HC Deb 14 April 1988 vol 131 cc362-97
Mr. Robin Cook (Livingston)

I beg to move amendment No. 10, in page 7, line 7, leave out clause 8.

Mr. Speaker

With this it will be convenient to take the following: Amendment No. 62, in page 7, line 13, after 'descriptions', insert 'provided that the manner of recovery shall not include the withholding of dentures or dental appliances from the person for whom they were prescribed'.

Amendment No. 63, in page 8, line 17, after 'descriptions', insert 'provided that the manner of recovery shall not include the withholding of dentures or dental appliances from the person for whom they were prescribed'.

Amendment No. 12, in page 9, line 13, leave out subsection (7).

Government amendment No. 38.

Mr. Cook

The amendment seeks to remove the most offensive clause in the Bill, relating to charges for dental examinations.

Routine dental examinations have been free since the inception of the National Health Service 40 years ago. Clause 8 will mean that National Health Service dentists will become a shade more expensive than solicitors, who, in general, give their advice free.

I appreciate that hon. Members on both sides of the House find the clause offensive. I am modestly encouraged by the press, who have promised me that there will be a revolt of some 20 Conservative Members at the conclusion of the debate. [AN HON. MEMBER: "Where are they?"] Let us not be partisan. We are seeking grappling irons to throw across the Chamber to Conservative Back Benchers.

Yesterday, we had a revolt of only 10 Conservative Members. The press has promised me that matters will be even better than tonight on Monday, when from 10 last night to 20 tonight, we can hope that the number will be 40. That is a pleasing geometric progression that I hope will be borne out.

My only surprise is that apparently the Secretary of State does not intend to join us in our Lobby tonight. On the same day as the Secretary of State's Department produced the Bill, it also produced a White Paper which recorded: the Government attaches great importance to the promotion of good health and the prevention of ill-health. The clause, which provides charges for routine screening, is in flat conflict with that stated commitment to the prevention of ill-health.

It is now four months since the White Paper and the Bill were published. The first question that the Secretary of State has to answer is where in Britain we can find any organisation committed to dental health that supports the proposal and that during the past four months in which the proposals were under debate has been convinced by the Government's argument. If the Secretary of State has to admit—as I suspect he will—that those four months have failed to convince a single organisation of the merits of the proposals, I have to put it to him that the sensible and courageous course would be to pack in and forget this lonely and friendless measure.

There are two reasons why the clause has failed to win friends. First, routine dental examination has to be the basis of any preventive approach to dental health. That statement is so obvious that it does not require elaboration. It is safe to say that all hon. Members have lost their milk teeth. We know that the earlier caries can be detected, the less amount of tooth needs to be destroyed for filling and the less chance there is of teeth being removed.

It is worth stressing and elaborating the extent to which dental examination is important screening, not only for dental health but for general health. My hon. Friend the Member for Cumbernauld and Kilsyth (Mr. Hogg) had a tumour removed from his mouth following referral after a routine dental examination in which it was discovered by the dentist. In some cases, such a referral can be life-saving.

It is worth recording that dental and oral cancer is now almost as common as cancer of the cervix. Last night, the House properly and fully debated arrangements for routine screening for cancer of the cervix. Treasury Ministers know that we have our differences with the Government's record on that matter, but at least the Government have admitted the need for systematic screening for cancer of the cervix.

It would be perverse if, the very next day, the House were to pass a proposal that threatens one of the most effective means of screening for a form of cancer almost as common as cancer of the cervix. Indeed, free dental examinations are possibly the most effective way of screening for oral cancer. A study by the Bristol dental hospital discovered that there were more referrals for oral cancer to the hospital from dentists than from GPs and that the referrals from dentists were at an earlier stage in the cancer. That is a vital point, with which my hon. Friend agrees. With his experience, he is well placed to guide the House.

It is vital that oral cancer is detected at an early stage, because the opportunity for surgical intervention in the mouth is limited by its character. The only chance of success in operations is if the operation comes at an early stage.

Other systematic diseases can be detected by dental examination. Mouth ulcers can indicate the onset of severe diseases such as Crohn's disease or now, tragically, AIDS. I find it odd that we should be placing an impediment on routine health screening, thereby losing one opportunity, however limited, for the early detection of AIDS.

There can be no doubt about the importance of the dental examination. I assume that the Secretary of State will agree. He would be in some difficulty in favouring a preventive approach to health care if he did not support the importance of the dental examination. The Secretary of State has an invidious task to discharge in maintaining that he accepts the importance of the dental examination, but that he can introduce a charge on that examination without discouraging people to attend for it.

That brings me to the second reason why the clause is so friendless. The proposition is such patent nonsense that it cannot seriously be submitted that we can introduce a new charge for dental examination without it affecting the people who attend for that examination.

Some patients will find it difficult to afford the fee. The exemptions from charge for dental charges are much more limited than the exemptions for prescription charges. People on incomes just above the poverty line will find that they are liable for the full charge of £3 for a dental examination.

It is ironic and troubling that the people who will be affected are the same people who, in the past fortnight, have been affected by the cuts in housing benefit. Yesterday, during the debate on social security changes, I referred to constituents on an income of £72 a week who had lost £11 a week in housing benefit. I am advised that it is unlikely that that couple will qualify for exemption from dental charges. They will have to pay for any future routine dental examinations, and it is obvious that will be a significant deterrent to those on a diminished income from coming for a routine examination.

Other patients may be able to afford a dental examination, but simply will not see the sense in paying for it. If they do not feel that there is anything wrong with their teeth, they will not see the importance of having an examination.

I am surprised that I need to point that out to a Government who are so infatuated with market economics. The Secretary of State came to office with something of a reputation as a pioneer of enterprise capitalism, pushing forward the frontier of the market. The Secretary of State will know that one cannot believe in a market unless one accepts that the pricing mechanism works. In other words, an increase in price must lead to a reduction in demand. Nobody with the Secretary of State's faith in the market can really expect us to believe that he thinks that he can increase the charge for dental examinations from zero to £3 without a very serious reduction in demand.

Nor is it necessary for us to reason that proposition only from abstract economic theory; we can prove it from the empirical evidence of history. During the past eight years the Government have persistently increased the charges for routine dental treatment. Yesterday, I noted that comparisons of the record with the last Labour Government were very popular with this Government. Let me remind them of one particular comparison.

In 1979 the maximum charge for routine dental treatment under the Labour Government was £5. The similar charge in 1988 is £115. After this Bill, the charge will be £150. That is an increase of 3,000 per cent., somewhat in advance of the rate of inflation. In the course of those nine years, the biggest leap came in 1985. In that year, the maximum charge for routine dental treatment leapt from £14.50 to £115.

It is instructive to note what happened to the demand for treatment in the subsequent year. The number of fillings completed in the subsequent year was down by 5 million, the number of root treatments was down by 140,000 and the number of treatments for gum disease was down by 1 million. Those figures went down not because the incidence of gum disease and caries went down but because fewer people presented themselves to the dentist because they were deterred by the charge. The only treatment that increased in that year was the number of extractions, for which the charge is relatively cheap. In other words, patients lost teeth that previously would have been saved.

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If the increase in 1985 had that effect, we can expect with confidence that an increase from zero to £3 will also result in a reduction in the demand for dental examinations. That reduction can also be numbered in millions.

What is to be achieved by that lost opportunity and those lost teeth? It is to achieve a revenue saving from this proposal of £50 million. This is not a Government who are strapped for the odd bob or two. We saw only last month just how well financed the Government are. They do not need to sell the principle of free preventive screening for such a paltry price. They do not need to put at risk the dental and oral health of those who will be put off from coming forward because of the charge. Perhaps most importantly, the House does not need to let them do it. Together we can stop them.

Opposition Members are accustomed to voting against the Government. We have had quite a bit of practice since the general election. All we require in order to stop this piece of friendless nonsense is for Government Back Benchers, who know it is wrong and that it will adversely affect the dental and oral health of their constituents, to join us in the Lobby.

Mr. Robin Maxwell-Hyslop (Tiverton)

It is really a very simple question: do we want to encourage people to have more dental examinations or do we want them to be discouraged from having dental examinations? It is as simple as that.

When I asked my right hon. Friend the Secretary of State and his hon. Friends in debate whether they believed that imposing charges would make it more or less likely that patients would offer themselves for examination, not surprisingly, I did not receive any convincing answer because they knew as well as I do that when a charge is imposed it will make it less probable, not more probable, that people will offer themselves for examination.

The second question is, is it desirable that people should offer themselves for examination? The answer to that is equally clearly yes. It is desirable in the interests not only of dental health but of early treatment for other diseases that become apparent only when there is a proper dental examination. Moreover, it is an examination that general practitioners, despite their very extensive training, are not trained to undertake. That is why I shall vote for the amendment to remove the clause.

Mr. Fearn

I wish to speak to amendments Nos. 62 and 63, which make it clear that the manner of recovery of charges shall not include the withholding of dentures from patients who need them. That would be a cruel and unusual punishment for poverty. We do not like any of the new charges anyway and we shall be voting against them in any Division tonight. It is particularly distasteful that the Government seek to impose a charge for dental inspections, which will militate against the maintenance of the good dental health of the population.

Working on the assumption that we shall not overthrow the Government's majority in the cause of civilised behaviour on this occasion, as has been the case so often lately, it would at least be a gesture for the Government to concede that they do not need a power to withhold dentures from a patient who needs them until he or she has scraped together enough money to pay the charges.

Mr. John Greenway (Ryedale)

I have a great deal of sympathy for those who argue that phasing out free dental examination is not the right step to be taking at this time. However, I ask those who are thinking of joining the Opposition in the Lobby to reflect on the discussions that have been taking place in the dental profession for some months about the need for a new system of remuneration for dental practitioners. I dwelt on that point at length on Second Reading.

If all the diseases that a dentist looks for when undertaking an examination are as important and far-reaching as has been made out, the question we should be addressing is what contractual relationship a dentist should have with his patient. Clearly, the present remuneration system that rewards a dentist, regardless of who pays the charge, with a paltry sum of £3.90 for an examination is ludicrously inadequate.

There is another reason why that is so. In the past, when the dental rates study group has considered what fees to apportion to the various items of treatment that dentists carry out, the examination fee has always received little additional money. The reason is that dentists would be adequately remunerated through the treatment that was necessary. Thankfully, in this day and age, we see improving dental health. It is improving to such an extent that patients who have the good sense to go to their dentist regularly need little, if any, treatment. I can tell the House that many practitioners are increasingly finding that, after a routine examination, their patients require no treatment.

That is why the General Dental Service committee has proposed to the Department the need for a new annual registration contract. That contract would replace the present dental examination and screening arrangements. I warmly commend that scheme to the House. The argument should not be about what charge there should be per dental examination and who should pay it, but about what structure of remuneration we require.

There is not time in this debate to go into that aspect more deeply. However, can I tell my right hon. Friend the Secretary of State that I support what the Government have in mind. I can also tell him that I have lobbied for the contract throughout the dental profession and there is great support for it from many forward-thinking dental practitioners. I am disappointed that formal discussions on the new contract have not yet commenced. I believe that we should pursue the new contract arrangement, which the White Paper sets out, with all urgency, so that if, as I believe will be the case, the House votes to phase out a free dental examination, there could be an opportunity for us to phase out the free examination and introduce the new annual registration contract at the same time. That would send a clear signal to the public that regular attendance is what the Government want to see and to encourage.

On Second Reading, I made reference to a study that was being carried out on the subject of "Barriers to the receipt of dental care". That study—a very small one, based on just over 100 families—has now been completed and it indicates precisely those points which discourage attendance that I outlined to the House some four months ago. In particular, it shows that many people, despite the fact that they would be entitled to free examination and even free treatment on exemption if they went to the dentist now, do not attend because there is no perceived need to see a dentist.

