§ 2.35 p.m.
§ Mrs. Eveline Hill (Manchester, Wythenshawe)I am quite certain that those of us who have read the Ministry of Health Report for 1955 cannot fail to have been impressed by the facts revealed in that portion of it relating to dental health. It shows that it is rare indeed to find a five-year old child or an 18-year old adolescent completely free of dental decay. That means that individuals, through a period of growth of two sets of teeth, have been subject to dental ill-health.
Unlike many diseases in the field of public health, many of which have been controlled by specific drugs and by vaccines, there is no easy way to dental health; it is something which has to be dealt with by the individual and by the dental surgeon. It is that point which causes me to raise this matter now. It is probable that many people will not enjoy their Christmas pudding or other of their Christmas fare because their teeth are not in thoroughly good order, and such foods may affect them painfully.
It is because dental diseases are not killers that we probably fail to give them the attention which they should really have. On the other hand, they vitally affect our robust health. We are all aware that serious dental complaints can affect other parts of the body. Mothers, teachers, health visitors and district nurses can all play a part in encouraging dental hygiene and, through that, dental health, but much more needs to be done in that direction by means of propaganda. The dental surgeon plays a vitally important part. The regular visit to the dentist, when he can give skilled attention to something which is quite minor, preventing it from becoming much more serious, is of the utmost importance.
We are woefully short of those dentists in our Service. Not only that, but they are not evenly distributed, which is a very important factor. One wonders what would be the position of, say, expectant and nursing mothers and young children, if they all sought the dental treatment which the Health Service says that they are entitled to—to say nothing of the 1682 adolescents. There are just not enough dentists to go round, and something needs to be done about it.
The Report also makes the significant statement that of children between the ages of 3 and 4, only 15 per cent. have been treated in any one year, and that of children between the ages of 5 and 14 about 40 per cent. have been treated in any one year, which goes to show that through the school dental service a rather greater percentage of children have some treatment.
In 1948 there were about 1,052 dentists in the school dental service, but by 1951 the figure had dropped to 816. I well remember the alarm felt throughout local authorities at that time at that drop in the number of dentists. By 1955, however, the figure had risen to 1,178. The point is that that number depends upon the average age of the personnel, and in the dental profession it is rather high. The McNair Report estimates that half the number of present registered dentists are over middle age, and that about 8,000 of the present total number of about 16,000 dentists will retire by 1966. There will be some recruits but they will not make up for that wastage. Time passes very rapidly these days, and 1966 will soon be upon us. Sixteen thousand dentists is inadequate for a good dental service for our population today. When all is said and done, we are a very much larger population now than we were when a previous committee dealt with this matter.
A further point is that our recruitment at the present moment cannot be above 650 per year. This is not a new problem because it was discussed as far back as 1944 by the Teviot Committee, which reported on the shortage and made recommendations. Unfortunately, since that time nothing in particular has been done, and those dentists about whom that Committee were talking then are twelve years older and some of them not with us at all.
At the inception of the present Health Service, the demand for dentures swept the profession and attracted many dentists from the more tedious and probably less remunerative side of the Service. We have heard of them earning high salaries, but since those early days of the Health Service they have 1683 sustained cuts in their salaries and in their income, despite the falling value of money. I feel that it is this uncertainty of income and lack of appreciation of the importance of the dental profession in the health scheme which has had an effect on recruitment. A further irritation has been in the dentists' minds lately, and that is the number of matters which have to be referred to the Dental Assessments Board. Many of them feel that that is a reflection on their capabilities, and it reduces their confidence in being members of the dental profession.
We know that the Dental Assessments Board has, at any rate, two jobs. It considers payments, and it has to safeguard against abuse. I think that we might have a little more confidence in the dentists and not have so many matters referred to the Board, because that can on occasion cause delay and the dentist not giving his patient treatment as quickly as he would like treatment which, in a comparable sphere, the medical man likes to give to his patient. I think that is something that the Minister might look into.
Recent examination of this problem by the McNair Committee has done something to encourage students to come forward, because they feel that here at least something will be done to give this profession its right importance and a status comparable with the medical profession, which its contribution to the health of the community really warrants. Dentistry is a profession in which women can take quite an important part. They arc, to my mind, very suitable for this profession, but I do not think that quite enough emphasis has been placed upon it at school-leaving time, when careers are being considered for girls.
