HC Deb 15 March 1994 vol 239 cc855-62

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

10.53 pm
Mr. Dafydd Wigley (Caernarfon)

This year, 1994, is supposed to be Worldwide Year of Oral Health. Wales appears to be celebrating the year with the imminent total collapse of the national health dental service. The NHS was conceived in Wales and we have a commitment to sustaining it. In Gwent, Aneurin Bevan's county, there are 154 registered dentists, only 22 of whom offer a full NHS dental service. In Dwyfor, the home of Lloyd George, that other founder of the welfare state, there are now no NHS dentists in the whole district.

The degree of the collapse was described graphically in last Sunday's edition of Wales on Sunday. I pay tribute to Michael Settle for his report entitled "Crisis in Dental Care", which shows that the total number of dentists in Wales is 857, 316 of whom are already refusing to take new NHS patients. The position is getting worse by the week. Those staying in the NHS find more people turning to them as other dentists go private. An NHS dentist has an average of 2,000 patients on his lists while those taking private patients average 1,200 on their registers. Pressure is therefore increasing on the remaining dentists to go private.

The Wales on Sunday analysis showed that, of the 64 dentists currently employed in Gwynedd, 59 are refusing NHS patients in various circumstances. Of those 64, 48 are accepting no new adult patients on the NHS. Of the 16 who are accepting new cases, most have long waiting lists—one as long as six months—and some will not accept emergency cases on the NHS. In the Dwyfor area, no dentists are accepting new adult registrations. In Arfon, only three are accepting new adult patients, with 13 not accepting them. There is virtually no emergency cover in Arfon and none at all in Dwyfor.

In Gwynedd, the Welsh Office has provided for four full-time equivalent salaried dentists, but only one has so far been put in place, working three days a week—one day in Caernarfon, one in Pwllheli and one in Holyhead. A second salaried dentist is about to start on a three-days-a-week basis, but, apparently, it is a temporary appointment that will last for about six months. Those salaried dentists have potentially more than 100,000 patients to cope with.

I referred to the position in Dwyfor, where the NI-IS dental service in its traditional form has now totally evaporated. May I read from a letter from a constituent, Mrs. Ellen Owen of Rhoshirwaun? It is in Welsh but I shall furnish a translation afterwards. She said: Rwyf yn ysgrifennu' r llythyr yma i chwi oherwydd, ers peth amser rwan, rwyf yn trio cael hyd i ddeintydd sydd yn cymeryd rhywun ar y National Health, ond rwyf yn cael fy ngwrthod gan bob un. Dim ond dau ddeintydd sydd ym Mhwlheli ac maent hwythau wedi mynd yn breifat. Mae'n gywilydd o beth rwy'n meddwl bod rhaid trafeilio mor bell a Bangor hyd yn oed i gael triniaeth. Mae hynny tua deugain milltir o Rhoshirwaun … Mae'n lawn ar bobl sydd a digon o fodd i dalu, ond i rhywun fel ti sydd dim Ilawer o fodd sydd gyda gwr yn gorfod gweithio ar gyflog bach ac yn magu dau o hogiau bach mae'n anodd iawn. That translates: I am writing this letter to you because, for a long time now, I have been trying to find a dentist who takes people on the National Health, but I am being refused by everyone. There are only two dentists in Pwllheli, and they have gone private. It's appalling that I may have to travel as far away as Bangor to receive treatment. That is about forty miles from Rhoshirwaun … It's fine for people who have sufficient means to pay but for somebody like myself, who hasn't much money, with a husband who has to work on a small wage and bringing up two little boys, it's extremely difficult. That message will strike home with honourable Members.

A letter from another constituent, Mr. Frank Bolton of Borth-y-Gest in Porthmadog, said: My concern is firstly for those people, and Porthmadog is not short of them, who have a cash flow problem and will not be able to meet the costs of dental treatment as they escalate, which they undoubtedly will. My concern is secondly that this privatisation of the Health Service has caused no comment except at 'grass roots' level, and not much there. This leaves one worried as to just how much of the system can be whittled away without comment or concerted action by those affected. There is also the unfairness whereby one has paid National Insurance for thirty or forty years on the understanding that the National Health Service would provide treatment in return. That message chimes home for many people.

Another constituent of mine wrote: My wife and I have recently been forced to take out a Denplan insurance in order to stay on our present dentist's list at Penrhyndeudraeth. Many of my constituents have drawn that experience to my attention.