The second thing which the White Paper stresses, and which during the Second Reading debate my hon. Friend the Minister of State said that he would take urgent action upon, is the need to launch a dental awareness campaign. I understand that discussions are already well advanced on a new scheme to be launched in the west midlands later this year. We must pursue that with real vigour.

I say again to the House what I said on Second Reading—that, if the money which the Government raise from the phasing out of free examination is used to encourage more people to visit the dentist and to help dentists to establish bigger and better practice premises, this measure will indeed be worth while.

Dr. Lewis Moonie (Kirkcaldy)

There is a kernel of reason in what the hon. Member for Ryedale (Mr. Greenway) has been saying. However, accepting that the reduction in the number of treatments required is leading to a potential reduction in the dentist's income, I find it scarcely conceivable that the present system will be improved by bringing in a charge that will discourage people from visiting a dentist at all.

There are many irritating shortcomings in this Bill, and one or two glaring faults. This is one of the latter, for several reasons. I think that it is generally accepted as a principle of preventive medicine that all those at risk of the condition that we are trying to prevent should be encouraged to take advantage of the screening and treatment facilities that will prevent it. We know that dental health is improving in our young people in this country, and I am glad of that. I am sure that the Government will not have the cheek to claim credit for it, although they may well do so, but I do not think that many people outside their own ranks would believe them.

The improvement is due to many factors: to a general improvement in hygiene, changes in diet, the addition of fluoride to water and better screening in schools. It is gratifying that nowadays we have classes of children in secondary schools where one would be hard put to it to find a mouth with the fillings and extractions that were common 25 years ago when I was at school. Now, the broad smiles that we can give owe much more to the care of the dentist than to our own care of our teeth.

It is a principle that people should not be denied access to dental facilities, and it is not for the benefit of dental health alone. As my hon. Friend the Member for Livingston (Mr. Cook) has so rightly said, there are many other conditions involved which dentists, by reason of their long professional training, are qualified to pick up. Oral cancer is certainly the most serious of these. It is a hideous condition, almost always involving major surgery on the mouth and throat if there is to be any chance of survival, and still carrying a very low long-term survival rate, and that with a gross handicap.

It is not only a matter of oral cancer. The dentist can pick up a pre-cancerous lesion in the mouth, called leucoplakia, which is commonly associated with pipe smoking and irritation in the mouth. The Minister is nodding. Fortunately I do not have it. Leucoplakia is a condition which can be detected early and the patient can be advised as to its seriousness, and with the removal of the irritant stimulus it can be treated or reversed. Screening therefore offers us the chance not only to detect a cancer that will require major treatment to alleviate but to detect the pre-cancerous state and therefore prevent all the discomfort that that state could bring, and possibly death.

There are many other serious conditions that may be manifested through symptoms and signs in the oral cavity, including the very common one of anaemia, which may well be picked up, and some serious kinds as well as the common iron deficiency type. So it surely is a basic principle that we should be encouraging people to take advantage of the excellent screening facilities which are available in this country rather than trying to discourage them.

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I said that there was a kernel of truth in what the hon. Member for Ryedale said. In the present situation, in which dentists are increasingly finding that the work that they are doing in order to maintain their income is becoming more and more complicated and difficult to find, there is certainly a case for reviewing the way in which they are remunerated. Perhaps it should be changed to the way in which general medical practitioners are remunerated, with a capitation fee.

We have heard very little about the possibility of actively encouraging people to take advantage of dental screening. It tends to be opportunistic. If a person goes into a dental surgery that person is likely to be called up again at regular intervals, and that is a good thing, but there is no primary call-up system. Perhaps we should be looking at something like that.

It is possible for us to achieve a society in which we perhaps approach perfect dental health at very little additional cost compared with what we are now spending. That should be our ideal and our aim. Alas, this clause does nothing to improve dental health. It will discourage those most in need of the advice and treatment that a dentist can give them to stay away. For that reason, all hon. Members should join us in opposing it.

Mr. Roger Sims (Chislehurst)

The hon. Member for Kirkcaldy (Dr. Moonie) speaks with authority and I believe that he makes a powerful case.

The White Paper, which has been mentioned on several occasions, refers at paragraph 1.15 to a number of the measures which the Government propose to introduce, including a new contract for dentists which will encourage prevention and promote the quality of treatment provided".

In chapter 4 of the White Paper a more detailed explanation is given as to how that is to be achieved. But in paragraph 2.13 of the White Paper we read: As a result of improvements in the nation's dental health greater emphasis is now being given to regular dental examinations, preventive treatment and advice and proportionately less to interventive dentistry. Dental examinations are an increasing proportion of dentists' work.

It then goes on to say: The Government believes that it is reasonable for patients to contribute towards the cost of this part of the dental services and, of course, that is what subsection (7) of the clause does.

I am sure that there is no dispute about the value of the dental check-up. Members will have received abundant evidence from the dental professional organisations and possibly from individual dentists. The issues were discussed in detail at the Committee stage of the Bill. A check-up detects diseases, including oral cancer. It enables there to be a general check on the general state of oral and dental health of the patient, with an opportunity to halt decay at an early stage and for the dentist, or possibly the hygienist, if he has one, to give advice to the patient on general dental care. It must be right to encourage people to have dental check-ups.

In Committee and in letters to hon. Members the Minister of State has set out the exemptions to charges. He has also explained the proposed charges and how they will fit into the general context of the revised scale of charges for treatment. I accept that he has an argument, but the nub of the case is surely the fear which has already been voiced—whether the imposition of charges will deter people from having check-ups.

In Committee the Minister of State indicated that he was not persuaded that it would do so. We simply have to draw on our knowledge of human nature. I imagine that most of us go regularly to our dentists. I venture to bet that we do not go for a check-up with great enthusiasm and that if we can find a good reason for putting it off for a week or so, we do so. Surely the knowledge that we are likely to be charged for a check-up will hardly encourage us to go. If that applies to hon. Members, how much more will it apply to those who rarely go to the dentist but should, and indeed to some people who have never been at all? Surely there can be few more effective deterrents to them than to know that a charge will be imposed for a check-up.

The White Paper speaks of a new contract for dentists which will encourage prevention. Here the Government are proposing a new contract for patients which will discourage prevention. It is not irrational that those with reasonable means should pay a proportion of the cost of the dental work which needs to be carried out, but the hurdle that we have to surmount in improving the nation's dental health is to get people to be checked in the first place. Here we are proposing to make that hurdle higher.

No doubt my right hon. Friend will argue that the charge will raise money. So it will. But sooner or later the National Health Service will have to meet at least part of the cost of treatment or serious dental troubles which could have been dealt with much sooner and more cheaply if the patient had not been discouraged from having a dental check-up.

There are many very good provisions in the Bill, but it is marred by this proposal and the proposal which we shall discuss later in regard to eye tests. As I read it, the effect of amendment No. 10, which has been proposed by the Opposition Front Bench, would be to remove clause 8 completely from the Bill. That I am not minded to do because I approve of aspects of it. If amendment No. 12, which would delete subsection (7) referring specifically to charges, is put to the vote I will need a great deal of persuading not to support it.

Mr. David Hinchliffe (Wakefield)

Having listened to the hon. Member for Chislehurst (Mr. Sims) and other Tory Members, I am sure that many of them are sincere in their opposition to clause 8. While I welcome their opposition, I believe that their views are limited and that they are naive about what the Government are attempting to achieve through the clause.

We discussed clause 4 at 1 o'clock this morning, when many Tory Members who oppose clause 8 were probably drinking their Horlicks or were in bed. Clauses 4, 8 and 10 are all about delivering a fundamentally different system of health care. That must be understood. These clauses are not piecemeal provisions, but are part and parcel of a clear Government plan to bring to an end a fundamental principle which has underpinned the National Health Service since its inception in the 1940s—the right of people to free health care when they need it, regardless of their ability to pay.

These clauses should be considered alongside the funding crisis in the Health National Service, which is recognised everywhere in society with the exception of 10 Downing street. My central point is that the crisis is contrived and deliberate. It is geared to creating conditions in which people will accept the need for wholesale changes of the kind envisaged in clauses 8 and 10. Clearly, the Government wish to introduce a market system of health care. Hence the introduction of the charges proposed in clauses 8 and 10.

How has the crisis been contrived? First and foremost, the National Health Service workload has been increased by the Government's economic and social policies, which have vastly increased unemployment and poverty. This week we are all aware of the real difficulties that people are facing. Government policy has exacerbated housing problems and brought about massive increases in homelessness. The problems have a knock-on effect, resulting in earlier illnesses and deaths, which create more demands on the National Health Service. Numerous studies prove the point conclusively. I shall draw attention to just one. A recent study published by Professor John Fox of the City university showed that unemployed men and their wives have mortality rates 20 per cent. higher than those of people in work.

The second issue that has helped create a crisis is the constant obsession of the Tory party with reorganising the management of the National Health Service. The then Sir Keith Joseph, when he was the Member for Leeds, North-East, introduced area health authorities in the 1970s. Subsequently, his successor replaced them by district health authorities. Then we had the management nonsense introduced by the Griffiths structure which caused the problems in my health authority which I outlined early this morning.

Thirdly, as part of the contrived crisis, we have had the deliberate stimulation of private practice by the Government. The Government argue that private practice brings extra resources to the NHS. The truth is completely the opposite. The doctors who staff and run the commercial medical facilities are by and large the same people who are the consultants within the National Health Service. If they are not working in the National Health Service, NHS waiting lists will increase. The knock-on effect is that people see the need to pay to go privately and to queue jump to bribe a consultant so that they may have earlier access to treatment.

Government policy has deliberately set out to create a public expectation of having to pay. The clause follows on from the creation of that public expectation. The Government have created a public belief that we cannot afford a National Health Service. I reject that. The proof that the crisis has been contrived came in the Budget. The Budget proved that we could afford to pay for the National Health Service and that we could afford to fund the £2 billion cumulative under-spending by the Government. What did the Government choose to do? Did they choose to invest more in the NHS? No; they gave the money to people who already have plenty.

Clause 8 paves the way for the wholesale introduction of payment for health care. It is part and parcel of the destruction of the National Health Service, on which the Government are intent. It is part and parcel of the Prime Minister's attempt to eradicate Socialism. The Government may succeed in getting clauses 8 and 10 through, but they will never succeed in destroying people's strongly held belief that a Socialist approach to health care is the only approach that makes sense.

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Mr. Patrick Cormack (Staffordshire, South)

I do not subscribe at all to the concluding remarks of the hon. Member for Wakefield (Mr. Hinchliffe). To suggest that the National Health Service should be equated with Socialism would make Beveridge turn in his grave, as he is doubtless doing now, but I want to appeal briefly, Mr. Deputy Speaker, to my right hon. Friend to reconsider this measure.

I do not believe for a moment that my right hon. Friend is hell-bent on destroying the National Health Service. That is manifestly absurd. I believe that, together with his ministerial colleagues and the Prime Minister, he is right to look at the whole structure of the National Health Service and perhaps consider whether those who have benefited the most from the recent Budget should pay more. All these things should be open for examination. There are no sacred cows. When a review is undertaken, it should be done thoroughly. But the proposed review has not yet taken place. We are considering this afternoon the issues of prevention of disease and the plight of those who are least able to help themselves and to afford the necessary care. Whenever there is a doubt, the benefit should be given to the less well-off. I also happen to believe in the old adage that prevention is a hundred times better than cure. It is also a lot cheaper in the short run and in the long run.

