I beg to move
That this House takes note of the First Report and of the Ninth Special Report from the Estimates Committee relating to the Dental Services
I think that I should make one or two comments of a general nature before I deal specifically with the matters contained in these Reports, Although this is the first time that an investigation has been made by the Estimates Committee into the dental service, it is not in any sense comprehensive. It does not deal with the problems of remuneration of dentists. It deals only to a limited extent with one of the general problems that afflicts the dental service, namely, the shortage of dentists, and it does not deal with matters of the character of fluoridisation, because that does not come into the remit to the Estimates Committee.
One of the problems of dealing with dental matters is the nomenclature of the various bodies which are concerned with the administration of the service. The first body is the executive council, which operates as a health organisation, and which is not only concerned with dental matters but also medical matters. The point that is made about the executive councils is that they vary considerably in size, and it is recommended that those councils should be reviewed. When we find, as we do, that there may be as small a number as seven or eight dentists in one executive council and a number as great as 300 in another executive council, it seemed to the Committee that this matter ought to be reviewed with the idea of rationalising the situation.
It is, of course, realised that that could have implications on the medical side with which we are not directly concerned. The executive council has a duty to appoint a dental service committee which deals in the main with cases of those who are in breach of the terms of service. Generally, there has not been an extended amount of work in connection with these breaches.
The dental service committee comprises a chairman, three lay members and three dental members. At first sight, one would think that that was an adequate organisation to deal with the problems of breaches of terms of service. But there has been grafted on to the service procedure under Regulation 19 of the National Health Service Regulations, 1956, which may operate through what is called a local dental committee. This committee is composed entirely of members of the dental profession.
If any question of over-prescribing of dental treatment arises—which one would think a breach of the terms of service—it may be reported to the Minister who may decide to deal with the matter either through the regional dental officers or through the local dental committee. The Estimates Committee considered that this was a duplication of the work done by the dental service committee and as there is another alternative method which enables these matters to be referred to the regional dental officers, procedure other than Regulation 19 would be adequate to deal with cases of over-prescribing.
As I have said, the executive councils are very small. A situation may arise where only five or six dentists are available to serve on the local dental committee and they would know only too well the gentleman whom it was suggested was over-prescribing. There is an additional and fundamentally an estimate reason why the Regulation 19 procedure should be abolished. Twenty-seven people are employed in connection with that compared with 31 employed on the normal investigations. As a result of their research only 8 out of over 100 cases have been referred to the local dental committee under Regulation 19. In those circumstances the Estimates Committee feels strongly that this is only complicating the nomenclature of the service. It achieves no useful purpose and, to some extent, involves unnecessary expense.
I do not propose to go in detail through all the recommendations. But I should like to say something about the Dental Estimates Boards, the bodies which sit in Eastbourne for England and Wales and in Edinburgh for Scotland. A considerable amount of evidence was placed before the sub-committee which investigated this matter, and a visit was paid to Eastbourne. Quite a large amount of work goes on there. Over 15 million cases were dealt with at Eastbourne and 1½ million at Edinburgh. Although a substantial amount of money was being spent we were satisfied that on the whole it was being well spent. But the Committee was anxious that, if a commuter system could not be provided, there should at any rate be some sort of system arranged to save the work being done manually by the servants of the Board.
The fact that 15 million cases are dealt with makes it clear that this is a big job and worthy of careful investigation to see whether some form of mechanisation could be used. We ask that further consideration be given to some mechanical arrangement, i.e., punch card, etc. We did not feel competent to make any detailed recommendations. But we thought it appropriate to make a recommendation that there should be outside help to deal with this matter, which would appear to raise more unusual commutation problems than usual.
In addition, and perhaps more fundamentally, we take the view that consideration should be given to the amalgamation of the Edinburgh and Eastbourne bodies. We consider that the addition of 1½ million to the 15 million to 16 million cases dealt with at Eastbourne would not involve any great increase in overheads at Eastbourne. Obviously, there would be a saving in the total by such an amalgamation. The best situation for a joint board would have to be considered. It was thought by some that the North-East Coast might be an appropriate place. There was a suggestion that the saving would be small. But the Committee was of opinion that it would be quite substantial. It would, of course, be even more satisfactory to have the boards joined if some system of mechanisation such as I indicated just now could be employed.
Finally, I wish to deal with what I consider the most important part of our recommendations, putting dentistry into the position which it ought to occupy. Generally speaking, we found that the National Health Service dental work was reasonably satisfactory. I am pleased that the suggestion has been accepted that more information should be given on the medical cards of those who come to the National Health dental service for treatment. The Committee heard of a number of cases where there was doubt whether someone coming for attention would get an advantage if his teeth were not attended to under the Health Service, but privately.
This is a problem which I believe is inherent in the present set-up on the Health Service side. But suitable statements on the medical cards of those who go to the dentist under the Health Service might very well deal with that. That, however, is really not what seemed to the Committee to be the unsatisfactory aspect of the service.
What deeply concerned the Committee was the school dental service. It seemed that almost everywhere we turned there was evidence of lack of drive and knowledge of the responsibility and importance of this work. A memorandum on the service in England and Wales said that the aim was
…to inspect every child annually, to offer treatment to those who need it, and to provide treatment for all who accept the offer.
This ideal cannot be attained under present conditions. Table B shows about half the number of children in maintained schools are inspected each year, and that rather more than half of those who are found to require treatment actually receive it through the school dental service. Table B also shows that the percentage of pupils treated as compared with the number of children in maintained schools has fallen. In 1938, it was 32·1 per cent. but perhaps the 1947 figure would give a better picture. Then it was 29·7 per cent. Now it is 17·4 per cent. This is very disturbing in itself, and it is particularly so because there is no tie-up at all with the Health Service.
That column shows that the percentage of pupils who require treatment and who receive it has gone down from 73·7 per cent. in 1947 to 51·25 per cent. Thus, on any basis substantially fewer children are being inspected and treated.
We cannot be satisfied with such a situation. I do not suggest that it can easily be remedied. Productivity in dentistry occupied our consideration for a long time and the available figures do not clearly indicate where the trouble lies. Possibly it is a general malaise. There was a suggestion that some of the dentists in the school dental service were older and less able to take advantage of new techniques, but we could not find a satisfactory explanation.
