§ Order for Second Reading read.
§ 11.5 a.m.
§ The Minister of Health (Mr. Iain Macleod)
I beg to move, That the Bill be now read a Second time.
I cannot pretend that the previous history of this Measure has been exactly normal, and if I tried to do so I do not think the right hon. Lady the Member for Warrington (Dr. Summerskill) would allow me to get away merely with that. It has, indeed, had a very long history. The most important part of it, which relates to the granting of self-government to the dental profession, dates back to 1921 and 1878. The parts that have relation to the ancillary proposals date, in the main, from the mission sent out by the previous Socialist Government in 1950 to New Zealand, and many of the other measures are related to the Teviot Committee which reported finally in 1946. So it came that in 1951 this Bill, after being discussed with those who had a particular interest in it, was drafted by the previous Socialist Government, although after this lapse of time I do not think that any court would award me an affiliation order.
1350 The Conservative Government, when they took office in October, 1951, brought forward in their first Session this Measure. It passed through another place, as hon. Members will recall, and a great number of very important and useful Amendments were made to it. In the meantime, in the House of Commons, if I can use a carefully neutral phrase, the National Health Service Bill took rather longer than we had expected to pass through the House, and this and other Measures were accordingly dropped from the programme of that Session.
The time that has elapsed since then has, in part, been used for a number of discussions in which I have taken part with those who are particularly interested. There are certain differences in this Bill from that which was laid before another place in 1952, and I think that I can claim that those differences are improvements in the Bill.
The length of time that this Bill has been available enables me to concentrate my remarks on the four matters that are of particular importance—that is to say, the formation of a General Dental Council and, in particular, its composition; secondly, the simplified procedure for the admission of foreign dentists to the list; thirdly, the question of the restrictions on those practising the business of dentistry and the exemptions to that which are contained in the Bill; and, lastly, the more controversial matter of ancillaries.
I should like to make one general observation, namely, that it not infrequently happens that a Bill which commands quite a large measure of agreement has within it two or three Clauses which arouse controversy. It is natural, therefore, that around those controversial Clauses speeches should centre, and that some of them should take up a disproportionate amount of the time which Parliament has given to that Measure. But we would be quite wrong, in my view, if we did not realise that by far the most important thing in this Measure is the granting of self-government to the dental profession. That is infinitely more important in the history of the profession than either the success or the failure of an experiment which is provided for in the Bill.
Turning now to the first of the four matters about which I said I should say a few words, I want to deal with the 1351 composition of the General Dental Council. It is generally, but not universally, agreed, I think, that it would be a good move if the dental profession became self-governing, and I think most criticism would probably tend to concentrate, therefore, not on the formation of the General Dental Council but on its composition.
As those who have studied the Bill realise, its composition follows in many ways that of the General Medical Council, although it is a rather smaller body. It is to consist of thirty-five members, of whom thirty-one are registered dentists. Nineteen of those will be put forward by the licensing dental authorities, one for each of them, with the exception that there will be two for London, and the other sixteen will be either elected or nominated in different ways which are explained in the First Schedule. In addition, there will be six members from the General Medical Council who will have particular responsibilities in education and examination, and I am sure we should be wise to preserve this link.
The criticism which I hear and read about in my correspondence and in the papers which concern themselves with these matters comes down to one sentence; it is suggested that the composition of the General Dental Council, as outlined by the Government in the First Schedule, is too heavily weighted on the academic side and does not give any representation to what perhaps we can call the man in the surgery. That is certainly the main criticism which I have heard.
I put forward this composition, which, of course, we can discuss in detail in Committee if hon. Members wish to suggest Amendments to it, as what seems to me a reasonable solution, but I do not pretend that there is any precise formula by which one can gauge anything as important as the composition of the governing body of a profession, particularly, of course, when it is being formed for the first time; and I should be more than ready to listen, both here and in Committee, to hon. Members' views.
Subject to that, I feel that one can put these points: first of all, I very much hope that we shall not hear too much about a conflict which I believe is imaginary, or ought to be imaginary, between the academic and the ordinary 1352 dentist. People are not on a body like this to represent particular interests. I am quite certain that, just as in the General Medical Council, so in the new General Dental Council, when it comes about, those members, and particularly the 31 out of the 35 who are registered dentists, will represent their own profession before everything else. They may, perhaps have a subsidiary loyalty to a university or a school from which they are appointed, but I am quite certain that that will come second, and ought to come second, to their loyalty to the profession.
I am sure that is a sound general rule throughout the Health Service. People who are on hospital management committees or hospital boards are not there as representatives of employers, trade unions, the British Legion, or any other of the admirable bodies which may have put their names forward. They are there as citizens to do what they can to help forward the work of that board or committee, and I am sure that the same principle will apply here.
The second general point to make is that it is laid down in Clause I that the General Dental Council will concern itself with high professional standards of conduct and "high standards of professional education." With the importance attached to professional education, it seems to me right and inevitable that those who have gone furthest in their profession and in many ways are its most distinguished members should have an important recognition of their abilities in the places which they command on the General Dental Council.
I think we can keep this in perspective if we remember that those elected directly are nine out of thirty-five on the proposed General Dental Council and eleven out of forty-seven on the General Medical Council—and, of course, those eleven represent very many more than do the nine elected members. I recognise, however, that the dental profession, in a way which does not apply to the medical profession, is overwhelmingly a profession of general dental practitioners, and, as I have said, I am very ready to listen to arguments, if hon. Members wish to put them forward to me, on the composition of the Council.
I turn, next, to the second point, which is the question of the admission of foreign 1353 dentists to the list. The position at present is that it is possible for the General Medical Council to recognise a diploma, and, therefore, the difficulties do not arise in any way with the well-known diplomas or degrees from universities and colleges outside these islands. The difficulty comes about when diplomas are put forward as adequate about which it is not easy to obtain satisfactory information. We have provided in the Bill that it is possible for the General Dental Council to invite a dentist who has been unable to secure registration to take an examination if not enough is known about the diploma which he has previously secured.
This is a small problem. I am told that not more than fifty or sixty dentists in the country have so far failed to secure registration under the procedure laid down in the 1878 Act. All the same, it would be very valuable if we could find, among these fifty or sixty, recruits for our general Dental Service and we should be very happy indeed to have them. I must weigh that, on the one hand, against the need to protect the public, on the other hand.
Fears have been expressed about the sort of examination which this may be and whether it may not prove too difficult for those people who in many cases have not been able to practise for some time and whose skill may conceivably have deteriorated a little because of that. Although this is a matter which we shall leave to the General Dental Council, I am quite certain that the examination will be largely, if not wholly, practical; but I am sure that we can leave to the General Dental Council, whose regulations also come before the Privy Council in this matter, the detailed organisation of these examinations.
I should also point out that even though a dentist may prove successful in such an examination, that does not entitle him to an English qualification. It merely entitles him to have his name added to the foreign list, which is described in the Clauses.
I come next to the question of the restrictions on the practice of the business of dentistry by unregistered persons. There was some discussion, when the Bill came forward in 1952, about the position of the Co-operative Dental Association in this matter; but I think I can say that their position has been entirely met, 1354 subject to the point which they have raised with me that the language of the Bill in one place has an unintended effect upon them. Without going into details, it is a matter which can easily be put right by Amendment in Committee.
If I am to judge from my postbag, a matter which raises considerable doubts in people's minds is the treatment of the widows.
§ Mr. F. Beswick (Uxbridge)
Will the right hon. Gentleman tell us whether the point which he proposes to put right in Committee relates to the disciplinary action against the corporate bodies?
§ Mr. Macleod
No. It relates to the employment of oral hygienists. As the Bill stands, it has the entirely unintended effect that they would not be able to use them. That is a matter which we can put right in Committee.
The position of the widows or children or personal representatives raises a very difficult point indeed. It is suggested in these Clauses that we should have a time limit of three years beyond which it would not be competent for an unregistered person of this sort to carry on a dental practice. I think that most people are agreed that it is right, anyway for the future, that we should have a particular term to these activities.
What that term should be, whether three years or any other time, again is a matter only of judgment and one on which I should be very glad to listen to the opinion of the House; but it has also been put to me with some force that it is one thing to lay down for the future for people who are not yet in these circumstances what the term or restriction should be, and another to alter unfavourably the conditions in which people already exist. That is very much the case for considering differently those who are widows now and those who may come within the terms of the Clause in the future. There is a lot to be said for that point of view and I am very ready to look favourably, if we can, at the possibility of making the Bill a little less onerous for people in that position at present.
I come now to Clauses 18 to 22, round which controversy has concentrated—the Clauses relating to ancillaries. We must be absolutely clear here about the background to these proposals. There are a 1355 few cold, stark facts which I should like to give to the House, which we must have in our minds all the time when we judge whether or not these proposals are a sound basis for the future.
The first is that there is in this country a ratio of dentists to the population of one to 3,400 men, women and children. The second point is that although the numbers of those engaged in the priority services has been climbing steadily, as many of us thought they would, since the introduction of charges, it is now at a figure of about 1,000, which is certainly not more than 50 per cent. and perhaps not more than one-third of the number of dentists that we need to give a thoroughly efficient service. Thirdly, there is the problem of recruitment, and this is the crux of the whole matter.
The Teviot Committee recommended that we should try as quickly as we can to obtain a yearly intake into the dental schools of 900. I have to tell the House that not only have we got nowhere near that but, in my view, there is no chance in present circumstances at least of getting within range of that figure. The record seems to indicate that we shall be lucky if we can hold the figure at 450, or half the 900 which the Teviot Committee suggested. We have been up to a figure of 654 in 1947–48, and we have been down to 478 in 1954–55. There are these considerations to be added to that—first, that the pre-war intake was about, or, indeed, slightly under, 400 and, therefore, we are doing rather better than that; and, secondly, that the pattern of the intake into dental schools since the war follows remarkably closely that after the First World War.
I think that the steady decline in numbers ever since 1947–48, when the dental profession was enjoying a very high standard indeed of remuneration, goes to show that no single cause is at work here. In other words, one cannot attribute the decline wholly to matters of remuneration or matters concerned with the ancillary proposals which are brought forward in the Bill.
It was because the dental profession and the Government were so concerned about recruitment that we appointed a Committee under Sir Arnold, now Lord, McNair, to go into all the questions that arose from recruitment. Some of the 1356 letters that I have received recently about the Bill, which seemed to find something inconsistent between proposals for ancillaries and the appointment of the McNair Committee, may have overlooked an answer which I gave in the House to my hon. Friend the Member for Harrow, East (Mr. Ian Harvey) on 25th July, which I should like to read again.
I was asked whether I would give an assurance thatdue regard will be had to the views of the Committee on the Recruitment of Dentists recently appointed under the chairmanship of Sir Arnold McNair before an experiment in the use of ancillary workers of the type employed in New Zealand is initiated.I replied:Yes, I have no doubt that the Privy Council, with whom it will rest to initiate the experiment after consultation with the proposed General Dental Council, will wish to see the Report of Sir Arnold McNair's Committee before putting in hand this experiment which, in any case, could hardly be started within a year after the Dentists Bill becomes law."—[OFFICIAL REPORT, 25th July, 1955; Vol. 544, c. 80.]That assurance, given to the House before the Recess, stands.
In the face of these facts which I have outlined to the House—and there are others which fit into the same pattern that could well be given—the Government suggest that we must look at the question of employment of ancillary workers, and we put forward two proposals in the Bill. The first of these is, I think, generally welcomed and, therefore, I need say only a word or two about it. It is the suggestion about oral hygienists. They have been doing very valuable work. There are a few of them now and I hope to see their numbers grow. It is suggested that they will be able to work under strict control in private practice. The words of the Bill are,… under the direct personal supervision of a registered dentist.The second proposal goes a good deal further. It stems from the Report in 1950 of the United Kingdom mission which was sent out to New Zealand. Reading it again a few days ago, in preparation for this debate, I noticed that one of the Ministers who appointed the Committee was Mr. Hector McNeil, then Secretary of State for Scotland. As this is the first health debate that has taken place since his death, I should like to pay tribute to him, because very few indeed 1357 had more friends than Hector McNeil had on both sides of the House of Commons.
I do not want to go in detail into all the conclusions of the very distinguished body that examined the New Zealand scheme. I want to quote, only because I think it should be on record, paragraph 115 which is the main point of the Committee's conclusions. It says:We are of the unanimous opinion that the training of the New Zealand school dental nurse has resulted in a high standard of technical efficiency in the treatment of children within the limits laid down and we further consider that, subject to the staffing limitations, the dental nurse system in New Zealand meets an urgent need.It has never been suggested, of course, that one can translate automatically experience in New Zealand into experience in this country, and that is not suggested in the Bill. Indeed, it is of great importance that we be quite clear about what is suggested in the Bill.
There is no proposal in the Bill for the employment of these ancillaries yet in the national or local authority health services; nor is any opinion given, nor do I express such an opinion, as to whether this scheme will succeed or fail. All I am asking the House to agree to is to have an experiment on these lines, and what I am saying is that it seems clear from the best opinion available to us that the experiment in New Zealand has been worth while and that, therefore, we ought to look to see whether we in this country can learn from it.
The proposal is that for a limited list of school children, the dental ancillary worker—the word "nurse" cannot be used for that is a protected title—will be able to extract milk teeth, which, apparently, are called deciduous teeth, and to carry out fillings, that this work will be done under the direction of a registered dentist and that the regulations for this class will be made by the General Dental Council.
Since 1952, I have made three changes in this part of the Bill. The first is the most important. It was felt by a number of people in the dental profession that these provisions in the Bill in 1952 might be used to bring into the dental profession those very valuable people who stand behind the dentist and who are called by various titles but to whom we can refer to as dental technicians.
1358 It was not the intention of the Government, and I am certain that it was not the intention of the Socialist Government, who had so much to do with the drafting of the Bill, that any such change, which would be a change of the first importance, should be made by the provisions of the Bill. Therefore, I felt it right to state clearly, as we have done in Clause 19, that there is no such intention of bringing within the scope of the ancillary workers provisions the dental technicians to whom I have referred. I can understand that that will be a disappointment to them but it does not alter the position under the Bill, because, as I have said, there was no intention that the 1952 Measure would be used for such a purpose. It may be helpful to the dental profession if we make that absolutely clear in the Bill.
The second change I have made is to have a committee to look after this particularly important experiment; and the composition of that committee is laid down in the First Schedule. Those are the two most important changes.
The third concerns the actual word used, which is now "direction"—i.e., the direction of the registered dentist under which the ancillary worker will carry out her tasks.
I think I have made clear that the Government regard this as a worth-while experiment and have no intention of prejudging its success or failure. We have been very careful indeed to put the strictest controls that we can think of upon the regulations that are to be made for these Clauses of the Bill; and not only the General Dental Council, but the Privy Council and both Houses of Parliament, are there brought into the picture. I believe, therefore, that the public interest will be fully safeguarded.
I do not want to enter into an argument with the British Dental Association or anyone else on the merits of this scheme because, as I have told the House, I am insistent that what we are asking the House to agree to is an experiment. I do not know whether that experiment will succeed or fail. What does seem to me quite clear is that if one looks at the facts I have given to the House, one cannot afford to overlook the possibility of the increased use of ancillary workers in the dental profession. It seems that we may be able to learn from the New Zealand 1359 scheme, and we put forward that possibility to the House. Indeed, I do not see how anybody looking with an un-prejudiced eye on the present position with regard to the dental treatment of the priority classes dare oppose such an experiment as is put forward in the Bill.
Those are the matters on which I thought the House would be glad to hear from me and they are the matters which are of considerable importance. I say again that by far the most important of them, although not necessarily the one that will take up most of our time, is the granting of self-government to the dental profession. In a number of references which I have made, I have shown that I am perfectly ready to be receptive in Committee to suggestions which hon. Members, on whichever side they may sit, might wish to put forward.
I welcome very much the attitude that the British Dental Association has been taking towards this new Bill. The Association remains opposed—I should state this frankly—to the introduction of ancillaries, and it does not believe that the experiment will work, although I think that we ought to suspend judgment on both those matters. The Association said in a leader in its journal on 16th August this year that the Bill is to be welcomed as an improvement on the 1952 Bill. It expressed the view that it was too much to expect a Bill that would be wholly satisfactory to the whole of the profession, and I do not for one moment claim that this Bill is.
The Association said that it was the duty of everyone who could bring influence to bear to improve the Bill as much as possible before it reaches the Statute Book, and I am sure that that is the way in which we will study the Bill in Committee. For my part, I would be very glad to help in any way I can towards improving the Bill in Committee. But, on the principle of the Bill, I would claim that the Government have made a case. That case is the one I have outlined this morning, and I ask the House to give the Bill a Second Reading.
§ 11.38 a.m.
§ Dr. Edith Summerskill (Warrington)
This is a very small Bill but, in my opinion, a very important Bill. I think that we are debating a new form of preventive medicine, because I believe that 1360 what the Minister describes as an experiment will be a new form of dental health service which will completely transform the health services enjoyed by the children.
I was surprised to hear the Minister say—he said it on two or three occasions—that in his opinion the most important part of the Bill was the creation of the General Dental Council. I do not minimise that but it rather highlights the difference in approach between the Minister and myself. Professionally, that provision is certainly very important, but surely even the Minister will agree that the most important part of the Bill is the new experiment which we are about to undertake and about which I want to speak.
The Minister was quite correct when, in his opening remarks, he said that he knew he would not be able to finish without telling the House about the history of the Bill. This was originally a Labour Measure. It was a Labour Minister of Health—we should take credit for this—who took the initiative of sending a very important dental mission to New Zealand. The members reported back in 1950 on what they had seen. They had seen what is, in my opinion, a prototype of what we shall ask the House to emulate for Britain.
