HL Deb 04 April 1985 vol 462 cc398-421

2.56 p.m.

Lord Kilmarnock rose to move, That an humble Address be presented to Her Majesty praying that the National Health Service (Chages for Drugs and Appliances) Amendment Regulations 1985 (S.I. 1985, No. 326) be annulled.

The noble Lord said: My Lords, I beg to move the first Motion standing in my name and, with the leave of the House, I wish to speak to the other five Motions on the Order Paper. My main object in tabling these Prayers is to draw attention to the peacemeal, contradictory and—I am choosing my words—disingenuous method the Government have chosen to diminish the cost of the National Health Service. I shall also suggest that, taken together with other measures, the Government's emerging strategy appears to be the emasculation of primary health care as an integral part of the National Health Service.

First, let us look at the financial picture for 1985–86. We have already had to digest the limited drug list on which the Government planned to save £100 million a year. We argued at the time that they might have some hope of saving this sum with the full collaboration of the professions concerned, but they missed their chance and admitted that they expected to save less on their revised list—some £75 million on their estimate. This seemed, and seems, optimistic. But, even if we accept it, it must be presumed that the department has pledged £100 million to the Treasury and there are £25 million missing to be found.

I turn to the charges that we are debating. The Government have said—and the Secretary of State said it on the 11th March in the House of Commons, at col. 22—that the total saving from all the charges embodied in these regulations will be about £40 million. If the new prescription charges raise £19 million, as predicted, that leaves only £21 million to make up the total. Yet when we turn to the dental charges we find from a comparison of last year's with this year's supply estimates—which I have here in my hands—that these have been raised by a whopping £49 million from £173 million last year to £222 million this year. That is a figure that neither the Secretary of State nor the Minister of Health has mentioned in any speech of which I am aware. I shall refer later to the obvious adverse effects on dental care but for the moment I want to stick with the macro figures.

How then do we square the Secretary of State's projected savings of only £40 million from all these charges with the extra £68 million he will be getting in from the pharmaceutical and dental services taken together? The clue lies in the optical charges. Looking further down the pages in the supply estimates, we find that the department expects to take in only £7 million this year under the heading "Charges retained by opticians" as against £43 million the previous year, a shortfall of £37 million, which it appears is to be largely made up from the massive increases in dental charges.

We are not against the liberalisation of the supply of glasses, provided a safety net is maintained for the elderly and visually handicapped. However, it seems to us quite wrong that the cost of this policy should be offloaded on to another service—particularly when the general ophthalmic service, according to the same supply estimates, is expected to show a net decline in cost from £128 million to £124 million without any such fudging of the books. My point is that if savings of this kind are to be sought on the ophthalmic service, and from the limited list, they should be treated as a separate exercise. Indeed, there is no other way of monitoring how well they are working. To clobber the dental service to make up for any shortfall resulting from policies in the other areas is really inexcusable, and I believe the noble Lord, Lord Colwyn, will have a good deal to say on this when he comes to speak.

Let us now look at the prescription charges which are going up by less than the 25 per cent. being inflicted on the dental service, but still by a substantial 14 per cent., or nearly three times the rate of inflation. The Government constantly tell us that this really will not affect many people, because 70 per cent. of the prescriptions are exempt from charge in any case, but this percentage is misleading because it refers to prescriptions and not to patients. The elderly, as might be expected, account for a larger number of prescriptions per head than the rest of the population, but, taken together with children, they represent only 39 per cent. of that population. The likelihood, therefore, is that even if we allow for other exempted categories such as those on supplementary benefit, a good half of all patients will be confronted by this leap from £1.60 to £2 per prescription. It is also likely that many of these people will be on low pay or only just above the supplementary benefit level which would qualify them for exemption. So to brush this aside as a matter of little consequence is to be wilfully blind to social realities.

There is also a serious anomaly affecting the increased prescription charge. There are quite a number of cases in which the prescription cost will be less than the £2 charge and this applies to some drugs which are in constant use and in the top 100 league of prescribed drugs. I have some examples. Twenty penicillin tablets of 250mg cost the NHS £1.10. However, this is a prescription only drug, so the pharmacist cannot sell it over the counter or prescribe privately on a NHS script. Thus, the patient is giving 90p to the NHS on that prescription. I could go on. There are other examples. Hydrocortisone ointment costs the National Health Service £1.50, but the patient will have to pay £2, thus presenting 50p to the National Health Service.

In reply to the Question of my noble friend Lord Winstanley for Written Answer on 28th March 1985 the noble Baroness, Lady Trumpington, indicated at column 1277 of the Official Report, that if the cost was below £2, the pharmacist could sell the drug over the counter at the cheaper rate. The noble Baroness stated: If he does so and the patient buys the item, the prescription is, obviously, not dispensed. We believe it is right to leave the decision to individual pharmacists. We do not consider it necessary to issue formal guidance on this to pharmacists".

This is simply dodging the issue. If the item can be sold only against a prescription, the patient will have to go back to his doctor for a private script, which will consume time and probably money if transport is involved. This is likely to arise with frequency as most of the preparations which could previously be sold over the counter are on the black list. Also, the extended use of generic drugs will lead to a wider range of prescriptions costing under £2. It does not seem right to me that those whose treatment demands the cheaper products should be made to subsidise the more expensive prescriptions in this way. I should, therefore, like an assurance from the noble Baroness that this anomaly will be corrected, either by authorising pharmacists to refund the difference or by some other means, which I am sure the ingenuity of the Government can easily devise. The present situation is both unfair and ridiculous.

I have already spoken of the way the Government have indulged in creative accounting over the dental charges, and I shall leave it to the noble Lord, Lord Colwyn, with his first hand experience, to deal with the actual effects on dentists and their patients. I believe that my noble friend Lady Robson will have something to say here. I only want to say in passing that all the evidence I have seen convinces me that there will be a drastic decline in dental health if the Government persist in these swingeing charges; that the advances made over the past 20 years or so will be put into reverse; that people will avoid dentists like the plague rather than commit themselves to open-ended courses of treatment whose eventual cost to them cannot be predicted; or that they will limit their visits to emergencies and go increasingly for the cheapest option, which is extraction. If the Government want a toothless nation, they seem to be going the right way about it.

Perhaps the Government will change course in time, and we hope to hear from the noble Baroness that they are thinking again. I understand that the British Dental Association saw Mr. Kenneth Clarke on 20th March and that he gave them some assurances that he would think again if statistics could be provided to prove any decline in dental health as a result of these measures. However, that is something that could take years to assess, and what we want, and what the British public want, is action now. It is up to the noble Baroness to reassure us and, more importantly, the general public. This is a great opportunity for her to get off to a good start in her new post—about which I join in congratulating her—and she should not lose it.

