Dentistry

HL Deb 10 June 1992 vol 537 cc1328-54

7.9 p.m.

Lord Colwyn rose to ask Her Majesty's Government what proposals they have for the future development of dentistry in the United Kingdom.

The noble Lord said: My Lords, I am grateful to the noble Lord, Lord Tordoff, for giving me an extra couple of minutes in which to recover. I normally expect to travel from my surgery to the House in about 12 minutes, but I had reckoned without Beating Retreat on Horse Guards and I had to walk my bicycle a rather long way round. Hence my late arrival.

I am grateful to the usual channels for allowing me to raise this important subject this evening and to other noble Lords who are to contribute to the debate. Your Lordships will be aware that discussions about dentistry and its future within the National Health Service have been in the news during the last few weeks. I hope to be able to make some constructive comments which may help the department in its considerations.

I declare an interest as a practising dental surgeon. Following qualification in 1967 I had 15 years' experience of working in the National Health Service. My sentiments this evening are purely personal, although I have consulted the British Dental Association and the Dental Practice Board. I am also grateful to Tom Farrell, David Phillips, Kevin Lewis and the Forum for the Future of Dentistry for information and advice. Regrettably much of the paperwork arrived too late for inclusion this evening but I know that it will be useful for future discussions on dentistry.

As I said in the debate on Her Majesty's gracious Speech on 12th May, the next few months will be the most significant for the dental profession since 1948. Just before the election my right honourable friend the Prime Minister intervened to suspend the proposed 13.8 per cent. cut in fees which the Department of Health had suggested, potentially ignoring the normal processes by which dental remuneration is decided. During the past three months payments have continued at the 1991 level and the department has now estimated that a cut in the region of 23 per cent. is necessary to balance the budget.

There have been various meetings between the department and the British Dental Association, which have resulted in a proposed reduction of 7 per cent. in fees and a promise from my right honourable friend the Minister of a fundamental review of the way in which dentists are paid. I hope this evening to be able to make some suggestions for her consideration, as it is quite clear that the present system needs complete overhaul.

I am also concerned that, unless there can be a period of relative stability, dentists, who will be uncertain of their financial future, will try to balance their budgets by working even harder, causing a continued increase in payments and substantially compounding the problem, or even opting out of the National Health Service to the detriment of patient care and government commitment.

Although the dental remuneration system has worked well in the past, it has evolved into a highly complex scheme which is simply not working now. Although the Government are implementing in full the 8.5 per cent. Dentists and Doctors Review Body settlement and allowing a continuing excess payment, the result is generally perceived as a reduction in income.

That 7 per cent. cut drives some fees back below the October 1989 levels and will not spread the burden of recovering the overspend. For the practice with low or average practice expenses the effects are serious, but for the practice with above average costs the results are devastating. In 1991–92 the average practitioner's overheads consumed about 60 per cent. of gross fees earned. Assuming the same workload in 1992–93, a 7 per cent. fee cut would see that dentist's profits falling by 29 per cent. Lower practice costs of 50 per cent. or higher costs of 70 per cent. would see profits fall by 22 per cent. or 41 per cent. respectively, but there are many practices where costs are as high as 75 per cent. or 80 per cent. Here profits would fall by 51 per cent. and 65 per cent. That will cause serious problems.

A brief history might be useful. Dentistry came within the NHS at its conception in 1948 as a free service for all, and dentists were paid on a fixed fee per item of service basis. It was not until 1951 that charges were first introduced and patients made a contribution towards the cost of false teeth. That was followed in 1952 by a charge for other treatment as well as dentures, with all treatment limited to a maximum patient's charge. In 1977 separate charges were made for crowns in addition to dentures and other treatment, subject to an overall maximum. In 1985 the concept of a maximum charge of £17 plus 40 per cent. of the excess over that figure was introduced for other treatments in addition to charges for dentures and crowns up to an overall maximum. In 1988 non-exempt patients were required to pay 75 per cent. of all fees up to the maximum.

The new contract introduced in 1990 used a basic capitation system of registration. It is the success of the new contract, which was accepted by the profession under duress but made to work by the profession, which has caused the problems we see today. That new contract has greatly changed dental practice, which, despite reports to the contrary, is a great success and not in danger of imminent collapse. At the end of March about 27 million patients were registered, with an overall take-up rate of 52 per 100 adults and 57 per hundred children. Now 18 per cent. of all children under the age of two years are registered with GDS dentists. Very few children of that age would have been seen under the old contract and the introduction of young children to dental care involving dietary advice must be a move towards prevention, one of the objectives of the new contract.

It is the success of the new contract which has caused much of the trouble. Any increase in treatment means that the funding available for dentistry has to be shared out among more treatments, thus necessitating a cut in fees. The amount of money paid to GDS dentists in England and Wales in 1991–92 was 20 per cent. higher than in 1990–91. That increase is higher than was expected and occurred for a number of reasons. When the new fee levels were set to achieve the average dentist earnings recommended by the Doctors and Dentists Review Body, they were calculated on the basis of a forecast drop in output of 3 per cent. That resulted in a fee scale increase of 8.6 per cent. from 1st July on new courses of treatment. In the event, output increased during the year. Had that level of output been forecast, fee scale increases would have been lower or non-existent.

Some of the increase in output—about 2 per cent. —was the result of the work flow at the Dental Practice Board, which was able to decrease the amount of new contract work accumulated at the board. That made a significant contribution to the increase in output, but the larger part of the increase in claims was generated by dentists. They can do that in a number of ways: by working longer hours or faster, or by making greater use of auxiliary personnel for those treatments or advice they are qualified to provide. The changes made by the new contract, involving many changes to the narrative, may have had an impact on the balance of child and adult patients, the range of patients seen and the treatment pattern provided. For example, there may have been changes in the type of examination required, the type of treatment needed and the laboratory cost involved, and the dentist may have been called out to provide emergency cover. Any such changes have an impact on total GDS gross fees.

Dental remuneration is determined by a simple formula. The average dentist should earn the target average net income (TANI) of £35,815 as recommended by the Doctors and Dentists Review Body, plus an element in excess of £45,000 to cover practice expenses. The total is referred to as the target average gross income (TAGI).

I very much regret that my right honourable friend the Secretary of State in her various interviews on dental remuneration repeatedly referred to the fact that: a third of dentists earned over £100,000—which is a very substantial figure".

She also said that: a third over £100,000 is quite a lot—gross".

Although I cannot argue with her figures I believe that the statement gives the false impression that that is the sort of figure that many dentists actually take home. Practice costs, which can vary from between 40 per cent. to 70 per cent., are deducted from that figure. Therefore, I believe it is a mistake to give an impression of dental earnings being in the £100,000 range. A view of net earning potential would have provided a fairer comparison.

A substantial part of the expense element is made up of staff wages and rent, so that the average dentist is reimbursed for those items, plus other expenses, via the fee scale. Not all dentists are average. They do not all treat an average number of patients with an average amount of treatment of average quality. The aim is to enable the average practitioner to reach the target gross income, but the calculations are so sensitive that one false assumption can change the fee for a given item, which might affect the prescribing pattern in favour of or away from that item.

Over the past two decades 55 per cent. to 60 per cent. of all practitioners have not achieved the target gross income. Some exceed the target quite easily and some can achieve three or four times the target. That is why so few practitioners can relate to that average label.

