NHS Dentistry

HC Deb 18 February 1998 vol 306 cc1152-64

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

8.2 pm

Mr. Simon Hughes (Southwark, North and Bermondsey)

I am grateful for the opportunity to raise this matter. I could be very, very grateful because the main business has finished so early but, despite the fact that my colleagues are here in great force, I shall respect the things to which we always pay verbal tribute. This is half-term week, and the Minister's family are in London, so we shall not keep him here until the end of the available time. I hope that, in return, he will be particularly nice, helpful and responsive.

Fifteen years ago next week, I was elected to this place. When I was elected, one of the places that I knew from the beginning I would be proud to be the Member of Parliament for was Guy's hospital. One of the best things about the hospital is that it has one of the greatest dental hospitals in this country, with one of the greatest research records and ratings. That is at one end of the market of dentistry, as it were, and it is important.

At the other end, I am lucky to have, within 10 minutes' walk from the front door of my home in Bermondsey on the Old Kent road, a very good dentist. I am pleased and grateful for that. In many other parts of England, however, national health service dentistry is becoming a contradiction in terms.

In many parts of England, Wales, Scotland and Northern Ireland, NHS dentists are increasingly becoming an endangered species. The message that I want above all to give to the Minister is that it is for this Government to take urgent action, because otherwise, in many regions, NHS dentistry could become a thing of the past.

We look tonight—this is the first debate on dentistry since the White Paper on the health service was published—for a demonstration of a clear commitment to dentistry as a core part of the NHS. I should like the Minister to address two large subject headings. One is inequalities in dental and oral health and the other is inequity of access to dental services.

As in many other sectors of the NHS, NHS dental services are very much a lottery—of postcode and of geography. We cannot have a national dental service if access to it depends on where people live and if, in large parts of the country, people cannot register with an NHS dentist. With your leave, Mr. Deputy Speaker, my hon. Friend the Member for Taunton (Mrs. Ballard) will, I hope, say a few words that will reflect the fact that, in rural areas, the problems are much worse than in some urban areas. Many of my colleagues, not just in the south-west but in rural areas and in Wales, have exactly that experience.

I do not lay the blame at the Government's door. The 18 years of the previous Government saw a steady erosion of access to NHS dentistry. There was a reduction in services provided on the NHS for free and in the number of people who were registered with an NHS dentist. Government figures from the Minister's Department show that, over the past two years, the number of people who are registered with an NHS dentist has dropped by 800,000, and that the number has been falling at the rate of approximately—this is worrying indeed—500,000 per month so far this year. Those are frightening figures, and we need severe, urgent and effective action to start to remedy that decline.

It is even more important that we do so because the variations in the dental health of the population as a whole are unacceptably high. I entirely accept that the Government want to end inequities of health, with unequal distribution of health and welfare. Dental and oral health is just as much a part of that.

Before I elaborate on those two subject headings, I put three questions to the Minister, because this is a good opportunity to do so. First, there is little in the White Paper about dental care. Does he accept the premise that dentists should be as much involved in primary care groups as other practitioners in the health service? I should be happy if he gave me a considered answer later, but I ask him seriously to consider that issue.

Secondly—this point has been put to me by people in the service—it seems nonsense that, if people go to their dentist and an oral inspection reveals something that needs treatment by a consultant, they cannot be referred directly from the dentist to the consultant; they have to go from their dentist to their general practitioner and then to the consultant. If that is true, we could save much money, bureaucracy and delay by short-circuiting that.

Thirdly, my hon. Friend the Member for Kingston and Surbiton (Mr. Davey) has put it to me that we could open up dental services a bit. If people go to an optician, they receive a prescription for something, but they do not have, as it were, to cash it there; they may be able to have it dispensed somewhere else. If, for the foreseeable future— I shall have this debate with the Minister on another occasion—there are to be charges and different prices for any dental services, people should be able at least to shop around. They should not, as it were, be caught, being given the diagnosis and the remedy—for which they have to pay out of their own pocket—in the same place.