My noble friend Lady Robson is going to deal with charges for private beds in National Health Service hospitals, a subject about which she has great knowledge, so I shall not pursue it myself. However, I should like to ask the noble Baroness, Lady Trumpington, about income from overseas charges. She kindly wrote to me on 2nd April saying that £4 million had been collected since October 1982. This does not seem a great deal. I seem to remember that something like £6 million a year was originally mentioned. Can the noble Baroness say anything about the administrative costs of this operation and whether it is worthwhile continuing at all?

I recognise that in criticising these charges I might be asked to state where I, or we, would go for savings in the National Health Service. In the first place, it is worth putting on record that the much-publicised mounting cost of drugs is not in fact fully borne out by the figures. Between 1983 and 1984 the increase in prescriptions was only 1.67 per cent., which is rather low when one considers the demographic pressures on the health service.

The ingredient cost per script showed an increase of only 2.68 per cent. in 1984 over 1983, and the prescription price index after discount showed an increase of only 2.7 per cent. In the light of these figures one wonders why the Government had to rush into these draconian measures as though there were a wild escalation in high percentages of the cost of drugs to the National Health Service.

However, I think we all recognise that it is desirable to make savings where they can be made in order that the money can be reapplied elsewhere in the service where it is needed. I have stated in previous debates, and I shall not repeat it here in detail, that we believe that greater savings could have been achieved on drugs by a combination of generic substitution with the proposals of the Royal College of General Practitioners for responsible prescribing and of the pharmacists for reducing waste.

If we are looking for savings there is another area which ought to be looked at, and that is the Pharmaceutical Price Regulation Scheme. The Government have recently striven to reduce the allowable return on capital to the pharmaceutical industry on NHS business from some 25 per cent. to some 17 to 18 per cent. This profit target is based on submissions made by some 65 companies supplying the NHS who are permitted, as I understand it, to define their own capital base on which the margin of profit is allowed.

This clearly gives a lot of leeway in accounting terms. As the department's analysis of the returns has a built-in time lag of two years, it cannot be said that the Government are exercising a full and thorough control of cost through the PPRS. We are sympathetic to the industry's claim for a longer period of patent protection of innovative drugs, but there is a grey area which requires further effective scrutiny. I want to ask the noble Baroness whether the Government will take this into account in their review of the PPRS. They may well find some useful savings here.

Dental charges, prescription charges, the reduction of the general ophthalmic service, the limited list and the black list are all, I suspect, straws in the wind. Taken individually they may not seem to be of vast significance, but taken together they undoubtedly represent a creeping erosion of NHS primary health care. Since the Secretary of State now directly determines the appointments to family practitioner committees, these bodies will inevitably become his tools and implement his policy. It would be nice to know what that policy is.

The seemingly interminable delay in the publication of the Government's Green Paper on primary care and the continuing refusal to publish the Binder Hamlyn report can only lead one to suppose that there are radical proposals in the pipeline but that these are (how shall I put it?) the subject of disagreement in Government circles. If that is not so, I cannot think why the Government have not unveiled their proposals by now.

This delay is bad. It means that we are faced with the sort of ill-thought out and unco-ordinated measures we are debating today. There is no overview of the role of primary medicine, no Government commitment to it as the bedrock of the National Health Service, and no philosophy within which the National Health Service group practices can develop their potential, for example by taking on more ancillary staff to extend the range of work they handle, thus relieving the burden on hospitals and tackling ills at their source. All that is held up while the Government flirt with this and that type of privatisation and wonder which they can introduce with the least possible political storm. It would be far better if the Government, instead of toying with all these ideas, were to concentrate on helping to improve what we already have, which could, with a little help and a little imagination, produce a superb service for the whole community, without introducing first, second, third, fourth leagues in family medicine.

I therefore hope to hear three things from the noble Baroness this afternoon: first, that the Government will immediately remove the anomalies created by their £2 prescription charge; secondly, that they will also reconsider the ill-advised and deeply damaging level of dental charges they are proposing to implement in these regulations; and, finally, that they will not dismantle or severely cripple the family doctor service by encouraging the expansion of the private sector, supposedly to lift the burden on the public sector. This would be gross folly and would lead to guerrilla warfare between NHS practices striving to defend their terrain and private medical centres aiming to poach their patients to the point where the NHS practices become no longer viable. The principal sufferers, as in all civil wars, would be the citizen, the patient. If the Government do destroy family medicine in Britain, I can assure them they will live to regret it.

Moved, That an humble Address be presented to Her Majesty praying that the regulations be annulled—(Lord Kilmarnock.)

3.12 p.m.

Lord Colwyn

My Lords, I should like to thank the noble Lord, Lord Kilmarnock, for giving us this opportunity to discuss these regulations and, at the same time, welcome my noble friend Lady Trumpington to her new position on the Front Bench. Both my noble friend Lady Gardner of Parkes and I are away from our practices this afternoon, which, I assure your Lordships, must mean that we and our profession are taking this matter very seriously. I have spoken many times now on the question of dental charges and the harm that the rising charges are doing to dental health. I wish it were not necessary for me to do it again, but I should like to consider what has been happening.

On 11th March my right honourable friend the Secretary of State for Social Services made his announcement. He began rather well. He said that in the next financial year the health service plans to spend an extra £800 million, bringing total spending up to some £17½ billion. This is an increase of over 20 per cent. So far so good: it is confirmation of the Government's continuing support for the National Health Service. He then said that the Government believed there should be some increase in the contribution from direct charges and that they were seeking to raise an extra £19 million from prescription charges.

The Minister then went on to mention dental charges. He announced that charges for specific treatments—crowns, bridges, inlays and dentures—would increase by between 6 per cent. and 10 per cent., and the maximum charge for any single course of treatment would increase by just 4½ per cent. Then there was the bland statement that in future patients would pay the full cost of routine treatment up to a maximum of £17, rather than the present £14.50, as it was before 1st April, and would also have to pay two-fifths of any cost above that level. The Minister ended his speech by saying that the total income from charges next year would be increased by some £40 million. It might be thought that increases of 6 per cent. to 10 per cent. and 4½ per cent. in dental charges do not sound too bad. But the Minister's speech omitted some very crucial facts.

In England the DHSS proposes to collect £221 million in a full year of the new dental charges. In 1984–85, under the old dental charges, the figure was about £172 million. This represents not the comparatively small increases of 4½ per cent., 6 per cent. or 10 per cent. mentioned by the Minister, but an awesome 28 per cent. rise in revenue in a full year. In fact, this £49 million is more than the overall revenue increase of £40 million mentioned in the 11th March Statement.

Part of the increase is the result of growth in the service—and that is good—but the pure price effect is something like 23 per cent. Not only did the Secretary of State not mention this 23 per cent. increase in revenue from dental charges, approximately five times the current rate of inflation, but he also omitted to say that if the cost for specific treatments rises by 6 per cent. to 10 per cent., then the cost for routine treatment must be increased by about 40 per cent. to make up the proposed 23 per cent. increase in revenue. I repeat that the cost for routine treatment will have increased by about 40 per cent. under these new charges.

