§ The Minister for Health (Mr. Gerald Malone)
With permission, I would like to make a statement on the future of dentistry in the national health service.
Last April, I announced on behalf of all United Kingdom Health Ministers a package of reforms to the general dental services remuneration system. I can now tell the House that a year of constructive and detailed discussion with the General Dental Services Committee has resulted in agreement on that package. Implementation will start in September. This will do much to end uncertainty and to provide an atmosphere of stability and security for the dental profession. It creates a firm foundation for future work.
I wish to set out both an immediate and a long-term agenda. I will deal with the immediate agenda first.
The package has a number of elements, one of which is children's dentistry. At present, the treatment of children is funded through a monthly capitation payment to dentists, supplemented by weighted entry payments where significant additional treatment is needed. The new system retains capitation payments, and replaces weighted entry with a new set of fees for individual items of treatment. This will help ensure that children receive appropriate preventive advice and dental treatment.
For both adult and child dentistry, we will harmonise the registration period at 15 months. This will provide a period of continuing dental care following each course of treatment, while streamlining administrative procedures and reducing bureaucracy for dentists.
To help ensure that the public secure the best value for money from resources, we will introduce more rigorous prior approval for some courses of treatment from 1 December. This will ensure that all clinically essential services are available and are secured in the most cost-effective way. A joint working party between Health Departments and the General Dental Services Committee will develop our proposals further.
It is important to construct a remuneration system which encourages improvements in oral health. Our aim is to target substantial existing resources more effectively for the benefit of patients. We shall be working with the profession to monitor the outcome of the changes to the proposed fee scale to ensure that we achieve our objective.
I deal now with the longer-term agenda. I can now tell the House that we intend to pilot and evaluate a system of local contracting for primary care dentists in several areas around the UK. The chairman of the General Dental Services Committee has stated that it will work with us constructively. I welcome that approach. The pilots will require primary legislation, and it is the Government's intention to seek an opportunity to introduce a Bill. I hope that it will prove possible to publish a draft Bill for consultation this autumn. We want to make progress, with the agreement and commitment of the profession.
Such a Bill would provide an opportunity to tackle another agenda which has been set by the dental profession itself and which I have discussed recently with the General Dental Council. The council is charged under the Dentists Act 1984 with setting and maintaining professional standards for the benefit of dentists and patients alike. Last year, the council issued a consultation 312 document setting out its proposals to amend the Act to do away with a number of constraints to the development of the profession. I am now happy to announce that the Government are prepared to take forward their proposals.
First, the Government propose to set up new classes of dental auxiliaries and expand the range of work that they can do. That would allow the GDC to approve pilot studies of mixed-skill working. The aim is to allow dentists to manage their practices more effectively, provide more professional opportunities for hygienists and other dental auxiliaries and increase the amount of care available for patients. It will be necessary to ensure that those changes produce enhanced NHS services, targeted to need. The proposals will enable clinical dental technicians to practise legally in future.
Secondly, in cases of disciplinary proceedings, the Government propose to introduce conditional registration in addition to the sanctions currently in place. Another important component of that proposal would be the creation of a statutory career redevelopment scheme for dentists who do not demonstrate a sufficient level of competence. We also intend significantly to increase the lay representation on their council.
Thirdly, the Government propose to establish a complaints system for private patients, something that was urged upon me recently in a debate by my hon. Friend the Member for Cirencester and Tewkesbury (Mr. Clifton-Brown). That would enhance the GDC's powers to deal with complaints against dentists providing treatment outside the NHS.
Those proposals broadly mirror developments for the medical profession which were put to the House earlier this year and approved.
I recognise that, within a growing general dental service, there are some localised problems of accessibility. Health authorities are already able to apply to the Secretary of State to seek to appoint a salaried dentist and use the community dental services in areas where availability problems arise. In addition, we have been consulting within the NHS and the profession on an access fund for this year.
I am pleased to announce to the House that we shall shortly be seeking bids from health authorities in England for individual grants, in the region of £40,000, to enable them to fund local solutions to local problems of availability. An access scheme has already been successfully launched in Wales. We shall monitor the outcome carefully.
