Dental Services (Hansard, 15 March 1991)

§ Mr. Teddy Taylor (Southend, East)

I am grateful to my hon. Friend the Minister for Health for coming to the House for this brief debate on dental services. I am well aware that the Department of Health is one of the most demanding Departments, and its workload is even greater at present because of the reforms that are taking place in hospital services

Going to the dentist these days, Madam Deputy Speaker, which I hope you have not experienced recently, seems to be so expensive that many people must think that the fees that we pay cover all dental costs and that the taxpayer's contribution must be limited. The maximum charge for a course is now £200, and that must appear to be substantial in relation to the costs of the service. However, the truth is about a mile away.

In 1989, payments made to dentists in England were recorded in table 5.1 of the practitioner committee service publication as being about £927 million, of which the patient paid £361 million, and public funds contributed £565 million. The reason for that huge gap is simply that 41 per cent. of the population are wholly exempt from charges, and the remaining 59 per cent. pay three quarters of fees paid to dentists for care and treatment. To those who would understandably complain about the level of dental charges we must point out that the money they pay covers a lot less than half of that excellent service.

In other aspects of social services we are always conscious of the poor take-up of benefits, but, on the basis of simple statistics and of my own observations of dental clinics, dental staff go out of their way to ensure that those entitled to exemption actually receive it. A considerable part of dental work relates to the provision of synthetic dentures. Since being appointed adviser to the Association of Denture Prosthesis—that interest is recorded in the Register of Members' Interests—I have acquired a multitude of facts, figures and arguments to support a view that I have held for a long time, which is that the patients, the service and the taxpayer could benefit if the public were able to go directly to fully trained and qualified denturists for the fitting and manufacture of dentures. As a patient, I have always felt that there is something rather strange in a dentist examining the mouth, taking impressions, and trying and adjusting models constructed by dental technicians, when the technicians are often working in a laboratory far removed from the surgery, knowing little or nothing about the patient for whom the dentures are intended. A more meaningful relationship could be established between the patient and the technician if there were direct contact and if the technician could be readily available to patients for any adjustments or special needs. There could be considerable savings to the patient and the taxpayer if the work were undertaken directly and if there were at least an element of competition in service and costs.

After making contact with the association, I was heartened to find that this view was not just an unusual idea, but that a host of nations, aware of high medical and dental standards, had taken steps in law to ensure that dentures could be supplied to patients without the involvement of a dentist. Holland, New Zealand, Spain, 1402 Portugal, Canada, Finland and Australia have that practice and a host of states in the United States have taken similar steps. It appears to work well and effectively in the patients' interests. My first request to the Minister is that she makes inquiries in those countries to find out whether the arrangement is working well.

My next request is that the Minister makes specific inquiries to establish whether it is true that considerable savings can accrue to the public purse by adopting direct access to dental technicians. There is considerable evidence available from the United Kingdom, because I understand that, sadly, a considerable amount of direct work is being done, although it would appear to be conducted illegally. I have no idea of the savings that could accrue, but, according to careful estimates by the association, on the assumption that 60 per cent. of national health service dentures are supplied direct, the savings to the state could be more than £11 million. That is a great deal of money which could be used in other areas of medical or dental work. The figures are based on fittings supplied to dentists in the 1988–89 financial year.

Would such a change in practice shock the public? Strange to say, it appears that the public is way ahead of us. A MORI poll taken in November last year showed that no fewer than 60 per cent. of denture wearers would prefer to obtain them direct from a denturist. There appears to be support in, of all places, the so-called European Parliament. I would not wish to place any undue emphasis on that, but, as its public health committee has unanimously recommended that denturists should be introduced in every member state, the Minister might just wake up some morning to find that Jacques Delors has been to work and that a reform has been imposed on Britain by majority vote. Therefore, it would be wise to get down to work now, so that this can be properly planned and considered.

