HC Deb 09 September 2003 vol 410 cc30-52WH

2 pm

Mr. Paul Marsden (Shrewsbury and Atcham)

I am delighted to have this debate on such an important subject that causes so much angst among my constituents and, I am sure, those of many hon. Members. I have a declaration to make at the outset, which is that I have not seen an NHS dentist as a patient for more than three years. Before eyebrows are raised, I should say that I do not have particularly good teeth to boast about: it is merely that I cannot get an NHS dentist. I have not seen a private dentist either, and I am dreading the day when I shall eventually be faced with having to get one, because it is nigh on impossible in Shropshire.

The problem goes back some 10 years, so before Conservative Members get too excited about a lack of activity by the Labour Government, they should take some of the blame. Back in the early 1990s, changes were made to the contract between the Government, the Department of Health and NHS dentists. Back in 1992, there was an overspend of some £190 million, which resulted in the Department making unilateral fee cuts and a decrease of income of some 7 per cent. That led to a breakdown in the relationship between NHS dentists and the Department, which resulted in the exodus that we have experienced over the past 10 years or so. There are now 5 million fewer people registered with an NHS dentist.

We have now had six years of a Labour Government. The record from when that furore was going on back in 1992 is clear. The Labour party, as I remember quite well having had some inside knowledge of such matters, said in its 1992 manifesto: We will make sure every community has access to dentists, with the resources to provide full NHS cover. We will restore the free dental check. Although we may have seen some changes in attitudes by the new Labour party and, ultimately, the new Labour Government, all the subsequent warm words of support for NHS dentists have belied what has happened.

In 1996, in the run-up to the general election, the Prime Minister said on page 180 of his book "New Britain: My Vision of a Young Country": If things continue as at present and more people reach for their cheque books to pay for private insurance I genuinely believe that the NHS will cease to exist as we know it. He also said that a decade ago people would not have believed it if they had been told that they could not get an NHS dentist, only a private one. Straight after the general election he said: We will have a national health service restored to the basic principles of the British NHS—the health service that we founded".—[Official Report, 18 June 1997; Vol. 296, c. 304.] I wholeheartedly agree with him—there should be delivery, at the point of need, of a free service, not one that is charged for. However, we have since had six years of excuses and broken promises.

In September 1997, the then Health Minister, the right hon. Member for Darlington (Mr. Milburn), said in relation to NHS dentists that inequality and inaccessibility must be tackled head on now as part of the Government's drive to modernise NHS services". In 1999, another former Health Minister, the right hon. Member for Southampton, Itchen (Mr. Denham), said that this Government is committed to providing high quality dental care to a greater number of people. In January 2000, the then Under-Secretary of State for Health, Lord Hunt, said: The NHS of the 21st century must be built around the needs of the patient not the system…From next year, we want to see everyone able to access NHS dental services, no matter where they live". So it goes on. One reply after another has been made to parliamentary questions, and one promise after another has been made, and all have failed. In September 2000, Lord Hunt said that the Prime Minister's commitment…to give back dentistry to all who need it by September 2001 would be met. He added that the Government recognised that the traditional system is failing some patients and there are still too many patients who have problems finding an NHS dentist. That will change. Three years on, we are faced with more promises. Just in the past month, Health Ministers have promised that finally there will be change.

I want to give a taste of the problems that people face in different parts of the country. In October last year, people in Rossendale queued for three hours to try to register when they found out that a new dental surgery was opening. In Blackburn, the primary care trust spokeswoman Janet Ledward recently said: We have a serious shortage of dentists offering NHS treatment. In East Lancashire, the dental health consultant Dr. Gary White said: The biggest difficulty is that there simply aren't enough dentists being trained and that's a government problem. It was widely reported that in July in Carmarthen, south Wales, 600 people queued in the rain around the block when they heard that Brynteg dental surgery was opening. Half were turned away. Surgery staff received abusive phone calls because people were so fed up at not being able to register. London has the worst registration level and some of the worst oral health. In Scarborough, John Renshaw, the chairman of the British Dental Association, said that the situation is "desperate" and is a problem in the south, the north, the west—all over.

Dr. Donald Mackenzie from Lymington in Hampshire recently wrote to The Times, on the basis of his 25 years' experience as an NHS dentist, that he was deeply cynical about the Government's sudden 'commitment' to NHS dentistry, after years of a totally obvious policy of deliberately pushing dentistry out. A final example comes, of course, from Shropshire. My constituency is in the heart of Shropshire. I recently rang NHS Direct, the telephone service that is supposed to be the magic wand to solve all our ills and problems. I asked about NHS dentists. The lady was polite and helped as best she could. She asked for my name, which I gave, and then my address. As soon as I mentioned Shropshire she stopped me in mid-sentence and said, "Particularly bad area for dentists, Shropshire."

I asked whether I could find a dentist in Shropshire and she said: "You can't find an NHS dentist to register with as an adult in the whole county." I said, "Okay, I'll go further afield. How about south Cheshire?" We were struggling, but we managed to find one in Congleton, a wonderful part of the area, which I know quite well, having been born and bred in Cheshire. It is a lovely part of the world, but in spite of the enticement of travel to Congleton to see an NHS dentist, I do not think that patients in Shrewsbury should have to travel a round trip of 80 miles on rural roads to find one. There was none in north Herefordshire, either.

Matthew Green (Ludlow)

As a fellow Shropshire MP I can tell my hon. Friend that until recently I had an NHS dentist—45 minutes' drive away in Worcestershire. Sadly that surgery has now closed its books, owing to the death of one of the dentists. The nearest one at which I could register my family is in Staffordshire. Many of my constituents have had the same problem.

Mr. Marsden

My hon. Friend echoes my comments. We face a massive problem in the west midlands. I heard it said that it is the same in Wales. It is the same all over the country. The lady at NHS Direct told me, "We've had hundreds of calls from people in Shropshire, all trying to register with an NHS dentist." It is an absolute disgrace.

Mr. Russell Brown (Dumfries)

I appreciate that on the hon. Gentleman's grand tour of the UK he did not cross the border into Scotland. In view of the great shortage of dentists, what impact does he think the closure of the Edinburgh dental school in 1992 has had on dentistry?

Mr. Marsden

I am no expert on Scotland, but the hon. Gentleman's point shows that this is a deep-rooted problem. It goes back many years. That closure exacerbated a problem that was already quite profound some 10 years ago. I shall speak about dental graduates later.

