NHS: Dental Services
Baroness Thornton (Baronesses in Waiting, HM Household; Labour)
My Lords, I thank the noble Lord, Lord Colwyn, for initiating this debate. It has been an interesting discussion featuring our two dental experts, including the noble Lord, Lord Roberts, who seems to be working very hard today. I thank all noble Lords who have participated for their informed, interesting and varied contributions. I shall attempt to address the questions that have been raised but, should I fail to do so, I will write to noble Lords.
From the outset, it is important to say that our record on dentistry is strong, so I refute the suggestion from noble Lords that the system is failing, and I shall say something in support of that. England is a leader within Europe in improving oral health. According to the World Health Organisation database, our 12 year-olds have the best oral health in Europe, measured by decayed, missing or filled teeth.
Through the 11 per cent increase over the current year, our dental funding allocation for the NHS in 2008-09 will be £2,081 million, net of patient charge income. Therefore, this Government are demonstrating their commitment to improving access to dental services. That figure is 56 per cent higher than the net spend on dentistry in 2003-04, and more than double the equivalent spend in 1997-98— an increase of 117 per cent.
We are increasing our dental workforce. In July 2004, we launched Project 1000 with a commitment to recruit the equivalent of 1,000 more dentists. In fact, we exceeded that target. By October 2005, we had recruited the equivalent of 1,453 new whole-time dentists, including those returning from employment breaks and overseas dentists. We have also raised the number of dentists in training by 25 per cent. The first new cohort of additional students will graduate next year. We have established two new dental schools. We now have more than 4,000 more dentists than there were in 1997 and 300 per cent more dental care professionals. To ensure that the additional dental students will be able to pursue their careers in the NHS, last month we announced that new funding of £32 million will be made available to fund more vocational places. I hope that that addresses some of the concerns expressed by the noble Baroness, Lady Gardner.
The Government's starting point is to begin to rectify the longstanding access issues caused by the previous system, described so ably by the noble Lord, Lord Teverson. Thus, through the changes introduced in April 2006, we have given the local NHS the power to control its local services. Under the 1990 contract, if a dentist reduced or stopped his or her NHS work, there was very little that the local PCT could do to replace the lost services. Under the new system, the funding for that service remains with the local NHS, enabling it to build and plan a sustainable service to meet the local needs of the population, rather than the piecemeal system we had before.
We have radically simplified the patient charging system, to which reference has already been made, scrapping the confusing tariff of 400 charges under the old system. Now patients' treatment falls into one of three clear payment bands for courses of treatment, on which noble Lords have expressed some doubts, rather than fees for each item of service. We have reduced the maximum charge from £384 to £198, directly benefiting those with poor oral health. The reforms have also allowed us to remove the exclusive focus on active treatment and allowed dentists to concentrate more on preventive treatment.
The noble Lords, Lord James and Lord Teverson, both raised the issue that the new system has merely swapped dentists from one treadmill to another. This misrepresents the nature of the reforms. In fact, the noble Lord, Lord Teverson, did not make that criticism. For many years, dentists had complained that the old fee-per-item system created a treadmill effect and gave no time for preventive care. The new system, which we developed in close consultation with the British Dental Association and other stakeholders, guaranteed dentists the same income for delivering 5 per cent less activity than they did during the reference period. That enabled dentists, without any financial penalty, to spend more time on preventive care.
The noble Lord, Lord Colwyn, asked why the Government's view of the reforms appears to be out of step with some of our stakeholders. I am not going to pretend that everyone is happy—clearly, that is not the case—but with any major reform there will be people who will be unhappy and for whom it will take time to recognise the benefits of the new system. However, the citizens advice bureaux have stated publicly and repeatedly that they welcome the reforms and regard them as a sound basis on which to build dental services.
I suggest that lots of committed NHS dentists have realised, as the reforms have bedded down, that this is a workable system. The commitment that the reforms represented to NHS dental services is something that mainly private dentists may be uncomfortable with because if they have business models based on a local shortage of NHS services the resurgence of the NHS on dental services will, rightly, challenge them.
