§ 2.56 p.m.
§ Order of the Day for the Second Reading read.
§ THE LORD PRESIDENT OF THE COUNCIL (LORD WOOLTON)
My Lords, this Bill has three main objectives: first, to grant the dentists the status and dignity of a self-governing profession; secondly, to regulate the admission of foreign and Commonwealth dentists to the Dental Register; and thirdly, to provide for the training of what I call ancillary dental workers. The Bill for which I ask the approval of your Lordships represents the final step in the progress towards the position when the profession may be entrusted with authority for registration, discipline and education.
The Dentists Act, 1921, gave the profession some measure of self-government by establishing a Dental Board, but this Board remained subject in some respects to the jurisdiction of the General Medical Council. In 1946, the Final Report of the Inter-departmental Committee on Dentistry, under the Chairmanship of the noble Lord, Lord Teviot, declared thatthe time has come when dentistry should become a self-governing profession.Both the Dental Board and the General Medical Council advocated this step in their evidence before the Inter-departmental Committee. Many of the provisions of the Bill follow from this step. I think it is proper that I should say here how indebted we all are to the noble Lord, Lord Teviot, for the vast amount of work and consideration he gave to this subject. A new General Dental Council is to be set up, whose general concern, in the words of Clause 1 of the Bill,shall be to promote high standards of professional education and professional conduct among dentists.The Council is to be composed of thirty-four members, partly elected and partly nominated, all but four of them being registered dentists. In addition, there are to be six members of the General Medical Council who will act as members on the General Dental Council when matters 1020 concerning dental education and examinations are to be discussed. This essential link between the two professions is therefore properly preserved. The new Council will have transferred to it the previous functions of the Dental Board and the General Medical Council in relation to the visiting of dental schools and examinations, the registration of dentists and disciplinary procedure. In transferring these functions, the procedure has also been improved, mainly on the lines which were adopted for the medical profession in the Medical Act, 1950. For example, the Bill gives a new right of appeal to the Judicial Committee of the Privy Council against a decision of the Disciplinary Committee of the General Dental Council to remove a dentist's name from the register, in the same way as a doctor was given in the Medical Act, 1950, a similar right of appeal against a decision of the General Medical Council.
A more important change is made in regard to the registration in this country of dentists who have obtained their qualifications in Commonwealth or foreign countries. Under existing legislation— that is, the Dentists Act, 1878—the General Medical Council have power to register a Colonial or foreign dentist if he holds a certificate recognised by the Council as furnishing sufficient guarantee of his knowledge and skill, and if the certificate entitles him to practise in his own country. Apparently, this provision has caused considerable difficulty. While there are some certificates which the General Medical Council have been able to recognise as automatically entitling the holder to registration in this country, there are others about which it has not been possible to obtain sufficient information to decide whether they are equivalent to a qualification granted in this country. Secondly, there are qualifications which are certainly of this standard but which, by law, do not entitle the holder to practise in his own country without a further practising certificate. Both these difficulties will be removed by the Bill. Under Clause 16 the General Dental Council are to be empowered to recognise Commonwealth or foreign diplomas as entitling the holders to registration in this country without any further inquiry. If, however, the Council are not entirely satisfied about the value of a particular diploma, they can, under subsection (3), require the holder to sit 1021 for an examination, and the Council will then decide as a result whether or not to permit him to go on the Register.
The Bill also contains, from Clause 21 onwards, a number of miscellaneous provisions which restrict the carrying on of the business of dentistry by other than registered dentists. Since the start of the Health Service there has been an undesirable growth of arrangements whereby a dentist is, in effect, employed in his practice of dentistry by a lay person. There are many variations of these arrangements, but there is no doubt that they may hinder the professional freedom of the dentist; and it is possible that in the hands of less scrupulous people these powers may be used to secure the maximum payment of fees under the Health Service. While the Bill seeks to discourage such arrangements in future, it does not change the position of dental companies which were in existence at the time of the introduction of the Bill. Subject to the normal disciplinary safeguards, such companies are entitled to continue in the business of dentistry.
The Government intend on Committee stage to move an Amendment to Clause 22. This clause enables the Disciplinary Committee to remove the right of an existing dental company to continue in business if the company is convicted of certain offences, or a director or member of the operating staff is removed from the Dentists Register. The Amendment will give the company a right of appeal to the Judicial Committee of the Privy Council against, a decision of the Disciplinary Committee to take action of this kind in cases where a member of the company's operating staff has been removed from the Dentists Register and the acts which led to his removal were connived at by a director of the company. In this way, a company will have the same right of appeal against the removal of its right to continue in existence because of the misdeeds of a member of the operating staff as the individual himself has against the removal of his name from the Register.
I now come to that part of the Bill which introduces the only really new principle—namely, the power of the General Dental Council to establish classes of ancillary dental workers, that is, persons who have not undergone the full training necessary to become regis- 1022 tered dentists, but who have been specially trained to perform certain limited functions. At present, dentistry may be practised only by registered dentists or doctors. The Teviot Committee took much evidence on the desirability of introducing ancillary workers into the dental field. The Committee recommended in 1946 that the institution of any scheme should await proof of a shortage of dentists to work a comprehensive service, and that a scheme for training one type of ancillary worker, called the oral hygienist, should be initiated forthwith on such a scale as would provide adequate test of their value. Certainly no further proof is now needed that the public dental service for the priority classes of expectant and nursing mothers and young children is in serious need of additional man-power. The shortage of dentists for pre-school and school children is particularly acute. In December, 1951, there were the equivalent of just over 700 full-time dental officers employed on this type of work, whereas an adequate dental service for children would require some 2,800 full-time dentists, on the assumption that one dentist can undertake the annual care of about 2,500 children. It is quite clear that, with the wastage due to retirement, the number of dentists on the Register is likely to increase but slowly, notwithstanding the large increase in the number of men and women now qualifying annually as compared with before the war.
Your Lordships' judgment in this matter may be helped if I quote a few figures to you. In the years just before the war, the annual entry into the profession was of the order of 340; during the last five years the number of students entering dental schools has been between 600 and 650 a year. The capacity of the dental schools has been used to the utmost during recent years, and much consideration has been given to the possibilities of further expansion. But such expansion is a costly process and, even when it has been decided upon, it is inevitably a slow process. It is estimated that there are to-day some 10,000 practising dentists in England and Wales, and at the present rate of intake this number will not be greatly increased. The Teviot Committee estimated requirements at 20,000 dentists, a figure it would take twenty years to reach on the assumption that the annual 1023 intake at the dental schools would be 900 students, as compared with what it, in fact, is at present—namely, 600 to 650. Meanwhile, the public and, in particular, school children will have had at best an insufficient dental service.
While the shortage of dentists to work a comprehensive dental service has been making itself felt increasingly during the past few years, the scheme for the training of oral hygienists recommended by the Teviot Committee has been instituted by the Ministry of Health. It began in 1949, and provided for the training and employment of these oral hygienists who, under the supervision of registered dentists, scale, clean and polish teeth and instruct patients in the technique of oral hygiene. Dental workers of this type were used in the R.A.F. during the war, and in America they are employed both in public dental service and in private practice. The progress of the training scheme has been watched by a sub-committee of the Standing Dental Advisory Committee which forms part of the Central Health Services Council. The sub-committee, in an interim report, have said that the work of the hygienists is of a good standard, and is of value and assistance to dental officers. It is understood that the subcommittee's final report, which is to be issued shortly, confirms this view. In a recent pamphlet issued by the British Dental Association, the Association call for speedy action in the recruitment and training of oral hygienists to overcome the present serious crisis in the dental treatment of priority classes. This Bill will enable the General Dental Council, if they so decide, to give official recognition to oral hygienists, but it provides that they shall work only under the supervision of a registered dentist.
There is a second type of ancillary dental worker, who has existed in New Zealand since 1923 and who is known in that country as the school dental nurse. The New Zealand type of ancillary worker differs from the oral hygienist about whom I have been speaking, in so far as he is able also to undertake the extraction and the filling of teeth. A report on this type of dental worker has recently been made by the World Health Organisation. This report states that at first there were efforts by some sections of the dental profession to hinder and, if possible, to overthrow the scheme.