A few days ago I received an e-mail from a constituent. Mrs. Urquhart and her husband have just returned from the United States. Her husband is serving in the British Army. He has done four years in Germany followed by two years in the United States. She writes: I understood that dental care was going to be a problem on our return but I am incensed by the reality of the situation. I was given the name of two dentists in Shrewsbury who are accepting NHS patients. Both are only accepting under 18s—I will have to be treated privately…I believe that private health care should be a choice but I am being told that there is no choice available to me. We have been accepted onto our local NHS Doctor's list so why is the same facility not available for dental treatment? I concur with that. She continues:

After 2 years in the US, I am a big advocate of the NHS. I believe everyone should be entitled to medical and dental treatment, not just those who can afford it—and yet here I am in exactly that situation, dental treatment for those who can pay. I contacted Shropshire county primary care trust this morning and so this update is hot off the press. It says that some routine dental care can be offered to non-registered patients but the waiting time for routine care is 18 weeks at present…The Primary Care Trust has limited funding available for practice development grants during 2002–03…It has proved very difficult to attract new dentists into the area for either GDS or Salaried PDS posts. A recent dental workforce review commissioned from the University of Keele"— an authoritative source—

found a vacancy factor of 25 per cent. for associate dentists in Shropshire, equivalent to about 20 unfilled posts. We face a crisis in Shropshire and right across Britain. Registrations have fallen dramatically. The figures speak for themselves. In 1997 when Labour came to power 19,383,000 adults were registered. According to the latest figures, 16,793,000 adults are currently registered. My big worry is children. In 1997, 7,367,000 children were registered, but the figure is now down to 6,784,000. The future generation should be building a relationship with their local dentist, as they do with their local GP, and talking about ways to prevent tooth decay and gum disease, but they cannot do so. They are given a sticking plaster solution of dental access centres to get emergency care. That is not good enough.

Furthermore, since 1997 NHS patients have had to pay an extra £80 million in dental charges. That is a 20 per cent. increase in six years. A basic examination, a couple of X-rays and one filling will now cost £17.80. Most people simply put that off; they cannot afford it, especially those in socially deprived areas. It is not good enough for a Labour Government to say, "Well, we're afraid you will have to pay it; we have little sympathy for those who have to pay dental charges."

On completion of their studies, dental graduates are saddled with an average debt of £13,000, and 49 per cent. have to take part-time jobs during their studies just to make ends meet. Is it any wonder there is no throughput of new blood into the service? That is a ticking time bomb that will have an effect on oral health in the future. Many problems are being created now because of the lack of NHS dentists.

There are no exemptions for pensioners, save reductions for those on income support, although I acknowledge that those charges were railroaded through by the last Tory Government, who made pensioners pay. Likewise, there are a host of other small groups, such as prisoners, who are affected. They may be the forgotten people in society, but the Heath Minister's written reply on 4 July to my question on the matter stated that prisoners are now waiting for routine appointments between one and 55 days. That means that prisoners may have to wait for almost two months just to get an appointment. Many people in prison have been taking drugs, and when they start to come off drugs, one of the first things to hit them is the pain from tooth decay. They may not have been able to feel that pain for years, so they may not realise that they have problems.

We are shoring up enormous problems for children. When the Minister rises she will inevitably say that more money is being spent to tackle the problem, which is true, and I agree that the number of treatments is slightly up. However, people want to build up a relationship and have access to professional advice from someone whom they can get to know and trust because they see them every six or twelve months. At a dental access centre, the patient goes in and tries to describe the problem. Time is limited as the conveyor-belt system is designed to get people in and out quickly. I rang one in Shrewsbury this morning to ask how soon I could have a routine dental appointment, and was told that I could not be seen for 10 days. We have some great professionals in the service who do their best, but with the best will in the world, they will not be able to quiz me about my brushing routine or my diet, or talk to me about the problems they may spot in the teeth or gums. All they can do is to say that they have spotted where the problem is, and that they have to take the tooth out or plug the loose filling. They will not be able to build a relationship, which is so important, especially for children.

What do the Government propose to do? Out of a £1.2 billion budget, which will be handed over to the primary care trusts in April 2005, the Government say that they will give an extra £10 million to help out. On the face of it, that sounds like a reasonable sum, but to put it in perspective it is 0.0000008 per cent. of the budget that is currently available to provide NHS dental services. The Department of Heath's blurb sets out what the £10 million is for. It states:

An NHS team, backed by £9 million, will support PCTs where access is most challenging, providing advice and guidance on best practice in increasing access and modernising dentistry locally to tackle longstanding bottlenecks where it is hard to find an NHS dentist. The remaining £1 million will assist PCTs…in preparing for the change. That is derisible. It is an insult to say that that £10 million will start to deliver what we need. The British Dental Association says that it needs at least 4,000 dentists to be able to meet demand. The Minister cannot quibble with that. It is what the British people want. When they are given the opportunity, they seize it with both hands. They want to be able to register with an NHS dentist. They will go to the dental access centres for emergency treatment if they have to, but that is not the long-term solution.

There was an article in The Sunday Times last Sunday on the recruitment of 200 dentists from overseas. I am greatly alarmed by that prospect. Will we be plundering reserves of overseas professionals, many of whom come from developing nations that can least afford to give up their health care professionals to this country to service our NHS patients? As Ian Wylie, chief executive of the BDA, said:

This is really a sticking plaster for dentistry. We should be investing in homegrown undergraduates rather than poaching overseas dentists, especially where there is under-provision of dental care in their home countries. The outcome of all this is that we are being forced to take out private medical insurance for dental cover. People in deprived areas will not bother to take out insurance because they cannot afford it. For a family of two adults on level B—that is, people with relatively good teeth—the cost is £16.39 a month, which is about £400 a year. Two adults and two grown-up children in one family are expected to find £800 a year for basic cover. That is not good enough. It is a betrayal of Labour principles of many years to say to people, "We are going to force you to go private, because that is the solution to the crisis in NHS dentistry."

On 3 August, John Humphrys wrote in The Sunday Times: We have gone down the private road through default and that's not good enough. We cannot blame the dentists. They have a choice: charging about £50 on average for an appointment in the private sector or receiving only about £18 on average in the NHS. Serious money must be invested. We do not need gimmicks from the Government in the form of small handouts, with the claim that they will sort out the problem. They will not.

Mr. A. J. Beith (Berwick-upon-Tweed)

The problem that dentists most often raise is that they feel unable to complete the treatment that they consider appropriate for the patient under the current NHS financing arrangements.

Mr. Marsden

I agree. I wait to hear from the Minister how the proposed changes through the PCTs will tackle the source of the problems that my right hon. Friend mentioned. There is incredible frustration because the professionals want to do a good job. They want to improve the whole population's health, but the system very often works against them. It is about time that the Government started to give them what they need so that they can deliver that service. The BDA estimates that some 200 new dentists need to come on stream every year.

We have paid our taxes and the increased charges in national insurance, but we have a threadbare system for NHS dentistry. Only emergency treatment is available. NHS dentistry is inefficient, because it doubles up for many treatments, so there is no chance of developing a relationship with a dentist. As a result, people's health, especially that of the poorest and most vulnerable in society, will be affected for the rest of their lives.