Another constituent from Llanrug in the Afon area writes: I am writing on behalf of my two children that have been in terrible agony for over a week. They have tried all dentists locally and no one wants to know. That is the suffering that people are going through.

Mr. Elfyn Llwyd (Meirionnydd Nant Conwy)

May I congratulate my hon. Friend on obtaining time for the debate, which obviously reflects the current crisis in Gwynedd? I draw to his attention the astonishing fact that of the 12 dental practices in the borough of Aberconwy, only one is accepting new patients. That, if anything, must reflect the real crisis in the health service.

Mr. Wigley

Aberconwy in Gwynedd is another example and only last Saturday people in Llandudno drew that fact to my attention. My hon. Friend is absolutely right.

The problem is generally summed up by my constituent, Mr. Trevor Haines, who in lives in Llanystumdwy, Lloyd George's home village: I was very concerned when I learned from my dentist last autumn that he was withdrawing from the NHS. Since then every dentist I know in Dwyfor has withdrawn from the NHS. Many of the dentists are trying to persuade patients to insure for treatment with Denplan, a subsidiary of PPP, at a considerable cost for only partial cover. I have also found out that Denplan, and no doubt other medical insurers, have been actively encouraged by the Government to try and push people into taking out dental insurance. Many, if not all, are deprived of NHS dental treatment, and, since they cannot afford the private charges, a large number will be denied dental treatment. I am aware, like most others, of the duplicity of this Government, but I hardly expected them to destroy so quickly and blatantly an important part of the NHS. Those letters are unsolicited; they come from my constituents who are facing the problem at the sharp end.

The problems are happening outside my constituency, too, and the position is deteriorating rapidly in other parts of Wales such as Denbigh and Mold. In Pembroke, it is virtually impossible for adults to get on to dental registers. In 1990 there were 138 dentists providing NHS treatment for adults and children in Mid-Glamorgan. That figure is now down to 69. Since July 1992, no fewer than 65 dentists in Mid-Glamorgan stopped taking on adults as new cases on the NHS.

In South Glamorgan in the past 18 months, between 20 and 30 dentists have deregistered some of their NHS patients. Of the 138 dentists in south Glamorgan, only 36 are prepared to treat new NHS patients. The figures given to me by the South Glamorgan health officials are even worse than the indications of the Wales on Sunday report.

Along the Clwyd coastline there is an intriguingly difficult position. In towns such as Colwyn Bay, Abergele and Rhyl another phenomenon has developed—that of dental refugees. They are people from Gwynedd, who are unable to get treatment in their own county, travelling to Clwyd for treatment. They are in danger of overloading those dentists along the Clwyd coast who are still in the NHS.

The background to the problem is clearly of the Government's own making. In February 1992 the Government proposed to cut NHS fees for dentists by 13.8 per cent. —that figure was later adjusted to 7 per cent. As a direct result, the British Dental Association balloted its members, who voted not to take on new patients until the NHS dispute was totally resolved. We are now witnessing the effect of the working through of this phenomenon. During the past 12 months 500,000 people throughout the United Kingdom have been removed from registers by dentists.

The position is worse in counties such as Gwynedd, where the Welsh Office is unable to attract dentists to fill established posts, in addition to the failure to retain the remaining NHS dentists in the county. So there is a double factor exacerbating the problem in Gwynedd.

Over the years, Gwynedd has been below the authorised head count, so it is not a new problem, but it is one which the Welsh Office over the years has failed to rectify. The report on dental remuneration by Sir Kenneth Bloomfield in January 1993 is still awaiting a response from the Government. I find that amazing. The British Dental Association wrote on 9 February 1994: The present uncertainty about the Government's future intentions for dentistry is preventing dentists from making meaningful plans for their practices. Many have moved to the private sector to give themselves this much needed stability. In a recent survey of BDA members, we found that two in five dentists were not accepting new NHS patients and one in five were treating adult patients only on a private basis. That is the extent of the problem. I am told that, currently throughout Britain, as many as 25 dentists a month are going bankrupt because of the failure of the Government's funding of this important profession.

The general position of dental health in Wales is serious. The standard of teeth in Wales is not high. The study by the Office of Population Censuses and Surveys showed that, in Wales, only 68 per cent. of adults have sound and untreated teeth. That compares with 89 per cent. in the English midlands. In 1992, the condition of the teeth of five-year-old children in Wales was twice as bad as those in the west midlands or the south-west Thames areas. In Great Britain, only Scotland is worse. Forty-nine per cent. of five-year-olds in Wales have active decay in their teeth. In Mid-Glamorgan, the figure is as high as 60 per cent. That compares with only 25 per cent. in the south-west Thames area and only 20 per cent. in east Surrey.