Another factor which I think needs to be looked at is that of grants to enable students to take up the profession. I think that careful consideration should be given to these grants and their scope widened. It is true that greater numbers of students are coming forward at the present moment but they are still insufficient—that is what I want to stress—to ensure our having an adequate supply of dentists in order to give a very much better and fuller service than we have enjoyed hitherto.
If we get new students, coping with them presents a difficulty. It is a diffi- 1684 culty that needs examining and rectifying with all speed. That is again a reason why it was necessary to raise this matter as quickly as possible. The trouble at the moment is that there are insufficient places in the dental schools. We have to remember that whatever efforts are made now and however quickly they are made, it will probably by eight years before we can feel the real benefit of a vastly increased supply of members of the dental profession.
What can be done to improve this very difficult position in which we now find ourselves? We must have additional places in the dental schools, and we must have additional schools. I will mention one or two things which might be considered, and which I hope the Minister will be able to consider when he has been informed of them through the Parliamentary Secretary. Indeed, some of these points have been considered by the dental profession, since they are anxious that this matter should be put right. These are matters of major importance when considering where a new school should be or where a school should be expanded.
First, there must be a sufficiently large population to supply the clinical needs of training, and there must be a university background with a medical school to enable the teaching to go on. Where schools already exist the facilities available must show possibilities of expansion, to meet the new needs. In this regard, several suggestions have been made. For instance, Cardiff University has not a dental school. It does, I think, strike us that it would be advantageous to have a dental school in Wales, and Cardiff seems to be a suitable place. The suggestion made is that there should be a school there for at least fifty students.
In Scotland, Aberdeen is a possible centre and a new school there for twenty-five students would be very useful. In Glasgow, it is necessary either to enlarge the present school or preferably to erect a new school. Cambridge and Oxford should have dental schools, which they have not at present. Birmingham should have an enlarged dental school, because in an area like Birmingham there is a large population and a good field for the clinical work, and plenty of hospitals to which it could be attached. In London there are several hospitals with which 1685 dental schools could be associated. Manchester, Leeds, Sheffield and Liverpool are all thickly populated areas, as we know, but I think that with a very slight extension of the facilities provided there they might be adequately catered for.
It is necessary not only that we should have places for students, probably up to the number of 1,000 in place of the present maximum of 650, but that they should be evenly distributed so that all parts of the country can have the benefit of good dental service. It is quite obvious that not only the Minister of Health but the Minister of Education will have to take some part in improving this service by an increase of students, and I hope that the Minister will give urgent consideration to this matter in the light of the present difficulties.
§ 2.50 p.m.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)I want to intervene only very shortly, because I realise that the Parliamentary Secretary has a lot which she will want to say. I am grateful to the hon. Lady the Member for Wythenshawe (Mrs. Hill) for having raised this subject, which is a very important one, and I would agree that the suggestion she has made has been supported by the British Dental Association, whose recommendations I have before me.
In the Report now before us, it is urged that, on the question of recruitment, there should be a revision of the method of paying dentists. The Committee feels that the present basis is unsatisfactory and rather derogatory to the dental profession. I would very much welcome a re-examination of this matter, particularly in the light of the recommendations contained in the Guillebaud Report, which suggested that if people would put themselves into a good state of dental health the charges for treatment should be withdrawn. That seems to me a basis for reconsidering the form of payment at the same time.
I also think that the point made in the Report about more hospital posts is an important one, but we must, I think, whenever we consider the problem of recruitment, keep it in balance with the problem of prevention. I ask the Parliamentary Secretary to look again at the very lackadaisical way in which we seem 1686 to be approaching the problem of fluoridisation, the addition of fluorides to water, as one undoubtedly valuable method of preventing dental decay.
The problem of education and that of research has been raised. Much more research is needed to be done. I look forward to the day when we shall not talk continuously about the need for additional dentists, but shall have advanced a great deal in the prevention of the disease itself.