There is nothing to be ashamed of for any Minister to say "Yes, we will reconsider. We have got that particular thing wrong." It is a brave and courageous man who is able to change his mind. I hope very much that my right hon. Friend will announce this afternoon that there has been a change of mind, because I see nothing to be gained either for the nation's health or for the Government's health by persisting with this wrong-headed proposal.

Every remark that I make now could equally be applied when we discuss eye tests. I shall not seek to catch your eye then, Sir, because all these observations apply to both issues. I very much hope that when we vote the hon. Member for Livingston (Mr. Cook) will not seek a Division on the amendment that would delete the whole clause, because quite a number of us could not go with him, but if he seeks a Division on amendment No. 12 I shall be in the Lobby with him, unless my right hon. Friend concedes totally. I hope and believe that many of my hon. Friends, who take as much pride as I do in the contribution that the Conservative party has made over the years to the National Health Service, will be with me too.

Mr. Robin Cook

As the hon. Gentleman knows, I am always happy to seek consensus in the House, and I am happy to give an undertaking that we shall not needlessly divide the House twice. At the conclusion of the debate I shall endeavour to withdraw amendment No. 10 and to divide on amendment No. 12.

Mr. Cormack

That is a most helpful intervention and I am very glad that I gave way to the hon. Gentleman.

In conclusion, I shall amplify a point that I made a moment ago. We on this side of the House have much to be proud of in the National Health Service, as do Members in all political parties. It is a National Health Service which successive Governments since the war have developed from the blueprint of a great Liberal. We acknowledge that; we all should. There is no attempt by this Government to destroy what has been created, which is one of the things of which we in Britain have most cause to be proud in the 20th century. That it needs reviewing is beyond dispute; that there are problems within the Health Service no one can question; but until a review is complete and we have decided what shape the Health Service should take in the 21st century we have a duty in the House today not to impose extra burdens or to deter. If we do not deal with this clause we shall impose extra burdens where they should not be imposed, and we shall deter people from helping to safeguard their own health, and the country's economy in the process.

Mr. David Winnick (Walsall, North)

I cannot agree with the hon. Member for Staffordshire, South (Mr. Cormack) when he says that the Government's review of the National Health Service should not be a matter of great concern to us. I believe that the review is likely to lead to Government proposals to privatise much of the NHS. But I certainly agree with the bulk of the hon. Gentleman's remarks. I, too, take the view that anything that makes people more reluctant to go to the dentist is wrong. There has been a welcome increase in dental treatment and dental health altogether in the past few years.

I have some figures that I received from the Library, which I believe are correct. Whereas in 1976 there were about 26 million courses of dental treatment, 10 years later there were 32 million, although there is an indication of slight decline in the past 12 to 18 months in the numbers receiving dental treatment. That may be due to dental charges. Nevertheless, that substantial improvement in the numbers receiving dental treatment is surely much to be welcomed. I see that the Secretary of State nods his head in agreement.

Certainly, for those on limited incomes who will not be exempted from the charges, there will be greater reluctance to go to the dentist. Not everybody is over the moon about going to the dentist, as the hon. Member for Chislehurst (Mr. Sims) said earlier. Not everyone considers that the treat of the year. Therefore, it is pretty obvious that people who do not go regularly to the dentist would find it difficult financially in many cases, although not all, to meet the charges. They may find an added reason and incentive not to go.

The Secretary of State may well argue that £3 is a modest enough sum. It is not modest enough, however, for many people on limited incomes with family responsibilities. I am concerned that the charge of £3, if it goes into the Act and is not objected to strongly enough today in the Division, will be greater in 12 or 18 months' time. It is quite likely that any increase will be well beyond the rate of inflation. That has happened to prescription charges and several other health charges.

The Secretary of State for Social Services (Mr. John Moore)

Perhaps I can assist the House with facts, because the hon. Gentleman is a friend of mine. He might like to look at clause 8(4) where he will see the degree to which costs are contained and controlled.

Mr. Winnick

I understand that the Secretary of State is in some political difficulties—I am not being malicious—and if he says he is a friend of mine, although we are friends, I must say that being a friend of mine may not help the right hon. Gentleman in his current political troubles. If I say that I wish him well, I am sure he will take that in the spirit it is given.

It is all very well to say that the sum is set out in the regulations, but the Secretary of State knows very well that the Government could bring in amending legislation, which would increase the sum well beyond the rate of inflation.

Mr. Robin Cook

Before matters proceed and my hon. Friend the Member for Walsall, North (Mr. Winnick) gives too many concessions to the Secretary of State, I should say that clause 8(4) provides that regulations shall be made, but does not specify what may be in those regulations. As I understand it, the Government are proposing a charge of £3 on the basis that that would be 75 per cent. of the present cost of a dental examination. But nothing in the Bill prevents them from uprating that percentage to 100 per cent. and making a £4 charge.

Mr. Winnick

I am grateful to my hon. Friend. It is perfectly clear, going by what happened to prescription charges and their level when we left office, and now, which my hon. Friend remarked on when he moved the clause, that this Government are determined to put up health charges substantially, way beyond the rate of inflation. Therefore, we cannot be confident—no one can be—that in two or three years' time, and certainly before the end of this Parliament, the sum will not be £4 or higher.

I am one of those people who do go for check-ups every six months. I have been going to the dentist regularly since my late twenties and if I have any regret it is that I did not have regular check-ups at an earlier age. If my teeth are not perfect, and they are not, they are certainly far better than they would have been if I had not gone for six-monthly check-ups in the past 25 years or so. As that has helped me, I want to encourage as many other people to recognise the necessity of dental check-ups.

It gives me much pleasure, understandably, when on a six-monthly visit the dentist gives me the marvellous news that I do not need further treatment. I am over the moon because, although I always have an injection, I do not look forward to the treatment. As I am convinced that six-monthly check-ups have meant that my teeth are in a much better state of health than they would otherwise have been, I want to encourage as many people as I can to have them.

It worries me that a substantial number of people—they may well be in a minority—do not recognise the necessity of six or even 12-monthly check-ups. To the extent that this measure makes people more reluctant to go to the dentist, it is a retrogressive step. It should be objected to strongly and the measure should be dropped from the Bill.

Mr. Nicholas Bennett (Pembroke)

I support the Government because this is a modest clause which will encourage people to value their Health Service.

Last year when the Government originally suggested dental charges for examination and treatment people wrote to me saying, "We were not aware that check-ups were free because every time we go to our dentist he charges us." It came as a surprise that a check-up was free and that it was the treatment that they were paying for. Therefore, we must first bear in mind that people have not been deterred from having a check-up because they were under the impression, as I was until I came to the House, that they paid for it.

Dame Elaine Kellett-Bowman (Lancaster)

Will my hon. Friend give way?

Mr. Bennett

No. I should like to develop my speech.

The logic of the remarks of my hon. Friend the Member for Tiverton (Mr. Maxwell-Hyslop) is that we should not have any charges whatever. If we are to charge for treatment, it does not seem logical to object to charging for check-ups. If charges deter people, there should be no charges, yet—

Mr. Cormack


Mr. Michael Carttiss (Great Yarmouth)


Mr. Bennett

No, I shall not give way. The logic is there and my hon. Friends must follow it through. If charges deter people, hon. Members should be opposed to any charges, but I have not heard that put forward by anybody and I do not believe that that is the case.

The small sums involved, and they are small, must be considered in terms of the relative values people place on other things.

Mrs. Elizabeth Peacock (Batley and Spen)

Will my hon. Friend give way?

Mr. Bennett

No. I want to be brief and give my hon. Friends a chance to speak.

A charge of £3 is equal to two packets of cigarettes; it would not fill an average family motor car to drive more than 50 miles; and it is less than most people pay to buy a meal for one in a Chinese takeaway. Yet Opposition Members hypothesise that £3 is such a large sum that it will deter people from having a check-up.

Mrs. Peacock

It is to some people.

Mr. Bennett

The exemptions in the Bill for people on income support and those under the age of 19 deal with my hon. Friend's point. For the average person in work £3 is not a lot of money. Anyone who sees what people spend every day of the week in a supermarket, and what people spend in public houses and on holidays, and who considers that 60 per cent. of the population have a video recorder, yet believes that £3 for a check-up every six months will deter, is not living in the same world as my constituents and me.

An important principle is that those who can should pay towards their health care. The problem with our Health Service in the past 40 years has been that, because it is free at the point of contact, people do not value their health or the Health Service. If we had small charges—I would go as far as to say that we should have charges for visits to the doctor for those who can afford it—it would make people value the Health Service and health care, and it would ensure that our doctors and dentists were more orientated towards the customer.

If anything puts people off going to the dentist, it is not charges, but the times when dentists are open and our natural fear of dental treatment. I do not believe that £3 will deter people from visiting their dentist and I welcome this modest sum which will help people appreciate that their health is worth paying for.

5.15 pm
Mrs. Rosie Barnes (Greenwich)

I wish to make my stand on this issue clear. I have done so in the past and it must he repeated until the word is finally heard.

We are debating the principle that the NHS should be free at the point of use. There is no logic in having an NHS which provides free check-ups for some parts of the anatomy but not for others. We must ask ourselves whether this is an organ-by-organ charging system. If it is teeth and eyes now, what is next on the agenda? What is the logic in charging for check-ups for eyes and teeth but not for other organs? As far as I can see, none.

It has been clearly demonstrated that charging for check-ups acts as a disincentive for people to go for essential tests. The poorer members of our society, for whom a few pounds is the cost of their children's meals for the next couple of days, are far less likely to spend the money on these tests if the alternative is basics, such as food.

It is clear that tests on eyes and teeth prevent diseases. Many diseases are detected which a patient has no knowledge that he is carrying. It is fallacious to say that patients or their general practitioners can make good the gaps that charging for these tests will create. In particular, eye diseases—like other hon. Members I will not seek to be called again because the principle is the same for both eyes and teeth—such as glaucoma, which has no symptoms until it is irretrievable, will cause more blindness if the measure is passed.

We should seek increased, not reduced, screening. If we believe in primary health care, some facilities which are at present available only in the private sector, such as Well Woman screening offered by BUPA, should be considered for the NHS. It makes sense for health, so it makes sense for human beings. It also makes sense in cost terms, because early detection not only means that diseases are cheaper and easier to treat, but that people are not off work for months on end. Moreover, deaths can be prevented, so families are not thrown on to the resources of the state for their future maintenance.

To start charging for check-ups and examinations is completely at odds with the commitment to increase primary health care. It will deny people access to the first inroad to primary health care.

Mr. Jerry Hayes (Harlow)

First, I should like to congratulate my right hon. Friend the Minister for Health and my hon. Friend the Under-Secretary of State, the hon. Member for Derbyshire, South (Mrs. Currie), on the courteous and skilful way in which they moved and piloted the Bill through its Committee stage.

In my view, for what it is worth, the Health arid Medicines Bill is an excellent piece of legislation. It is all about preventive medicine, screening, encouraging people to go to the doctor and about doctors screening those people who are most vulnerable—

Mr. Nicholas Bennett


Mr. Hayes

My hon. Friend the Member for Pembroke (Mr. Bennett) has taken the word out of my mouth—but why do we have to have a measure that many Conservative Members believe will be a positive deterrent to people visiting their dentists? All of us who have contact with dentists will know that dentists can diagnose over 120 different diseases of the oral cavity, including cancer, leukaemia and AIDS. We know that this country, like many countries in the Western world, will be faced in the near future with what might be described—I do not exaggerate—as an epidemic of the AIDS virus. 1f the proposal goes through, it will be a positive deterrent for the diagnosis of that disease.