First, I should like to deal with the question of the General Dental Council. I admit that for a profession like the dental profession that proposal is of great importance and, of course, the profession will welcome it; but, quite rightly, they are concerned about the question of its composition. I was glad to hear from the Minister that he is sympathetic towards the appeal of members of the profession and that he will consider the question of composition. We on this side of the House have received, as no doubt have hon. Members opposite, a deputation from the profession. I attach great importance to the organisations which represent professions. They are of equal importance to those organisations which represent the craftsmen, the industries and trades of our country.
We in this House would not be doing our duty unless we considered very carefully the objections of the profession to the Bill. That should be made clear, and I am rather sorry that the Minister did not examine in more detail some of the objections, because members of the profession will read the OFFICIAL REPORT, 1361 as they are very closely concerned in this matter. It would be well to let them know that we have considered their objections. They are hard-working men doing a job which to me would be uncongenial. It is a job which calls not only for professional knowledge and good craftsmanship but also for physical fitness. One has to stand in an unnatural position for many hours every day of one's working life.
I was thinking when I looked at hon. Members opposite, many of whom I have never seen present before during a health debate, that they might have been primed by their dentists. Of course, a dentist is in an excellent position to prime a Member of Parliament. One simply cannot answer back. I have every sympathy with the dentists. They do a very good job. They have a difficult heritage. The register came into operation only in 1921, and there are all kinds of difficulties which fill some dentists with a little resentment.
They, of course, will welcome the establishment of the General Dental Council. I feel, however, that in respect of its composition the General Medical Council was probably taken as a suitable example to copy. It should be remembered—the figures which I shall give were provided by the dentists, and I have not checked them—that in the medical profession it is estimated that only 35 per cent. are in general practice. I confess that when they told me that the other night I was surprised. I did not realise that the figure was so low. In the dental profession 90 per cent. are in general practice.
It is for this reason that the Dental Association opposes the constitution of the General Dental Council as laid down in the Bill. It provides for more than twice as many representatives of the dental licensing bodies—that, as the Minister said, is the academic side of the profession—than the number of representatives elected by the profession. I thoroughly agree with the Minister that these councils are composed of men whom we hope will be objective in their decisions. Often they have to come to very important decisions. They have to discuss disciplinary measures, and sometimes they have to deprive a man of his whole livelihood, which is what happens if he is struck off the register.
1362 I recognise that one does not necessarily want them always to be subjective; they must be objective in their approach. On the other hand, it must be remembered that they have to make important decisions about whether a dentist is still a suitable man to pursue his profession. There should be on the Council a large proportion of men who understand the difficulties of the general practitioner. The man representing the licensing body, the academic man, may be a man of very high principles. He may say "This man is not fitted to continue in his profession" but, on the other hand, a man experienced as a general practitioner may take a different view.
One knows that so many of the cases that come before the General Medical Council are of the kind in which a woman charges a doctor with behaving improperly in the consulting room. That can also happen in the dentist's consulting room. Academically a man may be a first-rate dentist, but it is advisable to have men on the jury who have also been general practitioners in the consulting room and who know the difficulties and the background. It may be that they would exercise a little more tolerance and humanity. I give these details to press upon the Minister the reason why the composition of the General Dental Council should more nearly represent the composition of the profession.
§ Mr. Iain Macleod
I am not necessarily either agreeing or disagreeing with what the right hon. Lady says. I acknowledge that there is considerable force in it, but it does not necessarily follow that in regard to discipline it will be necessary to alter the composition of the Council, assuming that the House takes the same view as she does. An alternative might be to look at the composition of the disciplinary committee which would deal with these cases.
§ Dr. Summerskill
I am merely speaking from my experience of the General Medical Council, having seen it in operation—I am pleased to say not as one charged with any offence but as a spectator. It is poignant, it is something which one never forgets, when one sees a professional man charged with some of these grave offences and one realises that the men who are listening have the whole of his future life in their hands. Therefore, I plead that if a General 1363 Dental Council is to be set up we should make it as understanding and as tolerant and humane as possible.
There is one small anomaly—it is not mentioned in the Bill—in relation to the medical profession, which I think the dentists find a little irritating and which should be removed. I refer to the annual retention fee. I wonder whether the Minister, at this stage, when he is putting the dental profession on an even higher basis, has thought about abolishing the annual retention fee. I think it is one of two or three guineas.
§ Dr. Summerskill
If I say anything which is incorrect, I know that my hon. Friend will pull me up.
On the subject of the forty or fifty dentists who have failed to secure registration, and whom we will be able to absorb, I would express the view that nobody would object to that. We shall all welcome them in these days of the shortage of dentists.
Then I come to the question of the ancillary workers. Before I deal with the main provisions, may I follow the Minister in what he said? I am glad that he mentioned the technicians, because the dental technician is a hard-working craftsman who very often writes to Members of Parliament. Indeed, he likes sending circulars to Members of Parliament. I think that all of us, on both sides of the House, have received them.
I want to say, on a point which is not included in the Bill, something to the Minister, hoping that I may drop a few seeds now which might germinate later. I always find it difficult to understand why the work of these technicians, which is entirely mechanical, is regarded in a light different from that of those whose work is strictly analogous. I should have thought that the fitting of an artificial eye called for great accuracy, skilled craftsmanship and aesthetic appreciation. A perfect artificial eye today is entirely different from the artificial eye of fifty years ago. It is possible for some people to be entirely deceived by it, yet the ophthalmic surgeon is quite prepared to let technicians take an impression of the orbit and fit the artificial eye, although if the patient is dissatisfied with it—and 1364 an artificial eye is something which one's vanity demands should be the most perfect—it might reflect adversely on the ophthalmic surgeon.
However, the ophthalmic surgeon in any of our big hospitals in London, having removed the eye, says to the technician, "It is your job to fit the new one—to take the impression and do all the fitting." The sauce is true of the orthopaedic surgeon, who is prepared to let technicians fit the patient. Again, the whole reputation of the surgeon may suffer if the fitting is incorrectly or improperly done. I think that that work is analogous to the fitting of dentures.
In view of the shortage of dentists, the anticipated decrease which the Minister has mentioned, and the relatively small number of new entrants into the dental profession, I find it difficult to understand why the dental technician is not listened to more seriously. As I say, this is a matter which is not contained in the Bill. It is a matter which no doubt would cause some controversy in the profession. I hope, however, that the Minister will consider what I have said, particularly in relation to other aspects of dental surgery. To my hon. Friends behind me who are dentists I would say that I know that this is dangerous ground, but someone has to say this.
§ Mr. Baird
I think that my right hon. Friend is a little misled. Dental technicians in this country are organised in two national trade unions, and they have made no request at all for broadening the basis of their job. The people who have been writing to Members of Parliament have no standing in the dental profession at all, and represent a small number of dental technicians.
§ Dr. Summerskill
Well, yes. I am really getting down to the practical point; I think that the time may come, and that is all I am saying. I am treading very gently, but someone has to say these things. Someone has to inject a few new ideas, and we have to look at this subject in a practical way.
If the time comes, in a few years, when dental caries is so common that we go back about seventy-five years, we have ourselves to blame. The new entrants into this profession, which is not a popular profession, are small in number today, and we have to think of new ideas.
1365 Now I come to the question of ancillaries. Of course, the dental profession in the past has rejected any form of ancillary worker. But the hygienist today is not new. The dentist now has the power to employ them in private practice, and I find it very curious that there are dentists who are opposed to the introduction of dental hygienists.
A dentist friend of mine, a man of great common sense, recently wrote a letter about this Bill. He fully approves of it and welcomes it, and I should like to read from his letter to show his approach. I hope that my hon. Friends will agree with it. He writes:I have one hygienist working for me and I could do with half-a-dozen. They are invaluable for cleaning up mouths especially in children, and instructing as to the care of teeth. For patients undergoing an operation a clean mouth is essential, and for the pregnant women attending ante-natal clinics. Thus in short ancillary classes should be extended and much more widely distributed. It would be a great help towards solving the dental manpower position and in the education of the general public in dental care.That man is a hard worker. He has a social sense. But also he is a member of his professional organisation. Nevertheless, from his own experience and with a knowledge of what the public needs, he writes that letter.
However, the view has been expressed by the British Dental Association, or at least by the deputation of six or seven whom we met, that they are not prepared to accept these new dental ancillaries who will be used in the experiment which the Minister has talked about. They will be employed in filling children's teeth and extracting deciduous teeth which were described by the Minister as "milk teeth". In the youth of some hon. Members these teeth were probably pulled out by their mothers, if they did not drop out, or if the whole household was not overwhelmed because little Billy had swallowed one of his milk teeth—because it had "disappeared in the night".
These are the deciduous teeth, the milk teeth, the simple teeth which, if left long enough, fall out of their own accord. It is suggested that a new ancillary worker be introduced who will be allowed to pull them out and also to fill the teeth of these small children. The dentists fear the dilution of the profession and the general lowering of standards. That fear is understandable and we must examine it 1366 fairly and squarely. I would ask for that to be examined just as I would ask for an examination of the plea of any trade union that objected to dilution on comparable grounds.
I wish to say briefly what were the objections that were raised when we met the deputation. First, they object to the new ancillaries because they are to be permitted to fill and extract deciduous teeth without having had a full dental training. What is it proposed to do? It is proposed to get girls—if we follow the New Zealand example—highly intelligent girls with the right manner, who will be specially picked and who will be given a careful and thorough training in that particular mechanical work. Furthermore, and I do not think this happens in New Zealand, they will be supervised by a fully qualified dentist, and that is very important. They will not only be trained in this very localised work, but they will be supervised by a fully qualified dentist and never left alone. There will always be someone present to whom they can refer.
The dentists said that that proposal is an encroachment on their preserves. I cannot help remembering, and I am sure that some older hon. Members will remember, that prior to 1918, before the introduction of the maternity and child welfare clinics, the medical profession objected to this "encroachment upon their preserves". I remember doctors coming to my father, who was a doctor, and saying, "This is outrageous. This is the thin end of the wedge. The State is going to set up clinics where there will be midwives and nurses advising the mothers on child welfare. That is our job. This is an encroachment. Let us stop it now before it goes any further".
That was in 1918, and now there is no one here who would deny that the low infantile mortality rate in this country can be closely related to the operation of those clinics. The very babies in the prams in the streets of our slums today are proof of that. It was an encroachment on the doctors' preserves, we know, but it was in the interests of the people and the children of the country, in precisely the same way in which this reform will be in the interests of the children of the country. All we are anxious to do now is to promote the health of the children and reduce the morbidity rate.
1367 The dentists stressed to us that they objected to specialisation in a limited area of work. Again, may I remind the House of the tendency today towards specialisation? The old general practitioner did midwifery. He extracted teeth. He set fractures and did minor surgery. In the cottage hospitals of the country he did major surgery as well. I was a student and helped my father to do midwifery, to extract teeth, to set fractures, and we did minor surgery. We did it very well together.
The old G.P. was a craftsman. He never had any leisure. He never had any of what people today would call pleasure. His pleasure was in his job. He brought the child into the world and attended the child and adult right through life until, finally, he signed the death certificate. That was his work. That time has gone and we do not want it back. I am not for one moment saying that it was right. Now we tend to specialise more and more and to concentrate on more localised fields, as we are doing in this proposal in the Bill.
We are concentrating on the teeth of the children. May I remark again on the change that has come about? Midwives now give analgesia, gas and air and pethedine, but I remember the doctors saying that this was an encroachment on their profession and that midwives ought not to be allowed to enable mothers to have painless childbirth. Now they can do so, and district nurses can give injections.
One would say to the dentists "What is the alternative?" The alternative is that in a few years' time the children of this country will be completely deprived of dental treatment. Let us face up to it, because that is the answer to the figures given by the Minister today. The new entrants to the profession are not there, and the adults will probably demand more time and attention from dentists. That means that, unless we take this form of action, the children of the poor will inevitably suffer.
I wish now to refer to New Zealand, and to say that we are not venturing into a new field today without experience. Fortunately New Zealand provides the prototype. I am in quite an exceptional position this morning, because in 1943 the New Zealand Government invited me 1368 to go to their country, and I had one of those interesting little experiences which one generally has when one goes to other countries at the invitation of the Government, and when one is inclined to see something that we cannot do better in our own country.
In New Zealand, in 1943, the Government supplied me with a small aeroplane, and the Minister of Health and I, with two officials, and of course the pilot and assistant pilot—I am not quite sure what we call him—[An HON. MEMBER: "The auxiliary pilot"]—flew over the two islands of New Zealand. I remember the Minister of Health telling me "There is not much that we can show you." I said, "There must be some things you can do here that we have not got in Britain." Some of the older hon. Members here—and this is important, because I am giving hon. Members opposite some information with which to reassure their dental friends—will recall that great pioneer of child welfare work in New Zealand, Dr. Truby King. He recognised that theirs was a small island with a comparatively small population, and he not only established maternity and child welfare clinics because he was a humanitarian, but because he was also anxious that the babies of New Zealand should survive to populate the country.
In 1943, the expectation of life in New Zealand was the highest in the whole world, including this country, the United States and Europe, which reflected a low infantile mortality rate. I say this in order to point out that the New Zealand Government had already shown to the whole world that it was specially interested in child welfare, and, when we set up our maternity clinics in 1918, we had an eye on New Zealand, which had already set up clinics the example of which we might well follow.
With this background, and with New Zealand proud of its reputation, could anybody say that that Government would be prepared to introduce a third-rate dental service for its children? Of course, not. I visited these clinics in both islands, and it was a most remarkable experience. Some of these clinics are attached to schools and I went to one big one where there were twenty small dental chairs occupied by small children. Efficient young women were looking after them, 1369 and what astonished me was the complete quiet. There was not a sound, and one would have imagined that these children were sucking toffee apples rather than having their teeth attended to. These women, who had been specially chosen, had an expert manner with the children. There was no crying, yelling or disturbance; the women handled the children perfectly.
In 1943, we were not aware of this great shortage of dentists. Perhaps it was coming but we had not high-lighted the shortage of entrants to the profession. Time has passed, and, of course, in 1950, after the mission to which I have already referred had been sent out and I had read about the New Zealand school dental nurses, I agreed with every word that was said.
I have refreshed my memory again of a paragraph which I had marked to quote—paragraph 115—which the Minister has already quoted, in order to make it quite clear that that mission was unanimous in recommending that a scheme similar to the New Zealand one should be introduced to this country. May I read the names of the members of the mission—there are only five of them—so that any dentists in this country who may be resentful that I, as a doctor, have said the things I have said—although I am qualified to do dentistry—will know who these people are.
There was Professor Bradlaw who was the Chairman of the Standing Joint Advisory Committee, a professor of pathology and Dean of the Faculty of Dental Surgery at the Royal College of Surgery of England. He is a professor in the Sutherland Dental School, Newcastle, and was a member of the Inter-Departmental Committee on dentistry. It was Professor Bradlaw who led that important mission, which was respected by the whole of the dental and medical professions. Then there was Mr. Thomas H. J. Douglas, the senior dental officer of the Department of Health for Scotland; Mr. H. T. Roper-Hall, a private dental practitioner who also has medical qualifications; Mr. W. G. Senior, Principal Dental Officer of the Ministry of Health; and Dr. A. T. Wynne, Medical Officer of the Ministry of Education. These men went to New Zealand in 1950, examined this scheme and came back fully convinced 1370 that it was desirable at least to experiment with it in this country.
I feel that, while we use the word "experiment," as the Minister does, in order to reassure the House, I have confidence that the experiment will become part of the scheme, and that it will be highly successful, and thereby we shall enlarge our preventive health service in this country, and, at the same time, give help particularly to the children of the poor.
§ 12.7 p.m.
§ Mr. Gerald Howard (Cambridgeshire)
I should like to say a few words about the proposed composition of the General Dental Council. The Minister has indicated that he is prepared to listen to suggestions for amendment of its composition, as at present set out in the First Schedule.
I want respectfully to express the hope that nothing will be done that will decrease the number of representatives of the dental educational licensing authorities. I have had the opportunity, during the last ten years or so, to see a good deal of the work that has been done by General Medical Council, and to hear something about its history and the difficulties which it experiences. No doubt it will be well known to hon. Members that, when that Council was set up by the Medical Act of 1858, the representation of medical licensing authorities was limited, and, in the ensuing years, that caused a very considerable amount of trouble. Those who were not represented were aggrieved, and the sharing of representation was found to work extremely badly in practice, while new universities able to grant medical qualifications were constantly asking to be represented.
Anybody who has read the debates on the Medical Act, 1886, must realise the great difficulty experienced by that limited representation of the educational authorities, and so, by other Medical Acts, every medical licensing authority was given a representative. I therefore hope that that position will be maintained under this Bill because, if it is not, there is no reason to suppose that similar troubles may not afflict the proposed General Dental Council. Indeed, I am told that within the last year or two the Universities of Edinburgh and Glasgow have started to give dental qualifications, and 1371 no doubt other universities will follow suit. I feel that it would be a mistake for anything to be done that would in any way diminish the representation of those bodies.
The right hon. Lady mentioned the difference between the medical profession and the dental profession with regard to the actual percentage of their numbers who were, what might be called, general practitioners. The right hon. Lady gave the figure of 35 per cent. for the doctors and 90 per cent. for the dentists. If one looks at the composition of the two bodies, it does not appear that there is very much wrong with the proportions set out in the First Schedule because, I am told—and I am sure that I shall be corrected if I am wrong—that under the Medical Act, 1950, the General Medical Council was given twenty-eight representatives of licensing bodies and eleven elected representatives of the medical practitioners. Those eleven represent, approximately, 70,000 doctors of all kinds. Taking the right hon. Lady's figure of 35 per cent., that would mean that the eleven represented approximately 24,000 general practitioners.
