§ 10.5 p.m.
§ The Minister of Health (Mr. Kenneth Robinson)
I beg to move,That the Ancillary Dental Workers Regulations 1968, a draft of which was laid before this House on 29th January, be approved.I hasten to reassure the House that my intervention now will not be as lengthy as my earlier one. These Regulations were submitted for the approval of the Privy Council by the General Dental Council and, on behalf of the Privy Council, I now commend them to the House. They revoke and, with minor Amendments, replace, the Ancillary Dental Workers Regulations of 1957, which established a class of ancillary dental worker known as dental hygienists and provided for their training, examination, enrolment and discipline.
The primary purpose of these Regulations, however, is to establish another class of ancillary dental worker to be known as dental auxiliaries, to prescribe the work which they are permitted to do, the conditions under which it may be done, and to provide for their training, examination, enrolment and discipline.
I should first describe briefly the other changes which the Regulations introduce. They are intended to simplify, in the light of experience gained since 1957, the procedures through which the General Dental 1714 Council discharges its responsibilities for ensuring the high standard of professional conduct among ancillary dental workers and to permit a wider range of examining bodies.
The opportunity is also taken to increase the fee for first registration from £1 to £2, the maximum permitted under Section 41(9) of the Dentists Act, 1957. This is not unreasonable, since I understand that, even with the proposed increase, income from registration fees for ancillaries is so far insufficient to meet the costs incurred by the Council in discharging its responsibilities for this group of workers.
I come now to the main object of the draft Regulations. Under the Dentists Act 1957, the General Dental Council was required by the Privy Council to conduct an experiment in the training and employment of a class of ancillary dental worker who would be permitted to carry out the filling of teeth and the extraction of deciduous teeth in order to assess the value of such workers to the community. The first training course began in September, 1960, at a specially provided school for dental auxiliaries in the grounds of New Cross General Hospital; in July, 1961, Parliament approved the Dental Auxiliaries Regulations, Statutory Instrument No. 1365, which prescribed the range of work that these ancillary workers could undertake and specified the conditions under which it was to be done.
In due course the Council, as required by the Dentists Act, reported on the results of the experiment; their final report, which was laid before Parliament on 4th August was decidedly favourable, albeit with some reservations about the extent of supervision under which auxiliaries should work. In reply to a Question from the hon. Member for Glasgow, Govan (Mr. Rankin), on 28th November, 1966, I announced the Government's acknowledgement of the valuable contribution that dental auxiliaries could make to the dental health of the community and our intention to consult with the General Dental Council on the steps needed to establish the class on a permanent basis in the light of the Dentists Act, 1957.
These consultations led in due course to the submission to the Privy Council by the General Dental Council of the 1715 draft Regulations now before the House which, in essence, permit a dental auxiliary to extract deciduous teeth under local infiltration anaesthesia, to undertake simple fillings, to clean, polish and scale teeth, to apply prophylactic solutions and to give advice on oral hygiene, provided that the work is carried out in the course of providing national or local authority health services—in effect this means in hospitals, the priority and school dental services of local authorities and in health centres—and under the direction of a registered dentist after that dentist has examined the patient and indicated in writing to the auxiliary the specific treatment to be provided.
These requirements differ from those set out in the Dental Auxiliaries Regulations of 1961 only to the extent that the directing dentist has to provide a written indication of the treatment to be provided by an auxiliary. This I regard as a useful safeguard which should demonstrate beyond all reasonable doubt that dentists remain responsible for prescribing treatment and ensuring that the treatment so prescribed is satisfactorily carried out.
I wish to emphasise this, since I know that some dentists are not yet entirely convinced of the potential value of the auxiliary and have urged the General Dental Council and the Government to apply to dental auxiliaries a degree of personal supervision more restrictive than anything Parliament envisaged when it passed the Dentists Act, 1957—and, indeed, more onerous than has been found necessary or practicable even in the case of dental hygienists.
I recognise the genuine anxiety for the welfare of patients that lies behind some of this opposition to the permanent establishment of this class of dental auxiliary. But I am satisfied, having regard to the long and exhaustive experiment in their training and employment and to the findings of the assessors who inspected their work, that this anxiety is misplaced. Many honourable Members will recall similar doubts being expressed 10 years ago about the dangers of introducing dental hygienists. Just as these doubts and fears have subsided and dental hygienists have won for themselves a permanent place in the dental team, so I am sure will opposition to 1716 this new class disappear. Indeed, I was interested to note that in a recent survey a majority of younger dentists had no hesitation in supporting dental auxiliaries.