I remind noble Lords of the Tatersall Report in 1964, which stated: In short, nobody can assert with conviction that any individual dentist is getting what he is entitled to, let alone what he deserves".

The fee scale is meant to be neutral, in that it rewards all types of treatment at exactly the same level, but that is not the way the system works. In the current NHS system the winners inevitably will include those who have low fixed costs, can work very quickly and stick to basic dentistry, referring out anything troublesome or unprofitable, as well as those who invest as little as possible of their profits in their equipment and practices and use the cheapest materials. The losers are those in high-cost areas where overheads are more expensive and where the practitioner may take more time and trouble setting high standards and investing in modern equipment, a pleasant environment and good quality laboratory support and materials.

Nothing epitomises the folly of NHS averaging better than capitation. Although I am well aware of the differential in need for dental treatment in different parts of the country, to be paid the same rates whether one is treating the high-need or low-need patients, whether one's area is fluoridated or unfluoridated, or whether one practises in the cheapest or most expensive locality, is divisive, hurtful and demoralising to those on the wrong end of the system. If one sets high standards, works more slowly and is in a high-cost area, the NHS holds nothing but problems; movement into the private sector becomes the only alternative.

The uniform expense factor is of great concern to most dentists. Not only is it uniform throughout Great Britain, taking no account of varying overheads around the country, it acts to the advantage of the large practice and the high earning dentists. The constant overhead costs, such as rents and, to a certain extent wages —which are not directly proportional to the number of dentists in a practice—are spread among more than one dentist and the expense element for those items is a lower percentage per dentist in multiple practices. Also, for the high earning dentist, the expense element represents a smaller percentage of gross fees.

For those reasons there is a good case for the direct reimbursement of staff wages and rent as well as business rates—which already occurs. At present medical practitioners receive direct payments of 70 per cent. of expenses. That would probably be about right for dentists. Indeed, the concept of the fund-holding practice, which is already a great success in medicine, could be considered a valuable alternative.

Dentists are aggrieved by what they see as the inequalities of the balancing mechanism which, because it operates three years in arrears, seems manifestly unfair to many dentists, especially newcomers, those earning below the average and practitioners nearing the end of their career. The Dental Rates Study Group calculations have resulted in over-payments to dentists in each of the last three years, building up a very worrying potential debt for future dental practitioners to face. On the other hand, it must be government policy to encourage dentists to work hard, increase their productivity and give a better service. I am sure that serious consideration must be given to finding alternatives to the balancing procedures.

In the longer term—I appreciate that fundamental change to the new contract would probably not be considered at this time—moves toward a larger measure of capitation than exists at present for adult patients would be an advantage to the average practitioner. At present dental practitioners receive 47 pence per month for each adult registered with them. That figure could easily be increased to cover, say, the cost of any examinations and diagnostic procedures provided. Again, that would slightly reduce fee levels and dampen down high earners' gross fee levels. Overall, dentists would still receive the majority of their income from item of service fees, which is important.

An added bonus which would result from the inclusion of some small common items in capitation is that it would reduce the paperwork, since dentists would not have to submit an estimate to the Dental Practice Board if the only treatment required was that covered by the capitation fee; namely, examination, radiograph and reference models. I am informed that that represented about 20 per cent. of adult claims in the quarter ending March 1992.

One of the difficulties of moving adult treatment slightly more into capitation is the problem of patients' charges, which at present are 75 per cent. of the cost of treatment up to a maximum of £225. The monthly continuing care payments are free of patients' charges at present. The question of how to claim the patient's charge would have to be resolved, but I am sure that it is not insoluble. I suggest that the Government could easily reintroduce the free dental examination within that slight move towards adult capitation without having to return to the original system.

The proposed lowering of the prior approval threshold to £200 is a dramatic quick-fix control on the fee-per-item overspend. It was predictable enough in principle, if not in scale. But, for it to be effective in slowing or reducing costs, it will have to entail increased bureaucracy and delays in treatment. Prior approval for the more complex dentistry represents more stringent prescribing restrictions than for very many years, although now targeted to total treatment volume rather than the type of treatment. However, I have to say that a review of treatment patterns at the Dental Practice Board does not suggest long-term swings as prior approval requirements are changed. From that it is safe to assume that the vast majority of dentists provide treatment that they consider to be clinically necessary. The increase in some items and the decline in others is more likely to be related to other factors, such as changes in treatment philosophy.

The cost of a course of treatment has moved from £3.40 in 1964 to £28.20 in 1989–90, before the new contract came in. When those figures are adjusted to the 1989–90 level the figures are £25.30 and £28.20 respectively. In other words, the cost of a course of treatment has not increased as prior approval restrictions have been lifted. Those practices which never had a serious option of leaving the NHS may even be relieved that the fee cut announced is only 7 per cent., but they must remain disheartened. To maintain the same income the average practitioner will need to increase productivity—to work longer hours at the expense of time that he should be able to spend with his family.

In conclusion, I urge the Government to undertake the promised fundamental review of dentistry. It should be wide-ranging, comprehensive, independently led and, above all, free from domination by the representatives of the provider groups, such as the General Dental Services Committee. Unless that is assured, it is difficult to maintain the public interest in the context of determining the priorities of dental health and public expenditure. We cannot allow another meddling exercise to occur between the GDSC and the department, leading to another short-term solution.

There is no doubt that individual general dental practitioners in the United Kingdom give the most effective and efficient dental service in the industrial West. The NHS already represents very good value in terms of public expenditure. Nevertheless, the system of payments to dentists, particularly with regard to the provision of services to those in greatest need, is in need of urgent review. I have great doubt whether the profession's existing negotiators will be able to bring that about. Ordinary family dentists are not convinced that the negotiators are totally representative. Evidence must be heard from a full range of dental practitioners and interested parties, including the most important people in the scenario: the consumer and taxpayer.

In view of the debate last week on the Committee work of the House and the conclusion that the work of the ad hoc committees was impressive and should be widened, I venture to suggest that your Lordships' House should consider the appointment of a committee to inquire into the future of dentistry. I should be delighted to help in any way possible.

7.28 p.m.

Earl Russell

My Lords, I thank the noble Lord, Lord Colwyn, for introducing this topic. Having been yesterday in the situation in which he is today, I should like to offer my heartfelt sympathy. Unusually, I should like to declare an interest. It is one not where I fill but where I am filled. I declare an interest as a consumer and taxpayer. The noble Lord said that I am therefore one of the most important people. I should like to think so.

Over the years I have got to know my dentists very well, sometimes—I hope they will forgive me for saying this—rather better than I should have liked.

A long time ago during the Prime Ministership of Sir Edward Heath, I came to the conclusion that never again should we elect a Prime Minister with good teeth. That view, alas, has not yet gained general currency. One of the reasons that made me return to this country from the United States was the availability here of the National Health Service dentistry. I was finding its absence serious indeed. Therefore when I declare an interest in the debate I mean it literally. We should note how consistently the producer and the consumer—allegedly opposed interests—in fact speak with a single voice against the intrusion of a state which has got its costs wrong.

During the debate we shall hear a good many figures. The Secretary of State gave some. The Conservative Central Office press release contains some. I should like to know who are the dentists with whom the Secretary of State has talked. From what source does he receive information about figures?

The noble Lord, Lord Colwyn, described the system of the target average gross income. It is easy to mistake a hypothetical income for an actual income. The hypothetical income is what it would have been if the dentist's expenses had been as predicted. The noble Lord, Lord Colwyn, is entirely right about averages. A great many dentists' expenses are not as predicted. Therefore the dentists' actual net income may have nothing to do with calculations taking place centrally of what the dentists' income might have been.