My hon. Friend the Member for Pembroke made a courageous speech defending the proposal. I commend him for so doing, although I do not agree with him. He put to the House the simple proposition that, if people can afford to pay for treatment, they should do so. I agree with that. I believe in the free market. For what it is worth, I believe that if people go to the dentist and the dentist tells them that they require a certain treatment, they should pay for it if they can afford to do so. The same applies with the optometrist and the optician, but let us get people into the dentist's surgery in the first place. We all know how difficult it is to persuade people to go to the dentist. [Interruption.] I have heard my hon. Friend the Under-Secretary of State intervening from a sedentary position and will be happy to give way to her if she wishes—[Interruption.] My hon. Friend says that there is nothing that she wants to give me. [AN HON. MEMBER: "My hon. Friend is the lucky man."] I know that my hon. Friend the Under-Secretary of State is a strong believer in preventive medicine, but I am not sure whose day she has made.

I advise my hon. Friends, and especially my hon. Friend the Member for Pembroke, that the evidence is overwhelming in relation to what has happened when charges have been imposed. With your leave, Mr. Deputy Speaker, I shall give the figures.

In 1981, a report of the British Dental Association made it quite clear—[Interruption.] If the Under-Secretary of State keeps fluttering her eyelids at me, it is not surprising that I have lost my place. In 1971–72, when there was an increase in charges, the number of courses of treatment decreased by 7 per cent. In 1977–78, they decreased by 4 per cent. and they decreased by 4 per cent. again in 1984–85. My right hon. and hon. Friends on the Front Bench will say, "Just a moment, the volume of treatments as a generality decreased." In fact, the number of courses of treatment decreased. In my respectful submission, that is particularly significant.

In 1987, 2,600 oral cancers were discovered, many by dentists. Many doctors do not receive training in oral anatomy. They do not have that skill or understanding. I am sure that many Opposition Members who are members of the medical profession will accept that view, and I have received several letters from doctors accepting it. I challenge anyone to dispute it with facts and figures. By and large, doctors will not be able to diagnose the cancer until too late.

Many of my hon. Friends will know, and many members of the medical profession will understand, that there is a high mortality rate with oral cancers. Therefore, it is vital that they are diagnosed early. Dentists have the opportunity of screening millions of people who, by and large, are well. Many people visit a doctor only when they feel ill. By that time, it may well be too late. A moment ago, my hon. Friend the Member for Chislehurst (Mr. Sims) said that that would cost the Health Service a great deal of money in the long term.

I do not want to go into the Opposition Lobby against the Government. [Interruption.] I am sorry that my right hon. Friend the Secretary of State laughs at that. I believe that the Government and my right hon. Friend genuinely believe and care about the Health Service and do not want to dismantle it. His record and that of the Government are second to none. However, we would be foolish to deny that there are problems and to add to those problems by ruining a perfectly laudable piece of legislation by slapping on people a charge that would positively deter them from being treated.

Mr. John Home Robertson (East Lothian)

If the hon. Member for Harlow (Mr. Hayes) wanders around a dentist's surgery with as much agility as he wanders around the Chamber when he is delivering speeches, it will be difficult for his dentist to get near him to administer any treatment. Nevertheless, I agree with him. He and a number of his hon. Friends are quite right—prevention is better than cure. The best way of preventing dental disease must be to ensure that people attend their dentists and have any problems diagnosed.

It was distressing to listen to the hon. Member for Pembroke (Mr. Bennett) a moment ago. We are used to him being wheeled in to defend the indefensible. If he goes on like this, he could well end up as a Parliamentary Private Secretary. I last heard him defend the Government on the School Boards (Scotland) Bill, which is a long way from Pembroke. However, here he is again. He said that it is right that people should be required to pay for their basic treatment. I suppose that it is just about as logical as saying that there should be a poll tax, and I suppose that he supports that. Perhaps he will suggest that his constituents should have to pay for corresponding with him or for going to his constituency surgery. That may be an appealing thought—

Mr. Nicholas Bennett

I never thought of that.

Mr. Home Robertson

Well, the hon. Gentleman has got the idea now.

I should like to preface my remarks by saying something nice about the Under-Secretary of State for Health and Social Security—

Mrs. Currie


Mr. Home Robertson

The hon. Lady says "No", but I shall say it anyway. She had a signal achievement some months ago when she persuaded the Government to ban the manufacture or sale in this country of oral tobacco products, such as Skoal Bandits. Having taken a private Members' Bill through the House to ban the sale of such products to youngsters, I am delighted that the Government have achieved that. The hon. Lady did that because she recognised the serious danger of that type of product to oral health. I wonder how on earth she can square that action with the matter that we are debating today. On the one hand, the Government are taking dramatic interventionist action to prevent trade in that kind of poison, but on the other hand they are introducing a charge that will deter people from attending their dentist to have regular examinations to prevent precisely the same diseases from spreading in this country.

I agree with hon. Members on both sides of the House that it is important that we protect this principle, in order to try and improve dental health. Nowhere is it more desperately needed than in the country which I help to represent, Scotland. As my hon. Friends the Members for Kirkcaldy (Dr. Moonie) and for Livingston (Mr. Cook) will know, dental health in Scotland is about the worst in the whole world, for a whole range of reasons: because of people's diet, because of their lifestyles and because they do not attend the dentist's surgery as often as they should.

It would be relevant to put on record some reference to a report that was laid before the Government by the Scottish Health Service Planning Council—a Government body. I am referring to the SHARPEN—Scottish Health Authorities Review of Priorities for the Eighties and Nineties—report, which was submitted to Ministers last year. It says, among other things: While the oral health of the Scottish population has improved progressively over recent years it is still considerably worse than it might he and throughout the whole community compares unfavourably with England and Wales.

Quoting from memory, I understand that over one third of our population in Scotland have none of their own teeth. Perhaps the Minister can confirm that abysmal figure. The situation in our country is dreadful and action is needed to do something about it.

5.30 pm

If I may quote again from the report, it says: The regular take-up of dental services should be encouraged by every possible means". How on earth will that be achieved by this measure?

The final paragraph of this section of the report says: The proportion of the costs of dental treatment met directly by patients should not increase disproportionately. Nor should they reach a level which discourages regular routine dental care. In the general dental service clinical examination and advice including advice on prevention, diet and oral hygiene should continue to be available to all patients free of charge. That is what the Scottish Health Service Planning Council told the Scottish Office last year. It was a specific recommendation aimed at dealing with a serious problem which affects far too many of our people in Scotland. We are beginning to make some headway in improving dental health in Scotland. Why on earth are the Government now suggesting, for a paltry financial gain, that we put all that at risk?

The Minister's hon. Friends are right in the warnings that they are giving him about this. I go further than the hon. Member for Staffordshire, South (Mr. Cormack). I sincerely hope that there is not a Division on this. There appears to be a clear consensus tonight that the Government have made a mistake. Everyone can see that, and there would be no shame in the Minister's withdrawing this part of the Bill at this stage. The whole House could then go forward constructively.

Mr. Peter Griffiths (Portsmouth, North)

Governments, like individuals, are always faced with the question of deciding priorities, accepting costs in the seeking of advantages. When we debated this subject in Committee I started with the point of view of my hon. Friend the Member for Harlow (Mr. Hayes). I listened carefully to the response of my right hon. Friend the Minister for Health when he explained the purpose of the proposal. That is something that has not been picked up in this debate. The Minister pointed out that this was not, as the hon. Member for East Lothian (Mr. Home Robertson) said just now, for a small increase in Government finances: every penny of the money that is raised from these inspection charges and the inspection charges which are to be discussed later will be added to an even larger sum of over £500 million, to be used solely and entirely for improvements in primary health care in the National Health Service. That is the key.

I do not agree with my hon. Friend the Member for Pembroke (Mr. Bennett), who suggests that a £3 charge is not a deterrent. It is to some and, in a working-class constituency like mine, it will undoubtedly deter some people. But it will not be a deterrent to those who do not have to pay, to those who already attend their dentist privately, to those who do not go to the dentist at all or to those who can comfortably afford to pay the charge. A small number of people will find it a burden. I know that and I would not be able to support the Government on this part of the clause, as I told my hon. Friend the Minister in Committee, unless I was given the absolute assurance that the money so raised would be devoted to something more useful.

I disagree with the hon. Member for Greenwich (Mrs. Barnes) who said that there was something wrong with a system of priorities—I think that she called it an organ-by-organ approach. There is a case for such a system. I do not believe that the National Health Service is to spend £50 million on keeping free dental checks for that very small group of people who will be deterred, because it is such a small group and because there are other things that are so much more important. We would all have our own list of priorities.

Mr. Robert N. Wareing (Liverpool, West Derby)

Individuals do not count?

Mr. Griffiths

I do not agree with the comment that individuals do not count, which I hear from the Opposition Front Bench. I am suggesting that each one of us would have his own list of priorities. But I am persuaded, after listening to the Minister's assurance, that the best way ahead would be to allow the Government to use this Bill as a vehicle for the general improvement of primary health care—and one of the costs of that will be this part of this clause. I do not welcome it, but I accept it and shall support the Government in the Lobby.

Mr. Dalyell

May I ask the Secretary of State a factual but pertinent question against this background? I am probably the only hon. Member on the Opposition Benches who has experience of the Department of Health, albeit as a lowly parliamentary private secretary to Dick Crossman from 1968 to 1970. If I recall events of 20 years ago, it is simply to ask whether the practice has changed. I well remember that time and in those days. if any proposal was put forward, there would certainly be discussions with Sir Alan Marre, or whoever was the permanent secretary, and the officials. But absolutely crucially important was the view of Sir George Godber. as he then was, and Dr. Henry Yellowlees—but particularly Sir George Godber as chief medical officer.

I understand perfectly well that the House of Commons cannot reasonably ask to be told what civil servants have said to their Ministers, but I think the House is entitled to ask the rather different question: what has the chief medical officer, in his professional capacity, said about any proposal for a change such as this, to levy charges for dental examinations? I ask in general terms, therefore, what is the view of the chief medical officer of this proposal and, in particular terms, whether he has expressed a view on whether dentists will come to rely not so much on their clinical judgment as on their perception of the depth of their patients' pockets?

There is a real human problem here. Dentists are decent people but they are also realistic people. Very often they will make decisions out of kindness which will mean that a patient whom they think cannot easily afford treatment will not have to pay out the £150—the argument against which was deployed by my hon. Friend the Member for Livingston (Mr. Cook).

My question, however, concerns the precise advice that has been received from the chief medical officer and his colleagues. After all, we have here a Department that has turned down the technical advice of its own committee on AIDS. The Department's committee was overturned. Has the chief medical officer, by any chance, been overturned on this matter? Parliament at least has the right to know what the chief medical officer has said about this proposal.

Mr. Cartiss

There was a certain amount of levity earlier, which was particularly provoked by my hon. Friend the Member for Harlow (Mr. Hayes). This is quite the most miserable and petty idea that the Government have introduced. My feeling about my right hon. and hon. Friends on the Front Bench is that they tend not to be sufficiently Right-wing in their policies. On this issue, they have made a grave mistake. I very much hope that there is still time to reconsider the proposal to introduce charges for dental check-ups.

I respect the views expressed by my hon. Friend the Member for Pembroke (Mr. Bennett). I believe that he speaks for a number of my colleagues—no doubt this will be a continuing debate—when he says that he would like charges to be introduced for other checks. This proposal should not be allowed to go through without expressions of concern from those who, in every other respect, support and welcome the way in which my right hon. Friend the Secretary of State is promoting sound policies, ensuring a mammoth investment in the Health Service. If we fail to express our concern about the impact of these charges for the sake of this tiny sum of money, my hon. Friend the Member for Pembroke and other hon. Friends, for perfectly sound and logical reasons, given their outlook, may be putting forward next year and the year after charges for other examinations.

