HC Deb 19 July 1996 vol 281 cc1479-84

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

2.30 pm
Mr. Graham Allen (Nottingham, North)

I should like to raise the topic of dentistry, particularly dentistry in my constituency of Nottingham, North.

It is important to place it on record that there has been a vast and quiet privatisation of dental care by the Government since 1979, which has gone unnoticed by the press and the public. Dentistry is one of those things that affects individuals only when they feel the need for dental care. In many ways, the Government have escaped proper public scrutiny of what they have done.

A local dentist in my constituency recently said to me: I am trying to remain in the NHS but quite frankly it isn't possible. There is a surplus of patients who … can't afford private treatment, which is putting me under increasing pressure. My list is now closed, I can't take any more NHS patients. In talking to local dentists in my constituency, I am struck above all by their dedication. They do not want to leave NHS dentistry, but they are being forced out of it by Government policies. That fact became evident to me during the numerous meetings that I have had with local dentists; it has also become evident to the Select Committee on Health. In its fourth report for the 1992–93 Session, it concluded: For present and potential non-exempt NHS dental patients access to NHS services is becoming increasingly difficult". That difficulty has, of course, affected everyone. In my region, a recent Harris poll commissioned by the British Dental Association stated that 25 per cent.—one in four people—in the east midlands had trouble finding a local dentist willing to treat them on the NHS. We are now reaching the position where about half the adult population of the UK is not registered with an NHS dentist. Probably even more tragically, 41 per cent. of children are not registered with an NHS dentist. In short, British dentistry is not safe in the Government's hands.

Denplan, the health and dental insurers, found that only 60 per cent. of dentists were treating any NHS patients. In 1989, that figure was 90 per cent. and it was probably even higher than that in 1979. We must confront the problem that as a result of Government policy the era of free, regular dental checks in constituencies up and down the United Kingdom is well and truly over. There has been a process of back-door privatisation of which people are not aware. I am afraid that we are looking at a dental—or oral—health disaster in the UK owing to the failure to take adequate preventive measures.

Since 1992, more than 1 million people nationwide have been taken off NHS dental lists. In the Trent area, which covers my Nottingham constituency, 65,000 people have been deregistered. These people are being denied treatment on the NHS because dentists can no longer afford to take on NHS patients. Instead, they must devote ever-increasing time to their private patients to balance their books.

Countless constituents of mine have been approached to go private. The regular mailshot for NHS patients is a common occurrence. I repeat that neither patients nor practitioners in Nottingham want to be in that position. The Government, as a matter of policy, have made a systematic attempt to force adults out of NHS dentistry, deliberately opting out of a service which we have taken for granted and which many of us believed that we had already paid for. The next toothache might be the stimulus that we need to consider whether the recent 1 p tax cut was really worth it. Even Conservative Members share my view. According to a recent Harris poll, 44 per cent. of Conservative Members of Parliament believe that NHS dental care will be restricted to children and those on low income if present trends continue.

The recent farce regarding the Government's contract with Nottingham dentists has aggravated many problems. Dentists have had to spend three years wrangling with the Government. Dentists' fees have only just returned to their 1991 levels, not allowing for inflation, following a fee cut of 7 per cent. in 1992. Now all but the simplest dental work must be referred, with a lengthy wait, for what is called prior approval. One third of all patients on dental lists, mainly children and those on low income, are still entitled to free dental treatment, but the two thirds of adults who pay some of the cost of their treatment contribute more than 80 per cent. of dental costs, so the Government pay only 20 per cent. of the cost of treatment.

Nottingham dentists, like those elsewhere, have a choice. They may choose the contractual confusion and mess of that 80–20 split between private and NHS funding and the requirement to fight through the bureaucracy and fight with Government about fee levels. Or they may choose the simplicity of charging 100 per cent. privately, avoiding the difficulties with the Government that have been so apparent in recent years—a Government who do not give a damn about NHS dentistry.

The Government have deliberately designed a policy to underfund NHS dentistry and drive dentists into private practice. Sadly, the policy has been a success. Increasingly, and reluctantly, many of the dental practitioners whom I have met in Nottingham are being forced by it into one of three categories: those who no longer take on NHS patients, those who no longer roll their patients' registration forward when it expires—even that period has been reduced from 22 months to 15 months—and those who are actively deregistering their patients.

None of the local dentists whom I have spoken to wants to make those choices, but when one dentist reduces the number of NHS registrations that they will handle, that demand does not go away. People look elsewhere for a dentist who will register them, putting increasing pressure on the declining number of dentists in the district until they, too, have little alternative but to limit the number of NHS patients, and so it goes on: a local snowball develops until most local practitioners move into the private sector, excluding vast numbers of people from effective dental treatment.

In recent years, there has been a massive but largely unnoticed switch. The 1994 survey by Denplan, which I mentioned, found that only 60 per cent. of dentists were treating any NHS patients compared with 90 per cent. in 1989. Wholly NHS dentists will soon be an extinct species, replaced by a tiny, overworked band of community dentists. Dentistry is becoming a safety net welfare service for the underprivileged and the very young rather than something that we have taken for granted ever since the modern dental service was established.