I am briefed by my own dentist whose anxiety about the issue is deep and intense. He has always been dedicated to the health service. He has been extremely anxious about his future in it ever since the introduction of the dental contract which, in his view —it seems correct—is where the trouble stems from. If there is not an urgent resolution of the immediate issue, then I believe that he will leave the health service. Since he is a very good dentist—when I declare an interest, I mean it—that would concern me deeply.

We have not only a long-term problem. I agree with the noble Lord, Lord Colwyn, that there is a strong case for overhauling the way in which dentists' remuneration is calculated. There is also the urgent short-term problem of a shortfall of income, as many dentists perceive it. Since the Adam Smith principle that a deal must be in the interest of both parties is perfectly sound, if the dentists are not satisfied with the deal that they are offered they will not continue to undertake the work. Since there is private dentistry, there is competition. The Government must face that.

The contract calculated expenses by a gross formula applying a flat rate nationally. Every Londoner will tell you that that simply does not work. Anyone who pays the same rent for premises in Sheffield as he would pay in London is not a good man of business. Anyone who pays the same laboratory costs in London as he would in Sheffield is probably not a good man of business. The laboratory costs, in particular in a good practice, are a vital part of the costs.

Secondly, it is not only a national flat rate formula. It is also an inaccurate calculation of costs. Over the years this Government have been extremely prone to that. But it seems to be almost on the level of the miscalculation of the standard spending assessments at the introduction of the poll tax. If nothing is done about the miscalculation, the effects may be equally serious.

I understand that there is a need to watch costs, but it is not intelligent to pretend that items cost less than they actually do. If you are cutting costs you must do so by undertaking the work you can afford and by not doing the work you cannot afford. Cutting costs by pretending that costs are lower than they are is an exercise in fiction. Watching such a style of cost cutting I am sometimes reminded of a devastating onslaught by one literary critic on another when he observed on the fifth page, "He is not one of the abler practitioners of this form of criticism." Similarly one may say that the Government are not always among the abler practitioners of this form of cost cutting.

The effect of the contract was to reduce my dentist's income in a practice, newly and very well equipped, to £11,400 a year. Naturally he reacted as you and I would do by working all the hours that God sends and a few that He did not. I have much cause to be thankful to my dentist for doing so.

That extra effort by the dentists produced earnings which led the department to allege that there was an overpayment. It was money which the Government had not expected them to earn. They were given an economic incentive which they took. I believe that anyone holding Conservative principles would have recognised that they would do so and should praise them for it. When people have worked six days a week from 9 a.m. until 6 p.m. or on one of those days until 9 p.m., the shock at having such an incentive taken away makes them consider leaving the health service.

We should consider the steady trend towards longer hours in all the public services. The paradigm public servant of the 1980s was the signalman raised to unfortunate immortality in the Hidden Report who was working so long that he had simply lost any ability to concentrate on what he was doing. In medical matters, that is, to put it no higher, unfortunate.

The noble Lord, Lord Colwyn, also referred to the cut in the prior approval threshold from £600 to £200. As he said, that is an occasion for a great deal more bureaucracy which involves a great deal more cost. The department should consider whether the operation of that system will lead to a reduction in costs or whether the administrative costs may be close to the amount of dental saving. From the dentists' point of view, as from that of a university teacher, such a factor causes intense irritation and leads to remarks that one would not repeat in this Chamber.

I make one final point. During the election campaign I listened to the Prime Minister on the Walden programme repeating his pledge to a publicly funded health service, funded out of taxation, and free at the point of delivery. Unlike some, I recognised that pledge as totally sincere. On the other hand, as I listened I felt a great deal of doubt as to whether he would succeed in delivering the pledge. In order to succeed in doing so, he must get his costs right; and that is a matter on which the Government do not have a good record. He made no exception of the dental service. I did not understand him to intend to make any exception of it. Therefore if he is to make good one of the most significant of his election pledges—without which it is a wide open question whether the election would have gone the way it did—he must make sure that dentists make an honest living and stay in the health service.

7.40 p.m.

Baroness O'Cathain

My Lords, it probably seems strange to your Lordships that I have put down my name to speak in this debate. I did so for three reasons. The first is that dental health is very important to every consumer. Like the noble Earl, Lord Russell, I speak as a consumer. It is important to every consumer—to every person—in this country and I have always been intensely interested in anything that affects the consumer.

The second reason is that the future of dentistry seems to me to hinge on the absolute necessity to ensure that the management of change is effected in the most economic and socially acceptable way. As someone who has to cope with that difficult and demanding task on a daily basis I felt that I might have something to offer on that score. The third reason is that the future of any organisation, function or concept depends on the current state of that organisation, function or concept, and the current situation of dentistry gives me some cause for concern which I should like to share with your Lordships. That concern was described in great detail by the noble Lord, Lord Colwyn.

Both the previous speakers spoke in depth about the contract, TAGI and TANI. I shall not go over that ground again. I want to talk about the future of dentistry. Dental health is something that we take very much for granted. It looms large in our lives only when we have a raging toothache. My generation, and those of an even older generation, still regard a visit to the dentist as a really terrifying experience. In fact, I often say to my banking colleagues that a visit to a bank, with its forbidding surroundings and strict tellers behind bullet-proof glass, is third in the list of the least-pleasant forays of the average consumer after the dentist and the self-service petrol station. Incidentally, lest any of my banking colleagues should perchance come across what I have just said I must put the record straight; banks are improving their customer care. But a visit to the dentists is no less terrifying!

It is a mark of how wonderful the developments in dentistry have been that today's generation does not have anything like the same level of fear. It is also a situation that leads one to the conclusion that dentists are now victims of their own success. Those of us who had a mouth full of fillings before the age of 12 and those of us who had schoolfriends who had false teeth while still at school, find it hard to believe that nowadays the young people who have fillings—even one or two—are the exception rather than the rule. The dental profession has achieved remarkable success during a relatively short period of time in being largely instrumental in bringing that about. It has been due partially to regular examinations and due partially to its mission to save teeth and not to drill and fill at random. The improvement in dental health is also due, of course, to better education—schoolchildren are encouraged to look after their teeth —and also, I am quite sure, to something as simple as TV advertisements. The third reason for improved dental health must be fluoride—however controversial that whole issue has been.

Those are some of the very real plus points. But I have already made the statement that I think that dentists are the victims of their own success; and that very success questions the future shape and size of the profession and the emphases that will have to be laid upon the training of the entrants to the profession. The future of the profession is fraught with the problems of change.

Change is one of the most difficult issues that face any of us in our daily lives and the management of change is the biggest single issue facing us in our business and commercial lives. Dentists are not immune to this problem and I believe that it will become an even greater issue in the immediate and longer-term future.

As I read the situation the demand for dentists is bound to reduce if the dental health of the nation continues to improve so significantly. That demand will not tail off for some time while people such as myself still have to rely on the dentist for considerable "care and maintenance" due to the problems encountered in early childhood (in another country, I hasten to add!). But I can see a situation developing where in about 10 or 15 years' time the numbers of new intakes into the profession could be reduced significantly. This change will have to be managed. That is no easy task as the management of change in a declining market is the most difficult problem of all.