The general welcome for the 11 per cent funding uplift, the clear upsurge of interest from corporates in providing NHS services, and the fact that PCTs generally report no difficulty in attracting dentists to provide new services suggest a rather different picture from the one in the headlines. Tackling the problems that began in the early 1990s will not be an overnight job, but the Government are very serious about getting NHS dentistry back on track.
As I have mentioned, we appreciate just how big a change the reforms were for PCTs and the dental profession alike, and we have continuously offered support during this process. The noble Lord, Lord Colwyn, is correct to say that those local relationships lie at the heart of the improvements that need to take place.
As well as making year-on-year increases in the funding available to PCTs to commission dental services, we have made increasing access to dentistry a national priority in the 2008 operating framework. We have also extended the ring fencing, mentioned by several noble Lords, of dental funding to 2011. I will address the issue raised by the noble Earl, but I shall take some time to explore what seems to be a misunderstanding by some PCTs on the position. I promise to get back to him on that. We are seeking to offer commissioners further stability when planning their dental services over the next period.
I hear the concerns raised by the noble Lord, Lord Colwyn, and others about PCT funding. Dental budgets are now allocated net of patient charge income for good reason. The reforms give local control and management of NHS dentistry to PCTs so that they can determine what dental services are commissioned in their area. But as the amount of patient charge income is largely determined by what services are commissioned and how those services are delivered, it makes sense for the local body to oversee the whole dental budget. We cannot plan centrally for the effects of such local decisions. For example, a local decision to prioritise orthodontics or other services for children will directly affect patient charge income and needs to be based on local priorities and assessment of needs.
Patient charge revenue was reduced in the first year of the new system. It is too early to measure the settled-state level of patient charge income under the new system but the indications are that 2007-08 will see patient charge levels closer to those predicted. We have provided guidance and data to PCTs to help them and their dentists understand the local factors affecting levels of charge income and to help them correct any problems that may have arisen as the new system was bedding down. We have also provided, and continue to provide, practical support and guidance to PCTs on commissioning appropriate dental services. These have been both direct from Department of Health officials, including the chief dental officer, and through the primary care contracting team, who are experienced NHS managers providing hands-on, tailored support to PCTs as well as a whole suite of guidance available to all dental commissioners through the website. For example, we will shortly be issuing updated guidance to PCTs on handling end-of-year issues with their contract holders, which I know is an issue of particular interest, as has been mentioned by noble Lords several times during the debate.
Annual service levels are agreed between the PCT and the dentists at the beginning of the year for all existing dentists and will be based on the actual patterns of service the dentist provided under the old contract. Ninety-seven per cent of contracted activity was delivered in the first year of reforms. Indeed, Suzie Sanderson, chair of the British Dental Association's executive board acknowledged that in the press release issued on the subject. She said:
"We know from our own research that many primary care trusts have shown understanding when examining end of year issues."
The BDA's own research showed that in 25 per cent of underdelivered contracts, PCTs had written off the shortfall entirely. However, PCTs have the responsibility, as the local commissioners of dental services, to use flexibility and choice within the new contract to handle such end of year issues as they feel appropriate. If they feel that necessary resources are not being used effectively they can re-invest them in other local dental services to help ensure that patient demand is met.
On the flipside, I heard the noble Lords, Lord Colwyn and Lord James, describing practitioners with the reverse problem of delivering all their contracted activity before the end of the year. The only reason that they would have to shut up shop early and head for the golf course, as the media have recently reported, and which the noble Lord, Lord James, mentioned, would be if they were spending less time with their patients than they had done previously. PCTs have the flexibility to increase contracts where this is appropriate and have guidance on providing alternative care to any patients affected by a dentist meeting his contract too early. While we are not content when even a single patient remains affected, we are pleased to say that anecdotal reports suggest that this has been far less of an issue this year than it was last year. PCTs have used the support I have just outlined greatly to improve the provision of services across the country.