I do not take the view that, for five years after a general election, a manifesto must be regarded as being written on tablets of stone. On a number of occasions my hon. Friends on the Front Bench have been able to persuade me to enter the Lobby enthusiastically because, although I may have had reservations about some aspects of what they were doing, it was in the manifesto.

My hon. Friend the Member for Portsmouth, North (Mr. Griffiths) argued that this is a sound proposal because it will make available a complete package that will improve primary health care. If that was such a good idea when my right hon. Friend suggested it in the autumn of 1987, it was a jolly good idea in May 1987, when it could have been included in our manifesto and put forward. I have no concerns or anxieties about the social security system. We passed the Social Security Act 1986 and had the election in June 1987. If this proposal was such an important and vital feature of the Conservative party's approach to primary health care it should have been in the manifesto and we should have knocked on doors saying "This is what we shall do."

5.45 pm

As times change, Governments must respond and come up with different proposals that were not in their manifesto. Every party has done so, and it is an inevitable part of a five-year parliamentary system. If this proposal were coming forward two or three years into this Parliament, I would say that my right hon. Friend the Secretary of State had decided, after examining all the issues, that this was the right thing to do. I cannot understand how it suddenly emerged as a crucial feature of the Conservative party's approach to primary health care in October or November when we did not say in May or June to the voters that this is what we wanted to do.

On that basis alone I am unable to support the Government on this proposal. Most reluctantly, I shall join Opposition Members in the Lobby because on this issue they are right. One of the problems with the Government is their unwillingness to recognise the force of argument and the concern that exists. That has been my profound view over the five years that I have sat in this Chamber. I have sat silent, with enthusiasm for some measures and not so much enthusiasm for others. We are talking about peanuts in a massive programme of investment for the Health Service.

I can do no better than conclude my remarks by observing, please think again. My right hon. Friend the Secretary of State, my right hon. Friend the Minister of State and my hon. Friend the Under-Secretary of State, who did not flutter her eyes at me but left the Chamber, are doing a first-class job. Conservatives throughout the country and many people who do not support our party are proud of what they are doing, despite all the media hype about problems in the Health Service. Why spoil that for this piddling, miserable proposal? I should want to say the same—I probably will not be able to catch your eye, Mr. Speaker—about the eye test charges.

I can do no better than echo the words of the hon. Member for Greenwich (Mrs. Barnes), who identified, as did other hon. Members in Committee, a range of matters that can be highlighted by dental tests. My hon. Friend the Member for Portsmouth, North said that he knows that some people will be deterred and will find it a burden. If that is so—I believe it to be so—no hon. Member can possibly fail to support the amendment.

Mr. Archy Kirkwood (Roxburgh and Berwickshire)

My main reason for speaking in the debate stems from the remarks of the hon. Member for Portsmouth, North (Mr. Griffiths). One of the most interesting issues that emerged from the speeches of the hon. Members for Tiverton (Mr. Maxwell-Hyslop), for Staffordshire, South (Mr. Cormack) and for Great Yarmouth (Mr. Carttiss)—the hon. Member for Great Yarmouth made a particularly courageous speech, and I commend him for it—was the support they all gave to the need for preventive dental measures. Prevention has received a general welcome and an encouraging degree of cross-party support. Prevention should not become a party political issue; it is too important to be dragged down into the Punch and Judy antics of party politics.

But the hon. Member for Portsmouth, North has sold his support far too cheaply. He seemed to be saying that he has allowed himself to be persuaded by the Government because they have said that money realised by charges will be translated into other preventive sectors. That is not a good argument, because the cost-effectiveness of charging £3 for a check-up is open to serious question. If the immediate saving is £50 million, the total cost, in the fullness of time, to the Government in picking up the cost of subsequent dental treatment, even though they are only partially funding it, will still be far more than £50 million. For that reason, if for no other, the argument that swayed the hon. Member for Portsmouth, North is false. I hope that he will reconsider his position. The position he adopted earlier prior to being persuaded by the Secretary of State was sounder.

The subject before the House is important. I am pleased that the hon. Member for Livingston (Mr. Cook) has agreed to shift the focus of his attack to amendment No. 12 this evening—it goes more to the heart of the argument.

I wish also to pick up something said by my constituent, the hon. Member for East Lothian (Mr. Home Robertson), whose interests I always seek to advance in the House. He made an important point that applies to Scotland, where particular problems arise for people on the margins of benefits and low income earners, who will be most affected by the proposal. It will have a very severe impact, especially in the central industrial belt in Scotland. The traditionally bad diet and unhealthy lifestyles in that area are responsible for some of the problems that manifest themselves in the relatively poor statistics on bad dental health north of the border. So this argument is apposite to Scotland.

The point made by the hon. Member for Greenwich (Mrs. Barnes) was also important. If we allow the Government to introduce this change, what element of the Health Service will be next on the agenda for charges? That is a worrying feature of the charges. A point that had not occurred to me before listening to this debate was the likelihood that these charges will in future be treated by the Treasury just like any others. If extra revenue has to be raised from the health budget in future, the Treasury will not differentiate between money that has been allocated for improvements in preventive medicine and other general revenue, and the charges for the check-ups will spiral in the same way as general charges have in the past. That is inevitable, and it is another reason why the hon. Member for Portsmouth, North should reconsider his view unless the Secretary of State gives us a guarantee that that will not happen.

The increase to £3 is a serious one to some of my constituents and will certainly deter a significant proportion of those who visit the dentist. It is a good idea to encourage people to go to the dentist—

Mr. Graham Allen (Nottingham, North)

On a point of order, Mr. Deputy Speaker. Will you inform us about the practice of passing notes to right hon. and hon. Members on the Front Bench? The odd discreet note is to be welcomed, but there is a flow of paper. I realise that the Secretary of State and his Ministers may not be fully conversant with their briefs, but would you tell us what the practice normally is?

Mr. Deputy Speaker (Sir Paul Dean)

I see nothing out of order; it is perfectly normal practice.

Mr. Kirkwood

In any case, I was about to end my remarks.

Far from moving in the direction of imposing charges for dental check-ups, there is an economic case for giving people a positive financial incentive of, say, £3 to have their teeth checked once every six months or so. On a cost-benefit analysis, I believe that would pay dividends in the long run, and would show that the Government have got this aspect of the Bill very wrong.

Of course we can argue about whether people who can afford to pay should make a contribution to other, more general medical treatment, but as Conservative Members in this debate have eloquently said, there is no case for making this insignificant saving, which will make significant and damaging inroads into what we are all trying to establish—a future system of health care which is properly funded and which will encourage people to engage in preventive medicine rather than waiting until treatment is necessary, by which time important dental symptoms and oral conditions may have been missed and cannot consequently be treated properly.

This proposal to introduce a charge is a retrograde step, and I hope that Conservative Members will not only make speeches against the Government but will encourage their colleagues to follow them into the Lobby against the Government and in support of the amendment.

Mr. Sam Galbraith (Strathkelvin and Bearsden)

I have been most impressed by some of the speeches by Conservative Members tonight—in particular, that by the hon. Member for Chislehurst (Mr. Sims), who made a reasoned and considered speech about prevention, in which I know he takes an interest. It is difficult for me to add much to what he said, so I shall make only two brief points about what is involved here.

I hope that the Minister will not start talking about who first introduced charges to the National Health Service. We had an agreement in Committee not to do that any more. I admit that I did it first, but I have kept to the agreement since then. An important principle is involved: the difference between charging for treatment and charging for a screening process. Now, for the first time ever, we are going to charge for screening.

I hope, too, that the Minister will not say that we need to target screening and that it is no use having blanket screening. If he has a brief saying that, he should put it aside, for two reasons. Targeting is not applicable in this case. Dental disease occurs at all ages, and unless one identifies a specific disease—that is not the case here—targeting screening is not relevant to the dental examination.

I reinforce the point made by my hon. Friend the Member for Livingston (Mr. Cook) about other diseases, particularly cancer of the mouth. He mentioned the study from Bristol. The important point about that is that the diagnoses were made earlier. That is the important thing about going to the dentist. People go to a general practitioner because of some major problem, but a higher proportion of cases in the Bristol study were picked up at stage one, rather than stages three or four, as is common at a general practitioner's. That is the important point about having the screening test, in which diseases are picked up. It is no good saying that patients have other symptoms and diseases that will take them to the doctor. They often think they have a dental problem and go to the dentist first. If that is prevented by a charge, there will be a delay in the diagnosis.

Finally, the hon. Member for Pembroke (Mr. Bennett) seemed to say that £3 was not much—merely the price of driving a car a certain distance. I do not think he realises how much it is to many people who do not pay charges. Even I did not realise how much it meant to many people until I became a Member of Parliament. Many of us lead slightly closeted, ivory-tower, academic lives, but to a large number of our constituents £3 is a lot of money, and it will act as a disincentive to treatment.

I end by congratulating the hon. Member for Staffordshire, South (Mr. Cormack) on what he said. It would not be a sign of weakness to concede this matter, but rather a sign of strength. As the hon. Member for Great Yarmouth (Mr. Carttiss) said, one of the problems of this Government is that they produce Bills which they regard as being written on tablets of stone and seem to regard it as a sign of virility to change nothing in Committee. That is a sad reflection on our democracy, and, as the hon. Member for Staffordshire, South said, it would be a sign of strength to reconsider this matter. If the Government do not, I hope that as many hon. Members as possible will join in the Lobby tonight.

Mrs. Margaret Ewing (Moray)

I hope that it will not be necessary to divide the House on this issue. It is clear from the strength of argument of all parties that there is a consensus. The arguments propounded by the hon. Member for Great Yarmouth (Mr. Carttiss) reflected the view of the public when he spoke of these measures as being seen as penny-pinching and petty. He echoed the views of the public and of the professions who are most directly involved in dentistry and optical work. They have argued strongly that these parts of the Bill should be withdrawn to enable them to continue with their vital work.

A basic principle is at stake in the amendments. All of us have grown up to see the National Health Service providing equality of access to a service of equal standards. This measure means that a tax is imposed on access to dental treatment, and later on access to optical tests. The Secretary of State may well raise the question of exemptions. The issue is not the people who will be exempted from these charges; it is the people living on the margins of poverty. The £3 charge can mean a difference for many poor families. They see that amount as a way of saving something for school meals and clothing for their youngsters, and this measure will prevent them from taking the opportunity of a free dental examination. That will have many knock-on effects.

6 pm

This group of poor families is the most vulnerable. People who live on the margins of poverty often skimp on what we may regard as basic essentials, such as toothpaste, but they do not see them as essentials. The diet of people living on the margins of poverty can be badly affected by their income. They are the people whom the Secretary of State should ensure has access to free dental examinations. They must be considered, and I therefore hope that the Secretary of State will concede these points.

After the Health and Medicines Bill was published I spoke to many of the dentists in my constituency. There was a sense of outrage and they spoke at length about the various diseases that can be detected by a simple dental examination. During the week in which I spoke to those dentists, one dentist had diagnosed a throat cancer in an early dental examination. That is a significant point. The Government argue that more emphasis must be placed on primary health care and preventive medicine, but these charges will prevent people having access to that.

As the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) said, if the Government concede this point, it will be seen as a strength. It will do a great deal to restore public confidence in where the NHS is going and in the Government's attitudes. It will do a great deal to boost the morale of the professions. There will be loud applause all round if the Government concede this point. The Government should forget the penny pinching and concede that there are valid, widely accepted arguments against these charges.