NHS dentistry is a broken promise. It now delivers a two-tier system that forces people into the private sector and into paying money for what should be a basic right. Labour should hang its head in shame.

Several hon. Members


Mr. Deputy Speaker (Sir Nicholas Winterton)

Order. Before I call the hon. Member for Crewe and Nantwich (Mrs. Dunwoody), may I seek the co-operation of hon. Members? It is my intention to begin the winding-up speeches at 3 o'clock. Members will therefore realise how long they may have, if they are courteous enough to assist all those standing to contribute to the debate.

2.25 pm
Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

I hope to be reasonably brief. In my constituency it is not possible to get an NHS dentist. In July, I raised the matter with the Department of Health, which sent me an encouraging letter saying that not only will NHS dentistry be given a considerable increase in its annual budget, but a working party, led by the chief dental officer, is suggesting field sites. I am not sure what a field site is; the phrase conjures up pictures of things that I do not want to think about in relation to dentistry.

There should be a significant move away from the present system of item of service contracts, but we are in an extraordinary situation where, although a quarter of the population, and many children, can receive NHS dental treatment, the rest of us cannot. That is quite frightening.

We must be clear. It is not a matter of suggesting that a long-term solution will provide a fully salaried service—that was suggested by the Socialist Health Association more than 30 years ago. We cannot continue to allow a profession such as dentistry to be treated as it is in this country. If it is true that the average dentist earns £60,000 a year without private practice, some would say that dentists are not among the most poorly paid. Some years ago in my constituency, there were no NHS dentists, and I insisted that some should be appointed. All that happened was that a practice ran for a certain time, and then the practitioners looked over at one or two of their colleagues who were extremely well remunerated and decided to accept private patients only.

Indeed, some practices will not accept even children as NHS patients. When I went to that practice in my constituency to discuss what it was doing, the dentist concerned said, "We need exactly the same remuneration as doctors and the same terms and conditions." I pointed out to him that on the door of his practice there was a notice that I thought had some relevance to his rates of pay. It said: "Even if you have received treatment in this practice, if there is an emergency, do not come here. Go to the local accident and emergency service of the NHS." In other words, the practice was not even providing emergency cover.

We must have a little clear thinking about what is going on in the NHS. It is all very well to receive a letter saying, "Of course we are concerned about dentistry in Crewe, but we have had a look at the website, and we understand that there may be some vacancies in Winsford or Northwich for your constituents", but neither area is easily reached by public transport, let alone the kind of transport that would get my constituents to a dentist's surgery when they need care.

It is much more important that we seriously ask the following questions: if primary care trusts are to be responsible for providing health care, who will tell them the terms and conditions on which people will be employed? Will those people be fully salaried? Will the PCTs have enough money to run the service efficiently? If not, what will happen to dentistry in this country?

I do not believe that anyone can run a health or dentistry service—or, indeed, any of the services provided by the professions supplementary to medicine—on the basis that if the going gets rough, people can always be told that they can pay to get the level of care that they deserve. That is not a responsible attitude, it cannot be defended, and it is not what I expect from a Labour Government.

Some of the problems inevitably stem from the fact that we are not training enough dentists. Certainly, we are not thinking clearly enough about what we do with the ones that we have. There is no use in saying that we are going to move away from piecework in dentistry if we do not actually do it. There is no use in saying that in future we want people who provide dental care for the whole population, unless we not only make it worth their while, but insist that the constant development of private care does not leech away the expertise that the NHS requires and leave large numbers of my constituents with no care at all.

There are two people to whom most women cleave with a violence that surprises the male of the species: the first is their hairdresser, and the second is their dentist. The reason for that is that they create a relationship of reliability and trust. It is even worse when one's children find it impossible to receive NHS dental care. That is returning to a situation that existed when I was a child, when the level of oral care in this country was appalling. It was regarded as an act of God. If a person did not have the money, they could not receive the sort of dental care that was essential.

I am sympathetic to the difficulties that any Government face, but a number of urgent decisions need to be taken. The sums of money being spent on the dental service are obviously not producing the results or the level of care that we want or, to be frank, the level of expertise that is necessary. It is clear that the profession is concerned about its own terms and conditions, but it still has not succeeded in evolving a working partnership with the NHS that will produce the level of service that we all need.

It is all very well to say that a change, by handing responsibility to another part of the NHS, will alter the situation. That is unrealistic. Primary care trusts cannot create dentists if they do not exist. Dentists will be sucked from other parts of the world, and almost inevitably they will not be trained in this country and will come from countries with a lower standard of living—countries that are even worse served by dentists than we are. That is morally unjustifiable, short-sighted and absurd because it does not work. It did not work in the NHS, and it certainly will not work in dentistry.

In my lifetime the provision of sufficient professionals in health care has always gone through a feast and famine cycle. A Conservative Government decide we have too many doctors, so they cut down the number. We decide that we have to do something about it, so we create another way of training people, and then say that we have too many. That inability to match care needs to the number of people being trained and the rates and conditions of pay that they receive is a failure on the part of successive Governments.

I am concerned about what is happening in Cheshire. I do not know why people do not want to go to Shropshire; I would have thought that that was a rather posh part, as it looks rather nice. Usually, there is no difficulty in attracting health professionals to attractive places, but they are not quite so keen on Liverpool 8. Cheshire is getting into exactly the same situation, and it is not acceptable. Health care cannot be rationed by payment. If it is, we get into a situation that we have already reached in my constituency, where some people in need of long-term care no longer have a dentist. When they were told recently that a salaried dentist had been appointed, they were told not to tell anybody else because there would be such pressure on those facilities that the dentist would not be able to cope.

Politics is a difficult art, but on the whole people do not cast their votes on foreign affairs. I was brought up by a man who said that one can make a speech on foreign affairs for 45 minutes, and the first question that will be asked is, "Why doesn't the light at the end of my road work?" So if there is a little message that the Minister wants to take away from the afternoon's debate, I hope that it will be sensible. We need a salaried service to train people and to get dental care operating now—not in five or 10 years. It is an urgent problem and solving it must be high on the list for a Government who want to be re-elected.

People have a strange, old-fashioned attitude to their elected representatives. If we cannot provide what they want, they will look elsewhere. I do not intend dentistry to be enunciated as one of the reasons to get rid of a Labour Government—I can think of one or two, but I do not want dentistry to be one of them.

Several hon. Members rose

Mr. Deputy Speaker

Order. May I make a plea for short speeches, please?

2.35 pm
Mr. Andrew Turner (Isle of Wight)

I congratulate the hon. Member for Shrewsbury and Atcham (Mr. Marsden) on securing the debate.

I will start with some basic information. In my constituency, 80,000 people are not registered with an NHS dentist. That is more than the total population of many constituencies represented in the House. That is not because mine is a wealthy constituency—its GDP is less than 75 per cent. of the national average—but because there is a crisis in dental services on the Isle of Wight that extends beyond a shortage of NHS dentists to a shortage of all dentists.