At a time when there are not enough registered dentists, it is important that the skills of those we have should be deployed to the best advantage. Surely, like their medical colleagues, dentists should delegate to less highly qualified, but well trained and expert ancillary workers, some of the less exacting, but time consuming, procedures. There is no doubt that ancillary dental workers have made a notable contribution to the promotion of dental health in, for example, New Zealand and, given the safeguards in these Regulations, I see no reason to doubt that dental auxiliaries will make a similar contribution to the improvement of the priority and school dental services in this country, too.
Some members of the profession believe that auxiliaries should be permitted to work only under the direct personal supervision of dentists. The Government cannot accept this. Not only does it go further than Parliament intended in 1957 but it would, as I have indicated, impose on auxiliaries restrictions more onerous than a general dental practitioner would regard as acceptable for his dental hygienist. Moreover, "direct personal supervision" is a somewhat inflexible phrase and takes little account of the skill and experience of individuals.
"Direction" enables a dental officer to assess, in the light of his personal knowledge of the auxiliaries in his team, the degree of supervision each one needs, varying from the very close supervision that a recently qualified and inexperienced auxiliary clearly must have, to the minimum essential direction required by a skilled and experienced auxiliary. It would be wasteful and uneconomic to apply the same rigid standards to all, regardless of individual skills and reliability.
The operative date for these Regulations is 1st September, 1969. Before the Regulations can come into force, the experimental arrangements under which training at the School for Dental Auxiliaries is now being carried on will have to be terminated. The choice of 1st September, 1969, will enable the General 1717 Dental Council and the Secretary of State for Scotland and I to fulfil the obligation we feel to students now in training; that they should be able to complete the course and sit the final examination under the same terms and conditions as they were accepted for training. It has the further advantage, however, of ensuring that the transition to more permanent arrangements will be as smooth as possible and that there will be no hiatus in training between the termination of the experimental scheme and the beginning of the new permanent training arrangements.
I refer briefly to the powers conferred on Health Ministers by the Dentists Act, with the consent of the Treasury, to reimburse to the General Dental Council the costs of the training school at New Cross and the payment of maintenance grants to student dental auxiliaries. These powers will expire on the termination of the experimental scheme, and we are therefore proposing to seek in the Health Services and Public Health Bill, now in Standing Committee, new powers which will enable us to continue to meet the expenses incurred in the training of auxiliaries when these Regulations come into operation. We shall be introducing a suitable Amendment to this effect in Committee.
I have watched these trainee dental auxiliaries at work and have been greatly impressed with what I have seen. I believe that the House will welcome, as I do, the establishment of this class on a permanent basis, and the Regulations, which bring this about. I am confident that the dental auxiliary will make a significant contribution to the improved dental health of our children.
§ 10.15 p.m.
§ Mr. Tim Fortescue (Liverpool, Garston)
We on this side of the House welcome these Regulations and we are grateful to the Minister for his very full explanation of them. We welcome them rather as one welcomes an old friend to whom one said goodbye many years ago and never expected to see again. It is a remarkable fact that the last debate on dental matters in this House took place in November 1955. It was on the Second Reading of the Dentists Bill, which became the Dentists Act, 1956. It had a very short Report and Third Reading stage on 26th January, 1956. Nothing 1718 was said except for a few short remarks on the consolidating Act of 1957. Since then the dentists have not appeared on our horizon. However, they have not been idle for in the period between then and now there has been a great improvement in the number of dentists and in the dental services provided.
My right hon. Friend the Member for Enfield, West (Mr. Iain Macleod), who was Minister of Health in 1955, said in that debate that we had less than half the number of dentists we needed at that time. He said that we needed to take in an extra 900 recruits a year and at that time the number was about 470. We are all glad to know that since then the position has gradually improved and for the year 1967–68 the number approaches 900—it is in the 890s. There can be little doubt that this improvement has been in part due to the presence of dental hygienists and auxiliaries who have made life so much more pleasant for practising dentists.
It seems a long time since that debate, but no time was wasted—at any rate not at first. The Dentists Act, 1956, was consolidated in the Act of 1957. After that Measure received the Royal Assent, the Ancillary Dental Workers Regulations were laid. Dr. Summerskill, as she was then, from this Dispatch Box chided the Ministry of Health for the long delay in producing the Regulations. How times have changed! The then Minister said he was very sorry and hoped that it would not happen again. As a result of those Regulations, the dentists got on with their job and established a high-powered committee, acquired premises at New Cross and formed the dental school. Students entered the scheme in 1960. In 1963 they reported that the work was going well, but up to that date they did not have sufficient evidence to say whether the scheme would be a success or not. They reported again in 1966. Although their approval was perhaps a little grudging, on the whole they came down on the side of the experiment. The Privy Council promptly told them that they could get on with this job. They terminated the scheme and new draft Regulations were made for auxiliaries on a permanent basis, which are the Regulations before us this evening.