1024 This view soon changed, however, and the New Zealand Dental Association unanimously passed a resolution hoping that it would be possible to extend the work. The Association, in fact, claims much of the credit for the institution and the development of the scheme. By 1949, the New Zealand dental ancillaries were responsible for the dental treatment of 84 per cent, of the primary schoolchildren in New Zealand. The success of the scheme has been confirmed by the report of a United Kingdom Dental Mission which visited New Zealand early in 1950 to study the scheme, and which included the President-elect of the British Dental Association, who described himself as an independent private practitioner. The conclusions of this Mission were unanimous and they were these:… the training of the New Zealand school dental nurses has resulted in a high standard of technical efficiency in the treatment of children within the limits laid down and … subject to the staffing limitations, the dental nurse system in New Zealand meets an urgent need.The report continues:Should His Majesty's Government decide to accept some like system of dental auxiliaries, we recognise that it would be a matter for those responsible to consider what modifications would be necessary to adapt that system to the existing pre-school and school dental services in this country, and in what direction these services would require to be modified; and it would also be important to secure the fullest co-operation with the dental profession as was, in fact, done in New Zealand.In view of that report, it is not surprising that the Government should now consider whether ancillary dental workers, similar to those working in New Zealand, would help to meet the urgent need in this country. The Bill does not, however, empower the General Dental Council to introduce this type of worker straight away, or indeed at all, until an experimental scheme has been carried out and its results show that such ancillaries can be used successfully in this country.
Clause 19 of the Bill provides that the Council are to arrange for the training and subsequent employment of a number of persons whose work will include the extraction and filling of teeth. The Minister of Health and the Secretary of State for Scotland are empowered to give financial help towards the cost of this experiment, and a two-year course of 1025 training is envisaged. After the first batch of dental workers have been trained, and then been employed for a year, the Council are to report on the success or otherwise of the experiment. When the success or otherwise of the experiment can be judged, and only then, if the results justify such action the Council are enabled, in conjunction with the Privy Council, to proceed to draft regulations to establish a class of such ancillary workers of this type. Moreover, Parliament retains the control of the position, for these draft regulations must, in turn, be approved by a Resolution of each House. When Parliament has approved these regulations, these ancillary workers, like all other ancillary workers, may be employed, under the terms of the Bill, only under the supervision of a registered dentist. There is the additional proviso that in their case they may be employed only in the national or a local health authority service—that is to say, in hospitals, school clinics, maternity and child welfare clinics and the like, but not in the general dental service carried on in private surgeries under the National Health Service.
I realise that, so far as the New Zealand type of worker is concerned, there are divergencies of opinion within the dental profession, but the various safeguards laid down in this Bill should ensure that the introduction of this type of ancillary dental worker into this country will be made, if at all, only following much deliberation, including the experimental scheme and after the approval of Parliament has been secured. I have taken some time in referring particularly to the oral hygienist and to the New Zealand type of ancillary dental worker. The Teviot Committee referred to other types of dentists' assistants as ancillary dental workers—I have in mind the dental mechanic and the chair-side assistant, who is responsible for the sterilisation of instruments and the preparation of fillings. The Bill, however, limits the term "ancillary dental worker" to those who practise some form of dentistry—that is to say, those who have contact with the patient and perform some operation on the mouth. It would, for instance, be possible to create a class of dental workers who would not only make dentures but would also take impressions of the mouth 1026 and fit the dentures—work which can at present be performed only by registered dentists.
Whether such a class or other classes of ancillary workers shall be created is a matter for the dentists to decide. The initiative lies with the General Dental Council under Clause 18 of the Bill and I would remind your Lordships that thirty of the thirty-four members of the Council are themselves registered dentists. The only obligation placed upon the Council, so far as ancillary workers are concerned, is that they shall conduct an experimental scheme such as that to which I have already referred under the heading of the New Zealand type of worker. If ancillary workers are to be introduced into this country, there should, therefore, be no danger of a fall in the standard of dental treatment, and there is every prospect that they may eventually help to fill a serious gap in the present health services—a gap which otherwise could be filled only by speeding up the training of registered dentists, with the inevitable consequence of a lowering of the present very high standards of professional qualification. Many thousands of children are now being deprived of dental aid and education. I think it is important to the health of the nation that we should seek whatever means are at our disposal for meeting this need. I hope that I have convinced your Lordships that these provisions relating to ancillary workers are reasonable and sensible, and that the dental profession itself is well protected. I trust that this Bill will commend itself to your Lordships. In moving that it be read a second time, I wish to state that, since I have heard in private conversations that there are some doubts about some of these ancillary workers, I will arrange that there shall be a reasonable amount of time between the Second Reading and the Committee stage in order that we may have such consultations as will help to clear up any doubts in your Lordships' minds. I beg to move.
§ Moved, That the Bill be now read 2a.—(Lord Woolton.)
§ 3.22 p.m.
§ LORD TEVIOT
My Lords, I should first of all thank my noble friend who has so ably moved the Second Reading of this Bill for his kind reference to myself. Naturally, this Bill brings me a great deal of pleasure. I had thought that after 1027 the two and a half years' work of my Committee there was at least a possibility that their Report would be pigeon-holed. However, the new Government have produced a Bill, which to a large extent agrees with the Report. I have naturally consulted my dental friends in regard to the Bill and, generally speaking, they are well satisfied with its provisions. There are one or two slight alterations that will be suggested on the Committee stage, but the main bone of contention, as the noble Lord suggested, will be the ancillary workers. I propose to spend a little time in discussing that question, and in doing so I shall, of course, take into account the advice given to me by members of the dental profession, who are far more capable than I am of judging the importance of the question.
The institution of a General Dental Council is a matter of great satisfaction to the dental profession. It raises the level of the profession and gives it the same sort of status as the General Medical Council gives the medical profession. I can assure my noble friend, Lord Woolton, that dentists are very gratified about this—particularly as it was one of the recommendations in my Committee's Report. My noble friend referred to the placing of the ancillary workers under the supervision of a dental surgeon. I would urge upon him that another word should be placed before the word "supervision," and that is the word "personal." We apprehend great danger unless personal supervision by a fully-qualified dental surgeon is exercised during the treatment of a patient.
§ LORD WOOLTON
I am sorry to interrupt my noble friend, but I am wondering what kind of supervision there could be other than personal supervision.
§ LORD TEVIOT
I think it will be an answer to the noble Lord if I say that in New Zealand ancillary workers sometimes do their work 200 miles away from the nearest qualified dental surgeon. It might well be so in some places in this country. My Committee went very thoroughly into this question, and your Lordships will find on page 32 of the Report (sub-paragraph 3) these words:The registered dentist under whose personal supervision the work is performed:—We had considerable discussion on this subject and that was the conclusion at which we arrived.
- (a) must always be present when operative work is being carried on;
- (b) must not supervise more than two persons at one time if he himself is performing operative work at the same time, or more than six persons at one time if he himself is not so performing;
- (c) must prescribe the treatment to be given and inspect every case after treatment and be responsible for the efficient carrying out of the treatment."
The noble Lord, Lord Woolton, referred to oral hygiene, but we considered it proper that an ancillary worker should do scaling, polishing and oral hygiene—which embodied instructions to the patient on how to maintain the mouth in a good state with the object of preserving the teeth. I remember seeing, during a journey I made in China, in every school and every works tin mugs and tooth brushes hanging up—and there the people had the most wonderful teeth. I wonder how many children here know how to clean their teeth properly—I doubt, indeed, whether a great many grown-up people know. I am a great age, but I have lost only four teeth. I put this down to the fact that after every meal I clean my teeth. Decay of the teeth, as every one knows, is caused by particles of food getting between the teeth and being left there for hours or days. I believe that oral hygiene, plus the toothbrush—in the use of which the oral hygienist would instruct people—would enormously reduce the number of patients in schools.
From the information which I can obtain I am afraid that I cannot entirely agree with my noble friend that to-day there are not enough dentists to provide reasonable treatment for adult patients in this country. It will be remembered that, when the National Health Service Act was passed, providing for free dental treatment, a tremendous number of people rushed to have their mouths looked at and to receive dental treatment. Noble Lords will also remember that, when a very moderate payment was introduced for the supply of dentures the immediate drop in the number of patients was most noticeable. I very much regret this new charge of up to £1 which is to be made. I believe that the number of patients will be enormously reduced, and I am told by my dental friends that, judging by present experience, there will be a very large reduction in the number of patients seeking treatment. 1029 In regard to the schools and children, there is no doubt that the situation is deplorable. They are appallingly short of treatment and inspection. Let me for a moment refer to the children. Does it not occur to your Lordships that none of us would care to send his children to be treated by an ancillary worker for an extraction or a filling? It does not very much matter that a man of my age should have a filling done not too well; it does not have to last very long. But with a child which has its permanent second teeth, surely it is: far more important that a dental surgeon, rather than any ancillary worker, should do the filling, because one hopes that the filling of the child's permanent teeth will last very nearly for the rest of its life, which will be very much longer than I can possibly anticipate mine will be. Therefore, I go so far as to say that I should like to see a reduction in the service to the grownup people, and an increase in the service to the children. At the moment, there is no inducement in that direction. As noble Lords who have studied this question will know, it barely offers a living for a dental surgeon to become a children's dentist. We have to offer the inducement of a reasonable return for work of that sort. So I am afraid that I must part company with my noble friend in this idea that we should permit those who have only two years' training to embark on extractions and fillings.