The First Schedule provides for nineteen representatives for the dental licensing authorities and for nine elected representatives from the general practitioners. I am told that the total number of practising dentists is some 15,000. Again, taking the right hon. Lady's figure of 90 per cent., that means the representation of some 13,500 dentists. On that basis, it does not look as though it can be said that the practising dentists have very much to complain about on the ground of under-representation.
I quite appreciate the point made about the disciplinary powers of both the General Medical Council and the proposed General Dental Council. I agree with the right hon. Lady that nobody who has been present at the sittings of the Disciplinary Committee of the General Medical Council can feel other than that every care is taken to ensure that the composition of that body is such as adequately to deal with the gravest possible professional matters of life and death which come before it.
I agree with the Minister in thinking that that could be done without any interference with the composition of the 1372 General Dental Council as such, but, if necessary, with the composition of the Disciplinary Committee itself. As the Minister said, the primary duty of the General Medical Council is that of professional education. Indeed, when one looks at Clause 1, one sees that the duty of promoting the highest standards of professional education comes first among the objects with which the General Dental Council is to concern itself. That being so, it must surely be right to have a representative of every one of those bodies which are at the moment carrying on that education.
The value of the Council cannot be better exemplified than by something that was said some years ago by Sir Donald Macallister who was, possibly, one of the most famous Presidents of the General Medical Council. He said:The Council were able to control and elevate medical education because our resolutions are the expression of an agreement amicably reached, and that is possible because on the Council all the medical faculties and corporations are represented.I hope that, in the light of the experience of the General Medical Council, nothing will be done by way of amendment of this Bill to cut down in any way the number of representatives of those bodies who have carried on and are carrying on that professional education, the promotion of which it will be the primary task of the new General Dental Council to ensure.
§ 12.16 p.m.
§ Mr. F. Beswick (Uxbridge)
I wish, first, to join with my right hon. Friend the Member for Warrington (Dr. Summerskill) in paying a tribute to the members of the dental profession—even if only as a precautionary measure. I am sure that the whole House has an admiration for this profession and for the way in which its members carry out their tasks. I also want to say a word or two about the proposed composition of the General Dental Council. Both the hon. and learned Member for Cambridgeshire (Mr. Gerald Howard) and the Minister spoke only of the respective claims of the academic and practising dentists. But surely there is another interest which is very involved in all this, that of the patient.
As the Bill is now worded, only four of the 35 members of the proposed Council will not be dentists. I should have thought that as the general tendency in 1373 these matters is now to give a greater opportunity for an expression of opinion by what is sometimes called the consumer, in this case the patient, four out of 35 was rather small. When the Minister comes to consider the claims which will undoubtedly be put before him in Committee, I hope that he will not overlook those of the general public.
I welcome what the Minister had to say about the possibility of certain unregistered foreign practitioners again being allowed to practice their profession. On the other hand, I wonder whether the right hon. Gentleman and my right hon. Friend were not a little too optimistic in thinking that under the present proposals such people will necessarily be allowed to practise their old profession. The Minister said that there had been no difficulty in the past in cases where foreigners, or people from abroad who may now he naturalised British subjects, held a recognised diploma or degree. That is not so. Indeed, there were many tragic instances of people holding recognised diplomas and degrees not being allowed to register in this country.
I, like many hon. Members, raised on several occasions in this House the cases of such individuals. I remember spending the whole of one morning with the Secretary of the General Medical Council on the matter. I thought at the time that there was a racial prejudice against those individuals who came to this country as refugees in the time of Hitler and who were not allowed to practise here. After speaking to the Secretary, I was satisfied that there was no such racial prejudice.
However, even though these people, who mostly came from Germany, held the highest qualifications—diplomas or degrees—the wording of the regulations was such that, the syllabus in Germany having been compressed into a slightly shorter period than that in this country, it was not possible, so the Secretary of the General Medical Council assured me, to accept their names for registration in this country.
That was the legal position, as I understand. Having had some experience in these matters, I could not accept the view that the standard of conservative dentistry in Germany before the war was in any way lower than ours. Therefore, it seemed to me to be both an injustice to the individuals concerned and, indeed, 1374 something less than reasonable to the general public of this country—who were short of dental practitioners—to prevent these people from taking up their profession here.
The Bill will provide for new regulations to be made. I understand from the Minister's optimism that that will not, on the old grounds, at any rate, rule out these unregistered practitioners. They will now be able to take an examination. In the meantime, however, much has happened to these individuals. One, at least, has taken his life, and two or three others have left the country. None has been allowed to keep in practice. One examination will clearly cause great difficulties to these individuals. Can the Minister say exactly upon what he bases his optimism—which was also expressed by my right hon. Friend—that these 30 or 40 people will stand a chance of taking up their profession once more?
Is there any possibility of a refresher course for them, or, instead of merely having one examination, instituting a period of practice under supervision, after which time it will be possible for them to prove whether or not their former skills are still with them? I hope that either during this debate or the Committee stage the Minister will be able to give us some assurance upon those points. There seems to be a feeling among Members on both sides of the House that these unfortunate people might now be allowed to do something in the dental world.
The Minister said that there was only one minor point upon which he was in disagreement with the Co-operative Dental Association. I was surprised to hear him say that. He made no reference to the proposals contained in the Bill for further restrictions upon bodies corporate. The Minister has come down very severely indeed upon such bodies, and has not said one word this morning to justify these restrictions. To the best of my knowledge he did not even refer to them. Surely he should provide some evidence in justification of this action. Evidence was given before the Teviot Committee upon this point. Paragraph 121 says:We do not recommend that the carrying on of business by dental companies should be prohibited.1375 It also says that, in the absence of evidence:We do not think that Parliament should be asked to pass restrictive legislation of that kind.In fact, Parliament is now being asked to do so. Despite that recommendation of the Teviot Committee, the Minister did not make one reference to it in his admirable speech—and I greatly admired his speech, which was made without any notes.
§ Mr. Macleod
If the hon. Member will look at Clause 24, which imposes some of these restrictions, he will see that this will not apply to the Co-operative Dental Association, because it is already in existence. As far as I know, the Clause was amended to meet some of the points raised by them, including the matter of the appeal, in another place, in 1952. I do not think that the Co-operative Dental Association will be hampered in any way by the restrictions to be placed upon new dental companies.
§ Mr. Beswick
It is quite true that the proposal to prohibit any corporate body from entering into practice in future will not apply to those already in operation, but it is not simply the Co-operative Dental Association which is concerned. It may well be that at some time in the future two or three dentists may get together and may prefer to practise under some co-partnership scheme. A very interesting experiment in this direction is being carried out in another profession. I do not want to draw too close an analogy, but I am thinking at the moment of the architectural profession.
If two or three dentists wish to set up in practice as a co-partnership organisation, registered under the Industrial and Provident Societies Acts, they would be forbidden under the Bill. If there is something bad about the way in which some of these organisations carry out their work the Minister now has power to close them down and to stop them practising. Surely it would be better to deal with any such malpractices in bodies corporate upon an individual basis, rather than allow those organisations who are now practising, and whose professional standards may not be as high as we require, to continue to do so while preventing any other similar organisation from setting up in practice in future.
1376 That seems to me to be a rather strange way of going about this business.
I now turn to the proposed penalties, and the discipline to be exercised in relation to those bodies in future. If any one dentist, being a dentist practising as a member of a body corporate, is guilty of a criminal act, not only is he but all his colleagues are to be punished. If one member of an organisation employing 60 or 70 professional men is guilty of embezzlement in future, and he is a director—as he may well be, because the majority of directors of the Co-operative Dental Association, for example, are also practising dentists—not only will he be punished in the criminal courts, but, under the Bill, the organisation will be closed down and prohibited from practising in the future. There is provision for appeal, but the Bill does give power for such a body corporate to be closed down. This kind of group punishment is not carried out in any other profession, and I should have thought it was rather unfair to institute it in regard to this one.
There is one other unfairness. If a dentist, being an individual practising dentist, is held to be guilty of unprofessional conduct and is struck off the register, if he can later bring fresh evidence and can prove his case on appeal, he can be reinstated upon the register, but if that dentist had been a member of a body corporate, and that body corporate had been wound up or closed down as a result of disciplinary action, no provision is made to allow that body to set up in practice once more. That seems to be an unfair discrimination against bodies corporate, and I hope that the Minister will examine this point before the Bill becomes law.
Clause 24 (3, b) says that if any misdemeanour on the part of a professional dentist is held to have been connived at by a director of the body corporate, certain penalties will follow. There again, I should have thought that it would have been more just if, instead of imposing penalties upon all the directors, they had been imposed upon the one who had connived who might quite conceivably have been acting entirely unbeknown to the rest of his colleagues.
The Minister has discriminated very harshly against these bodies corporate. I cannot think that they are wholly 1377 wrong; indeed, he admits that many of them are practising under the highest standards of professional conduct, and I hope that before we pass the Bill through Committee he will re-examine some of the points which I have raised.
§ 12.30 p.m.
§ Sir Hugh Linstead (Putney)
I was very interested in the remarks of the hon. Member for Uxbridge (Mr. Beswick) about the position of corporate bodies under this Bill. Most of the provisions of Clause 24 of the Bill are taken from the Pharmacy Acts, where a corresponding state of affairs exists. They have been in operation under those Acts for twenty years, and they have been found to work quite satisfactorily. Although I agree that there is power here for the Council or for the disciplinary committee to disqualify the whole of a corporate body, in fact, if the precedent of the Pharmacy Acts is to be taken, that sort of extreme penalty is not exacted. I do not think, judging by those precedents, that they will be treated in the way in which the hon. Gentleman fears.
Dentistry is essentially a professional occupation to be carried out by individuals who are to be trusted as individuals, and I should have thought that the accident of corporate bodies having historically found their way into that profession should not be used as a reason for extending the scope of the corporate bodies within what is essentially an individual profession. Once the element of finance and other things break into the professional field, one has to be extremely cautious, and I should have thought that the provisions of Clause 24 could be very strongly justified with this consideration in mind.
§ Mr. Beswick
Can the hon. Member justify that statement? He is saying that this Clause could be justified, but he has given no evidence to the House to back up what he is saying.
§ Sir H. Linstead
I do not want to occupy the time of the House too much, but if the hon. Gentleman and I happen to be serving in the Committee dealing with this Bill, we may have an opportunity of exchanging ideas and information on this particular topic.
I personally welcome the Bill, and I welcome, also, the approach of the 1378 Minister and, if I may say so, that of the right hon. Lady the Member for Warrington (Dr. Summerskill), in treating very carefully the views of the dental profession towards the Bill. I am sure that it is essential that the profession should be carried with the Ministry in legislation of this kind. Of all the professions in the National Health Service, I think that the dental profession is probably the least happy at the present time. The dentists seem to have had all sorts of misunderstandings with the Ministry, and the result has been that they are disgruntled and not happy in their professional work. Anything that can be done to make certain that this Bill is put into a form which carries the bulk of the dental profession with the Minister is, I am sure, a good thing.
There is a big element of public relations in the contents of the Bill. I welcome the establishment of the General Dental Council very largely from that point of view, because it makes the dental profession, quite clearly, mistress in its own house, and, to a much larger extent than hitherto, responsible for its own development and its own destiny.
I am one of those who think that the composition of the Dental Council may have to be looked at again, but I accept the opinion, expressed by my hon. Friend just now, about the dangers of not getting complete representation of the dental schools. I should have thought that it would have been possible, without increasing the number of the General Dental Council, which, at 35, is a fairly large body, to arrange that there should be more representation of practising dentists on the committee, or any other committees of the General Dental Council particularly concerned with the affairs of practising dentists. It may be that the solution is to be found there rather than in merely adding a few more people to the General Dental Council, which is already a fairly substantial body.
I agree most strongly with what the hon. Member for Uxbridge had to say about the 30 or 40 German dentists who are still not registered in this country. I, like him, have made a careful and detailed investigation into the reasons why these highly-qualified people were excluded under existing legislation. I was not impressed by the legal opinion 1379 which the Dental Board received, but, having received that opinion, I think that they were bound by it.
The effect of the legal opinion they received was that every application for admission by a German dentist had to be measured by the standards in British dentistry of the year in which he made the application to be admitted. So the man who qualified in 1912 in Germany had to be measured by the standard of dental education in England of, we will say, 1945. The older and more distinguished the applicant, the less chance he had of seeing the length of curriculum in Germany measure up to the modern curriculum in this country. As a result many distinguished people were left out by what seem to me purely mechanical methods of measurement.
I hope that the Minister will be able to tell us that that particular legal difficulty has been swept away, and that some of these men may be brought in without examination, or, if they have to take an examination, that some facilities will be made available for them to have three or six months' practical revision work, so that they can get their muscles, fingers and skill back into form. I think that this small but important reserve of manpower ought to be brought into circulation.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
I am sure that the hon. Member would include the Polish dentists who are in exactly the same position.
§ Sir H. Linstead
I would, certainly. The investigations I made concerned the group of German dentists, but I have no doubt that the same applies to a number of other refugees.
Another point to which the Minister drew attention was the position of certain widows of dentists. I was glad to hear him say that it may be possible to differentiate between the widows who have certain vested interests at the moment, and those who may be widowed after this Bill becomes an Act. It seems to me that, in practice, it will be very difficult to draw any satisfactory line between giving a widow a definite right to carry on a practice with a registered dentist, and giving her only a minimum 1380 period of time within which reasonably to dispose of the practice.
If we take the second course—and I think that we shall have to, because I do not think that we can allow a widow indefinitely to carry on her husband's practice—I should have thought that the period of three years was as good as five years or seven years. The sooner she has to face up to disposing of the practice, and probably the earlier she has to vacate it in that unenviable situation, the better. I understand that there is the possibility of separating the two classes of widows.
The only other point that I wish to make relates to the major problem behind this legislation and behind the whole of the state of the dental profession. It is the question of manpower. The Bill attempts to provide some solution, some alleviation of the present difficulties, but I do not believe that it will in fact provide enough manpower to come anywhere near meeting the needs of the country. I do not think that the Minister can do more because of the necessity of carrying the dental profession with him, but when we have the Teviot Committee saying that we need about 8,000 additional dentists, which means doubling the content of the dental schools, and the fact that at present there is a falling off in the number of students, so that we need 500 more dental students every year to get to the Teviot Committee's figures, I can see nothing in this Bill which will bring us remotely up to the need.
Two points about manpower ought to be stressed. When some of us were discussing with vice-chancellors of universities not long ago the available pool of unused, good grammar school material for higher technological education, they told us that, by and large, in their science faculties they were taking all the worthwhile secondary school boys and girls they could lay their hands on and that there were no reserves in the secondary schools of unused university quality material.
If that is so in relation to science degrees I suspect it is true, also, in relation to medicine and dentistry. The manpower is not there, unless we are prepared to lower our standards, which none of us would wish to do. The same problem may exist in relation to the oral hygienists and the New Zealand auxiliary scheme. The Minister there is going into a limited 1381 field of supply. There is a great demand for teachers, shorthand typists and office workers from the very group of women from whom the Minister hopes eventually to be able to draw his additional material.
For all these reasons we are not likely to get from the Bill anything like the full manpower needed. If that is so, it suggests that a very great act of statesmanship is required within the dental profession, which has to think out afresh the whole of its professional organisation and methods of work. It has to find ways of ensuring more pairs of hands to work under the supervision of dentists. I do not speak of dilution, which at once puts up the backs of organised bodies of professional men or craftsmen, but of a much wider conception of the dentist and his position in the health field.
The dentist has to see himself in future as the leader of a team. I do not see why the dentist, even in private practice, should not have four or five chairs, with different types of auxiliary worker attending to patients at the same time. The quality of individual dental care which is given today falls far below the best that ought to be available. Let me take the personal example of a child of mine going to a dentist. The first thing the dentist did was to take a plaster cast of the jaws, and to work out from it what was likely to be their development in ten or fifteen years' time and what, therefore, ought to be done now to prevent malformation.
That should represent the approach of the first-class dentist to every patient that goes into his surgery. The patient should be looked at for nutritional and preventive problems in relation to the livelihood of that patient in ten or fifteen years' time. Having done that sort of diagnosis, the dentist should say, "The job to he done at the moment is so and so, and the people to do it are so and so." It may be that a dental hygienist is needed, a New Zealand auxiliary, or a dental technician, and he would hand over that particular technical job to the right person, under his personal supervision.
That conception of the development of dental practice will require an act of statesmanship on the part of dental leaders. They will have more and more to persuade the rank and file of dentists to have more pairs of hands under their control if the dental needs of the country are to be met. While I welcome the Bill 1382 as a considerable step forward in the direction of establishing a better position for the dental profession and of doing something to fill the manpower need, I feel that we are only on the fringe of the problems. The dental profession should give thought to some of these problems over the years to come.
§ 12.45 p.m.
§ Mr. John Hynd (Sheffield, Attercliffe)
Like most hon. Members who have spoken, I welcome the Bill, particularly for three reasons. The first is that, as the Minister pointed out, it raises the status of the dental profession and, although he did not mention this, it may have a good effect upon recruiting. Hitherto aspirants to the field of medicine have been more attracted to general medical practice than to dental practice, because dentistry has been rather in the position of a stepson to the medical profession. I hope that the Bill will attract some of these people to the dental profession, which is now standing on its own feet.
