§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Jim Marshall.]
§ 12 midnight.
§ Mr. Michael Shersby (Uxbridge)
My reason for seeking the Adjournment this evening is that the National Health Service comes to an end this week, so far as dental services are concerned, in the village of Harefield, which is situated in my constituency. That means that the population of Harefield, which is between 8,000 and 9,000, will no longer be able to obtain dental treatment unless people are either prepared to seek private treatment or to travel at considerable inconvenience to Uxbrige, Ruislip or North-wood.
It will assist the House to appreciate the inconvenience to my constituents in having to seek National Health Service treatment in any of those towns if I explain that they are about three miles distant. I should also explain that Harefield, which many people still describe as the last village of Middlesex—and a very beautiful village it is—is separated from those towns by the green belt, in the form of several miles of open country, and that bus services to and from Uxbridge, Ruislip and Northwood are notorious for their unreliability. Sometimes, as my constituents know only too well, the services are non-existent.
The House will therefore appreciate that what seems but a short journey to the nearest large town is in reality a difficult one, particularly for elderly people and for parents with young families, and, of course, it is also an additional expense.
For several years past Harefield has been served by two dental practitioners, and occasionally by three. I was therefore surprised when in January my attention was drawn by several constituents to the fact that there would shortly be none.
To clarify the position, I put down a parliamentary Question to the Secretary of State for Social Services. I asked him 817 how many dentists provided dental treatment under the National Health Service in Harefield and whether he was satisfied that the service provided was adequate for the area. In reply to my Question, the Minister of State said that three dentists provided National Health Service general dental services in Harefield and that he was not aware of any special difficulty in obtaining dental treatment there.
I can only tell you, Mr. Deputy Speaker, that my constituents who saw the Minister's reply knew different, and I was assured by them that he was wrong. I therefore pursued the matter with the area health authority and with the Hillingdon Area Family Practitioner Committee. On 13th February I was informed by Mr. Donald, the administrator of the family practitioner committee, of a very different situation from the one indicated in the Minister's reply.
I quote from Mr. Donald's letter:One practitioner left the area about 18 months ago without informing the family practitioner committee, and payments were still being authorised by the Dental Estimates Board until six months ago. His name has now been removed from the dental list. A further dentist intends to resign on 19th March 1978, and has directed his associate not to accept any more National Health Service patients, so there will be no National Health Service dental treatment provided in Harefield after that date. I am endeavouring to rectify the matter and have been in touch with various people, including Mr. W. F. Hollis, the Secretary of the Hillingdon Local Dental Committee. Although neither he nor the family practitioner committee has the authority to direct a person to the area to practise, Mr. Hollis is formulating plans with the hope of providing dental services again.As I was about to telephone the Minister to tell him of the situation in Harefield, his private secretary telephoned mine to tell me that his original answer was indeed wrong, and he confirmed what the family practitioner committee had told me in the letter from Mr. Donald.
My next step was to raise the matter with Mr. Hollis, secretary of the Hillingdon Local Dental Committee. He confirmed that neither his committee nor the family practitioner committee had any jurisdiction over the placement of dental practitioners.
Mr. Hollis also told me—and I quote from his letter of 2nd March:While appreciating the difficulties—of the people of Harefield, we feel that this—sort of situation has arisen solely due to the—recalci- 818 trance of the present ministerial policy and that it is indeed a mere forerunner of what may be anticipated nationally. No individual practitioner can be expected to invest the many thousands of pounds necessary to be put at risk in establishing a practice without a reasonable return for his endeavour. You will no doubt be aware of the bankruptcies of many such young practitioners who have endeavoured to get on their feet and finished in financial failure during this last twelve months.The irreparable loss of initiative which this destruction induces leaves them with the alternatives of either emigration or the resignation of acceptance of a post of salaried service wherein their productivity to the nation is historically fractional to that which it is statistically proven to be in contractual service to the family practitioner committee.I am directed to inform you that Harefield is symptomatic of what must inevitably be anticipated nationally while a ministerially maintained policy is so rigidly adhered to, which in itself necessitates the administration of treatments, the reward for which does not even meet the overheads incurred.It is my understanding that there are two aspects of the dental practitioner NHS contract which it is essential to be aware of. First, dental practitioners are not State employees with a guaranteed income. They are self-employed, fee-earning professional people who finance and manage their own practices and who can face bankruptcy if income fails to cover outgoings. Secondly, they have an absolute contractual right to decline to treat patients under the NHS if the terms are unacceptable. If the terms are unrealistic, as the profession's leaders now believe, the dentists can no longer go on treating patients under the NHS at the expense of their own fivelihoods. It is because the terms are unrealistic that my constituents in Harefield will no longer be able to get treatment under the NHS after the end of this week.