In talking with my dental friends, I have been told of many instances where an extraction, badly carried out, particularly in young children, definitely does damage the jaw to a great extent. I will come to that subject a little later when I will deal with it rather more fully. My noble friend has said a good deal about New Zealand. I have read a good many of the reports from missions and others who have visited the country, and I am not sure in my own mind whether, by and large, there is anything being done in New Zealand that we should adopt here. I do not think it is possible for us to do it—but I will elaborate that point later. We are to embark on a three-year experiment. Let us for a moment consider what that means. After three years, there will be people operating, so far as I can make out, as a dental surgeon does to-day—scaling, cleaning, polishing, carrying out oral hygiene, extracting and filling. That pretty well embraces the 1030 whole of the work that a fully-fledged, highly educated dental surgeon does. It is a frightful responsibility to take. Suppose that at the end of the three years' experiment it proves to have been a failure. It is horrible to think of what harm may have been done in those three years. I am afraid that I cannot in any way support that idea.
Let me now come to this question of teaching these ancillary workers. As the noble Lord said, the dental schools to-day are fully employed, and I am informed that there are 2.4 people waiting for every vacancy there is. If the teaching is to be interfered with, it will mean that we shall have fewer highly qualified, fully trained dental surgeons, because surely it would mean taking away the people who are now teaching men and women to become dental surgeons. We know that ancillary workers are, generally speaking, women or girls, and I am told that the experience is that in that profession they last for only ten years; the women get married, or they go off to do something else. The fully qualified dental surgeon, on the other hand, averages forty years' work in the service of dentistry. So, if we are going to divert some of the teachers from the training of fully qualified dental surgeons to producing these ancillary workers, it seems to me not a very sound proposition.
In my Committee's Report we laid it down very strongly that on no account were dental hygienists or ancillary workers to be involved in interference with living tissue. Clause 19 requires the Dental Council to make regulations to establish a class of ancillary workers to do extractions and fillings. I put it to your Lordships: can two years' training produce an ancillary worker able to do practically everything now done by a fully trained dental surgeon, whom it takes four to five years to train, without involving a great risk as to the results of the treatment? If it is possible to get the money, I believe that the solution to this problem is to increase the school capacity for dental training. Ancillary training would delay this, and, in my view, would assuredly mean a diminution in numbers of possible dental surgeons. It does not seem to me to be sound, from the point of view, either of efficiency or of economy. As I have said, girls work for ten years and men for forty 1031 years. I have already mentioned that I feel that there must be some incentive to encourage the dental surgeon to do more school work. I know that the situation in the schools is extremely dangerous and very difficult. The position with regard to children is most unsatisfactory. But, by doing as I suggest, and also, perhaps, by allowing the fully qualified dental mechanic to do a little of the work that is now done entirely by a dental surgeon, I think we might be able to relieve the dental surgeon of a certain amount of work, and thus enable him to give more time to the patient.
Although it was not in our terms of reference, we stated in our Report how strongly we felt about the question of diet. If I may, I will read what we say about that on page 30, paragraph 158:As a dental Committee, therefore, we urge upon the Government with all the force at our command that they should take measures to make available to all, and most of all to expectant and nursing mothers, children and adolescents, the diet which medical and dental science finds in its progress from time to time to be the best for the promotion of health.Then we list the types of diet which we think would help. Your Lordships will no doubt smile when I tell you that the first item mentioned is "bread of high extraction." I was horrified to hear the noble Lord, Lord Horder, only a day or so ago, when speaking about agene, say that it does not matter, that this beautiful white bread is something that people should have, and so on. A very eminent member of the medical profession said to me: "I do not want to eat what poisons a dog," and I quite agree with him. America has banished agene, and I think that matter is something we must consider. I believe that the condition of children, and especially of their teeth, could be helped by school meals. I would prefer to see a good deal of money spent on doing things of the sort I have mentioned, before we go so far as to give people who are not fully qualified dental surgeons the right to extract or fill either children's teeth or those of anybody else. My Lords, I thank you for listening to me. I hope I have not spoken too long. I regret not to be able to agree entirely with my noble friend who so ably moved the Second Reading of this Bill, but I have stated the considered opinion I have formed as a result of two and a half years with my dentist friends.
§ 3.45 p.m.
§ LORD NATHAN
My Lords, after a fairly long interval I hope to resume some active part in the deliberations of your Lordships' House, I am glad that the first occasion for my doing so arises on a Bill which presents no Party issues. Indeed, how can it present Party issues, since it is introduced by the present Government and was largely prepared by the late Government? Apart from the issues to which reference was made by the Lord President in moving the Second Reading of the Bill, and by the noble Lord, Lord Teviot, there are no controversial issues. I was glad that the Lord President indicated that conversations would take place with a view to allaying the anxieties which undoubtedly are felt in certain quarters about the clauses relating to ancillary workers, a matter to which the noble Lord, Lord Teviot, devoted the greater part of his observations to-day. Noble Lords who have studied this matter would wish to express appreciation of the stalwart work done by the noble Lord whose name has been given to this Report.
This Bill marks the coming to maturity of the dental profession. It has for long been under some degree of tutelage. The General Medical Council has been exercising, latterly in less degree but earlier more actively, a certain supervision over the activities of the Dental Board. Even until now, reports from the Dental Board on questions of discipline have had to be referred to the General Medical Council. As some of your Lordships know, I am myself a lay member of the General Medical Council. In the initial instance I was the only lay member, the appointed in succession to the noble Lord, the late Lord Hacking, whom many will recall as having taken an active part in the discussions upon the Medical Act of 1950. I think it is not out of place that I should say that Lord Hacking left the General Medical Council with a memory of one who, as a lay member of the Council, had performed a most useful service to the medical profession.
At sittings of the recently created statutory Medical Disciplinary Committee, of which I am also a lay member, I have often thought how absurd it was that this profession of dentistry should still have to present recommendations for confirmation or otherwise to the General 1033 Medical Council, who have little concern with the activities of the dental profession, save as a matter of history. I think it was stated in the Report of the Teviot Committee that at: the dental profession had now proved itself fit for self-government. That self-government is given by this Bill. The Dental Board, becoming the General Dental Council, will now be in a position to exercise disciplinary control over the members of the profession without any reference to the General Medical Council, as has been the case hitherto. The profession will have become a profession independent and self-governing. It will now be a profession that has graduated.
I have no authority to speak in the name of the General Medical Council, but I believe I am expressing the views of my fellow members of that body when I say, in regard to this Bill, that they have long felt that the dental profession has come of age and should be put into a position to manage its own affairs, subject to such slight continuing help in the field of education as is indicated by the provision in the present Bill for the nomination of six members by the General Medical Council for educational purposes. I shall also, I believe, be right in saying that the mood of the General Medical Council is one of positive satisfaction, as distinct from resigned acceptance, that the transfer of powers is about to be effected. With regard to education, your Lordships will have observed that the General Medical Council is to have representation upon the about-to-be created statutory Dental Education Committee. That is entirely in line with the Report of the Teviot Committee, and, by those somewhat tenuous means, within the realm of education contact is maintained between the two General Councils—the medical and the dental.
Those of your Lordships who remember the debates on the Medical Act of 1950 will recall that, on matters of discipline, a great deal of discussion took place regarding the size of the Disciplinary Committee prescribed by the Medical Act. This consists of nineteen members of the General Medical Council. Many of your Lordships, and honourable members of the Lower House who held the same view, were of the opinion that that was too large a number adequately and 1034 properly, in the normal case, to sit in adjudication upon the matters coming before a disciplinary committee. Consequently, the Medical Act provided that the Medical Disciplinary Committee should sit in panels of not more than nine. Experience thus far shows that this arrangement has worked not too badly, yet, perhaps, not entirely satisfactorily. I observe that under the present Bill the Dental Disciplinary Committee is to be limited to eleven members, including the President, and it will not sit in panels but as a body. I think that the principle of having a Committee of eleven to sit as a whole is preferable to the method adopted in the Medical Act, and I am glad that this course has been followed.
I note what the Lord President of the Council said with regard to the authority given to the General Dental Council to recognise Colonial and foreign qualifications. I hope that the discretion which it is proposed to vest in the General Dental Council, whilst being exercised—as it must be—with due regard to the requirements of the public interest, will also be exercised with some regard, so far as may properly be, to those dentists who have foreign qualifications, some of whom have come as refugees to this country. This is a matter upon which, I know, there has been a good deal of "to-ing" and "fro-ing" for a period of some years. In some quarters there is a feeling that a certain degree of hardship is caused, perhaps unnecessarily. I express no opinion myself, for I am not qualified to do so. But, subject to the safeguarding of the interests of the public, I trust that some amelioration will be possible of the situation as it exists to-day.