Another issue which has greatly concerned the profession is that dentists have been remunerated through a system with a balancing mechanism, whereby overpayments in one year were recovered in subsequent years. However, over a number of years, up to 1993–94, an overpayment amounting to some £16,500 per dentist arose. I have had many representations on the issue. I have listened to the views of my right hon. and hon. Friends, and also to Opposition Members, who have urged me to mitigate the burden of those overpayments.
In view of the agreement reached with the profession, I have decided not to pursue that course of action. Instead, I have decided to announce today a total waiver of the overpayments. As a consequence, I understand that the chairman and executive of the General Dental Services Committee will recommend that the dispute started in 1992 be called off.
313 NHS dentistry is a success story. Since 1992, the number of dentists on English health authorities' lists has increased by around 500, to nearly 16,000. The number of adult treatments has gone up by 50 per cent. since 1979. Expenditure on the general dental services is up by 57 per cent. over the same period. We now have an agreed way forward. In my statement, I have set out an exciting and challenging new agenda for the profession and for the NHS. I intend to pursue it with vigour, and I commend it to the House.
§ Mr. Henry McLeish (Fife, Central)
Does the Minister not accept that, against the background of the crisis now gripping NHS dentistry, his statement will be seen as muddled and misguided, and will be a bitter disappointment to the public, professionals and Parliament? Will he acknowledge that this package is further evidence, if any were needed, that the Government are determined to drive dentistry out of the NHS by promoting further privatisation of adult treatment and retaining a residual welfare service for children and people on benefit?
Is the Minister oblivious to the main problem: to ensure that adults get routine NHS general dental services throughout the country? On that issue, does he accept that, in London and the south-west, one in six of the population has difficulty finding an NHS dentist? Does he further accept that there has been a significant fall in the registration of young adults over the age of 18? Why does nothing in his statement address those issues?
No one will disagree with more assistance being given to children, nor with the proposals to maintain professional standards. The belated attempt to solve the payments problem is welcomed by most people, and the Government have belatedly accepted that there are localised difficulties in terms of access, but will the Minister explain the knee-jerk reaction to the crisis facing children in NHS dentistry?
Will the Minister confirm that the proposed amount to be spent is £10 million, and that it will in effect be transferred from adult dentistry? Will he also explain why the item-of-service payments, which have been reintroduced, provide dentists with more money for taking teeth out than for filling them, which will undermine preventive health care?
Does the Minister accept that the reduction in the registration period from 24 to 15 months—or, to use his words, to "harmonise" the phase of registration—could mean that millions of adults will be removed from NHS dentists' registers? I urge the Minister to tell the House whether 2 million, 3 million or 4 million will be removed at a stroke. Can he explain whether the new rigorous prior approval for expensive treatments—crowns and bridges— is designed to improve dental care or merely to provide the cash for transferring to children's treatment?
The Minister's statement does not in any way address the key issue of health inequalities in dental services throughout the country. We need a package to ensure the right of all sections of the community in all parts of the country to comprehensive NHS dental care. The Government have squandered yet another opportunity. We 314 need to keep dentistry within the NHS. The Government have shown by their actions today that they do not share that aspiration.
§ Mr. Malone
We have just heard the usual drivel from the hon. Member for Fife, Central (Mr. McLeish), whose view of NHS dentistry is totally unsupported by the evidence. The truth is that NHS dentistry is succeeding. It is receiving record funding from the Government. The number of people who are maintained on registers is broadly the same as it was in the past, in spite of the perverted statistics put out by the hon. Member for Southwark and Bermondsey (Mr. Hughes)—who, rather interestingly, counts those who come off the register automatically and then refuses to look at the figures for those who go on the register, which gives an entirely different picture.
The hon. Member for Fife, Central raised yet again the bogus issue of privatisation. Health service dentistry is receiving additional investment.
§ Mr. Malone
I shall come to each of those points. The hon. Gentleman need not butt in from a sedentary position.
The hon. Gentleman spoke about the undermining of preventive care. Nothing will do that. He made some spurious suggestion that funding for children's treatment will come from adult care. I explained to the House in my statement that the weighted payments that are presently given will fund the fees for patient care for children, and that there will be a ceiling within which the treatment will take place. That has always been the case.
I now come to the hon. Gentleman's point about the 15-month period. The reason why there is a continuous care period of 15 months is that some 4.5 million people were rolling off the register each year, which suggests that they were not receiving treatment. The 15-month period will encourage dentists to provide a course of treatment for patients who need it, and they will then remain on the register. It is in the interest of dentists that they do so.
