HC Deb 21 June 1973 vol 858 cc987-1000

9.48 p.m.

Mr. Michael Meacher (Oldham, West)

In raising the need for an urgent improvement in the prevention aspect of National Health Service dentistry I am fully aware of the considerable achievement of the National Health Service dental service in its curative role over the past 25 years. The number of dental courses has been doubled over this period and the number of persons over the age of 30 who have lost all their own teeth has been cut by half.

At the same time I am sure the Minister would agree that the state of the nation's teeth remains very bad and that enormous improvements lie within our grasp if certain relatively small but important reforms are accepted and implemented. Hence my appeal tonight.

The facts are not in dispute, because they are drawn from the official Government survey published in 1971 entitled "Adult Dental Health in England and Wales". This survey found that the average adult who still retained at least some of his own teeth had a staggering total of 19 decayed, missing or filled teeth. Furthermore, over half of all the persons in Britain over the age of 45 had lost all their teeth. This is by no means inevitable or likely, because it is double the number in the United States. It remains true that virtually all school children suffer from gum disease. In their late thirties nearly half the population experience the disease in its terminal stages and are about to lose teeth as a result. In the late fifties the future is just less than 95 per cent. By any standards this is surely a very unsatisfactory and deplorable record, though still a very costly one. At present we have the reputation of being the world's most toothless nation, and we pay out hundreds of millions of pounds a year for this distinction. Not only is tooth disease the second most costly affliction with a direct charge to the Exchequer of some £120 million a year but indirectly it results in a loss of 2 million working days a year and some 70,000 bouts sickness for which benefit is paid.

It seems clear that responsiblity for this lamentable state of affairs lies partly with public apathy but also partly with a system of dental care which is not geared to the general medical switch from cure to prevention.

At present dentists have little incentive to educate the general public in proper dental health, and surveys have shown that only one in 50 patients claims to have been taught how to brush his teeth, a very important and basic operation which very few people do properly.

Against this background I believe that there are several new policies which the Government ought to adopt. The key to the prevention objective is, in my view, widespread fluoridation of water supplies. I am aware that this is hotly contested by a very small but highly vociferous minority, but I submit to the Minister that scientific agreement on the desirability of water fluoridation is overwhelming, and I believe that that is a view which is also firmly held by the Ministry. I quote from a departmental leaflet which summarises the fluoridation studies in the United Kingdom and the results achieved after 11 years, Report on Public Health and Medical Subjects, No. 122, HMSO, 1969: In the fluorinated study areas the amount of decay in the temporary teeth of children aged from 3 to 7 inclusive fell by as much as half. The number of children free from decay more than doubled and the number of children with 10 or more decayed teeth fell by more than four-fifths. In the permanent teeth of children aged 8, 9 and 10 the reduction in the amount of decay has been about one-third and there has been a substantial increase in the proportion with no dental decay. These changes are in marked contrast to those which took place in the unfluorinated control areas where the amount of decay fell by only one-fifth in the 3 to 7 age group and by only one-twentieth in the age group 8 to 10. That is an official departmental publication and it puts the view very strongly and well.

I would make just one other small quote which is also very significant: Although fluoridation in Kilmarnock ceased in 1962 studies of the dental health of children in that town 0and its control area were continued. The findings are very interesting, for they show how, again, dental cases in young Kilmarnock children who have had little or no fluoride is climbing back to its pre-fluoridation level. That indicates overwelmingly, clearly, and consistently with other evidence the importance of fluoridation.

It is almost universally accepted by all reasonable persons that fluoridation of tap water up to a concentration of one part per million reduces the incidence of dental decay by half among children living in treated areas, and its early benefit lasts throughout life, and it is also totally safe.

However—and this is the point—there has been extreme pusillanimity. Only some 10 of England's 221 water systems now use this prophylactic—that is just about half, or less—although local authorities covering as much as two-thirds of the population have now decided that they are in favour in principle. The discrepancy arises because the water incoming areas are not coterminous with the local authority areas, and if a single minority local authority objects the change-over is, under the present regulations, blocked.

For example, Sheffield, Rotherham and Doncaster are in the catchment of one water area but the opposition of Doncaster has frustrated the will of the other two. In the case of Walsall, West Bromwich, Warley, and Dudley, Dudley has frustrated the decision of the other three. Does the Minister think that this is democracy? Is it not a travesty of democracy that the long-term dental interests of millions of children should be sacrificed to the blocking manoeuvres of a no doubt sincere but very small and, I believe, misguided minority?