These increases in dental charges can do nothing but harm for dental health. The dental profession has been trying for many years to encourage people to visit their dentists regularly. It is an understatement for me to say that these increases win dissuade them from doing so. Indeed, in 1981 the Government's own Dental Strategy Review Group concluded: There can be no doubt that any charge to patients will deter some from seeking the treatment they need. The level of charges should therefore be set as low as possible". What a pity, my Lords, that the Government cannot take their own advice.

A few weeks ago I spoke about the appalling statistics of increases in dental charges. I have no reason to take back these words. In fact, they are even more applicable today than they were when I first said them. I think I speak for my profession when I say that we have serious doubts about the practical aspects of collecting these new charges. Successive Governments have all used the dental practitioner as an unpaid tax collector but, under the new system, the dentist is under a legal obligation to give the patient an estimate of the cost of treatment. In many cases this will be difficult or impossible, with the prospect of under-collected amounts being unrecoverable and over-collected amounts needing to be refunded. This will cause extra administrative costs to most practices.

The new system also takes no account of fees that are at the discretion of the Dental Estimates Board, details of which are not available to practising dentists. I should appreciate the comments of my noble friend the Minister on the view that it is now high time that these discretionay figures were made available to the profession.

When I last spoke on this subject I gave my noble friend Lord Caithness evidence which, in my opinion, clearly showed that the increase in charges was affecting the groups of the population most at risk. I think that my noble friend Lady Gardner may have something to say on this. The Minister was very prompt in his reply, with contradictory figures which I am afraid I find hard to understand. I very much regret that the situation has now arisen whereby it is no longer possible to accept such figures and statistics from the DHSS on trust. I feel that perhaps unwittingly the department have manipulated the figures to suit themselves. I am sorry to have to say that, but my right honourable friend the Minister of Health's recent statement, when he averaged the charge revenue over all adults of working age rather than just the adults actually receiving treatment, is an example of this more-than-simple political adjustment.

Finally, I ask the Minister to tell us what steps her department proposes to take to monitor the health consequences of these new charges, and I ask her for an assurance that the charges will be reviewed as soon as evidence emerges that dental health is being damaged.

3.21 p.m.

Baroness Robson of Kiddington

My Lords, I rise to support my noble friend Lord Kilmarnock in the Motion before the House. I am delighted that he should have enabled us to discuss the very real problem that now faces us. As my noble friend said, I am going to speak mainly about private patients and private beds in hospitals, but I should like to re-emphasise and support his concern about the increased prescription charges, particularly for those drugs that do not cost £2. It is very easy to suggest that you go back to your general practitioner and get a private prescription, for which you pay £1.10 or £1.50. But how will that affect people who live in rural areas where there is not always a chemist round the corner from the general practitioner's surgery? I believe that not only is it going to cost the patient something extra to get the private prescription but it is also going to cost an enormous amount of time and effort. This is what I find unforgivable.

We have just heard from the noble Lord, Lord Colwyn, his thoughts on the effect of the increased charges for dental services. I came to this country in 1939 from a country which is well known for its good teeth: Sweden. I was shocked when I arrived here to see young people of 21 years of age with a set of false teeth; that was not uncommon pre-war. My concern is that the new, increased charges, particularly as they affect the age group between 18 and 25, are going to put us back into the same position. The noble Lord, Lord Colwyn, said that there is a 40 per cent. increase in the cost to a person who wants to have his teeth dealt with properly. A young man or woman in the age group 18 to 25 who, at the Government's urging, is prepared to take a reasonably low-paid job (because that is the only way to get a job these days if you are in that age group) is going to opt, if he goes to the dentist at all, for the cheapest form of treatment.

I have here an example of the difference; it was supplied to me by the dental association. If he goes to the dentist and just has his tooth extracted, it will cost him £3.30. If he goes to have proper treatment it is going to cost him £36.10. In the past he would have had to pay only £14.50. Under the present system, with the £17 maximum plus 40 per cent. of the rest of the charges, he will pay £26.64. That is a rise of 70 per cent. in what he is asked to pay. I wonder whether noble Lords believe that a young person between the ages of 18 and 25 is going to have the money to pay the £26.64, or whether he or she will not opt just to have a tooth extracted. If that happens, we are going back almost to pre-first World War conditions; and I would hope the Government will think again.

I said that I wanted to talk about increased charges for private patients in hospitals, which have gone up by 14 per cent. under the new rates. This is a much greater increase than one would have expected, in view of the fact that inflation was not 14 per cent. last year. But whereas the first two regulations are aimed at saving money, one would assume that the increased charges for private patients was an attempt to earn more income for the National Health Service from private subscribers. At the time of the Statement in this House on the new charges the noble Lord, Lord Glenarthur, stated that the income from private patients to the NHS was £62 million per annum. That is quite a sum of money and is something that is very much welcomed by health authorities, particularly in these days of what I would call cuts in the financial position of the health service.

I very much regret the previous Administration's decision to phase out private patient's beds from National Health Service hospitals, because I believe that they have been, to a large extent, responsible for the growth in private hospitals. I was always against queue-jumping for operating theatres, but it would not have been beyond the wit of man to think up an alternative way of running private hospital beds in NHS hospitals. I have before me the new set of charges, which means that we in the NHS have to charge for a London teaching hospital £166 a day, for a provincial teaching hospital £137 a day, and for a London special health authority hospital £183 a day.

It is no secret that for many years I was connected with Queeen Charlotte's and Chelsea Hospital for Women, but the private beds in Queen Charlotte's are all maternity ones and, as your Lordships know, private insurance is not mad keen to insure you against the risk of pregnancy. So any patient in Queen Charlotte's will have to pay out of her own income £183 a day. I do not believe that that will increase the income from private patients in Queen Charlotte's Hospital, because I do not believe that they will be able to afford it.

When you compare charges for teaching hospitals, both provincial and in London, with the average charge per day in a private BUPA hospital, which I have been informed is between £120 and £130 a day, you see that there is a big difference. Not only is there a big difference in charges; the facilities that are put at the disposal of a patient in a private hospital are, in most cases, immeasurably superior to those that we can provide in the NHS. Many people would prefer to be private patients in a NHS hospital, but they will not be if the difference in charges is so great that they would be economically better off by going to a private hospital.

I have made it my business to make some inquiries from a number of district health authorities in close proximity to private hospitals, and they estimate that with the new charges they will not be gaining income. They will be losing between £100,000 and £200,000 a year of their private patient income. So the aim of the Government, which one assumes was to increase the income to the NHS, in my view will not materialise.

There is another point about private beds in NHS hospitals. I would plead with the noble Baroness to plead with the Secretary of State in the other place to think about this point. It concerns the blanket charge for private beds. When I was a governor of University College Hospital we had a private wing, and the charges were the same for whatever room you had in that private wing. This does not help to fill all the rooms because if a patient comes to have a look and you happen to have a room which has a bathroom—that will cost £166 a day—the patient will choose that room. If she then has a look at a room at the back which does not have a private bathroom and has no outlook and the price is the same, the room will stay unused. The patient who cannot be accommodated in the good accommodation which exists in the NHS will go to a private hospital.