In order to ensure that the great strides made by the profession are not jeopardised it is imperative both that cognisance is taken of that now and plans to cope with the future drawn up.

Of course, no one can foretell the future and my tentative assessment of what might happen is as likely as anybody else to be completely wrong. But one way of making an attempt to forecast what the future of dentistry might be is to extrapolate from the present. And what a sorry picture emerges to those not intimately connected with the profession. I confess that my knowledge of the current position is at best scanty, told to me by my dentist when he had me captive in his chair of torture while I had no chance of answering back or of asking questions. Doubtless the rights and wrongs of the current situation will be well detailed this evening and we have already heard many. Suffice it to say that I feel very sad that a profession which has served the consumer so well—the nation so well—should be threatening to strike, or the equivalent.

It is also a sad irony that the dentists, despite their tremendous service to the nation's well-being, do not have a great deal of support from the public. That is understandable: they are not a high-profile body; usually the dentist is not the person at the centre of a life or death situation; the dentists' waiting rooms are not filled to overflowing by the hypochondriacs who want a quick fix in the form of Valium. All of this suggests that they will have little or no support from the general public for their action. The dentists are demoralised and I believe it behoves the Government to try as hard as they can to sort out this problem.

It also behoves the dentist to defuse the situationthere— has been some fairly inflammatory writing coming from their side of the divide (if divide it is). I fear that such sanctions as the dentists propose will not grab the headlines and that the two groups of people to suffer will be the dentists themselves and those of the population who are genuinely unable to pay for the increased consultation and treatment fees.

Dentists admit that there have been some rotten apples in the barrel; that some people have charged for treatment not undertaken. It is sad that those dentists who do all in their power to help their patients are being tarred by the same brush. I am sure that there are many NHS dentists who, like mine, put themselves out constantly for their patients. My dentist opens on Saturday morning to treat people, like me, who cannot visit their dentist during the normal working week. He also insists on visiting my extremely disabled husband at home, after a long and hard day's work, in order to ascertain whether the problem can be dealt with at home rather than subjecting my husband to the difficult manoeuvring of a wheelchair in a dentist's surgery. There are rotten apples in almost every barrel one cares to look into. Proper policing of the new contracts must be undertaken until such time as we have a more widespread sense of honesty in our nation.

The action that is proposed must by its very nature be short term. Everybody refers to short-termism in the City—it is a pity that it should be present also in the professions. That short-term action could jeopardise the long-term orderly development of the dental service just at a time when all the indications are that some pretty fundamental examination should be undertaken into the services that in future should be provided by the dentists.

I should like to ask a couple of questions. Why should the taxpayer pay for cosmetic dentistry? Perhaps the answer is that the psychological health of the patient is impaired without it. However, the dental health of a patient is almost certainly not impaired. I am told that a truly permanent filling material is not yet available, but when it is the demand for renewals should be considerably reduced. The demand for dentists might be limited to maintenance and repair and to orthodontics, both of which should be provided under the NHS dental contract; but I believe that everything else should be paid for. It appears to me that we are in the age-old dilemma of needs versus wants.

There is only one way to solve the current problem which, in turn, will lead to an orderly development of the future of dentistry. It is that the heat should be taken out of the current situation and that the Government should assist the profession to plan for the changed future. The suggestion that the negotiations group should be widened is excellent. I hope that in reply the Minister will give us some hope that the current uneasy state of affairs is containable, and capable of being resolved in such a manner as to ensure that there is an orderly, managed process of change leading to a great future for dentistry in this country.

7.50 p.m.

Baroness Eccles of Moulton

My Lords, perhaps I may begin by thanking my noble friend Lord Colwyn for setting out the complexities of this Question in such meticulous detail.

I thought I might address the Question on the future development of dentistry from the point of view of the steadily improving oral health of the population and how that links with the aims of the health authority. As my noble friend said, the new contract has successfully changed dental practice and that is demonstrated by the increasing numbers of both adults and children now consulting a dentist.

As chairman of a district health authority, I am particularly interested in anything which contributes to health gain and the quality of life of the population for which my authority is responsible. Sounder teeth staying put for longer must count on both those scores. Under the National Health Service reforms, emphasis has shifted from funds attached to hospital beds and other health services funded on an incremental basis to capitation funding based on the health needs of the population. As we all know, the consequence is that the money follows the patient and health authorities enter into contracts with the providers of the services.

An important part of the process of deciding which services to purchase is assessing what will be needed. At the same time, we attempt to identify illness which can be prevented. Oral health has a substantial contribution to make to improvements in general health. One of the local indicators used by the health service as a measure of the general health of the population is the incidence of tooth decay.

In order to encourage the health service to concentrate on promotion and prevention, targets are set. In that regard, a thread of government policy can be traced through first, Working for Patients, continuing through the Citizen's Charter to the Patient's Charter. That policy advocates the setting of targets both nationally and locally. Local targets are of particular interest and also feature in the Green Paper, Health of the Nation. Those local targets could be relevant in the field of oral health.

Statistics show that there is a wide geographical disparity in the incidence of decay. I give just one example. The best record for a health district of decayed, missing or filled teeth per five year-old child is 0.5, or one for every two children, and the worst is 3.5 or seven times as bad. It may be that local targets would encourage an improvement.

It would be possible to continue that line of thought to consider the benefits of fluoride in the public water supply, but that subject on its own stimulates many lively debates which are perhaps better not continued with now.

The recent history of oral health and the contribution which the new contract makes, with its implications for continuing care, is another interesting aspect of the subject under question. A few facts and figures give us some insight into what has happened. Bearing in mind that the adult population increased by 11 per cent. between 1968 and 1988, the number of adults during that period with some of their own teeth increased by 41 per cent. The total number of teeth in the heads of the adult population increased from 0.5 billion to over 0.75 billion and the number of wholly sound teeth increased from just under 300 million to just under 500 million. Perhaps most remarkable of all, the number of teeth repaired and saved by dentists during that same period has increased from 156 million to 268 million.

Looking forward—and that is where the benefits which the contract brings come in—total tooth loss is predicted to fall over the next 35 years to 1 per cent. from a level of 20 per cent. in 1988. However, what is far more important than strings of numbers is the relief from stress, pain and discomfort that modern dental practice can bring. It is now well known that the new contract has resulted in more people attending the dentist, thus preventing decay and removal. As my noble friend Lord Colwyn said, children between 0 and two years old have been registered. That is new and is part of the scheme of continuing care with emphasis on prevention. However, we must not forget that it is early days. Prevention takes a while to shine through and 18 months is a short time in which to see results.

In order that the dental service should continue to attract the highest calibre of practitioner, it is clear that the present complexities which exist in the remuneration arrangements for the service need to be tackled. No doubt the proposed fundamental review will address those questions.

7.55 p.m.

Lord Butterfield

My Lords, I hope that your Lordships will excuse me for inserting myself in the gap but I wanted to make a few remarks in support of our dental profession. I speak because I am chairman of the School Council of the United Medical and Dental Schools of Guy's and St. Thomas' Hospitals. I wish to make it quite clear that I agree very much with what the noble Baroness, Lady Eccles, has just said about the need to attract good people into dentistry for the future.