I do not propose to spend time upon the debatable question of ancillary workers. The Lord President of the Council has said that this is a matter which is to be the subject of informal discussions. It is certainly one upon which different members of your Lordships' House may well hold differing views. I know that there are certain anxieties; and I trust that the discussions which are to take place will result in those anxieties being allayed. I will say only this from my own experience in these matters. I have a responsibility in connection with Westminster Hospital, of which, as some of your Lordships know, I am Chairman. There we have an oral 1035 hygienist. I made inquiries, in the light of this Bill, as to how this recent acquisition was fulfilling her functions, and I am bound to tell your Lordships that the result of my inquiries was very satisfactory. I was told that the oral hygienist was an admirable and most useful addition to the staff of the hospital. Oral hygiene is, of course, ancillary work within the meaning of this Bill. In view of the fact that in the profession, for instance, of the ophthalmological surgeon, assistance is given by orthoptists, who perform—naturally after a course of training and gaining a diploma—highly skilled operations of a minor character upon the eye, I can scarcely see why it should not be possible for people without dental qualifications, yet who have undergone a reasonable period of training and obtained an appropriate diploma, to be employed for comparable purposes in dental work, without danger to the public interest.
Above all, I would say it must be a prime interest that the School Medical Service, which—I think the Lord President of the Council and Lord Teviot both agreed upon this—is the foundation of sound teeth for the future, must be put upon a satisfactory footing. It must be made possible to provide adequate dental service for thousands of children for whom at the present time the service is inadequate. It is much to be doubted whether the dentists' profession will be able to provide fully qualified dentists in sufficient numbers within a measurable future period to staff that service. It may be—I do not know—that unless a service by ancillary workers, duly trained and, of course, acting only under the supervision of qualified dentists, can be established, the present generation of schoolchildren, and possibly some later generations, will be condemned to go without that dental treatment on which so much of their oral well-being in later life depends. I trust that the various organisations interested in this matter—with whom, no doubt, consultations will be held—will feel their anxieties allayed regarding the Bill now before your Lordships' House. I hope that in the outcome it will be acceptable to an overwhelming majority, if not to all those concerned, to seek modifications of the provisions about ancillary workers. At all events, at this moment I may say to 1036 noble Lords sitting opposite that they will be supported by noble Lords on this side of the House in giving a Second Reading to this Bill.
§ 4.0 p.m.
§ LORD WEBB-JOHNSON
My Lords, I support the Motion to give this Bill a Second Reading, because it embraces two objectives with which, up to a point, I have been in sympathy for many years. Naturally, I welcome the formation of the General Dental Council. My fears that those who framed the Bill were blind to the fact that dentistry is a branch of medicine are allayed by the fact that there is provision for this Education Committee of the General Dental Council, with representatives of the General Medical Council on it. Moreover, the academic and scientific side of dentistry is safeguarded in its relation to medicine by the fact that the dental schools are in association with the universities. One of the most famous of these university dental schools is that at Manchester University. Of course, it is difficult to reconcile some of the remarks of the Lord President with those of the Chancellor of the University of Manchester. The relationship of the academic and scientific side of dentistry with surgery is also safeguarded. Its academic home is the Royal College of Surgeons, where there is a faculty of dental surgery and where the greatest number of qualified dentists take their diploma and also seek to take the higher diploma of Fellowship.
I come to the question of ancillaries—let us call them dental nurses, because that describes the functions which I think they ought to fulfil. I am all in favour of encouraging the training of such dental nurses, provided that the limits of their activities are narrower than are at present laid down in the Bill. I always thought that the 1921 Act was too restrictive. It seemed to me ridiculous that in dental surgery the dental surgeon should be able to have the assistance of a dental nurse or hygienist only in a hospital or public clinic, and should not have the assistance of such an individual in private practice. I think the Lord President was in error when he said that under the present law they can be used in private practice. I believe that on inquiry he will find that that is not so. The value of the dental hygienist and nurse has been amply proved. It was proved dramatically in 1037 the Royal Air Force. The work done by dental hygienists in that service was of an outstanding standard and could not have been better; but, as recommended in the Teviot Committee Report, their work was confined to scaling, cleaning and polishing teeth, and to instruction in oral hygiene. The dental hygienists were not used for filling, or for preparing cavities to be filled, ensuring that they should be free from all infection, or for extractions.
Should a dental nurse do more than a fully trained nurse who assists a general surgeon? The general surgeon does not call on a nurse to undertake actual operative work; he does not, in undertaking an operation, ask the nurse to saw through the bone while he goes and has a look at another case. In the same way, as the Teviot Report lays down, the dental nurse should not be permitted to interfere with living tissues. We should bear in mind another paragraph of the Teviot Report, which my noble friend was perhaps too modest to read and which says that if the recommendation to establish a class of oral hygienists is carried out, thatmay be expected to reduce the incidence of parodontal diseases, diminish the need for treatment by the dentist and improve the general health.Surely that is a better objective than putting operative work into the hands of semi-skilled people.
One wonders why these proposals have been made. Is it because of a belief in the principle of relieving dentists of this operative work, or is it just a matter of expediency? Is it merely a question of a shortage of dentists for priority groups, for children and expectant and nursing mothers? I agree that in another place it was stated that the dental service is out of balance, largely because, in spite of warnings, it was launched in such a way as to create an overwhelming demand. Among the reasons given by the Chancellor of the Exchequer for the charges for dental services is that the Government wish to make sure that the demand of those who most need help receives preference. It was said that it would free more dentists to meet the needs of the priority classes. So it is proposed to provide the priority classes with second-class services, given by unqualified dentists. It will be a service which the Government 1038 cannot claim is of the highest standard available. I should have thought they might well concentrate on attracting the highly qualified dental surgeon to look after the priority classes. I am informed that the drift back to the school dental service has already begun. This is attributed to three causes: the fact that the initial rush is over, that a charge for certain dental services has been imposed, and that the Whitley Council have improved conditions in the school service. I am sure that the better way to provide an adequate dental service for priority classes is to train dental surgeons, rather than ancillaries, to do operative work. Oral hygienists for the work I have indicated can be trained in shorter time and made available much more quickly. There was a good school service before the National Health Service came into being. I agree with my noble friend Lord Teviot that any attempt to train dental ancillaries up to the stage of being regarded as qualified to undertake extractions and fillings is hound to encroach on the facilities for training dentists.
In regard to the New Zealand service, I do not think the conditions there are comparable with those existing here. Although the Lord President quoted from their Report, I thought the Committee were distinctly lukewarm. The Report did say that there was technical efficiency, which meets the urgent need. It then went on to say, "should His Majesty's Government decide to adopt" (but it did not recommend them to adopt) "they will have to make provisions in certain services." It also said that it is most important to secure the co-operation of the profession. It looks to me as though the profession, through its representative bodies, is opposed to the scheme in its fullness. An independent United States observer of the New Zealand scheme expressed the opinion that the care of the children's teeth was almost entirely remitted to the dental nurses; that few dentists remained interested; and that the scientific aspect of children's dentistry was largely ignored. As to supervision, that, of course, requires most careful definition. Supervision in New Zealand consists of a principal dental officer, having eighty dental nurses under his charge, and he visits each of them at least three times a year. There is, further, a dental nurses inspector, who 1039 also has to visit the dental nurses three times a year. That is entirely different from what was recommended in the Report of the Committee of my noble friend Lord Teviot.
I wish to deal shortly with the question of dangers. Under the Bill this scheme is not confined to children. The plea is "Save the children," or what you will. But that is not stated in the Bill. The Lord President of the Council persuasively told us that it is all to be in the hands of the General Dental Council. But is it? The Bill says the Council "shall" institute, not they "may." And by carrying out this instruction they will create a body of partly trained dental workers. The noble and learned Lord on the Woolsack may, ultimately, have to decide where liability lies in case of any accident at the hands of these workers. No doubt they can be made technically competent, but they will not have had enough scientific training to make them competent to form a diagnosis, especially during that vital period of the eruption of the second dentition.
I hope that noble Lords will give anxious thought to this Bill before it reaches its later stages, and that the Government will emulate Agag and pay attention to some injunctions in the Book of Common Prayer: that this isnot to be enterprised nor taken in hand unadvisedly, lightly or wantonly, but reverently, discreetly, advisedly and soberly."Reverently," I think, is appropriate, because everyone who seriously practises surgery approaches his patient and his surgical task with (my predecessor in the Chair of the College claimed that he always did) reverence in regard to his load of responsibility and the human life at stake. The suggestion is most serious. I hoped that the Government would be anxious for advice and discussion, and I am greatly relieved to have the assurance of the Lord President of the Council that this is so, and that there will be ample time between the Second Reading and the Committee stage for us to consider the Bill further. My last word is a plea that the Government should in this matter be content to go slowly, step by step; and that they should be content with developing a big corps of oral hygienists. After all, we are to-day in this difficulty because someone tried to go too fast.