The need is obvious, from the figures which the Minister gave us and which rather shook me. He said that recruitment was running at the rate of 450 per year. I remember not very long ago when Government supporters were accusing the Socialist Party of killing the school dental service because with the introduction of the National Health Scheme, and the greater attention thereby given to the general dental health of the population, the school dental service was suffering from our inability to attract the necessary numbers to fill up the vacancies in it. From the Minister's figures it seems that we are very little further ahead than before the war. I therefore welcome the Bill all the more. After all those accusations against the Labour Party, the Minister now has to admit that he is introducing our Bill that we introduced when we were in office.
My second reason for welcoming the Bill—I am not necessarily giving these reasons in order of priority—is that it seeks to deal with the long-outstanding question of foreign dentists. The third reason is that it raises the question of auxiliaries—a subject on which I do not consider myself qualified to speak—and will give the House an opportunity of hearing the different points of view on this very controversial question and coming to some satisfactory conclusion.
1383 The Bill takes away certain powers of the General Medical Council which that body has held for nearly a hundred years. As one who has the honour to serve on that august body I think I can assure the House that that Council, and the individual members on it, far from resenting this reduction in their powers, welcome it because it gives the dental profession a status to which they readily recognise its development in the last eighty years or so has entitled it. The provisions about the establishment of the General Dental Council, in fact, follow the evidence that was given before the Teviot Committee by the General Medical Council itself. No hon. Member ought therefore to have doubts about the attitude of the General Medical Council.
The General Medical Council was given responsibility in 1878 for setting up a Dentists' Register and supervising the education and disciplinary codes of the dental profession. The development that has taken place since then is emphasised by recalling what one of the distinguished Presidents of the General Medical Council, Sir Donald Macallister, said in 1919. He said:Dentistry was originally put under the General Medical Council because there was no dental profession.Even further back, the "British Medical Journal" in 1878 actually went as far as to say that medicine was already a profession but dentistry was only a business. We have travelled a long way since then. The Dental Board was established in 1921, and this Bill, originally formulated in 1952, will now, I am confident, pass through the House, although some Amendments may be necessary during the Committee stage.
Although such matters as education and discipline are now being handed over from the General Medical Council to the dental profession itself, we are not losing the vast experience that the General Medical Council has gained over some eighty years in matters of education and discipline in the dental field. The Bill provides that there shall be six members of the General Medical Council on the new Dental Council, and those members will be able to contribute a great deal of accumulated experience. That is an important and valuable link.
1384 Much has been said about the constitution of the Council—among others by the hon. and learned Member for Cambridgeshire (Mr. Gerald Howard)—but before hon. Members decide whether or not the proposal for the constitution as embodied in the Bill is satisfactory, I should like to mention one consideration. The proposed General Dental Council is not a delegate body on which every interest in the profession must be carefully balanced. The purposes of the Council include not only discipline, but all the wide field of constant supervision and examination of the educational process, curricula and a host of other things.
To suggest, therefore, that we should merely try to balance the representation of the practising dentists with that of the licensing bodies would be rather ridiculous. If we did that we should have to consider also an equal balance of what might be called consumer representation. I do not think that any one would suggest that.
The important consideration is the purpose of the Council. I do not know quite how far that will be developed, but in the General Medical Council the greatest proportion of committee work is concerned with matters to which practising medical practitioners can not be regarded as having much to contribute. The general medical practitioner will be much more involved in disciplinary matters because, as the Minister points out, it is the general practitioner who knows best the day-to-day difficulties and dangers of practice. He has not a great deal of specialised knowledge, although he has something to contribute to all the intricate questions of examinations, teaching curricula, the various kinds of drugs and so on.
Apart from the disciplinary side, we have, on the General Medical Council, a pharmaceutical committee, an examinations committee—a whole range of committees on which it is necessary to have a fairly wide representation of the academic side. It is therefore necessary to have the fullest possible representation of the licensing bodies. Each such body has its own experience to offer on examinations and other such subjects, and it would be rather absurd merely to load the committee with sixteen elected members in order to balance the sixteen representatives of the licensing bodies.
1385 It would be equally wrong, in order to get a better balance, that licensing bodies should share representatives—that two universities should share one representative. That experiment was made by the General Medical Council many years ago, and it was found quite impracticable. If two bodies share one representative, that person will come from one body. When he has been on the Council for two or three years and is beginning to get the necessary experience of the work, the other body will think it is about time that it had a turn, and the tendency is for the switching of representatives to go on all the time. For that reason, and others, the General Medical Council dropped that practice and now gives full representation to the licensing bodies. That has proved very satisfactory and has eliminated such difficulties as I have outlined.
I do not want to say much about foreign refugee dentists. Like other hon. Members, I think it is high time that this unnecessary and unhappy situation was rectified. These foreign dentists are experiencing special difficulties, and will experience them even in getting the opportunities that the Bill seems to provide—although we are not quite clear how far it does provide for their getting back into the profession. Some of those difficulties have been mentioned by the hon. Member for Putney (Sir H. Linstead)—lack of practice in muscular control is one; they must have practice with the new equipment they are to handle.
Above all, there is still a fear that there might be a certain resistance to their entering the profession. That is not entirely unfounded. I remember that, during the war, many eminent specialists came here from Germany and other countries which were over-run by Hitler. At that time we were very short of doctors—they were desperately needed in the Army and in Civil Defence as well as for civilian purposes—but we were not able to get the medical profession to accept those men on their merits. So far as I remember, under the arrangements that were made only a handful were allowed to practise—and then only as general practitioners. That demonstrates that even in such desperate need as there then was there is a latent resentment. I hope that we shall have an assurance that we need have no fears on that score.
1386 The provision made for the entry of such a dentist is not very clear. The Explanatory and Financial Memorandum lays it down that he may be allowed to enter the profession provided that… he holds a Commonwealth or foreign diploma and satisfies the Council that he has the requisite knowledge and skill.That is very good, but it then says:For proof of this the Council may, if it so wishes, require the dentist to sit for an examination.I hope that that means that if the Council is satisfied that the individual has the necessary skill and experience he may be appointed without an examination. I hope that that is what it means. It seems to say that, but I should like to hear from the Minister what he thinks.
May we be assured that if the Council feels that a man should sit for an examination, the examination will be adapted to the peculiar circumstances of these applicants? I know that an assurance has been given by the Minister that the examination will be more of a practical nature, but I should like an assurance that the Council itself will arrange that the examination will not only be mainly practical but will have regard also to the difficulties and special circumstances of such an applicant.
I should like to know if the Minister thinks it will be possible for these applicants to undergo a refresher course, perhaps practising in a hospital, under supervision, and to receive in addition some kind of grant. Clearly these men have to make a decision. They may have some kind of work already, and they have to make up their minds whether to undergo a period of training to enable them to sit for the examination and endeavour to maintain themselves in the meantime. If it is found desirable that they should spend six months or more in actual training under supervision in a hospital or some other institution where dentists practise, will the Minister consider the possibility of making a grant to these people—as has already been done in the case of public education—in view of the small numbers involved?
I do not feel that I am qualified to make a decision on the question of ancillaries. I have studied all the representations which have been made to me on this subject, and I should like to hear the views of others. On the other points 1387 which I have mentioned, if the Minister can give me the assurances that I ask for, I shall gladly support the Bill.
§ 1.3 p.m.
§ Mr. J. K. Vaughan-Morgan (Reigate)
The hon. Member for Attercliffe (Mr. J. Hynd) referred to the school dental service. I do not know whether he was here when my right hon. Friend was speaking.
§ Mr. Vaughan-Morgan
If so, he will recall the remarkable figures which my right hon. Friend gave. He said that the numbers engaged in the school dental service had risen from about 800 in 1951 to about 1,000 now, which is a substantial improvement.
My right hon. Friend is to be congratulated on bringing forward this Bill in a less contentious atmosphere than would have been the case if the Bill had been introduced two years ago. Indeed, the only real rift in the harmony today is that which looked as if it might develop between the right hon. Lady the Member for Warrington (Dr. Summer-skill) and the hon. Member for Wolverhampton, North-East (Mr. Baird) on the subject of dental technicians. As the hon. Member for Wolverhampton, North-East is not here. I can safely say that I am delighted that the right hon. Lady spoke in defence of the dental technicians who are now endeavouring to raise the status of their craft with the almost unpronounceable name. There may be no question of any step forward at present, but perhaps the day will come when it will come about.
On the question of ancillary workers, to the impartial layman—as I am in these matters—the arguments which the right hon. Lady deployed in her admirable speech seem incontrovertible. But in fact we are not today asked to judge on the merits or the demerits of ancillary workers. All we are deciding in the Bill is whether there should be authorised an experiment which will be controlled by the dental profession itself. Any scheme emerging from this will then need the approval of Parliament. It is only at that later stage that we need an argument as to whether or not the use of ancillary workers be justified.
1388 The public as a whole will think it wrong that there should be such fierce opposition to an experiment. They will feel that it is rather a dog-in-the-manger attitude, and, to speak candidly, rather a diehard and dogged dog-in-the-manger attitude at that. Here is a chance to survey this problem, and ultimately, as the right hon. Lady said, we may find in this tentative experiment a solution to some of the difficulties that beset dentistry as a whole.
I do not want to repeat any of the arguments so far heard in the debate, but may I draw the attention of my right hon. Friend to one curious omission in this Bill, namely, that there is nothing to protect the use of the title "dentist"? Under the existing law one is not allowed to practise dentistry without being qualified. However, as the Acts have been amended in the course of time, there has occurred this curious omission by which the title "dentist" can be used by those who are not actually on the Dental Register, and I suggest that before the Committee stage is reached this point should be examined.
The other main matter which has been raised is the question of the constitution of the General Dental Council. I have listened to all the arguments for increasing the representation of the licensing bodies, of the general practitioners, and even of the man in the street—or the man in the chair, or the consumer, whatever one may call him. Having heard and balanced all the arguments so far, it seems to me that the membership of the dental profession is so different from that of the medical profession that there is a very strong argument for giving a slightly increased membership to the general practitioners—by increasing their representation from nine to twelve. Then we shall have a not unreasonable number of general practitioners.
We shall not get too cumbersome a body if the membership is increased to thirty-eight, and there will be roughly parity or near-parity between the academic and non-academic members. I feel that that solution might meet the arguments which have been put forward—and I thought they were very reasonable on this point—by the British Dental Association.
I was glad to hear my right hon. Friend say that he will be sympathetic 1389 to any suggestions which may be brought forward in order to help the position of those lay persons who are now carrying on dental partnerships. Most of us will agree that without question in this day and age no lay person should carry on a dentistry business indefinitely, but we have to consider the rights and interests of those affected by the Bill if the proposed limit of, say, three years is suddenly introduced.
I wondered—and this occurred to me only today—whether my right hon. Friend would consider a proposal: that the limit of three years should not come into operation at once when the Bill becomes law but should be deferred for, let us say, seven years. This would give to the existing practitioner or his representatives, if he died now, a ten-year purchase of the present practice, gradually dwindling to three years. I have not considered all the implications, but perhaps my right hon. Friend would think about it and see whether it would not be a way of protecting this legitimate right.
We all welcome the Bill which, after nearly a hundred years of tutelage by the General Medical Council, gives this no less important branch of medicine an equivalent status.
§ 1.12 p.m.
§ Mr. A. E. Oram (East Ham, South)
I have listened with care to the debate so far in the hope that certain doubts and misgivings which I have about the Bill would be dispelled, but I must say that those doubts remain. They are largely those which were expressed by my hon. Friend the Member for Uxbridge (Mr. Beswick) and they relate, first, to the composition of the proposed General Dental Council and, secondly, to the position of corporate bodies under the Bill.
I want to underline what my hon. Friend the Member for Uxbridge said about the need for the general public interest to be more adequately represented on the Council than is at present proposed. The provision of only four independent members is felt to be completely inadequate. We have to recognise that in the provision of vital public services, as dentistry undoubtedly is, equally with any other activity in the commercial field, there are broadly two sets of interests.
1390 On the one hand, there are the interests of those who provide the services—the workers in the profession—and, on the other hand, there are the interests of those who need the services—the public. It seems to me that although one would not advocate a 50–50 representation of those two interests, the present proposal is completely inadequate in the representation of the public interest.
It may be that those two interests do not necessarily conflict for a long time, but I suggest that there are occasions on which they may well conflict. Even within the present Bill there is one instance where that is true—the question of ancillary workers. The Minister apparently thinks—and my sympathies are with him—that it is in the public interest to proceed with this experiment, but we understand that the organised profession is not so sure about it. I will not attempt to say which is right, but I point to this as an instance where the two interests—that of the profession and that of the public—may well be in conflict. Issues of that kind may well crop up once the Council is established and there ought to be a much more adequate voice for the general public interest.
I suppose the theory is that when a body of workers reaches the status which we define as a profession, they can be entrusted to look after the public interest, but I urge members of the profession not to be too self-righteous about these things. The hon. Member for Putney (Sir H. Linstead) was rather horrified and used an expression about the undesirability of "elements of finance" entering into professional matters. I think that that implies that members of profession are more angelic than they often are. In the early days of setting up the Health Service both the dentistry profession and the medical profession showed that they were not entirely above commercial considerations. I think that we must not get too high in our notions about professional standards.
I understand the general position taken up by the Minister on Clause 24 and the position of corporate bodies. In recent years, I understand, there have been undesirable practices on the part of a number of corporate bodies in the dentistry 1391 profession, and this may well be a necessary provision in order to put a stop to their activities; but the fact that a certain number of corporate bodies have been guilty of operating at standards lower than those we should desire is surely no reason to prohibit the development of good corporate bodies—and I submit that there are good corporate bodies operating today within the sphere of dentistry.
The Minister mentioned the Co-operative Dental Association and I think that both he and the profession generally would agree that the standards of that organisation are of the very highest. It seems to me that if there are black sheep in the profession, it is not a good policy, in order to get rid of the black sheep, to condemn the white sheep to slaughter as well. I should like to see the door left open for the development of desirable corporate bodies in this profession, and as the Bill is drafted that door will be closed.
My hon. Friend the Member for Uxbridge put forward an interesting and, I think, important suggestion about the possible development of co-operative co-partnership schemes within the dental profession, and I believe that in the provision of professional services generally the co-operative co-partnership method is admirable. I listened with interest to the suggestion of the hon. Member for Putney that a few dentists could well have a number of dental chairs under their supervision, with ancillaries working with them, the idea being that there should be a dental centre rather than individual dentists' surgeries.
If we are to go in for bigger units of that kind, then I would point out that we have had a number of instances in recent years of the development of co-operative co-partnership in the provision of professional services. Architects have been mentioned and I can also think of film producers and technicians, and commercial artists. Why should not that also apply in this sphere of dentistry?
It seems to me that the door is being closed against what may well prove in the future to be a desirable development. At the moment, it would appear that ordinary partnerships are all right. They would not come under the classification of "corporate bodies" and they would be 1392 able to proceed. I hope that that will be possible also in the case of co-operative co-partnerships where it is necessary for them to register under the Industrial and Provident Societies Acts, thus becoming corporate bodies. The party opposite has been showing an interest in co-partnership in recent months and I invite the Minister to consider whether he may not be missing an opportunity here of putting into practice some of the professions that his party has been making.
My hon. Friend the Member for Uxbridge dealt also with the vulnerability of existing corporate bodies, like the Co-operative Dental Association, which can continue in operation—that is, their vulnerability under the disciplinary Clauses of the Bill. If one officer of a corporate body commits a misdemeanour the whole of that organisation suffers. That seems to me wholly unjust.
§ Mr. Oram
Yes, but we do not want them to run the risk. It seems to me that an individual, quite rightly, should face the consequences of his misdemeanour and a corporate body, quite rightly, should face the consequences of its collective misdemeanour or if it collectively condones or connives at the misdemeanour of an individual. I should not object to the individual and the corporate body suffering in that case, but I cannot accept—and this is what the Bill threatens—that a corporate body should suffer even if it knows nothing about the misdeameanour of the individual and even if the misdemeanour had nothing to do with dentistry as such. In other spheres covered by the Companies Act, a company is not vulnerable to that extent. I see no reason why that vulnerability should be increased in the case of corporate bodies that undertake dentistry.
These criticisms of mine, and similar criticisms that have been voiced by other hon. Members, do not in any great measure detract from the general welcome that we give to the Bill. It promises in many respects to do important and good things, but I have tried to indicate certain weaknesses in it and I invite the Minister to consider whether some of the matters that I have mentioned cannot be altered. I hope that at a later stage he will consider improving the Bill in these respects.
§ 1.22 p.m.
§ Air Commodore A. V. Harvey (Macclesfield)
At the outset, like many hon. Members, I should like to congratulate my right hon. Friend on the introduction of the Bill. It goes a long way towards meeting a really urgent requirement. I have listened to many speeches by the right hon. Lady the Member for Warrington (Dr. Summer-skill) in the last ten years, but I think that her speech today was the most agreeable that I have heard her make. It was constructive, to the point and witty. Obviously, she is well versed in this subject.
Well as the Bill is constructed, I am not convinced that in itself it will materially add to the dental service in the immediate years ahead. There is a great shortage of dentists. My right hon. Friend has given figures, with which we are familiar, and has confirmed that young men are not coming into the dentistry profession in increasing numbers. One can understand that, because there are so many openings for young men in the various professions and in industry and they are particularly sought after by the large corporations. One can understand, therefore, that what is not altogether an attractive profession does not appeal to them.
It is the children who will be most affected in the years to come. Today, in many areas ten of thousands of children have not yet had their teeth examined. That in itself is bad, dangerous and will be costly to the country. The number of dentists on the register at the beginning of January was 15,198 and, by 1958, 5,085 of them will be due to retire. If that situation continues, the service can break down over a period of time. That is why I emphasise that I should like to hear more of what is going to be done to get men into the profession. We may be told that that will be left to the General Dental Council but, after all, we here should be reassured about what the future holds.