There is a tremendous opportunity for oral health gain in Wales. The Welsh health planning forum set targets in 1992, including reducing the level of tooth decay in five-year-olds in Wales from 2.8 in 1990 to 2.0 in 2002, and to increase the proportion in the 35 to 44 age group in Wales with more than 21 natural teeth from 77 per cent. to 89 per cent. Those targets have no chance of being achieved on the basis of the current collapse in the NHS system.

This crisis is frustrating not only to patients, but to dentists. I received a letter from dentist in my constituency which says: In my opinion, the only way that the dental profession is going to attain sufficient funding to achieve a good, acceptable standard of dental care is directly from the patients. The Government has to solve the problem of properly funding the dental care of those who cannot afford it, not the dentists. Dentists are trained to fix people's mouths and not socio-economic problems. Having said that, it can be quite heartbreaking to see patients who could have a tooth saved but who decide to have it extracted for financial reasons. And this is happening more and more frequently. What can be done about the problem? First, I believe that we must ask what.has happened to the local incentive schemes for dentists, which began in Wales in 1990. They are supposed to help towards the cost of setting up and expanding dental practices in areas where there is a serious shortage of general dental practitioners. How many family health services associations in Wales are participating in the scheme? How much has been spent since 1990 and how many additional dentists have been set up? What are the targets for the scheme in Wales for 1994–95? Is it true that that scheme is on ice while the Government dither on how to act on the Bloomfield report?

Secondly, what happened to the promise made by the Welsh Office a year ago that we would have four salaried dentists in Gwynedd? Where are they? The Government cannot recruit, because they simply are not paying them enough. It is much more attractive for a young dentist to go to the private sector, where they can earn up to £60,000 treating private patients, rather than the £19,000 at which salaried posts in Gwynedd are being advertised.

Thirdly, I specifically call today for an immediate comprehensive response by the Government to the Bloomfield report and to the Select Committee recommendations; and for a commitment to substantial additional funding for NHS dental treatment fees. I ask in all seriousness for an immediate change in social security legislation to enable everyone on benefits, pensions, low wages, and for children to have full reimbursement of dental charges if they have to go for private treatment because no NHS dentists are available locally and quickly. That is the sort of self-correcting cash punishment that perhaps the Secretary of State for Wales would understand. If the Welsh Office failed to provide NHS treatment, it would have to pick up the bill for patients going privately, not the patients who cannot afford missing out on dental treatment. Can more dentists be trained and can we have an educational drive to that end? That would take years to work through, but it is needed. Can the salaried dentists' pay scale be increased to help the crisis areas and will the Government consider the ease with which a dentist can build up a practice on the NHS, then abandon ship and turn completely private, using the NHS list as a base?

Before the last election, the Government made much noise about the NHS being safe in their hands. Today, we see that promise for what it was: worthless, hollow words. The Government's complacency can be interpreted only as tacit approval of the privatisation by stealth that is taking place in the NHS sector. The NHS was born in Wales and we have no intention of allowing the Tory regime to kill it off.

In terms of dental services, the NHS is certainly not safe in Tory hands. The Government must stand up and be counted—and perhaps the Minister can start tonight with a suitable apology.

11.10 pm
The Parliamentary Under-Secretary of State for Wales (Mr. Gwilym Jones)

I assure the hon. Member for Caernarfon (Mr. Wigley) that the Government remain entirely committed to an effective and accessible NHS dental service. The facts speak for themselves. More NHS dentists are practising in Wales than ever before; more NHS patients are being treated than ever before; and more money is being spent on NHS dentistry than at any other time in our history.

The progress made is obvious to all who examine the figures. The number of general dental practitioners in Wales has risen from 592 in 1979 to 807 in 1993, an increase of more than 36 per cent.; during that time, the population rose by only 3 per cent. Patient registration levels, at more than 1.7 million, are the highest ever, with 67 per cent. of all children and 57 per cent. of all adults currently registered with an NHS dentist. No wonder the number of courses of treatment for adults has risen to nearly 1.4 million in 1993.