I want to pay tribute to our witnesses for their extreme helpfulness. But we found that those from the Ministry of Education were rather inclined to take this matter as being purely one for the local authorities. We certainly want the local authorities to play their part, but they must be given guidance and in this case there has been very little. I think I am correct in saying that only four or five circulars dealing with the school dental service were issued by the Ministry of Education to the local authorities between 1944 and 1962, when we started our investigations.
What is needed is more drive. This is really at the root of many of our troubles in dentistry. When young people's teeth are not properly attended to, this leads to a great deal of trouble later in life. We do not consider that the present arrangements between the Ministry of Health and the Ministry of Education produce the essential drive. We have, therefore, recommended that responsibility in this important matter should be transferred from the Ministry of Education to the Ministry of Health.
We consider that the admissable regional dental officers, who normally deal with Health Service matters, and who are, everyone agrees, very competent, should be the persons responsible for invigorating the school dental service. We are satisfied that some local authorities are doing a really good job but we found that there must be very many who are not.
I draw the attention of hon. Members to Recommendation No. 10, in which we stated:
The regulations concerning dentists employed in health centres in England and Wales should be amended so as to provide that the duties at present carried out in respect of these by the Regional Dental Officers should be carried out by the Dental Estimates Board.
That was turned down by the Ministry in words which are rather interesting, for the Department stated:
The duties carried out by the Dental Estimates Board in respect of general dental practitioners are designed to promote good practice in a service where remuneration is by items of service,
That is exactly the position in the school dental service. Remuneration is by way of items of service. In the view of the Ministry of Health, the Dental Estimates Board is not so well placed to carry out the very different duty of supervising and stimulating the work of a salaried dentist. The Ministry stated:
So long therefore as dentists in health centres are remunerated by salary he"—
that is, the Minister—
considers that the present arrangements, which imposed this duty on his Regional Dental Officers, ought to be retained.
I urge that when the review of the regional dental officers' work is being undertaken—and we have been promised that this will happen—consideration will be given to this important matter of getting their help in the school dental service.
It is an extraordinary thing that, with 7 million children throughout the country, we had evidence before us from the Ministry of Education to show that their Ministry had only one dental officer to look after them all and that he preferred to call himself a medical officer. This is an indication of the Cinderella position of the dental services. We on the Estimates Committee hope that some of the facts we have adduced will be of help in considering these important matters.
I am sure that all hon. Members will wish to join me in congratulating the hon. Member for Aldershot (Sir E. Errington) not only for his speech in introducing the Report, but on having chaired the sub-committee which carried out this valuable and thorough investigation into the administration of the dental services.
The Estimates Committee is traditionally concerned with effecting savings, but those who have had the honour of serving on it know that the Committee interprets this in very wide terms and that it is no less concerned with promoting the efficiency of the services under examination. I believe that on occasions the Committee has recommended actual increases in Government expenditure in the short term to bring about long-term savings.
The Estimates Committee is not concerned with policy and I am sure that it is because of this that we have the rather limited nature of the recommendations in the Report we are considering. I have done some arithmetic on the subject and have discovered that of the 23 recommendations in the Report most are of a minor character, while three or four are of real substance.
We also have under consideration the Ninth Special Report of the Estimates Committee which incorporates the observations of the Health Ministers on those recommendations. Out of the 23, nine have been accepted, nine rejected and the remaining five not rejected, not accepted, part-rejected, part-accepted or even deferred. It seems that all the recommendations of any real substance have been rejected.
This is not the way to treat the Estimates Committee. I would be the last to suggest that every one of its recommendations should be mandatory. That would be ridiculous. However, they should carry more weight with Government Departments and Ministers than they appear to have done in this case. In general, the Committee's arguments in favour of its recommendations are more cogent than those of the Health Ministers in rejecting those they have rejected.
Following the example of the hon. Member for Aldershot, I will take the school dental service as an example. No one can be satisfied with the present state of this service. That there is a very serious staff shortage is admitted in the joint memorandum of the Ministry of Education and Ministry of Health and this is dealt with in more detail in the Association of Municipal Corporations' memorandum, in which it is stated:
…the present staffing of the school dental service is dependent on an increasingly ageing permanent cadre (some of whom have already reached retiring age or are within a
year or two of it), a high proportion of part-time dentists working on a sessional basis and new entrants to the profession, who normally remain in the local authority service for a very short time until they are able to establish themselves in private practice. Part-time dental officers, often married women with domestic responsibilities, mean that the dental service frequently has to be organised on a sessional basis which cannot correspond to full-time clinics. This contributes to lack of productivity.
Admittedly, numbers in the school dental service have risen in recent years, but the rise has hardly, if at all, kept pace with the rise in the school population and the situation is certainly no better than it wasten years ago. The memorandum suggests that, ideally, there should be one dentist to 3,000 children if the school dental service is to be run efficiently. The table in the Report shows that at present we have one to every 6,588 children. In other words, according to those who are running the service we have substantially less than half the number of dentists needed. This is no occasion for complacency.
The Committee's recommendation No. 19 states:
The responsibilities for the School Dental Service…at present exercised on behalf of the Minister of Health by the Minister of Education, should be assumed by the Minister of Health.
As the hon. Member for Aldershot reminded us, that recommendation was saying that the Minister of Health should assume full responsibility for the school dental service, which responsibility is at present shared by him with the Minister of Education. It was a modest proposal and the arguments in support of it were convincing. However, it was too revolutionary for the Minister of Health who, I sometimes think, is the only true Conservative left in our midst. That recommendation was rejected out of hand.
It is arguable whether the school dental service should continue in its present form and whether it is the best method of deploying the dental skills which are in extremely short supply. It is essential that special attention is paid to schoolchildren's teeth and that every effort is made to combat dental neglect when it occurs—and it occurs all too often. Nevertheless, the present system seems to cut across the lines of the general dental service and could lead to overlapping and confusion. I can confirm this from the experience of my own family. The profession as a whole is unenthusiastic, to put it no higher, about the organisation of the school dental service, and many dentists believe that better results could be achieved by a quite different administrative structure. That involves wider considerations on which I hope to touch later.
Recommendation No. 3 proposes areview that would lead to the consolidation of the areas covered by executive committees, so that these committees would not necessarily cover only one local health authority area—the almost invariable case at present—but might cover two or several areas. That would not require any new legislation; the Minister of Health already has the power under, I think, Section 31 of the National Health Service Act, to set up these larger areas.