§ 2.51 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)I am grateful to my hon. Friend the Member for Wythenshawe (Mrs. Hill) for having raised this very interesting debate because it has given us an opportunity to focus attention on the very valuable Report received from the McNair Committee. I, on behalf of my right hon. Friend—and, as I am sure, other hon. Members would wish to do—thank the Chairman and members of that Committee for the valuable study of this pressing problem which they have made. The Report is being studied as a matter of great urgency, but most of its recommendations require joint or concerted action by a considerable number of bodies, and there are very substantial financial implications which also have to be considered. I am sure, therefore, that the House will not expect me to announce any firm decisions today, but it may be useful to comment on some of the more important recommendations made by the Committee.
There is undeniably a great shortage of dentists, a fact which is well known to all of us. We have at present about 15,900 dentists on the Dentists' Register, 14,900 of them living in the United Kingdom. That means that there is only one dentist to every 3,273 of the population. which is much lower than in Canada, Sweden. Norway or the United States, Unfortunately, as my hon. Friend pointed out, we are now about to experience the results of the very small entrance to the dental schools in earlier years and we shall be losing that very large body of dentists which took advantage of the 1921 Act and who are now reaching retiring age.
On the question of the intake into the dental schools, there has been a steady 1687 improvement in the last three years, and the schools are practically up to capacity at the present time. There has been a growing awareness about the opportunities which the dental profession can provide, and in the case of one school all its vacancies have been taken up this year for the first time in twenty years.
The Inter-departmental Committee on Dentists which reported in October, 1945, gave the figure of 20,000 as being the requirement of dentists in the country. Clearly, the possibility of attaining anything like that number over, say, the next ten years will depend on a very large number of factors, including the public demand, the effectiveness of dental health education, the proportion of dental skill which is applied to the priority classes—children, young persons, expectant and nursing mothers—the contribution which we believe ancillary workers can make, the development of fluoridation, the question of diet, the extension of dental research, and the better organisation of the profession. All these things, we believe, have a very real contribution to make to the problem.
The McNair Committee accepted the Teviot Committee target of 20,000 dentists, and agreed that even over so long a period as twenty years this would call for an annual output of at least 800 newly-qualified dentists who would practise in Great Britain. Allowing for wastage, which is normally about 10 per cent., and the training of students who will not practise in this country for any length of time, the McNair Committee recommend an intake of 1,000 a year. We shall therefore need 8,000 new dentists or an average of 800 a year over the next ten years if even the present strength is to be maintained.
The maximum number of students that can normally be accepted each year is 645. As I have said, we are virtually full up this year for the first time for many years, which is a sign of good progress. The adoption of the McNair figure of 1,000 a year would entail providing places for an additional 350 students. My hon. Friend mentioned several places where she thought we might appropriately have a dental school, and she spent many millions of pounds in seconds. I know that she is aware, as we are, that this is a matter where one sets the capital 1688 expense against other priorities in the Service. One also must consider the staffing that will be required. It is a longterm problem and one which raises very substantial problems.
Oft of the problems is that we have to get enough students of the right calibre who will be able to take the course which we have to provide, and also a supply of teachers, if we are to meet this additional intake of 350 a year. We have also to provide the places. One of the problems in the past few years has been that some applicants could not be considered for vacancies because they lacked the necessary educational qualifications for the course. These are vast and complicated matters on which consultation is taking place between the other Ministries concerned and the professional bodies. I know that the House will appreciate that my right hon. Friend is unable today to announce any final decisions on the recommendations of the Committee.
On dental health education, the McNair Committee came to the conclusion that the main reason for the shortage of dental students in the past, although admittedly recruitment has been improving, is that the public does not appreciate the true importance of dental health, and that because of that the profession does not enjoy the status which it merits. One of the most important recommendations of the McNair Committee, therefore, is that a comprehensive programme of dental health education should be undertaken. It proposes the setting up of an independent and representative standing committee to examine the problem.
Clearly, that will have to be done in consultation not only with the Ministry of Health, but with the Ministries of Education and Labour and the Departments of Scottish Health and Education, the General Dental Council, the British Dental Association, the dental schools, local authorities, and possibly commerce. I am pleased to tell the House that the British Dental Association and the General Dental Council have warmly welcomed the proposal and have offered their co-operation.
The McNair Committee drew attention not only to the need to enlist more women into the profession, but also to the positive advantage which for them dentistry has over many other professions.
1689 I should like strongly to support that recommendation. Women have certain qualtities which appear to make them eminently suitable members of the dental profession. They have a natural aptitude for any healing art, and most of them have a gift for the handling of children which is particularly useful in the dental profession.
