§ Mr. Geoffrey Clifton-Brown (Cirencester and Tewkesbury)
I am grateful for the opportunity to raise the subject of dental care. It is a tribute to my hon. Friend the Minister of State that when I discussed with him the possibility of raising the matter on the Adjournment, he readily agreed. I am grateful to him for that, and I welcome him to the Front Bench today.
The debate has three purposes: first, to highlight one highly unsatisfactory constituency case of unnecessary and unsatisfactory dental treatment; secondly, to reveal the shortcomings of the way in which the General Dental Council—the dentists' regulatory body—can deal with such cases; and, thirdly, to demonstrate the shortage of dentists providing NHS treatment in Gloucestershire.
I am well aware of the vast annual growth in state spending on NHS dental services. Since 1979, there has been a 69 per cent. increase in real terms in spending, reaching £1.3 billion in 1992–93. The problem is that, as in other areas of the NHS, technology has moved on at such a rate that ever more complex dental treatments are possible. People's expectations are higher than ever before, and some new treatments are extremely costly for the NHS to provide. Everyone should be entitled to receive reasonable treatment under the NHS, however, and most people should now, with correct dental care, expect to keep their real teeth for most of their lives.
Before I outline the facts relating to the case of my constituent, Mrs. Gee, I should state that I went to great lengths to check the facts, including corresponding with the dentist concerned and the independent consultant who reviewed the work. Mrs. Gee came to see me at the House so that I was able to question her face to face. I am convinced that there are a small minority of rogue dentists who undertake treatment that is unnecessary, or who augment basic treatment merely to earn increased fees. Of course, such cases are difficult to prove.
Mrs. Gee's case began in October 1993 when, after some minor dental treatment involving a filling costing only £55, Mr. Scott-Holeyman of Moreton-in-Marsh, suggested that some additional dental work to replace an existing denture would be ideal. A new bridge would be fitted, and root treatment carried out. It was explained that the work would cost £1,500 and that having the work done privately would ensure top-quality bridgework with well-fitting crowns and pure gold posts. Mrs. Gee took the word of the dentist that the work was necessary and would improve her quality of life. In reality, as she was to find out later, the work was possibly unnecessary and could offer only a marginal advantage over the existing denture.
My constituent was in constant pain from the bridge as soon as it was fitted. She endured 17 visits to the dentist—totalling more than 30 hours—where, on each occasion, minor adjustments were made, such as grinding down the teeth. The bridge, however, remained in place. Eventually she asked for a second opinion from the dentist's partner. It became clear from using a mould that the bite was seriously wrong, with the top and bottom teeth failing to meet.
To this day, the dentist who treated Mrs. Gee cannot accept that his treatment was unsatisfactory. In a letter to me dated 28 February 1996, he stated: 1003I am unsure about exactly what it is I am supposed to have done.But the evidence is clear, because Mrs. Gee immediately sought a report from a consultant in restorative dentistry, which stated that a fixed bridge of the type that was used may not have been appropriate, and that the pre-existing removable denture may well have been better in the circumstances.
Mrs. Gee finally went to have restorative work done at Birmingham dental hospital more than a year after the original treatment, and the bridge was removed. Five teeth were affected by the attempted bridge work, two of which have been lost and the remaining three extensively restored. The major point is that, two years later, remedial dental treatment continues at the taxpayer's expense in the NHS hospital at Birmingham. Mrs. Gee has had to endure 28 separate and very painful visits to the dental hospital to put right work that may not have been necessary in the first place.
On my constituent's behalf, I took up the case with the General Dental Council which in theory has a remit to regulate the profession under the Dentists Act 1984. The GDC investigated Mrs. Gee's complaint, but concluded that there was not a prima facie case of serious professional misconduct by the dentist. The GDC can suspend a dentist only when serious professional misconduct has been proved. Although I am not a lawyer, that would amount in my opinion to something as serious as pulling out all of someone's teeth, or rape or a similar act. My constituent underwent unsatisfactory treatment, but it did not amount to serious professional misconduct and—under its present constitution—the GDC had no power to act.
Court action would be difficult without access to all the documents relating to Mrs. Gee's treatment. There are double standards on the part of the GDC, because it is reluctant to co-operate with her since completing its own investigation. Mrs. Gee supplied a copy of her own report and an assessment of the original treatment before the restorative work commenced for the GDC disciplinary hearing to which I referred. The GDC happily passed that report on to the dentist so that it could be used in his own defence. Mrs. Gee, however, cannot get from the Birmingham dental hospital a document relating to her own treatment that would form a central part of any court action. That is unsatisfactory, and I hope that my hon. Friend the Minister will request a copy of the report from Birmingham dental hospital so that he can satisfy himself as to the seriousness of the case.