For example, the community dental access project set up by Tower Hamlets PCT in 2003 brings the dentists to the community through a range of dental services. Tower Hamlets has historically been an area of poor oral health and low uptake of dental care. The project, which has been developed at every step with the local community, uses a fleet of mobile dental surgeries to travel out into the heart of the community to locations selected by the local community. Both screening and treatment services are offered and the project uses link workers to help local people understand their dental treatment and how to access care.
The project has brought dentistry much closer to patients and the mobile services are very popular, with sometimes 100 people being screened in a day at a community event. However, I can assure noble Lords that the Government are not looking through rose-tinted spectacles, and we know that we still have work to do to ensure that everyone in this country who wants to see an NHS dentist can do so quickly and easily.
Several noble Lords said that the number of patients accessing NHS dental care has dropped by 0.5 million in the 24-month period ending September 2007 compared to the 24 months ending March 2006. I need to make it clear that these figures do not reflect the current situation. The noble Earl referred to the figures. The most recently published figures cover September 2005 to September 2007. Around 4 per cent of services had to be replaced during 2006 when the reforms were introduced, equating to around 960,000 patients. The statistics show that drop.
I am pleased to say that the current picture is far healthier with access improving as new services open across the country. We know that PCTs across the country are commissioning new and expanded services and that there is no shortage of dentists putting themselves forward for these new contracts. Furthermore, the majority of PCTs now run dental access helplines quickly to match up patients seeking NHS care with the services available. However, because the data available are retrospective and look back over the previous two years, it will take a little more time for the current growth in access to work its way into the figures for the loss of service immediately after the 2006 introduction of the new system.
Several noble Lords mentioned surveys that show a bleak picture. Without going into too much detail, there are surveys and surveys; it is a mixed picture. The Citizens Advice/MORI survey indeed showed a need to improve access, but in publishing the survey, Citizens Advice also welcomed the extra investment that we are making precisely to that end.
The Greater London Authority survey published in November concluded that London is well served by NHS dentists and found that, although the majority of dentists said that they were willing and able to take on new NHS patients, there was a problem in persuading some groups in society to come forward for treatment, which is why I so warmly commended the Tower Hamlets outreach service. In other surveys, the Commission for Patient and Public Involvement in Health survey was based on a self-selecting sample. As a result, those findings must be open to question. For example, the claim that six per cent of the population has resorted to self-treatment would mean that 3 million people had done so, making DIY dentistry marginally more popular as a pastime than freshwater angling. I suggest that that is probably not the case.
My key point is that primary health care trusts are commissioning new services now. We are starting to see reports in local newspapers that reflect that from places as far afield as Gainsborough, Wantage, Newquay, Plymouth, Norwich and west Essex—the sort of places where access problems have been most acute.
The noble Baroness, Lady Finlay, and others, raised the issue of hospital admissions for dental problems. I will not repeat myself by talking about the new services being commissioned, but I am sure that noble Lords will be interested to hear that the proportion of all dental admissions that were emergency admissions has dropped from 8.1 per cent in 2005-06 to 7.4 per cent in 2006-07. The article used the overall rise in emergency admissions, while omitting the fact that, as a proportion, dental admissions were down.
However, dealing with access is only one part of reforming the NHS. We need a quality service. The noble Lord, Lord Colwyn, raised the issue of the NHS next stage review and how dentistry fits into it. In 2007, my noble friend Lord Darzi invited stakeholders, including the British Dental Association and the General Dental Council, to submit their policy ideas to the review. They responded to that invitation and attended the national stakeholder forum to discuss their concerns.
The noble Lord, Lord Colwyn, also asked why the Patients Association poll of MPs showed that dentistry topped the concerns in correspondence. I acknowledge that there are concerns about access to dentistry; that is what this debate is about. In fairness, there are some long-running problems. As I said, our increased spending on dentistry and the inclusion of dentistry in the NHS operating framework is starting to address that issue.