That fault has existed as long as I can remember and I think it is about time that we had a graded charge for NHS private accommodation. I sincerely hope that the noble Baroness will bring this to the attention of the Secretary of State.

3.32 p.m.

Baroness Gardner of Parkes

My Lords, I, too, should like to congratulate the noble Baroness, Lady Trumpington, on her new post. I should like to reverse the line of speech of the noble Baroness, Lady Robson, because I intend briefly to comment upon her subject of hospital charges and then go at much greater length into the dental aspect. I was very interested when the noble Baroness referred to the charges for private patients in NHS hospitals, because I am still a member of a special health authority. I understand that our health authority, which happens to cover the National Heart Hospital, is specially bracketed at a high level. At the meeting the other night, I thought the figure of £250 a day was quoted.

Baroness Robson of Kiddington

My Lords, yes.

Baroness Gardner of Parkes

My Lords, people were not particularly unhappy about the charge of £250 a day, although I am very aware of the point the noble Baroness makes that one wants a room of first quality for that price. Although the hospitals are pleased that they are now able to charge more—a few years ago the charges were so low that we had a constant influx of foreign visitors because it was so inexpensive to come; now hospital treatment is a more realistically priced item—their concern at the moment is that you pay the same no matter what treatment you are having. If you come in for major heart surgery you are still getting quite a bargain at £250 a day because that is all in—there are no extras whatsoever.

If you go to one of the private hospitals you will find theatre charges, charges for drugs, and all sorts of extras that are added on, which make a difference. But if, on the other hand, you go into the National Heart Hospital for a minor investigation, it is a very expensive thing to have done there. So they believe it is necessary to have some right to vary charges according to the complexity of the treatment given and the costs of the treatment being provided. I should like to make that point in this speech so that it will be on record for the Minister to consider.

I should now like to go back to the dental charges, which are much more directly in my line. I must declare an interest as a general dental practitioner. I think that these new charges are wrong in principle and hopeless in terms of practicality. In terms of principle, we were told when a Statement was last made—I think it was in November—that we were to expect increases in line with inflation; "roughly in line with inflation" may have been the term used. As I understand it, this Government are extremely proud of their record on lowering inflation. Therefore to me it is quite impossible to accept that a 25 per cent. increase is in line with inflation.

I can understand one of the motives behind the change of structure. I think it must have been brought in as a deterrent to over-prescribing, because in recent times we have had quite a lot of evidence of a few bad dentists who were doing unnecessary work for patients. Because the patient is going to pay a proportion of the charge he will certainly be policing—if I may use that word—every bit of treatment that is carried out as it is hitting his pocket directly. That may have been the motive behind it, but it is not going to produce the desired result. Instead, all those people who are in difficulty meeting charges will be in much greater difficulty.

If the DHSS carried out an analysis, it would find, because this is certainly the common word in the dental profession, that at present the most expensive treatments—crowns, bridges, all sorts of elaborate and expensive treatment—are carried out in areas of perhaps high unemployment but certainly of high priority classes. They are the many young people who pay nothing, the many unemployed who pay nothing, or people in categories which are not liable for charges. When these people attend the dentist they can be offered any form of treatment, no matter how expensive or elaborate. There is no ceiling, and many dental treatments now cost over £1,000. If the patient does not have to meet any charge, the dentist need not think twice about carrying out his idealistic dentistry, which we should all like to be able to afford.

On the other hand—and this is commonly the case in my practice—where people have just enough to live on, the patient will say, "I cannot manage to meet these dental charges. What can I do about it?". You reply, "There is a special form. It is this pink form F1D. You can complete this form and apply for assistance with your dental charges." That is a very desirable situation. But the F1D form is, sadly, far less desirable. It is extremely complicated. The dentist must sign Part 1. He must sign where it is stated: I have undertaken"— not "I am willing"— I have undertaken to provide the patient with dental treatment/dentures under the National Health Service". That, of course, immediately places the dentist under an obligation, even though the patient might have come in with a preliminary inquiry to ask about assistance and might not even wish to go to that dentist after receiving permission to get treatment free of charge. Therefore, it is wrong that the dentist should be placed under an obligation at that point. I think the dentist should be able to sign a declaration stating, "I am willing to undertake treatment for the patient" and the contract between dentist and patient should come at a later stage.

We then come to Part 2 of the form which is headed: To be completed by the patient except when the charge is incurred by a married woman living with her husband when it should be completed by her husband". I find that an interesting point. I understand that that is not in the normal procedures of our law, though tax law still looks upon the wife as a chattel of the husband. The form goes on to state: All references on this form to a married woman, a wife or a husband, should be regarded as applying, as appropriate, to other persons living together as man and wife". I know of cases where the husband regularly completes the form. I know of many fewer cases of people living together where the form is taken home and the other party completes it. Either the whole thing is beyond people or they do not wish to know about it.

There then follows nine questions to be completed in claiming fir remission of charges on grounds of income. The usual information is required, such as name and address and those in the household. It is then stated: Do not include sub-tenants paying you rent". Very few of these people hoping to receive assistance have many sub-tenants paying them rent.

You then have to declare that you have no dependants, or that you are married and have dependants, and complete all sorts of details. Having gone through all the easy questions, you then get down to those relating to rent, rates and mortgage repayments. You have to declare whether you pay them and how much they are each week; whether there are any rebates and whether payments include heating. You have to state: My rent and rates without rebate would be… —or, "I own the house but make a payment of so many pounds a week".

I have often tried to help people complete these forms, but they cannot answer many of these points even when they want to. Declarations on the form include: I live as a member of someone else's household. I am a commercial boarder". It then goes on to savings: Total savings and investments of myself and my dependants, other than my owner-occupied property, are £ If none, write 'none'. Weekly income: Current weekly income for self and dependants from all sources is There is then a list of about 10 different categories. My occupation is", and it has to be listed all again.

Then there is this nice statement: After deducting from the gross amount any income tax and, in the case of earnings, national insurance contributions and fares to work". That is an interestng one—"fares to work"—because they are not normally allowable on any form, but they are on this one. If earnings vary from week to week, enter an average figure If you have not understood at all, have a guess!

Then: Hire purchase payments: Other expenses such as special diet, domestic assistance, life insurance". There is a declaration at the end and a big warning that false information will leave you liable to prosecution.

It means that this new scale of charges will require thousands more people to apply for this pink form, F1D. It will involve the DHSS in a great deal of work looking through those forms. I believe that the forms should be simplified in such a way that people can answer them more clearly and they can be assessed more rapidly.

