§ Mr. Hugo Swire (East Devon) (Con)
I am delighted to have the opportunity to discuss the provision of dentistry in East Devon.
The chronic shortage of dentists in East Devon is by no means a recent phenomenon. It is widely acknowledged that there has been a long-standing need to develop capacity, especially in Exmouth, and the problem is simple: as dentists who do work on behalf of the NHS become exclusively private practices or retire, they are not being replaced. At a time when the East Devon primary care trust recognises that capacity should be increasing, it is being lost.
The East Devon primary care trust underlined the uncertainty among dental professionals about the future of their businesses and pointed out that no practices in East Devon were registering new NHS patients. The emergency dental clinic based in Exeter is testament to that dire situation, as shortages in my own and neighbouring constituencies have led to extreme pressure on the service and a tripling of the number of patients attending the Sunday session. The primary care trust notes that the services are struggling to manage the demand from patients. Because there are so few NHS dentists, the emergency clinics are being stretched to breaking point.
The growing population in Exmouth should have necessitated two extra dentists to cover the demand, but instead it has lost one and is shortly to lose another. No successors have been appointed and, with local practices full to capacity, patients wishing to register with an NHS dentist are faced with unacceptable journeys—in some cases, round trips in excess of 50 miles—just to see a dentist.
The retirement of Martin Lewis and that of Bernard Jones, whose practice is on the Exeter road, will result in some 5,000 people having to re-register with practices as far away as Cullompton or Crediton. There is even talk locally of patients having to travel as far as Plymouth. For many, that is too much of a strain. One of the reasons for Mr. Jones's retirement is the cost of adapting his premises to meet the terms of the Disability Discrimination Act 1995. A further problem in Exmouth is with Mr. Alistair Danby's attempt to open a clinic in Rolle road. I urge the primary care trust and East Devon district council to resolve the matter urgently and help to locate Mr. Danby in suitable premises in Exmouth.
Some 32.3 per cent. of my constituents are of pensionable age, the second highest proportion in the country, compared with a United Kingdom average of only 18.5 per cent. Not only are there many older, vulnerable people in my constituency, but because of demographics and the sparseness of settlements, it is tricky for many people to travel so far to see a dentist. In my constituency, only 5 per cent. of people use public transport as a means of travelling to work; the United Kingdom average is 14.6 per cent. That shows that access to public transport is limited in many areas, and it is relatively slow, time-consuming and costly and for many older people it takes a great deal of effort.
Surprisingly, East Devon is the 139th most sparsely populated of the 659 constituencies in the United Kingdom. The access domain of the indices of 454WH deprivation 2000, which ranked all 8,414 wards in England based on the April 1998 boundaries by geographical access to services, showed that East Devon contains many wards with low-ranking access to services.
Colaton Raleigh, Beer, Colyton and Sidmouth Rural are all in the top 25 per cent. most access-deprived wards in the United Kingdom, while many parts of Exmouth are in the top 50 per cent. Not having a dentist within easy reach merely exacerbates the problems that many of my constituents already face.
In assessing the cost and time of making the seemingly inevitable journey from Cullompton to Exmouth, I have acquired the following figures: a daily bus pass from Exmouth to Cullompton costs £6 for an adult, £4 for a child and £3 for an old-age pensioner. That is by no means the worst of it. If, having been in the unlikely but extremely fortunate position of catching a bus from Exmouth, one were to catch a connecting service from Exeter without any delay, it would take one and a half hours to reach Cullompton. In the very best case scenario, that would involve a three-hour round trip. In reality, that journey is likely to last anything between four and five hours, which is quite simply preposterous.
Scores of letters from concerned constituents, extremely worried by the prospect of having to travel so far, have prompted me to secure this debate. I have also received my first ever letter from a stalwart of Exmouth, the Exmouth town crier, the estimable Tregarthen Gibson. He asked for my help for the population of Exmouth, which is, after all, Devon's largest town. Unless we get urgent extra dentistry in Exmouth, even Mr. Tregarthen Gibson's teeth might be under threat. The prospect of a whimper rather than a cry from our town crier is too tragic to contemplate—but I digress.