On inequalities in dental health, my colleagues and I in this Parliament, as in previous Parliaments, believe that the rising cost of dental care is one of the most crucial factors in deterring people from regular dental check-ups. We believe strongly—the evidence is strong—that this is a false economy as regular checks reduce the need for emergency care, which ultimately is more costly for both the individual and the state. People aged between 25 and 35 are apparently much less likely than any other section of the population to be registered with a dentist. That stores up problems for the future, because that is exactly the period during which problems can set in.

It is an anomaly—I know that the Government are reviewing those issues—that people have to pay for a consultation with their dentist, whereas they can see their GP for free. That is not logical. Charging for dental care is just as much a disincentive to good oral and dental health as charging for a visit to a GP would be a disincentive to good physical health. That is demonstrated by the fact that the over-75 age group is the only section of the population in which dental registration is not declining, because that group does not face a bill for dental care.

My friend and colleague, one of the professors at Guy's dental school, tells me that not just dental examination but oral examination is hugely important. There are as many deaths in Britain from oral cancer as there are from cervical cancer. I understand that we are talking about double the population because we are talking about men and women, but nevertheless the figures are not insubstantial.

More than 50 per cent, of people with HIV have a diagnosable, specifically recognisable lesion and many of them are spotted, before people have understood that they are afflicted by the HIV virus, by dentists and dental practitioners; and 80 per cent, of people with AIDS have a specifically recognisable lesion that dental practitioners can spot. Therefore, we are talking not just about care of the teeth but about many other things which present in the mouth as health issues first.

I hope that the case for better access is well made. The figures are there to justify it and I hope that the Minister will give a positive response.

I come now to inequity of access in terms of geography. In reality, we have a rationed dental service—rationing by post code and by local provision. In my time in the House, we have never debated whether there should be rationing, let alone that sort of rationing, and it has never been agreed as an NHS policy. If it is not an agreed NHS policy, there should not be rationing, so we would argue that we need to remedy the fact that it is.

At the moment, we effectively have not a two-tier service but a two-type service, depending on where one lives. Access to NHS dentistry is a hit-and-miss affair depending on which town or county one lives in. That means that there is not equality of access to dental care. The priority must be dental registration. According to my figures, as many as 40 per cent, of children and 50 per cent, of adults may well now not be registered with a dentist. If NHS dentists become scarcer, those figures will rise.

The British Dental Association tells me that at least 5 million people may be dropped from dental registers this year simply because they had not visited their dentists during the previous 15 months. I hope that my hon. Friend the Member for Carshalton and Wallington (Mr. Brake) will catch your eye, Mr. Deputy Speaker, to make a simple point about that.

Ms Julia Drown (South Swindon)

Does the hon. Gentleman agree that we should urge all dentists in our constituencies to allow those people who have not visited their dentists in the allowable period back on to their lists, and encourage dentists to do everything that they can to keep people visiting them so that they automatically stay on their lists?

Mr. Hughes

I agree without reservation. I hope that I can persuade the Minister that, given that the 15-month watershed was not of his making but was inherited from his predecessor, that policy should be reversed so that we need no longer have such a watershed which, as the hon. Lady implied, causes so many people to drop off the list.

Many people today—perhaps millions—are deregistered without knowing it. Before Christmas, the Liberal Democrats highlighted the issue, but the Government did not respond as acutely and urgently as they could to ensure—the hon. Lady's point—that people knew what was going on and to ensure steps were taken to prevent people from falling off the list, as some now have. Staying on the list is the only way of avoiding prohibitively high prices for dental treatment. Those not on the list do not get free or NHS-paid-for dental care.

Ms Drown

rose—

Mr. Hughes

I would rather not give way, only because of my undertaking to the Minister, which is important. The hon. Lady can have a word with the Minister later.

There are two specific follow-on problems. Patients who want to register sometimes cannot find a dentist with whom to register, and some cannot get back on to the list where they were and cannot find anywhere else. That is a particular problem in rural areas. Those who are unregistered and need emergency treatment are in trouble, and it can cost them a fortune.