From the time when the patient comes in and asks for the form any amount of time can elapse—three or four months, or even longer—before an answer comes back, sometimes saying that a patient can meet all his own charges, at other times saying that he can meet up to the first £25 and at yet others saying that he is exempt from everything. But in each case there is a long time lapse. There is no way that one can phone and get a quick answer for people.

A patient may arrive in pain, with no money, and want help through one of these F1D forms. Do you send him away in agony or do you carry out the treatment for him? I believe that every dentist would carry out the treatment, but it is done out of the goodness of his heart, because he may never see a penny for that work. If the answer comes back that the patient should pay, he is certainly not going to bring back the form, nor come back himself, because he has said that he does not have the money whether or not he is assessed as being liable. The dentist carries that burden.

I think that there should be provision within the treatment scale for emergency relief of pain for patients who have no money and who have applied through these F1D forms. It is impossible to ask them to wait in pain. It is equally unfair to ask a dentist to wait all that time and then perhaps never get a penny.

There are other practical points which I think are wrong. One horrifies me personally. Few people probably will realise this, but I have read the little thing that comes out about the new fees. It says that in calculating the amount—the first £17, plus 40 per cent. thereafter—you should round your answer down to the nearest penny. That means that you have to take a bag of small change with you every day to the surgery. You have to be like a small shopkeeper, working out whether the change is 1p or 4p. We had a similar situation in 1970 when Sir Keith Joseph was Secretary of State. There were so many complaints from the profession that we were assured that we should never again be put back to the small shopkeeper status, with a bag of small coins—yet here we are again.

Lord Graham of Edmonton

It is the same Government, my Lords.

Baroness Gardner of Parkes

It is even more difficult this time. Last time it was 50 per cent. and most people can divide by two. For 40 per cent. you need a calculator. You will probably have to try to employ an even more skilled chair-side assistant. She no longer has to be able to do just the physical work required in a surgery for the low fees that are paid by the health service; she has to be able to get out her calculator and, with the scale of fees, work out every penny.

My noble friend Lord Colwyn mentioned the fact that we are expected to give our patients an estimate in advance. That is totally hopeless. There is no way you can give your patients an estimate in advance—it will be difficult enough to work it out after you have done it. That is another important point.

Then the bad debts will abound because it is up to the dentist to collect the money. If you do not collect it, that is your loss. It still goes through your National Health payment schedule on the basis that you have had it. You meet your superannuation on the basis that you have had it. You are also assessed in terms of calculation through the DHSS as to what net income you are earning. It is presumed that you have had that money, and if you have not had it that is out of your pocket and it is just bad luck.

There was rather a lack of notice and there was certainly a lack of consultation. For example, the General Dental Practitioners' Association, who have over 2,000 members, were very disappointed that there was no consultation with them. They point out that for the maximum charge now of £115 for routine work you would have had to have had £262 worth of treatment. A very real problem exists in cases where the fee is unknown. This applies in many cases, particularly surgical ones. A patient comes in and may ask to have his tooth extracted on the basis that the noble Baroness, Lady Robson, mentioned. Such a patient may say "I cannot afford to have anything else. I shall have the tooth out."

The tooth then breaks. It is brittle, or it has been root filled. There are many reasons why a tooth breaks, including perhaps the nature of the bone. You find yourself instead having immediately to carry out a surgical operation to remove the segments. You cannot leave the patient walking around with half a broken tooth, an exposed nerve and in great pain. Therefore you carry out that operation. Remember that I am talking of the patient who could not afford to pay more than the £3.30 and that is why he asked to have his tooth out. That operation may represent £20, £30, £40 or £50 worth of work. There is no way of knowing because the Dental Estimates Board assesses it afterwards when you send in the X-rays and the history of what time it took you. What happens then? That patient has already told you that he either cannot or will not pay more than the £3.30. Presumably you will just do that work for 60 per cent. of the fee that is agreed. There is no way you will see that other 40 per cent. Therefore I think the bad debts will be a real problem.

I have discussed the whole matter in a great degree of detail. I do not see any reason why I should say any more on this our last day before Easter. However, I hope that I have made clear that in two ways I think that these charges are wrong. One is the principle that it is not in line with inflation, and the other is the practicality aspect; that it will be extremely difficult to operate. We have been told that the Minister will look at it again if it proves difficult. My concern there is how long it will be before you can prove anything and what damage can be done in that time.

3.47 p.m.

Lord Ennals

My Lords, the noble Baroness is to be congratulated not on the length of her speech but on the depth of feeling that came through. I hope the Secretary of State will read not only the speech of the noble Baroness and the noble Lord, Lord Colwyn, but also others. However, the speech from the noble Baroness was really a cri de coeur. If I was now thinking of changing my profession, she does not encourage me to apply to become a dentist. However, maybe that is not a problem.

Turning to the noble Baroness on the Front Bench, when she dealt a little earlier today with supplementary benefit regulations, every single speaker from all parts of the House was extremely critical of the regulations. The only nice thing that the speakers had to say to the noble Baroness, as I wish to say, was to congratulate her on having taken on her job—or, rather, the wisdom of someone who appointed her to her job. If I may say so, if we look at this afternoon's debate, not a single word has been said in favour of what the noble Baroness, Lady Trumpington, has to justify. I think quite clearly the DHSS needed a tough Minister to knock some sense into today's ministerial team. I am certain that, whatever else we feel, we wish her well in her monumental task.

I want to start in a slightly reverse order. I want to start with the question of charges for overseas visitors. I do this because I want to put down a series of questions, the answers to which will not automatically be within the vivid memory of the noble Baroness. However, I thought I should bring them up first in order that she may be able to answer them in the course of time.

I want to ask the Minister what is the total revenue from these charges for overseas visitors, both inpatients and outpatients, in the year just ended? How much will we have brought in? Secondly, what is the anticipated additional income as a result of these regulations? Thirdly, to how many people do these charges apply? Fourthly, does the revenue go to the district health authority or is there some system of central control over the revenue? I put these questions, as I said at the beginning, in order to give some notice to the noble Baroness. I hope that she will accept my pleasure, having once had responsibility for the Commonwealth War Graves Commission, that it is now to be exempt—and that is the last nice thing that I shall say about any of the regulations we are discussing.

I move now to the question of dental charges. Much of what I might have wanted to say has been expressed from the heart by the noble Baroness, Lady Gardner of Parkes, and by the noble Lord, Lord Colwyn. It is a tremendous advantage to have people with this professional experience to enlighten and inform our debates. Patients who are not exempt from National Health Service dental charges will be paying most of the cost of their treatment for the very first time. For millions of courses of treatment the service will be paying nothing, or next to nothing, towards the cost. Charges for dental treatment are rising, as stated by the noble Lord, Lord Colwyn, by 25 per cent. If we add this to the increase in prescription charges, to which I shall come, and the ending for most people of NHS spectacles, it is really inevitable that people, and certainly dentists, are saying that for many dental patients the service has now become virtually a privatised service. This is what concerns us.