The case for such a reorganisation goes far beyond the dental services, but I believe that the arguments adduced here apply with no less force to the general medical services and the general pharmaceutical services. There might be considerable advantages in reducing the number of executive committees for all purposes. That, apparently, was too radical a solution for the right hon. Gentleman, who says, in the Ninth Report that it would not save very much, and might, in any case, happen in a decade or two if we have regional local government. That means that we are not even to get a review of the situation.
The proposal that the two Dental Estimates Boards—for England and Wales and for Scotland—should be merged met with a similar negative response on the part of the Departments concerned, despite the obvious advantages.
It is a very long time since the House discussed the dental services, and I want now to widen the debate rather beyond the immediate scope of the Report of the Estimates Committee and to raise one or two issues which, although not directly related to the Report, are referred to both explicitly and implicitly in the evidence.
The Minister may not realise that there is a great deal of malaise in the whole dental profession at this time, and a good deal of public dissatisfaction, too, with the dental services as they are now functioning. To a large extent, though not entirely, these symptoms derive from a single cause—the acute shortage of dentists in all branches of the service. I do not think that that is disputed by anybody. It is certainly admitted in page 363 of the memorandum on dental manpower, and it is frequently referred to in the evidence before the Committee.
The McNair Committee, which reported in 1956, recommended that the output of the dental training schools should be increased to at least 900 annually, compared with the current figure of about 560—in other words, almost a 100 per cent, increase—and that that output of 900 trained dentists a year should continue until the dental register reached a figure of 20,000, which is the equivalent of a 25 per cent. increase on the strength at that time and a 20 per cent. increase on the present strength.
Government action on that Report has been dilatory in the extreme. They can now tell us that plans are in hand for the expansion of existing training schools, but it is quite clear from this Report that the work on expanding these departments will not be completed until well after 1968. That, in turn, means that the output will not reach the McNair annual target—which the Estimates Committee now suggests may well be inadequate—until about 15 years after the McNair Report. The target for the dental register will not be reached for many years after that—probably not until the late 1970s.
What does this shortage of dentists mean? It means, as we have shown, an inadequate school dental service. It also means an understaffed—and, I think, an under-developed—hospital dental service. It means the virtual absence of any emergency service, and it means the serious neglect of such underprivileged groups as the mentally disordered, the elderly and the chronic sick, in hospitals and institutions. It also means an excessive load on the general dental service, which sets up pressure that drives even conscientious dentists in general practice to confine their work to simple straightforward treatments and rather to neglect the more complex, time-consuming treatments which a patient's dental condition may really need.
This position sets up a feeling of disappointment and frustration in the profession. That is inevitable when we get highly-qualified professional men devoting 90 per cent, to 95 per cent. of their time to purely routine work and, by the nature of the service under which they work, virtually unable to exercise to the full the skills and techniques which they labouriously acquired during a long period of training.
It is not only pressure of work that brings about that situation. It is also the functioning of the Dental Estimates Board. The Estimates Committee's Report devotes many paragraphs to the Board, and gives it a reasonably clean bill of health. Most of us would agree with the verdict that the Board carries out its work with considerable efficiency. Equally, one must agree that some such organisation is necessary in the interests of the taxpayer and the Exchequer. As long as we have the present basis of dental remuneration, which involves some direct financial incentive, there must be a check of this kind.
Nevertheless, from conversations and correspondence I have had with dentists, I find that there is considerable dissatisfaction with the working of the Board in certain respects and, more particularly, with that part of the Board's operations concerning prior approval of treatments. The Report itself mentions a growing tendency of the Board towards more and more clinical interference with dentists' work. That is certainly borne out by what I have myself heard.
One of the things that irks dentists is that there is, apparently, a set of rules at the Board which enables clerks to approve a certain proportion of the estismates requiring prior approval. That set of rules is kept quite secret from the profession, and so is the Board's pricing system. The dentists, very naturally, ask why this is not published—
I am very glad to know that, at least, the Estimates Committee saw it. My point is that if a set of rules that enables a clerk to approve estimates were published there should be no need for prior approval, because the dentists themselves would know what they could do within those rules which would receive final approval after treatment. I should have thought that that was an effective and safe way of cutting down the number of cases requiring prior approval.
I have also had a number of complaints about such things as chrome cobalt dentures, which very experienced dentists consider to be necessary for their patients. The Estimates Board often turns this down as luxury treatment. I have had complaints about general an aesthetics which have been disallowed by the Board, and dentists ask"How can a Board, sitting in Eastbourne, know what my patients need in the way of an an aesthetic?" This is a matter which should surely be left to the clinical judgment of the dentist. One must ask whether there are not dangers in curbing excessive treatment too much and whether the Dental Estimates Board is not in danger of imposing inferior standards of work and treatment upon the profession.
At any rate, there is some friction and resentment in the profession towards the Board at present. It is not enough for the Minister—as he may well do—to point to the comparatively small number of refusals of approval, or to the even smaller number of appeals, because an experienced dentist knows very well what will or will not get by and he will not waste time in fruitless argument with the Board which will almost certainly end in defeat for him.
Does not the Minister think that the time has come to take a long hard look at the dental services? I do not want to make any specific proposals for changes this morning. I would prefer to put a few questions to the Minister and perhaps indicate one or two possible lines of inquiry. Is the right hon. Gentleman satisfied, for example, that the fee per item system of remuneration is fair to the practitioner, economic from the taxpayer's point of view and good for the patient? In other words, does it encourage the best standards of dental practice? If the answers to these questions suggest that a change of some kind might be desirable, I would only say that there are many indications that the profession, in its present state of mind, is ready to face quite radical changes in the services.
Has the Minister or the Dental Estimates Board taken fully into consideration the enormous increase in a dentist's potential output which has resulted from the installation of modern equipment and techniques, and, in particular, the high-speed drill developments which probably date from not much more than the last five years? I have made inquiries, because I have had much correspondence, and I have found nobody who suggests that the high-speed drill does less than double the number of fillings which could be done with the older traditional method in the same time. One dentist told me that a procedure which used to take half an hour now takes one minute, with no reduction in the standard or quality of the work.