I raised that problem with the Isle of Wight primary care trust not long after I was elected, but the crisis has got worse rather than better. In February I received a letter from the PCT that said: We have successfully bid for additional resources to set up a new practice on the Island". The then Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), wrote: I am aware that there are currently no NHS dentists on the Island who are accepting new patients…New patients wishing to access NHS dentistry in the surrounding area can obtain information on practices accepting adult patients from the dental helpline which is operated by the Personal Dental Service, part of the Isle of Wight Healthcare Trust. Perhaps the hon. Lady did not realise that the surrounding area is not replete with dentists, except when they are sailing. People have had to go to Southsea, Portsmouth, Cosham, Southampton or Lymington to find dentists who are taking patients on to their lists.

In May, the PCT confirmed that it had been successful in opening a new dental practice in Ryde with two dentists, thanks to a grant from the Department of Health. I acknowledge that, but, within a fortnight, it was taking no further patients because it was full. Since then, not one, not two, but three dentists on the island have said that they intend to retire from practice within the next six months. My constituents do not find that satisfactory. One wrote: I have been advised by the Dental Helpline that I would need to travel to Portsmouth to see an NHS dentist—which is out of the question, as I have a two year old boy and a five month old baby to take with me. Another wrote: They recommended that I telephoned the Dental Helpline…or NHS Direct…Along with several hundred other NHS patients I found it impossible to get through to the former…Several days later I gave up and tried the NHS Direct number, only to be given, guess what, the Dental Helpline number…Now, what kind of NHS is this? Another writes of her practice in Sandown: I received a letter stating that they no longer treated National Health patients. That is not exactly the position; in fact one dentist has retired and they were unable to fill the place so they are not retaining those NHS patients. She continues: On telephoning the number given, I was told that the only dentist available was in Portsmouth or Southampton. I explained that I am disabled and can only go by car, and asked if the fares were refundable"— those fares are £37 return by car to the mainland—

I was told no. My husband was born on the Island and cannot work because he cares for me. What am I supposed to do? And what did we pay National Insurance for all our working lives if we cannot now get treatment"? Alison Holbrook, the assistant social responsibility adviser for the diocese of Portsmouth, took a trip to the mainland with three borrowed young children to see what it was like. She describes it at length. She had to leave at 10.14 am. It cost her £18.75 to get from Freshwater to Ryde. They chose the hovercraft rather than the catamaran, because it is quicker and there is time for the connection. That was a good thing, because the train up Ryde pier from the esplanade left at 11.35 and the bus got in at 11.34. It cost them £19.95 to cross the Solent. They got to Southsea at 12.05 and walked for 25 minutes to the dentist. They had to pay £10 each to register with a new NHS dentist.

After lunch the group went back to the hover terminal for the 14.15 crossing. Alison says: Disembarkation from the hovercraft was delayed due to the sheer number of passengers and special equipment being moved into place for a disabled passenger. We had one minute to get the bus, when one of the children said they needed to go to the toilet. We missed the bus so ended up getting on our original intended bus, the 14.45 no. 7A to Freshwater…Arrival at Freshwater was 16.20. The journey lasted from 10.14 to 16.20, and that would have applied whether the person had three children or one. It took six hours and six minutes—a whole day.

Mollie writes:

I think the journey is a waste of time, because the bus took us 1 hour and 20 minutes. The Hovercraft took 10 minutes and then a 20 minute walk to the dentist … Going to Southsea is quite annoying because all that journey just to have a 10 minute check up on your teeth. Harry writes: It took more than two hours from Freshwater all the way to Southsea. It was horrible. They did not even see the dentist. because this was just an experiment.

My constituents do not want to be told that there is a dentist on the mainland. It is impractical to tell a mother with young children, particularly children at school, to take a day off school or a day off work to go to the mainland, particularly for repeat treatment. It is also an insult. It is an insult for the national health service to tell someone that a service is available when it is not available and is totally impractical. It is a particular insult when the Prime Minister said in 1999 that he would provide access to NHS dentists within two years.

I sympathise greatly with the Minister, who has been plunged into this from another Department. She sits here and shakes her head in disbelief at some of the points made by the hon. Member for Shrewsbury and Atcham. I sympathise with her, but she must find an answer.

2.42 pm
Mr. Simon Thomas (Ceredigion)

I congratulate the hon. Member for Shrewsbury and Atcham (Mr. Marsden) on initiating the debate, but I am afraid that his experiences in Shrewsbury are reflected across the border in Wales. Like him, I do not have an NHS dentist. I have been unable to register with an NHS dentist in Aberystwyth for more than five years. The sheer misery engendered by poor NHS provision in Ceredigion has been a real eye-opener for me in the last three years.

What I have seen is symptomatic of a much deeper deterioration in NHS dental provision. That is going almost unreported, which is why this debate is important. The Prime Minister's commitment, which was mentioned by the hon. Member for Isle of Wight (Mr. Turner), has been forgotten, iced over, glossed over and even spun. "You can phone NHS Direct"—that is what the Government meant by a promise of access to an NHS dentist.

In my constituency, NHS dentistry is already the preserve of the few, not the many. Just 31 per cent. of the population are registered with a dentist. That reflects a wider trend in Wales: just two thirds of Welsh children, for example, are registered with NHS dentists.

I can sense already that the Minister will say that NHS dentistry in Wales is now the responsibility of the National Assembly for Wales, but remuneration and training are the responsibility of this place, and we have heard from hon. Members on both sides of the Chamber that remuneration and training are at the heart of the crisis in NHS dentistry.

The only response that the Assembly has been able to make is to provide grants to dentists to set up in, for example, rural areas, but as the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) mentioned, all that happens is that over time those dentists privatise their lists and become, in essence, private dentists with a very small number of NHS patients, if any. That is a complete waste of public money. It is a crying shame that we are throwing good money after bad, trying to support dentists going to rural areas when we know damn well that in two or three years they will be private dentists and we will have to repeat the same process all over again. I have received an immense amount of correspondence on the issue, like many other hon. Members. Last summer, I went out into the streets of my constituency and did a street survey to see what people were experiencing with NHS dentistry. Some of my constituents' comments, like those of the hon. Member for Isle of Wight, illustrate the situation.

A married couple in Cardigan said that they had phoned 20 dentists, who would take patients only if they agreed to be private. NHS Direct could recommend only one dentist in west Wales, and that was in Ammanford. That is a good day's journey away—I hazard to say that it is similar to crossing the Solent. One may only have to cross a river, but that is a long way away in a rural area. Mr. and Mrs. J. in Llanrhystud said that NHS Direct had suggested Barmouth to them. Anyone with any sense of the geography of Wales will know that that is a ridiculous distance to ask people from somewhere south of Aberystwyth to travel for treatment. Somebody in New Quay was told that they could not register, and it was suggested that they go to Tenby or Llanelli. Those are distances of seventy or eighty miles that cannot —I checked that fact—be travelled in a day on public transport. One constituent of mine, an old age pensioner who needed to make two trips to have her dentures redone, was told to go to Brecon. That would have involved two overnight stays. Solutions are very slow to emerge.