With more patients registered and more treatment provided than ever before, expenditure levels are also at an all-time high. In the last financial year, nearly £74 million was spent on NHS dentistry in Wales, in real terms an increase of 87 per cent. since 1978–79.

I was disappointed when the hon. Gentleman lapsed into the usual "knock the NHS" conclusion at the end of his speech. He came out with, in effect, the same gross insult to the excellent staff who are working for the NHS in Wales. They are our greatest asset. They continue to achieve record increases in the number of patients being treated in Wales—and, moreover, to achieve improvement in the quality of health care. The most recent survey conducted by. the National Association of Health Authorities and Trusts showed that 87 per cent. of the public were satisfied with the NHS in Wales.

We in Wales are, indeed, fortunate to enjoy a good and productive relationship with the dental profession. Its members talk to my officials and to me. I last met representatives of the British Dental Association and the General Dental Services Committee on 8 December. They know that my door is open if they wish to explore any matter of mutual concern.

I am pleased to maintain an open door, if only because I recognise the huge strides that have been made, particularly in recent years. The other day, I talked to a constituent who, as a boy in the valleys, had had his teeth ripped out with no thought of conservation or health promotion. Not surprisingly, he took great pleasure in the fact that his two children—who are in their late teens and have grown up under the present Administration—have but one filling between them. That story can be repeated many times, and is an eloquent testimony to standards that the Government are committed to retaining.

I recognise, however, that if those achievements are to he sustained and improved in the long term, there is an overriding need to tackle the roots of the current problems in the dental remuneration system. The hon. Gentleman may be aware of some of those problems, but it may be helpful if I explain the background. Dental remuneration is determined by the Government on the basis of the recommendation of the doctors' and dentists' review body. In 1991–92, the review body recommended that dentists should receive an average net income of some £32,000; in the event, they received an average of about £12,000 more than that.

A cut in fees of some 23 per cent. would have been necessary if the target pay for dentists were to be brought into line with the review body's recommendation for the following year. We decided, however, to introduce a cut of just 7 per cent., which should still have enabled dentists to receive, on average, about £4,000 more than the net income of nearly £36,000 recommended by their review body. Although their income remained higher, on average, than that recommended, dentists, inevitably and understand-ably, reacted badly to the fee adjustment, and some decided that they would no longer accept new NHS patients or provide emergency treatment for unregistered patients. Others decided to offer only private treatment to patients not exempt from NHS charges. As independent contractors, they are, of course, free to do this if they wish.

Clearly, the situation was far from satisfactory and needed to be addressed in the interests of all parties. A fundamental review of the dental remuneration system was requested by the pay review body in its 22nd report and that request was repeated by the profession in 1992. The Government met the professions's request for an independent review, and Sir Kenneth Bloomfield was asked to produce a report identifying options for change. The report was published and widely circulated last year. Consultation was drawn to a close five months later, at about the time the Select Committee on Health published the report of its inquiry into dental services.

Unfortunately, and despite out extensive consultations, there was no consensus about solutions. That had been noted by both Sir Kenneth and the Select Committee in their inquiries. Indeed, it is significant that the Committee noted in its report: there was … more consensus amongst witnesses concerning the problems than concerning solutions". Against that background, it was imperative that we should take time to consider all of the many options for change and all the views submitted on them. I am pleased to advise that we are now close to announcing our proposals. We shall, of course, be consulting closely and fully with the profession and others interested in the proposals. In the meantime, we are determined that the profession should be properly rewarded for its work in improving the oral health of the nation. Our commitment is underlined by our recent decisions to increase the level of fees paid to dentists—a 2.9 per cent. increase from 1 January and a further 3 per cent. from 1 April.

That does not sound to me like a service abandoned by the Government; rather, we see pay recommendations accepted and implemented in full and a willingness to inquire into the universally acknowledged problems in the present system, to consult and listen to the profession and to consider with the greatest care the many representations received. There is no hint here of lack of commitment.

The general dental service provides the vast majority of dental services, but we should acknowledge also the contribution made by other branches of the profession. The hospital services have an important role to play in dealing with the more complex and difficult cases. That sector, too, has seen growth in its activity, with a corresponding increase of 62 per cent. in the number of dental specialists employed since 1979. Wales now has more restorative dental consultants outside teaching hospitals and located in district hospitals than any other part of the United Kingdom.