Would it cost a fortune to pay for the training and education of denturists? I doubt whether there is a real problem, because the training would be on a fee-paying basis. Again the Minister may inquire.

Would we be creating an entirely new principle in medicine? I cannot see how that would be the case. For the fitting of artificial limbs, eyes and hearing aids, there is no question of the profession having a monopoly. The one obvious worry that the public may have is whether when, having dentures fitted, there may be a medical problem. Might a qualified denturist not see or identify serious medical problems that a fully trained dentist could identify? The issue worries me, but countries that have studied this carefully do not appear to come to that conclusion. The general view appears to be that if a denturist is trained to identify conditions of the mouth, his professional duty will be to refer the patient to another professional for a proper diagnosis. Again, I hope that the Minister will consider that matter. What has happened in other countries? Have serious problems arisen? Or can the problem be overcome with proper training on the identification of mouth and gum problems?

The time has come for proper and serious inquiries to be made. We are not talking about a minor problem, affecting a small minority. Believe it or not, Madam Deputy Speaker, more than 1 million synthetic dentures are supplied yearly to our population of more than 50 million. If we could provide savings for patients and for the public purse, and ensure a more direct relationship 1403 between the patient and the person supplying and manufacturing dentures, we could initiate real and meaningful inquiries about future legislative reform.

I thank the Minister for coming here on a Friday afternoon after she has had such a busy week. I hope that she can give me some assurances.

§ The Minister for Health (Mrs. Virginia Bottomley)

I congratulate my hon. Friend the Member for Southend, East (Mr. Taylor) on raising this subject on behalf of denturists who, through the Association of Denture Prosthesis, have for some time been seeking a change in legislation to enable them to provide dentures directly to the public.

My hon. Friend said that the denturists' campaign has been such that in a few countries legislation has been amended to allow individuals with limited, but clearly defined, clinical training to undertake certain types of prosthetic treatment. The scope of the treatment that they can provide varies widely from one country to another.

It is perhaps more relevant, although perhaps somewhat invidious of my hon. Friend, to compare the United Kingdom position with that of other countries in the European Community. My hon. Friend will know that the Department has already sought to obtain information about practices in other member states. I am happy to reassure my hon. Friend that our inquiries about those countries in which denturists are permitted to practice will be extended to determine how those arrangements are working.

My hon. Friend raised a number of important points about which further information will help to inform our policy. We need to ask ourselves whether any relaxation in the Dentists Act 1984 to allow denturists to deal directly with patients would improve the quality of service to the public. Patients should quite rightly be able to expect to obtain dentures which are comfortable and functional. They should also be able to obtain dentures at reasonable cost under the NHS.

My hon. Friend referred to the increase to £200 of the maximum charge for dental treatment which I announced to the House earlier this week. He is quite right to say that some 41 per cent. of the population pay no charges at all. We estimate that very few people will be affected by the increase in the maximum charge. For those adults who pay charges, the average amount paid for a course of treatment in 1989–90 was £25. That is nowhere near the present maximum or the new maximum from 1 April. We estimate that under 1 per cent. of all courses of treatment will be affected by this change.

My hon. Friend, who rightly seeks savings for the health service where they are possible, argued that considerable savings could accrue to the public purse if denturists were allowed to provide dentures directly to patients, thus cutting out the dentist middleman.

My hon. Friend will be fully aware that the Association of Denture Prosthesis made a complaint to the Office of Fair Trading in 1985 on the ground that dentists were abusing their monopoly through high prices and profits from the supply of private dentures. Following his investigation of the complaint, the Director General of Fair Trading concluded that the NHS provided a 1404 competitive alternative to private treatment, and saw little justification for the introduction of denturism on economic grounds.

I should explain how fees to dentists are calculated. Fees paid to dentists for NHS treatment, including those for the provision and fitting of dentures where laboratory work is involved, are set by the dental rates study group. This is a non-departmental public body comprising representatives of the health departments and the dental profession under an independent chairman.

