoke-on-Trent, Central mentioned. His were most valuable suggestions. Perhaps the best thing that I can do is to see that they are brought to the notice of the McNair Committee and that its views upon them are invited.
I thought that I was going to have the extraordinary experience of agreeing with the hon. Member for Wolverhampton, North-East, but it did not take us long to find points of divergence. I agree with him that there is no easy answer to the question of recruitment, and that recruitment by no means turns entirely on remuneration. The decline started in 1948–49, when the dentists were earning large incomes, and I am sure that it is very closely linked with matters of status.
The hon. Member was rather illogical in complaining on the one hand of the haphazard and casual way in which we were introducing this new provision while at the same time grumbling that we had taken a very long time to make the necessary investigations. Unlike the Danckwerts award, which was also incidentally made by a judge, or any other arrangement that the hon. Member mentioned, this arrangement in the end came by agreement and not by arbitration or in any other way.
I agree that the most detailed investigation took a long time, but it had to be carried out because this is a very large sum of public money, and the Public Accounts Committee has expressed itself more than once in very strong terms about the need for full investigation before advances are made. It was after 1868 that investigation that I made the double proposal to the profession, as a settlements of its claims at present, of the cancellation of the 10 per cent. cut as an interim measure and the working out of a scale of fees.
I do not agree with the hon. Member for Wolverhampton, North-East about the school dental service. I think that it is going very well. Last Friday a county dental officer told me that in 1950 he had four dental officers and now he has nineteen. That has made a substantial difference to the dental health of the children.
§ Mr. Macleod
No, it is not, but I should have thought we are as near, proportionately, the number of between 2,000 and 3,000 we need in the school dental service as we are to the number of 20,000 that we need in the general dental service: indeed, 40,000 is a figure that I have sometimes seen mentioned.
So I regard this as essentially an interim measure. I think it is right that we should undertake it. This cut has been in effect for a very long time, and it is right that we should restore it. It is of equal importance that as soon as possible we have a fully adequate scale of fees. That we are engaged in working out. The other point which has been raised tonight on recruitment is covered by the appointment of the McNair Committee, which I am certain will be extremely valuable. I join with hon. Members in hoping that it will look on its work as a matter of urgency, and that we shall have its conclusions as soon as possible.
§ Mr. Stan Awbery (Bristol, Central)
In view of the fact that the Minister has now agreed to deal generously with the dentists and restore their 10 per cent. cut, can we express the hope that the dentists will deal generously with their mechanics, because the mechanics suffered equally with the dentists when the reduction took place?
§ Question put and agreed to.1869
That a Supplementary sum, not exceeding £3,007,000, be granted to Her Majesty, to defray the charge which will come in course of payment during the year ending on the 31st day of March 1956, for the provision of a comprehensive health service for England and Wales and other services connected therewith, including medical services for pensioners, &c., disabled as a result of war, or of service in the Armed Forces after the 2nd day of September 1939, the treatment abroad of respiratory tuberculosis, certain training arrangements, the purchase of appliances, equipment, stores, &c., necessary for the services, and certain expenses in connection with civil defence.