Our dental profession has played its part with the rest of the world's dentists in ensuring that we face up to the problems of caries from sucrose and sticky sweets. It has faced up to the possibilities of prevention through fluoride in our water. It has done remarkable work in improving the technique of dental care following the Nuffield inquiry into four-handed dentistry, as it is called. I should like to say that those of us who have enjoyed four-handed dentistry have been moved quite quickly from the fear of the old dentist situation to a much happier circumstance. It is now true to say that one lies down in the kind of space-ship situation, one is given an injection to take the pain out of it all and it is all so quick. The super speed drills and the four hands managing the whole operation have greatly changed dentistry for the patient. I believe that our dentists should be given full credit for that.

As has been said, in some ways dentists are doing themselves a disservice. They have increased their productivity. I asked one of my professors at Guy's about this and he pointed out that in one group 6.6 million cases had been treated in 1980 and 7.3 million in 1981, which is a sizeable increase in throughput. Therefore, although four-handed dentistry involves more cost because you have to have an extra member of staff on your payroll, it provides a nicer form of dentistry.

The other important matter which I should convey in my brief intervention is that our dentists are accepting increasing responsibility for overall health; and I am glad to have heard that from an active member of the administrative side of the health service. Dentists are becoming oral doctors. At the moment we must realise that there is a very severe risk of AIDS affecting some young people, and AIDS is not infrequently diagnosed in the dental chair.

The other point which is neglected is that oral cancer has become statistically the sixth most common cause of new growth of cancer. That has been detected by our dentists much more than by the other parts of the medical/dental professions.

I hope that in their consideration of the future of dentistry, the Government will cosset the dentists and their morale. Indeed, as far as I am concerned, those who produce more work will be able to cosset their bank accounts and their holiday opportunities.

We did not welcome the Minister properly when she first appeared in a debate in this Chamber to speak from the Dispatch Box. I recognise that the noble Baroness, Lady Cumberlege, has a fairly tough assignment because she is coming into a situation where demand for community care will escalate, and there is no doubt that something must be done to help our dentists. I wish her well.

A few years ago I led an inquiry into dental research. We found that British dentists provided 9 per cent. of the world's published dental research. It is true that compared to some parts of the dental world our dentists were not using molecular biology and monoclonal antibodies to anything like the same extent. I believe that if they had the opportunity to use them in the dental schools, they would.

I must make a plea for more research in dental schools. Otherwise we will not attract the kind of people the dental profession needs. There has been a reduction in the number of applicants—boys and girls in school can find out about the fluoride effect on caries. There has also been a tendency for A-level standards to be worrying for dental needs. We must put the situation right. It is in our own interests to ensure that the dental schools attract good quality applicants and take in good students so that our children do not encounter the dreadful fears about dentists that we had.

I conclude by saying that my dentist has completely cured me of anxiety. I do not look forward to seeing him, but I do not fear it.

8 p.m.

Lord Winstanley

My Lords, I am delighted that the noble Lord, Lord Butterfield, was able to interpolate his remarks in the gap. They were extremely important and I hope that they will be carefully considered by the Minister and others interested in this subject.

Whenever the noble Lord, Lord Colwyn, addresses your Lordships' House he always does his homework with great care. As a result, his speeches, on whatever topic, are always worth listening to and studying. I suspect that on this occasion the noble Lord has not had to do much homework. He has been speaking to us on a subject with which he has lived for many years and which is at the forefront of his mind most of the time.

It is perhaps a pity that much of the noble Lord's speech, and other speeches made in this debate, concerned money. Although I say it is a pity, it is inevitable. I know a great many dentists. It always seems to me that they are starving fairly comfortably. However, that does not mean that they do not have genuine grievances regarding remuneration. They do. Unless those grievances are remedied the national dental service will disappear. They must be dealt with and soon.

The noble Lord, Lord Colwyn, went through the history of the matter and the way in which the present system of remuneration was arrived at. I go back to the beginning. When the National Health Service began on 5th July 1948 I was a general practitioner. At the time I regarded dental health as a crucial and vital part of ordinary health. I looked with great care at the way in which the dentists were then working. Noble Lords may remember that dentists' remuneration was fixed in a different way from that of general practitioners.

I perhaps wander from the point when I say that general practitioners entered the National Health Service on a system of pay which was unknown at that time. The Spens Committee was set up under Sir Will Spens and general practitioners were told that their remuneration would be in accordance with the recommendations of that committee. In the meantime they were paid provisionally. After around three years the Spens Committee reported and the Government fulfilled their obligation by adjusting the pay to that recommended by the committee. But they did not backdate it to the 5th July 1948. That caused a serious grievance.

In the end the matter went to arbitration and before the courts. The doctors and the Minister of Health went before Mr. Justice Danckwerts. He came down wholly on the side of the doctors and we all received back pay for the three years. As a result of that my children always went to sleep with the words, "God bless Mr. Justice Danckwerts".

There was another consequence. It meant that when one spoke about remuneration to a Minister of Health and mentioned going before the courts or to arbitration, the Minister of Health ran a mile. The department had been bitten once and did not intend to be bitten again. Therefore I say to my colleagues in dentistry, do not rely on going to arbitration or before the courts because it will not be allowed.

One of the most important elements of the history of the development of the dental remuneration system given to us by the noble Lord, Lord Colwyn, concerned expenses. Dental expenses are repaid by a calculation in which they are included in piece-rate pay. That is an absurd system. Of course, dentists were always paid piecework. As I said, when we started and waited for the Spens Committee to report, the dentists were immediately on piecework. The payments were based on what was then thought to be a proper level of chair hours' work which a dentist could do in a week. It was thought at that time that a conscientious and efficient dentist could manage only around 32 or 33 chair hours a week with real efficiency. In fact they were working 70 hours a week. My noble friend Lord Russell mentioned "all the hours God sends". Of course they earned a fortune. The rumour then got around that here were all these people making vast amounts of money. But in many ways they made it at the professional cost of dentistry. They worked far too hard.

Dentistry is now an intricate and delicate matter. It has changed a lot in my time. Whenever a friend tells me he has some delicate dental manoeuvring to be carried out by a dental surgeon, my advice to him is always to make his appointment for the morning, rather than the evening. By the time evening comes the dentist is dead beat and the standard of his work is nothing like as high as it is in the morning. I am sure that the noble Lord, Lord Colwyn, will confirm that.

The reimbursement of expenses was the method used with general practitioners in the National Health Service for many years. At that time Mr. Kenneth Robinson and Sir Derek Stevenson went into purdah and held discussions. They came out with a new contract for general practitioners which suddenly reimbursed doctors for the expenses that they had actually incurred. That is the only sensible way to proceed. If a dentist, for the benefit of his patients, provides extremely expensive equipment—and it is extremely expensive; if he has an efficient staff to help him, which again is for the benefit of his patients; if he spends a lot of money and always provides a good service, then he is entitled to direct reimbursement for what he has spent. Why cannot we employ that kind of arrangement? As the noble Lord illustrated, the present arrangement is absurd. It leads to a lot of anomalies and a great many injustices.

The noble Lord mentioned the capitation fee. The present one is derisory. The system has perhaps been a good one where at long last a patient is registered with a dental surgeon who becomes nominally responsible for that person's care. If a decent capitation fee was paid it could cover the provision of at least an annual dental examination which would be free, and any further investigations which arose as a necessity from that examination. That also is a point to which the noble Lord, Lord Colwyn, referred.