The House would be entitled to ask why the dental profession is dragging its feet. A sceptic might say that the dental profession is aware of the three-year time limit within which medical negligence cases must be brought. This period is fast approaching its end. But why must we have this limit at all? The Minister will know for example, that negligence claims against employers can take much longer than three years to come to court, and can take six or more years to do so.
It has been important to highlight the issues surrounding Mrs. Gee's case because they highlight the shortcomings of the GDC's regulatory structure. All treatment under the NHS is subject to a complaints procedure that is not open to private dentists. Therefore, people such as Mrs. Gee have no redress under the NHS. It is high time that the GDC modernised its 1004 procedures in line with those adopted for doctors by the General Medical Council. Dentists who fall short of the serious professional misconduct category could then be disciplined for persistent professional misconduct. In particular, there must be powers to suspend dentists temporarily while they undergo re-training and to ensure that all dentists undergo continual professional development throughout their careers. That happens in many other professions, including my own—chartered surveying.
I urge my hon. Friend to initiate an urgent consultation with the dental profession to implement these changes and all the changes recommended in the GDC consultation paper put out in November 1995, with a view to legislation along the lines of the Medical (Professional Performance) Act 1995 which will give the GMC powers to regulate GPs from next year. The people of this country need to be reassured on this matter.
Action is vital because the provision of NHS dentistry in the rural areas of Gloucestershire is unsatisfactory. My constituency has one of the highest proportions of NHS dentists either opting out entirely of providing NHS treatment or merely treating children and those with exemption certificates. The health authority has attempted to alleviate the situation by employing salaried dental staff in local clinics. But the health authority provision lags behind potential local demand by a long way. For example, there is only one NHS salaried dentist in the Tewkesbury area every other Friday from 9 am to 1 pm and from 2 pm to 5 pm—this, Mr. Deputy Speaker, to serve a population of about 14,000.
How can the situation be improved? The health authority is keen to have at least one extra salaried post, but its hands are tied by the national Department of Health rules on salary levels which mean that the health authority is unable to employ the extra salaried dentists that it needs.
Gloucestershire health authority has unfilled posts because it cannot attract dentists. Health authorities should be given more flexibility in, for example, the fringe benefits that they can offer salaried dentists, such as moving expenses and increased housing allowance, to fill unfilled posts. Ultimately, there are no other mechanisms whereby the NHS can provide NHS dentistry, if there are unfilled posts.
I hope that there will be action as a result of this debate. First, I look to the Minister to demand the document from the Birmingham dental hospital which catalogues Mrs. Gee's ordeal and is central to her being able to pursue successful legal action.
Secondly, I look to the Minister for action to ensure that the General Dental Council quickly follows the route taken by the General Medical Council to deal with rogue dentists who exploit private and, indeed, NHS patients. Finally, I hope that the Minister will look again at the regulations governing salaried NHS dental staff to find out what can be done to ensure that the vacant posts are filled by allowing health authorities greater flexibility in the allowances that they can offer to attract and retain dental staff.
I would like to think that, in raising this matter today on behalf of my constituents, the dental situation in Gloucestershire will improve rapidly. I am thankful for the opportunity to raise the matter.
§ The Minister for Health (Mr. Gerald Malone)
First, I am pleased to be able to respond to the particular and the general issues that my hon. Friend the Member for Cirencester and Tewkesbury (Mr. Clifton-Brown) raised and to congratulate him on using one of the most powerful tools we have to raise the complaints of individual constituents and their concerns in this forum.
Since last November, my hon. Friend has been working hard on Mrs. Gee's behalf to ensure that the problems that she has had following her dental treatment are properly addressed. I know too that the case raises wider issues, which will be of interest to all patients when they make choices about their dental health care.
My hon. Friend will be well aware that Mrs. Gee's case is still subject to the legal process. I am sure that he will understand why, when I discuss it, I want to do so in terms of the general principles that it raises, but I will also respond to one or two of the points he made. I am pleased to be able to say that I will also let the House know about some of the successful things that are going on in dentistry today, including our plans for a new complaints procedure for NHS patients, which has some bearing on Mrs. Gee's case.
It is to standards of service that I shall first turn my attention. The case raises two aspects of that matter, which go to the heart of Government policy for dentistry. Those are to ensure high standards of patient treatment and care and a mechanism whereby there can be an effective response when things go wrong, as they surely do from time to time in any profession.