Even more blatant is the example of the Isle of Wight, which is an entirely discrete area, which gets its water from no other place and whose water goes to no other place. The county council has three times voted in favour of water fluoridation but has been thwarted by the point-blank refusal of the water board—on what authority is unclear.

The first request I make of the Minister is that, as water fluoridation is so supremely important in preventive dentistry, the ten water undertakings that have refused to fluoridate on principle, even though the relevant local authorities have all voted in favour, be required to do so unless there are strong, technical, viable reasons why they should not do so.

> Two of the arguments that are put against water fluoridation I hope the Minister will disregard. The first, which is more of an emotional reaction, is that it tampers with a natural process. In fact, nature has already been interfered with, in the sense that in parts of North-East Essex, parts of South Derbyshire and the Hartlepools, there is already well over one part per million of fluoride in the tap water, and sometimes five parts, and the fluoridation is having to be diluted. It is entirely wrong to suggest that the insertion of fluoride into the water is unnatural.

Secondly, it is argued that there can always be topical or self-administered applications of fluoride for those individuals who particularly wish it. But, again, it is known that these applications are enormously less effective in countering dental decay than is systematic fluoridation, and they are certainly unlikely to breach the major class and regional barriers in dental care.

Cost cannot be considered to be a serious objection. The cost of fluoridation has remained at about 5p per head of the population per year. What is proposed is to cut dental decay by half at a cost of only about £2.3 million a year, and that is an excellent bargain.

I appeal to the Minister to make his position crystal clear on the question of water fluoridation, which I am convinced is the nub of the matter. Is he in favour of water fluoridation on the grounds of its immense and unequalled preventive potential, or is he not? If he is, as I suspect, does he agree that less than 100 per cent. unanimous agreement applied to local authorities in a given area is not only democratic, but proper and reasonable? Does he agree, for example, that a two-thirds majority would suffice for a decision on the introduction of water fluoridation? Whether it is two-thirds, three-quarters or half is not so much the point. The point is that it should be less than 100 per cent. I believe that this is fundamental not only for its own sake and for the sake of the children who would gain, in their millions, but because it would transform the whole orientation of the dental profession decisively towards prevention.

If the Minister is seriously in favour but fears that there may be political difficulties, he may like to consult his Shadow in this matter——

It being Ten o'clock, the Motion for the Adjournment of the House lapsed, without Question put.

Motion made, and Question proposed, That this House do now adjourn. —[Mr. Fox.]

Mr. Meacher

I was saying that if the Minister feels that there are political difficulties about this matter, he may care to consult his Shadow and seek to construct an agreed bipartisan formula, bearing in mind its overriding importance. It might be possible.

I want also to comment on the attitude of the Department as revealed in regard to the excellent television programme "Open Door", prepared by members of King's College Hospital Dental School. In a letter to an hon. Member the Minister said that a working party composed of representatives of the Government and the British Dental Association was examining this matter. I hope that this is not to be used as a further excuse for delay because the matter has been thrashed out endlessly, and I believe the results to be entirely clear. We now need action and the exercise of some political will.

The Minister also said—and I find this rather disturbing—that there was insufficient evidence to justify the use of any method of fluoridation other than the fluoridation of water supplies. He went on to say that these measures were expensive and that the best use of funds dictated the continued use of existing restorative treatment. I hope that the Department will take the view, which is surely the correct one, that there is sufficient published evidence to show the efficacy of topical fluoride applications, provided that they are carried out correctly. I hope that the Minister will also feel that even if the costs are equal it is far better to prevent disease and to have a sound tooth rather than one which has been mutilated by caries and then filled, however beautiful the restoration may be.

My second strong request, therefore, is that dentists should have an in-built incentive to promote preventive care. I should have thought that the present system, with the payment of a fee for each item of service, prejudiced rational therapy. Is it not anomalous that the > application of a fluoride solution, which in my view is effective in preventing decay but which leaves no trace, is not rewarded by any fee, whereas the application of a solution of silver nitrate, which is a relatively useless procedure, is rewarded with a fee because it leaves an ugly black stain and so can be checked?

More seriously, is it not disturbing that undergraduate students who increasingly are being taught these preventive techniques feel frustrated when they enter general practice and find that they cannot use these techniques and must resort to a private fee, charged to those who can afford it, if they are to put them into operation? The Minister will know that many dentists advise privately for a fee, and the case has been brought to my notice of a dentist who is reported to charge £3 each for teaching children how to brush their teeth. He takes children in groups of six for 30 minutes, thereby making £18 per half-hour as a result of private practice.