There are shortages of places to go to the dentist but there is also an increasing shortage of dentists. That is a result of the systematic and growing underfunding of dentists. Many dentists have been driven to private practice because of the difficulty that they faced in delivering high-quality treatment within the fee scales. The fee scales set three or four years ago by the Government clearly had a huge consequence of people leaving the NHS and going into private practice.

Mr. Lembit Öpik (Montgomeryshire)

Is my hon. Friend aware that, in some parts of mid-Wales, dentists who were practising have closed down and left, leaving people with a choice of either going private, waiting or having no dental care at all? In effect, many people in the country now regard dentistry as being privatised through the back door.

Mr. Hughes

My hon. Friend speaks about a part of Wales which he and I know well, and people do have that perception. They think that the NHS has lost much of its dental service, which has been privatised. That was never the intention, and it should not be the intention. My hon. Friend the Member for Taunton (Mrs. Ballard) told me earlier today that she had never understood why, from the beginning of the NHS, dentistry and ophthalmology have been treated separately from core services so that people obtain them from different places rather than going to the GP or a common place of provision.

Mr. Paul Tyler (North Cornwall)

rose—

Mr. Hughes

I shall give way for the last time, or the Minister will not have his pizza with his kids.

Mr. Tyler

Will my hon. Friend address a particular point which a number of my constituents have raised— that there is no NHS dentistry in large chunks of north Cornwall? Many of them have paid considerable national insurance contributions over many years. They thought that that was an insurance policy to enable them to take advantage of an NHS. That is simply not there. The occasional provision in a caravan of a salaried dentist, when and if they can get there, is simply not an NHS dentistry service. I hope that, in addressing that wider problem, my hon. Friend will ask the Minister to deal with the specific question of the rural areas which simply cannot now recruit new dentists to provide that service.

Mr. Hughes

My hon. Friend makes the point well, and I am sure that the Minister is seized of it. That is not an isolated example. We could, as I presume the Minister would accept, present dossiers of evidence from probably every county in England and, arguably, most counties in Wales too, making exactly that point. Often there is no dentist at all, or one only occasionally, and that is not a comprehensive health service.

Dental services are underfunded, and it is not surprising that dental practitioners have reduced the dental services that they provide. The BDA estimates that £40 million needs to be invested in NHS dentistry. I do not pretend that that figure is perfect. On 1 January 1998, when millions of people fell off the dental registers, Ministers announced an extra £10 million for the service. That is welcome money, and I heard the Prime Minister's reply to my right hon. Friend the leader of the Liberal Democrats at Question Time today.

However, investment from the war chest of money being stashed up by the Government in things such as dentists, dental training and dental health is far better than keeping it locked in the bank and paying off a bit more of our national debt. We need the money and investment to increase registration rates, retain the dentists within the NHS and guarantee the availability of emergency treatment for all non-registered patients.

We need an effective strategy for oral health promotion. That means the reintroduction of free dental checks to encourage regular visits and free treatments for all, but particularly for children, the elderly and those on low incomes. Secondly, as we have long argued, dental health must be an integral part of national and local health promotion initiatives.

Thirdly, I make the gentle suggestion of a White Paper, or a Green Paper, on dentistry. That would be welcome. It could reasonably be done and I make that as a constructive suggestion. In due course, it would be a helpful way forward. For understandable reasons, the White Paper has little in it about dentistry, and oral health was not mentioned at all in the Green Paper on public health.

Fourthly, we need incentives to attract dentists into poorly served areas and to bring them back from the private sector into the NHS. Health authorities need support in that respect. Lastly, we need an increase in the number of dentists being trained.

Core dental services must be put back in the NHS mainstream, and that means free dental services in terms of checks and provision. If the health of the nation is to be improved, the health of people's teeth and mouths is as important as the health of any other part of their anatomy. We hope that the Government will respond, because it is vital to the health of the nation as a whole.