The hon. Gentleman also raised the issue of prior approval. It will improve dental care, because it will ensure that what is clinically necessary and appropriate for patients will be delivered. What is important is that the protocols will be decided with the dental profession and will be developed during the coming months. Dentists very much welcome that.
Yes, things are different under this Government compared with the previous Labour Government. The hon. Gentleman may be interested in the notice from the British Dental Association, which is headed "Notice to Patients". It says:For the time being some patients may be unable to obtain dental treatment under the National Health Service … The British Dental Association regrets that this situation has arisen and hopes that a viable and progressive NHS Dental Service can be restored in the very near future.It was, in 1979. It has been developed since, and that is an achievement of this Government.
§ Sir Peter Emery (Honiton)
Although I thank my hon. Friend for that statement, which certainly goes a long way 315 to meeting many of the difficulties in the profession, I believe that it has not immediately met one great worry. Being parochial, I think of Sidmouth, Budleigh Salterton and Exmouth, where people are having to travel perhaps 20 miles to register with a dentist.
Will my hon. Friend consider providing capital to attract dentists into setting up a house and clinic, so that they can take on the great registration that exists not just in my area, but in many areas of the south-west? That would much more quickly get over the immediate problem, which I am sure my hon. Friend wishes to do.
§ Mr. Malone
Yes, indeed. The fund I have announced to the House this afternoon is designed precisely to meet such a need, where it is clearly demonstrated that there is a requirement for NHS dentistry that cannot be met. Many of my right hon. and hon. Friends have written to me about access, and I have listened to them most carefully.
My right hon. Friend will be well aware of the legislative framework within which we normally provide NHS dentistry if no dentist wishes to provide NHS care. There are two means of doing so: either through the community dental service or through the appointment of a salaried dentist. That system has proved to be too inflexible, and that is why I have announced in principle to the House today a scheme that will meet local flexibilities and needs—which is why it is not prescriptive. It will be up to local health authorities to devise schemes that match the local situation.
The representations have been listened to and responded to. I very much hope that my right hon. Friend will now take up the matter directly with his local health authority, so that it may bid for the fund that has been put in place.
§ Mr. Simon Hughes (Southwark and Bermondsey)
I and my colleagues give a cautious welcome to the Minister's statement, as far as it goes. Does he agree that, unless there is both the commitment and the finance in the next few months, we shall not be able to rescue NHS dentistry from the jaws of disappearance?
Specifically, is it Government policy to reinstate to the NHS all the work that has been lost over the past four years? Is it Government policy that the 1.8 million net patients who have been lost to the NHS will go back to being inscribed on NHS rolls? Is it Government policy that, not just in the south-west but all over the country, there will be access for every citizen, adult and child, to a local NHS dentist?
If so, will the Minister answer the last crucial question? Does the new settlement mean that there is more money for dental remuneration, and does it mean that, once again, there will be free dental checks on the NHS for all adults and all children all over the country, as needed?
§ Mr. Malone
I will answer the point about additional resources first, because that is at the core of the matter. Since 1979, this Government have provided, on an on-going basis, dramatic additional resources for NHS care. Total real expenditure is £1.4 billion up—60 per cent.—on the 1978–79 figures. It is all very well for the Labour party to talk about fiddling figures; it is nothing of the sort. These are the facts, and to try to suggest by simple assertion that they are not is an absurdity into 316 which Opposition Front-Bench Members fall far too often. Net spending is up by 37 per cent. on 1978–79 figures.
The hon. Gentleman lives in a fantasy land. He totally fails to understand the system if he thinks that people who may have required NHS dentistry in the past and now need it will receive it in terms. I do not know what system of compulsory treatment the Liberal party proposes to employ to seek them out. Time and again, the hon. Gentleman has fiddled the figures relating to NHS dentistry. What is more, when he is discovered fiddling the figures, he changes the ground rules.
I shall tell the House exactly what the hon. Gentleman has done. He has claimed that one patient is deregistered every two minutes, but depending on the basis of calculating the two minutes—I took it to be the normal division of time by two minute segments—some 45 are registered at the same time.