The laboratory components of these fees are based on an average cost calculated separately for each item using a representative sample of current trade catalogues. There are no arrangements to ensure that dental laboratories actually receive the calculated average amount. The relationship between dentists and the laboratories whose services they employ is one of free-market economics.

The fees that dentists receive include an allowance sufficient to ensure that they can use the services of reputable laboratories and so purchase services of the required quality. Clearly, where expenses are reimbursed on an average basis through the fee scale, all dentists have a powerful incentive to shop around laboratories for the best price while, of course, maintaining professional and quality standards. This incentive to search out value for money helps the Government to contain the costs of the general dental service. Dentists must decide for themselves which laboratories they use and the Government would certainly not wish to interfere in what is an entirely private transaction between dentists and dental laboratories, but dentists must not lose sight of the fact that under their terms of service with the NHS they are made personally responsible for ensuring products supplied by the laboratory and fitted in their patients' mouths are of a quality fit for the purpose for which they are used.

Dental service committees of family health services authorities may investigate complaints about alleged use of substandard materials in the same way as any other complaint that a dentist has not provided the proper standard of care.

Fees set for any particular item of treatment partly reflect the laboratory and material costs involved in that particular item of treatment, but also serve as a means of helping to deliver the target average net income, as recommended by the Doctors and Dentists Remuneration Review Body, and practice expenses due to the average dentist.

At a time when the number of dentures provided is declining—in 1988–89, for example, 461,950 complete dentures were provided in England and Wales, whereas only a year later only 369,370 were provided, and dentists' work load is shifting more towards preventive treatment and continuing care—it does not follow that a further reduction in denture work would necessarily lead to a proportionate reduction in their practice expenses or justify under the present arrangements a significant reduction in their net income target. Some of their standing costs might simply have to be redistributed to other fees.

It is in that context that the effect on dental remuneration as a whole of any reduction in denture work undertaken by dentists would need to be considered. It is not at all certain that the Doctors' and Dentists Remuneration Review Body would reduce the target average net income were dentists not to do this work. In those circumstances, as my hon. Friend will readily 1405 appreciate, there would be no reduction of costs; on the contrary, any payments to denturists for providing dentures would be an additional cost. Essentially the changes that my hon. Friend is advocating would have substantial implications for the way in which dental services would be financed.

I mentioned that patients have a right to expect that their dentures should be functional and comfortable, and my hon. Friend has suggested that an opinion poll last year indicated that many denture wearers would prefer to obtain them direct from a denturist. Until now there has been little quantifiable evidence to enable us to measure patient satisfaction. We saw, in 1987, a report from the National Consumer Council which showed that patients did not generally complain about the cost of dentures, but, rather, they were more likely to be dissatisfied over the quality and final fit. At the same time Age Concern, which my hon. Friend will know is particularly interested in problems of the elderly, was unequivocal that the responsibility for fitting dentures should remain with dentists and should not be passed to dental technicians.

In that same year, the then president of the General Dental Council conceded that the council continued to receive a steady flow of complaints from patients about unsatisfactory dentures". We have recently received the final draft of a study carried out by the dental practice board into the provision of complete dentures in the general dental services. Patient satisfaction was the major area of interest in the study and three different aspects were addressed. These were the level of satisfaction with the course of treatment, whether the new dentures met the patient's expectations and whether the dentures were being used and found satisfactory for the purposes for which they had been provided. The study suggests areas where improvements are necessary. In the meantime, the Department is already preparing a training package that is directed at improving the dentist-dental technician interface. We hope that that in turn will lead to an improved service for the patient. Clearly it is the relative contribution of the dentist and the technician that is of great importance in achieving a quality service for the patient.

A further important argument concerns the availability of the service. Dental auxiliaries are, in general, of great use where demand for dental treatment is high and manpower is insufficient to meet the needs. The General Dental Council may, by statutory instrument, make regulations for the establishment of classes of dental auxiliaries who may undertake dental work.