The National Assembly, together with the Government, have considered access to NHS dentistry. The Health Committee's report of March 2001 holds the key. It said that the current remuneration system in the general dental service is at the heart of the access problem". That was in 2001, and it remains the position today.

The awful situation in dentistry has allowed fluoridation to raise its ugly head once again. I am opposed to that. I made my remarks on the matter last night during the debate on the Water Bill—the hon. Member for Stroud (Mr. Drew) was also present. It is interesting to note that the National Assembly Government suggested giving free school breakfasts to children. That was the platform of their success in the National Assembly elections last May—they would provide free school breakfasts for children, but there was no mention of cleaning the children's teeth after that school breakfast. That would do a damn sight more to improve dental health than fluoridating the children's water. Taking the coke machines out of schools would also help a great deal.

Like the hon. Member for Crewe and Nantwich, I feel that only a system of salaried NHS dentists can tackle the huge gap in provision that exists today. We need to consider the introduction of a bulk payment system, and remunerating dentists for the preventive work they undertake and not just the treatment that they carry out. Fluoridation is a cop out, and a tacit acknowledgement by the Government that their provision of NHS dentistry is failing the vast majority of people in this country.

2.47 pm
Mr. David Drew (Stroud)

I start by concurring with the hon. Member for Ceredigion (Mr. Thomas). Fluoridation is the wrong approach to a difficult problem. I despair of the BDA. It is a membership organisation, so it could lead its members by persuading them to come back into the NHS. Let us not fool ourselves, the debate is about money.

What worries some of us is that the same debate could happen with respect to doctors and general practice. We must be aware of the problems that my dentist has spoken about to me. I declare an interest, as I am still with an NHS dentist. I shall not quote him, as he would probably be drummed out of the profession. He said to me from the outset that once people see the other side and the benefits offered by private practice—the fact that they can pick and choose their patients, the plans offered to them, and the hours they workthey will not come back again. It defeats the whole purpose of public service.

I have always believed that those in public service must accept that they have to make sacrifices as well as taking some of the benefits. One benefit is the belief that people still have—whether rightly or not, I do not know—that the public holds a person in greater esteem because they work in public service. That is not compatible with pretending that those in public service can get the rewards and benefits that they want.

I feel most strongly that the Government have a huge problem. My hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) always got the tone right. I receive more complaints about this health issue than about any other. Usually, an MP can sympathise and suggest to constituents ways in which they can work round the system, and can help them to tackle what is undoubtedly a very difficult problem. In reality, however, we must say, "I'm sorry, but that's just tough." That is what we get when we have a privatised system working out of the NHS. It is not acceptable.

The Government are not doing enough, and I worry that they are trying to create the illusion that they are doing something about the general dental service with dental access centres and salaried dentists. When dentists see what they can get by going private, they will leave. Only a small, dedicated group of professionals will want to stay in the NHS—or, dare I say it, those professionals who work in areas where they are unlikely to get enough private patients and who may see the benefits of the NHS.

That dilemma is faced not only by the Government but by dentists, who must make those sacrifices if they are to service the population of this country. Negotiations must now take place nationally and locally to try to fix this problem. It has been gestating for too long. We have seen what has gone wrong. I call on my hon. Friend the Minister to tell us what negotiations are taking place, what the cost is and if we are prepared to pay it. We must say to dentists, "This is what the Government are prepared to come up with. What are you prepared to sacrifice to come back to the NHS?" If they are public servants, they must realise that their obligation is to all their patients, not just to children. Concentrating on servicing the needs of children is a nice idea, but when they reach 18 their teeth are no longer of concern. That is unacceptable. We must make progress.

I despair at some of the packages that are presented to patients as though they are what they need. We all know that money is made not in dental care but on hygiene products and all the other things that come with them. They may be important, but they are not the point of a dentist. As my dentist says, a dentist's central concern is pain control. People need a dentist when their teeth are causing them difficulties. We must build prevention into dental care, but let us not fool ourselves that we are getting the icing on the cake. What we want are the ingredients of the cake, and to go back to the basics of good dental care. We are all aware that things will be much worse in the future if there is no preventive approach. I want to know from the Government what negotiations are taking place and what deal needs to be struck, so that we can get on and strike it.

Several hon. Members


Mr. Deputy Speaker

Order. Before I call the next speaker, I should tell hon. Members that I want to get two more speakers in before 3 pm.

2.53 pm
Mr. A. J. Beith (Berwick-upon-Tweed)

My hon. Friend the Member for Shrewsbury and Atcham (Mr. Marsden) described the situation in Shropshire. I am glad that he raised that issue today, and am grateful to many other hon. Members for describing situations similar to the one in Northumberland in the Berwick-upon-Tweed constituency. The problem began to affect Berwick two to three years ago when dentists started to accept only children on the NHS. The situation has worsened, and it is now very difficult to register a child with an NHS dentist.

The initial argument was that patients could go to another town such as Eyemouth, which is not too far away. However, Eyemouth stopped accepting English patients in its dental practices. Dentists started to say, "You can go to Wooler, which is 16 miles away, or Alnwick, which is 30 miles away." The same situation began to develop there. A practice in Alnwick started to practise purely private dentistry. Indeed, it wrote to patients telling them about the virtues of Denplan and saying, "We should like to emphasise that your next appointment will still be available on the NHS. We look forward to discussing the changes with you." Some of those discussions took a hostile turn, especially those involving the patients who showed me the letter.

When the dentists were no longer available 30 miles away, patients were told, "The only thing you can do is to go to the dental hospital in Newcastle 66 miles away", but only emergency treatment is available there. As several hon. Members have said, the situation is unacceptable. It is like saying to someone in London that if they want to see a dentist, they should go to Rugby or Ipswich—indeed, the train services might be better—and that when they get there, they can receive only emergency treatment.

The method that the Government and the health care trust adopted to provide some immediate relief was to try to install a salaried dentist in the infirmary in Berwick, where there is room, and where accommodation has been made available. However, they had great difficulty in making the appointment. One senior, experienced dentist who thought of taking it on told me that he had been informed that if he were appointed, he could provide only emergency treatment, and not the dental care that he thought a patient needed. It would simply be a question of removing the tooth, or possibly repairing the filling, which, as a professional dentist, was not what he would want to do. He was being asked to make the wrong clinical judgment about what was right for the patient.

The dentist also explained to me that the rate of pay was £70 for a three-hour session. For an experienced professional, that is unreasonable—it is an inadequate rate of pay for someone who can provide a high standard of service and who will be called on in a fairly desperate situation. The health care trust has therefore had considerable difficulty in filling that post. People have been assured that there will be a dentist at the hospital, but they still see advertisements in the local paper seeking to fill the appointment.