A typical letter comes from Mr. Yorke from Exmouth, who, reliant on incapacity benefit and pension credit like many others, has been told that he will have to travel to Cullompton to register with a dentist. He says:I find it appalling that to get dental treatment I am expected to make a round trip of about 40–50 miles. To do this on public transport would probably take me a whole day and cause me considerable pain and distress.Exmouth town council has also written to me, expressing its concern about the shortage of NHS registered dentists. It outlines two very important factors as to the effects the shortages are having.Appointments have to be made some 3 months ahead in many cases as dentists' books are full. The result is that problems can soon turn into an emergency, resulting in premium charges being levied. Private treatment is already expensive for the average person. The number of Dentists who are practising National Health Service Dentists are now few and far between.I do not wish to trespass on my neighbour's turf, but during my research for this debate I spoke to David Lidden, whose dental practice in New street, Honiton looks after the Swire family's teeth. His story is not untypical. The practice consists of four dentists, each of whom see 30 to 40 people a day, not so much to earn money—although that is unquestionably a factor for some dentists—but to get through the ever-increasing numbers of people queueing to see them. The result is that the dentists cannot spend enough time with each patient, and are, in David Lidden's own words, administering "pastoral care"—that is, putting patients 455WH out of pain—nothing more. The practice has an average 10 calls a day from people inquiring about treatment. The practice policy is not to turn people in acute pain away; none the less, they turn people away each and every day. I will not stray over the border any more; I know that my hon. Friend the Member for Tiverton and Honiton (Mrs. Browning) wishes to contribute to the debate.
§ The Parliamentary Under-Secretary of State for Health (Miss Melanie Johnson)
I am happy for the hon. Member for Tiverton and Honiton (Mrs. Browning) to take part, as long as I have enough time to reply.
§ Mr. Swire
I took the precaution of telephoning the Minister's office this morning to clear that in advance.
Dr. Kenneth Croft, a dentist based in Exmouth, is extremely concerned about the shortages and the proposed changes to the dental profession. His concerns relate largely to the uncertainty that will hit the profession when the budget and commissioning for NHS dentistry devolve to primary care trusts from 1 April 2005. There is consternation about the many unknowns that face dentist professionals. As such, many are not prepared to wait and are opting instead for the relative security of exclusively private practice.
Dr. Croft is as anxious as any other dentist about the outcome. He says:Dentists are cagey as they don't know what's going on so won't take on NHS patients".Many are frustrated because they do not yet have the details to enable them to plan and budget for the changes. Payment is projected to be based on 2002 earnings while taking account for inflation by 2005, yet dentists who already own computer equipment will be expected to upgrade it so that they may be monitored by the local primary care trust. For Dr. Croft. that has been estimated at £4,000. He argues that that is an investment that dentists in their mid to late fifties, who are nearing retirement at 60, simply will not make.
I asked Dr. Croft about the additional £10 bounty that I read was being offered in parts of Exeter—a claim made by the Under-Secretary of State for Environment, Food and Rural Affairs, the hon. Member for Exeter (Mr. Bradshaw). I understand that that has been dismissed by many local dentists as nothing more than a gimmick. I will give an example to show why. Dr. Croft charges £31 for a private assessment with X-rays, and is paid £6 for an NHS assessment. With the extra £10, he would receive only £16, which is just over half of what he would receive privately.
Dr. Croft is, unsurprisingly, cynical about what the Government are doing, and sees it as being along the lines of dentists making the investment and the Government taking the credit. He believes that the Government are ultimately trying to force dentists out of the health service. With the retirement of Bernard Jones, there will be seven registered NHS dentists left in Exmouth, of whom one is part-time; I hope that the reduction stops there, but I doubt that it will.
456WH The Government also appear to be failing in getting the public to take oral health seriously. When my party left office in 1997, 68 per cent. of under-18s were registered with dentists. By December last year, that figure had dramatically reduced to 60 per cent.—a reduction of more than 1 million teenagers and children. Likewise, for over-18s, the figures make for worrying reading: more than 52 per cent. were registered in 1997, but that has dropped under the Government to 45 per cent., which represents 3 million fewer people registering.