Little by little in the primary health care service, as the noble Lord, Lord Kilmarnock, said, there is a biting away. We are not seeing this within the context of the Government's White Paper on primary health care or the Binder Hamlyn Report, which for months we have asked to be published. These new charges have been roundly condemned—and I think reasonably—by the British Dental Association. Dentists fear that the new charges will encourage people to have teeth extracted rather than conserved because extractions are cheaper. The British Dental Association—the noble Baroness, Lady Gardner, also mentioned this—has issued a warning that the charges will set dental health care back a generation. I believe that to be true. For millions of courses or relatively routine treatment, patients will pay the full cost. For many of the more complex and lengthy treatments, the National Health Service contribution will be extremely small. For others, the proportion that the NHS pays will vary widely and have no clear logic.

I notice that Mr. Ralph Followell, the immediate past chairman of the British Dental Association council, said that some patients who have been paying £14.50 could now be picking up a bill of£30 or £40. He went on to say that when an extraction costs a patient only £3.30 and a root filling and rebuilding a tooth could cost £30, a lot more teeth will be sacrificed that could be saved. I really think that the Government have to think again about the nation's teeth. It may be that, in general, dental health is improving. But by this decision of the Government, we are putting all this progress into reverse. I thought that the Daily Mirror hit the nail on the head when it stated in a leading article on 13th March: The new dental charges will be beyond the pockets of millions who are not entitled to free treatment … When it is much cheaper to have a tooth out than a tooth saved the purpose of the NHS is lost. We will be come what we were before the NHS began, a nation with rotting teeth". That is roughly what the noble Baroness said earlier in the debate.

Many concerned dentists do see this as a further step towards ending the National Health Service dental service in the same way as we heard in an earlier debate that many opticians see that National Health Service being phased out of their profession. We should not underestimate the strength of feeling which exists among members of the professions who are dedicated to the National Health Service and the cause of the professions which they serve.

I turn, thirdly and finally, to the new level of prescription charges. The new £2 fee is a tenfold increase over the 20p rate which existed when this Government came to power. They have in the course of six years—I was about to say six short years, but as far as I am concerned they have been six damned long years—multiplied by 1,000 per cent. the cost of prescription charges. Why have they done that? It certainly cannot be justified with regard to the rate of inflation. I think that the noble Lord, Lord Kilmarnock, said that we are talking about 3 per cent., but my percentage is rather different. I think that it is a 25 per cent. increase compared with 5 per cent. on the rate of inflation. Therefore, whether it be 3, 5, 4 or 8 per cent., in no way can it be argued that it has been done to keep pace with inflation.

Moreover, it cannot be justified in terms or the increase in drug costs. We do not need to go into the detail of this matter because this House has many times debated drug costs. The Government are dealing with drug prices and drug profits in two ways: through the limited list system, by which they hope to save £75 million, and by further adjustments to the Pharmaceutical Price Regulation Scheme (PPRS). I hope that the noble Baroness when she comes to reply—and if she cannot include this matter in her reply I hope that she will write to me—will say what progress is being made in the review of the PPRS which is now being carried out. In any case, does the noble Baroness accept that half of all £2 prescriptions—and this issue was referred to by both the noble Baroness, Lady Robson, and the noble Lord, Lord Kilmarnock—will cost more than the cost of the ingredients? My information is that the cost of half of all prescripions dispensed will be either equal to or more than the actual cost of the ingredients. I hope that the noble Baroness will confirm that point.

The Government's only explanation or excuse is that this is a way of paying for the National Health Service. None of the other arguments applies. The Government's conclusion is that we should constantly find ways of increasing the burden placed on those who need treatment. Time and again I have argued from this Dispatch Box, not only from my own personal view but on behalf of my party, that we believe, as we did when the health service was created, that basically it should be a service provided free at the the point of delivery. We are moving very rapidly away from that point; we are increasingly putting the burden of treatment for sickness not on the generality of the population but on the sick themselves. It is this Government's policy in issue after issue to bring in charges, and they are all charges on the sick—charges on people who need treatment, charges on people who need to go to the dentist, charges on people who need prescriptions because they have been to the doctor, and charges on people who need spectacles because they have been to the optician. It is they who have to pay, according to this Government, and not those who are fit.

Before the noble Lord, Lord Glenarthur, was moved—I was going to say to another place; I do not know whether he was moved to a higher office—he asked me on 11th November how I would pay for increases in the cost of the National Health Service. My answer is absolutely clear, and it is that the National Health Service should be paid for by the taxpayer and not by putting increased charges on to those who are unfortunate enough to be sick. I hold this as a deep principle.

I believe the Government would get a vote of confidence from the electorate if they were to spend more on the National Health Service. Of all the services, it is quite clear from opinion polls that the National Health Service is the most popular; and whenever the public are asked whether they are prepared to see more money going to the National Health Service they say, "Yes". If they are asked what, if there is to be more public expenditure, should have the highest share, they say, "The National Health Service".

All tests of opinion prove that this should be done not by heavier increases in charges on the patient, on the sick, but by taxation itself, spreading the burden across the whole nation. This was the concept of the NHS and it is being undermined by the Government. If the Government want more money nationally for the NHS then there are of course many ways. I will give only one example. They might tighten up on the cheating by some consultants for the benefit of their private patients. When recently the Government audited just one-sixth of district health authorities in England and Wales they found that corruption was responsible for a £10 million loss to the National Health Service. On that basis, if one assumes that that one-sixth of the district health authorities was a fair sample, £60 million could be saved simply on stopping fraud—more money than is to be obtained by the regulations that are before your Lordships' House this evening. That would be a far better way of doing it. Let us get rid of any dishonesty and let the patients get the best that there can be for them.

Just in conclusion before I sit down, I must say that there is a certain sense of frustration that I discern today, first, that the rules governing the proceedings of this House deny us the right to vote against the regulations. I understand this and one just has to accept it; but, secondly, it is frustrating that your Lordships are sitting, with all the skill and experience which has been demonstrated today, to debate regulations which came into effect four days ago. I really think that our business managers—and I hesitate to say this in the presence of the Opposition Chief Whip—and the Government ought somehow to ensure that, if your Lordships are to be taken seriously—and I believe every one of us believes that we should be—we should be able to debate issues like this before they actually come into effect.

Baroness Trumpington

My Lords, may I first of all thank those noble Lords who have welcomed me to this particular hot seat. I must say that I have wondered during the course of this afternoon: with noble friends like those behind me, who wants enemies? Today we have been debating, at the instigation of the noble Lord, Lord Kilmarnock, five sets of regulations with one thing in common. All of them are concerned with raising revenue for the National Health Service, and the Government's policy is quite clear. We believe that it is perfectly fair and reasonable to raise a modest proportion of the money which we need to run, and to continue to improve, the National Health Service from patients who can afford to pay. I would add that people who cannot afford to meet these charges will not be expected to do so.