To arrive at a decent system of remuneration for dentists, when one is relying on a piecework system, is a complex matter. It will not be easy by normal systems of negotiation. It was calculated—and was certainly true in my time—that dentists tended to reach their maximum earnings capacity around the age of 32. They were fit and well and could do long chair hours and therefore get through a great deal of work. After the age of 33 or 34 their earnings dived sharply. That is the opposite to what happens in other professions. Some noble Lords may be barristers and I doubt that they would say their earnings dived sharply when they reached the age of 33. They do not even arrive at any earnings until they are much older. That is something to be considered and in doing so we must bear in mind that dental surgeons efficiently can only do a certain number of chair hours. They should not be induced to do a great deal more. It is important to remember that.

Both the noble Baronesses, Lady O'Cathain and Lady Eccles of Moulton, mentioned fluoridation and then both backed rapidly off the subject. I was astonished. They came along and dipped their toes into the water and then rapidly plucked them out again as if it were very cold. They should not be so reluctant. I am delighted to see the noble Baroness, Lady Gardner of Parkes, with us. I am sure she will agree with me that the fluoridation of water has been of immense benefit. It is partly responsible for the striking and spectacular decline in the incidence of dental caries. I do not know what it is like now, but there was a time when most of Birmingham's water was fluoridated. It had no patients with dental caries for the students to study, so patients had to be bussed in from places such as Dudley and other less fortunate places which did not have fluoridated water.

We spent hours and hours in your Lordships' House passing the water fluoridation Bill which removed any uncertainty about the legality of adding fluoride to water in certain circumstances. But many of the water authorities have been extremely reluctant to take the necessary action. In many parts of the country we still have water authorities which have not yet seized the opportunity which your Lordships' House and the other place gave them. That is also an important matter.

I repeat that dental health is a very important part of general health. It is important that we maintain a national dental service in the same way as we have a National Health Service. If the service proceeds as it is now, with the kind of difficulties which have been introduced in recent years, I can see a time when we shall have no national dental service at all. When the noble Baroness replies can she say whether it is the Government's intention to retain by some means or other a national dental service within the meaning of those words or whether they are prepared to see it gradually wither away and disappear?

That could be done gradually. When I was last in general medical practice in Worsley and Salford, just outside Manchester, in a group practice, next door we had a dental practice with two partners who did very good work. They also had a private practice in Dusseldorf. These two chaps worked turn and turn about. One week one would be in Worsley and the other in Dusseldorf. The following week they would reverse their roles. With inducements a dentist can make an immense amount of money by leaving the national dental service and going elsewhere. There is an inducement for many dental surgeons working under the National Health Service to give it up and to go for wholly private work. In those circumstances we are doing the National Health Service itself very great damage indeed. When the noble Baroness replies to this debate I hope that she will tell us clearly whether it is the Government's intention to retain a national dental service or whether the Government are prepared to see it wither away.

8.13 p.m.

Lord Carter

My Lords, like other noble Lords I would like to thank the noble Lord, Lord Colwyn, for tabling this Question and to congratulate him on his impeccable timing, not just in getting here but on the date of the Question. I am not sure that the Minister will agree about the timing. Noble Lords know that I have an involvement in agriculture, both inside and outside this House. I believe that the Minister also has a family connection with agriculture. Does she agree with me that the complexities of the system for remunerating dentists make the common agricultural policy look quite straightforward?

The facts are quite clear. On 10th February this year the review body on doctors' and dentists' pay recommended an 8.5 per cent. increase in dentists' net pay. That was called the target average net income. The Government accepted the recommendation in full and without phasing. On the same day the Government announced that in order to achieve the 8.5 per cent. increase in net pay they proposed a reduction in dental fees of 13.8 per cent. from 1st April. On 20th February the Government panicked and suspended the proposed fee cut, ostensibly until the Dental Rates Study Group (DRSG), met in May. I note in passing that it was clear then that a general election was likely to be called some time before the DRSG was likely to meet.

We now have the new package proposed by the Government on 2nd June. The fee cut now proposed is 7 per cent., thus showing that there was something badly wrong with the 13.8 per cent. cut proposed in February. With all these facts in mind it is clear that the Independent newspaper got it about right yesterday in its leader column which said: The concept of overpayment in a system in which standard fees are paid, on a piece-rate basis, for particular services is one that would only occur to the most dedicated of bureaucrats. What has happened is that the dentists have been too successful for their own good in implementing the government policies". The article continued: The present system is complex, rigid, pays no attention to regional variations in costs and does nothing to encourage price competition between dentists. It should be replaced". This whole exercise of two steps backward and one step forward calls into question the competence and quality of the machinery which is used for these complex calculations. The figures themselves are fiendishly complex. But there is an aspect of the calculations that I find puzzling. I understand that a departmental survey indicated that dentists' net income was of the order of 33 per cent. of turnover. That means that, by difference, expenses must be 67 per cent. of turnover. The department's estimate of expenses for 1992–93 is about £47,000. That implies a turnover of the order of £70,000 and not the much higher figure that the Government have calculated of £92,000.

Perhaps the Minister can explain this rather curious conflict in the calculations. The basis of the expenses estimate is in the order of £47,000. If that is 67 per cent. of the turnover then that turnover is of the order of £70,000 and not the £92,000 figure which the Government have used.

As regards expenses, I find it hard to understand why it took three years for these matters to be calculated. I do not know whether noble Lords have seen the advertisements in the newspapers this week which point out to company directors that if they do not get their accounts in within six months they stand to be fined by the Companies Office. One of the most worrying aspects of the situation is the declining number of dentists prepared to offer treatment on the health service. A departmental survey carried out earlier this year indicated refusals by 75 per cent. of dentists in some parts of London; 73 per cent. in Kingston and Richmond; and 67 per cent. in Bromley. Other figures apply to other districts and they reduce to 36 per cent. in Bolton. This matter was discussed on 16th January in a Starred Question.

Can the Minister tell the House whether the Government have updated the January figures? What is the department's estimate of the number of dentists who are likely to leave the health service as a result of the most recent proposals? We know that the Labour Party has been criticised by the Government for giving a number of warnings about a two-tier health service. That is certainly happening now in the dental service which is also most definitely not free at the point of delivery. The percentage of fees paid by patients has increased from 16 per cent. in 1976 to 38 per cent. in 1991.

The other aspect of the Government's proposals concerns reference to the Dental Practice Board (DPB) for approval of all courses of treatment which cost over £200. The figure was formerly £600. That is bound to lead to bureaucratic delay and thus to increased pain and discomfort for patients. In their statement the Government say that these proposals will apply to about 3 per cent. of treatments. Can the Minister say what is the number of references to the DPB represented by 3 per cent. of treatments? How many actual references will there be? Also, can the Minister tell the House of the Government's estimate of the time taken to process the applications? The British Dental Association estimates that it will be in the order of three to six months. Do the Government agree with that figure? If not, will the Minister say what is the Government's own estimate?

Entirely properly, the Government are worried about the reaction of the public and the dental profession to their proposals. To enable Conservative MPs to handle their constituents' questions the Conservative Research Department issued a brief to Conservative MPs dated 2nd June, the same date on which the Government's proposals were announced. It contains the following sections: "Key Points", "Questions and Answers", "The Dental Service—The Government's Record", and including, Annex A. Draft paragraphs for MPs to use in reply to letters from Dentists and, Annex B. Draft paragraphs for MPs to use in reply to letters from Patients". The document is headed: Prepared For: the information of Members, to coincide with the Secretary of State's meeting with dental representatives". The brief has the same date as the Government's proposals and clearly contains information that is part of the confidential position paper that was prepared for the Dental Rates Study Group. Indeed, it includes some figures that were not in the Government's Statement. Given that it, too, is dated 2nd June and contains information from the confidential paper, perhaps the Minister can tell the House how the Conservative Research Department obtained that information. Was there some consultation with officials at the department, or is it a specialised version of open government?