Mr. Moore

Amendment No. 38 is a direct response to the activities of the Opposition Front Bench, and I acknowledge the activities of all members of the Committee. In Committee the Opposition tabled an amendment with the same purpose as amendment No. 38, to exempt all 16 and 17-year-olds from all dental charges. For technical reasons we could not accept the Opposition's amendment as drafted, although we undertook to consider it and come forward with an amendment. I am happy to fulfil that undertaking. Amendment No. 38 is effectively identical to the Opposition's amendment except for the technical redrafting. I know that the Opposition would wish me to acknowledge that.

The hon. Member for Southport (Mr. Fearn) has tabled amendments which are linked. Amendment No. 63 relates to Scotland as opposed to England and Wales. Under the regulations governing the general dental services a dentist has the right not to proceed with or complete a course of treatment where the patient is liable to pay a charge or the full charge has not been paid. Most of us would consider that fair and reasonable. After all, dentists are professional people who must balance their books and run their businessess like anyone else. If they provide a service and have reason to believe that payment may not be forthcoming, they have a right to discontinue the provision of that service.

In practice, dentists often rely on good will and do not insist on full payment in advance or they take an initial part payment and collect the balance on completion. The amendments would force them in some cases where dentures or other appliances are involved to carry through the course of treatment to the end, even when they have every reason to believe that they will not receive the proportion of the fee which is payable by the patient. The dentist can only either write off the loans or go to the trouble or expense of recovery through the courts. The NHS cannot make up the loss in these circumstances.

Amendments Nos. 62 and 63 would create considerable difficulties for dentists and cause unnecessary friction between them and their patients. I do not believe that the amendments would serve a useful purpose. If a patient needs dentures and they have been prescribed, all he has to do to receive them is to pay the appropriate charge if he is not exempt or entitled to help on low-income grounds. I hope that the hon. Member for Southport will not press the amendments.

I should like to respond specifically to the fair point made by the hon. Member for Linlithgow (Mr. Dalyell). The White Paper on primary health care was endorsed by the chief medical officer. I draw the hon. Gentleman's attention to the specific dental charges sections, 2.11, 2.12, 2.13 and 2.14, on promoting health.

Mr. Dalyell

Is it a fact that the Government's proposals have the full and unambiguous approval of the chief medical officer and his advisers?

Mr. Moore

I apologise again for my inability to make a loud noise. The White Paper on primary health care, which unambiguously endorses these points, was endorsed by the chief medical officer.

I shall do what my hon. Friend the Member for Portsmouth, North (Mr. Griffiths) did, and very well, when he sought to put the debate in context. The debate's context is how we try to allocate priorities for more spending on the family practitioner services. We should start with that point because it is an important feature which surrounds the nature of this proposal, the controversiality of which I do not for one moment doubt, having sat throughout this debate on Report, let alone the debate during the past few months.

The family practitioner services have already had an increase in real terms expenditure of about 43 per cent., or £1.5 billion, in the past nine years. I do not think that anyone would disagree with that; it is endorsed by both sides of the House. That amount compares with public expenditure increases in a similar period of 14 per cent. As my hon. Friend the Member for Portsmouth, North rightly pointed out, last autumn my right hon. Friend the Chief Secretary announced, in the public expenditure proposals, substantial increases in real terms for the period up to 1991. It is within the context of these family practitioner services that we must consider the general dental service. That service has had its gross expenditure increased by 37 per cent. in real terms, with the Government's gross expenditure increasing in the same period by 20 per cent. in real terms. The Government committed £521 million last year.

I have referred to the White Paper on primary health care, "Promoting Better Health", which my right hon. Friend the Minister for Health introduced on 25 November 1987. I read with great interest all the Standing Committee Hansards, especially the comments of the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) in support, in a bipartisan way, of many of the aspects of the White Paper. The House will be aware of the Government's ambition, which is shared by many hon. Members on both sides of the House, above and beyond the public expenditure programmes, to spend more on family practitioner services.

The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) asked us, rightly, to address the question of the extent to which those aims should be financed by maintaining or changing the present balance between public expenditure and charges within the general dental service and beyond the planned public expenditure. It is a legitimate point that any Government in looking at their priorities should consider on top of the already planned proposals for increases. It is crucial, in that context, therefore, to understand what has been happening in dental health and why; then we can understand why the Government believe that their proposals are fully justified.

The view is almost universally held that dental health has been undergoing major improvements. Valid points have been made about variations in Scotland and elsewhere but the pattern for the United Kingdom as a whole has been one of steady improvement over the past few decades—under Governments of all political parties. Let me give one or two examples which are germane to my argument. In 1973, 29 per cent. of five-year-old children were free of dental decay. By 1983—a decade later—the figure was 52 per cent., showing an amazing and very welcome improvement. Let us take a different date for adults. In 1968, 37 per cent. of adults had no natural teeth. By 1985, that figure had gone down to 22 per cent. Both those examples show a clear pattern of improvement, although I accpt that there are considerable regional variations, which I shall go into in a moment.

Let us also consider the courses of treatment given. The number of courses of treatment, for all ages, has risen by 19 per cent. since 1979. However, what is particularly important is that courses of treatment given to those over the age of 65 have risen by 92 per cent. Another critical factor which has not been mentioned so far—

Mr. Robin Cook

Will the right hon. Gentleman give way?

Mr. Moore

Perhaps the hon. Gentleman would allow me to finish my point first. A further factor illustrating the change in the nature of Britain's dental health is that since 1979 the number of dentists has risen by 20 per cent.

Mr. Cook

In his reply to my hon. Friend the Member for Linlithgow (Mr. Dalyell) the Secretary of State stressed that the proposals in the White Paper had been specifically approved by the chief medical officer. I wonder whether he could give us some guidance. Since he made that observation, my hon. Friend the Member for Peckham (Ms. Harman) and I have been trying to find the reference in the White Paper to charges for dental examinations. So far we have been unable to find any such reference. Can the Secretary of State guide us as to where we may find it?

Mr. Moore

With pleasure. The hon. Gentleman will find the precise reference on page 9, at paragraph 2.13. Let me deal with the changing pattern—

Mr. Barry Jones (Alyn and Deeside)

I have sat through the debate, although I have not attempted to take part. Further to the question asked by my hon. Friend the Member for Linlithgow (Mr. Dalyell) and perhaps also to the recent intervention by my hon. Friend the Member for Livingston (Mr. Cook), could the Secretary of State say where in chapter 4 of the document "Promoting Better Health" that reference is to the chief medical officer having given his full support to charging?

Mr. Moore

I do not think that it is normal practice to include such a reference. The hon. Member for Linlithgow, whose memories go back to the days of the late Richard Crossman, will no doubt know whether that practice has been followed in every White Paper produced by every Government Department. I have specifically answered the question asked by the hon. Member for Linlithgow. We do not include such information when we write White Papers. [Interruption.] As I said, the chief medical officer endorsed it; I could not have been more specific.

Let us consider changes in treatments. That is an important subject especially in relation to a factual error earlier in the debate, which I must correct. The number of extractions has fallen by about 13 per cent. over the past decade and the number of fillings by 21 per cent. Both those developments reflect the pattern of improvement in dental health. Meanwhile, the number of crowns fitted has risen by 83 per cent. and the number of bridges fitted by 535 per cent. That is a clear indication of the changing pattern.

What are the reasons for the improvement? Clearly, it would be quite improper if those of us who visit dentists did not compliment them on their activities first. But another point that emerged repeatedly in Committee was that half the nation does not visit the dentist regularly—a point referred to by my hon. Friend the Member for Ryedale (Mr. Greenway). As hon. Members know, many other critical factors are involved in improved dental health. The first is better diet, although the hon. Member for East Lothian (Mr. Home Robertson) referred to Scotland's particular problems in that regard. The reduction in the amount of sugar consumed has been a key factor in the improvement of dental health.

Mr. Cormack

I appreciate the way in which my right hon. Friend is seeking to reply to the debate and I sympathise with him. Would he not agree that inspections may also have played a significant part?

Mr. Moore

I shall be coming to that very point in a few moments, and I appreciate my hon. Friend's genuine sympathy.

I have referred to better diet and reduced sugar consumption. Better information is also a critical feature. There is now better information on dental hygiene, on methods of brushing one's teeth and looking after them, and the information given to children is especially important. A crucial factor that has not been mentioned so far is fluoride. I am talking not just about fluoridation but about fluoride in toothpaste. About 90 per cent. of all toothpaste purchased today contains fluoride and most of us are exposed to fluoride in that way. We have a nation of better-informed people taking better care of themselves.

It is very important that hon. Members on both sides of the House should understand that all these improvements have been happening at a time when the percentage of the general dental service paid for by charges has been increasing. The Opposition have disagreed with that pattern over the past few years. The reality is that in 1978–79 20 per cent. of the overall revenue for the general dental services came from charges. By 1986–87 that figure was 30 per cent. That represents a substantial increase in the proportion paid for by charges rather than by the taxpayer. Nevertheless, throughout that period there has been a significant improvement in dental health.

Let me again put the proposals in context. This year, the proposals, including examination charges as well as the proportional charge increases, would take the percentage of care paid for by charges from 30 per cent. to 32 per cent., thus reducing the taxpayer supplement to the general dental service from 70 per cent. to 68 per cent. This is the basis on which we should view the increased public expenditure proposals for primary health care and the increased proportion that the Government propose should come from charges for the general dental service.

Two key questions have emerged from this afternoon's debate in addition to my remarks about improvements in dental health. The first, which my hon. Friend the Member for Tiverton (Mr. Maxwell-Hyslop) has consistently asked, is "Do we have evidence to suggest that charges will deter?" The second concerns the extent to which we are helping those who cannot afford the present pattern or a changed pattern of charges. But the critical question is that relating to deterrence. I start by reminding hon. Members who have not had the opportunity to read what I found to be an extremely good set of Committee Hansards of what my right hon. Friend the Minister for Health said : Unless the deterrent argument can be made to run much faster and further than I believe it can, most of the arguments about the effects on the detection of other forms of ill health fall, because they depend on the proposition that large numbers of people will cease to come forward for examination or treatment."—[Official Report, Standing Committee A, 9 February 1988, c. 620.] Let me examine some of the questions about the deterrent effect of charges. They are valid questions because they reflect the worries surrounding this debate. First, I should remind the House that in 1968—I agreed that I would not say who did what when increasing charges for dental services—came the first increase in routine dental treatment charges since charges for dentures were introduced in 1951. Since 1968 a pattern of increases has been established, and sometimes those increases have been major. Against that background, we can study the pattern of courses of treatment. In answer to my hon. Friend the Member for Harlow (Mr. Hayes) and others, there has been no year since 1968 in which the number of courses of dental treatment has not increased, and I shall deal with both the short-term and the long-term impacts in a moment.

The hon. Member for Livingston (Mr. Cook) made one or two remarks about changes in the number of fillings. I appreciate that it is sometimes difficult to get the exact facts, but let me tell him those facts of which I am informed. The hon. Gentleman is right to say that after the increase in charges in 1985 the number of fillings fell, though by 6 million and not by 5 million. As a result of improved dental care, however, the figure has been declining for many years. The number of extractions did not rise. The number of extractions has been declining steadily since 1979—a total decline of 13 per cent. from just over 4 million to under 3½ million. Moreover, treatment for gum disease rose by 5 per cent. in the year following the 1985 increases in charges.

The hon. Member for Livingston is right to say that short-term changes occur in the pattern of demand from time to time.

Several Hon. Members


Mr. Moore

Let me finish this point and perhaps obviate the need for hon. Members to ask questions and further delay the debate.