Does not the Minister think it highly anomalous that restorative dentistry should be available under the National Health Service, whereas preventive dentistry is available at present only in the private sector?

Even within the present pay system the Government could provide a real economic incentive to dentists to do important preventive work. I know that the Minister takes the view that there is nothing to stop this taking place within the NHS already, but I ask him to be realistic. At present, to carry out preventive work of any length, as against inserting fillings, is wholly uneconomic. I am sure that dentists would confirm that. At the same time, the hon. Gentleman must know that the Department takes the strict and puritanical view that what cannot be seen to be done cannot be paid for within the NHS. That is putting it rather more crudely and brutally than he might like but that is what, in effect, it comes down to.

In particular, I ask the Minister to introduce scale fees for several items of preventive work which are at present excluded. I stress especially the topical application of fluoride solutions or gels, instruction in oral hygiene techniques, including the use of disclosing tablets, the application of fissure sealants, which are extremely important and can be checked and which block up potential sources of decay later, and instruction in dietary techniques.

I see no reason why these items should not be included within the scale of fees under the existing system. To have them provided within the NHS would not only do a great deal of good for the population but would begin to turn the dental profession markedly more towards prevention.

There are several other policies that I believe the Government could and should adopt where only lip service has so far been paid. First, the Government should promote a more vigorous national campaign for dental health by having proper dental care taught systematically in the primary schools—it is virtually impossible to teach teenagers or young adults anything; it has to be done very early on—and by advertising more forcibly the carious effects of certain foodstuffs. If the power of the cigarette manufacturers has begun to be challenged and taken on—albeit rather weakly, so far—I believe that the power of the sugar and flour manufacturers equally needs to be challenged in this respect, because of the extremely harmful results of those substances.

The Government should sponsor a sustained campaign—and I mean a sustained campaign, because I think that it has been partial and fragmentary in the past—to get the adult population to attend dental clinics regularly—since only about two-thirds do so at present—and not merely when pain is felt or decay has gone so far that it is beyond repair.

It is clear that for the purposes of such a campaign, dental charges should be reduced rather than increased, or, as I would argue, preferably removed altogether. I cannot expect the Minister to agree with that, but I put it to him that the payment of half the cost of dental treatment up to a maximum of £10 constitutes a deterrent when it is added to the emotional deterrent that so many people feel in visiting the dentist. However, I am glad to note that that is beginning to change.

I think that the lowering of the exemption age limit from 21 to 18 was an undesirable act of policy and should be reversed, since it removes from free dental treatment the category in which the incidence of dental decay is near its peak.

The imposition of VAT on toothpaste, combined with its removal from chocolates and sweets, is clearly a shocking decision, which subordinates good dentistry to short-term political ends. I hope that on further consideration it will be reversed at an early opportunity.

Lastly, I ask that many more hygienists and auxiliaries should be trained as probably the most economic means of countering chronic gum disease. At present, there are only about 500 oral hygienists, which means about one per 20 dentists, on average, when the target should be about one to two dentists. This is another instance in which expenditure now would involve considerable cost saving in the long run.

The demands that I have made tonight are moderate. They are backed by the British Dental Association and by all progressive members of the dental profession. Of course, more money is needed for National Health Service dentistry and we need more dentists since, relative to population, we have only half the proportion that one finds in West Germany and the United States, and only one-quarter of the proportion in Sweden.

I have deliberately geared my requests to the more specific and directly practicable measures. I hope, therefore, that the Minister will be able to respond favourably to what I believe is a crucial public health issue.

10.11 p.m.

The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)

I congratulate the hon. Member for Oldham, West (Mr. Meacher) on the full and clear case that he has assembled and put forward to the House for a broad reappraisal of some priorities and guidelines for dental treatment.

The rather lugubrious set of figures about dental health which the hon. Member put to the House, which perhaps made even your teeth ache, Mr. Deputy Speaker, was, nevertheless, only too near the bone—if that is the right word to use—but the hon. Gentleman went on to open up an area that is important and valuable. The Government welcome any development that may lead to improved dental health, and particularly developments that are likely to reduce the ever-growing demand for the traditional forms of conservation of natural teeth. I fully accept that prevention is always preferable to expensive, and sometimes disagreeable, cures.