As a layman, I hesitate to offer opinions, but it is our duty in the House to say what we think. After listening to the various deputations that have come to see us, my humble opinion is that more use could be made of ancillary workers. I well remember going to a dental officer in the Royal Air Force 1394 during the war to have treatment and seeing a W.A.A.F. in white uniform starting to scale teeth. The work was extremely well carried out and I should have thought that it would have been of great benefit to extend the work of such people. It would save the dentists a great deal of time and worry.
Under the three years' experiment which is provided for in Clause 20, I understand that 80 hygienists will be trained. The scheme is to cost £100,000. It sounds a great deal of money, but it is a very small sum compared with what is spent overall in the National Health Service today. The work intended to be carried out is the filling and extracting of children's milk teeth. I agree that it is an experiment, but we are told that a similar experiment has already been carried out in New Zealand and is there looked upon as having been really worth while and beneficial to the health of the nation. It is vitally necessary that the best use be made of existing personnel within the profession. Physiotherapists and radiographers are part of the medical profession and their duties are clearly defined, but the dentistry profession seems to be holding back and trying to keep a water-tight compartment to itself. I may be wrong but that is the impression that one gathers.
Over a period of five years the supply of dentures has cost £100 million, a vast sum, and it is estimated that one in every six of the population will shortly require full upper and lower dentures. These figures are simply staggering, and I wonder whether the people who have had these teeth have had value for money. I doubt it very much, because dentists are very over-worked and 20 per cent. of their time in clinics is taken up in the measurement and fitting of dentures.
I am told that the prosthetist ancillaries have about seven years' training. That is a very long apprenticeship for any man. His job is to see that teeth fit well. He measures up and he sees the job right through from beginning to end. It seems to me a much better system than the existing arrangement whereby teeth are sent away to be manufactured and come back, perhaps from a place 200 miles away, only to be found to be a bad fit. I wonder just how many sets of teeth that have been paid for out of this vast 1395 sum are now in a cupboard in the bathroom or in a drawer in the dressing table, tucked away and given up as a bad job because people simply cannot adapt themselves to them. I should think that there are a great many.
The most satisfactory dentures are those supplied when the chairside and laboratory work is carried out by the same person. I am told that at least 200 of these technicians are available. Very little training would be required and the dentists would retain complete clinical responsibility. I hope that this matter will not be left for four or five years to see how we get along. After all, these men are working in the profession, and with full supervision, surely, use could be made of their services to a greater extent.
I was relieved to hear my right hon. Friend the Minister mention the widows. Not a great many would be involved, But on reading the Bill I think that great hardship might be caused. My hon. Friend the Member for Putney (Sir H. Linstead), whose speech I admired, went so far as to suggest that three years was too long a period and that practices should be disposed of earlier. I simply could not agree. As I see it, unless a move is made in the other direction to extend the period to five or seven years, great hardship is likely to ensue.
In dentistry, as in many other professions, sons frequently follow in the footsteps of their fathers, and this is something which should be encouraged; but under the Bill in its present form I cannot see that this will happen. A boy of 16 would have to undergo National Service and would not be able to enter his father's practice until the age of 24 or 25. As I say, a period of three years is harsh, and I should have thought that seven years would have been more suitable.
When my hon. Friend the Member for Putney suggests that practices should be disposed of in less than three years, what does he imagine the widows will have for a living? Imagine a woman in her sixties whose husband had put his life's work into the practice. Probably he had put little money aside, having educated his children and borne all the expense that goes with life today. I should have thought that if we could not agree on a period of years within which to dispose 1396 of a practice, some form of compensation ought to be provided. If we are to have a National Health Service as such, the interests of men who have put in a life's work should be taken care of.
It frequently happens in industry that a firm employing, say, 800 people and whose business has expanded during the last ten or fifteen years has considered it prudent to introduce a pension scheme. An employee aged 60 might have been with the firm for forty years. It is always a problem to decide how to provide for such men, who will be retiring within a few years. But when a man has given his life's work and a pension scheme is introduced or compensation is involved, I believe it to be the duty of any firm or Government to ensure that these men are provided for. They have just as much right as any other individuals to have their future assured.
I wish the Minister well with the Bill. I am sure that no party politics will enter into it, and the Bill will undoubtedly be improved in all aspects in Committee. This great profession is now to be placed on the same footing as the medical profession with its General Medical Council, and we hope to see it go ahead and make plans to recruit more men into the profession. I suggest to my right hon. Friend that we earnestly look towards using more and more of the men and women within the profession to take care of the health of our children.
§ 1.35 p.m.
§ Mr. Ron Ledger (Romford)
I too, with other hon. Members who have spoken, welcome the Bill. There is, however, one part of it which gives me considerable concern, not so much for what it contains but for what is left out. The Minister appears to have given the impression, at any rate, that his attention to Clauses 18 to 22 is such that he is not likely to allow the General Dental Council to contract out of its obligations. It is only because the Minister appears to have given an assurance of that nature that I feel there is the possibility that the Bill will deal with the most important problem in the dental service today.
Most hon. Members who have spoken have stressed that the biggest problem is the shortage of dentists. The figures given by the Minister were alarming enough in that it is obvious that the 1397 Teviot Committee completely underestimated the possibilities of establishing a comprehensive dental service. That Committee suggested that the schools would require an intake of 900 pupils a year to provide for a comprehensive service in twenty years' time. Now the Minister tells us that the schools are not managing to take in half that number.
It is not sufficient to content ourselves by saying that if we bring in a Bill which will grant a higher status to dentists, that will necessarily help in recruitment. There is a lot to be said for the fact that status is probably much better when earned than granted. It may be that in the profession we could find one or two things which tend to reduce a dentist's importance in the eyes of his patients. It is an astonishing fact that people rarely put their dentist on the same plane as their doctor, yet in so many instances the dentist can save the doctor a considerable amount of work if he can engage upon conservative dentistry. Many of the sore throats and upset stomachs that doctors have to deal with derive from the fact that patients have not been able to receive adequate dental attention.
The Minister could be wrong in saying that the most important part of the Bill was the fact that dentists are to be given self-government. If the dental profession does not succeed in bringing into its ranks sufficient numbers of dentists to deal with its problems, it might be simply a question of having passed the responsibility for failure to the General Dental Council.
Clauses 18 to 22 relate to recruitment. I should like to refer to a figure which was given by the hon. and gallant Member for Macclesfield (Air Commodore Harvey), a figure which was not given by the Minister but which, I think, would have underlined his argument considerably as to the crisis in the dental profession. The Minister gave figures to show that we were short of dentists and that the intake in the schools was far from satisfactory.
Dentistry is an ageing profession. The average age of a dentist is about 55. The Minister did not give us the number of dentists who may—not those who necessarily will—retire by 1958. The fact that they represent one-third of the number of dentists in practice and that 1398 their number cannot be made up by the number of entrants into schools and other sources of recruitment, underlines the seriousness of the situation which we may face in three years' time.
I do not think that the provision in the Bill for an experimental scheme even scratches the surface of the problem. Even if the scheme is a good one and is successful, it would appear that at the end of three years we may have a minimum of eighty ancillaries who have been trained to do a limited amount of work. We must bear that in mind when considering the number of dentists we are likely to lose in that time. It will be agreed that although the experiment is probably worth while, and we must continue with it, it does not deal with the problem of establishing an adequate dental service.
Therefore, it is right that hon. Members should have said that the dental profession may have to look into itself—it is better for it to do it itself—to see whether or not it can make far more use of the ancillaries, the dental technicians who already exist. There is a feeling on the part of the members of the dental profession that they will lose a certain amount of authority if they pass on important work to the ancillaries. There is the argument put forward by my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird), that the attitude of the two unions which represent the ancillaries is not necessarily—I think that that is the strongest he could say—in favour of the approach that has been made to many Members by a grade of ancillaries who want to have access to the mouth.
I have here a telegram received at the House today, which says:To supplement the shortage of dentists a resolution was passed at the U.S.D.A.W. Midland Conference for dental technicians for ancillaries from selected technicians to have access to the mouth under supervision.I think that this attitude within the unions has always been there, but as they have had to negotiate with the dentists on wages and conditions of work, it was hardly likely that they would have pressed too early without full consideration for any sort of encroachment on to the previous preserves of the dentists themselves. However, I think that that argument has been dispensed with.
1399 I want to deal with what I think might be a useful suggestion for consideration by the Minister. The hon. and gallant Member for Macclesfield pointed out that there were ancillaries, highly-skilled and artistic men, in the profession whose job it was to produce the dentures. These men serve five years apprenticeship and two years as an improver, but there are considerable weaknesses in the present scheme under which they work. They are not allowed into the surgery and they are not allowed to see the patient for whom they make the denture.
It seems a peculiar situation that a person should make dentures and never see the mouths for which they are made. That reflects the considerable skill of these technicians, in that more often than not they are successful in making a very good denture. But, as they are highly skilled and do the job so satisfactorily, would not it be a logical step to allow them, under supervision, to approach the patient at the point at which the dental surgeon has completed what he might call the cut of the bone and tissue? That is a phrase they use. The surgeon has extracted the teeth, the gums have been prepared and then it is simply a matter of making the denture.
It seems a logical step, in view of the skill of the technicians and bearing in mind the acute shortage of dentists, that they should be allowed access to the mouth, under supervision. What exactly would it mean? Apart from the fact that the status of the dentist will have been raised by the Bill, the status of the technician will have been raised, and we will in two cases and not one effectively have increased recruitment to the profession. The effect on the actual dental work will be considerable, because if it is true that the dentist spends 20 per cent. of his time on the making and fitting of dentures, then to relieve him of those duties would be equivalent to adding to the service 2,000 or 3,000 dentists.
Then the time factor comes in, and that is important. We understand that the crisis in the profession is upon us and that the difficulty will increase and reach a peak in three or four years. If there is to be a remedy it should be one that will come into effect at the quickest possible time. I hope that the Minister 1400 is comparing what I am suggesting with his suggestion for bringing ancillaries under the Bill—the selected technicians who have received seven years' training. Such people may have been in the profession for forty years and they have considerable skill. A relatively short period of training would be required to enable them to go into the surgery and work from the very beginning on the fitting of dentures.
I have been given an estimate based upon a course which has been approved by dental surgeons. I use that phrase guardedly—not approved by an organisation of dental surgeons but by dental surgeons. It is a course which would fit selected ancillaries for work as prosthetists in six months. In six months 1,000 to 2,000 of these ancillaries would become available for this work. I suggest that, if there is this serious crisis, it would be difficult for the Minister to ignore a suggestion which would produce such a comparatively quick remedy.
Perhaps I should make it clear at this stage that neither I nor any other hon. Member would be agreeable to the introduction at any time of any ancillary to do work which would not be supervised by a dental surgeon. That is not intended; it is not wanted. It would be suggested that the dental surgeon would say when the mouth was ready for the work of the prosthetist, and when the work had been completed he would have to sign a certificate of clearance. That would be absolutely essential. Because I should not like people to think that on this nonpolitical issue I was being revolutionary in any way, it is as well to draw a comparison between this branch of the medical profession and other branches.
The comparison is that of Roehampton, where the medical prosthetists there make and fit artificial limbs and then go further—and this is required sometimes in the fitting of dentures—and help the patients to get used to the limbs and advise them on how best to wear and use them. There are many difficult factors involved. It would be wrong for anyone here to say, "Here is a scheme; all you have to do is to put it into the Bill, and all your problems are solved." I am certainly not suggesting that, but I suggest that the serious nature of the problem merits the attention of the Minister to any of the suggestions which 1401 would appear to offer help in the situation. The acceptance of a scheme such as this would not help to solve the whole problem, but in adopting a Measure of this kind we can, in fact, raise the status of the dental surgeon in an effective way. Having completed his work he will then be able to delegate certain of the work and his patients will be aware of the fact. The very fact that he has ancillaries working with him will tend to raise his standard.
Because of the nature of a dental surgeon's work, it is always very difficult to feel any sort of real affection for him. Memories of a dentist's surgery are not the sort of memories which lend themselves to affectionate thinking. But I feel that we should all appreciate far more the skill of the dentist were we assured that far more of his work was concerned with preserving our teeth rather than repairing them.
I wish to finish on the note that was introduced by my right hon. Friend the Member for Warrington (Dr. Summerskill). She said that if we do not solve this problem, the children will suffer. I suggest that not only the children, but adults are already suffering. It was my own experience recently that, twelve months after receiving treatment, I applied for an inspection and I found that I could not have one for a month. When I attend, and if there is anything which requires to be done, I shall probably be told that I must wait another month. If there is any considerable degree of work to be done—say one or two fillings—it may be another month or two before the work is completed. It is possible for a comparatively small amount of treatment to take three or four months to complete, because 20 per cent. of the working time of the dental surgeon is taken up with fitting and measuring for dentures.
To underline the importance of this matter with regard to the children, I wish to draw the attention of the House to the report of the principal School Medical Officer of the Nottinghamshire County Council. He requires twenty-two dentists for his service and he has only five of them. On the figures given by the Minister, and from the conclusions we should draw if we accept them, and if 50 per cent. of the 5,000 due to retire in three years do retire, we can only say that this 1402 medical officer can not only not expect to maintain his present level of 50 per cent. of requirements, but that the chances are that the percentage will fall. He says that he has 85,000 children in his area and that of those only 32,000 could be inspected. Of that figure, over 28,000 were found to have defective teeth, and 23,000 were referred. Minor dental defects were not referred. This suggests that the situation with regard to schoolchildren is very serious, not only because there are no dentists for the service, but also because the teeth of the children appear to be in a rather bad state.
Unless we do something now to see that the dentists perform the conservative task for which they are trained, it will appear that the day may well come in the very near future when almost all of their work will be concerned with the fitting of dentures. I therefore make a serious plea that the Minister give consideration to the further proposals in connection with Clauses 18 to 22. If the Minister wishes to assure us of his concern that we should have a comprehensive dental service, the only way in which he can do it is to show us, or tell us through this Bill, how it is possible to fill in this gap and supply us with the two-thirds of the necessary number of dentists who are missing and who are required for this comprehensive dental service.
§ 1.55 p.m.
§ Mr. C. N. Thornton-Kemsley (North Angus and Mearns)
This has been a harmonious debate, acceptably introduced by my right hon. Friend the Minister of Health in a speech made entirely without notes. I think that not remarkable, because it reflects what we all know to be the deep personal interest taken by my right hon. Friend in the problems confronting him. If I disrupt the harmony of the debate in any way, I do so because I do not think that it would be right were the House and the country to gain the impression that we are dealing with anything but a dissatisfied profession.
I move among my constituents, as do all hon. Members, and I have made it my job lately to talk to dentists and to try to discover the views held by the rank and file. There is not the slightest doubt that throughout the profession there is a sense of injustice and uncertainty. I shall try to point to some of the reasons 1403 which I think exist for that, and show what could be done about it.
First, and it is perhaps strange that I should put this first, the profession has suffered from a bad Press. When the Health Service was started the profession was faced with a demand for the services of its members far beyond their capacity to fulfil, and they were given an acceptable scale of fees. If the ordinary dentist worked reasonably hard and did sound work, he was criticised very often for refusing to meet cases of need. If, on the other hand, he worked like a slave and made a large income, he was all too often castigated for being a profiteer. The Press, or perhaps I should say certain sections of the Press, spotlighted the misdemeanours of the few without recognising the very fine job done by the great majority of dentists in the country in their efforts to cope with an impossible situation. That bad Press has had an unfortunate effect on the profession, in my opinion.
Secondly, there came cuts of 20 per cent. and then 10 per cent. in remuneration. In my view, professional men ought not to be subjected to cuts of that order in their remuneration. They should be able to see where they are going and know what they may expect when looking ahead through the years. We must all be glad that increases have now been agreed with the British Dental Association; that new scales are being worked out in the light of those increases; and that the 10 per cent. cut has been restored.
In parenthesis, I wish to put this view and to ask my hon. Friend the Parliamentary Secretary to confirm what I think is the position about arbitration in the event of disagreement about remuneration. Some dentists to whom I have spoken have been uncertain whether there is a right of arbitration. Some have even said that the negotiations between the Health Ministries and the Association broke down. I have said that is not true, that they did not break down but resulted in agreement and that as a result they are to get new scales.
As I understand the position, and this is the question I want to ask, disputes within the National Health Service are covered by Section 13 of the National Health Service (Amendment) Act, 1949, 1404 which would bring such disputes within the scope of the Conciliation Act and the Industrial Court Act. This would mean that, if a dispute occurred, the services of the Ministry of Labour would be available, and the matter might be referred to the Industrial Court or to some other form of arbitration.
I come back to my theme of the reasons for what I think is a sense of injustice and uncertainty in the profession, and I say that the third reason is a consciousness that the profession is a small one, and that it is in a weak bargaining position in that it has no trade union or dental guild which could fight its battles against the imposition of unfair conditions. Nor, indeed, as professional men, would dentists want any such organisation. That weakness of bargaining power did not matter so much in the past but, in my view, it does matter now, and matters very much, when the employer of the vast majority of the dentists in the country is one body—the State.
Fourthly, I come to the question which I must call by the term used by the profession itself—the question of dilution. I want to make it clear straight away that, in my understanding of the position, there is no objection to the employment of dental hygienists for scaling and cleaning teeth or for oral health propaganda. They are allowed by the 1921 Act, but they do not undertake any work which interferes with living tissues. It is on that point that the profession is apprehensive. What I understand the profession to fear are proposals to prepare for an experiment on the lines of the New Zealand scheme in advance of any possible findings of the McNair Committee.