Why are the terms unrealistic? Why cannot a person in Harefield get a tooth pulled after the end of this week? I have been doing a little research and have found out why. It is because, as I understand it, one key element of the present dispute between the dental profession and the Department of Health and Social Security is that the earnings of dentists have fallen behind comparable earnings. In fact, I find that there has been only a 3 per cent. increase in NHS fees since 1975 and that by April last year dentists' pay had fallen 19 per cent. behind comparable earnings. The gap is much more today.
819 There is also the rising cost of buying equipment which faces particularly the young dentist who is probably buying his home at the same time. A very recent estimate shows that the total cost of 10 basic surgery items necessary to practise dentistry has risen from £1,740 in 1969 to £6,697 today. That means that in 1969 the surgery cost in terms of NHS net income was 5.8 months, based on the target average NHS income of general dental practitioners of £3,590. Today it is 10 months, based on a target average income of £8,010.
It seems pretty clear that the fees are too low and that the cost of equipment is too high. An NHS dentist can no longer make an adequate return to meet his costs, let alone make a reasonable living. I understand also that dental mechanics are leaving their jobs in increasing numbers. This leads to even greater difficulties in getting work done on such things as false teeth.
What is to happen to my constituents in Harefield? What steps will the Minister and the Government take to ensure that the NHS continues to function in this last village in Middlesex so that the 9,000 people living there can receive the services towards which they have contributed for so many years?
Will the Minister consider, perhaps as a temporary measure, providing a mobile surgery, or will he issue advice to permit community dental officers in Hilling-don to give dental care and treatment to the pensioners in Harefield who find it difficult to travel elsewhere for treatment? If a mobile surgery is not the answer, perhaps a temporary service could be provided at a health centre.
In addition, will the Minister consider authorising the health authorities in Hillingdon, at their discretion, to provide facilities for the dental treatment of people in Harefield and to make use of any spare capacity there might be after the community dental staff have discharged their duties towards children and others for whom they are already responsible? I understand from a recent announcement in the House that they can now extend their service to the handicapped.
Finally, will the Minister give an assurance that the Government will take 820 early action to implement the recommendations of the Doctors and Dentists Review Body so that we can once again have NHS dentists, not only in Harefield but in many other parts of the country where the dental service is on the point of collapse?
§ 12.11 a.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)
I am grateful to the hon. Member for Uxbridge (Mr. Shersby) for this opportunity to comment on a matter which is clearly of concern both to him and to many people in the Harefield district. I have carefully noted the points that he has raised. Before dealing with these points, and to put them into perspective, I should like to clarify a subject which is often misunderstood by patients and by the public, in general—that is the position of dentists in the NHS general dental services.
It is important to recognise that dentists in the general dental services are independent contractors with family practitioner committees, which are the local bodies responsible for administering all the family practitioner services. The dentists are self-employed professional men who apply to have their names entered on the family practitioner committee's dental list. Their being on the dental list means that they have agreed to provide dental treatment under NHS arrangements for the patients they accept for that purpose. They are bound by the general dental services regulations only in respect of the patients they accept for a course of treatment.
Dentists do not have "lists" of patients as doctors do, nor are patients "registered" with them. This is because in 1948 there were not enough dentists to guarantee a continuing service for the whole population. Even now, despite a steady annual increase in the number of dentists included in the dental list, there are still not enough to make it feasible to guarantee fully comprehensive NHS treatments on demand to all comers. This is why we have thought it important to provide, through the area health authorities' own services, a priority service for certain groups of patients.