Despite some sedentary interruptions, I have tried not to refer to the massive increases in charges of 35 per cent. in 1976 and 27 per cent. in 1977, but even following those increases there was still an increase in take-up of courses of treatment. The pattern of overall increase with occasional short-term interruptions has meant a steady average increase of 2.7 per cent. per year. That is clear from the data that my right hon. Friend the Minister for Health and I have available, and nothing that was said in Committee sustains any argument to the contrary.

Ms. Harriet Harman (Peckham)

The Minister has talked about the deterrent effect of charging for treatment, but charges for examination are being introduced for the first time. Secondly, does he agree with the British Dental Association and all other independent experts that an increase in charges is followed by a slowing down in the increase in courses of treatment and the graph never actually catches up to the position that would have been achieved if the rate of increase had not been checked by the steep increase in charges?

Mr. Moore

As I have said, I do not believe that that case is sustained either by the arguments put in Committee or by the data that I have studied.

Mr. Hayes

My right hon. Friend is absolutely right about treatment volumes, but every time charges have risen—in 1971–72, 1972–73, 1977–78, 1978–79, 1984–85 and 1985–86—although treatment volumes have continued to rise, the treatment per course has gone down. That is a British Dental Association statistic. My right hon. Friend will correct me if I am wrong, but I believe that my right hon. Friend the Minister for Health accepted that. The argument is about the rate of recovery.

Mr. Moore

Like my right hon. Friend the Minister for Health, I have studied all the data carefully. Although the long-term trend line shows short-term fallbacks, and it would be wrong to ignore market reaction, there are also years in which the increase is greater than the overall trend. producing a sustained increase of about 2.7 per cent. per year. Those who do not accept that argument seem to ignore the fact that that has occurred despite massive increases in charges in some years—as high as 35 per cent. under the Labour Government.

Mr. Galbraith

Will the Minister give way?

Mr. Moore

I should like to continue as we are getting short of time.

With regard to the second point made by the hon. Member for Peckham (Ms. Harman), all our experience relates to free examinations and in many ways confirms the weakness of the argument that a modest charge will be a deterrent. Although examinations have been free of charge, only half the nation avails itself of the service. As was properly pointed out in Committee, the variations occur by region and social class and have far more to do with factors other than the theoretical possibility of a charge. As my hon. Friend the Member for Ryedale said, the Tidman and Brown study is extremely relevant in this regard.

I was fascinated to read the 19 March editorial of the British Dental Journal, which cited a study entitled, "Barriers to the Receipt of Dental Care". The key point, which is not unfamiliar to most of us as lay people, is fear. The editorial preferred to use the word "anxiety", but it referred to a whole series of factors, beginning as follows: A generalised dislike of going to the dentist … Fear of pain. Fear focused on an aspect of treatment. 'Guilt' embarrassment … The possibility of receiving poor or unnecessary treatment. Only then does it mention the potential cost. I do not suggest for a moment that cost was not a factor, but for most people it was not the major factor.

Members who did not have the privilege of being on the Standing Committee may not realise that a 75 per cent. charge for examinations on a proportional basis will mean that for some of the more modest treatments the charge with the examination will remain the same or even be lower than at present. I accept that the numbers are modest, but they are still significant for those who avail themselves of regular dental care.

The hon. Member for Strathkelvin and Bearsden did not wish me to mention this, but I cannot resist pointing out the actual sum involved. It is a very modest amount for those who are not exempt. I do not deny that £3 has value and is difficult for some people to find, but that sum once or twice a year must be compared, as my hon. Friend the Member for Pembroke (Mr. Bennett) pointed out, with expenditure by the average family of more than £8 per week on alcohol, £4.55 on tobacco, more than £2 per week on toiletries and about £20 per year on toothpaste. Moreover, a large number of people will still be exempt from any charges at all. All the current exemptions will be maintained—for all children under 16, for young people aged 16 and 17, for students under 19, for expectant or nursing mothers and for people on low incomes, not just those on income support and family credit but those just above that level due to the special low-income scheme covering an additional £200,000 on application.

With 38 per cent. of the population exempt, I do riot believe that a shift in charges increasing patient contributions to general dental services this year from 30 per cent. to 32 per cent. will deter people from seeking treatment.

Dr. Moonie

Will the Minister give way?

Mr. Moore

No, I am trying to conclude my remarks.

We shall continue to protect those who cannot afford the very modest examination charge and we shall release additional resources beyond the increases in public expenditure already agreed. That increase will be spent in primary health care. My hon. Friend the Member for Portsmouth, North was particularly concerned about this. The increase will be used especially in dental health to encourage prevention, to increase resources for fluoridation, to improve vocational and postgraduate training for dentists and on a new programme to promote dental awareness, especially among the young. However difficult decisions about priorities may sometimes be for Parliament, I hope that on the basis of what I have said the House will accept the justification for the Government's very solid proposals.

6.30 pm
Mr. Robin Cook

With the leave of the House, Mr. Deputy Speaker, I should like to respond to the debate. I shall do so briefly, because I appreciate that there comes a time when the House wishes to come to a decision and it can be exceedingly brusque to those who stand in the way at that moment.

We have had an interesting debate. To those sitting on the Opposition Benches it has been revealing to observe the extent to which the Government's Back Benchers are prepared to come out openly in support of this measure. In the course of the debate, eight Conservative Members have spoken. Of those eight, five came out flatly against the proposal for charges on dental examinations. I am rather pained that so many of them had to express such reluctance at joining me in the Division Lobby. but I appreciate, and commend them on, their courage in overcoming that natural distaste.

Of the remaining three Conservative Members, one, if I may say so to the hon. Member for Ryedale (Mr. Greenway), made a speech of sustained agnosticism, at the end of which I found it difficult to know quite where he stood in relation to charges. But two out of eight—one in four—came down in favour of charges for dental examinations. The hon. Member for Pembroke (Mr. Bennett) had the candour and courage to say that he was, broadly speaking, in favour of charging for just about everything, including visits to general practitioners, and the hon. Member for Portsmouth, North (Mr. Griffiths) had the intellectual rigour and honesty to say that these charges will act as a deterrent—to a minority, yes, but nevertheless they will act as a deterrent to some people who will be put off from presenting themselves for a dental examination. Those were the friends of the proposal.

The Secretary of State, reasonably and understandably, sought in response to widen the debate to take in a discussion on the state of the nation's dental health. Of course it will be welcome in all quarters of the House that the nation's dental health is in an improved state. There are a number of different variables for that—diet, better standards of dental hygiene, community education in schools, and, most obviously of all, probably the single largest influence, the fluoridation of our water supply.

But the key question is not whether the nation's teeth are in a better state than before; the key question to which we must address ourselves in the debate is whether charges for dental examinations promote or detract from a further improvement in the state of dental health.

The Secretary of State grounded his argument against charges being a deterrent rather heavily on what happened in 1986. The figures that I have for 1986 are markedly different from the figures that the Secretary of State quoted. Mine come from the Dental Estimates Board. Its account for the year from April 1985 to April 1986 shows that the number of fillings did fall, from 33 million to 28 million—a drop of 5 million—and that the number of treatments for gum diseases fell from 2.4 million to 1.5 million—a reduction of well over a third. That was a reduction, but well ahead of trends. In each of the three years in the past 20 years in which there has been a substantial increase in dental charges, there has, in the following year, been a substantial drop in the graph of upward increases in treatment courses. That is what the Secretary of State referred to in his speech as a market reaction.

We can expect a market reaction to charges being brought in for dental examinations, and I for one do not believe that preventive medicine of this important character should be exposed to a market reaction. Yesterday we debated the Government's proposals for cervical cancer screening. Does anybody imagine that we would take seriously a Government who proposed a fee for screening for cervical cancer? Would the hon. Member for Pembroke be prepared to rise in his place to justify such a fee on the basis that he justified these charges—on the ground that it would encourage women to buy the services more? Of course not.

If any Government were benighted enough to propose a charge for cervical cancer smears, that Government would be laughed out of court by the Chamber because everybody, but everybody, would appreciate that such a charge would deter people from coming forward and would flatly contradict the idea of that screening being a preventive process. Precisely the same argument applies to charges for dental examinations.

If we are serious about making that a screening process to encourage the nation to have a healthy set of teeth, we must recognise that that service must be available free and we should not bring in any charges that will deter anybody, even if they are a minority.

On that basis, we wish to move to a vote. I accept the point raised by those who have taken part in the debate, that it would be more appropriate to divide on amendment No. 12 than on amendment No. 10. Therefore, with the leave of the House, I seek to withdraw amendment No. 10, and will move amendment No. 12 formally.

Amendment, by leave, withdrawn.

Amendment proposed: No. 12, in page 9, line 13, leave out subsection (7).—[Mr. Robin Cook.]

Question put, That the amendment be made:—

The House divided: Ayes 206, Noes 287.

Division No. 258] [6.35 pm
Abbott, Ms Diane Dunnachie, Jimmy
Adams, Allen (Paisley N) Dunwoody, Hon Mrs Gwyneth
Allen, Graham Dykes, Hugh
Archer, Rt Hon Peter Eadie, Alexander
Armstrong, Hilary Eastham, Ken
Ashley, Rt Hon Jack Ewing, Mrs Margaret (Moray)
Banks, Tony (Newham NW) Fatchett, Derek
Barnes, Mrs Rosie (Greenwich) Fearn, Ronald
Barron, Kevin Field, Frank (Birkenhead)
Battle, John Fields, Terry (L'pool B G'n)
Beckett, Margaret Fisher, Mark
Bell, Stuart Flannery, Martin
Benn, Rt Hon Tony Flynn, Paul
Bennett, A. F. (D'nt'n & R'dish) Foot, Rt Hon Michael
Bermingham, Gerald Foster, Derek
Bidwell, Sydney Fraser, John
Blair, Tony Fry, Peter
Boateng, Paul Fyfe, Maria
Boyes, Roland Galbraith, Sam
Bradley, Keith Galloway, George
Bray, Dr Jeremy Garrett, John (Norwich South)
Brown, Gordon (D'mline E) George, Bruce
Brown, Nicholas (Newcastle E) Gilbert, Rt Hon Dr John
Bruce, Malcolm (Gordon) Godman, Dr Norman A.
Buchan, Norman Graham, Thomas
Buckley, George J. Grant, Bernie (Tottenham)
Caborn, Richard Griffiths, Nigel (Edinburgh S)
Campbell-Savours, D. N. Griffiths, Win (Bridgend)
Canavan, Dennis Grocott, Bruce
Carttiss, Michael Hardy, Peter
Cartwright, John Harman, Ms Harriet
Clarke, Tom (Monklands W) Hawkins, Christopher
Clay, Bob Hayes, Jerry
Clelland, David Hayhoe, Rt Hon Sir Barney
Clwyd, Mrs Ann Haynes, Frank
Cohen, Harry Heffer, Eric S.