The former family health services authority that is now the Nottingham health authority is swamped with people searching for an NHS dentist. In the Trent region. more than 20,000 people asked for help between July 1992 and September 1995. In less than six months last year, the corresponding national figure increased by 25 per cent. Put simply, the provision of NHS dentistry in Nottingham, like many other urban areas, is shrinking and patients are beginning to suffer. Health authorities have a duty eventually to find those people a dentist, but many of my constituents must travel 10 to 20 miles to reach dentists who will take them. It is not easy to travel those distances with children or shopping and it certainly does not encourage people, particularly children, to visit the dentist. Many of the vast improvements in oral health since the NHS was established 50 years ago are bottoming out as tooth decay, particularly among children, shows signs of increasing. That is what the Government will be remembered for as privatisation continues.

The Government estimate that the new rigorous prior approval proposals will reduce the amount of expensive complex work done on the NHS by about 5 per cent. According to the BDA, that will save £10 million this year alone. Knowing that prior approval is a lengthy and difficult process, dentists either prolong NHS treatment or do it quickly privately, which is yet another obstacle to people taking up effective NHS dental care. Once again, the screw is being turned on dentists as they are encouraged to shift patients to private contracts, a process that has taken place inexorably and as a matter of policy since the Government came to office in 1979. Incredible damage has been done over that period and it will be extremely difficult to halt and reverse it.

We must look urgently at how to attract more dental practices to inner-city areas and rapidly halt the privatisation of dental services. Once dentists have had enough of trying to wring sufficient funds out of the NHS and go private, it will be hard to bring them back. Sadly, that shows the success of the Government's agreed policy. The few remaining dentists who will take on new NHS registrations are in huge demand and can no longer cope. The Government's plans to introduce grants for new dentists in areas with specific problems are like sticking a plaster over a haemorrhage. We must prevent a further drift towards private dental work, and actively encourage and support NHS dentistry as the foundation of proper oral care. Decimating NHS dentistry, then throwing in a few extra community dentists, is no way to run a national health service for dental care.

This century has seen massive improvements in dental care for all, but that is now under threat. In the past half century, we have seen that oral health can be effectively tackled only through preventive medicine—free regular check-ups and easy, cheap and convenient treatment. That is the approach that must now be taken. I understand that the next Labour Government will work closely with dentists to establish how that can most effectively be done. We shall seek to make progress with voluntary fluoridation, which has been shown to be one of the best ways of preventing tooth decay.

Adults as well as children need to visit their dentists regularly for check-ups to prevent the development of painful and expensive work later. I am not about to pretend that anyone looks forward to trips to the dentist, which is all the more reason why the Government must stop making it increasingly hard for my constituents, particularly children, to have the NHS dental services that they need.

It is important that the public are aware of the crisis which the Government have deliberately engendered in NHS dental care. My constituents are suffering because of that systematic neglect over recent years. I hope that the Minister will tell the House and my constituents what he intends to do to deal with the problem, rather than just let it get worse and worse. If the Government are content to let this problem drift on, health care—and particularly dental care—will be set back 30 or 40 years. I hope that the Government will make it plain that that is not what they want and that even at this late stage they will reverse their policies to ensure that it will not happen.

2.44 pm
The Parliamentary Under-Secretary of State for Health (Mr. John Horam)

I am delighted that the hon. Member for Nottingham, North (Mr. Allen) has raised this subject, even though it is close to the end of the Session, because it gives me the opportunity to point out that, contrary to the one-sided picture that he painted, the Government are committed to a comprehensive and effective national health service dental service. Our record speaks for itself.

On 31 March, the total number of dentists on family health services authority lists was 15,998, which is 3,900 more than it was in 1979 and the second highest figure ever. Since 1978–79, funding for NHS dentistry has increased by 54 per cent. in real terms. Over the same period, the number of adult courses of treatment rose by 7.82 million. At the beginning of this year, more than 6 million children were registered for capitation, helping to ensure that they receive regular care for their teeth at a critical age.

Our major investment in NHS dentistry has produced results—the oral health of the nation has improved. When seen over a longer period, that improvement is enormous. We forget all too easily the pain and discomfort that poor oral health caused in earlier generations. Perhaps hon. Members of my generation will remember the gloomy and inadequate dentists I visited. When the discipline of parental urging was removed when I got older, I forgot to go to the dentist for three or four years and, as a result, I have far more fillings than I should have for a man of my age. That is what it was like when we were young, and I do not believe that that would happen to anything like that extent today.

Our task is not to look back but to look forward. NHS dentistry cannot afford to stand still if it is to meet the challenges of the future, such as building on past improvements in oral health, targeting more accurately the groups of patients who are our highest priority and improving value for money. Those principles were underpinned in the recent wide-ranging statement on the future of NHS dentistry, which my hon. Friend the Minister for Health made not so long ago. A key element in the statement was the announcement that a year of detailed and constructive negotiations with the profession had resulted in an agreement on the reform of the general dental services pay system.