On the other hand, there is no doubt that the enthusiasm of those who are concerned to promote preventive dentistry—a concern which I accept to be wholly desirable—has, largely as a result of recent Press and television publicity—which the hon. Gentleman may have seen—led some sections of the public to believe that there is available a series of treatments which, if made available generally to National Health Service patients, would eliminate dental caries and the need for the more traditional forms of conservative and restorative treatments altogether. That, I am sure, is a misleading oversimplification.

I accept the thesis put forward by the hon. Gentleman as his first priority. The simplest, least expensive and most effective form of preventing dental disease is fluoridation of public water supplies. Even fluoridation does not eliminate dental caries altogether, however, though the incidence is reduced, as the hon. Gentleman said, by as much as half, and no other measure so far discovered is as effective. That is why the Government continue to support fluoridation as a proven and practical method of reducing dental disease and have urged local authorities to make arrangements for its introduction in their areas as quickly as possible.

The hon. Gentleman—again fairly I concede—wants the Government to take a tougher and more explicit line in that direction. I must ask him to weigh the difficulties with which we are faced, even though he makes an appeal that we should introduce a bi-partisan approach to overcome some of the difficulties.

The Government are faced with a situation met by the hon. Gentleman's party when it was in power. Some people have strong feelings about the introduction of fluoridation on ethical grounds, and a rather larger number have stronger feelings about forcing even small groups of the population to submit to practices with which they disagree or disapprove of no ethical grounds.

We may find that a measure introduced into the House of Commons, even on a bi-partisan basis by the two Front Benches, would be severely let down by the reception it received from hon. Members on the back benches. It is by no means as easy and straightforward to introduce such a measure as may seem to be the case, but I give this hint, and no more, that the situation will change, at least in the direction of the administration, because, as the hon. Gentleman knows, the reorganisation of the National Health Service will lead on 1st April 1974 to the transference of at least part of the powers in this field from local authorities to the central Department. We shall then have a new situation which we shall have to appraise—it will not be easy to appraise it—much more from the point of view of power being located centrally than is the case at the moment.

The other preventive measures which currently are attracting considerable public attention——

Mr. Meacher

Before the hon. Gentleman leaves the question of water fluoridation, even within the new local government structure there will, I think, still be the problem of whether 100 per cent. agreement among the relevant authorities in any water catchment area is required. The Minister has not answered my question, whether he agrees that 100 per cent. is a unique requirement in this case, which does not, so far as I know, exist in any parallel situation. Would it not be fair if that were reduced to, say, 75 per cent. or 67 per cent. or some similar percentage that he might care to choose? Would that not be fair and proper as well as democratic?

Mr. Alison

I should want to weigh carefully what the hon. Gentleman says. I cannot commit myself on that at present. We are confronted with real difficulties from the point of view of the central Government under the present set-up, but that situation will change, at least so far as responsibility goes. One central authority will be responsible for policy in a matter in which the policy responsibility now lies in a very dispersed and diffused way throughout the local government sector.

The other preventive measures that the hon. Gentleman mentioned, which are currently attracting considerable public attention, are broadly of two kinds—those which can be carried out only by a dental surgeon or trained ancillary working under his supervision, and those which may be applied by patients themselves. The former include topical applications of fluorides and fissure sealants; the latter fluoride tablets, mouth-rinses and, of course, effective methods of tooth brushing and personal oral hygiene.

I was interested in this context to read the inaugural address of the new President of the British Dental Association, Professor F. E. Lawton, who said last week: Alternative methods of administration of fluoride by tablets, in milk, or table salt, or by incorporation in tooth paste are less effective than water fluoridation and, since they depend on co-operation by the individual, are less easy to control. All other ways of protecting the tooth surfaces require the use of trained personnel … none of the classical methods of individual topical application is able to prevent as many cavities as could be treated in the same working time. He went on to say that supervised mouth rinsing or toothbrushing with diluted fluoride solutions is less effective in reduction of caries and that, although they can be administered to groups of children at a time—I am left stunned by the notion of a practitioner netting 18 quid in half an hour in this context, but I must leave that aside—they represent uneconomical use of dentists' time.