In circumstances like this, how realistic are the current piece-work rates, so to speak, which are designed to produce an average net income of about £2,500 per annum? I am told by one of two dentists and a hygienist working together that they can gross £100 a day comfortably on National Health Service fees alone without any strain and doing work of the highest standard. If it is true—and I see no reason why a dentist should tell me if it were not true—it means that these dentists are earning not £2,500 each but substantially more than £10,000 per annum if they are doing a full week's work. Is the system geared to cope with this situation? Is the Estimates Board forced to be too rigid in its methods? Is this system the best way of remunerating a dentist in general practice?
Is it not also time that we looked at the definition of dental fitness under which the Estimates Board operates, which, I understand, is
such a reasonable standard of dental efficiency and oral health as is necessary to safeguard general health."?
Is not this a rather minimal standard? Could we not aim a little higher and revise the definition? As one dentist said to me,"You could certainly conform to the existing standard by having no teeth at all."
I turn now to the problems of the dental ancillaries who potentially could contribute so much more to the service than they are doing. Why have we so few dental hygienists? One learns from the Report that 350 have been trained and have obtained a certificate, but only 108, or less than one-third, are enrolled with the General Dental Council and entitled to practise. Is this a question of remuneration? Are they getting trained and then, for one reason or another, leaving dentistry? Or is it that there are not enough group practices? Presumably only a group practice can afford to employ a full-time hygienist Are we giving sufficient encouragement to group practice in the service?
There is also the question of dental auxiliaries, who were introduced so very cautiously. I do not blame the Minister or his predecessor for that. I know that there were great difficulties with the profession. We are now in the first experimental period, which will end next year, and then there will be a report by the General Dental Council on the working of the auxiliaries. Assuming that the report is favourable—and I have no reason to think that it will not be—are auxiliaries still to be limited to the school dental service? One dentist said that if we are to accept people of lower skills it is far safer that they should operate on adults rather than children. I hope that auxiliaries will be encouraged as at any rate one way of mitigating the shortage of dentists.
Lastly, on ancillaries, there is a serious situation in respect of dental technicians. Many are leaving the craft and it is not surprising when one considers the technician's pay and status. A fully trained technician receives barely £600 a year and a senior technician not much more than £700. There is no scheme for registering technicians, which many have been pressing for for a long time. One scheme was prepared in consultation with the British Dental Association, but then the association withheld its support for it and, as far as I can see, the scheme has foundered for the time being.
Does the Minister not think that it would assist the service if dental technicians could be trained to fit as well as manufacture dentures? I believe that there are to be discussions during the next few days between officers of the right hon. Gentleman's Department and representatives of the Association for Dental Prosthesis. I hope that encouragement will be given to this development and that the Minister will not be deflected by any closed-shop mentality on the part of the British Dental Association.
There is another reason why we should encourage this, and that is that I am told that many dentists are now refusing to accept National Health Service patients for dentures at the present level of fees that they are allowed. They find conservation work alone quite sufficient to maintain the income that they need. I should like to know whether the present form of general dental practice has, in the Minister's opinion, proved appropriate to the Health Service. I think that many of us would have liked to have seen dentistry functioning at health centres, but, for reasons which are given in the Report, and which we all know, the idea of health centres never really"got off the ground".
It is a little disappointing to learn that dentistry is practised at only 11 health centres in England and Wales and one in Scotland. Would not the dental needs of the population perhaps be met better than they are at present by a system of clinics, largely based on hospitals, equipped with the best modern equipment and staffed not only with dentists but with a whole range of ancillaries, possibly incorporating the school dental service?
The Health Service has brought about a significant improvement in the dental health of our people, but, at the same time, we are still a long way from reaching the standard of dental health which is enjoyed by many comparable countries. Perhaps fluoridation will help, and I should like to take this opportunity of supporting the lead which the right hon. Gentleman has given to local health authorities to embark on fluoridation of their water supplies.
But there are those who are more pessimistic than I am about our dental health and I would remind the House that the British Dental Journal stated in December, 1961, that
dental disease in Britain is now out of control.
Those are very worrying words. At any rate, I hope that the right hon. Gentleman will agree that there is no cause
for complacency. I also hope the Minister will agree, although I am sure he will not, that this is no time for putting disincentives, such as the £1 charge for treatment, in the way of people who need dental attention.
I shall understand, of course, if he does not announce any specific changes in policy today, but I hope at least that he can say that he is considering quite objectively the whole of the present system and that his mind is not closed to change. He should be aware that there is a ground swell of dissatisfaction and frustration among the dental profession today. I am not talking so much about remuneration, because the skilled hard-working dentist with proper modern equipment and with a well-organised practice can earn a substantial income, far beyond the average net figure which was indicated by the Review Body. It is much more things like the conditions of work, the system of payment, the incentive always to do the simple patching-up jobs, the concentration on routine work and the frictions with the Dental Estimates Board; these are the things which are worrying the better type of dentist, and these are the things to which the right hon. Gentleman should turn his attention.
As I rise to my feet I am reminded of that feeling of unease and apprehension which I always experience in the waiting room before going to see my dentist. This apprehension is today increased lest, if I make any remark which my dentist might regard as derogatory to the profession, when I next see him the instrument of20th century torture known as the drill—and I fear it will not be a high-speed drill—will be relentlessly operated by my dentist.
Before I turn to these Reports I should like to make two comments. First, as a recent Member of Parliament I should like to say how much I appreciate the honour and privilege of serving on the Estimates Committee. Being apart from the bustle and the sometimes electric atmosphere of this House, it makes a most valuable and useful contribution to the work of Parliament as a whole. It is conducted in an atmosphere of co-operation and harmony quite apart from party politics. I should like to pay a tribute, therefore, to the chairman of the sub-committee and to my colleagues on it. I am sure that I learned a great deal from spending many happy afternoons considering the whole of the dental service. At the same time, one should not forget the Clerks who assist the Committee to a great extent.
I should like to reflect, however, on whether the work of the sub-committee could be improved if more assistance were afforded to us. Abroad, for example in America, there are congressional committees which vote themselves large amounts of money, equip themselves with technical staff and investigate matters much more thoroughly than we do here. I would not like to see that approach adopted in this country, but I was conscious, when we considered the dental service as a whole, of a real lack of knowledge of the technical terms with which we were dealing and the real problems of the dentists. Perhaps I may simply leave the matter there. It is a reflection, and I hope that it may fall on the ears of the Chairman of the Estimates Committee.