§ LORD WOOLTON
My Lords, I did not want to interrupt the noble Lord while he was speaking. I am sure that he would be the last one to misrepresent me, but he did, in fact, misquote me. I did not say that the New Zealand type of nurse should practise in this country in private. What I said was that dental workers of this type were used in the R.A.F. during the war, and in America dental hygienists are employed, both in the public dental service and in private dental service. It was in America, and not in this country, that I said they were so employed.
§ 4.16 p.m.
§ LORD AMULREE
My Lords, I do not want to take up a great deal of your Lordships' time, as there are many other noble Lords who wish to speak on this Motion for Second Reading. However, I want to endorse the plea of the noble Lord, Lord Nathan, for some of the foreign refugee dentists who are at present working in this country, and to ask that special attention shall be paid to them when the General Dental Council which is to be established comes to consider what people with foreign qualifications shall be permitted to practise in this country. The type of fear which filled my mind when I first read this Bill, particularly Clauses 18 and 19, has been put before your Lordships so well by my noble friend Lord Webb-Johnson that I need say very little on that subject. But I should like to support his plea for the employment of oral hygienists on a wide scale, so that they could work not only in the public service, in the Armed Services, or in the National Health Service, but also in private practice. That would allow a great many qualified dentists. who at present have to spend a certain amount of their time doing scaling, polishing and cleaning, to give more time to patients for whom they could do more important dental work.
I was pleased to hear the Lord President of the Council say that there would be plenty of time to discuss this very vexed question of the dental ancillaries doing extractions and fillings. Like my noble friend, Lord Webb-Johnson, I feel that it is a major task to give to an unqualified person. One might in a similar way say that, because we now 1041 have a shortage of doctors—possibly only temporarily—certain medical students ought to be allowed to work upon some types of patients in order to overcome the difficulties created by that shortage. There is a great deal of comparability between the two positions, because certain forms of extraction can be as difficult and as dangerous to the patient as some of the most complicated surgical operations. I noticed that according to a report by an American surgeon on the New Zealand scheme (I think the report was one put before the United Nations) a large proportion of the young men in the New Zealand army—I believe it was 52 or 55 per cent.—were found to be suffering from grave dental defects. Supposing that were so, then the matter should be looked into very carefully. It shows perhaps that the scheme in that country is not quite so. successful as some of its protagonists have made it out to be.
§ 4.20 p.m.
§ LORD WILLIAMS
My Lords, I shall not detain the House very long because, in moving the Second Reading, the noble Lord, the Lord President of the Council, gave a certain undertaking which goes some way to removing one of the objections which I have to a particular clause of the Bill. At this stage I should perhaps declare an interest. I am a Director of the Co-operative Wholesale Society. That Society is a shareholder in the Co-operative Dental Association, Limited, an Association which is a private company, limited by shares—the holding being of a nominal character—on which the payment of interest is at a fixed rate, and on which no dividends have been paid.
The noble Lord dealt with Clause 22 of the Bill, but gave adequate reasons for a change compared with the present position. Under the 1921 Act,A body corporate may carry on the business of dentistry if—Now there is a distinct change in the present Bill, because in future no new corporate body can undertake the work of dentistry, and I should have liked the 1042 Lord President of the Council to give us more information as to why no new corporate body can come into existence. The noble Lord mentioned, in passing, that one or two corporate bodies had been guilty of malpractices, but I should have thought it would be possible to deal with those malpractices without creating such a closed corporation that in future no new corporate body could come into existence. I shall have a word to say about that in a moment.
- (a) it carries on no business other than dentistry or some business ancillary to the business of dentistry; and,
- (b) a majority of the directors and all the operating staff thereof are registered dentists."
Another extremely interesting feature of Clause 22 is this. If the name of a director or a member of the operating staff is erased from the Register on any of the grounds mentioned in Section 13 of the Dentists Act, 1878, the Disciplinary Committee may proceed to declare that the corporate body is no longer entitled to the protection given to it in the Act of 1921. Now it is quite clear that Clause 22 is aimed at dealing with corporate bodies, and it is pertinent to ask—because we have no information—why it is that this particular clause in the first place prevents any new corporate body from coming into existence, and, secondly, gives very wide powers for the Disciplinary Committee to deal with existing corporate bodies in the event of misconduct, not on the part of the corporate body itself, but on the part of one of its staff. In a moment or two I will deal with that matter from the point of view of the corporate body itself. It cannot be accepted that the skilled operating staffs of corporate bodies are less efficient, less skilled or less desirous of promoting the highest traditions of the dental service. They are no less eager in that direction than any practitioner who is in private practice on his own behalf. If the position is that Clause 22 must remain, then it is essential that some amendment should be made along the lines suggested by the Lord President of the Council.
I should like to draw attention to Section 13 of the Dentists Act, 1878. That section says this:Where a person registered on the dentists register has either before or after the passing of this Act, and either before or after he is so registered, been convicted either in Her Majesty's dominions or elsewhere, of an offence which, if committed in England, would be a felony or misdemeanour, or been guilty of any infamous or disgraceful conduct in a professional respect, that person shall be liable to have his name erased from the register.1043 I referred to the Co-operative Dentists Association. It has at the present moment forty-one surgeries with a professional operating staff of seventy. Assuming that any member of that staff misappropriated either the funds or the property of the Association, and that the Association decided to prosecute and the member of the staff were convicted, then, as the Bill now stands, it is competent for the Disciplinary Committee to decide that the corporate body itself shall not have the protection of the 1921 Act. If that does not give rise to some serious situations so far as a corporate body is concerned, then I am afraid that I do not quite understand the matter. The corporate body will be placed in that position, and it will hesitate to prosecute if, in succeeding in the prosecution, it is itself liable to be dealt with. We feel that that matter needs consideration. It may well be that what is suggested by the Lord President of the Council will not be sufficient to meet the position—that is, the right of appeal on the part of the corporation because of something which has been done by a servant. If the corporation itself is guilty of an offence let it have that right of appeal; but the position I have outlined needs to be considered in connection with the suggested appeal. Because of the undertaking which has been given by the Lord President of the Council—and I should like an assurance from him that we may look at the matter before the Committee stage—I will not take up the time of the House any further, except to thank the noble Lord for the undertaking he has given.
§ LORD WOOLTON
My Lords, I shall be glad to talk with the noble Lord about this matter, with competent advisers.
§ 4.30 p.m.
§ LORD MANCROFT
My Lords, some years ago the late noble Lord, Lord Ararat, advised your Lordships' House that noble statesmen should not itch to interfere in matters which they do not understand. After the rebuke which was administered a week or so ago by the noble Lord, Lord Horder, to another noble Lord who had interfered in a speech of his on a subject in which, according to Lord Horder, the noble Lord was not sufficiently versed, I 1044 hesitate, being wholly unqualified, to interfere this afternoon. I do so, however, because I have for some considerable time past been the chairman of the public health committee of my local authority—namely, St. Marylebone, which covers Harley Street, Welbeck Street and Wimpole Street, and therefore probably has more dentists to the acre than any other borough in the country. A great many of them have, in the course of the last few weeks, been on my doorstep, but I should be disguising the truth if I said that they were all wholly in favour of every clause in this Bill.
The clause concerning ancillary workers is causing considerable misgivings. I hope that, after the speech of the noble Lord the Lord President this afternoon, and the undertaking he has given, many of these misgivings will disappear. It is most important that they should disappear. We ought to have learned our lesson, surely, when the National Health Service Bill was before the country. That was a most unhappy experience. We got off on the wrong foot because a great deal of the doctors' good will had been lost before the Bill became an Act. I am certain, therefore, that it is essential that the discussions which Lord Woolton has mentioned should take place and that these difficulties should be ironed out. It is always difficult to reconcile the demand for an improved professional status with the needs of the public, but both these features are of great importance. In my opinion, the dental profession has always been underrated, and I am very happy to see in this Bill words which are dear to the heart of a Tory, words which signify self-government, in this instance to the dental profession.
Equally, the public's needs are very great. There has been very considerable misgiving, I know, concerning this £1 charge. It seems to be a wrong policy that we should penalise the man who goes frequently to the dentist, and so keeps his teeth and mouth in good order and saves the dentists much work, by making him pay the same as the man who never goes to the dentist and needs a major job when he does go. With regard to the vexed question of ancillaries, I myself have only one major objection, and that is the word itself. A more clumsy word to describe such an important branch of a profession cannot 1045 be imagined. I hope that the noble Lord, Lord Woolton, will consult Sir Alan Herbert or Sir Ernest Gowers and see whether he cannot get a better word from one of them. But may I recommend him not to look to a dictionary of synonyms for help? The first word he will find there is "stop gap."