Speaking in the House of Lords on 1 December 2003, Lord Colwyn, himself a dentist, alluded to many of the problems facing dental surgery that Dr. Croft referred to. In his anticipation of the abolition of the Dental Practice Board in 2005, he said thatwe must not forget that there are practice owners who have borrowed money, mortgaged their houses and invested capital to provide the premises from which this service is to be provided, and they are now going to be subjected to a limited income. It will be obvious to the Minister that no one who has invested in their own business in this way will be happy with this restriction. So there is still a real risk that many dentists will either leave the NHS or increase their private work in the face of this uncertainty."—[Official Report, House of Lords, 1 December 2003; Vol. 655, c. 134.]Until the Minister addresses those genuine concerns, we cannot hope that the situation with which we are faced will improve. Also, when will the review of the dental work force—promised in 2001 by the then Minister with responsibility for dentistry, Lord Hunt—be published?
The British Dental Association believes that there is a need for a 25 per cent. increase in the annual graduation figures for dental students. There are currently 800 a year. Last year, there were more entrants to the General Dental Council's register from abroad than from new graduates in the United Kingdom. Many of the issues surrounding the dearth of NHS dentists may partly be explained by the fact that dentistry's share of total NHS spend has fallen over the years from 5 per cent. to 3 per cent.
Such experiences are being repeated not just in my part of Devon but all over the county. In North Devon, the same problems emerge. I have spoken to Orlando Fraser, the Conservative prospective parliamentary candidate for North Devon, whose research suggests that, because of the past parsimony in respect of NHS funding, more dentists are choosing to treat only, or mostly, private patients other than children and pregnant mothers—a development that he says is leading to shortages of NHS dentists in North Devon and, by inference, greater waiting times for NHS patients.
The problem that we must overcome is not just a short-term one; it is a medium and long-term one, too. It is not just local, but national. However, despite promises of cash injections by the Government, it has become apparent that newly qualified dentists, crippled by debt, are avoiding NHS work. Young dentists are opting for better-paid private work rather than NHS jobs in clinics in a bid to improve their finances faster.
A British Dental Association survey found that average debt among dental students rose by 23 per cent. in 2002 alone, with final-year students being an average of £12,700 in debt. The percentage of graduates with debts over £30,000 has also more than tripled since 2001. 457WH A third of those taking part in the survey said that their level of debt would influence their career choice, with the influence stronger where there were higher levels of debt.
A survey published earlier this year found that over half of dentists' income comes from treating private patients and that more than a quarter of UK dental patients now pay privately for their care. A report by the Audit Commission published last September showed that 40 per cent. of dentists will not take on new NHS patients. We have even heard that the Welsh Assembly has begun offering grants of up to £50,000 to encourage dentists to set up practices in areas where the shortages are worst. A team from Pembrokeshire's local health board is apparently combing recruitment fairs as far afield as London to try to find more dentists.
It is quite possible that we will end up with a better system as a result of "Options for change"—which, incidentally, was last heard of in a military context as there was a 1991 paper with the same name. The fear is that by putting dentists on a salary, which is what it will do, fewer patients will be treated. What can the Government do? I hope that the Minister will resist the temptation to throw figures at us this afternoon as the Minister of State, the hon. Member for Doncaster, Central (Ms Winterton), does when questioned. We hear that a total of £1.2 billion is devolved to primary care trusts; £59 million—
§ Sitting suspended for a Division in the House.3.59 pm
§ On resuming—
§ Mr. Swire
This morning, BBC Radio Devon asked me, in a rather cynical fashion, what the point of the debate was, as if it would not achieve anything, but I earnestly hope that it will. I hope that the Minister will not re-announce the old figures of £1.2 billion and £59 million—all the figures that have been thrown around the Chamber over the past few months. I also hope that she will not blame everything on the last Tory Government and what happened back in 1992. Equally, if she refers to the 20 per cent. cuts, that argument is wearing a bit thin, given the pronouncements made this morning by my right hon. Friend the Member for West Dorset (Mr. Letwin) that we would at least match, if not exceed, Labour's expenditure on the NHS.