However, the Government are not complacent—far from it. It would be misleading for me to imply that all in the garden is rosy. The hon. Gentleman has quite rightly highlighted the difficulties that are experienced in some areas of Wales in obtaining dental treatment in the location of choice. That has been caused largely by the less-than-ideal distribution of the services that are currently available.

We should recognise that dentists put their own money at risk when they open a new practice, and they may see that risk as greater when the population is sparse or where they feel that it would be difficult to establish a viable practice. But for every area where there is a problem, there are others where no difficulty is experienced in obtaining NHS treatment. Indeed, Gwynedd is the only area in Wales where the family health services authority has reported being unable to arrange NHS treatment for an inquirer. Even there, such treatment would have been available if the patient had been prepared to travel.

I am happy to report to the House that, as a direct result of the Secretary of State's permission to employ salaried dentists, the situation has improved. No one in Gwynedd should now be denied or totally refused NHS treatment, although I acknowledge that patients may have to travel. I recognise the need to address this problem. Patients should not have to travel long distances or wait for treatment.

The hon. Gentleman referred to the number of dentists who have closed their books. Those figures need to be interpreted with caution. Before 1990, dentists did not have lists as such. Following the new contract, all practising dentists would have open lists because their remuneration depended in part on the number of registered patients. It was equally inevitable that, in time, some lists would become full and would close. What matters is not the number of open lists but whether treatment is available. I can tell the hon. Gentleman that in Pwllheli the salaried dentist is offering two days' cover a week from Monday and that there is one whole-time equivalent community dentist available to provide emergency cover. In Dwyfor there are four dentists, all treating existing registered national health service patients but not accepting new NHS patients. In Pembroke the family health services authority and the profession's representative body advise that NHS dentists are available to new NHS patients.

Mr. Wigley

The Minister has stated that all four dentists in Dwyfor were accepting people currently on the NHS. That is not true. I have quoted letters from people who have been told that they have to move away from the NHS or go on to a private plan if they wish to remain with their dentist. If 300 of the 850 dentists in Wales have withdrawn from taking on new patients, does the Minister realise that most will continue not to accept them, whatever happens? How on earth will he get the NHS dental service back on the rails?

Mr. Jones

I am seeking to give the hon. Gentleman the latest information. The advice to me is that the four dentists in Dwyfor are treating existing registered NHS patients but not accepting new NHS patients. That is the latest information.

The Welsh Office is doing much to assist family health services authorities to attract dentists to the areas of greatest need. We have introduced the highly successful location incentive scheme. Under it, grants are available to dentists who wish to set up or expand their practice in areas where there is a shortfall of dentists. Seven schemes are funded in the current year.

In addition, the Welsh Office is funding various local initiatives throughout Wales that aim to improve the standards and level of services available. Those initiatives are usually targeted on areas of greatest need, and the hon. Gentleman will be pleased to know that 50 per cent. of the current funding is directed to the Gwynedd family health services authority to finance initiatives in that area. Further initiatives from Gwynedd and elsewhere are under consideration.

However, those initiatives and the location incentives that I have already mentioned are not always sufficient in themselves to secure comprehensive general dental services for an area. In those circumstances, the community dental services are providing a valuable safety net function to patients who would otherwise be unable to obtain treatment. We are committed to the continuation of this service, and the health authorities who manage it are charged with keeping the need for such services under review and with making appropriate provision for it.

My officials are exploring innovative ways of expanding and strengthening the community dental services safety net function in Wales. There have been discussions with the staff side of the profession with a view to identifying arrangements particular to our needs. Those discussions are well advanced and principles are agreed. I hope that the outcome will provide greater flexibility of services and better targeting of resources, particularly in those areas of Wales where general dental services have been weaker.

It is also open to family health services authorities to apply for approval to appoint salaried dentists if they consider that that is necessary to ensure adequate provision. This scheme can be attractive to dentists who, for whatever reason, do not wish to practise on their own account or as part of a managed service. To date, five authorities have made applications and seven posts have been approved. Three salaried dentists are already in post—two in Gwynedd and one in Dyfed. A further dentist is shortly to commence work in Powys. Other applications are under consideration, and I expect shortly to announce approval of additional posts.

I have already shown that I support innovation. Family health services authorities bringing forward proposals for new authorities will find that I shall deal with them sympathetically and expeditiously, provided that they demonstrate need. The picture is not one of failure and complacency, such as the hon. Gentleman sought to paint.

The motion having been made after Ten o'clock and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.

Adjourned at twenty-three minutes past Eleven o'clock.

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