The McNair Committee was set up upon the insistence or at the request of the profession. I should say that it was about the first time in history that any profession has come to the Government and said, "Will you set up a powerful committee to see what we can do about recruitment to our own profession?" It was set up by the Government at the request of the profession to inquire into the reason for the lack of suitable entrants to the profession, and—here I quote—…to indicate the possible directions in which remedies might be sought.1405 It is not at all impossible that the McNair Committee may suggest that some kind of experiment on the lines which the Government propose should take place, but I think we are wrong to assume that it will do so. I think we are wrong to prejudge the findings of that very powerful Committee. Meanwhile, it seems to me to be unwise, to say the least, to introduce something which, if I may adapt the phrase used in the Teviot Report, will "forgo the co-operation of the profession."
May I now try to show what I think are the grounds for some of the objections to this suggested solution? This has nothing whatever to do, as the hon. Member for Romford (Mr. Ledger) suggested, with a fear of losing authority. I do not think that dentists care a rap about losing authority. It is a real anxiety that the interests of the patient may suffer that really is at the root of it. Ancillary workers will be able to undertake fillings and extractions and other work upon living tissues, which can now only be done by trained and registered practitioners, and I would invite the attention of the House to this point.
Hitherto, in all these professional matters, we have, rightly, I think, and progressively imposed higher and higher, standards upon entrants to the major professions. For the first time, we are going to reverse that process Secondly, there is the fact that the field for recruitment for these new ancillary workers will inevitably be the same field from which are drawn recruits for the nursing profession and for the other medical auxiliary work—a field which is mostly the province of women and in respect of which the wastage is particularly high.
May I now say a word about the composition of the General Dental Council, in particular to my hon. and learned Friend the Member for Cambridgeshire (Mr. Gerald Howard)? The composition of the General Medical Council is not, in my view, a precedent that ought to be followed. I am a layman in these matters, and I have no real knowledge of medicine or dentistry, but it seems to me that the practice of medicine is one which involves a practical knowledge of every part of the human body—ears, nose, throat, heart, lungs and every different part.
The practice of dentistry on the other hand has a fairly limited application to 1406 the mouth, teeth, jaws and so on, which is very different from the wide variety of organs covered by the specialist schools represented on the General Medical Council. It seems to me that it surely is not necessary in these circumstances to have as many as nineteen representatives of the universities out of thirty-five on the proposed General Dental Council. I doubt if this over-representation of the somewhat rarefied atmosphere of academic study is really necessary or in the best interests of the profession as a whole.
The House may not be conscious of it, but what I have been trying to do all the time is to lead up to the only really important question which I think faces the country in this connection—the question of the recruitment of new entrants to the profession. I believe that the number of practising dentists, which has been given today, is not nearly as large as the number on the register. I suppose the number is about 12,500, or something like that.
The Teviot Committee, reporting upon the assumption that everyone who requires dental treatment would demand it, estimated the need for dentists in this country at about 20,000, as against the 12,500, or whatever it may be, that we have at present. To raise the number to that figure would involve an annual intake of about a thousand students, and to maintain the register at its present level would require about 700 new students a year, but, as my right hon. Friend told the House this afternoon, we are getting an intake of under 500.
A serious thing is that dentists are not putting their sons to the profession, because that has been a basic source of new entrants in the past. While I do not say that the medical profession is overcrowded, it is a fact that young men and women are going forward eagerly to join that profession and the veterinary profession whereas they are not coming forward to be dentists. In some way we must double the present rate of recruitment to the dental profession.
We all hope that the McNair Committee will suggest ways and means by which that can be done. In the meantime it seems to me that our task must be to restore confidence in the future. How are we to do that? I would suggest that, first, we should defer all talk about 1407 dilution until we know what the McNair Committee advises about it. Having set up that powerful body, let us first see what it advises on that point. Secondly, let us assert the Government's belief in general practice, and back that up by increasing the representation of practising dentists upon the General Dental Council.
§ 2.11 p.m.
§ Mr. Somerville Hastings (Barking)
I desire to add my word of welcome to what I regard as in principle a very good Bill. Throughout my professional life, I have been concerned with the surgery of the head and neck, and that has brought me into almost daily contact with dentists and their problems. Therefore, I can claim to have some knowledge of their work, and, perhaps, of their aspirations.
This Bill deals with two points, the self-government of the profession and the dental ancillary workers. I will deal with each. I fully appreciate the very just desire of the dentists to be a self-governing profession, but I am a little afraid that, as the Bill stands, they are going to cut themselves off too much from the medical profession. I think it was Herbert Spencer who said that specialisation is the law of progress. That may be true, but specialisation also has its dangers, as I, who have been a specialist all my life, can definitely say.
One cannot cut up the body into little bits and treat each part separately. Disease in any one area may affect any other part. The mind may affect the body, and the body the mind. Therefore, it seems to me that the dental surgeon must be able to recognise anything that he comes across in the mouth. Many diseases are first observed and recognised in the mouth. Lead poisoning, for instance, is recognised by just a blue line on the gums. Phosphorous poisoning—fortunately rare nowadays—is recognised by the condition of the gums, and so is scurvy. One could go on giving similar examples.
The doctor and the dentist are closely associated, and the dentist must have some knowledge of general medicine. Twice during the last two years I have been to the new town of Harlow where there are what are called health centres. They are not strictly health centres 1408 because they do not come under the Act; they are group practices, in which both doctors and dentists are involved. To my intense surprise I found, in talking both to the doctors and the dentists working there, that they were constantly getting help from one another. The dentists were helping the doctors and the doctors the dentists. The dentists were frequently coming across something upon which they wanted the opinion of a doctor and vice versa.
I think I am right in saying that the Bill proposes that the General Dental Council should consist of thirty-five members of whom thirty-one should be dentists, and that, in addition, for training and examination, six members should be appointed by the General Medical Council. I have had something to do with the training of dental students. In my day, the dental students were, to some extent, trained with the medical students. I think that is a very good thing.
My criticism of this scheme of the General Dental Council is that I am inclined to fear that it gives the dentists too much isolation. I should like to see more representatives of the medical profession on that Council, and, conversely, to see some representatives of the dental profession on the General Medical Council. I am convinced that if the dentists become isolated like the chiropodists and the physiotherapists, disaster must follow because the dentist has such a very wide sphere.
I have looked in vain in the Bill for a definition of "dentist," and I have not been able to find it in the Acts of 1878 and 1921. That is a very good thing because, as I have tried to show, the dentist may have to deal with anything that he comes upon in the mouth—developmental faults, tumours, cancer, and other affections. Indeed, as every dentist knows, the wisdom tooth does not behave like a tooth at all, but more as a part of the throat. Many dentists realise how important it is to have a broad outlook, and therefore many of them take what is called the double qualification. They become doctors as well as dentists.
That is my first point. I want the Minister to consider whether the General Dental Council ought not to be broadened so that, not only as regards training and examination, but also as regards all the work of dentistry, there should be more 1409 constant and direct contact with other members of the wider medical profession.
I will now say a word or two about the ancillary dental scheme. The first thing that occurs to me is that it is a little dangerous to let the dentists who, generally speaking, are opposed to this scheme, determine whether or not it is a success. I do not know how else the Minister is going to do it, but is it not a little like appointing a committee of butchers to determine the desirability of vegetarianism. I hope that the Minister will use his powers of observation and will not depend too much on the dentists to determine the success or otherwise of the scheme.
Much has been said about dental mechanics, or technicians — or prosthetists, as they call themselves. I have seen much of their work. Technically, it is first-class; I am astonished at their capacity and skill, and I would give them status and registration. I would allow them, if necessary, to see patients, accompanied by the dental surgeons. But that is not what they want. They are asking that the dental surgeons should do all that is necessary to the existing teeth, and that the patient should then be passed over exclusively to their tender mercies. I cannot agree to that, because the fitting of teeth is a very complicated process. Balance, pressure, changes in the jaws and many other factors have to be considered, and the prosthetist working alone would, in my opinion, be a public danger.
§ Mr. Ledger
My hon. Friend is not expressing the view of the prosthetists. They say quite definitely in their recommendations that the dentist retains the clinical responsibility and the final responsibility after the work has been done. It should be made quite clear that they accept that.
§ Mr. Hastings
I have talked to these prosthetists. I know what they put in their papers, and I know what they want. If they are prepared to take their place in working with the dental surgeons in the same way that I want the other ancillary dental workers to do, more power to their elbows; but not otherwise.
Much has been said about the New Zealand scheme. I have recently re-read the Report by Professor Bradlaw and others. After a three weeks' visit to New 1410 Zealand, they reported very favourably, but I have seen other less favourable reports. These dental nurses of New Zealand are given the entire charge of 500 or more children, in places quite remote from any dental surgeon. They may be as much as 200 miles from the nearest one. What they can do they do very well. They clean up the teeth, stop them and extract them, but what they do not do—because they have no knowledge—is to appreciate unusual pathological conditions. They do not deal with the development of the jaw as a whole, which is so important and which needs a very great deal of training to understand and appreciate.
I do not want that sort of service. The Bill does not provide it, because again and again we find that the ancillary dental worker must work with and under the direction of the dental surgeon.
§ Air Commodore Harvey
I do not differ from the hon. Gentleman, but does he realise that in the case of New Zealand, if it had not been for the work of these nurses, many of those children would have had no attention at all? Surely some attention is better than none. The right hon. Member for Warrington (Dr. Summerskill), speaking of her visit to New Zealand, said that they were supervised by dental surgeons in the clinics.
§ Mr. Hastings
They are not really supervised. I agree that some dental service is better than none, but I suggest that we can provide an even better service than New Zealand. I propose to explain how it can be done.
The dental surgeon who looked after my teeth until he retired from practice was a Fellow of the Royal College of Surgeons—a very distinguished man who had written largely on his subject and was head of the dental department of a large teaching hospital. When he was scraping my teeth, removing the tartar and carrying out simple stoppings it used to worry me, because I knew that somebody much less skilled could do those things equally well. I should have been very unhappy if the decision as to what ought to be done had been left in the hands of any less distinguished man, but the carrying out of these simple tasks could be done quite well by someone less skilled and experienced. What I ask for myself I ask for all.
1411 I entirely agree with the hon. Member for Putney (Sir H. Linstead). I want to see the dental surgeon supervising ancillary workers and being ready to be called in at any time. I should like to see him supervising two, three or even more ancillary workers. But he must supervise directly, and not at the end of a telephone. When stopping a tooth, even the best of operators can suddenly penetrate into the pulp cavity, as the dentist would call it, or into the nerve, as most of us would say—and that requires immediate and skilled treatment. Therefore, while I agree that these dental ancillary workers are of great value, I say that they must be constantly supervised by dental surgeons. I am not at all sure that it is wise to allow them to extract even deciduous or milk teeth.
§ Mr. Hastings
Oh, yes, but there are not enough dentists to go round. That is the problem. What we must do is to make the best possible use of the dentists we have.
I have been to the clinics and seen the training of dental hygienists. I have seen them working in school clinics, and I feel that their work can be extended—but whether it should be extended to the extraction of milk teeth I am not sure, because I have seen serious injuries following the extraction of such teeth. It is quite easy to crush a tooth and leave pieces in the jaw, or to interfere with the development of the permanent teeth later on by unskilful extraction.
There are many Committee points which I should have liked to deal with. I am sorry that the Minister wants to give up all possibilities of a single portal of entry to the dental profession. I know that such a system has never been put into operation but I do not see why it should not be. Another point worthy of consideration is that of annual payment for retention on the register.
Lastly, there is the question of foreign dentists who want to be placed upon our register. The only quarrel I have with 1412 the Bill in this respect is that such dentists will be allowed only two tries at their examination. I have known medical students, whom we call "chronics," who, after many years, have at last qualified—and some of them have proved to be very, good practitioners. These foreign dentists are bound to experience difficulty with the language, in making themselves understood, and weights and measures and certain aspects of our practice may be different from theirs. I would ask the Minister to reconsider whether it would not be possible to give them more than a second try if they fail in their examination.
I am afraid that I have detained the House for too long, and I should like to end by giving my welcome to the Bill, and expressing the hope that I may have an opportunity of assisting the Minister in improving it even further in the Committee stage.
§ 2.30 p.m.
§ Mr. Graham Page (Crosby)
I rise with considerable diffidence after the hon. Member for Barking (Mr. Hastings), whose knowledge of these matters is so great. I do so only as a layman and because of my anxiety about the proposed scheme for ancillary dental workers. I hope that during the Committee stage the Bill will be amended to allow us to call them something else than ancillary dental workers. Perhaps we may be able to call them dental nurses, if this scheme goes through.
I welcome the Bill in respect of the establishment of the Dental Council, self-government within the profession and the Clauses about the foreign dentists, all of which seem to me to be progress for the dental profession.
I am worried about Clauses 18 to 22. We have had an assurance from the Minister that there is to be an experiment. Looking at these Clauses, I can only find that the experiment is mentioned in Clause 20, and that Clauses 18 and 19 give power to the Dental Council to establish a class of ancillary dental workers without any experiment. It may be that the Bill should be looked at again from that point of view.
I think that all the speakers in this debate have assumed that this scheme is merely an experiment, so perhaps I may assume that for a moment and ask 1413 whether it is the right experiment. If the experiment is satisfactory, it is hoped that the shortage of dentists, particularly in the National Health Service, will be overcome. There has, of course, been an increase in the number of dentists within national and local government health services within the past few years. It has steadily risen since 1949, when it was 732, to 850 in 1952, and 960 in 1954. Those figures are the equivalent of full-time employees.
May I say that we differ from New Zealand practice in that the general practitioner in this country does an enormous amount of child work through the Health Service. There is no such free service for children in New Zealand. There is that rather important distinction in our services here as compared with the New Zealand experiment, which has been quoted so many times in the debate.
Nevertheless, will this experiment, if it is successful, in any way help to fill the gap? All that the experiment will do is to produce, at the end of four years, 80 half-qualified dentists, as a cost to somebody of about £145,000. In those four years, we could produce exactly the same number of fully-qualified dentists at much less cost. I understand that the cost of tuition fees for a fully-qualified dentist is about £400 or £500, and with maintenance grants over the four years of a total of about £1,000, we could, by an expenditure of £1,500, produce a fully-qualified dentist in that period. Under this experiment we are producing a half-qualified dentist at a cost of about £1,800. If this effort and money is to be spent, would it not be better to spend it in producing a fully-qualified dentist rather than a half-qualified dentist?
I was extremely impressed by the speech of my hon. Friend the Member for Putney (Sir H. Linstead), who envisaged senior dentists supervising four or five, as I would call them, assistant dentists. He said that the dental profession must review its work and consider a new set-up in the profession to attract more people to the profession, and so fill the gap which exists in the profession at present. Where I would differ from my hon. Friend in his view of the development of the profession would be that I would rather not have under senior dentists ancillary workers, half-trained dentists, people who had been trained 1414 for dead-end employment at the end of two years.
Would not the experiment be better carried out if the training of student dentists were so arranged that they could undertake practical work after a period of two years, or at certain stages in their training? The experiment under this Bill is for training dental nurses, as I prefer to call them, for two years to do certain dental work. Then their training stops. The profession, therefore, considers that there is dilution in the professional qualifications. If, instead of training these dental nurses for what I have termed dead-end employment, dental students, who were intending to become dentists, could be put into practical work at certain stages in their training, that I think, would be a compromise which would satisfy the dental profession and overcome their fears about dilution.
There is accommodation for further student training. I understand that the intake of students at the moment is 470, and that the capacity for training dentists is 650. If we are to have any experiment at all, cannot we increase that capacity for training fully-qualified dentists, and encourage the students by grants? If money is to be spent on ancillary workers, would it not be better to spend it on bringing fully-qualified dentists into existence by encouraging the student dentist by grant, and fill the gap in that way.
§ Dr. Summerskill
May I interrupt the hon. Gentleman's very interesting argument? He referred to the training of nurses, but that is an error of nomenclature. The girl who does this work is not a nurse. The hon. Member also said that this was a dead-end job, but surely it can only be a dead-end job if the production of children ceases.
§ Mr. Page
The right hon. Lady misunderstood me. Under the proposed experiment we are to train young ladies up to a certain point to do certain things in dentistry. We are not then going on to train them to become dentists. They stop at that stage of their training. I am asking that the experiment should assist students who intend to become full dentists. There would have to be some reorganisation of the training of dentists so that at certain stages the students 1415 would be capable of undertaking practical work. I do not know how the training of dentists is organised, but if a young man in his first year or first two years were trained to deal with fillings and extractions of deciduous teeth one would know that at the end of the two years he would be up to the standard required by this experiment, and would carry on to become a fully qualified dentist.
§ Mr. William Shepherd (Cheadle)
What is to happen if a man goes into practice as a student dentist? Will he not lose the opportunity to qualify fully as a dentist?
§ Mr. Page
That is bound up with the reorganisation of the training of dentists. It may take longer if the student is put into practical work as part of his training. Under the experiment proposed in the Bill I fear there will be more and more half-qualified dentists or ancillary workers employed under an ever-fewer number of qualified dentists.
My criticism of certain Clauses does not detract from my general welcome to the Bill. I should not dream of voting against it merely because of that criticism. I hope that at a later stage we shall lose Clauses 18 to 22 and replace them with an experiment which will produce dentists and not semi-dentists.
§ Dr. Summerskill
May I ask the hon. Gentleman to realise between now and the Committee—I am sure he is interested in the matter—that his suggestion amounts to putting, not half-qualified but one-tenth-qualified dentists to practise on the children for a month or two?
§ Mr. Page
I have not suggested that at all. I understand that it takes four years, or under some conditions five years, for a dentist to become qualified. I suggest that after two years the student be put on practical work. The experiment under the Bill suggests that after two years' training young ladies are to be put on practical work. I am not suggesting anything worse but something very much better than the experiment proposed in the Bill.