I have one or two small questions to ask the Minister. Why cannot hygienists 1719 and auxiliaries under these or any other Regulations clean and polish teeth, especially the teeth of children with whom they work most of the time, without the permission of a registered dentist? Dr. Summerskill, as she then was, asked this question in 1957. My right hon. Friend the Member for Enfield, West told her that he agreed with her in principle and that no doubt the General Dental Council and the Privy Council would take note of what she said. Neither the General Dental Council nor the Privy Council has taken the slightest notice of what she said, although that was 11 years ago. What is the reason for this apparent intransigence in face of the views of so eminent a personality?
Next, why can dental hygienists under these Regulations work outside the National Health Service whereas dental auxiliaries can work only within the National Health Service? This seems to be a distinction which needs some explanation. It is not apparent to me why this should be so. There must be a reason, and I should like to know what it is.
Finally, the Minister indicated, though he did not state, that all the recommendations the General Dental Council made in its Final Report had not been incorporated in these Regulations. There are two which do not appear—first, that a dentist must examine the patient before he is treated by a dental auxiliary and, secondly, that a dentist must be within call when a dental auxiliary is extracting a tooth or filling a tooth. These were firm recommendations in the Final Report of the General Dental Council in 1966. Neither appears in these Regulations.
I believe that it is for that reason that some members of the dental profession have a slight suspicion that these auxiliaries will infiltrate too far and too much into their lives and into their professional scheme of things. For that reason I was delighted to hear the Minister say today that it was his strongly held view that the responsibility for dental treatment must always remain with the dental practitioner or the dental surgeon and that there can be no question of an auxiliary or a hygienist taking that responsibility. I believe that with that assurance and 1720 that safeguard all fears and misgivings among the dental profession will be removed and I was very glad to hear it.
With those very few words I welcome the new Regulations.
§ 10.22 p.m.
§ Mr. Eric Ogden (Liverpool, West Derby)
First, I offer my congratulations and good wishes to the hon. Member for Liverpool, Garston (Mr. Fortescue) on his first appearance on the Opposition Front Bench. If we must have Opposition Front Bench spokesmen, I prefer them to come, in limited numbers, from Merseyside. I assure and warn the hon. Gentleman that we shall watch his activities carefully.
I have two questions for my right hon. Friend the Minister. On Part II, Regulation 4, paragraphs (2) and (3), which provide for re-enrolment every 12 months, why has 12 months been chosen—it seems to be not too long a time—instead or two or three years? Secondly, on Part III, Regulation 7, which deals with training, examinations and courses of instruction, I have in my constituency of Liverpool, West Derby the North-East Liverpool Technical College, which is engaged, and has been engaged for some time, on training courses for dental technicians, mechanics and other dental workers. Can I have the Minister's assurance, because the College is concerned with these regulations, that the intentions of the Regulations can be made available to those who are at present engaged upon similar or previous courses? They are concerned about the effects of this and about how soon it is proposed to extend the experiment to the North-West. Any information which can be provided direct to this and to other establishments will be welcome.
§ 10.23 p.m.
§ Dr. M. P. Winstanley (Cheadle)
I am glad to join the hon. Member for Liverpool, Garston (Mr. Fortescue) in giving a welcome to the Regulations. By discussing the Regulations at all we are emphasising and underlining something rather unusual in our law, namely, that for many years now we have exercised very strict control over what people do in patients' mouths while we do not exercise much control over what people do inside other orifices. It is interesting to note, as was highlighted earlier, that 1721 the whole field of dentistry has been pretty carefully controlled, whereas the field of medicine certainly has not.
It is a long time since I advocated the greater use of auxiliaries and ancillaries of one kind and another in the whole field of medicine. At that time, in common with many others, I came in for a certain amount of criticism from my colleagues in the medical profession and from my friends in the dental profession. There is a resistance among professional men to anything which they feel could possibly lead to a dilution of their professional standards.
Nevertheless, we must accept, as the Minister has accepted in bringing forward these Regulations, that, if we are to maintain the standards which we wish to maintain in medicine and in dentistry, we must make more use of ancillaries of one kind and another. When there is a shortage of doctors, it is essential that the doctors we have spend their time doctoring. Similarly, with a shortage of dentists, it is essential that the dentists we have spend their time using the high degree of skill with which they have been equipped. There are limits to the extent to which one can make these arrangements, of course, and I am glad that opinion within the dental profession has now, apparently, changed. This is a credit to the way in which the subject has been approached. If we were to introduce Regulations of this kind with indecent haste, we should merely arouse intense antagonism within the dental profession. By doing it more gradually, however, we have reached a stage at which the dentists themselves welcome the move.