I was very disappointed to read this Ninth Special Report which contains the comments of my right hon. Friends the Minister of Health and the Minister of Education. As the hon. Member for St. Pancras, North (Mr. K. Robinson) pointed out, very few of the recommendations of this Committee were accepted and, indeed, those two which seemed to me to be the cardinal ones, concerning the Dental Estimates Board and the school dental service, were rejected. I agree with a great deal of what the hon. Member for St. Pancras, North said, and in particular applaud his very constructive approach to these problems. Indeed, it is a pity that the Reports from the Estimates Committee do not receive greater publicity than they do. My hon. Friend the Member for Aldershot (Sir E. Errington) referred to the fact that this was a rare occasion for debating these matters. I wish that more opportunities were available or, failing that, that more publicity could be given to the matters which are mentioned in these Reports.
I should like to turn to three recommendations of the Estimates Committee which were rejected; first, the Dental Estimates Board. I am surprised that my right hon. Friend could not see his way to agree with our recommendation that amalgamation would be desirable. Be that as it may, the Dental Estimates Board performs a very valuable function, though it is to be criticised, if at all, for its treatment of orthodontics. I was not aware of what"orthodontics" were when I started to look into this matter, and I am not absolutely certain that I know what they are now, but, broadly speaking, I understand that"orthodontics" relates to treatment rather than to extractions. The aim is to conserve rather than to do away with teeth. It is a comparatively new line of treatment and dentists have to take special courses in it. In these cases it is up to the Dental Estimates Board to give approval before a course of treatment may be given by a dentist.
The hon. Member for St. Pancras, North, referred to the feeling in the profession about this matter and I agree wholeheartedly with him. The dentists to whom I have spoken have always felt that it is somewhat odd that in a matter which involves the mouth of a patient which only the dentist himself has seen, an experienced person in, say, Eastbourne, should decide whether a certain form of treatment is right or wrong. Indeed, it is within my knowledge that in the case of one child, so much time elapsed before approval was finally given that the shape of the child's mouth had altered and the treatment which was approved was no longer right.
The Committee's recommendation on that aspect of the question of time—Recommendation No. 4—was not accepted by my right hon. Friend, who said that both Ministers had satisfied themselves that orthodontic cases were dealt with without undue delay. I urge him to look at this again. It may well be that in general there is no undue delay, but I should not like to think that there are any cases at all in which undue delay can result in damage to a patient.
My second point concerns the school dental service. I share the view of my hon. Friend the Member for Aldershot, and of the hon. Member for St. Pancras, North that all is not right with this service. The recommendations put forward by the Committee on what should be done about it have been universally rejected by my right hon. Friend. My hon. Friend the Member for Aldershot referred to the school dental service as the Cinderella of the Ministry of Education, and this is a fair designation. I do not in this context blame my right hon. Friend the Minister of Health, because I believe that the blame lies entirely upon the adequate shoulders of my right hon. Friend the Minister of Education.
It seems to me that the school dental service lacks three things. It lacks enough dentists, it lacks enough good dentists and, thirdly and, perhaps, most important, it lacks the will to see that the service is run efficiently and effectively. If I may enlarge briefly upon these three points, the evidence produced to the Committee was quite clear. The hon. Member for St. Pancras, North has referred to figures and I will not mention them again. There are not enough school dentists and it has not been found easy to attract men into this side of the profession.
My second point is that there are not enough good dentists. I do not mean that the dentists in the service are not technically competent—I am certain that they are competent—but they are not themselves sufficiently able to give the treatment which is necessary as a result of inspections and it then falls to parents to see that their child is treated outside in the general dental service.
My third point relates to the will of the Ministry of Education. When a child goes to school, he is supposed to be inspected by a member of the school dental service. These inspections are carried out in many cases, but not in all cases. The most serious aspect is that, once a child has been inspected and found to be in need of treatment, there is no record and no certainty that the child will be treated within the period of the school year. It is possible that he may be treated during the holidays by the general dental service. No record of this is available, however, and too many inspections showing a need for treatment result in insufficient treatment being given.
If my right hon. Friend the Minister of Education would agree with me, I should be delighted, but I do not expect him to do so. My hope is that he will look at this matter again and see whether he can either improve the service which he provides or consider whether his right hon. Friend the Minister of Health might be able and in a better position to provide this service which is so badly needed.
Any remarks which we might make here today in criticism of the dental profession would be out of place and inappropriate. I believe that the dental profession performs an important, valuable and too often unsung service to the community. I am not sure that the efforts and endeavours of the dentists are in all cases channelled where the need is greatest and I look to my right hon. Friend to ensure that they are so channelled.
The opening remarks of the hon. Member for Bristol, North-East (Mr. Hopkins), when he mentioned his trepidation at the response of his dentist to his remarks today, recalled tome one of the greatest acts of courage which I can remember. It happened in 1948, when my family dentist had his drill poised over my wife's mouth and began a diatribe against the National Health Service and, in particular, against the then Minister of Health. When my wife said that she approved of the Health Service and considered the late Aneurin Bevan to be a great man, she clutched the chair and hoped for the best as the drill was inserted.
I agree very much with the hon. Member's remarks about the service which is rendered to the House by those who serve on the Estimates and other Committees which, from time to time, put in a tremendous amount of thought and effort to give detailed attention to extremely complicated problems. If an item of payment forservice were introduced for Members of Parliament, there might, perhaps, be a little more equity in view of the terrific amount of time which is given by some hon. Members as compared, perhaps, with others who are not able to devote so much of their time to this extramural or extra-upstairs work. It is only by a Committee of that type that one is able to get to the details.
The National Health Service has so many ramifications that it is only by a Committee sitting almost day in and day out, receiving the advice of experts and questioning at great length people who have specialised knowledge of the subject, that we are able to get to grips with the problems. As my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) has said, the times that we are able to discuss dental health problems in the House are few and far between. I hope that now we have been able to get as far as this, discussing for the first time for many years the dental health services, we might sometime be able to look at ophthalmics.
What has emerged from the contributions to the debate so far has been stress on the importance of the way in which there should be integration between the school health service and the general dental services provided through other means.
The House will be most interested to hear from the Minister concerned why the recommendation contained in the Ninth Special Report—the recommendation which is concerned with what is perhaps the key question in this problem—has been turned down. When we examine the statistics presented by the Report we are left with a keen sense of disappointment that the declared policy of conservation in dentistry has been far from successful.