In the 1985–86 financial year, patients' charges will account for some 3.2 per cent. of total health service spending. This is a modest figure, and it is in line with the proportion which has prevailed at certain times in the past. For example, in 1969–70, when the noble Lord, Lord Wilson of Rievaulx, was Prime Minister, patients' charges accounted for 3.5 per cent. of national health costs; but that modest percentage amounts to a considerable sum of money. For England alone in 1985–86, charges will bring in some £460 million. I have listened carefully to noble Lords opposite, and I have read what was said in another place when these regulations were debated, and I can only say that, first, I still have no clear idea exactly what the policy of the Opposition parties is as regards charges; and, secondly, I have yet to hear any reasonable explanation of how they would make good the revenue which would be lost if they failed to continue to raise money from charges at the present levels.

I think that the policy of the Social Democrats (whether or not they speak also for their partners in the Alliance I do not know) is to increase charges in line with inflation. Their spokesman in another place said that 1979 should be taken as the base year. Again, whether he meant that the charges were about what he would like them to be before or after we put them up in 1979 was not clear. I hope it was the latter, as the Labour Government had failed to increase prescription charges at all while they let inflation rip, and had left dental charges unchanged since 1977. In any case they would, so they say, have raised charges a lot less than this Government have done, and I have to ask them whether this means that they would have spent less on the NHS than we have done and, if not, where they imagine they would have got the money from.

We are not making any change whatsoever to the arrangements which exist for enabling people receiving supplementary benefit or family income supplement, or who have a low income, to obtain free prescriptions and free or reduced charge dental treatment. People who cannot afford these charges do not have to pay them. There are also other wide-ranging arrangements for exemption from charges so that, for example, 72 per cent. of prescription items are dispensed free.

Let me now turn to as many as possible of the various points raised by your Lordships. I start with the noble Lord, Lord Kilmarnock. He raised the point that many drugs which patients could buy over the counter from chemists are now black-listed. Any drug which was previously available for counter sale in a pharmacy is still available. The selected list makes no change. The noble Lord also wanted an assurance that the Government will not dismantle general medical services in favour of private practice. The Government are on record many times as saying that the National Health Service is safe with us. It is entirely consistent with that promise for those people who can afford to do so to make a contribution to the cost of their treatment. These contributions are to the benefit of the National Health Service at large, on which this Government's expenditure is constantly increasing.

The noble Lord, Lord Kilmarnock, also said that although £2 is less than half the average cost of a prescription item, some items actually cost less than £2. There is nothing new about this. Even when the last Labour Administration froze the prescription charges at an absurdly low level some items cost less than the charge. It is inevitable when a flat-rate charge is fixed to cover a large number of items that some of these items will cost less than the charge. Others, of course, will cost considerably more. But we have to look at the charges in the round. The total income received from the charges goes to offset the total national health drug bill and reduce the financial burden borne by the taxpayer. I certainly cannot give the noble Lord any assurance that we shall change that situation.

The noble Lord also raised the point that pharmacists should advise patients of drugs prescribed but available at less than the prescription charge. I do not think one has to persuade pharmacists to do this. I should have thought this simply followed a natural desire to sell. The noble Lord, Lord Kilmarnock, asked whether charges have been increased to recover the £25 million lost on the original estimate of savings through the selected list. The original estimate of £100 million a year was only a rough estimate and it will take a year or two for full savings to build up. The shortfall is temporary and may not occur if doctors prescribe sensibly across the whole range of drugs. Certainly the revised estimate of savings from the selected list played no part in the setting of this year's prescription and dental charges.

With regard to overseas visitors' charges, and whether the administrative costs make collection worthwhile, there is no convincing evidence that administering the scheme, as recommended in the department's guidance, carries significant costs. We are aware that two authorities which earn substantial income from the scheme—over £100,000 each in 1983–84—employed an additional member of staff, but there is no evidence that authorities with smaller incomes have employed extra staff. By adding one simple question to those which all patients have to answer when first attending for treatment it is possible to identify those who are more likely to be charged.

Several noble Lords suggested that prescription charges deter people from seeking the treatment they need. That does not square with the facts. The number of prescription items dispensed has increased from 300 million in 1981 to an estimated 320 million in 1984; it is unlikely to drop in 1985. I have said before, and I shall say again, that there are wide exemption arrangements. Over 72 per cent. of prescription items are dispensed free. Pre-payment certificates are available for people who need a lot of prescriptions and 6 per cent. of prescription items go to holders of pre-payment certificates. These arrangements ensure that nobody is denied medication on financial grounds.

The noble Lord, Lord Kimarnock, also asked about the percentage of people exempt as distinct from items which attract no charge. He referred to the percentage of the population which is exempt from prescription charges. The percentage is misleading. What is relevant is the percentage of medicines which are required by the population which are exempt from charges. This is about 72 per cent. of all items dispensed.

The noble Lord, Lord Kilmarnock, also suggested that the loss from optical charges has been loaded on to dental charges. This is not the case. The savings from the changes to the general ophthalmic service more than offset the loss of income from optical charges. The noble Lord also asked when the Green Paper on primary health care will appear. My right honourable friend the Secretary of State for Social Services has said that the Green Paper will be published in the summer. The review of the pharmaceutical price regulation scheme is not strictly related to the regulations we are debating.

Returning to the dental side, many nobleLords, particularly the noble Lord, Lord Kilmarnock, my noble friend Lord Colwyn and the noble Baroness, Lady Robson, suggested that the change in the charging system will lead to people choosing cheaper forms of treatment, such as extractions, rather than more expensive treatment which will enable them to keep their own teeth. I would say first of all that it is only people who can afford the charges who have to pay them. It is right that people should be able to choose what they spend their money on. There is often a choice between various types of treatment; and patients, guided by their dentist, should be able to weigh up the clinical, aesthetic and cost considerations and decide for themselves. But I see no reason why certain forms of dental treatment should be more heavily subsidised than others. Secondly, all the evidence is that people are choosing to retain their natural teeth—lucky things!

The noble Lord, Lord Kilmarnock, and my noble friend Lord Colwyn suggested that these increases will deter people from going to the dentist. All I can say is that there is no evidence that increases in charges deter people. On the contrary, the number of courses of dental treatment in England and Wales has risen from the figure of 28.5 million in 1979 to 32.6 million last year.

My noble friend Lord Colwyn, as he said, was kind enough to give me notice of the points that he wished to raise. Time is going by, the hour is very late for this particular day just before Easter. If I undertake to read the answers to his points, I hope your Lordships will forgive me if I leave the dental situation there. The noble Lord, Lord Ennals, referred to some of the same matters.

Lord Ennals

My Lords, may I have a copy?