In February, the Government said that they were proposing a thorough review of the remuneration system—we can all agree with that statement—and that undertaking was repeated in the Statement of 2nd June. Can the Minister tell the House the timetable for the review? When is it expected to be completed and when will it report? Will the review result in the setting up of a system that is simpler and fairer and which avoids the miscalculations of recent years?

On 5th December 1991, the then Secretary of State for Health, Mr. Waldegrave, referring to miscalculations in 1988–89, said in a Written Answer: The principal reasons for the overpayment were that the calculation of the 1988 dental fee scale was based on forecasts which over-estimated dentists' practice expenses and underestimated the volume of treatment to be undertaken by dentists … We shall be reviewing procedures with a view to avoiding such large scale variations in processing rates in the future and to insulate the dentists' pay system from these". —{Official Report, Commons, 5/12/91; col. 201.] That was in 1988–89, but despite that assurance from the Secretary of State the same mistakes were still being made this year. Obviously, therefore, the system had to be overhauled.

Will the proposed review deal with the cogent suggestions that were made by the Review Body on Doctors' and Dentists' Pay, which noted the lack of incentive to invest in modern dental equipment? That point was mentioned by the noble Lord, Lord Colwyn. The review body suggested the principle that a higher proportion of dentists' income should come from capitation-based payments as opposed to the more volatile "piecework" payments, to use the words of the review body. It also recommended greater direct reimbursement of both revenue and capital expenditure and said that any system should avoid the problems arising from the averaging of expenses and of target incomes. We are all familiar with the old phrase that averages murder all truth, —which is certainly the case with the calculation of dentists' pay.

The proposed review has a great deal to do and time is short. We must hope that while it is in progress the Government and the profession can find an interim solution that makes the care of patients a paramount objective and not just a secondary function of abstruse and extremely complex calculations.

When the new contract was formulated in 1990, I understand that it was expected that 18 million patients would be treated. In fact, dentists treated about 24 million people. I understand also that the Government actually advertised in order to encourage demand, incurring expenditure of about £3,000 for the family health service authorities. The noble Lord, Lord Colwyn, said that about 27 million patients are now registered, but I have been told that 30 million patients were registered in April 1992. It would be interesting if the Minister could give the House the up-to-date figure. It is certainly very much greater than the figure that was expected when the contract was formulated.

We all know that the Government believe in an internal market for health care. There are two sides in every market —supply and demand. The demand for dental services is clearly present. It is the Government's job to set up a system of remuneration for dentists which will produce the supply.

8.23 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)

My Lords, I should like to thank my noble friend Lord Colwyn for introducing this interesting and timely debate. As always, he was in tune and on time. During the debate we have heard many important and stimulating points and I should like to return in detail to some of them later in my speech.

However, I start from a position on which we can all agree. We should judge the success or otherwise of National Health Service dentistry by the quality of the service available to patients and by the state of the nation's dental health. Despite the concerns voiced this evening, I believe that on that basis we have every reason to judge the NHS dental service very favourably. I heartily endorse the view of my noble friend Lord Colwyn that, contrary to much of what is said, dental practice in this country is a success. That view was also expressed by the noble Baroness, Lady O'Cathain, and my noble friend Lady Eccles of Moulton, who has already been very active in counting the nation's teeth.

Over recent years dental health in this country has improved markedly, so much so that many other countries envy our progress. As has been said, the dental health of children in particular has advanced in leaps and bounds. We now look forward to the day when decay in children's teeth can be virtually eliminated. We have already met the World Health Organisation's target for the year 2000 of 12 year-olds having, on average, no more than three decayed, missing or filled teeth. In our Green Paper The Health of the Nation, the Government have proposed an even more ambitious target.

These improvements in the early years should be carried on throughout life—and they will be. Within the next 20 years, we can expect that only one person in every 10 will ever have to rely on dentures. As my noble friend Lady Eccles of Moulton said, that presents a remarkable comparison to the position just 20 years ago when nearly four people in every 10 had no natural teeth at all.

The advances have not come about unaided. To a large extent, they result from substantial improvements in the dental care available in this country over the last decade. The statistics bear this out. Since 1979, annual gross spending on NHS dental services has risen by 43 per cent. ahead of inflation. Over the same period, the number of dentists in Great Britain has grown by 27 per cent. There are now over seven million more courses of adult dental treatment carried out every year—an increase of nearly 43 per cent. since the Government came to power. That record underlines, as I am sure the noble Lord, Lord Winstanley, will note, the Government's strong commitment to the NHS dental service.

But an effective dental service is not built on numbers alone. It is the quality of care that counts. To improve that quality the Government introduced in October 1990 a new dental contract. The new contract establishes the concept of all-round continuing care. It promotes the prevention of disease and offers a full range of dental care to patients. It brings in emergency cover and treatment plans. Patients can now have certain restorations repaired or replaced for free if they go wrong. They have better information about dental care and oral health.

The new contract is not only good for patients. It is good for dentists. It gives them greater clinical freedom in the materials and treatments at their disposal. It encourages them to keep their clinical knowledge up to date, with the new post-graduate education allowance. We introduced new maternity and long-term sickness payments, and dentists can now get their business rates directly reimbursed. The new capitation payments for children and continuing care payments for adults give the dentists greater stability of income.

These are significant gains. They are the way towards a better dental service and better dental health, bringing tangible improvements in the quality of people's daily lives, as several of your Lordships have mentioned. It is against that background of advance and improvement that we must consider the current issues facing NHS dentistry.

I have noted what many noble Lords have had to say about the difficulties of finding an NHS dentist in certain parts of the country. However, we must be careful not to exaggerate the extent of the problem. Today's problems, to which the noble Lord, Lord Carter, referred, tend to centre around the South East of England. Significant levels of private dental practice are virtually unheard of elsewhere. NHS dentistry is available in all areas and there was, in fact, a small net increase in Great Britain in the number of NHS dentists in the first year of the new contract. Our most recent survey showed that over three-quarters of dentists were accepting all patients for NHS treatment, and 85 per cent. are accepting children as NHS patients.

Of course, the Government are concerned about the difficulties that do exist. Their commitment to the NHS dental service is neither partial nor regional. It is absolute. We will take what steps we have to to ensure that the commitment has true meaning for everybody. Patients who experience a problem finding an NHS dentist should contact their local family health services authority, which will be able to put them in touch with their local NHS dentists. If the FHSA has real difficulty in finding an NHS dentist, then it can, and should, employ a salaried practitioner who will provide NHS services for those who need them. The department will be writing to all family health service authorities shortly to remind them of this possible course of action.

A number of commentators have sought to make a connection between difficulties in finding an NHS dentist and the proposals for a reduction in dental fees made by my right honourable friend to the dentists last week. The British Dental Association is, I understand, considering whether my right honourable friend's proposals are a matter for resignation or other forms of industrial action by dentists. Like the noble Baroness, Lady O'Cathain, I hope that it does not come to that, for in the event it would be patients who suffered. Certainly, it need not, for I find the BDA's line of reasoning hard to follow. Even after the proposed reduction of 7 per cent. in dental fees, the average dentist would still be left with a net income of around £40,000 a year. Most people would, I think, be glad to earn as much. It is hard to see how such an income adds up to a case for resignation.