According to the figures, there was an average increase of 50 per cent. in the number of decayed, missing and filled teeth in a child of 5 between 1945 and today. We can in no way be proud of that, considering the amount of time and attention that has been devoted to this declared policy of conservation.
Perhaps even more startling is the degree to which we have failed in respect of the generation covering the age range between 18 and 28, in respect of which we should have been able to register the most progress, since a comprehensive dental health service has been in existence during the lifetime of most of these people.
A most salutary article appeared in this respect recently in the British Dental Journal, concerning research that had been carried out, with the agreement of the Army Dental Service, when 875 recruits went through a process of detailed examination in order that statistics could be prepared concerning the health of their mouths, dentistry and teeth. I do not wish to weary the House with figures, but the detailed results showed that the number of missing teeth was roughly one in five; the proportion wearing dentures upon entering the Army at the age of 18 was one in 10; the proportion of those needing dentures after their first examination in the Army was one in four and, perhaps most staggering of all, in these days of education—the proportion that had a complete lack of any oral hygiene was 51·8 per cent. More than half the people between the ages of 18 and 28, in that group of 875, did not clean their teeth.
I wonder how it is that in 1963—when even the commercial television advertisements explain why it is so important to clean one's teeth—we could have reached this situation, when we have had a comprehensive dental health service since 1948.
I welcome the comment made by my hon. Friend the Member for St. Pancras, North that we should try to do something in preventive work by the extension of fluoridation.
The hon. Member has drawn attention to many shortcomings, which he appears to attribute to the Health Service. Does he not agree that many of the troubles to which he has referred would be removed if parents paid more attention to the habits of their children, in connection both with cleaning their teeth and sucking sweets?
I am not going to be drawn too far into that question now, because whenever we are confronted with a problem of this kind—and it is just the same as the problem that we shall be discussing shortly with regard to education—there is always argument whether the Ministry of Health or the Ministry of Education is responsible. The parents say that the schools are responsible; the schools say that the parents are responsible. All I say is that parents, the Health Service and the education authorities must all accept some responsibility.
I congratulate the Minister—and this is one of the very few occasions on which I am able to do that—on his stand for fluoridation, in spite of the pressures that have arisen from small groups within the community which are opposed to it, and in spite of the fact that he approached the matter with some degree of timidity. When he agreed to carry out investigations in Anglesey, Watford and Kilmarnock this process had already been well tested in 17 countries, and the results were well known through the World Health Organisation.
Nevertheless, with a thoroughness that is perhaps to be commended, we still went through with our own tests, the results of which were published this year. They show that there can be a considerable saving of teeth if fluoridation, as recommended by the Ministry, is adopted by local health authorities and water authorities to a much wider degree than it is at present.
Those who object, for various reasons, never seem to worry about the dozen or more chemicals which already exist in the normal water that we drink. We do not distill our water. We have certain standards, and chemicals are already included. I was interested to read of the Watford experiment, and the way in which careful control was exercised in respect of the exact amount of fluoride permitted to be injected into the water, the controlled quantities and very line and precise apparatus which made it impossible for over-dosage to occur.
In addition to all this, there were more than 50 spot checks each week, to ensure that the right quantity of fluoride was used. The cost was 31s. per 1 million gallons of water. A case has put up that this problem could be overcome by persuading children to use toothpaste containing stannous fluoride, but this could not possibly do the job that the fluoridation of water will do, for the reason I have already mentioned, namely, that half our children are not cleaning their teeth. That would mean that half would be subject to dental caries.
The Anglesey figures were remarkable. They showed that between 1955—when tests began—and 1961 the proportion of decayed teeth fell from 3·9 per cent. to less than 0·9 per cent. while, in the controlled area where no fluoride was added, the proportion increased from 3·9 per cent. to 4·1 per cent. I can give comparable figures, right through the scale, which are absolutely incontrovertible and which, I hope, will persuade local authorities to press forward far more quickly with the fluoridation of water.
No, because in many parts of the country fluoride is already there, and has been for centuries. In parts of Derbyshire, for instance, the fluorid content of the water is higher than that recommended in the Report. In many cases it is not necessary. But where there is an inadequate amount of fluoride to serve the purpose the deficiency should be made up.
I agree with the hon. Member. No doubt the Minister will have taken note of this point. When he replies he will doubtless recommend measures of this kind, and will also assure us that he will devote even greater energy to his campaign to persuade local authorities to proceed more quickly.
The most important recommendation of the Estimates Committee was Recommendation No. 19, to which hon. Members have referred and which has been rejected—the question of the transfer of the school dental service to the Ministry of Health. Again and again we are told that we cannot interfere with a situation which involves two Government Departments. Empires are established within Ministries, and we are told that we cannot move responsibilities from one to another because it would be so complicated. We get a whole string of words such as"integration","joint consultation","arrangements", and"lines of communication that would have to be cleared", but we do not get away from the basic problem upon which the Estimates Committee put its finger.
Dental health must not be divided between two Ministries if we are ever to have a service which does its job really well. If the Government are sincere in giving first priority to conservation, it is obvious that the teeth of children should be accorded higher priority than the teeth of old-age pensioners. It is at that stage that the greater weight of effort should be placed in order to ensure that absolutely first class dentistry is available to care for children's teeth at the time when habits of oral hygiene are being established and the teeth are being formed.
The trouble is that the whole cash incentive is on the other side. A dentist is encouraged to go into general practice and to do his work as quickly as possible, and those who are prepared to serve in the school dental service have to do so at a financial disadvantage. If we are to maintain the right priorities the financial incentives should go to those who do the work of conservation at the point where its importance is greatest. This means not only that Recommendation No. 19 should be accepted by the Government but that, at the same time, there should be a complete reorganisation of the career structure and pay scales within the school dental service to put it at the top of the tree. The integration of the school dental service with the general dental practitioner service can be achieved only if both come under the one Ministry.
My hon. Friend the Member for St. Pancras, North, referring to Recommendation No. 22 on the extension of the dental hygienist service, spoke of the rather disappointing results so far. It should be possible to have a very rapid extension of this service. Married women who would be prepared to do the work on a sessional basis because their children are, perhaps, at school could be trained for this purpose and could give a service which might help a lot in reducing the enormous number of people—one in every two at the age of 18—who are not prepared to clean their teeth. Has the Minister considered employment by session?