Traditionally, health authorities have provided dental care for children and expectant and nursing mothers, and, as my right hon. Friend the Secretary of 821 State said in a Written Answer on 26th October 1977, we propose to allow health authorities, at their discretion, to extend this service to handicapped adults who, because of their handicap, are unable to obtain routine dental treatment from any other NHS source. It will be for each area health authority to assess the need in its area and to weigh this against the existing commitments of its community dental staff for the dental health of schoolchildren and other priority classes.
No one is registered with a dentist, but, having accepted a patient for a course of dental treatment, the dentist is obliged by his terms of service to provide, or arrange for the patient to have, all the treatment necessary for dental fitness which the patient is willing to undergo. His obligation to that patient is discharged when the course of treatment is complete. I am, of course, aware that many dentists treat regular patients on a continuing basis although they are under no obligation to do so.
I have gone into some detail in explaining the background to the nature of the dentist's contract in order to illustrate why a dentist on a family practitioner committee dental list is free to accept or refuse any patient for NHS treatment and to practise privately, and why, under existing legislation, neither FPCs nor my right hon. Friend the Secretary of State have the power to compel a dentist to accept any particular patient, to provide any particular item of treatment or to practise in any particular area.
Dentists who may have provided NHS treatment, even on a regular basis to some patients, are at liberty to give notice of removal of their names from a dental list at any time and henceforth to offer nothing but private treatment. This I understand to be the case with two dentists who are at present providing some NHS treatment in Harefield but will shortly be withdrawing their names.
Harefield is a somewhat isolated community in the north-west corner of the area administered by the Hillingdon Area Health Authority. It adjoins that of the Hertfordshire Area Health Authority.
The population of Harefield has in the past been fortunate in that full- or part-time general dental services have been provided in the locality by two or three practitioners, and I can understand the 822 misgivings felt by some residents now that the local coverage is diminishing. There are at the moment two practitioners with addresses in Harefield on the Hillingdon Family Practitioner Committee's dental list, but both have given the three months' notice of withdrawal which is required under their terms of service. Unless by June this year another dentist offers general dental services there, the dental list will no longer contain a Harefield address. I am indeed sorry that, even now, Harefield residents may not be able to obtain acceptance for another course of NHS treatment there and will have to seek treatment elsewhere.
Obtaining dental treatment at a surgery some miles from one's home or place of work is the experience of many, particularly in the less urbanised or rural areas, but I sympathise with those people whose routine of life is disturbed or who have to go to new lengths to obtain the dental treatment which they need.
However, those who have access to transport should find no difficulty in reaching a dentist Records show 68 practitoners providing general dental services on the dental list of the Hillingdon Family Practitioner Committee and in that area the ratio of dentists to population is better than the national average. Since Harefield is so close to Hertfordshire, it is worthy of note that the ratio of dentists to population in Hertfordshire Family Practitioner Committee's area is also appreciably better than the national average.
The problem which is brought to light in relation to Harefield is thus not so much that there are no dentists to treat the population but rather that there are no longer general dental services available, as it were, on the doorstep. It becomes a problem of transporation for those who do not normally move outside the confines of Harefield. I am given to understand that Harefield is not without a bus service, although I note the hon. Members comments about its inadequacy. Public transport apart, I should be surprised to find a community in which members, even the aged and infirm, could not be helped by family, friends or neighbours to travel the few miles to keep an appointment with a dentist in a nearby town.
I should also mention the provision in the general dental services for dentists 823 to visit patients in their own homes, up to five miles from the surgery, if the patients's condition so requires. Where any necessary dental treatment cannot be carried out at home, the ambulance authority is required to provide or arrange for suitable transport to the surgery if the patient is considered medically unfit to travel by any other means.
A service is provided in Harefield by the community dental service for schoolchildren and other priority patients. There is a single dental surgery in Harefield Health Centre. Until recently, this was operated for three days a week and demand was such that the area health authority had intended to make it a full-time clinic. Unfortunately, the dental officer employed there has recently left to return to hospital work. The health authority is seeking to recruit a full-time dental officer for the clinic and, as an interim measure, has put in a dental officer from another part of the area two days a week.