The General Dental Council shares our aim that the dental profession should promote high standards of treatment and care. I suspect that my hon. Friend—perhaps unconsciously—was a little more vigorous towards the GDC, rather than to me, than he should have been when dealing with this issue. As he pointed out, it has raised issues that have come to my attention on which we need to make progress. I have found the council extremely keen to move down the route that he suggested to ensure that patients get quality of care and high standards are promoted. It is part of its direct remit, flowing from the Dentists Act 1984, to promote high standards of professional education and conduct among all dentists—this is the important point—whether they be NHS or private dentists, which was the case with Mrs. Gee.
To be legally entitled to practise dentistry, all dentists must appear on the GDC register; they must be suitably qualified. To that end, the GDC assesses standards of dental education at the universities and postgraduate bodies, which enables it to ensure that the qualifying examinations meet the appropriate standards. In the NHS, too, we aim to promote high professional standards throughout. It is a requirement of the dentists' terms of service that they keep their clinical skills up to date.
To enable them to comply with that requirement, we provide a postgraduate education allowance, which allows them to claim a fee when they attend a postgraduate course and helps to ensure that their income is maintained and that there is no disincentive to keep up to date with skills. As my hon. Friend rightly pointed out, in dentistry, as in so many other areas of medicine, skills need to be developed to cope with the changing technology to which he referred. That 1006 provision is just one aspect of the dentists' NHS terms of service, which place the accent very firmly indeed on providing high standards of patient care.
The second aspect concerns what happens when treatment does not turn out as well as patients and dentists hope. Of course, I acknowledge that patients need to have the security of the knowledge that their concerns will be addressed and remedies provided. I am pleased to be able to tell my hon. Friend that much work is being done in that area following the publication of Professor Wilson's committee's report "Being Heard" and our response "Acting on Complaints". From 1 April, a new complaints procedure, which will be common throughout the NHS, will be put in place.
The aim of the new system, which has been worked out with the profession, is to make the complaints procedure more accessible, speedier and fairer to all. I am sure that the whole House will welcome that, as many hon. Members already have. For all family health service practitioners, the new system will replace the present formal system.
§ Mr. Malone
My hon. Friend has probably anticipated the fact that I will come to that point, because I understand Mrs. Gee's case to be in that category. I thought that it would be helpful, as my hon. Friend raised the subject of general standards of quality, if I dealt with his NHS constituents—of whom there are many—as well as with what happens with private dentistry.
The new complaints procedure will be practice-based. It will follow the introduction of a new terms of service provision for dentists. Where it is not possible to resolve complaints at the practice level, which should be the first and most convenient port of call, the local health authority will have an independent review role to play to offer conciliation and take unresolved issues forward.
The patients' rights of redress do not end there. If a patient is unhappy following independent review by the health authority, or has been denied an independent review, he or she will also have the right to take the case to the health service commissioner. From 1 April, subject to the approval of Parliament, the commissioner will be able to consider clinical matters as well as administrative maladministration. That is probably the most important aspect of what happens in cases of this sort, although Mrs. Gee's was not an NHS case. The new system will widen matters to an extent that will help the public greatly.
The new system has two principal aims. One is patient confidentiality and the other is early resolution; both are extremely important. All NHS dentists and the new health authorities have received guidance about the new system. Much work has been done to get it into place and to ensure that everyone understands what procedures need to be followed so that, as at 1 April, it is up and running.
Those are the provisions that will be in place to deal with NHS patient complaints, which may arise in my hon. Friend's constituency, although I hope that there will not be too many of them. I hope that those that do arise will be rapidly resolved. As my hon. Friend rightly pointed out, the provisions do not apply to cases such as that of Mrs. Gee, whose treatment was undertaken on a private basis.
1007 I emphasise to my hon. Friend, who rightly asks what Mrs. Gee should do in those circumstances, that private patients also have their remedies. They can get help from a range of sources. They can get it from the British Dental Association, which provides guidance to its members in dealing with complaints. If Mrs. Gee had been privately insured with a scheme such as Denplan, she would have found that such schemes—which are becoming fairly common—usually provide a conciliation service as part of good business practice.
Of course, the General Dental Council, which deals with matters of professional conduct and upholds professional standards, has a keen interest in all those matters, which are at the centre of my hon. Friend's arguments and of his queries about how we can take the matter forward and develop the council's ability to deal with such problems. At present, where a dentist's fitness to practise is judged by the health committee to be seriously impaired, the GDC may order the dentist's registration to be suspended or to be conditional on complying with conditions imposed for the protection of the public or in the dentist's interests.
I shall now deal with the points raised by my hon. Friend about where we go from here, because, as he asserted, change is needed. The General Dental Council has approached my Department with a view to amending the Dentists Act 1984 so that it can set up a system to deal with patients' complaints about treatment outside the NHS. We shall consider that proposal sympathetically, all the better informed for my hon. Friend's powerful arguments about why that should be done.