Cook, Robin (Livingston) Henderson, Doug
Coombs, Simon (Swindon) Hicks, Robert (Cornwall SE)
Corbett, Robin Hinchliffe, David
Corbyn, Jeremy Hogg, N. (C'nauld & Kilsyth)
Cormack, Patrick Home Robertson, John
Cox, Tom Hood, Jimmy
Cummings, John Howarth, George (Knowsley N)
Dalyell, Tam Howells, Geraint
Darling, Alistair Hoyle, Doug
Davies, Rt Hon Denzil (Llanelli) Hughes, John (Coventry NE)
Davies, Ron (Caerphilly) Hughes, Robert (Aberdeen N)
Davis, Terry (B'ham Hodge H'I) Illsley, Eric
Day, Stephen Janner, Greville
Dewar, Donald John, Brynmor
Dixon, Don Jones, Barry (Alyn & Deeside)
Dobson, Frank Jones, Ieuan (Ynys Môn)
Doran, Frank Jones, Martyn (Clwyd S W)
Duffy, A. E. P. Kennedy, Charles
Killedder, James Pendry, Tom
Kirkwood, Archy Pike, Peter L.
Knight, Dame Jill (Edgbaston) Powell, Ray (Ogmore)
Knox, David Prescott, John
Leadbitter, Ted Quin, Ms Joyce
Leighton, Ron Radice, Giles
Lewis, Terry Randall, Stuart
Litherland, Robert Redmond, Martin
Livingstone, Ken Rees, Rt Hon Merlyn
Livsey, Richard Reid, Dr John
Lloyd, Tony (Stretford) Richardson, Jo
Lofthouse, Geoffrey Roberts, Allan (Bootle)
Loyden, Eddie Robertson, George
McAllion, John Robinson, Geoffrey
McAvoy, Thomas Rogers, Allan
McFall, John Rooker, Jeff
McKay, Allen (Barnsley West) Ross, Ernie (Dundee W)
McKelvey, William Rowlands, Ted
McLeish, Henry Ruddock, Joan
McNamara, Kevin Sedgemore, Brian
McTaggart, Bob Sheerman, Barry
Madden, Max Sheldon, Rt Hon Robert
Madel, David Shore, Rt Hon Peter
Mahon, Mrs Alice Short, Clare
Marek, Dr John Sims, Roger
Marshall, David (Shettleston) Skinner, Dennis
Marshall, Jim (Leicester S) Smith, Andrew (Oxford E)
Martin, Michael J. (Springburn) Smith, C. (Isl'ton & F'bury)
Martlew, Eric Soley, Clive
Maxwell-Hyslop, Robin Spearing, Nigel
Meacher, Michael Steinberg, Gerry
Michie, Bill (Sheffield Heeley) Stott, Roger
Millan, Rt Hon Bruce Straw, Jack
Mitchell, Austin (G't Grimsby) Taylor, Matthew (Truro)
Molyneaux, Rt Hon James Turner, Dennis
Moonie, Dr Lewis Vaz, Keith
Morgan, Rhodri Wall, Pat
Morley, Elliott Walley, Joan
Morris, Rt Hon J. (Aberavon) Wardell, Gareth (Gower)
Mowlam, Marjorie Wareing, Robert N.
Mullin, Chris Welsh, Andrew (Angus E)
Murphy, Paul Williams, Rt Hon Alan
Oakes, Rt Hon Gordon Williams, Alan W. (Carm'then)
O'Brien, William Winnick, David
O'Neill, Martin Winterton, Mrs Ann
Orme, Rt Hon Stanley Worthington, Tony
Owen, Rt Hon Dr David Young, David (Bolton SE)
Parry, Robert
Patchett, Terry Tellers for the Ayes:
Pattie, Rt Hon Sir Geoffrey Mrs. Llin Golding and
Peacock, Mrs Elizabeth Mr. Frank Cook.
Adley, Robert Bowis. John
Aitken, Jonathan Boyson, Rt Hon Dr Sir Rhodes
Alison, Rt Hon Michael Braine, Rt Hon Sir Bernard
Allason, Rupert Brandon-Bravo, Martin
Amery, Rt Hon Julian Brazier, Julian
Amos, Alan Bright, Graham
Arbuthnot, James Brittan, Rt Hon Leon
Arnold, Jacques (Gravesham) Brooke, Rt Hon Peter
Arnold, Tom (Hazel Grove) Brown, Michael (Brigg & Cl't's)
Ashby, David Bruce, Ian (Dorset South)
Aspinwall, Jack Buck, Sir Antony
Atkinson, David Burns, Simon
Baker, Nicholas (Dorset N) Burt, Alistair
Baldry, Tony Butcher, John
Banks, Robert (Harrogate) Butler, Chris
Batiste, Spencer Carlisle, John, (Luton N)
Bellingham, Henry Carlisle, Kenneth (Lincoln)
Bennett, Nicholas (Pembroke) Carrington, Matthew
Biggs-Davison, Sir John Cash, William
Blackburn, Dr John G. Chalker, Rt Hon Mrs Lynda
Blaker, Rt Hon Sir Peter Channon, Rt Hon Paul
Body, Sir Richard Chope, Christopher
Bonsor, Sir Nicholas Clark, Dr Michael (Rochford)
Boswell, Tim Clark, Sir W. (Croydon S)
Bottomley, Peter Clarke, Rt Hon K. (Rushcliffe)
Bowden, A (Brighton K'pto'n) Colvin, Michael
Bowden, Gerald (Dulwich) Conway, Derek
Coombs, Anthony (Wyre F'rest) Key, Robert
Cope, John King, Roger (B'ham N'thfield)
Couchman, James King, Rt Hon Tom (Bridgwater)
Cran, James Kirkhope, Timothy
Currie, Mrs Edwina Knapman, Roger
Curry, David Knight, Greg (Derby North)
Davies, Q. (Stamp'd & Spald'g) Knowles, Michael
Davis, David (Boothferry) Lamont, Rt Hon Norman
Dickens, Geoffrey Lang, Ian
Dorrell, Stephen Latham, Michael
Douglas-Hamilton, Lord James Lawrence, Ivan
Dover, Den Lee, John (Pendle)
Dunn, Bob Lightbown, David
Durant, Tony Lilley, Peter
Eggar, Tim Lloyd, Sir Ian (Havant)
Evans, David (Welwyn Hatf'd) Lloyd, Peter (Fareham)
Evennett, David Lord, Michael
Fallon, Michael Luce, Rt Hon Richard
Farr, Sir John Lyell, Sir Nicholas
Favell, Tony McCrindle, Robert
Fookes, Miss Janet Macfarlane, Sir Neil
Forman, Nigel MacGregor, Rt Hon John
Forsyth, Michael (Stirling) MacKay, Andrew (E Berkshire)
Forth, Eric Maclean, David
Fowler, Rt Hon Norman McLoughlin, Patrick
Fox, Sir Marcus McNair-Wilson, M. (Newbury)
Franks, Cecil McNair-Wilson, P. (New Forest)
Freeman, Roger Major, Rt Hon John
Gale, Roger Malins, Humfrey
Garel-Jones, Tristan Mans, Keith
Gill, Christopher Maples, John
Glyn, Dr Alan Marlow, Tony
Goodhart, Sir Philip Marshall, John(Hendon S)
Goodlad, Alastair Martin, David (Portsmouth S)
Goodson-Wickes, Dr Charles Mates, Michael
Gorman, Mrs Teresa Maude, Hon Francis
Gorst, John Mawhinney, Dr Brian
Gow, Ian Mayhew, Rt Hon Sir Patrick
Gower, Sir Raymond Mellor, David
Grant, Sir Anthony (CambsSW) Miller, Hal
Greenway, John (Ryedale) Mitchell, Andrew (Gedling)
Griffiths, Sir Eldon (Bury St E') Mitchell, David (Hants NW)
Griffiths, Peter (Portsmouth N) Moate, Roger
Grist, Ian Monro, Sir Hector
Ground, Patrick Moore, Rt Hon John
Grylls, Michael Morris, M (N'hampton S)
Gummer, Rt Hon John Selwyn Morrison, Hon Sir Charles
Hamilton, Hon Archie (Epsom) Morrison, Hon P (Chester)
Hampson, Dr Keith Moss, Malcolm
Hanley, Jeremy Moynihan, Hon Colin
Hargreaves, A. (B'ham H'll Gr') Neale, Gerrard
Hargreaves, Ken (Hyndburn) Needham, Richard
Harris, David Nelson, Anthony
Hayward, Robert Neubert, Michael
Heathcoat-Amory, David Newton, Rt Hon Tony
Heddle, John Nicholls, Patrick
Heseltine, Rt Hon Michael Nicholson, David (Taunton)
Higgins, Rt Hon Terence L. Nicholson, Emma (Devon West)
Hind, Kenneth Onslow, Rt Hon Cranley
Hogg, Hon Douglas (Gr'th'm) Oppenheim, Phillip
Hordern, Sir Peter Page, Richard
Howard, Michael Paice, James
Howarth, Alan (Strat'd-on-A) Parkinson, Rt Hon Cecil
Howarth, G. (Cannock & B'wd) Patnick, Irvine
Howe, Rt Hon Sir Geoffrey Patten, Chris (Bath)
Howell, Ralph (North Norfolk) Patten, John (Oxford W)
Hughes, Robert G. (Harrow W) Pawsey, James
Hunt, David (Wirral W) Porter, David (Waveney)
Hunt, John (Ravensbourne) Portillo, Michael
Hurd, Rt Hon Douglas Price, Sir David
Irvine, Michael Raffan, Keith
Irving, Charles Raison, Rt Hon Timothy
Jack, Michael Rathbone, Tim
Jackson, Robert Redwood, John
Janman, Tim Renton, Tim
Jessel, Toby Rhodes James, Robert
Johnson Smith, Sir Geoffrey Riddick, Graham
Jones, Gwilym (Cardiff N) Rifkind, Rt Hon Malcolm
Jones, Robert B (Herts W) Roberts, Wyn (Conwy)
Kellett-Bowman, Dame Elaine Roe, Mrs Marion
Rossi, Sir Hugh Thompson, Patrick (Norwich N)
Rost, Peter Thornton, Malcolm
Rowe, Andrew Thurnham, Peter
Rumbold, Mrs Angela Townsend, Cyril D. (B'heath)
Ryder, Richard Tracey, Richard
Sackville, Hon Tom Tredinnick, David
Sainsbury, Hon Tim Trippier, David
Sayeed, Jonathan Trotter, Neville
Scott, Nicholas Twinn, Dr Ian
Shaw, David (Dover) Vaughan, Sir Gerard
Shaw, Sir Giles (Pudsey) Viggers, Peter
Shaw, Sir Michael (Scarb') Waddington, Rt Hon David
Shephard, Mrs G. (Norfolk SW) Wakeham, Rt Hon John
Shepherd, Richard (Aldridge) Waldegrave, Hon William
Skeet, Sir Trevor Walden, George
Smith, Sir Dudley (Warwick) Walker, Bill (T'side North)
Smith, Tim (Beaconsfield) Walters, Dennis
Soames, Hon Nicholas Ward, John
Spicer, Michael (S Worcs) Wardle, Charles (Bexhill)
Squire, Robin Warren, Kenneth
Stanbrook, Ivor Wells, Bowen
Stanley, Rt Hon John Wheeler, John
Stern, Michael Whitney, Ray
Stevens, Lewis Widdecombe, Ann
Stewart, Allan (Eastwood) Wiggin, Jerry
Stewart, Ian (Hertfordshire N) Wilshire, David
Stokes, John Winterton, Mrs Ann
Sumberg, David Wolfson, Mark
Summerson, Hugo Wood, Timothy
Tapsell, Sir Peter Woodcock, Mike
Taylor, Ian (Esher) Yeo, Tim
Taylor, John M (Solihull) Young, Sir George (Acton)
Taylor, Teddy (S'end E) Younger, Rt Hon George
Tebbit, Rt Hon Norman
Temple-Morris, Peter Tellers for the Noes:
Thatcher, Rt Hon Margaret Mr. Robert Boscawen and
Thompson, D. (Calder Valley)

Question accordingly negatived.

Amendment made: No. 38, in page 9, line 16, at end insert— '(8) In paragraph 2(4)(a) of Schedule 12 to the National Health Service Act 1977 and paragraph 2(4)(a) of Schedule 11 to the National Health Service (Scotland) Act 1978 for "16" there shall be substituted "18"'.—[Mr. Moore.]

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