Having been found out on that, and the facts not suiting him, the hon. Gentleman then moved on to something that proved more esoteric. More recently, he claimed that one patient has disappeared every eight working day seconds. So we got out the calculator. We assumed working days to be Monday to Friday, and, giving the hon. Gentleman the benefit of the doubt, we worked out relatively shortly that more than four are registered at the same time. So once again the hon. Gentleman has got it wrong.
§ Mrs. Marion Roe (Broxbourne)
I congratulate my hon. Friend and the representatives of the dental profession on finally settling their long-standing pay dispute and on the major strides forward that have obviously been made during the negotiations. As Chairman of the Health Select Committee, I welcome the introduction of a new system of rewarding activity, with particular reference to children's oral health. However, as the Minister will know, the continuing trend of improvement in children's oral health has not been maintained in recent years. Will he confirm that children's oral health will now receive the focus it deserves, and will be put at the top of the priority list?
§ Mr. Malone
I agree entirely with my hon. Friend. I thank her for drawing attention to the co-operation of the profession in setting the agenda in lengthy discussions that she acknowledges are now productive.
My hon. Friend referred to children's oral health. It was precisely because it had become evident that the rate of improvement in children's oral health was not being maintained that we decided to look into the issue. My hon. Friend is quite right. We are seeking to ensure that activity relates to oral health and not just to the weighted payments that were previously in place, which meant that a dentist got more cash for putting on to his or her list a child with a bad oral health problem.
However, that did not generate activity. The purpose of the new scheme is to generate such activity, which should improve oral health dramatically. I can confirm that we shall continue to monitor the scheme as it unfolds, and ensure that it promotes the increased activity and improvement in oral health that we believe it promises. If, however, it does not fulfil that promise, I have no hesitation in saying that I shall be prepared to approach the issue again.
§ Mr. Dennis Skinner (Bolsover)
Does the Minister accept that, for the greater part of the past 17 years, the 317 dentistry element of the national health service has fallen apart? He comes here today attempting to introduce pilot schemes in local areas prior to a general election to give the impression that they will get rid of all the problems that have arisen in those 17 years, together with some auxiliaries. Are we going back to the 1930s, when my father was down the pit, and, if somebody wanted a tooth out and they had no money, there was no national health service and people would say, "Go to Tony Skinner, he has a good pair of pliers"? What a fine state of affairs we have reached.
§ Mr. Malone
I always knew that the hon. Gentleman's family was multi-skilled, but I did not know that it went that far. He harked back to the 1930s. I hope that he will not hark back to the 1950s when, under a Labour Government, a compulsory decrease in dental fees of 20 per cent. was imposed in one year, followed by another of 10 per cent., and there was talk of using military dentists to break a strike. That was acceded to by the saint of the health service, Nye Bevan, so we do not want to get back to the agenda set by the Labour party.
Our agenda is one of continued investment in the health service. The facts absolutely belie the hon. Gentleman's accusation that the service is falling apart. It is receiving increasing investment, and more dentists than ever before are providing NHS treatment. The hon. Gentleman is entirely wrong.
§ Madam Speaker
Order. If I am to attempt to call all the hon. Members who are rising, I must now have short, brisk questions, and short, brisk answers from the Minister.
§ Sir Alan Haselhurst (Saffron Walden)
Is it not well nigh impossible to interpret any part of my hon. Friend's statement as making access to NHS dentistry more difficult? On the contrary, does it not give a clear signal to health authorities, such as North Essex health authority, that there is now an additional means of trying to supply areas such as Saffron Walden, where there are currently no NHS dentists?
§ Mr. Malone
My hon. Friend is quite right. I shall expect him to speak to his local health authority to see whether a scheme can be devised.
§ Mr. D. N. Campbell-Savours (Workington)
The Minister will know that I have been corresponding regularly with his Department about what has been described to me as a crisis in dentistry in west Cumbria. We have been viewing the scheme in Wales quite enviously. May I ask the Minister in advance to look favourably on any bid that Cumbria might wish to make?
§ Mr. Malone
I will certainly take the hon. Gentleman's representations into account if such a bid is made.
§ Mr. James Couchman (Gillingham)
My hon. Friend's statement is very welcome, as is the fact that a long-running dispute now appears to be over.
318 During my hon. Friend's discussions with them, have dentists said whether more of their number will be prepared to take on new NHS patients? May I also ask him whether he believes that this will solve the problem of the scarcity of orthodontic treatment?