There is a special factor regarding recruitment into the dental profession which should be borne in mind. In the past, there were a good many people on the dental register who were known as registered dentists, that is, men who had not qualified in the ordinary sense but who have been practising for a certain number of years prior to the original Dentists Act. They were allowed automatically on the register by virtue of their having been engaged in active practice. But these dentists have never occupied places in the dental schools. Now that they have, so to speak, died out with the passage of time, we have, in a sense, a shortage because the dental schools were 1722 not expanded sufficiently rapidly to make up for this loss in recruitment. Fortunately, some expansion has taken place, but, even so, with the greater emphasis on preventive dentistry nowadays, which results in more work, though very valuable work, we need more people in dentistry.
I am sure that this is the right way to go about it. As I look forward to the future of our medical services, I am certain that it will depend on the greater use of ancillaries. Nevertheless, at every stage we must proceed with care so that those in the professions concerned feel that they are in control; and not only must they feel that they are in control but, in the public interest, they ought, in fact, to remain in control. I shall be very interested to hear, during our proceedings in Standing Committee on the Health Services and Public Health Bill, what the right hon. Gentleman's thoughts are about the future. If this sort of move is to go well, the ancillaries, the hygienists and others, must remain not merely now but always under the effective control of the dental surgeons with whom they work.
Now, one or two questions for the Minister. I notice that the dental prosthetists—I prefer to call them dental mechanics, because it is rather easier to say—are conspicuous by their absence from the Regulations. I know that they have, through their organisation, been agitating for some time to be allowed to make dentures individually and separately, not under the control of a dentist. I am not sure that I agree with that, but I am wondering why there is no provision for them under the Regulations. Perhaps the Minister will comment on that.
§ Mr. Deputy Speaker (Sir Eric Fletcher)
Order. We cannot discuss in this debate matters which are not raised by the Regulations.
§ Dr. Winstanley
Very well, Mr. Deputy Speaker. Perhaps we can discuss them on the other occasion to which the right hon. Gentleman referred. I shall make a point of doing so.
I welcome the Regulations. I hope that the Minister will be able to assure us that they have the support of the professional organisations concerned. He may, at least, be glad to know that they have my support.
§ 10.30 p.m.
§ Mr. K. Robinson
With the leave of the House, perhaps I may reply to the points raised.
I have seen so much of the hon. Member for Liverpool, Garston (Mr. Fortescue) in Standing Committee that 1 had not appreciated that this was his first appearance at the Dispatch Box opposite. I should like to add my congratulations to him.
I was interested in his historical reminiscences about the last time we discussed dentists. Relying entirely on my memory, I seem to recall a debate on an Estimates Committee Report on the dental services which I think was one other occasion since then. But I agree with the implication that we do not very often discuss the dental profession's affairs in the House, perhaps not as often as they deserve.
There is the same answer to all the hon. Gentleman's questions on why the hygienists cannot clean or polish teeth except under supervision and why they can work outside the N.H.S., although this new class of dental auxiliaries can work only within it—and, indeed, in the priority classes in the school dental service and health centres. The answer is that these are the arrangements that the Privy Council has made with the General Dental Council to obtain its agreement.
It is understandable that with a new class of auxiliaries there are some misgivings in the profession. There always are in these matters. Therefore, it is reasonable that we should accept certain restrictions in order to help allay these professional anxieties. That is really the broad answer to both those points.
My hon. Friend the Member for Liverpool, West Derby (Mr. Ogden) asked why there was only a 12 months' interval for re-enrolment. The answer is simply that the class will maintain its registration each year just as a dentist does, and as I believe is the practice in most professional groups where registration is involved.
As to the possibility of a course in the North-West, or perhaps more particularly in the Merseyside area, there are no present plans to open other schools, but the experimental scheme has not yet come to an end. There certainly would be no statutory obstacle to other schools, provided the necessary powers are 1724 obtained in the Health Services and Public Health Bill, under the new Clause to which I briefly referred in my opening remarks.
I very much agree with the hon. Member for Cheadle (Dr. Winstanley) that this is just one more example of how we can help the professions associated with the Health Service to make the best use of manpower resources, particularly skilled manpower resources. I am sure that one of the best economies we can make is to ensure that all our professional groups exercise the skills for which they are trained and leave to others the lesser skills which require a lesser degree of training.
I repeat that I am very glad that the Regulations have met with the approval of the House.
§ Question put and agreed to.
That the Ancillary Dental Workers Regulations 1968, a draft of which was laid before this House on 29th January, be approved.