Perhaps the classical example of nice phraseology is to be found in the Government's observations where, in connection with teeth, it is said that"inquiry is on foot". I hope that these inquiries will be pressed forward, but with reference to another part of the anatomy, perhaps the Government will get its teeth into it. As my hon. Friend the Member for St. Pancras, has rightly said, the Government's attitude to the recommendations in the Report is no tribute to the excellent work of the Estimates Committee. There is too much of this sort of response, saying that inquiries are on foot or that there will be further discussions. When hundreds more teeth have been pulled and hundreds more cavities have been filled, there will still be inquiries on foot between the various Departments about what should be done.
Turning to Recommendation No. 3, one wonders how the Government reconcile the half-hearted welcome they give to the suggestion that executive councils might cover a wider area for certain specific purpose with what they propose to do in London. They have produced a London Government Bill which will have the result that, instead of there being six executive councils, there will be 32. I hope that the Minister will tell us whether this will, in fact, take place.
I think that it will be a tragedy for the whole organisation of dental practice in the community if it does. I know that he is having discussions on the matter, and I hope that at some time dentists and doctors who are responsible to their executive councils through their local committees in London will be put out of the agony of not quite knowing what the future of their administrations will be.
The Committee spotlights the fact that the ordinary dentist working in the community is subject to many anomalies in his pay structure because of the items of service method of payment. The dentist has his top earning capacity, alas, only between the ages of 30 and 44. The older he becomes, the more experience he gains, the more he can expect his earning capacity to drop because, of course, there is a considerable amount of physical effort and concentration required in dentistry and the burden becomes greater after a man reaches 44. Plainly, this is an anomaly. A man should be entitled to expect that, as he gets older and gains more experience, his earning capacity, if anything, will rise.
The items of service system militates against a dentist taking adequate time to do good work. The pressure of the present system means that, between the ages of 30 and 44, the more people the dentist can put through the chair the more likely will he be able to put away some savings for his later years when he cannot do the same amount of work. There is, in consequence, a pressure upon him as a younger man to work quickly, to work, perhaps, without fully considering the very complicated jobs which take a long time. He will tend to prefer to do work which will give him the quickest possible turnover.
As I remember it, the evidence given to the Committee supports the point which the hon. Gentleman is making, but the reason why earning capacity falls after the age of 45 is that the dentist is then prepared to spend less time at the chair-side than in the years before. If the hon. Gentleman is suggesting that the older dentist does not do his work so well, he is, I think, being rather unfair.
I do not suggest that at all. I am pointing out that the financial incentive and pressure is for the dentist to do the maximum amount of work in the shortest possible time. A good dentist, just like a good doctor, needs time; he should not feel under pressure because of financial incentives. If he decides that he would prefer to do the classical complicated job which takes a considerable amount of time—and which will give him great satisfaction in the standard of service he gives—he should have the opportunity.
But the present system of payment does not give him that opportunity. It pushes him in the opposite direction. Indeed, it pushes him in the direction where it is possible, if someone wishes to adopt a completely commercial outlook, to organise the practice in such a way that there are six chairs in a row and a sort of conveyor belt system with patients being brought in in a constant stream, a filling here, an extraction there, and so forth, the whole business being organised in a mechanised way when it should, of course, be treated as a very human subject.
As the hon. Member for Bristol, North-East reminded us, dentistry involves all kinds of emotional considerations apart from the purely physical one of having one's teeth attended to. Our aim is to improve the quality of work. I make no criticism of the dentists. As my hon. Friend the Member for St. Pancras, North has said, there are too few of them trying to do too much, and, in the circumstances, one can only commend them for the excellent standards which they maintain. But it is our job to see that they have better opportunities within the Service.
I was very pleased to read Recommendation No. 23, drawing attention to the vital need for refresher courses. But, here again, the items of service payment system leads to a financial disincentive against a dentist taking a refresher course. This should not be so. I have in mind particularly the great growth of information recently in periodontology. Research is yielding greater knowledge each year. One cannot separate the health and care of the gums and mouth from the health of the teeth. In present circumstances, we tend to concentrate purely on the teeth, dealing with cavities to be filled, decayed teeth which require extraction, or gaps to be filled, if necessary, by dentures rather than devote study to the whole subject of oral hygiene, the way the gums react, and the supporting nerves and tissues within the mouth.
I think, perhaps, insufficient thought is being paid—although my hon. Friend the Member for St. Pancras, North did give some forward-looking ideas—to what one might envisage if one were seeking reorganisation of the dental service, but I think that one possible way which might be examined with a great deal of care is an extension of the Health Service into an occupational health service—treating a man's teeth at work, by a dentist attached to an occupational unit. That might be a way of meeting some of the anomalies which exist at present.
I had the privilege recently of going over a unit at Unilevers, not far from this House, and seeing the standard of work. There were three dentists who were doing an absolutely first-class job with every possible facility available to them, and, of course, every encouragement to the workers at Unilevers to go to them at the first sign of any trouble, to have regular check-ups and to have troubles prevented. The dentists were able to do their work with ample time, in their own way, with complete vocational satisfaction.
I think that in these Health Service debates, no matter on what particular subject, we suffer from a similar kind of approach, in that we think in terms of production, as in an industry, in which success is measured by the number of dentists we have, the number of teeth we pull, the number of beds occupied, and the number of hospitals we build, whereas the time we are looking to is the time when the dentists are, so to say, out of work because so many dental troubles have been eradicated and when there are fewer and fewer demands arising from dental ill-health or any other ill-health.
It is because it is the Minister's declared policy that conservation has priority that I think that the Estimates Committee deserves far more support than it has received for its work which has gone into the excellent First Report. It makes the Ninth Special Report, which side-steps so many of the important issues, a totally inadequate commentary.
Robert Burns described toothache as"the hell o' a' disease", and I should imagine that most of us who have experienced it will agree with Burns's description.
It might be said that the function of the vast organisation represented by the dental service has been to try to remove from the experience of childhood, and also the experience of adult years, those sojourns in hell which have from time to time created the apprehensions which filled my colleague for Bristol, North-East (Mr. Hopkins) who served with me on the Committee when he had to venture to the dentist to have this trouble dealt with. We built up this vast organisation to eradicate the pain of bad teeth, the pain of extraction, and the pain of treatment. These pains, today, ought no longer to exist in dentists' surgeries.