8.19 pm

Mrs. Jackie Ballard (Taunton)

I wish to talk briefly about two issues—rural access and the public health implications of the decline of NHS dentistry. Some places have suffered more deregistrations than others, and places such as Cornwall, Somerset, Gloucestershire and Hampshire appear near the top of the league tables. Access to NHS dentistry is often most difficult in rural areas, where access to other services can also be difficult.

My awareness of the difficulties of access started seven years ago when my dentist in Taunton told me that he could no longer keep me as an NHS patient. Because of the fee structure, he felt he was unable to provide a high-quality service. When I raised the issue in the local press, I was denigrated by local Tories who said "Problem, what problem?" The Conservatives' interest in the subject is evident tonight by the empty Benches.

One dental practitioner in Taunton accepts new NHS patients. In the whole of my constituency, only two practices accept new NHS patients. In the constituency of my hon. Friend the Member for Somerton and Frome (Mr. Heath), people from Frome must travel 15 miles to Wincanton to find the nearest dentist who will take new NHS patients. Across Somerset as a county, only 10 out of 71 practitioners accept new NHS patients. More worryingly, less than half those practices will take new child registrations. There are many other problems of access to public and community services in rural areas.

I should be the first to say that those problems have not appeared in the past nine months. They are the result of 18 years of under-resourcing by the previous Conservative Government. That is why the Conservatives' new-found concern about the countryside is taken by rural dwellers with a pinch of salt. I do not blame the lack of NHS dentistry on the Government. I agree with the Prime Minister who, when Leader of the Opposition, told the then Prime Minister: I do not know how he dare mention dentistry in the NHS after what his Government have done to it."—[Official Report, 15 October 1996; Vol. 282, c. 586.] People now want to know what the present Government are going to do about it.

I shall now refer to the public health implications of the reduced availability of NHS dentistry. Even if people can find an NHS dentist, two things put them off visiting the dentist—fear of the drill and fear of the bill. In a poll published two years ago, 50 per cent, of people said that they would go to the dentist more often if check-ups were free. The figure was even higher among young people— 63 per cent, said they would go more often if check-ups were free. The implications of check-up fees deterring people from going to the dentists are that there will be a reduction in oral health.

I am told by local GPs that there has been increasing demands on their services caused by poor oral hygiene, gum disease and mouth infections which would previously be seen at an early stage and prevented by a dentist. Regular dental check-ups—as my hon. Friend the Member for Southwark, North and Bermondsey (Mr. Hughes) said earlier—help the early detection of other illnesses.

The British Dental Journal said this year that there was increasing evidence that dental health—especially gum disease—may be linked to coronary heart disease. I am not a biologist, and I do not understand the link, but I am sure that the scientists could explain it. The link is especially obvious in men aged between 40 and 50. That could put poor oral health alongside smoking and fatty diet as a significant factor in the development of heart disease.

We heard earlier that as many people die from oral cancer as from cervical cancer, and the figure is about the same as for those who die from skin cancer, which is not gender specific. In a survey of Members of Parliament in 1997, 90 per cent, of Labour Members said that they wanted to see a reduction in oral cancer as a public health target. The incidence of oral cancer is increasing, and yet dental check-ups could detect it at an early stage. As we know, early detection greatly improves the survival rate for any cancer.

Two weeks ago, in a response to my hon. Friend the Member for Torbay (Mr. Sanders), the Prime Minister said that the Government want as much NHS dentistry as possible".—[Official Report, 4 February 1998; Vol. 305, c. 1039.] Liberal Democrats also want that as soon as possible— but we want it sooner rather than later.

8.25 pm

Mr. Tom Brake (Carshalton and Wallington)

I shall refer to one aspect of NHS dentistry—the deregistration of patients. This is a subject of some seriousness, which The Times and The Sun have highlighted in recent days, giving rise to headlines like "Tooth of the Matter" and "MP Knows the Drill." It is an issue of national concern.

The British Dental Association has estimated that up to 8,500 patients per constituency will fall off the lists as a result of the change from 24 months to 15 months. As my hon. Friend the Member for Southwark, North and Bermondsey (Mr. Hughes) has said, that is equivalent to up to 5 million patients in 12 months. The British Dental Trade Association said that, far from enabling preventive care, "deregistration hinders accessible dentistry". It also pointed out that the NHS White Paper mentions dentistry only twice.