I believe that noble Lords who have been worrying about these clauses are worrying unnecessarily and making a mountain out of a molehill. The noble Lord, Lord Webb-Johnson (who I am sorry td see is not at the moment in his place) talks about the "partially-trained" man; but that is not a very helpful description. These men will not be "partially trained"; they will be trained to carry out a specific job. It would not be right to describe a Red Cross nurse or a hospital sister as "partially trained" because she is not allowed to amputate a leg; she is trained to do her own job. All these people must be fully trained for their own job. I also hope the noble Lord, Lord Woolton, will be able to satisfy us on the question of personal supervision. New Zealand is not a fair parallel, since its distances are so much greater and its population largely rural. I know that we shall be able to avoid having one dentist per 200 miles to supervise the ancillary workers. No major dental operations within the scope allowed to an ancillary should be carried out without the personal supervision and instruction of the dental surgeon. If there is any difficult job, the surgeon must surely do it. Surely the fact that the ancillary does merely the straightforward jobs must enhance the status of the dental profession, rather than derogate from it. The important and difficult work goes to the dental surgeon, and the light work to the ancillary.
I liked Lord Nathan's parallel between the ophthalmic specialist and the orthoptist. The noble Lord and I in our own profession—the legal profession—know that the solicitor's clerk does a great deal of the work, but we do not think any the less of him because he is not a fully-qualified solicitor. The two branches run together. Provided, then, that we have these safeguards, and provided that this scheme does not detract from the numbers of men and women who may wish to become fully qualified dental surgeons, let us give it a trial. I believe 1046 that the Dental Council, armed with these new powers, will be able to make this scheme work to the satisfaction not only of those in the profession but of patients as well. Let us, I repeat, give it a trial and do our best to make it work.
With regard to the dental technicians, the craftsmen who make dentures but who are not at the moment allowed to fit them, I believe that they are agitating for the insertion of certain Amendments to this Bill—though so far I have not seen any forthcoming. They have also complained that they are not represented on the new Dental Council. I hope that the registered dental surgeons and the Government will resist any move for such representation; I think it would be wrong to have any but fully-qualified professional people as members of it. I know there is a recommendation by Major-General Helliwell in the Teviot Report supporting greater recognition for technicians; but it is, I think, a minority recommendation. One thing worries me. In the report which technicians have issued there appear these observations:Nor should it be overlooked that already a substantial amount of prosthetic work is carried out by dental technicians in this country with the connivance of qualified dentists, although strictly speaking such work is illegal under the present Dentists Act and will be equally illegal under the existing provisions of the new Dentists Bill.If that statement is correct, I think it discloses an unfortunate state of affairs and one which should be looked into. There should not be any halfway house when a breach of the law is being connived at.
With regard to the children, we all want to see an improvement in the dental health of children in schools. It is important that under such a scheme there should be only one master. At the moment, the Ministry of Health, the Ministry of Education and the local government authorities all have a hand in this matter. I should like to see the scheme come under one master, so that we have one person responsible and one person who could be attacked, if necessary, if the scheme is not working properly. That, after all, is the function of Parliament. With those observations, with the earnest desire to see this Bill work, and in the knowledge that if these conferences take place it will work, I 1047 beg to support the motion for Second Reading.
§ 4.40 p.m.
§ LORD SILKIN
My Lords, I find myself in the pleasant and somewhat unusual position of agreeing with a great deal of what the Lord President of the Council said in introducing this Bill. He has had a good deal of support from this side of the House. Such disagreement as has been expressed has come from his own side. If, in the later stages of the Bill, after discussions have taken place, he should be in need of any assistance, I freely offer him my own humble help, so far as it is in my power to give it to him.
§ LORD SILKIN
I was very glad indeed that the Lord President stressed the shortage of dentists. How grave that shortage is, is perhaps not entirely appreciated, even by those who know that there is a shortage. The Teviot Committee estimated that there was a need in active practice of some 20,000 dentists. That was six years ago. Since then, the population has somewhat increased. The actual number of dentists in active practice to-day, as estimated by the Ministry of Health, is about 10,000. That is to say, we have half the dentists that are estimated to be necessary. But the position is likely to be even worse in due course, because in 1946 some 27 per cent. of the dentists then in practice were on the register as a result of the Dentists Act of 1921, and no new persons are coming on the register in that category. That 27 per cent. is a gradually dying number, so that within a few years, perhaps ten at the outside, there will be no more of those and none will have been recruited. Therefore the number will have been depleted still more. The recruitment to the profession is quite insufficient, even to maintain existing numbers. The number of dentists has actually decreased since the Teviot Report was published, although we are much more teeth-conscious than we were and the need is greater. This shortage is felt particularly in the school dental service. Almost every speaker has testified to that fact, including (I was glad to see) Mr. Butler, the Chancellor of the Exchequer, in his speech on January 29. 1048 He made an emphatic statement about the shortage of dentists for the school medical service and the priority classes.
Let me give just one or two examples of what this shortage means in terms of actual areas. In the County of Dorset, for instance, the senior dental officer reported that the teeth of only one in three of the school children had been inspected in the year 1950. In Derbyshire only one child in six was examined. Even in the City of Manchester they have only half the dentists that they need—and so I could go on. This shortage is not confined to any particular area; it extends practically to the whole of the country. Those of us who have had the misfortune to visit dentists in the last few years will know from practical experience that they have long waiting lists, that they are very overworked and that it is exceedingly difficult for the ordinary person to get attention within a reasonable time. That is a situation which has to be dealt with, and I understand one of the purposes of this Bill, apart from giving the dental profession the status to which it is entitled, is to see what can be done to alleviate the shortage.
There are a number of possible ways of dealing with it. One of them I think the noble Lord, Lord Teviot, hinted at. I did not know whether he was really serious, but he suggested that the shortage was less acute because of the charge that has been imposed for teeth. If that were so, it would be a deplorable fact. Of course, a very effective method of dealing with the shortage would be to make the charges so high that very few people could afford to go to their dentist. But I hope that that is not the intention of His Majesty's Government. At any rate, that is a subject which we are going to discuss more fully to-morrow and Thursday. Another method of dealing with the shortage is by increasing training facilities. The Lord President dealt with that. The fact is that to-day training is being extended to the fullest possible extent, and there are no further facilities. I understand that the facilities are for about 600 students per annum, and that actually between 600 and 650 are being trained. It is quite impossible to train more and there is no likelihood of these facilities being increased within a reasonable period. Therefore, if we take this acute shortage seriously, the only possible course open to us is to do something on 1049 the lines of Clauses 18 and 19 of the Bill. I was glad to get support from the noble Lord who, I was going to say, represents the dental profession in this House, but that is not quite correct; at any rate, he speaks for them.
I do not want at this hour to emphasise or enlarge upon the question of the dental ancillaries. They will be the subject of discussion later on, and I hope that I may be privileged to take some part in those discussions. But I do want to say a word about the dental technicians. I believe that their proper use could considerably alleviate the pressure. I hope that the House will not be unduly prejudiced against them because they made what the noble Lord, Lord Mancroft, regards as extravagant claims (which may or may not be justified), for representation on the Dental Council. They are a body of men who have great experience and, in the making of teeth and dentures, are a vital part of the dental profession. They do everything in connection with dentures except fit them. It always struck me, in my own personal experience, as somewhat anomalous that the person who actually did the job of making the sets had no access to the patient in fitting. The mechanic sits in his workshop and makes the teeth in accordance with an impression made by the dentist. He hands them back to the dentist and the dentist tries them on the patient and makes various alterations. They then go back to the mechanic. It always seemed to me rather anomalous that the person making them should not be the person who took the actual impressions. If they were admitted to the patient, I think it would relieve the profession to a very great extent. I understand that there are some 2,000 dental technicians, or prosthetists as they call themselves, who might well be regarded as qualified to carry out this work.
I know that there may be objections from within the profession, and possibly also from the medical profession, but there is nothing very novel in the suggestion. A number of noble Lords have given parallels; may I give one? The chiropodist is a medical ancillary. If properly carried out, chiropody is a highly skilled business. Nevertheless, there is in existence, under the wing of the British Medical Association, a group of chiropodists who carry on their practice without any substantial supervision. 1050 They have received training and have passed examinations, and they are taught that they must deal with feet only where the case is reasonably straightforward. I see no reason why properly trained prosthetists should not have access to the patient. I see no reason why they should not be of valuable assistance to dentists. Apart from anything else, it would afford the dentist the opportunity of concentrating on what should be the more important and valuable part of his work—namely, the conservation of teeth. The business of a dentist should be to preserve teeth, and not primarily to take them out and replace them with false ones. Apart from relieving the general pressure, I believe that if it were possible for prosthetists to assist dentists in this way, it would be for the benefit of dental health in general and would give dentists the opportunity of doing the really important work which at present many of them have no opportunity to carry out. Like the noble Lord who has just spoken, I know very little about this subject, and it is the last thing upon which I should wish to be dogmatic. I am encouraged to put forward this suggestion because the noble Lord, the Lord President of the Council, has offered to consult noble Lords on the Bill, and when the time arrives I should like to have an opportunity of elaborating this case and putting forward the safeguards which there will have to be, and which it is suggested should be incorporated in any proposal for the use of dental prosthetists.