§ Air Commodore Harvey
Can my hon. Friend suggest how more men can be brought into the profession as dentists?
§ 2.45 p.m.
§ Mr. Charles Royle (Salford, West)
Like other hon. Members, I am reticent about participating in the debate, not being associated in any way with the dental or medical professions.
I was rather amused when my hon. Friend the Member for Barking (Mr. Hastings) brought my trade into the discussion this morning. It reminded me how, in my enthusiasm for the National Health Service Act, I was indignant when I received a number of stereotyped postcards from dentists in my constituency in 1948 to tell me why they were not joining the Service. I became so indignant that finally I replied to one of them:I am in receipt of your card, in which you say that you are not going into the Health Service. Neither am and I am also a butcher.No further action was taken against me.
The Bill deals with what is obviously a specialist matter and my only interest in it can be the general one that the patients of dentists are our constituents. With other hon. Members, I welcome the incoming of the General Dental Council, with an autonomy which is more than well-deserved. From 1921 the dentists themselves have developed a situation which entitles them to separation. I agree with my hon. Friend the Member for Barking about the association between the medical profession and the dentists. Separation is desirable because there is something very different between the outlook of the two professions. It is better that the dentists should have their own Council with autonomy and responsibility for it.
I am also interested in recruitment, which is the greatest problem facing the dental profession. I have tried to give it a small amount of thought, and I am wondering whether the Parliamentary Secretary can refer to the many educational grants that local authorities can distribute. Might there not be co-ordination of these grants to enable a young man or woman to go forward in this profession with greater financial assistance than is at present available?
I would like the Ministry to make adequate grants to the General Dental Council to give greater encouragement to young people who want to come into the profession. I have my doubts about the 1417 ancillaries. One looks at the dental profession with a certain amount of awe and hesitates to be enthusiastic about dental ancillaries of the type envisaged. My right hon. Friend the Member for Warrington (Dr. Summerskill) went into ecstasies over the New Zealand scheme. We must remember, however, that the suggestion is that ancillaries shall work on our children's mouths—the most important time of all. I wonder whether my right hon. Friend, or the Parliamentary Secretary, can confirm or deny that in the New Zealand scheme there is a wastage of 80 per cent. amongst ancillaries?
§ The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)
Perhaps I can answer that at once, and say that it is under 10 per cent.
§ Dr. Summerskill
And who has informed my hon. Friend the Member for Salford, West (Mr. Royle) that becoming a wife, and bearing children, is wastage? I should have thought it extremely productive.
§ Mr. Royle
I accept that.
The Parliamentary Secretary says that the wastage is 10 per cent. I bow to superior knowledge, but I got the figure from the dentists in my constituency, who were very emphatic about it. It would not be of much use introducing such a scheme if the wastage among ancillaries were so great. I should like more evidence that it is 10 per cent., and not 80 per cent., as I have been informed.
Then there are the dental technicians. I stand to be corrected, but I believe that among the technicians are some of the younger men and women—already on the inside of the profession—who might be trained, not only as ancillaries, as has been suggested, but form excellent material for training as dentists in the full sense. With the kind of encouragement which I have mentioned, many of those technicians might qualify. There 1418 is no mention of the technician in the Bill. There is no plan at all for him for the future.
Perhaps I may be allowed to give an analogy with the medical profession. Men and women in our pathological laboratories, who are doing tremendously good work, are described as technicians. Although they are under the control of a highly-trained pathologist they do the work, but in many cases their salaries are not a quarter of what is received by the supervising pathologist. Similarly, I feel that technicians in the dental profession are being neglected, and are not getting the opportunity they deserve.
The hon. Member for North Angus and Mearns (Mr. Thornton-Kemsley) spoke of the present earnings of dentists. We all know that the dentists had a wonderful time immediately after the National Health Service Act came into operation, but I am quite certain that that has changed. I am told by the dentists in my constituency—a highly industrialised constituency—that their average gross earnings do not amount to as much as £1,500 per annum.
§ Miss Hornsby-Smithindicated dissent.
§ Miss Hornsby-Smith
Is the hon. Member seriously suggesting that as the gross figure? The dentist gets 52 per cent. for overheads. If he is receiving only £1,500, that would bring the figure to under £750 for full-time dental services, and it bears no relationship to the facts.
§ Mr. Royle
As the hon. Lady does not accept what I say, I am not accepting what she says, and I shall take steps to get this matter challenged. I believe it to be perfectly true.
Another matter referred to by the hon. Member for North Angus and Mearns 1419 was arbitration. Arbitration arises in every branch of life when there is a difference of opinion as to emoluments, and I feel that proper arbitration arrangements should be provided for dentists when there is any dispute about their earnings. I have intervened in this debate, as a layman, in order to get clarification on some difficult points, but the general principle of the Bill is first-rate and I wish it every success.
§ 2.58 p.m.
§ Mr. S. Storey (Stretford)
I want to join in the general welcome which has been given to the Bill, and to say one or two things about the composition of the General Dental Council, and about the scheme for ancillaries. As the Minister emphasised the over-riding condition for the Council is that its members should sit, not as representatives of particular interests but as representing the whole profession.
I listened with great interest to what was said by my hon. and learned Friend the Member for Cambridgeshire (Mr. Gerald Howard) about academic representation. I agree very largely with what he said. He pointed out the possibility of an increasing number of dental authorities, which would increase the academic representation. As a result, the practising dentists on the General Dental Council will start by being outnumbered by the academic interests by about two to one, and may later be even more outnumbered. It is essential that the General Dental Council should start with the full confidence of the practising members of the profession. I hope, therefore, that the Minister will consider whether it is possible either to increase their representation on the General Dental Council or, as my hon. Friend the Member for Putney (Sir H. Linstead) suggested, ensure that they have adequate representation on those committees of the Dental Council which deal particularly with the practising dentist.
I feel that the scheme for ancillaries is an experiment that has to be made. It is certainly necessary because of the shortage of dentists. It is true that the McNair Committee has been sitting, and some dentists feel that it is putting the cart before the horse to provide for the experiment until we have had the Report of that Committee. I therefore welcome 1420 the assurance which the Minister repeated today, that a start will not be made with this experiment until after the McNair Committee has reported and the Report has been considered.
There is one point in the provisions for the ancillary scheme which causes me a little anxiety. That concerns the provision in Clause 19 (2) that work shall only be carried out after a registered dentist has indicated to the ancillary dental worker the course of treatment to be provided. That seems to me to be completely right, but I am worried by the proviso with which it is qualified—"so long as the General Dental Council think it advisable." In New Zealand children only enter the scheme after they have been rendered dentally fit by a qualified dentist, and further, if the child fails to attend his appointments or if he fails to carry out the oral hygiene which is laid down, he is not allowed to re-enter the scheme until he has been rendered dentally fit by a dentist at the parents' expense.
Here we are so understaffed that I think we cannot assume that the children will reach the ancillary in the same state of dental fitness as the children should do in New Zealand. In view of that fact, I think we should consider very carefully whether there should be that proviso. It seems to me that we should lay down quite definitely, not just so long as the General Dental Council thinks fit, that this work should be carried out only under the instructions of a fully qualified dentist. I hope that the Minister will consider that point between now and the Committee stage because it causes me some anxiety.
Even if this experiment succeeds, we shall still be faced with a great shortage of dentists. I listened with great interest to what my hon. Friend the Member for Putney said about ancillaries working under a qualified dentist. I think there is much to be said for that. I might even be tempted to follow the example of my hon. Friend the Member for North Angus and Mearns (Mr. Thornton-Kemsley) and say something about giving security to the profession on the question of their future earnings, on the desirability of ensuring greater consultation between the Minister and the profession in fixing those earnings, and about some greater right of arbitration.
1421 These are matters, however, which can be fully discussed when we have the McNair Committee Report before us. I do not think there is anything in the Bill which will prejudice discussion at that time, and therefore, with the qualifications which I have raised, I welcome the Bill and express the hope that it will soon pass on to the Statute Book.
§ 3.3 p.m.
§ Mr. John Baird (Wolverhampton, North-East)
As the only practising dentist taking part in this debate, and as this is one of the very few occasions when I can say that I am speaking for the whole of my profession—I seldom agree with the profession, but in this case I do—let me say how much I appreciate the spirit in which the debate has been conducted and the many contributions which have been made. I, and I am sure the profession, cannot agree with them all, but I do appreciate the high level of the debate today.
As the Minister said in what I thought was a very able and conciliatory speech, there are four main issues in the Bill. There are the questions of the setting up of the General Dental Council, the position of widows and lay persons, foreign dentists, and ancillaries. On three of these matters I think we are all in agreement.
On the setting up of the General Dental Council, it is not so long since 1921 when we in the dental profession got a decent status. I think that this is the logical next step after that—setting up a General Dental Council to govern our profession. My hon. Friend the Member for Barking (Mr. Hastings) made a point which has to be answered: he said there was a danger that if we had our own General Dental Council the dental profession might become isolated from the large body of the medical profession. I do not think it will become isolated because of any organisational change. In my opinion, this Bill will benefit us, because, when we have our own General Dental Council, those of us in the profession will be able to speak with more authority to our friends in the medical profession.
In the past, dentists have had some grievances about this. The Minister knows quite well that one of the reasons we do not get recruits to the school dental service is the status of the school dentist. We have been long pressing for some 1422 improvement. A school dentist may be in charge of the service for a large city, but if he wishes to approach the local health authority he must do so through the senior medical officer of health. We have asked that such a dentist should have a right of direct approach. Now that we are to have a General Dental Council it will be an example to local authorities to treat dentists in the local service in a better way.
The structure of the new General Dental Council is a Committee point, but I hope that in Committee the Minister will find some way out of what is a very difficult problem. I am certain that there is a way whereby we can increase the number of general practitioners on the Council. I am not suggesting that they should be in a majority but I think their numbers might well be increased.
Several hon. Members have raised the question of lay people and, especially, of widows. This is a very difficult problem. Whether it was right or wrong, when we introduced the National Health Service in 1946–47 we abolished the sale and purchase of medical practices, but we allowed this rather obnoxious system to continue in dentistry. Whether we like it or not, the sale of his practice is one of the dental surgeon's methods of saving. If anything happens to him, he feels, he can look forward to his wife being able to sell at least the goodwill of the practice.
I am in favour of setting a time limit for the widow to sell the practice, but now that we have a National Health Service it is not as easy to sell the goodwill as it was in the past, because it is easier for the young man to set up on his own without buying a practice. Goodwill can still be sold, but it is more difficult to sell it. I should have thought that five years was a much better period than three years for this purpose, and I ask the Minister to consider this suggestion.
I am glad that the Minister is to distinguish between those widows already carrying on a practice and those who will come under the Bill subsequently. I know a widow whose husband was a friend of mine—he was killed accidentally—and whose son is in his first year as a dental student. If the Bill is passed in its present form, she will have to sell her practice twelve months before he is ready to take it over.
1423 In certain instances there are cases of hardship, and I should like the Minister to consider this suggestion: where a widow or trustee, because of special hardship, feels that she or he would like to continue a little longer before selling the practice, there should be the right to appeal to the General Dental Council for an extension of time. I know that that is imposing a rather difficult job on the General Dental Council but the possibility of making the time limit a little more flexible for special cases is one which the Minister should consider.
I am glad that the Minister is to deal with the question of foreign dentists. These people came to our shores as refugees many years ago. Most of them are quite competent dentists but for one reason or another it has been difficult for them to prove their status. Now, at last, there is to be a possibility for them to get on to the register. As my hon. Friend the Member for Uxbridge (Mr. Beswick) said, we hope that the examination will be chiefly practical and will not be too stiff, because, after all these years, it is difficult for them to find their feet immediately. In the school dental service, for instance, many of them could make a much better contribution than the ancillaries whom we talk of introducing.
The most controversial issue in the Bill is the question of the dilution of the profession by the introduction of ancillaries into dental practice. The Minister was very cautious—much more cautious than my right hon. Friend the Member for Warrington (Dr. Summerskill)—when he said that this is only an experiment and that we are not going to commit ourselves one way or another until we know the result of the experiment. Like the Minister, I want to be cautious also. We on this side of the House welcome the Bill and we welcome the experiment. If, as a result of the experiment, something can be done to make a contribution to this terrible problem of the shortage of dentists, we shall all be very happy indeed.
To my friends in the dental profession, I would say that while they are grumbling about this proposal they must remember that there are in the Bill many more safeguards for the dental profession than there were in the 1952 Bill, and we must thank the Minister for them. But as a practising dentist it is only right that I 1424 should warn the House about the dangers of too much dilution.
I was surprised at the number of hon. Members on both sides of the House who were not advocating this very modified experiment but advocating wholesale dilution. The profession is an ageing profession and in a few more years we shall be in very serious difficulty unless something is done. While I welcome the experiment, I would say to those who have been speaking in the manner to which I have referred that no one should think that by accepting this easy way out we shall solve the problem of dental manpower. We shall not. It will be a minor contribution and only a minor contribution to the problem.
I should also like to say another word of warning. I thought that my right hon. Friend the Member for Warrington was completely wrong about milk teeth. There are great dangers in extracting deciduous teeth. The teeth may be taken out too soon or too late and in that way alter the whole occlusion of the mouth. I remember very vividly, as a young man just qualified, taking baby teeth out and removing some of the germs of the permanent teeth. It is very easily done. When an inexperienced person is extracting milk teeth it is easy for him to extract the germs of the permanent teeth as well. There are, dangers in allowing semi-qualified people to deal with living tissue.
The New Zealand experiment is very interesting, but "dental nurses" is not a proper name for these girls. We must think of a different name. They are not nurses. They have a different status altogether. I always respect the views of the hon. Member for Putney (Sir H. Linstead) on medical and dental problems, but I thought that he went much too far when he said that, because of the shortage of men in the profession, dentists in future would have to revolutionise their whole approach and he envisaged them as specialists on almost Olympian heights examining models of mouths brought to them and then handing over the job with instructions to other less experienced people.
What will the patients say about it? We must think of the patients. We have raised the standards of the dental profession to try to protect the people. If 1425 we are to lower the status because of the shortage of dentists—not in the way that is suggested in the Bill, but in the way that some hon. Members suggest—we may find ourselves in serious difficulties. I believe that dilution should be the last, and not the first, method of solving the serious problem of manpower shortage. Only if we find that there is no other way of getting the manpower into the profession should we accept dilution.
I should like to deal for a moment with the question of dental technicians, to whom a number of hon. Members have referred. I also received a circular from the organisation called the Joint Negotiating Committee for Dental Prosthetists, representing the Association for Dental Prosthetists, formerly the Incorporated Dental Technicians Association and the Dental Technological Society. No such organisation is recognised by any branch of the dental profession. I have been a member of the House for ten years and I have found that this organisation always crops up when there is dental legislation and it dies a death until the next legislation comes along. But as far as the dental profession is concerned, they do not recognise any such organisation.
In the London area, the dental technicians are organised by the Goldsmiths' and Silversmiths' and Allied Trade Union with their own dental section, while for the rest of the country they are under U.S.D.A.W., certain branches of which have followed the lead of this organisation. Over the country as a whole, however, the trade unions have said that their task at the present time is the raising of the status within the workshop. What is to happen in future, I do not know.
At present, there is no method by which to judge a dental technician. He may serve his five years' apprenticeship, he may take a course in dental mechanics at one of the Guilds' institutes, but there is no way in which one can say that he is or is not entitled to work in a surgery. Dental technicians need sit no examinations and it would be entirely wrong to allow them to work in the mouth until there is some way of judging their ability on merit. At present, however, no such method exists.
§ Air Commodore Harvey
Has consideration ever been given to co-ordinating these men as a body to raise their standard in order to make full use of their services?
§ Mr. Baird
We have been considering that over the past ten years. It was answered when the National Health Service Bill was introduced by the Labour Government, it was discussed during the Committee stage at that time and it was discussed when the amending Bill was introduced in 1950 or 1951 and I am sure that the Minister must have discussed it again. No one in a position of authority accepts the arguments put forward by that organisation at the present time.
I believe that there are other ways of tackling the question of shortage before rushing into the danger of general dilution. As has been said already, the profession has a bad publicity, and in more ways than one. The dental profession is interesting and varied, much more so than some branches of medicine, but seldom do we get that over to the general public. I hope that one of the first tasks of the General Dental Council will he a campaign to educate the young men and women in the interest and value of the profession.
My right hon. Friend said some most unromantic things about sticking fingers into people's mouths.
§ Mr. Baird
Doctors stick fingers in other places which are much worse.
Some hon. Members have also argued about the poor dentists, how they have been knocked from pillar to post and how their remuneration has so often been cut. It is quite true that the dentists have not felt the same sense of security that some professions have had, and there are various reasons for this. I think that the Spens Committee was wrong in its recommendations to the Government in 1945. I shall not go into that now, but it should be publicly known. Remuneration in dentistry today is better than that in 1427 almost any other profession I know which is of a similar standing.
The "British Dental Journal" this week publishes figures showing that the average income of dentists under the National Health Service is about £1,500 a year net. That is apart altogether from what they can make in private practice. The figures I have make the figure more like £1,800 a year net. Although there are some pockets in industrial areas where dentists are doing very badly, over the country as a whole the "British Dental Journal" suggests that the average income is £1,500; I think it is more like £1,800 a year. In the years when the dentists are making better earnings, between 35 and 50, the net income is nearer £3,000 than £2,000 a year.
The day after a young man qualifies, he can find a job anywhere at £25 a week. As a dental surgeon employing assistants myself, I know that there is a shortage and that it is most difficult to get assistants. The usual salary for a young man on qualifying is either £20 a week plus a percentage or up to £30 a week in many cases. There is a financial attraction, if only it were publicised. I believe that it is a congenial job which is well paid. I recommend any young man to go into this profession if he has the wherewithal to find his education. Of course, that is one of the difficulties.