Ms Drown

The hon. Gentleman points out that the trade associations say that there is a great danger to dental health as a result of deregistration. Is it not the case that all that a dentist needs to do is to say that he will accept patients back on to his books, and then there would be no problem? Is it not the responsibility of dentists, as much as anyone else, to solve the problem?

Mr. Brake

The hon. Lady makes a valid point. However, there are already enormous difficulties in getting on to an NHS dentist's list, and I suspect that people who lose their place will find it difficult to get back in future. In a letter to me on the subject, a private individual said that he welcomed the efforts to publicise the true state of affairs that exists here and doubtless across the country. Those examples highlight the seriousness of the issue. I hope that the Minister will seriously consider the restoration of the 24-month period.

8.27 pm

The Minister of State, Department of Health (Mr. Alan Milburn)

I congratulate the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) on securing the debate, and I thank him for honouring the commitment that he gave to me in private. He will allow me to get home and, I hope, to see the kids, which will be refreshing in the middle of the week.

It has been a good, well-tempered debate. I hate to break that trend, but it is important to recognise the scale of the problem. We should do what we can to address it, but we must not create a crisis out of a problem and, in his early remarks, the hon. Gentleman was in danger of doing so. I shall reply in some detail to the points that he made.

That is not to say that the hon. Gentleman and his colleagues have not managed to raise some important issues. I have noted with a great deal of interest that they have been expending considerable effort and not a little ingenuity on raising one particular issue: the registration of patients. I understand, for example, that the hon. Member for Carshalton and Wallington (Mr. Brake) is even offering photo opportunities of himself with his mouth wide open. That is always extremely dangerous for a politician. I would ask him to take heed of the age-old adage that all politicians should bear in mind: before opening mouth, make sure that brain is engaged. I am sure that in his case that will be perfectly true.

I shall deal with the issue of the registration period in a moment, but I shall first set out why NHS dentistry is not about single-issue slogans. The issues that we must address are extremely complex. Anybody who pretends that there is an immediate solution to some of the difficulties we all face has simply got it wrong.

The Government value the important contribution to public health that dentists make through their work. Since the NHS dental service was established almost 50 years ago, there have been major improvements in the oral health of the population, especially among children. It is important that we recognise that, for all the problems, we have taken great strides forward. Our generation, and those that will follow, are in a far better position than the generations that have gone before.

Much of that is due to the success of the NHS and the considerable contribution that dentists have made to it. However, we should not rest on our laurels. The Government are committed to NHS dentistry. Dentistry has achieved much in the past, but we want it to achieve even more in the future. We want it to improve further, both to reduce inequalities in oral health and to improve the population's access to NHS services—two of the points made by the hon. Member for Southwark, North and Bermondsey.

I should like to make one very important point, to which the hon. Gentleman alluded. Improvements in oral health depend not just on the availability of dental treatment. Prevention has a key role to play, too. For example, there is overwhelming evidence that fluoridation of the water supply reduces tooth decay in children.

At the moment, legislation leaves the water industry, which was privatised by the previous Government, in the position to decide whether to agree to local health authority requests for new fluoridation schemes. Therefore, a health decision has been taken by privatised water companies. That seems to me and to the Government to be anomalous. The Government believe that the position needs to be reviewed, but we of course acknowledge that hon. Members on both sides of the House hold extremely strong views on fluoridation. That is why the public health Green Paper, "Our Healthier Nation", which we recently published, seeks to take account of those views and—I hope—find a way forward.

It is also important to acknowledge the contribution that dentists can make to prevention through oral health promotion and education and through screening. We also took that into account in preparing the Green paper. There is an important role for dentists in the early detection of pre-malignancies and cancers of the mouth—an issue raised by the hon. Members for Taunton (Mrs. Ballard) and for Carshalton and Wallington. For the future, further work needs to be done on how best to diagnose and manage such conditions. We are looking at those issues. To coin another old adage, prevention is better than cure. We are exploring ways of making that come to life in oral health.