The package has a number of elements and implementation will begin in September. First, it targets the substantial existing resources more effectively, with the aim of improving child oral health and giving value for money to the taxpayer. In addition to the capitation payment made for each child registered, a new set of fees for individual items of treatment will be introduced. That fee scale will replace the weighted entry payments that are currently paid where significant treatment is required. It will be a simpler system oriented towards children.

Secondly, for both adult and child dentistry, we are to harmonise the registration period at 15 months. That will provide a period of continuing dental care following each course of treatment, while streamlining administration procedures, reducing bureaucracy for dentists, and ensuring that the public secure the best value for money from the available resources. In other words, we are reducing administration, bureaucracy and waste—something the Labour party claims that it would do if it were in power.

The reforms also include an agreement to introduce more careful prior approval. That will ensure that all clinically essential services are available and are secured in the most cost-effective way. In view of the agreement with the profession, we have waived the overpayments that built up over a number of years to 1993–94. They amounted to some £16,500 per dentist and were the consequence of a remuneration system with a balancing mechanism that recovered overpayment in one year in subsequent years.

The British Dental Association has ended its long-running dispute with the Government as a result of the reform agreement, combined with the waiver of overpayments. Those developments remove the uncertainty that dentists have been under for several years and they should promote an atmosphere of stability and security in the NHS general dental service. More importantly, they draw a line beneath the past and allow us to concentrate on the future. That can be only beneficial for patients and dentists alike.

Accessibility to NHS primary care dental services is very important. I am aware that, despite a healthy national picture with the second highest number of dentists ever, patients experience difficulties obtaining treatment in some local areas. The hon. Gentleman referred to services in his area. It is particularly difficult to obtain treatment in rural areas, where the distances are greater and it is harder to find a dentist nearby. There also tend to be fewer dentists in the more affluent areas.

We must tackle those localised problems, so the Government have launched an access fund that will target local needs through local solutions. I look forward to seeing health authorities—wherever they may be located—working with the profession to devise innovative and effective schemes that help to improve access appropriate to their areas. In addition, health authorities are able to apply to the Secretary of State to appoint a salaried dentist, and they can use community dental services when there are shortages. As the hon. Gentleman will know, many salaried dentists have been appointed under the scheme.

Let me look further ahead. At present, dentists work within a fairly rigid national system. One of the lessons that we have learnt in other parts of the NHS is that bringing an element of local flexibility into service provision can prove invaluable in helping to targe resources to meet local needs and demands. That is why the Government intend to pilot and evaluate a system of local contracting for primary care dentists in several areas of the United Kingdom. Health authorities will be able to target local needs more effectively, using their knowledge of local conditions and of local patient needs.

The chairman of the general dental services committee of the British Dental Association has promised to work with us constructively—thus achieving the good, co-operative relationship between the profession and the Government that the hon. Gentleman called for. The pilots will require primary legislation, and the Government intend to seek an opportunity to introduce a Bill. I hope that the next parliamentary Session will be a long one, so that we may introduce that legislation. We hope that it will prove possible to publish a draft Bill for consultation this autumn.

We recognise that changes in organisation must be paired with measures that will secure the highest professional standards into the 21st century. Such a Bill would also provide an opportunity to make changes to the Dentists Act 1984. Those changes have been requested by the General Dental Council, which is charged with setting and maintaining professional standards. The changes include setting up new classes of auxiliaries and expanding the range of work that they can do. The aim is to allow dentists to manage their practices more effectively, to provide more professional opportunities for hygienists and other dental auxiliaries, and to increase the amount of patient care available.

The council also intends to create a statutory career redevelopment scheme for dentists who must improve their level of competence. It will introduce conditional registration in addition to the sanctions that are currently in place for disciplinary proceedings. In other words, rather than the current heavy-handed approach, we shall have a system that is much more conducive to ironing out the problems of dentists who are judged to be less than fully competent. The aim is to help rather than hurt.

Finally, the GDC wants to establish a complaints system for private patients. As hon. Members know, Parliament passed legislation this Session dealing with a new complaints system throughout the NHS. It is important to complement that with a complaints system for private patients. That would enhance the GDC's powers to deal with complaints against dentists providing treatment outside the NHS. The proposals mirror developments in the medical profession and will ensure that professional standards are maintained and developed.

I assure the hon. Gentleman that NHS dentistry is, and remains, a Government priority. The programme of initiatives unveiled recently is firm evidence of our commitment to effective and efficient NHS provision. We now have an agreed way forward, a constructive working relationship with the profession and adequate resources. Although I concede that there is still much work to do, I believe that we have taken the first important steps to strengthen the current service and to provide the firm foundations for future work.

Question put and agreed to.

Adjourned accordingly at seven minutes to Three o'clock.