Of fissure sealants he said: Further research is needed to establish the long-term effectiveness of these materials to determine the frequency at which they must be applied and to ensure that the maturation of the enamel which normally renders it increasingly resistant to caries attack is not significantly interfered with. It is clear that the general adoption of these measures is not as simple as it appears at first sight. First, it poses a considerable manpower problem. Ever since 1948 there has been a shortage of dentists, and although, as a result of the programme of expanding dental schools which successive Governments have supported, we are now, I believe, within sight of overcoming that shortage, there is no doubt that at present the extra work load involved in making topical application of fluoride freely available to all children could be accepted only at the cost of diverting effort and resources from the more traditional forms of dental treatment, the demand for which will continue unabated for a long time to come. Moreover, I understand that topical application is effective only if it is repeated at regular intervals—this is what Professor Lawton was hinting at—perhaps as often as twice a year.

The hon. Member urges the Government to train more hygienists; that would be an essential corollary to any decision to make preventive measures more widely available and it is a possibility that we are actively exploring. Although hygienists can be trained in a much shorter time and the facilities required for their training are much less elaborate than those required for the training of dental students, obviously, expansion of such facilities is not something that can be done overnight, as the lion. Member's figures of the numbers per 100,000 of the population clearly demonstrate.

Against this background, can we be sure that the public would readily accept even longer waiting times for appointments for the more conventional treatments? Can we be sure, too, that patients and their parents would be prepared to co-operate to the extent that is essential for these measures to succeed? Even the self-administered measures require at least initial instruction by dentists or ancillary dental workers, and in some cases would depend on the willing and continued co-operation of schools and school, teachers as well.

The hon. Member urges the Government actively to promote a programme of dental health education, including a campaign to encourage patients to visit their dentists regularly. I have no doubt that, to quote Professor Lawton again, The one way in which worthwhile and effective dental health education does take place is in individual confrontation while the patient is receiving treatment in the surgery. With this in mind, whatever their attitude to charges, successive Governments have preserved the right of all patients to a free initial examination—up to twice a year for adults and three times a year for the priority classes. This is a not inconsiderable incentive to patients to visit the dentist regularly, but though last year general dental practitioners in England examined more than 20.9 million patients, regrettably the average adult is still not as regular an attender as ideally he should be. I am not sure how far publicity campaigns of the kind the hon. Member suggests would help to overcome public inertia. In 1971 my Department supported a British Dental Association poster campaign to encourage regular visits to the dentist in a number of test areas. The results were inconclusive since, though the number of courses of treatment provided increased in the test areas, so did those in control areas. We did not know how much we had been able to achieve.

I agree with the hon. Member that there is need for further research and experiment in dental health education designed to bring home to the public at large the importance of oral hygiene and particularly the part which each individual can and must play in caring for his teeth. How to get this message across to the maximum number of people is a matter on which the Government must look, as we do, to the Health Education Council for expert advice, and we are looking to it with greater financial encouragement.

In the first 25 years of the National Health Service the dental profession has had remarkable success in educating the public in the benefits to general health of good dental health. It would be a tragedy if the too precipitate diversion of resources to preventive treatment for children were to leave dentists and ancillaries with insufficient time to meet the conventional needs of other patients or, because we could not secure the high degree of patient co-operation and self-help that is essential for success, general standards of dental health that we have so laboriously built up were to be allowed to deteriorate.

Mr. Meacher

Is that not an argument precisely for water fluoridation? Will the hon. Gentleman answer the point whether he is prepared to consider paying dentists for the kind of preventive attention which I have briefly dealt with and including it within a scale of fees? That is very important.

Mr. Alison

We have touched on fluoridation. The inclusion of these forms of treatment in the scale of fees and charges would have to be negotiated with the profession. But one can get free advice on this now, during the course of the examination. So at least the possibility of this can be brought home to the public, even as things are, without any charges being involved. But it involves the real possibility, given a relatively static manpower situation, that one can only increase this form of treatment at the direct cost of reductions in the conventional forms. Alas, the topical forms of treatment are not one-off and once-and-for-all. One does not, as it were, make oneself waterproof for life.

All this is not to say that the Government are complacent about the dental services available to National Health Service patients or to imply that we are not interested in preventive dentistry. Research to assess and, we hope, to improve the efficacy of these services is being actively pursued with Government support and encouragement at several centres. Moreover, the Working Party on Dental Services, to which the hon. Gentleman alluded, is actively considering this and other related problems, particularly preventive dentistry. I understand that my right hon. Friends the health Ministers are likely to receive an interim report on the subject of preventive dentistry from the working party very shortly.

Bearing in mind the limitations on resources generally and the other factors that I have mentioned, I am sure that it is right to proceed cautiously, weighing carefully the consequences of introducing new treatments in order to ensure that the balance of our dental services is not disturbed to the detriment of the dental health of the people of this country.