The hon. Member for Southwark, North and Bermondsey referred to dental checks and his party's manifesto promise, on which it fought the election, to restore free dental checks. He is well aware that there is help to protect the most vulnerable groups, but that the Government are considering such issues, particularly dental health checks, in the comprehensive spending review. I remind him that the comprehensive spending review is being conducted in the context of our election manifesto commitment that, if someone is ill or injured, there will be an NHS service to help, and that access will be based on need and need alone. We are exploring those issues.

Mr. Simon Hughes

If, as I hope, the Government are persuaded by the argument and the preventive health care case, which the Minister has endorsed, on restoring free dental checks, they will be unreservedly supported by my party, and applauded for doing so.

Mr. Milburn

I thank the hon. Gentleman for that. In due course, the results of the comprehensive spending review will become known. Although prevention is important, treatment has a an equally vital role in tackling oral health problems.

Mr. Tyler

Before the Minister leaves the subject of prevention, will he comment on the previous Government's abolition of the school dental service, which did hugely valuable work and in which prevention was very much the order of the day? I know that there are arguments both ways, but will he at least give an undertaking to examine the particular role performed by the service? It was extremely valuable in deprived rural areas—and no doubt in deprived urban areas—where going to a dentist was not a normal family habit, as it was in better-off areas.

Mr. Milburn

We must have in mind the outcome that we want. We all want improvements in the population's oral health and, particularly, we want guarantees that children's oral health is safeguarded. There are a variety of ways of doing that. The school dental service was one way; ensuring access to an NHS dentist is another. When I address the way in which we are trying to improve access, perhaps I shall be able to offer the hon. Gentleman assurances that we are determined to tackle the access problems that he and his hon. Friends have raised.

It is vital that NHS dental services are properly planned, to address the differing health needs of different parts of the country. As the hon. Member for Southwark, North and Bermondsey is aware, we set out in our White Paper, "The New NHS", how every health authority will work with NHS trusts, primary care groups, other primary care professionals, the public and other partner organisations to develop a health improvement programme for each area.

I shall give the hon. Gentleman two assurances. First, in response to the direct question that the hon. Gentleman asked, we expect primary care groups to engage with dentists in their area. That is extremely important. It is important that primary care groups are not just the sole preserve of family doctors. We want other primary care professionals, dentists and community nurses equally to be engaged.

Secondly, and equally important, as the health improvement programme for an area is the local strategy for providing health and health care, it is extremely important that dentists are involved in the process of drawing it up. Indeed, I would expect oral health to feature in health improvement programmes generally. I hope that that helps to satisfy the hon. Gentleman's concerns on that issue. I am determined that, as part of the new NHS, general dental services should contribute increasingly to the improvements in public health that we seek. We are thinking how best to use the resources available to meet those objectives and improve the responsiveness, efficiency and fairness of the service.

So far, so good. I think that there is unanimity across the Floor of the House. [HON. MEMBERS: "Stop now."] I cannot stop now, because it is important that we nail a couple of accusations that have been levelled, and put the issue in perspective.

The hon. Gentleman said that NHS dentists are becoming an endangered species. I have heard others say that, nowadays, no one can find an NHS dentist. That is an absolute myth. Most of the population find NHS dentistry accessible. The tens of millions of people registered with dentists prove that. So does the record number of dentists on health authority lists—more than 19,500 at the end of December last year. In other words, the vast majority of patients in the vast majority of places for the vast majority of the time are able to get access to an NHS dentist. That said, it is obvious that the running down of NHS dentistry by the previous Government has left certain parts of the country with acute and, in a few cases, long-term problems of access to general dental services. Where that happens, it is unacceptable, and we are determined to take action.