When I raised that matter in the House on several occasions, the then Under-Secretary of State for Health, now the Under-Secretary of State for Constitutional Affairs, the hon. Member for Tottenham (Mr. Lammy), said that all would be well with the new legislation, because it would give primary care trusts the leverage to ensure local commissioning."—[Official Report, 18 March 2003; Vol. 401, c. 758.] However, the leverage to ensure local commissioning has not solved the problem, which has a number of deep-seated, long-standing causes. One of those is the shortage of qualified dentists, otherwise we would not be seeking them from overseas. Reference was made earlier to past decisions that contributed to that shortage, such as the closure of dental training facilities in Edinburgh.

We cannot rely on long-term solutions for our constituents. It is unacceptable that people cannot register with an NHS dentist or obtain proper dental care. I look to the Minister to resolve the situation in my constituency and the other areas affected.

2.57 p.m.

Mr. Russell Brown (Dumfries)

I congratulate the hon. Member for Shrewsbury and Atcham (Mr. Marsden) on securing the debate. I also thank you, Mr. Deputy Speaker, for calling me to speak, because I realise that this is a devolved issue—responsibility for both the NHS and dentistry has been devolved to the Scottish Parliament.

I should like to make hon. Members aware of the situation in Scotland, because the issue is UK-wide. I indicated earlier the problem that we have had since the closure of the dental school in Edinburgh. There are now two dental schools left in Scotland that produce, on average, 120 graduates per year. However, the demand is such that the system needs to produce 125 to 130 qualified dentists annually. Moreover, some of those who qualify go south of the border, and some go overseas. We tend to focus on the UK's recruitment of professionals from Africa and Asia, but some of our professionals go to north America to ply their trade.

The issue has been brought into focus in my constituency because, in the past couple of weeks, the last NHS practice in Dumfries decided to go private. The letter that it sent to all its patients caused me some concern because it stated that over the past few years there had been a steady erosion of Government funding. Even the hon. Member for Shrewsbury and Atcham would probably admit that funding has been provided, although perhaps not as much as people would have liked.

I took exception to that. When I wrote to the local practice to raise the issue, the reply stated that the problem started in 1992, when the Doctors and Dentists Remuneration Review Body recommended an 8.6 per cent. fee increase. That translated to a 7 per cent. fee cut, as it was 15.6 per cent. down. It is a long way back to recover that.

We talk about spin in society, and I agree with my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) that it is the day-to-day things that determine whether the Government are in favour with the electorate. In that context, people may think that solely the present Government are to blame, but hon. Members can see that successive Governments have not delivered the service that we want.

It has been said that 4,000 extra dentists are required, but what will happen if we manage to secure them without changing our current structure? If we do not change the fee structure, we will lose them too. We are not getting enough dentists through in the first place, but even if we could suddenly magic them up, we would lose them as well. Even if there was an attempt to change the structure, I am not sure whether we could get some of the other people back.

The system is financially driven, which has forced people away. My hon. Friend the Member for Stroud (Mr. Drew) made that abundantly clear. Those who have left have seen what happens outside and will not want to come back. We need salaried dentists throughout the United Kingdom, and I want to hear from the Minister how we will tackle this serious problem, which means a great deal not only to hon. Members, but to the general public. We still have 35 NHS dentists in my constituency, but that is half the number that we want, and I worry when I see some of the criteria that must be met. Young people in full employment will get a dentist, but what happens to those who are unemployed? Those are the issues that need to be tackled, and like all hon. Members present today, I want an answer to the problem sooner rather than later.

3.1 pm

Dr. Evan Harris (Oxford, West and Abingdon)

The fact that we have had a large turnout and an excellent debate is a reflection of how seriously people take this issue and how large they judge the problem to be. In preparing for this debate, I quickly looked up some of the figures, rather like one quickly brushes one's teeth before going to the dentist, even if it is the only time that one does it for several months.

Mr. Simon Burns (West Chelmsford)

Speak for yourself.

Dr. Harris

The hon. Member for West Chelmsford (Mr. Burns) is probably the only person who does not brush extra hard just before he goes to see his dentist because he is blessed with gorgeous teeth, as he keeps telling everyone.

The problem is that we do not discuss the issue often enough. It is not seen as mainstream NHS, when that is exactly what it is and should be seen as. We owe a great debt to my hon. Friend the Member for Shrewsbury and Atcham (Mr. Marsden) for introducing this debate, and for providing in its scope and detail one of the best introductory speeches that I have heard. He considered the history of the problem: the worsening access, the broken promises and the failure of policy. He then took us on a tour of the country—like the Consumers Association, the health Which?, and the Audit Commission, he has done that. We are grateful to him for giving us the opportunity to discuss some of the problems in such a structured way.

The hon. Member for Crewe and Nantwich (Mrs. Dunwoody) reflected, as I shall, on how we have got to this position after six years of a Labour Government. The problem of access to what should be basic NHS care has got worse, and continuing initiatives have not tackled the problem. Ministers have given the impression that the problem is due to be tackled, but it has not been. The hon. Lady reflected that her party, which has a long and proud history of at least trying to expand access to NHS care and make it free at the point of delivery, may lose support and votes at the next election unless the Government act soon. Recent moves to give power to primary care trusts to provide NHS care are at least coherent with the need to ensure that commissioning for NHS dentistry services and acute and community dental services are considered together. If NHS dentistry access is defined as access and not registration, and people are still charged and therefore deterred from going, the point will have been missed and yet more expectations will be dashed.

The hon. Member for Isle of Wight (Mr. Turner) cleverly and amusingly showed what nonsense some of the access pledges are, expecting people to travel with or without public transport, as the crow flies, regardless of natural barriers, to receive NHS care when they are in pain or in an emergency.

The hon. Member for Ceredigion (Mr. Thomas) reflected on the problems in Wales and introduced the subject of fluoridation—the debate had been going 46 minutes before he did so. The Government must feel under pressure to make more progress on that issue, given their failure to provide holistic and preventive care in dentistry. Registration would be a means of doing so. The Liberal Democrats wanted to await the outcome of the York report and abide by its findings. Those findings were that fluoridation was safe, but that there was not sufficient, good quality evidence at that time to show that it is adequately effective. That is the authors' interpretation of the York report, although both sides of the debate seem to pray it in aid to support their position.

A fundamental question must be answered. Is it appropriate to fluoridate water, even if it is shown to most people's satisfaction to be effective and safe? Is that adulteration of the water supply going too far? I suspect that that will be left to a free vote, but we will not be in a position even to argue the principle until we see better evidence of the effectiveness of fluoridation. There are other mechanisms for improving dental health—including children's dental health—such as proper access to dental advice and to the best products, which will involve fluoride but not fluoridated water. The Government should allow a proper debate about fluoridation before introducing a Bill that has implications for fluoridation but does not necessarily tackle the principle.