This is a matter in which the general public are vitally concerned. It is not merely a matter for the dentist. We are all concerned to ensure that there is an adequate supply of members of the dental profession and others capable of dealing with our teeth, and perhaps one of the weaknesses of the Bill is that it gives dentists the last word in the setting up of these experimental classes of person. The public really are interested. There is a danger that dentists will be concerned mainly with the dignity of their own profession, and there ought to be some further right and opportunity for the public to say that certain types of ancillary services should be set up because they are necessary and in the public interest. It should not be possible for the dental profession to leap over these things, regardless of whether or not they are in the public interest. How such 1051 a provision will be incorporated in the Bill is a matter for discussion, but I believe that the dental profession will be as public spirited as most other professions, and, realising that there is no intention to encroach upon their legitimate preserves, will be prepared to consider this question in an objective and public-spirited manner.
§ 4.56 p.m.
My Lords, like my noble friend Lord Mancroft, I am afraid that I have no technical qualifications for intervening in this debate, but I do so because of a point concerning Clause 18 which has been brought to my attention by the Dental Laboratories section of the Surgical Instruments Manufacturing Association, which happens to be an association affiliated to the National Union of Manufacturers, of which I am a Vice-President. The Dental Laboratories section have expressed certain fears about this clause, though I hope that we shall find them unfounded. The section may be regarded as the employers' section, concerned with dental technicians, whose work of making, repairing and altering dentures, and so on, as the noble Lord, Lord Silkin, has just told us, is carried out largely in external laboratories. They have expressed the fear that, with the establishment of this new group of ancillary dental workers, the position of dental technicians may be encroached upon and prejudiced, with the result that the high level of skill and experience which those technicians have built up for themselves may be allowed to deteriorate. Their fears are perhaps justified when one realises that for the most part these technicians undergo a five-years' apprenticeship before they can be regarded as fully qualified. It would clearly be most unfortunate—and I am sure my noble friend who moved the Second Reading of this Bill will agree—both in the interests of the general public and of their own profession, if their qualifications, and therefore the excellence of their work, were in any way allowed to deteriorate.
As I say, these fears may be ill-founded, but so far as I can see, reading Clause 18, there is nothing to prevent an ancillary dental worker, if not fully occupied in his other work, from carrying on, 1052 perhaps part-time, and without proper qualification, the work that the technicians would be doing; in other words, to be doing work which would otherwise be sent out to these external laboratories. I do not know whether or not that is right. But assuming that those fears are well-founded, then I would suggest two possible and, as I think, very simple ways whereby they can be allayed—first, in Clause 18 (3) to insert a sub-paragraph to the effect that no ancillary dental worker will be permitted to undertake the work of dental technician unless he also possesses the full qualifications required of dental technicians to-day. I know that it is not for the Minister to make the regulations, but the other alternative is to ask my noble friend Lord Woolton whether he can give some assurance that he will use his best offices to suggest that a special class of these ancillary dental workers might be established, exclusively for the dental technicians, calling for the same level of qualifications, or at any rate no lower level of qualification than is applied today, such as the period of apprenticeship, and so forth.
I hope that I have made it clear that I am in no way anxious to condemn Clause 18 out of hand. I am merely trying to suggest something that may strengthen it and allay the fears of that section to which I have referred. I am not at all sure of this, but I rather hope that what I have suggested will not be unacceptable to the two trade unions to which most of these technicians belong. Perhaps the noble Lord, Lord Haden-Guest, will be able to confirm that, or otherwise, when he speaks. In the meantime, I would take the opportunity, when saying a few words in support of this Bill, of apologising to the noble Lord, Lord Woolton, for not having given him notice of the point which I wished to raise.
§ 5.0 p.m.
§ LORD BURDEN
My Lords, this is one of those Departmental measures which is pulled out of the pigeon-holes when Parliament has a little time in hand. I am sure that everyone will agree that it is a happy occurrence that we have some Parliamentary time to devote to the consideration of this Bill. I want to suggest that we must not be lulled into a false sense of security by the dulcet tones and the honeyed phrases of the noble Lord the Lord President of the Council. There have 1053 been, and will be in future, I am sure, many opportunities of examining, shall I say, the powers of persuasion of the noble Lord, but that is a fascinating subject which I will not presume to pursue this afternoon. I should, however, like to thank the noble Lord, Lord Teviot, for his very brave and outspoken speech on this matter. It was refreshing to listen to him.
The Bill, as I understand it, has one main object, and that is to enhance the dentistry profession as a profession. And that is something which is long overdue. But many parents have made heavy sacrifices in order to give their sons opportunity to undertake the long and expensive training necessary to qualify as surgeon-dentists. I want to suggest to the noble Lord in charge of this Bill that unless it is drastically amended the number of parents prepared to undertake that sacrifice will be seriously diminished. Let me explain why. Clauses 18 to 20, as I understand them, provide for a most damaging and dangerous form of dilution, and that dilution is to be tried out, in the main, on the school medical service. Dilution is to take place in a service provided for the young people who attend our ordinary schools. As I interpret this Bill, there is no limitation at all to the number of untrained people—call them what you will—who will work under the supervision of a fully qualified dentist.
Let me envisage a position which might easily arise. On the grounds of economy—somewhat fashionable in educational circles at the moment—it would be possible, as I understand this measure, for a local authority, if it were so minded, subject, of course, to the regulations which will be drafted—and this is a safeguard which I hope will be used—to have one surgeon-dentist only in its employ, all the rest in the service being these untrained, or partially-trained, people. I suggest to your Lordships that it would be a very grievous thing if a Bill, the professed object of which is to enhance the standards and the status of dentistry as a profession, should do that on the one hand, while, on the other, it provided for a serious dilution and undercutting, so to speak, of the dental profession in another way, and particularly at the expense of the school medical service. That service, as your Lordships 1054 know, is one which my very valued friend and colleague, Lord Haden-Guest, has played a most prominent part in the past in building up. Therefore, I hope that it may be possible for Clauses 18 to 20 to be taken out of the Bill entirely. In my view, they will create so many difficulties. But if it is not possible to delete them, I do ask that they shall be adequately and drastically amended so that the dilution to which I have referred does not take place, to the detriment of the profession as a whole. In view of the promise made by the noble Lord, Lord Woolton, I hope that I may have the privilege of sharing in those negotiations which he has told us will take place before the Bill is presented to the House for the Committee stage.
§ 5.10 p.m.
§ LORD HADEN-GUEST
My Lords, we have had an interesting and a long debate. To a large extent, it has revolved around the question of whether or not ancillary workers should be brought into existence by the provisions of Clauses 18, 19 and 20, and there have been criticisms of the proposal from noble Lords on both sides of the House. Before I say anything on general matters, I should like to say how glad I am to take part in this debate, first of all because I was associated with the first dental clinic that came into existence in London, in Surrey Row, in Blackfriars, just off the New Cut. That was an experiment which, by the way, was not done so expensively as we are now in the habit of doing experiments—we had a kitchen table and everything on the cheap side. But very good dentistry was done there by the then only school dentist in London. Dr. Wallis (I acted as anæsthetist), and the value of the work he did impressed the London County Council so much that other clinics were established until, as everyone knows, the school clinic movement now actually finds difficulty in getting enough dentists to meet its needs.
I am also glad to take part in this debate because it gives me an opportunity of paying tribute to the work of the noble Lord, Lord Teviot, who acted as Chairman of this extremely valuable and pioneering Committee, whose work is of outstanding value and use to the community. I am also glad because it is important that this Bill to which we are now asked to give a Second Reading establishes the dental profession on a new 1055 basis, with its own General Dental Council, instead of, as at present, being under the General Medical Council. The links between the medical and dental professions are close, but each profession has problems of its own, and it is proper and desirable that the General Dental Council should have control of its own large and increasingly important field of work and have its own independence and self-government. It is interesting to note that by a happy coincidence the Eleventh International Dental Congress is to be held in London this year. I hope that they will be interested in these deliberations in your Lordships' House.
I will not go into the work of the body which will govern the new dental organisation, because that has been referred to by other speakers. The Bill gives powers to the General Dental Council to establish classes of ancillary workers to carry out dental work of kinds, to be prescribed by regulation, which is to be carried out only under the supervision of registered dentists. I am afraid that my old friend Lord Burden may be disappointed with me to-day when I say that, in present circumstances, the existence of some form of dental ancillary workers is essential to get dental work done, especially for children and other priority classes. It cannot be done without that. Let me give your Lordships some figures by way of illustration. In England and Wales at the end of 1947, there were 921 school dentists; at the end of 1948, 880; at the end of 1949, 732; and there were three local authorities with no dentists at all. The London County Council ought to have 66 dentists at the present time: they have only 38. We have a deficiency in dental establishment which amounts to something like a disaster, and we cannot make it up. We shall never be able to make it up to children who have to grow up with bad teeth because they were not attended to in childhood, not kept clean and sweet and fillings given when required.