More generally, I believe that the proposals made by my right honourable friend are both fair and reasonable. They are fair to dentists, not least because the proposed reduction is substantially less than the full 23 per cent. cut that would have been needed to bring the average dentist's income down fully into line with the figure of £35,815 recommended for them by their independent pay review body. Dentists will be paid that recommendation in full. Moreover, even after the proposed reduction in fees, the average dentist would still earn some £5,000 a year above that figure.

The review body's recommendation itself represents an 8.5 per cent. pay increase above the figure for 1991–92. This increase is well above inflation and similar awards for doctors and nurses. It simply would not have been fair to other health service workers to have done nothing, allowing dentists to keep every penny of a substantial payment over and above the review body's recommendation, when that recommendation was itself well above the award for others. The Government's proposals preserve equity in the NHS.

At the time that the review body made its recommendation of an average net income for dentists of £35,815 there was not, as I recall, a great outcry in the profession. There was no talk then of resignation or industrial action. So I am bound to wonder why there should be this talk now, when my right honourable friend's proposals would leave the average dentist with an income £5,000 above the review body's recommendation. Those prepared to work for an average £35,000 must surely be content with £40,000.

Some people look for the reason for the current unhappiness among the various calculations of dentists' expenses, a point raised by my noble friend Lord Colwyn and the noble Lords, Lord Winstanley and Lord Carter. But in fact the Government have been quite fair and reasonable here as well. The allowance for expenses proposed by my right honourable friend for this year is £47,228—

Earl Russell

My Lords, I beg the noble Baroness's pardon for intervening. Can she tell us how this figure, in particular the £40,000 a year, was arrived at? Is it based on actual income and expenses of individual dentists, or does it rest on an average?

Baroness Cumberlege

My Lords, I shall be coming to that point in a little more detail later on. It is of course an average and that is the point I shall come to in a moment.

But in fact the Government have been quite fair and reasonable with regard to expenses. The allowance for expenses proposed by my right honourable friend for this year is £47,228, 11.6 per cent. above last year's figure. Taking this together with the review body's recommendation for dentists' net income in 1992–93 of £35,815, gives dentists a gross income of £83,000. And of course, I repeat, that even after my right honourable friend's proposals, the average dentist would actually receive around £5,000 more than that figure. All in all, average gross earnings per dentist would be around £88,000.

Lord Carter

My Lords, perhaps I may return to the point which I made. On the figures that the noble Baroness has just given, which I fully understand, it means that the department is working on a figure that expenses as a percentage of turnover are 57 per cent. However, the department's internal survey, which I believe is unpublished, shows that the figure is 67 per cent. There is something rather odd in the calculations somewhere.

Baroness Cumberlege

My Lords, I cannot answer the detail of that point but I shall write to the noble Lord.

The Government's proposals are also fair to patients. As a result, many would pay less for their dental treatment than would otherwise have been the case. Those who allege that my right honourable friend's proposal is an act of "creeping privatisation" might do well to ponder on the fact that it is an odd sort of privatisation that cuts what people have to pay for their NHS dental treatment.

Finally, the proposals are a reasonable step to control expenditure. In fact, £1,400 million was spent on the general dental service last year—a vast sum.

But, under the current fee scale, payments to dentists are running some half a million pounds above budget every day. The sensible control of public expenditure demands that action is taken to rectify this problem.

I should now like to turn to some of the specific points which have been raised in the debate. The noble Earl, Lord Russell, referred to his local dentist, whose earnings are low—under £12,000 a year, or they were originally before they were increased. They are without a doubt towards the very bottom of the scale of earnings for NHS dentists. Without more detail it is very difficult for me to comment on a specific case and I know that the noble Earl will appreciate that.

The noble Earl also asked about expenses and said that they did not reflect regional variations. I well understand that and I think that the fundamental review will have to tackle that issue head on. It also has to tackle the question of averages—average income, average dentists. I share the view expressed this evening that there is no average dentist. That person does not exist. That is one of the flaws in the present system. Again, hence the need for a fundamental review. However, to lift a phrase from the noble Lord, Lord Winstanley, it is not the Government's wish that anyone should starve, even comfortably.

I turn to the comments of the noble Lord, Lord Butterfield. As chairman of the Schools Council of the United Medical Schools, his views clearly carry great weight in this Chamber. I am sure he will he pleased to know that at present there are two applicants for each dental school place and that the standard of applicant, taking the United Kingdom as a whole, has slightly improved in 1991 over 1990. In other words, dentistry continues to attract many high quality candidates for the degree places available, a very necessary development, bearing in mind the increase in the incidence of cancer and the onslaught of Aids, as mentioned by the noble Lord.

The noble Lord, Lord Winstanley, set the historical scene for us. I am grateful to him for that and for giving us sound advice on making a dental appointment. I hope that I have covered many of the other valuable points that he and the noble Baronesses have made this evening in some of the comments I have made in summing up. I know that all these views will be taken into account when we come to consider the fundamental review. However, like other shrinking Baronesses tonight, I shall resist the temptation to enter into the fluoride debate. I shall also resist the temptation to get into the vagaries of the common agricultural policy, despite the seductive invitation of the noble Lord, Lord Carter, to do so.

The noble Lord, Lord Carter, asked about claims for prior approval. Lowering the cost ceiling for prior approval is still only a proposal. The administrative detail of processing claims at the Dental Practice Board will be worked out in detail if the proposal is adopted. I believe that we should bear in mind that the proposal will cover a mere 3 per cent. of treatments, or around 1 million, and the fact that the performance of the DPB has markedly improved over recent years. I do not believe that the BDA has real grounds for concern.

Questions were also raised about the proportion of dentists' income which is expenses related. That refers back to an earlier point. The Government's current estimate is 57 per cent., not 67 per cent. Another question which needs to be addressed is: when will the fundamental review begin and why has it not started now? The review was delayed while we concentrated on the reasonable and fair proposals that my right honourable friend offered the dentists. She wanted to hear at first hand the dentists' views on the form of the review before deciding how to carry the work forward. She discussed the matter with the BDA at a meeting last week. Officials will meet with the association again tomorrow to talk it through. My right honourable friend will take a decision shortly afterwards.

In closing, I should like to say a little more about the fundamental review of dental remuneration, to which my noble friend Lord Colwyn rightly gave weight in his speech. I hope that the review will pick up some of the interesting points raised by the noble Baroness, Lady O'Cathain, which also have the support of the noble Lord, Lord Carter. The current problems have thrown into sharp focus the fact that the way in which dentists are paid is not all that it should be. That point was made by the noble Earl. The system is unnecessarily arcane and complex. It is not delivering the objectives that the Government would like to see.

It is important to the Government, to dentists and to their patients that the system by which dentists are remunerated is both fair and effective. We look to the fundamental review to deliver that objective. We all owe a great debt to the dental profession for its commitment and hard work. The Government want a better and more stable system for dentists' pay in the future. The points made today by noble Lords, and earlier by my noble friend, will provide useful grist to the mill.

The review will build upon the Government's substantial and enduring commitment to the NHS dental service. It will build upon the service's many strengths to improve the system for dentists, for patients and for the nation's dental health. I very much welcome today's debate, out of which, as ever, has come much wise and important comment. It will assist the Government in their task of building a better NHS dental service for the future.