The hon. Member for Stroud (Mr. Drew) showed that there are problems in a market-based system. Private dentistry is a private business. He is right: there has been a failure in the market. An interesting question is whether it would be possible to bring dentistry back into the NHS.

My right hon. Friend the Member for Berwick-upon-Tweed (Mr. Beith) demonstrated one of the many sneaky ways in which private practitioners increase their market share under Denplan. Is it appropriate for a dentist to glower over someone in their chair and say, "You are going to switch to this very good, affordable plan that suits me better"? There is a serious question about whether that is the best way to do it. It may be how the Whips in some parties work in Westminster, but it is inappropriate for dental care. He also identified the problem of how long one has to wait for emergency treatment and how it is difficult for dentists who just do emergency work to provide effective and holistic treatment.

The hon. Member for Dumfries (Mr. Brown) raised the problem of dental supply, which is critical to the debate. It is not rocket science, but Governments have been unable to provide throughput from dental schools to provide adequate capacity in the system and an adequate market, so that the NHS can compete with private dentistry. If private dentists' lists were only half full, because there were more dentists, they would be more willing to work with the NHS at whatever price was agreed. Can we get private dentists back into the NHS if the fee structure is changed? I believe so, but only by tackling the problems in the labour market.

I want to deal with some of the Government's broken promises, such as the broken promise to tackle health inequality. How can we have greater equality of health care when some people have to go private but cannot afford to, and when even those that can access NHS care have to pay charges that deter them and that they perhaps cannot afford? There are also problems of poor access, particularly for those who rely on public transport, because the Government's approach has been to provide access over distance, which is difficult when there is no public transport.

Another failure of the Government relates to prevention. As I and other hon. Members have said, we do not allow holistic or proper preventive care to be given. That is a significant failure of policy. If we can prevent dental ill health, it will be cost effective in the long run. It has been a failure of the market because of an inadequate labour force. It is a failure of choice for patients who are lucky to get any option at all in an emergency or a routine setting. For a Government who talk so much about choice, it must be very disappointing.

We should have an NHS that is free at the point of delivery, comprehensive and universal. Why should teeth be excluded? How can we have a system in which there are charges even for NHS treatment? The revenue raised from charges has risen by 20 per cent. in six years under this Government? When Ministers attack the Conservatives, they talk about an NHS that is free at the point of delivery. They should look to their own policies and practice, because it is not always free. Charges deter people, especially the poorest.

Are the Conservatives willing to apologise for the imposition of that contract in 1992, which everyone agrees started the problem, and for forcing pensioners to pay for dental checks? We must also ask the Government serious questions about the cost-effectiveness of their dental access scheme, because the cost per treatment is significantly higher by several factors than the cost of NHS dentistry by a GDS dentist. There are questions for both the other parties and for all policy makers? Will we have charges for NHS dentistry? I do not think that we should. We will debate this issue at our conference later this month. I hope that it will be the start of the debate and that other parties will also consider the matter.

3.11 pm
Mr. Simon Burns (West Chelmsford)

One of the most interesting and obvious themes of all the contributions today, particularly those of my hon. Friend the Member for Isle of Wight (Mr. Turner) and the hon. Member for Crewe and Nantwich (Mrs. Dunwoody), is the serious problem of access to NHS dentists in this country. Fortunately, my constituents do not suffer to the same extent as those in the Isle of Wight or in Crewe and Nantwich. We still have some good, dedicated NHS practices, and a number of the private practices in Chelmsford see children on NHS terms. Nevertheless, although we do not have the same scale of problem, there is still a significant problem of access to NHS dentists even in areas like Chelmsford.

My hon. Friend the Member for Isle of Wight reminded us—I suspect that some hon. Members did not want to be reminded—of the great show of spin at the 1999 Labour party conference, when the Prime Minister, that master of spin, announced that within the next two years everyone would be able to see an NHS dentist. As the hon. Member for Ceredigion (Mr. Thomas) rather cruelly reminded us, we did not read the small print. Apparently, access to an NHS dentist in most cases means ringing NHS Direct and being sent half way round the country to try to find one.

Four years after that bold promise from a Government who are long on giving promises but short on living up to and realising them, where are we? The percentage of adults registered with a dentist in England has declined from 52 per cent. in 1997 to 44 per cent. at present. Fortunately, the decline among children is less; it has fallen from 62 per cent to 60 per cent. In London, which has the largest population concentration in this country, the percentage of adults registered with dentists has declined from 49 per cent. in 1997 to just 37 per cent. The percentage of children registered has declined from 51 per cent. to 50 per cent.

My constituency and others have seen a consistent and steady decline, so that 1.5 million fewer people are now registered with an NHS dentist than were registered in 1998. That does not take into account the vast number of people—millions—who cannot register with an NHS dentist even if they want to. Probably the most absurd and distressing recent example of the consequences of the shortage was that of an NHS dental practice in west Wales that decided to increase its number of NHS patients by 300. Hundreds of people queued in the streets of Carmarthen overnight, rather as they do outside Wimbledon, in an attempt to be one of the lucky 300 able to register with an NHS dentist. There were allegations that bribes of up to 500 per cent. were offered, although not accepted, to try to get that valuable registration. Hon. Members will agree that that is just not acceptable.

What is needed is greater access to dental services. The need for a short-term fix drives individuals to see a dentist when they have an acute dental problem and they are in pain, but there is much more behind the decision to go to the dentist. It is crucial that regular check ups are carried out. Whether they should be every six months or every 12 months is an argument that I leave to clinical practitioners; some people do not have the luxury of taking such decisions because they cannot get access to an NHS dentist.

A check-up is crucial not simply to check the health of an individual's teeth, but because it may detect other medical problems. Dentists can pick up conditions in a dental check up that are unrelated to dental care, which is an important contribution to preventive medicine. An early intervention in a patient's medical condition might help to cure or to alleviate their problems. That is why it is so important to minimise the inequalities in dental care and do more to enable people to see a dentist.

As the hon. Member for Dumfries (Mr. Brown) said, finance is at the root of the matter. There is also an historical problem: ever since Nye Bevan set up the health service in the late 1940s. dentistry has been an add-on, not an integral part of the NHS as we understand it, with the principle that it is free at the point of use for all. The hon. Member for Oxford, West and Abingdon (Dr. Harris) wondered aloud about those discrepancies, and that is where they came from.

It is crucial that the money provided is spent cost effectively and efficiently to improve and enhance levels of dental care. If the Minister has time in her closing remarks, I would like her to explain how it will be spent, because there will be a fundamental change in the provision of dental care from April 2005, with commissioning through the PCTs. We still do not know exactly how the commissioning and the provision of services will be carried out, and we need to know. For example, the budgets will be cash limited, but how does the Minister envisage the commissioning being able to meet the requirements and the needs of the population in the local PCTs? How does the Minister think that PCTs will be able positively to encourage and increase the number of people who have access to NHS dentists rather than their having to rely on private dentistry?