It is unfortunate that general dental practitioners in Harefield now providing NHS treatment are soon to withdraw their services, but I think it unlikely that patients will no be able to get the treat-men they require in neighbouring towns. NHS dental treatment is available three miles away in Rickmansworth, four miles away in Northwood and also at Uxbridge and Watford, which are both within five miles of Harefield. There are also surgeries throughout the London area at distances in the range of six to 15 miles. Patients having difficulty in finding a dentist should contact the administrators of Hillingdon and Hertfordshire Family Practitioner Committees, who, although having no power to compel a dentist to accept a particular patient, will always do their best to help.
It might be helpful if I mention the manpower situation generally. It has a bearing on the Harefield problem. The McNair Committee on Recruitment to the Dental Profession recommended in 1956 that the capacity of dental schools should be increased so that at least 800 new dentists qualified each year to achieve a long-term target of 20,000 dentists on the register. This target is about to be reached. The existing capacity of dental schools, together with further developments already in hand, 824 provide the prospect of a continuing rise in the numbers of dentists on the register. There have been indications in recent years that, as more and more dentists come into the general dental service, the cover provided throughout the country is improving.
We must remember that dentists are professional business men. As such, they will have a keen eye for places where they can be fairly confident that their services will be in demand. It seems reasonable to conclude that as their numbers continue to increase there will be a gradual redistribution of dental manpower throughout the country. This should benefit the more isolated areas. Thus, although I have said that we have no powers to compel a dentist to practise in a particular area, the forces of the market place should provide an incentive to improve the general distribution of dentists.
I now turn to the major point made by the hon. Gentleman about the present situation between the Department and dentists. The letter which he quoted does not represent a correct view of the situation, nor did his remarks on the point. For reasons which I hope will be obvious, I do not wish to say too much tonight about this matter, but I wish to say one or two things in response to the hon. Gentleman.
It is a fact that some, but by no means all, dentists are acting on the British Dental Association's advice to be selective about the provision of NHS treatment. This follows from the disagreement between Ministers and the British Dental Association over the recovery of overpaid expenses. It is too early to say what is the full effect of the dentists' action. There are pockets of difficulty, but generally there has been no serious deterioration. It is hoped that dentists are responding to the appeal, in the personal letter the Secretary of State sent to all practitioners, not to make patients suffer because of this dispute.
My right hon. Friend the Secretary of State has urged the British Dental Association to return to the dental rates study group so that the right level of expenses for 1977–78 can be determined. The Secretary of State offered to look at other ways of recovering the recently identified overpayments since the profession's representatives do not like the 825 alternative proposal put forward by the Health Departments. I assure the hon. Gentleman that we remain open to any reasonable approach which the British Dental Association cares to make. We have also sought the views of the independent Review Body on Doctors' and Dentists' Remuneration on the general principles involved.
We look forward to that report in due course. The Review Body is expected to report to the Prime Minister in April.
We believe that any problems arising from the dispute with the dentists are temporary and that once the dispute is settled there will be a speedy return to normal working. In the meantime, advice to patients having difficulty in obtaining NHS treatment is to contact the administrator of their local family practitioner committee.
I do not think I should go any further tonight on the dispute, but I thought that it was worth while responding to the hon. Gentleman's remarks because obviously he feels, and perhaps his constituents also feel that withdrawal of services in Hare-field is a direct consequence of the dispute. I am not in a position to say whether that is the case, since no reason need be given for the withdrawal of the 826 provision of general dental services in the NHS. Obviously, some dentists may decide in their own interests at any particular time that they might want to practise elsewhere or go over to private practice completely. There are a number of dentists throughout the country who are in that position. There will always be changes, but one should not draw conclusions from changes in particular areas.
I concede that, when a change takes place such as the one to which we have referred, it is only natural that there is suspicion in the minds of local people that it is related to the current dispute. I cannot say whether that is so. I hope that once the dispute is resolved—I am sure that it will soon be settled amicably, given the good will and understanding that exist on both sides—we shall soon see a restoration of general dental services and that we shall be able to satisfy the hon. Gentleman's constituents that the NHS is responding to their needs for making dental treatment available rather nearer to their locality than it is likely to be over the next few months.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-five minutes past Twelve o'clock.