If the Minister's mailbag in Welwyn Hatfield is anything like mine, she will be aware of the problems. I hope that she will give some hope to my constituents who, as I hope she will have realised from what I have said, are increasingly worried about the lack of dental provision.
§ 4 pm
§ Mrs. Angela Browning (Tiverton and Honiton) (Con)
I congratulate my hon. Friend the Member for East Devon (Mr. Swire) on securing the debate. I shall add some points to those that he made, because part of East Devon district overlaps with my constituency, and we adjoin the city of Exeter. I, too, speak on behalf of constituents in East Devon, including very elderly frail people, some of whom are in residential care. For 458WH example, there is a lady in residential care in Broadclyst, in my constituency, whose dentist in Exeter no longer takes NHS patients.
In the Mid Devon part of my constituency, there are practices open—in Crediton, Cullompton and Tiverton—but the problem is the time taken to journey there from East Devon, coupled with the fact that no more dentists in the city of Exeter are taking on NHS patients. Over the past month I have corresponded with Jill Ashton, chief executive of Exeter primary care trust; she tells me that the trust urgently needs the dental access money that the Government have promised. It intends to use that money to give financial support to existing practices so that they can take more NHS patients, and to use it for out-of-hours work. I am concerned that if no one is taking on any more NHS patients in Exeter or in East Devon, the pressure on the Mid Devon part of my constituency will become acute.
The Minister should bear it in mind that that money is urgently needed. The primary care trust has to bid for it, and I do not know how long the process takes. I hope that she can give us some reassurance that that money will come through to the trusts very shortly.
§ 4.2 pm
§ The Parliamentary Under-Secretary of State for Health (Miss Melanie Johnson)
I welcome the fact that the hon. Member for East Devon (Mr. Swire) secured the debate, because it has given us the opportunity to discuss dentistry in East Devon and NHS dentistry in general.
The oral health of the population has improved enormously since the NHS was set up. However, that improvement has been uneven and there remain areas, both in inner cities and in 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 difficulty in finding an NHS dentist—a problem that the hon. Gentleman highlighted.
Hon. Members will be aware that dentists are self-employed, independent contractors, and that they can accept as many or as few NHS patients as they wish and alter that commitment at will, without reference to the primary care trust. In addition, dentists can, quite legally, accept only certain categories of patients, such as children and adults who are exempt from patient charges.
The existing funding arrangements are unsatisfactory because they reflect the history of dentists' varying willingness to treat rather than the NHS's need to secure dentistry. That goes back a long time in the history of dentistry. If dentists in an area reduce the amount of NHS work that they do, the associated financial resources are reduced and that money is lost to the PCT. We therefore recognise that primary care organisations—in England, the PCTs—have little influence and few levers with which to manage the dental service at the local level, or to make the best use of the £1.8 billion, including patients' contributions, currently spent on general dental services.
Against that background, the Health and Social Care (Community Health and Standards) Act 2003 is now on the statute book. One set of clauses that was welcomed 459WH by both sides in both Houses covered the reform of NHS dentistry; that was the first real reform since the NHS was established.
We know that in some areas our constituents experience problems in accessing NHS dental services, so it might help if I make it clear that our policy—as expressed in the recent Act—aims to change the status quo, rather than to maintain it. It aims 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.
The general principles proposed for the new primary dental service were set out in the report produced in August 2002 under the leadership of the then chief dental officer, Dame Margaret Seward, "NHS dentistry: Options for change". The report built on the outline programme for NHS dentistry that was set out in the NHS plan of 2002. One of the key recommendations of "Options for change" was that there be local commissioning of high-quality dental services, responsive to the needs and wishes of patients and better able to address inequalities in oral health. The report proposed that money should also be devolved to the local level to allow PCTs to secure provision of the new services. Under the new legislation, which provides a framework to take forward "Options for change", PCTs are given new powers to provide or secure the provision of primary dental services. The existing powers, under the National Health Service Act 1977, will be repealed to make way for new dental services contracts between PCTs and dental practices. The key aim of local commissioning is to provide a greater degree of operational control for the NHS locally, addressing the problem that I identified earlier, so that it can match planned services to the financial resources available to it. That would mean contracts for an agreed level of service over a fixed period of time, to be delivered to agreed quality standards.