Baroness Trumpington

My Lords, of course. My noble friend referred to the actual increase in dental charges. He rightly pointed out that the actual increase in the charge varies, and varies considerably, with the type of treatment given. We estimate that the average charge will rise by about 23 per cent. from £14.90 to £18.30. As regards the charges for routine treatment, there will be no increase at all in about 60 per cent. of cases because the patient is already paying the full cost. In about 15 per cent. of cases, the increase will be less than £5; in about 12 per cent. of cases, it will be between £5 and £10; and in about 10 per cent. of the cases between £10 and £20. In only about 3 per cent, or 4 per cent. of cases will the increase be more than £20.

My noble friend Lady Gardner also referred to the substance of the next part of the question by my noble friend Lord Colwyn. My noble friend referred to the administrative costs of the new scheme. I accept that there will be some additional administrative burden on dentists but I do not think that these costs will be as great as perhaps my noble friend suggested. As I have already said, only about one-fifth of visits to the dentist are affected by the new charges and some of these will only be affected by the new charges and some of these will only be affected by the rises in the set charges. I appreciate that dentists will only be able to give their patients an estimate of the cost before starting treatment and that they may have to tell them at least in broad terms of any increases resulting from additional treatment which they find it necessary to undertake. But, as charges are paid only by people who can afford to pay them I believe that in the overwhelming majority of cases patients will accept the treatment their dentist proposes and pay the charge, as they undertake to do when they sign the dental estimate form.

I think that we need to bear in mind the purpose of the change, which is to have a system which is fairer to patients. I think that the new system should be given a chance to work. My right honourable friend the Minister for Health has told representatives of the profession that, if they can come up with a system which is fair to the patient, easier for the dentist to administer and capable of raising the sums of money required, he will certainly consider it for the future.

My noble friend Lady Gardner, again in part of her speech, also referred to the remarks of my noble friend Lord Colwyn. In the course of his comments on the administration of this scheme, my noble friend referred to fees which are at the discretion of the Dental Estimates Board. The scheme does take account of them. These fees are for treatment which is subject to the prior approval of the board and therefore the dentist will normally know the fee and hence the appropriate charge before starting treatment. It is only in cases of emergency when the board turns a blind eye to the regulations that a problem may arise, the most common case being what appears to be a simple extraction, for which there is a set fee, turning out to be more difficult than expected. In most cases, the dentist will know from experience the size of fee which the board is likely to approve and therefore will be able to charge the patients a safe but not unreasonable amount, refunding any difference when notified of the fee by the board.

My noble friend suggested that the discretionary fees should be published. If they were published, they would no longer be discretionary. I can say, however, that we are always looking for ways of reducing the number of discretionary fees. The noble Lord, Lord Kilmarnock, asked about statistics on dental health, and my noble friend Lord Colwyn really accused the Government of manipulating figures to suit ourselves. I resent this very much and I hope he will withdraw the remarks he made, particluarly the remarks about being unable to trust the Ministry. I think that those are the most unhelpful remarks which have emerged from these Benches for a very long time and I hope that he will see fit to take them back.

Finally, my noble friend asked for an assurance that the charges will be reviewed as soon as evidence emerges, as he said, that dental health is being damaged. We have, as I have said, no evidence of that but my right honourable friend the Minister for Health has agreed to a proposal from the British Dental Association for a joint review of the available statistics to see whether it is possible to reach a joint view of the effect of increasing dental charges. I hope this will prove to be the case, if only to avoid the kind of sterile argument about statistics which has echoed through our debate today.

The noble Baroness, Lady Robson, referred to the need for people to have private prescriptions as a result of the introduction of the selected list. I think I have already dealt with that side of things. Referring to the increase in charges, the noble Baroness said that she doubted whether the overall income would be increased. These private patient charges are fixed by the Secretary of State's determination and not by the regulations, and so they are really irrelevant to what we are talking about.

My noble friend Lady Gardner of Parkes made a great many rather unpleasant remarks. As regards the expensive treatment which is given free to people, we know of no conclusive evidence of this, although it is true that the average cost of treatment given free to adults is somewhat higher than that for those who save to pay. My noble friend Lady Gardner also mentioned a statement by the Government that dental charges would only rise in line with inflation. No such statement has ever been made. My noble friend also mentioned the intention of changing the structure of the dental charges to discourage unnecessary treatment. That is not so. The intention is to make the system fairer.

The noble Lord, Lord Ennals, among many sweeping statements talked about patients paying the full cost. There is nothing new in this. Before 1st April, people whose routine treatment cost up to £14.50 paid the full cost. Now people whose routine treatment costs up to £17 will be paying the full cost. When the noble Lord, Lord Ennals, was Secretary of State, it was a case of paying the full cost of up to £5; he put it up from £3.50. The noble Lord asked also where the money from charges to overseas visitors goes. It goes to add to the health authority's resources.

Lord Ennals

How much?

Baroness Trumpington

My Lords, I do not have the figure for that, but I shall of course write to the noble Lord.

Quite honestly, I think the time has come when I must say that I shall write to other noble Lords. I am sorry that all this has taken place so late and that other noble Lords have spoken for so long, thereby preventing me from doing full justice in giving them answers. However, there is just one point I should like to finish on. We have no intention of changing things; we are committed to the National Health Service. We will defend the National Health Service, and these increased charges will help us to continue to improve the health service. I commend them to your Lordships.

Lord Kilmarnock

My Lords, I am afraid that before withdrawing this Motion I have to say to the noble Baroness that I found her reply most disappointing. I think that some noble Lords will resent the implication that they have spoken at excessive length on these very important matters, on which they have a right to expresss their opinion. In her speech, the noble Baroness introduced one or two moments of hilarity, for which I suppose we ought to be grateful to her. In particular, I was glad of her pledge of the Government's continuing support for the National Health Service family doctor service. We shall certainly be holding the Government to that when the Green Paper is finally published and we discuss these matters at greater length.

I was amazed to hear the noble Baroness say that there is no evidence that an increase in dental charges had ever deterred patients from going for dental treatment. That may very well be the case when there is an increase of 5 or 6 per cent., or an increase in line with inflation. But, to the best of my knowledge, people have not so far been faced with an increase of 40 per cent., which I think was mentioned by the noble Lord, Lord Colwyn, for certain types of treatment. It is simply unbelievable that people will not be deterred by massive increases of that kind.

The noble Baroness told us that optical charges are not a factor, and I was very glad to hear it. If that is so, and the Government are not concerned to recoup what they have lost, there seems to be even less of a case for hiking the dental charges by this enormous amount. In fact, the noble Baroness seems to me to have scored an own goal there. I also find it absolutely amazing that she should dismiss as "unpleasant" the extremely sensible and practical remarks which were made by the noble Baroness, Lady Gardner of Parkes, on the basis of very great personal and day-to-day working experience of these matters.

By convention we do not press Prayers such as these to a Division, but I am glad to say—and I can certainly guarantee it through a number of people to whom I have spoken—that people who are interested in these matters will read the report of this debate with close attention and will draw their own conclusions from it. My Lords, I beg leave to withdraw the Motion.

Motion, by leave, withdrawn.