As this case has illustrated, it is important that private patients should have access to an acceptable complaints procedure. It is in the interests not only of patients but of the profession as a whole that there should be a procedure whereby complaints can be sorted out before the present right of recourse, which is open to patients, including my hon. Friend's constituents, to pursue complaints through the courts, is used. It is important that we do what we can to widen the scope for patients to resolve matters—and resolve them quickly, because, in cases where pain is involved, people need to resolve them quickly. I hope that my hon. Friend will be reassured to hear that, since we were approached about the issue, we have been active in its pursuit and we will continue to remain active in ensuring that patient complaints, NHS or private, are properly and speedily dealt with.
The General Dental Council has plans to establish a statutory career redevelopment procedure that may be applicable to dentists whose performance, while not amounting to serious professional misconduct, falls below the high standards set by the profession. My hon. Friend made an apt analogy in referring to the legislation for doctors. Such a change would require primary legislation and an amendment to the Dentists Act 1984. In the meantime, any initiative by the General Dental Council to introduce voluntary participation in such procedures would be welcome. I hope that it has heard what he said and noted his concerns. Perhaps it will give that some thought.
My hon. Friend mentioned the availability of dentistry. As he knows, dentists are independent contractors and can choose where to set up in business and which patients they will see. Patients are able to choose whether to have treatment privately, under NHS provision or on a part-NHS, part-private basis. In that 1008 situation, our aim is to ensure that there is real choice for all patients at all times. That raises questions about the availability of general dental services, so I shall set out our plans on that important matter. As my hon. Friend alluded to it and it is important that the situation should be widely understood, I will consider the national situation before moving to the difficulties in his constituency.
First, the idea that NHS dentistry is disappearing across the country is far from the truth. It is not, and there is no evidence to support that contention. There are now more dentists providing NHS treatment on family health services authority lists. There were 15,942 on 30 December 1995, which is 516 up on June 1992. I lose no opportunity to put that fact firmly on record because, to hear some people talk about NHS dentistry, one would assume that it was dying. It is not. We are committed to NHS dentistry and to accessible and effective service. To that end, not only am I pleased that there are more dentists providing it, but the Government have supported it with cash. Between 1978–79 and 1994–95, expenditure grew 60 per cent. in real terms.
Although that may reassure my hon. Friend about the nation, he specifically raised constituency matters. Of course, I know that it may sometimes be difficult to obtain treatment in some parts of the country. For example, there is often difficulty in isolated rural communities; it is a problem of locality. My hon. Friend's constituency is an example of such problems. Some adult patients there have to travel further to find NHS dentists to treat them. That is why we have already approved the recruitment of salaried dentists to help meet shortfalls in provision.
Last week, Gloucestershire family health services authority reported that there were five salaried dentists in the county making such provision for patients. I understand the recruitment difficulties to which my hon. Friend alluded. It is sometimes frustrating for everyone trying to deliver the service that there appear to be mechanistic obstacles in the way, but I remind him that, at present, salaries for salaried dentists are recommended by the independent review body. That does not mean that I will not carefully consider his suggestions about flexibility. I am pleased to be able to say that we have approved the appointment of a further two salaried dentists in Gloucestershire. When appointed, they will help to augment existing salaried provision in the county.
§ Mr. Clifton-Brown
Does my hon. Friend accept that a possible way to ease the situation would be to move from a system of salaries for salaried dentists to one along locally determined pay lines, as nurses, for example, have done?
§ Mr. Malone
My hon. Friend makes some interesting suggestions. Should those who are in a position to take advantage of them choose to do so, I would not stand in their way. Flexibility is important in these matters. I listened carefully to my hon. Friend. I am anxious to ensure that existing FHSA mechanisms are used fully. Many problems could be resolved with primary legislation, to which we are committed in due course, when we enter into a purchaser-provider system.
My hon. Friend is interested not only in the long term but in the short term for his constituents. I conclude by dealing with the three specific points that he raised. 1009 First, I will write to him about the report that Mrs. Gee is trying obtain from the Birmingham dental hospital. Secondly, I can reassure him that we will consider sympathetically the GDC's plans to establish a statutory career redevelopment procedure that may be applicable to dentists whose performance, while it does not amount to serious professional misconduct, falls below the high standards set by the profession. Thirdly, we have a clear 1010 policy that effective NHS dentistry should be available to all who want to make use of it. We will take all available steps to ensure that it is. My hon. Friend has set out several practical ways that, in the context of his constituency, may be possible. I will consider that carefully as we take the discussion of this important matter forward.
§ It being Two o'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Sitting suspended, pursuant to Standing Order No. 10 (Wednesday sittings), till half-past Two o'clock.