The new system will make it possible to pass to PCTs the £1.2 billion of financial resources that are currently held centrally. Current spending will be protected and, once the reform system is in place, it will be possible over time to adjust and grow NHS allocations to take account of the health inequalities that would persist under the old system. As I have said, existing patterns of expenditure on dentistry reflect the varying willingness of dentists to treat, rather than the needs of the NHS to secure dentistry. In the longer term, NHS funding allocations for dentistry will need to take oral health needs into account, as general allocations currently do in relation to general health needs. The Health and Social Care (Community Health and Standards) Act 2003 will result in a modernised primary dental service, properly integrated with primary care services in the rest of the NHS.
Following the publication of "Options for change" the dental profession was invited to come forward with ideas for testing the proposals in the report. The response was overwhelming: work is under way with dentists in 50 different sites testing ideas, 20 of whom are considering ways of paying for the service. We already have five years' experience of local commissioning of dentistry under the personal dental services pilot programme, where resources are devolved to the front 460WH line. Those pilots are now treating 750,000 people a year and have shown what works well and what less well. The field sites are building on that learning to refine a simple but robust "base contract", which all PCTs and dentist should have in place by April 2005.
Dentists' gross earnings will be protected for three years from April 2005, and will be assessed on the most recent gross earnings, and we are in discussion with the dental IT system suppliers in preparation for that change. More detailed proposals have been sent to the BDA in recent days, which hon. Members may not have caught up with yet. That would be understandable.
The main issue, which is difficult to address locally, lies with work force numbers. It has proven very difficult to attract new dentists into the East Devon area, either for GDS or salaried posts in the dental access centre. There are a number of unfilled posts across the South West Peninsula area. Numbers of dentists in the general dental services nationally are now fairly stable after steady increases for many years, but the current GDS system has provided no method of securing any overall increase in the volume of NHS treatment provided by an increase in the work force. That underlies the need to move to the new contractual framework that I have set out.
The review that was undertaken in response to the Health Committee report fully involved the dental profession—professional bodies, the BDA, dental academics and so on. We expect to announce the outcome of that review shortly. We are taking measures to sustain NHS dentistry until implementation of the Bill allows the NHS to address local historical anomalies. Last August we announced additional funds to support PCTs as they get to grips with the new agenda. We have established an NHS dentistry support team backed by £9 million to help PCTs tackle local access problems in the run up to local commissioning in 2005.
Last September we announced additional funding of £65.2 million to support change and help improve access quality and choice for patients. That funding is now being targeted at PCTs where access is a real problem: £35 million is being used to enable PCTs to improve access, choice and quality for patients, £30 million is being used for information technology to integrate dentistry, and £200,000 is being used to develop dental leadership skills. That funding comes on top of the £9 million that I mentioned. A further £15 million of revenue in 2004–05 for access was announced on 25 November 2003.
Of course, the hon. Gentleman has brought to our attention the local position in East Devon. In my early remarks, I noted that there was a high level of discontent with the current arrangements. Dentists tell us that the current remuneration system feels like a treadmill, it is the main cause of dissatisfaction amongst dentists and patients, it is regarded as inefficient, and it leads to poor-quality services. It is the main barrier to dentists agreeing to undertake NHS work. Notwithstanding that, the hon. Member for Tiverton and Honiton (Mrs. Browning) has spoken about the availability of dentists in parts of her constituency. The picture is not universally difficult, even in East Devon.
The new legislation will establish a new foundation for taking forward NHS dentistry by agreeing longer-term contracts between PCTs. I am aware that the East 461WH Devon PCT is working on a plan to improve access to NHS dentistry in its area. Over £1.5 of the access money that we have announced is available in the South West Peninsula strategic health authority area. How that money is to be used to improve access is a decision for the NHS to take locally.
Finally, an increasing number of dentists committed to providing NHS services have indicated that they cannot wait until April 2005 to move away from the treadmill that I mentioned. PDS pilots offer PCTs and dentists an opportunity to experience the new ways of working in advance of the implementation of the Act in April 2005.