I remind the House that, from the inception of the NHS, dentists have been free-standing, independent contractors. Where they decide to locate their businesses—for that is what they are—is a matter for them. Tragically, in the view of some, they choose to locate their businesses in the leafy shires rather than in hard-pressed rural areas or the inner cities, where oral health problems are arguably greatest. If anyone pretends that he has a simple answer to that complex problem, I should be delighted to hear it. I do not believe that there is a simple answer. We need to plan incrementally to make improvements year by year. That is precisely what we want to do, but the hon. Member for North Cornwall (Mr. Tyler) has a big idea.

Mr. Tyler

I wish I had. I want to go back to the point that the Minister made about the severity of the situation. Will he confirm that a dentist who reduces the NHS participation in his list from 90 per cent, to 10 per cent, is still included on the list of NHS dentists? Will he confirm that as a result of that, the number of dentists taking NHS patients can increase, but the number of patients on anyone's list can fall dramatically? As my hon. Friends have said, in several parts of the country that appears to be the case.

I endorse what the Minister has said about the way in which that has happened and the role of the previous regime, but the situation is serious in many parts of the country. As he correctly said a few moments ago, they happen to be parts of the country in which people can least afford to pay for dentistry. That is why there is such a crisis in those areas. I accept that it is not everywhere, but where it is an issue, it is a serious one.

Mr. Milburn

I agree. This debate is in danger of becoming almost too consensual. I want to reassure the hon. Gentleman that the Government not only recognise the problem but are taking positive steps to solve it. The investing in dentistry initiative was launched in September to, may I say, an almost universally warm welcome from, among others, the British Dental Association. It is an extremely important initiative. It will improve the availability of general dental services and extend the benefits of good oral health, by focusing help on the areas with the most serious problems.

Among a range of possibilities, grants may be made available to dentists to expand existing practices or set up new ones in return for long-term commitment to the NHS. Schemes may be able to help newly qualified dentists and those with domestic commitments who want to return to work part time. Up to £9 million has been made available for 1997–98.

The hon. Member for Taunton (Mrs. Ballard) raised local concerns, which I well understand. I can tell her that of the 200 applications that we have so far received from dentists wanting to expand their commitment to NHS dentistry as a result of the Government's initiative, some 73 have come from the South and West region of the national health service. I recognise that there are particular problems in her area. She may be pleased to know that 13 proposals for investing in dentistry schemes were recently received from Somerset health authority. Of those, one was for an orthodontic clinic in Taunton and one was for improvements to a surgery in Taunton. All those proposals are currently under consideration.

We are extremely encouraged by the positive response that we have had to the investing in dentistry initiative. We are giving dentists incentives to come back into NHS dentistry. We are providing meaningful opportunities for them to re-engage with their NHS patients. On 1 January this year, I was able to announce £10 million for next year to maintain the Government's drive to improve access to NHS dentistry and to tackle oral health inequalities through the initiative.

Ms Drown

I am grateful to my hon. Friend for agreeing to a bid to the initial investing in dentistry fund, which will mean that next summer in South Swindon we shall have for the first time in a long time a dentist accepting NHS patients. However, that is only a step. Will my hon. Friend assure me that the new bids from South Swindon will continue to be considered until we have a satisfactory NHS dental service in my constituency?

Mr. Milburn

I can assure my hon. Friend that I expect to see many more bids come in over the course of the next few months and beyond and that all the bids we receive will be looked at seriously. I am aware of the problems in Swindon and in the Wiltshire health authority area generally in respect of access to NHS dentists. We have made a start on addressing those problems, and we shall continue to tackle them. It is important that we target resources on the areas where there are most problems, such as that of my hon. Friend and of the hon. Member for Taunton.

Mrs. Ballard

I am delighted that the Minister recognises that there is a problem in the south-west, in Somerset and in Taunton in particular. Earlier he referred to dentists preferring to work in the leafy shires, but by many people's definition, the county town of Somerset might have appeared to be just such a place. I hope that the bids that the Minister gets from Taunton and Somerset will receive a favourable response.

Mr. Milburn

They will be properly and fully evaluated, but, as the hon. Lady is well aware, whether they receive a favourable response is a different matter. In due course, a decision will be made.