There has been a problem with capacity in the dental service in relation to dentists and dental nurses. Will the Minister confirm that part of the problem is historic and is due to decisions taken in the 1970s that were based on then valid opinions and the closure of one of the dental schools. It is now clear that we need more dentists. We can of course seek dentists from overseas, but that is a short-term solution. What can be done and what is going to be done to increase the number of trainees so as to ensure that in the longer term we will have enough dentists and dental nurses to fill the capacity that the service requires in order to meet the needs of the population?

3.20 pm
The Parliamentary Under-Secretary of State for Health (Miss Melanie Johnson)

I thank all Members who have contributed to this useful debate and especially the hon. Member for Shrewsbury and Atcham (Mr. Marsden) for raising the issue of NHS dentistry.

I stress at the outset that the Government are not complacent about the difficulties in NHS dentistry. We accept that the situation needs to be improved, which is why only yesterday in another place there was the Second Reading of the Health and Social Care (Community Health and Standards) Bill, which will reform NHS dentistry for the first time since the establishment of the NHS. It is time for change in dentistry. We have recognised that and are taking steps, as a number of hon. Members mentioned, to make those changes.

The oral health of the population has improved enormously since the NHS was set up, and it continues to improve. However, I entirely accept that the improvement is uneven and that there remain areas in both inner cities and rural England where dental disease remains high. The Government are committed to reducing those health inequalities. Equally challenging is the fact that in some areas, people have difficulties in finding an NHS dentist. All of us are aware of such problems from our constituents, so it might be helpful if I make it clear that the Bill is not about maintaining the status quo, but about changing it. The provisions are designed to widen access to NHS dental services and provide a more up-to-date legal framework that will better allow primary care trusts to develop and plan those services strategically.

Under the new legislation, which provides a framework to take forward the "Options for Change" paper published in August last year, the PCTs are to be given new powers to provide or secure the provision of primary dental services. The existing powers under the National Health Service Act 1977, under which the general dental services are provided, are to be repealed to make way for new general dental service contracts between PCTs and dental practices.

However, the high street dentist—the general dental practitioner—is a self-employed independent contractor providing the services. Dentists can practise wherever they like and there are no restrictions. Provided that they meet the conditions of suitability, they have an automatic right to provide NHS general dental services. They can accept as many or as few NHS patients as they wish, and they can currently alter that commitment at will without reference to the PCT.

The key aim of local commissioning is to provide a greater degree of operational control for the NHS locally, so that planned services can be matched to the financial resources available. That would mean contracts for an agreed level of service over a fixed period to be delivered to agreed quality standards.

Following the publication of "Options for Change", the dental profession was invited to submit ideas for testing the proposals in that report. The response was overwhelming. There was a very positive attitude among members of the profession to the idea of doing things differently, and work goes ahead with dentists on 50 different sites to test the ideas. I fear that those may be some of the field sites referred to by my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody). Some 20 of those projects will examine different ways of paying for the service.

We already have experience of nearly five years of local commissioning of dentistry under the personal dental services pilot programme, in which resources are devolved to the front line. Those pilot schemes now treat 750,000 people a year, and have shown what works well and less well. The so-called field sites will build on that learning. The proposals in the Bill will underpin a modernised primary dental service, provided through contracts between the primary care trusts and dental practices.

The hon. Member for Shrewsbury and Atcham raised the issue under debate, and I believe that it was his local situation that led him to do so. I was pleased to hear that he accepted that it was a long-standing problem. However, I also accept the point made by my hon. Friend the Member for Crewe and Nantwich that urgent action is needed.

I shall quickly outline the situation in Shrewsbury. The three-surgery dental access centre has been operational since 1999. Following a recent expansion programme, there are now seven further centres across the county PCT area. At those centres, salaried dentists employed by the trust provide the full range of NHS treatment. The current priority is to meet the demand for urgent treatment, although some routine dental care can be offered to non-registered patients. A number of other steps have been taken in the area, but time and the need to respond to other questions will not allow me to go into detail about them.

The key point concerns the work force, and we should recognise that that issue is difficult to address locally. It has proved difficult to attract new dentists into the Shrewsbury area for either general dental services or salaried posts in the dental access centre, and there are a number of unfilled posts in the county. The issue is therefore not necessarily as simple as hon. Members make out. The money is available to pay for the dentists, if we could only recruit them.

Mr. Marsden

I accept what the Minister says. I agree that the PCT will be in a better position to move things forward. However, the Government and the Shropshire PCT have shown a fundamental lack of urgency, and that lack of urgency is replicated throughout the UK. I am not aware that more money will be made available to begin to solve that fundamental problem. People out there are fed up with yet more promises.

Miss Johnson

Since April 1997, dentists' NHS fees have increased by 26 per cent., in line with the recommendations of the independent review body. Anyone would accept that that is a reasonable increase. This year, dentists have received, in addition, £33 million of commitment payments, under a new scheme that was introduced in 2000. There are, therefore, a number of steps being taken to improve funding. I accept that Opposition Members—and some Government Members—may still say that more money needs to be ploughed into the service. However, those Opposition Members who voted against the increases in funding to the NHS have little basis for making that point.

I shall briefly sketch the changes introduced in the Bill, and the effect that they would have. In future, the allocations to PCTs will include funding currently harnessed by their local dentists, and they will be required to spend at least an agreed amount, and more if their local priorities indicate the need. PCTs will be able to take those decisions and employ dentists in the way that I outlined earlier, in order to address the priorities of local provision. At present, the method of payment means that the funds—which, as hon. Members know, are non-cash limited—are spent only to the extent that dentists wish to carry out treatment on the NHS, so that will be a significant change. The reforms have the endorsement of the British Dental Association. I reiterate that a huge amount of extra funding has been provided for NHS dentistry by way of fees and extra money.

Many hon. Members raised the matter of work force planning. A review is under way and we shall report on it by the end of the year. It will include examination of the present age structure, the increasing number of women dentists and the impact of our reforms on contractual and remuneration arrangements. It is intended to make NHS dentistry more attractive to dental practices. Other issues, which no one has touched on, such as the skill mix of different professions in dentistry, are for the future. Many things need to be done, but as of 2002 there are nearly 18,500 dentists in England. That is an increase on the 1997 figure of 16,700-odd.

In response to the hon. Member for Ceredigion (Mr. Thomas), I point out that the matter in question is a devolved one, and apart from the Health and Social Care (Community Health and Standards) Bill, I cannot comment on matters in Wales.

Mr. Deputy Speaker

Order. The Minister will have to leave her remarks there, although we congratulate her on trying to get so much into them.