The number of dentists has been increasing substantially. In 1979, there were 13,993 dentists providing general dental services. However, that figure had risen substantially by 1990 to 18,011. Some have tried quite irresponsibly to argue that because of the new dental contract introduced on 1 October, dentists might withdraw from the NHS. I hope that my hon. Friend and others concerned about the matter will be aware that that is not the case. Soon after the new dental contract was introduced, the British Dental Association conducted a survey of dentists which showed that 96 per cent. were still treating child patients, 90 per cent. were still treating adult patients and 85 per cent. were also accepting new adult patients for continuing care. Altogether more than 12 1406 million patients have signed on under the new arrangements which, as my hon. Friend will be well aware, place the emphasis on prevention and continuing care instead of on the old drill-and-fill ethos.

I have mentioned the supply of dentists; we should also not lose sight of the possible demand for treatment— particularly dentures—in the future. My hon. Friend will be aware of the survey of adult dental health carried out in 1988 by the Office of Population Censuses and Surveys, the results of which were published on 12 February 1991. This clearly illustrates a continuing trend of improving dental health.

One of the most encouraging features of the report is the confirmation that more and more people can look forward to keeping their natural teeth. The 1988 survey showed that only 21 per cent. of the adult population was edentulous compared with 30 per cent. in 1978. It is confidently predicted that the number of complete denture wearers will continue to fall until by the year 2028 only 6 per cent. of the population will be wearing complete dentures. There is hope for us all! Those will be the more elderly of the population whose treatment is likely to require considerable skill and experience, perhaps requiring treatment by restorative consultants in hospitals.

Against that background we must consider very carefully before deciding that there should be any diminution of the work undertaken by dentists. I should add that the Department is undertaking a survey of dental manpower later this year and we shall have a clearer picture of future manpower needs when it is completed.

However, the Dentists Act 1984 specifically prohibits dental auxiliaries of any class from fitting, inserting or fixing dentures or artificial teeth for a good reason. It protects the public by restricting dental practice to those who are properly trained and qualified. The provision of dentures cannot be considered in isolation from the total oral and general health care of patients. The insertion of a denture significantly changes the oral environment and this may have harmful effects on any remaining teeth, the gums and oral mucous membranes or the whole of the masticatory apparatus.

In the Department of Health, we are convinced that a patient's oral health will be better served if, when dentures are required, that function is carried out by a person who is trained to prescribe and fit dentures; can recognise pathological conditions which may be caused or exacerbated by dentures; and can at the same time advise the patient—particularly where partial dentures are being fitted—of any other dental treatment which should be carried out.

I am sure that my hon. Friend is aware that about 2,000 new cases of oral cancer are reported each year, most in the 50 to 70 age group. It is vital that early diagnosis is made and any precancerous conditions recognised, and dental surgeons are uniquely placed and qualified to undertake that work. There are many other conditions in the mouth that are markers of systemic disease, such as diabetes, anaemias and malabsorption syndrome, as well as numerous mucosal conditions which require treatment before dentures are constructed—indeed it is estimated that approximately half of all persons with dentures show evidence of some form of oral pathological condition.

My hon. Friend will appreciate that while we welcome the contributions made by dental technicians, we believe 1407 that they should work with dental practitioners as part of a team to ensure that patients receive a quality service that protects their oral health and general well-being.

I thank my hon. Friend for this debate, which has provided me with the opportunity to give an overview of the way that we see dental technicians and denturists working in the provision of dentures, ensuring that we all have the services that we require. My hon. Friend has identified a number of areas that will benefit from Further 1408 examination. I have given an undertaking to secure further information. I appreciate his contribution in ensuring that, as we carry forward our policies of evaluating the way in which our dental surgeries are provided, the role and contribution of denturists is thoroughly and properly examined. We want the benefit of their contribution as well as that of other practitioners in this sector.