I am prepared to agree that ancillary dental workers, trained for two years, cannot possibly have the same experience, the same clinical knowledge and the same judgment as well-trained dental practitioners; but an ancillary dental worker is very much better than no one at all, and at the present moment there are a large number of children, pregnant 1056 women and women suckling their children who have difficulty in getting treatment. I have been told lately that, because charges are now to be made for various dental services which hitherto have been given either at a very cheap rate or for nothing, there will be a slump in private dentistry, and the dentists will go back to the school dental service, which certainly needs recruits. I am by no means convinced that that is true. I am sure that a good many dentists will prefer to go on in private work.
I believe that the setting up of this dental service of ancillary workers under supervision—and by that I mean, under the close personal supervision of dentists—will be a valuable thing. Let me give one or two facts, because this is a matter to be judged not on our feelings but on the facts. In December, 1951, there were 15,347 persons on the Dental Register, but this number included many in the Commonwealth and abroad. It is estimated that at present there are 10,000 dentists available for general dental services in England and Wales—that is, one to every 4,300 of the general population. This includes, of course, children, who are a priority class because lack of attention in childhood causes great dental trouble in later years. But there are also two other priority classes—expectant mothers and nursing mothers. In December, 1951, there were the equivalent of 716 whole-time dental officers in the school dental service—that is, one dental officer to about 7,000 children. In order to provide even a passable service, we want at least double that number, and that is doubtful; and to provide a full dental service there should be four times that number—something like 2,800. That number is simply unobtainable at the present time, and there is no way of producing this extra number of dentists within any reasonable period. Unless something on a new scale is done, we are threatened with a whole generation of children with neglected teeth and all the ill-health that this brings. As I have already said, I myself started seeing children in the first dental clinic in London, at a time when I was medically examining them in my capacity as medical officer of the clinic. I realised how greatly their health was deteriorating, largely due to the bad condition of their teeth.
1057 It is urgent that steps be taken now, and this experimental scheme deserves full support. I do not think all noble Lords have noticed how carefully guarded this experimental scheme is. It is to be carried out under the control of the dental profession itself, and I believe that they will make it a success. I believe that however the dental profession expands in numbers during the next few years—and I hope that it will attract the students and secure an increase in numbers—it is unlikely to be able to meet the full demand. And we cannot afford to have a generation of children left without adequate dental treatment. In my view, the demand for dental services in the future—that is, the dental service all over the country as a whole—is likely to expand, rather than to contract. Nor can we shut our eyes to the fact that other fields for the employment of dentists will be opening up in many countries, from the Near East to the Far East, and from Great Britain to the Commonwealth overseas and the rapidly developing Colonies of Africa. I do not think we shall find in future that dentists will be prepared to stay at home. I certainly know that that is the case with regard to medical men, who are more and more tending to expand over the habitable globe, largely within the periphery of those countries within our own sphere and realm of interest.
I should like now to refer to another aspect of the problem, which I feel is one that ought to be explored but which I think has not been touched upon, other than obliquely, during this debate—namely, the question of getting reinforcements for the dental profession from foreign dentists already qualified. Some foreign dentists have been admitted to the Dental Register, but many have not. I believe that a careful and detailed scrutiny of this problem might open the way to securing new recruits. The Dental Register, as it is operated now, is governed by rules which are definite and precise—and I am sure noble Lords will agree that that should be so. But they do not always correspond to the realities of the present-day world, nor to the training given, either on the Continent of Europe or in the United States.
Let me give two examples. A teacher of dentistry in one of the famous schools of Europe—that of Vienna—over a period of years could not be brought on the 1058 Dentists Register of this country because he could not provide evidence of the right type of experience according to British standards of training. That seems to me to be a grotesque situation. The second case refers to Harvard University, in the United States. A dentist qualified at Harvard is not entitled to be registered in this country unless he has also taken out a registration in one of the States of America. I have quoted those two examples to show the difficulties which have arisen. And there are other anomalies. In fact, the measures which the General Medical Council take to judge of the capacity of a dentist or a doctor from a foreign land are very narrowly drawn indeed, and have to be kept to an extreme exactitude. If those whose claims could not be substantiated exactly according to what is laid down were admitted, then the system of registration would break down. But under this Bill I think it ought to be possible for us to have a further look at the whole situation with regard to dental qualifications, because from my experience (and for the last few years I have travelled very largely over Europe and other parts of the world in connection with looking after medical staffing, and I have also seen dentists) I believe that there are a considerable number of qualified dentists who might be brought to work in this country and who would be most useful to us.
During the course of the debate I found myself agreeing very largely with the noble Lord, Lord Woolton—this, of course, is not a Party Bill at all. I was delighted to hear the speech of the noble Lord, Lord Teviot; while the noble Lord. Lord Webb-Johnson, who speaks from a forthright and knowledgeable point of view, is always well worth hearing. I am afraid that I did not entirely agree with the point of view advanced by the noble Lord, Lord Amulree. I venture to think that if he will look more closely into the facts as they are he will see that, whether we like it or not, we have got to have this new class of dental assistants to put the dental affairs of this country into order, and particularly those with regard to children. With the noble Lord, Lord Mancroft, I agree; and it would be impertinent of me to try to add anything to the eloquent speeches of the noble Lord, Lord Silkin, and other speakers. We have had an excellent discussion on the 1059 subject. I would conclude by saying how glad I was to hear the proposal made by the noble Lord, Lord Woolton, that, in order to agree on a method of bringing into operation a new kind of dental ancillary, we should have private consultations before the Committee stage. I feel that that would be most helpful.
§ 5.27 p.m.
THE EARL OF ONSLOW
My Lords, this has been a long and interesting debate, as the last speaker has said, and I think it is fair to say that, by and large, all sections of your Lordships' House welcome the Bill as a long-term means to improve the dental health of our people, and in particular that of the children. Noble Lords who spoke in the debate really divided themselves into two camps: those who more or less agree with the Bill as a whole (barring a few minor Committee points), and those who were worried by one of the most important parts of the Bill, that is to say, the part dealing with the dental ancillary, whom the noble Lord, Lord Webb-Johnson, would prefer to be called a "dental nurse." I have to advise the noble Lord that the word "nurse" cannot be used in this country owing to the special protection it enjoys under other Acts of Parliament. Your Lordships will see from the Bill that one of the duties to be left to the General Dental Council is that of evolving a suitable name for the dental ancillary, and I hope they will evolve an intelligible one.
I think the real point has been made quite plainly by several speakers on both sides of the House. The fact is that we have not nearly enough dentists, and there is no hope of securing them in the foreseeable future. We must face that fact, whatever our wishes may be in other ways. Are we going to sit down under that difficulty? Obviously we cannot. Therefore we must find the next best thing to what we should hope for but cannot get. Surely, our aim must be to obtain the greatest good for the greatest number, rather than complete dental treatment for a restricted number. Clearly, the main place where this shortage lies is in the schools. The noble Lord, Lord Haden-Guest, quoted some figures in his speech showing that in the schools we should have 2,800 dentists, but have now only 700. Of course, the position is absurd. People have been 1060 rather derogatory of these young ladies, calling them "untrained" and "partly trained," and using other such adjectives. If what is proposed comes to pass, it will be entirely erroneous to call them "untrained" or "partly trained." They will, in point of fact, be highly trained in one particular aspect of the dental profession, just as a machine-gunner in the Army is very highly trained in that particular job but is not trained as an artillery man. You do not call a machine-gunner "untrained" because you happen at the time to be talking about the Royal Artillery.
The other day, when we were debating health, several noble Lords opposite quoted Sir Edward Mellanby, and I think it may be appropriate for me to quote an extract from his "better half's" letter to one of the officials of the Ministry. Lady Mellanby says:We had a grand time and thoroughly enjoyed both Australia and New Zealand. I have never seen so many five-year-old children with such beautifully filled teeth. I am afraid I must admit that I have been horrified at the state of some of the children's mouths (five-year-olds) that I have been examining in London since my return. Give me dental nurses of the type used in New Zealand every time for young children.That is a very high recommendation for this service, a service which might well be tried. Of course, the proposed scheme is new. It has to be experimental and we want it to start off on the right foot. I am only too glad to support the suggestion made by my noble friend Lord Woolton, that there should be long and thorough discussions on the subject before we come to Committee stage.
§ On Question, Bill read 2ª; and committed to a Committee of the Whole House.