Something must be done to solve this problem of manpower. I recently came back from Russia. I know that there they may have more authority than we have, but by varying the grants to the various professions they are able to direct the labour into those professions or industries where it is most required in the national interest. It is essential not to leave the matter to the local authorities, one paying one amount and another paying a different amount. We should have a national scheme to give adequate grants to young men and women to come into the profession.
The hon. Member for Putney was of the opinion that in the grammar schools there was not sufficient manpower left to provide the additional number of dentists required, but the young girls whom he is talking of training to become dental nurses—to use that word again—are just the type of people who should become dental surgeons. Why cannot we train 1428 these girls and give them the full education to make them dental surgeons? In Russia, Poland and Czechoslovakia more than 50 per cent. of the dental surgeons are women. Women make good dental surgeons. If we offered the proper financial inducement we could get the recruits we require.
I have one final suggestion to put to the McNair Committee. I have been into this question rather fully. I am satisfied that if we had efficient organisation in the teaching hospitals we could cut by six months the amount of time taken to turn out a dentist. By streamlining the courses, without reducing standards at all, we could cut the amount of time by at least six months. Indeed, some people to whom I have talked have said that it could be cut by a bit more than that. We must look at this point before we go into the question of the wholesale dilution of the profession.
We all look with interest at the experiment which the Minister is conducting in the training of dental nurses. I am sure that they will make some contribution, but I warn the House that there are dangers in going too far along this road. I hope that we shall think twice before we go any further in the way of reducing standards. Let our aim always be to try to raise them rather than to bring them down.
§ 3.24 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)
This has been a very happy and most helpful debate. It is many years since it could be said that a Measure coming under the Health Ministry commanded such general support in principle on both sides of the House. Indeed, the standard was set by the right hon. Member for Warrington (Dr. Summerskill) who, if I may say so, I thought made the best speech which I have ever heard her make—though I must confess to some bias, because I agreed with about 98 per cent. of what she said. Other helpful comments and suggestions were made, and some suggestions gave rise to controversy. I shall deal with three or four of the major points which have brought forth suggestions and controversy rather than those items in the Bill which commanded universal support.
We all welcome the autonomy of the dental profession. Many hon. Members 1429 spoke on the question of whether the general practitioner should have a greater measure of representation on the Dental Council. I repeat the words of my right hon. Friend that we shall certainly look at this matter again during the Committee stage.
At the same time I think it fair to say that we should not lose sight of the fact that the prime function of the General Dental Council will be that of education and standards within its own profession. I do not think it unreasonable that the people charged with this vitally important task should include a substantial proportion of those who have gone the furthest in the profession, and by their skill and knowledge have shown their ability to train others and lead them in new sciences and skills. It may well be unwise to limit the very necessary representation of the various dental schools and faculties but we shall look sympathetically at the possibility of adjusting the representation of those members coming from the general practitioner side.
The hon. Member for East Ham, South (Mr. Oram) suggested, if I understood him aright, that we should treat the Council rather like a consumer council and have consumer representation. I think that a false interpretation of what the General Dental Council will stand for. The hon. Member made the analogy with the unions, but I am sure that no craft union would allow non-operators to decide what should be the apprenticeship conditions in the craft. This is a body which is to control and decide the purely professional standards of a very great profession, and I think it generally agreed that there is a fair lay representation and that it is not necessary to have a wide lay representation on what is very much a professional body.
I wish to say a word on the question of foreign dentists, which drew interesting comments from a number of hon. Members including the hon. Member for Uxbridge (Mr. Beswick) and the hon. and learned Member for Cambridgeshire (Mr. Gerald Howard), the hon. Member for Putney (Sir H. Linstead) and the hon. Member for Attercliffe (Mr. J. Hynd). Those foreign dentists whose qualifications in their own country are recognised as being of the required standard can already be approved to practise in this 1430 country, because we know the standard of the diplomas in their country are adequate. But a problem arises where the General Dental Council is not satisfied that the diplomas in a particular country are akin to the standard which we require in this country.
The new provisions will provide an opportunity for those dentists—I think there are only about fifty at present—who, possibly after a short refresher course, could take an examination which I believe it is the intention should be mainly a practical one.
§ Mr. J. Hynd
Does the Minister mean that in a number of cases where the diplomas held are recognised and the men concerned have hitherto been excluded only by technical disabilities which are now removed by the Bill, those people will automatically come on the register without an examination?
§ Miss Hornsby-Smith
if they are recognised diplomas.
Concerning the refresher period in which the hon. Member was particularly interested, we cannot commit the new Dental Council. That is a matter which the dental schools would have to consider, and I think that if the figure of fifty were divided among the dental schools, it would merely mean about four in each of the schools. I feel certain that the matter will at least be very favourably considered when the Bill goes on the Statute Book.
May I also say at this stage that the provisions of this Bill apply equally to Scotland, and indeed as far as representation on the General Dental Council is concerned, I understand that the Scots are very adequately represented? In reply to one small point brought out by the right hon. Lady the Member for Warrington, may I say that the question of the retention fee would be very much a matter for the new General Dental Council to decide?
Many hon. Members have raised the question of what would be the position under the new Bill of widows of dentists, who hitherto have been able to continue their husbands' dental practices until such time as they wished, and thereafter sell the goodwill of the practices. I think the general feeling of the House is that it would not be desirable that there should be an indefinite period in which they 1431 can continue such practices under a manager-dentist, as it were. On the other hand, there is certainly some controversy whether the period should be three years, and the hon. Member for Wolverhampton, North-East (Mr. Baird) has suggested that it should be five years.
Again, the question of the existing widows was raised by other hon. Members. This also is a Committee matter, which we can look into to see if we can meet what would be cases of real hardship on the lines which my right hon. Friend outlined. We might possibly look at the question of the existing widows in the new conditions and see to what extent they might continue, and if we could reach some acceptable compromise in the Committee stage.
Turning to the subject of the shortage of dentists and the question of dentists' pay, I would salute the very courageous and forthright speech of the hon. Member for Wolverhampton, North-East. After all, the hon. Gentleman is the only practising dentist in the House. He is a member of the British Dental Association, and I am grateful to him for the very practical and very fair approach which he made to the problems, on some of which or some part of which, I know, his professional association would have dealt more strongly than he did with the issues confronting us today.
All hon. Members have said that there is a very grave shortage of dentists indeed, and there is no doubt—unhappy though it is for me to have to make the statement—that, however successful our efforts in recruiting dentists may be, and however successful the McNair Committee may be in its recommendations—and we all wish it well in its proceedings—it is beyond the bounds of practical possibility that we shall be able to double the present number of dentists within a reasonable period of time. That is the problem which faces the House today.
It has been suggested, particularly by the hon. Member for Salford, West (Mr. Royle) that the level of pay is a deterrent. I think it is fair to point out that when my right hon. Friend was moving the Supplementary Estimate on 12th July, he announced that, as a result of the restoration of the 10 per cent. cut, the average dentist would receive, including Exchequer superannuation, about £2,000 1432 a year net. That compares with the average net income of a general medical practitioner of £2,200, and retains the comparison with doctors which was advocated by the Spens Report. In view of that, I do not think it is just to suggest that this is such an abominably paid profession.
Indeed, the hon. Member for Wolverhampton, North-East has always very strongly deprecated what I believe is unfortunate propaganda about the rate of remuneration of dentists. In the same debate on 12th July, the hon. Member for Wolverhampton, North-East said this: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."—[OFFICIAL REPORT, 12th July, 1955; Vol. 543, c. 1863.]He has spoken in similar terms this afternoon.
I do not think it unfair to say that because, perhaps, a minority of dentists have been so busy crying "Wolf" about their own profession, and because there have been the grossest misrepresentations in certain national newspapers about the remuneration which dentists now enjoy, it is quite possible that they have scared off many recruits to their profession by putting out false figures of the average remuneration which can be made, if I may again quote the hon. Gentleman, by a "live," agile and active dentist in his profession.
It is important that we should realise that the figures which I have given to the House—and I can assure the hon. Member for Salford, West that they are based not merely on estimates but on cheques which we have to pay out through the Dental Estimates Board to members of the profession, and we are very conscious of the actual sums—
§ Miss Hornsby-Smith
If the hon. Gentleman is asking me to give the figures of the dentists to whom he referred, then I must point out that it 1433 would be quite improper for us to reveal the incomes of individual dentists. I can only give what I can assure the hon. Gentleman is the average net amount paid to a dentist over the whole country after the deduction of 52 per cent. for overhead expenses, and provided he gives his full time to the Service.
There is one other point on the question of recruitment which we must bear in mind, and here I would particularly refer the hon. Member for Crosby (Mr. Page) to the few observations I propose to make about the difficult problem of recruitment at the present time. There has been a fall in the number of recruits to the dental profession, starting from the years when the fees were the highest ever, before the 25 per cent. cut was introduced and before there was any suggestion of either a new Dentists Bill or of ancillaries. Therefore, it cannot be claimed that the decline is, in the main, due either to the fees or remuneration, or, indeed, to any fear or threat of ancillaries.
Further, there is the unhappy point that many of those who apply to enter the dental profession fail in their examinations. It is true to say that there is a higher level of failure in relation to this profession than among almost any other entrants seeking to go into kindred professions. The hon. Gentleman made an interesting suggestion in relation to the period of training, and that, I am assured, is a matter which will be very fully considered by the McNair Committee.
I will deal with the question of ancillaries, which drew the most comment from hon. Members, but, first, a word about the dental technicians, a subject on which I rather thought that the right hon. Lady was throwing herself to the wolves, and on which I rather expected that there would be some divergence of opinion between herself and her hon. Friend. The hon. Member for Wolverhampton, North-East pointed out that the body which has made the strongest representation about the inclusion in the Bill of some opportunities for dental technicians to carry out operations in the mouth is that of the Joint Negotiating Committee for Dental Prosthesis. I agree with the hon. Member for Wolverhampton, North-East that in no sense can that body be 1434 said to speak for the bulk of dental technicians on that matter. Indeed, some 6,500 of the dental technicians already in dentistry actually come under U.S.D.A.W., or the Guild, and only some 1,500 members are attached to the negotiating committee which has made the joint representations.
This is a most highly controversial subject, not least because the recognised trade unions representing that body have never asked for these powers. As my right hon. Friend has already said, the Government's view is that such a very far-reaching and highly controversial question as this should not be brought into the Bill by the back door, if one might so express it, when it has not been asked for by the majority of the technicians, and when there is, at the moment, no standard of examination which really decides the qualifications or otherwise of these technicians.
§ Mr. Ledger
Surely the point should be made that these people are concerned only with a selected number of technicians. They are not attempting to speak on behalf of all technicians.
§ Miss Hornsby-Smith
Who is to select them? It is a very controversial matter, and one in relation to which we should have to be certain that a proper qualifying examination was instituted.
If, in future, the matter is raised, at least with the majority consent of those members who are technicians, some appropriate qualifications would have to be considered which it would be necessary for such technicians to have, in their own and in the public's interest. As to the general question of the two types of ancillaries, oral hygienists have received general support in the House and are also supported by the British Dental Association.
I take up the point which was made earlier by the right hon. Member for Warrington: the Bill is not wholly concerned with dentists. Clauses 1 to 17, it is true, deal mainly with the requirements of dentists, but Clauses 18 to 20 spotlight the requirements of the public, and all the Clauses dealing with ancillaries are substantially based upon the great need of the public for additional dental services.
We deplore the shortage of dentists, but we must be realistic in our approach 1435 to this matter. We must realise that, although 650 places are available in dental schools at the moment—and there will be more because of certain increases which will come about under the hospital building scheme—only 478 applications were successful in 1954–55.
Against this unhappy picture of the small number of entrants and the very high number of failures—which is one of the severe problems facing the McNair Committee—we must consider the present-day demand. The Teviot Committee suggested that we should need 20,000 dentists, and that estimate was made before the Health Service had been instituted and the demand had increased. In order to give a full service today we should require many more than 20,000 dentists. At the moment we have 12,000 in active practice. With the best will in the world, we are unlikely to double that figure in any foreseeable span of years.
I should like to give the House some figures in relation to the demand, because insufficient attention has been riveted upon the tremendous and growing demand of the public and the even greater demand we shall get if we make all the public as dentally conscious as we should like them to be. First, it is an unhappy fact that we have been a long way behind other countries in our dental consciousness. New Zealand has very much pioneered the course in dental welfare.
The position has improved in recent years, and we are delighted to see the increasing number of treatments now being applied to the under-21's. We are delighted that the deliberate priority given to expectant mothers, children and young persons by Her Majesty's Government has resulted in the percentage of under-21's hi relation to the total number of treatments rising from 28 per cent. in 1950 to 49 per cent. last year. It was 51 per cent. in the first three months of this year. Whereas 1,200,000 treatments were given to the under-21's, in 1950, the figure last year was 2,900,000, an increase of practically two-and-a-half times. We welcome it, but it brings with it its problem, because of the increase in demand and the grave shortage of dentists.
I want to say a few words on the educational side. There is considerable publicity, which has been produced not only by the Ministry of Health but by the 1436 clinics, in consultation with the Ministry of Education. Literature, films, slides, models and all the general paraphernalia of publicity have been circulated to the local authorities and to the schools, but, as in the distribution of all literature, the greatest difficulty is not its distribution but in getting the public to absorb it.
The demand for dental care, as the figures which I have given outline, is growing faster than we can meet it. Even though we are pleased that there has been an increase in dental care, there are still two very grave facts which show that we have a long way to go. I think that these facts may shock some hon. Members who may not be aware of them. They emphasise the great need for the experiment provided for in the Bill to be carried out. When we realise that on current evidence children entering school at the age of five have, on the average, five teeth missing, decayed or filled, the House will have some realisation of the magnitude of this problem.
At the same time, although dental treatment for the under 21's is free, this figure reflects somewhat sadly on the dental consciousness of parents. They will willingly take their child quite regularly to the hairdresser or the barber, but they will not take the trouble to take it to the dentist.
The second fact—and here I have endeavoured, by collating the school dental figures and the general dental practitioner figures, to establish a fair estimate—is that roughly two-thirds of all children up to the age of 14 in any one year do not go near a dentist. That is the size of our problem. and I ask hon. Members to recognise that in the face of these facts we feel it is necessary to carry out this experiment, and to see if we can find some ancillary help to aid the dentists in their problem of giving adequate cover and service to the public, and particularly to the children of this country. We want them to have dental examination and the necessary dental treatment.
To my mind, the Clauses relating to ancillaries are clear cut. It is not a question, as some hon. Members would have us believe, of whether a child should be treated by a dentist or by a dental ancillary, but of whether the vast number of children should get any treatment at all.
1437 As my right hon. Friend said, this is an experiment. The memorandum circulated by the British Dental Association refers to unskilled operators. These dental ancillaries will have two years' training in a selective part of dental procedure. That two years compares with the two years' selective training of the average dentist in that kind of work. The experiment is recommended in the Bill. It will be conducted by the General Dental Council on which there are thirty-one dentists out of thirty-five members. The Council will set the standard and lay down the 'training, it will supply and judge the examinations and report on the experiment.
When I hear some criticisms of the experiment I would say to the British Dental Association that if it has so little faith in the ethical standards of its own profession as not to think that the Council will report honourably and fairly whether the experiment has succeeded or failed, then the profession has no right to be asking for autonomy. If, as I believe, the Dental Council will conduct the experiment fairly, ethically and efficiently, it has nothing to fear. If the experiment succeeds, the Council's duty is clear—to encourage the training and introduction of dental ancillaries. If the experiment fails the Council will so report to the Privy Council.
It has been suggested that if the scheme fails it might be forced upon the profession. If the scheme fails we have only to consider the safeguards which the Bill provides to reject out of hand any suggestion that an experiment which failed could possibly get past the General Dental Council. If it did, it would not only have to secure the acceptance of the Privy Council but it would have to pass both Houses of Parliament by affirmative Resolution. Can we believe that any experiment that failed could survive all these procedures, with hon. Members fully alive to its possibilities?
Dilution has been mentioned by many hon. Members. I will put this point, which was most ably put by the right hon. Member for Warrington. I do not believe that the introduction of dental ancillaries will dilute or in any way lower the status of the dentist, after the experience we have all seen in the medical profession. Does anyone suggest that the training and use of midwives dilutes the medical profession? Would anyone 1438 suggest that the work carried out by midwives is any less delicate or intimate in its relation to the patient than the work which these dental ancillaries will be called upon to undertake? We have seen the medical profession rise in status with their use of such ancillaries as midwives and physiotherapists; it has enhanced and added to its stature. If this experiment is carried out and succeeds, we shall hope for a similar result in the dental profession.
This has been the most controversial item in the Bill. The experiment will be controlled, conducted and judged by the General Dental Council. The ancillaries will work under the direction of qualified dentists, and, unlike the position in many sections of the scheme in New Zealand, they will work only in hospitals, clinics and health centres controlled by public authorities. In bringing this particular item of the Bill to the House our first interest must be whether we can make up the appalling gaps in the dental service which we supply to the public.
May I again say how grateful my right hon. Friend and myself are for the very generous support which we have had from all sides of the House for the Bill? Many points that have been raised we can consider in detail in Committee, and possibly we can go some way to meet some of the Amendments which have been suggested by hon. Members. I therefore hope that the Bill will receive its Second Reading with the support of all hon. Members.
§ Question put and agreed to.
§ Bill accordingly read a Second time.
§ Committed to a Standing Committee, pursuant to Standing Order No. 38 (Committal of Bills).