Opportunities for part-time work are numerous in dentistry, so it is easier for a married woman whose whole time is not required for domestic duties to engage in the part-time duties of her profession and thus make a substantial contribution to the needs of the country. As the House knows, Parliament has this year taken a big step towards improving the status of the profession. The Dentists' Act, 1956, provided for the establishment of a General Dental Council and gave self-government to the profession. The Council was set up in July, and creates a great opportunity for the leaders of the profession to show wisdom and foresight in the development of their profession.
The Committee also felt that discontent among dentists, resulting in a reluctance to encourage others to join the profession, as my hon. Friend thought, arose in part from the present method of remuneration. It recommended that a thorough review of the whole system of remuneration should be undertaken. We know that the British Dental Association has embarked on a study of this problem, and before forming any views on it ourselves we shall need to know the views which it will be putting forward to my right hon. Friend, The House will not expect me to make any statement in advance of our having very full consultation with the profession.
The Committee also recommended that there should be some possible relaxation in the types of treatment requiring prior approval of the Dental Estimates Board, which was another point made by my hon. Friend. In 1955 only one-fifth of all the courses of treatment included items of treatment which required prior approval of the Board, a smaller proportion than in the previous year. I think there is likely to be an even smaller proportion this year.
Hon. Members who were present were pleased to learn from my right hon. Friend last week that he had been able to include the rebuilding of the Birmingham Dental Hospital as one of the major pro- 1690 jects to start in 1958–59. The present plan is to provide hospital and teaching accommodation for an annual intake of 75 students, compared with the present number of 40 quoted in the McNair Report. On the basis of a five-year degree course of study this would increase the total population of dental students at Birmingham by 175.
The distribution of dentists taking part in the General Dental Service is very uneven between various parts of the country, being much higher in London and the South-East than in the Midlands. We hope that the profession will do all it can to persuade its members to staff those undermanned areas, realising that in showing such a sense of its responsibilities it will raise its prestige in the eyes of the public. In the School Dental Service, although there is a grave shortage, the number has risen in the United Kingdom from 807 in 1951, to 1,182 in 1955.
There was another particular aspect of the Report which highlighted the fact that in general practice the dentist's earnings fall off very considerably from middle-age onwards, arising from the fact that dental operations—most of which under present custom are performed standing—are arduous and demand a high degree of manual dexterity, so that under a system of remuneration based on piecework the dentist who is young and fit can earn a great deal more than the one who is older. This peculiar pattern of earnings does not obtain in the salaried local authority service. Once that material difference is fully appreciated it is to be hoped that the local authority service will prove more attractive to dentists. That service, with its many opportunities for sessional work with children, should be particularly attractive to women.
A feature of the dental services in this country is the preponderance of single-handed practices, resulting in very high overhead costs, a lack of opportunity for the dentist to concentrate on the work at which he is most apt, or which he finds most congenial, and a position in which the skill and experience of the older dentist is often not adequately used, and thus, from the point of view of earning capacity, fails to compensate for his growing inability to work for as long or as speedily as his younger colleagues. It is this structure of the profession which gives rise more than any other factor to 1691 the peculiar pattern of earnings, which drop considerably from middle age onwards.
No one will deny that the skill and experience which comes from a lifetime of practice should be recognised in the remuneration of a dentist if in fact he is applying that skill and experience and not spending his time on the more routine type of case which can be dealt with as ably and more speedily by his junior. Outside the hospitals and clinics the answer seems to lie in group practice.
One can envisage the dental team of the future as consisting of one member whose special interest lies in preventive dentistry and the care of children, another whose forte is conservative technique, another who has specialised in oral surgery, and another who has made the provision of dentures his speciality; all of them working under the leadership of the senior member of the firm, a man ripe in experience and diagnostic ability. Such a team, backed up by the skilled services of a dental hygienist and a dental technician, would go far to satisfy the professional aspirations of the young dental man and woman of the future. The time has perhaps come for the profession to give very serious thought to the advantages which would lie in the introduction of group practices of that kind.
I apologise, in view of the time limit, that I have not been able to deal with the other many points which have been raised. I wholeheartedly support what was said by the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) about fluoridation. I can assure him that we are going ahead as quickly as possible with the demonstrations of which he is aware.