§ Mr. Malone
Given the hypothesis that dentists were saying that they would not take on extra NHS work—or would withdraw from such work—because a dispute was in progress, I hope that a corollary of the end of that dispute will be many more dentists deciding to resume NHS care. I hope that the end of the dispute and, in particular, getting rid of the vexed issue of overpayments—which I know encouraged a number of dentists to give up NHS work—will enable us to put the matter behind us. The legislation to which I have referred is designed precisely to improve the teams, including orthodontists, who will provide care in the dentist's surgery.
§ Mr. Sam Galbraith (Strathkelvin and Bearsden)
Does the Minister agree that the best way in which to improve children's dental health is to put fluoride in the water? That being the case, what will he do about it?
§ Mr. Malone
As the hon. Gentleman knows, that is exactly the Government's policy. Our policy is that, where it is agreed locally that fluoride should be introduced into the water supply, it should be introduced. The hon. Gentleman comes from an area where that is a contentious issue. I will certainly back schemes that are initiated locally, with local support, and the Government stand ready to back them all with capital investment.
§ Mr. Barry Field (Isle of Wight)
As my hon. Friend will know, the writing off of overpayments will bring a big cheesy grin to the faces of members of the dental profession. Given the conversations that I have had with him, does he realise just how keen I am on pilot studies involving the Isle of Wight? Will he confirm that he will consider my bid for the island to have just one of the schemes that he has announced?
§ Mr. Malone
I have been delighted to note the bids from hon. Members on both sides of the House to participate in the next generation of NHS dentistry. My hon. Friend's bid has certainly been noted.
§ Mr. Dafydd Wigley (Caernarfon)
Why, oh why, has it taken four years for the Government to get themselves out of the hole they dug for themselves back in 1992? Why has NHS dentistry disappeared from my constituency for the past three years, despite the Welsh Office initiative? In the past two years, only one dentist in the constituency has been taking on new NHS patients, and we still do not have one additional dentist, in spite of the initiative taken two years ago, and the additional money that was supposed to come.
On Monday morning, I saw a constituent who had a serious toothache last Wednesday, but could get no treatment either in hospital or from a dentist. He was offered antibiotics, or the alternative of having a tooth removed. The position is a shambles. It is high time we saw real action, rather than the window dressing that has gone on in Wales for the past two years.
§ Mr. Malone
The hon. Gentleman entirely ignores the fact that we have made solid progress with the profession 319 in that time in resolving a huge range of outstanding issues that will direct dental health care far more appropriately to patients. I should have thought that he would welcome that. He cannot say that he has experienced problems in his constituency in the past, and then belittle a statement today that addresses those problems and takes forward the agenda of NHS dentistry as a whole.
§ Mr. Patrick Nicholls (Teignbridge)
My hon. Friend will recall that I am the adviser to the Clinical Dental Technicians Association. How will he take forward his remarks about legalising the practice of denturism? Will the access funds that he referred to a few moments ago be directed towards the problems at Newton Abbot about which I have spoken to him recently?
§ Mr. Malone
I forgot that my hon. Friend gave advice—probably to the relatives of the hon. Member for Bolsover (Mr. Skinner) who get their pliers out occasionally.
§ Mr. Malone
Well, dentists dictate their own terms of service when providing private care.
My hon. Friend has made representations to me on behalf of his constituents. I note his suggestion today, and assume that he will take it up with his local health authority.
§ Ms Jean Corston (Bristol, East)
Does the Minister accept that his statement that NHS dentistry is a success story is simply not true in my constituency, where there are only two dentists providing NHS dentistry? That is two dentists for nearly 80,000 people. Dentists cannot survive professionally unless they encourage their patients to apply for services such as Denplan, for which some people, particularly pensioners, cannot afford the premiums. Is not a consequence of that a decline in the nation's health, and the privatisation of dentistry?
§ Mr. Malone
I do not accept that the nation's oral health is declining. If one were to believe Opposition Members, one would wonder what those dentists who provide NHS dentistry were up to, and where they were located. According to Opposition Members, there are no NHS dentists in their constituencies. There are, however, 15,500 dentists providing NHS care, and only 500 providing a totally private practice. The hon. Lady is entirely wrong to characterise a successful national service in the way she does.