Mr. Simon Hughes

The Minister has made a perfectly good point about the history of independent contractors and the resulting anomalies and huge differences—for example, my area is well served, but that of my hon. Friend the Member for Taunton (Mrs. Ballard) is badly served. We would encourage him to act in a way that is consistent with the White Paper and require health authorities to plan for the necessary provision of dentists in their area; and to continue both incentive and disincentive schemes to make sure that gaps are filled and that, if someone wants to be a dentist in a place where there is no need for one, that person will not be greatly supported by the public funds of the NHS.

Mr. Milburn

Overall, the Government currently spend about £1,000 million, net of patient charge revenue, on general dental services in England, but that expenditure is wholly dependent on the level of activity of NHS dentists—it is demand-led. It is affected by a range of factors, including changing treatment patterns and a continuing shift to part-time working, especially as there are now more women dentists, which is a good thing, in my view.

Moving on to the points raised by hon. Members and by the BDA about some patients finding it difficult to get dental care under the NHS in future, apparently as a result of changes to the registration period for continuing dental care, I want to say loudly and clearly that that is simply not the case. Let me explain why.

From 1 April 1996, the previous Government made changes to the registration period for adults and children. Those changes were agreed with negotiators from the BDA. The registration period for both adult continuing care patients and children in capitation was harmonised to provide a period of continuing dental care for 15 months following each course of treatment. It had previously been 24 months for adults. Dentists receive a monthly fee for each child and adult registered with them under the NHS. That fee, which is to ensure that the patient receives a period of continuing care from the dentist with whom he or she is registered, is paid whether or not the patient attends the dentist again during the registration period.

Some recent publicity has given the incorrect impression that a new policy has been introduced with the intention of deregistering patients from the end of December last year. Not only is that untrue; it is nonsense.

Patients lapse from dentists' lists if they have not seen their dentist since registering. Before that change, each year, an average of 4.5 million patients lapsed from dentists' continuing care patient lists in England alone, indicating that they had not returned to their dentist in two years. That means that the dentist had been paid, but no continuing care had been provided.

The hon. Gentleman and his colleagues may think that that is a useful way in which to spend public money on NHS dentistry, but the Government and I do not. We want NHS dental moneys to be made increasingly available to encourage the active care of patients, because we are serious about improving the oral health of the population. That means that treatment must be targeted where it is most effective.

Patients who attend the dentist regularly will be unaffected by the change, as their registration period will roll forward, but much has been made of the implications for patients whose registration will lapse as a result of the shorter registration period.

The hon. Gentleman, his colleagues and the BDA have implied that patients subject to the shorter registration period will lose access to an NHS dentist. As my hon. Friend the Member for South Swindon (Ms Drown) rightly said, however, that will happen only if individual dentists refuse to re-register lapsed patients. It is for dentists to decide. If they decide not to re-register patients who were previously on their lists, their overall NHS work load, and therefore their income, will decline from previous levels. Evidence gathered in recent months shows that that is not happening to any significant extent. Indeed, many dentists seem to have been most anxious to encourage patients back to register again.

In case anyone is worried, the Government have made it absolutely clear that the money previously paid to dentists over the longer registration period, which has now been released, will not be lost from NHS dentistry. Any savings will be reinvested in the general dental service and targeted at achieving better oral health among the population. The shorter registration period already means that payments to dentists are now focused on patients who receive active care from them. That is the right priority, which will ensure real oral health gains.

The Government are moving the agenda for dentistry forward. As the hon. Gentleman is aware, a range of initiatives have already been taken, including the piloting of personal dental services, which will allow greater flexibility in the delivery of local dental care. I am aware that a bid from his area is currently being considered.

We inherited problems connected with the availability of NHS dental services and the considerable variations in oral health across the country. By the careful use of the resources available to us, and by seeking greater efficiency, flexibility and fairness, we shall tackle those inequalities in oral health status and improve access to NHS dental services. When we do so, I hope that we shall have the support of the hon. Gentleman and his party.

Question put and agreed to.

Adjourned accordingly at eight minutes to Nine o 'clock.