The noble Lord, Lord Roberts, raised the issue for Wales. As he will be well aware, dentistry in Wales is a matter devolved to the Welsh Assembly, so I have confined myself to issues concerned with English dentistry. The noble Baronesses, Lady Finlay and Lady Gardner, and the noble Lord, Lord Roberts, raised the issue of the proportion of adults and children who have no access. There has never been a time when more than 60 per cent of the population was in regular touch with an NHS dentist. My noble friend Lord Desai explained why that may be the case. That is almost certainly not a satisfactory position, but back in 1993, when there was no access problem, 40 per cent of the population chose either to go private or to go less regularly than every two years. We are determined to increase access: that is now an NHS priority. We need to be clear about the number of people who are using NHS dentistry.
The noble Lord, Lord Roberts, talked about charges and whether they should be scrapped. We think that it is better to have a system that exempts people in hardship from payment while charging those who can afford to pay. I should make it clear that half of all NHS patients in England are exempt from charges.
The noble Lord, Lord Roberts, and the noble Baroness, Lady Gardner, raised the issue of dentists needing to be adequately compensated for NHS work. The figures from specialist dentists' accountants show that NHS dentists' earnings have increased since 2005-06. Single-handed dentists now earn more than £100,000 a year. Indeed, dentists' expenses have fallen because the proportion of complex treatments has fallen, as we expected, under the new contract.
The noble Lord, Lord Colwyn, and the noble Baroness, Lady Gardner, raised the issue of income guarantee for dentists. Existing dentists' gross income was guaranteed for the first three years of the new system, but where practice has changed and dentists' costs have gone down, it is right that the PCT can renegotiate. The extension of the budget ring-fence shows the Government's commitment. Within this, the NHS is entitled to expect a fair price for a quality service.
The noble Baroness, Lady Gardner, raised the issue of the claw-back of funds because of the income guarantee. Dentists were guaranteed no less income than they earned under the old system. Activity is set at a level delivered under the old system, so if they do less work now—in other words, if they do not do the work that they have agreed to do—the NHS rightly reserves the right to ask for funds to be given back.
The noble Baroness, Lady Gardner, also raised the issue of dental products and lead in imported fillings. I recognise her concern, but I should add that dentists are responsible for the quality of the materials that they use and, as she will know, they must satisfy themselves that the products they use are of the required standard.
My noble friend Lord Desai was the one person who mentioned school dentists. In 2006, the National Screening Committee considered research into school dentistry and discovered, unsurprisingly, that middle class children were generally registered with a dentist, and that the parents of children in more deprived circumstances often failed to act on the advice that had been sent from schools and those children remained untreated. On the basis of this advice, we believe that the most effective method of improving the oral health of children is not the re-establishment of the school dental service but a combination of population-based inventions, such as water fluoridation—I am pleased that no one mentioned that today, although I have two pages on it—toothpaste schemes that build on the Brushing for Life initiative, improving access to NHS dentistry generally, and running campaigns that encourage families with children to visit their dentist regularly.
The noble Baroness, Lady Finlay of Llandaff, in her usual erudite and informed contribution to the debate, raised a number of important clinical matters, including patients with muscular dystrophy and cancer and the detection of oral cancer. With her permission, I will explore those and come back to her.
The noble Earl, Lord Howe, talked about the number of dentists and the fact that not enough are coming forward to do NHS work. In fact, PCTs at present report no shortage of dentists seeking to expand their NHS activity. For the first time in decades, dentists are competing to provide NHS care. It will take time for the new money to feed through to the new services, but it is not true that recruiting is the problem. The noble Earl highlighted the need to ensure that the money is effective, that it is going to the right places and that we are monitoring it in the right way. We all need to watch that.
The noble Lord, Lord Teverson, said that he felt fear coming into the Chamber, given that two dentists are present. I did not, because I have always had very good experiences with my dentist. The hygienist is a different matter, but it is probably better that we do not go there at this point.
I conclude our discussion today by reinforcing the point that the dental reforms of 2006 were an essential step towards solving the problems created by a previous treatment-focused, provider-led scheme. The reforms for the first time put the power into the hands of the local NHS to plan and to provide dental services to meet the local needs of the population. I reiterate our commitment to improving access to NHS dentistry. I thank the noble Lord, Lord Colwyn, again for bringing this subject to our attention and I thank all noble Lords for contributing to today's debate.