§ Mr. Ian Bruce (South Dorset)
My hon. Friend is, I suspect, as fed up of reading my letters on Weymouth and Portland as I am of writing them. May I congratulate him on producing the flexibility that Dorset health commission has asked for in terms of solving the problems in those areas? Will he ensure that we are one of the areas chosen for the pilot scheme? Will he give a commitment to ensure that, by the time of the general election, everyone who wants an NHS dentist will have one?
§ Mr. Malone
My hon. Friend is entirely wrong—I enjoy reading his correspondence, and I hope that he 320 thinks that I reply to it with some care. I have said to colleagues who want their constituencies to participate in the scheme that, if they fall within the rules, I expect the local health authority to put forward a proposal for consideration.
§ Mr. Gordon Prentice (Pendle)
How many areas in this country have localised problems of access? Barnoldswick, in my constituency, is a town of 10,000 people with only one NHS dentist. There is a waiting list as long as your arm, and it is impossible to get treatment in the area. Was not the Minister's statement totally fraudulent?
§ Mr. Mark Robinson (Somerton and Frome)
Following his welcome statement, will my hon. Friend consider launching a campaign to persuade those dentists who have shut their doors to new registrations— temporarily, I hope—to reopen them?
§ Mr. Malone
I very much hope that the statement will encourage those dentists who, in the light of the dispute, decided not to provide NHS dentistry to take a fresh look at the situation and review their decision. Having put the dispute behind us, I hope that we will enter a more positive phase and increase the expanding number of dentists providing NHS care.
§ Mr. Hugh Bayley (York)
Does the Minister recall the report of the Health Select Committee on NHS dentistry that concluded that improvements in oral health achieved by a positive health promotion strategy would enable the Government to reintroduce at no additional cost free dental checks and a free core service of routine treatment? Why was that idea not pursued with the BDA?
As someone who has been told by his NHS dentist to go private or to go away—[Interruption.] I can tell Conservative Members that I left that practice—may I ask the Government to give a guarantee to all taxpayers, who have paid for an NHS dental service, that they will get such a service?
§ Mr. Malone
I would not fancy looking into the hon. Gentleman's mouth on a regular basis, so perhaps that is understandable. His point is exactly the same as that made by his hon. Friends. It is entirely wrong. He is yet another who claims that the NHS dental service has disappeared. It palpably has not.
§ Mr. David Congdon (Croydon, North-East)
Does my hon. Friend agree that the facts that over the past four years, the number of patients registered—both adults and children—has increased, that the number of treatments has increased and that the state of the nation's teeth has improved show that the NHS dental service is neither in crisis nor a shambles? What steps in his proposals will give an incentive to dentists to carry out preventive treatment? On children's health, will he ensure that proper quality controls are in place for the reintroduction of an item-for-fee service?
§ Mr. Malone
Yes, I can give the latter undertaking. Dentists are professionals, who have to obey the clinical guidelines set by the profession. I expect them to 321 undertake preventive care. The corollary suggested by some Labour Members is that they behave badly and give unnecessary clinical treatment. I do not think that that is right. The system of improved payments for children's oral health care will strongly contribute to a general improvement in oral health care for children across the nation.
§ Mr. Nick Ainger (Pembroke)
The Minister and several hon. Members have referred to the Welsh scheme. I endorse the comments of those who have said that it has not been a success. As an example, a dentist was relocated to my constituency in December, but has now sent a letter to all her adult patients deregistering them. After sixth months, she faces bankruptcy because of her serious problems.
I urge the Minister to recognise that there is a real problem, especially in rural areas, both in Wales and England. What he has told us today does not go far enough. Can he give any idea how many dentists who have in the past four years deregistered adult and children patients will now come back into the NHS?
§ Mr. Malone
I cannot predict the precise number. We will exhort those who feel that the environment is better after the statement to resume NHS care. We will see what the numbers will be. It is important that the access schemes are successful in the long term. That will be one of the criteria that we will consider carefully when schemes are put forward by local health authorities.
Some of the relocation schemes we have tried in England did not work in the long term. We are well informed by the fact that they did not work. We will be careful, in spending the taxpayers' money on improving access to dental health care, that we get schemes that will endure and provide lasting benefits for NHS patients.