The other thing the service is trying to do, not only for the community, but for us as individuals, as parents, is to create in the minds of our children complete confidence in the dentist himself. The dentist, of course, plays his part in it, and the fears of the old days, when a boy or girl had to be taken to the dentist, do not, I think, any longer exist. It is perfectly true to say that children, whenever they feel need for dental care, go themselves directly to the dentist for treatment. Because of that I think the school dental service is tending to diminish, because the children, according to my own experience, are making use of the general dental service.
I think that we should be able to claim that remedial care, which is very important, should now be nationwide, not only for the adult but also for the child, and as a result of the examination to which Sub-Committee C, under the unflagging zeal of the hon. Member for Aldershot (Sir E. Errington), submitted the dental services we have had to come to conclusions which are somewhat critical of the policy and administration of the Government. It is the fact—and here I speak with personal knowledge—that in so far as adults are concerned in a large part of Scotland the dental services are not functioning as they ought to be at present.
I think it unfortunate that, while in Scotland we claim to have a separate Health Service, which was brought into being under a separate Act, when we are dealing with this important and massive Report, the Scottish Secretary of State is playing an entirely passive part, and the voice of Scotland, through its representative Minister, is not to be heard in any reply which will be made to the debate today. I am casting no doubt on the integrity of the Minister of Health, but in my view it is the province of the Secretary of State for Scotland, or one of the Under-Secretaries of State for Scotland, to speak for Scotland on this important matter today.
It is true to say that there are parts of Scotland where the modern dental health service is practically unknown. There is only a casual instrument in treatment and in care. And it is equally true to say that the method of treatment applied in Burns's day, the soporific, is still the main one which remains to sufferers in certain parts of the remote areas in Scotland.
Well, I was speaking rather of this soporific, where, in parts of Scotland today, there is not sufficient supply because of export demands.
I think that it is worth while noting that the Report which we have placed before the House has received a very good welcome. I feel the House will be interested to hear the view of the Scottish Secretary of the British Dental Association. He said to me in a letter dated 28th January, 1963:
In my opinion, it is the most interesting review that has ever been published on the dental service, and I think that, together with the other members of your Committee, you are to be congratulated on the excellent way in which you have discharged your task. Not only have you survived a deluge of conflicting and highly technical evidence but you have actually produced a constructive report which pinpoints weaknesses and offers solutions which, if taken up, should considerably improve the service available to the people.
Those weaknesses have been referred to by many hon. Members on both sides of the House, and I wish to look at some of them from the standpoint of Scotland. I note, particularly, Recommendations No. 1, 4, 12, 16, and 17. In my view, these are important recommendations. No. 1 deals with the services in the remoter areas. No. 4 deals with orthodontic cases. No. 12 deals with local responsibility for the school dental service. No. 16 deals with the need for maximum co-operation between local authorities and executive councils in providing dental treatment for school children. Finally, there is Recommendation No. 17, which says that where experimental ventures provide information which is useful and successful it ought immediately to be made available to other areas engaged in dental work.
I notice that all these recommendations, with perhaps some slight modification to one or two of them, are accepted by both the Minister of Health and the Secretary of State for Scotland, but nothing has been done about any of them, nor is there any evidence to show that it is proposed to do anything about them. I agree that it may be said in reply that action awaits the outcome of this debate, but the fact is that over a long period pressure has been exerted on both Ministers to do just what is recommended by the Committee in this Ninth Special Report.
Let me take as an example Recommendation No. 1, which deals with dental services in the sparsely populated areas where, at the moment, there is no adequate service. We had a special memorandum from the Secretary of State for Scotland, which dealt, among other matters, with the remote areas of Scotland. It contained interesting information, but it said nothing that had not been known to the Secretary of State for Scotland for along while. We were told that two dentists attend to the needs of 26,000 persons in the Stornoway area. According to the figures supplied to us, the average for Scotland as a whole is one dentist for 5,000 persons, which means that in Stornoway and the surrounding area two dentists have to look after five times the average number per dentist in Scotland as a whole. There is nothing new in this state of affairs. It has been known for a long time, and in accepting this recommendation the Government are simply playing for time, which has long been against them.
We were told in the memorandum that 10 dentists visit localities as widespread as Argyll, Bute, Inverness, Orkney, Ross and Cromarty, Sutherland, and Zetland, for which, in 1960, they were paid £3,545. What were they paid in 1962? A return of £350 is little enough in view of the area to be covered, apart from the work which has to be done. It is little wonder that there is difficulty in staffing the dental service in those parts of Scotland where the reward is so niggardly, and, again, there is nothing new in this state of affairs, either.
Because of the lack of dentists in these areas, the Secretary of State for Scotland has power to make arrangements with the local medical practitioner to do a limited number of extractions, but this is not a doctor's job. Both Ministers know that, yet they have allowed this practice to persist for far too many years. We are told in mitigation of this scarcity that school dentists are also available, but the school dentist today approaches his job from a different angle. He does not think merely in terms of extractions; he thinks in terms of dental care, of remedial treatment, and of all the other approaches which were so well outlined by my hon. Friend for Willesden, West (Mr. Pavitt).
That means that in the schools in the remote areas of Scotland we are training children to care for their teeth while they are growing up to be adults in places which lack a programme of full dental availability to which they have been trained, and which is as necessary for the adult as it is for the child. This, to me, is the chief criticism of the memorandum we received from the Secretary of State, because, apart from the figures it contains, which prove inadequacy, there is lack of vision in training children for something which will be non-existent when they grow up.
I know that the shortage of dentists is a severe handicap to achieving a scheme of the kind that we need, but a speedier building programme could help to overcome this difficulty. Looking at that part of the memorandum which deals with the expansion of training facilities in the dental hospital schools in Great Britain, I see that in Bristol, in Birmingham, and in University College Hospital, London, new dental colleges will be opened this year, or at the latest in 1964. I also note that Manchester, Cardiff, and London Hospital are to open new dental colleges which will be in operation by 1965 to provide the extra dentists that we need for those areas which lack sufficient dental facilities.
But when I look at the position with regard to Dundee and Glasgow, I find that the dental hospitals there will not be opened and in teaching use until 1967 in the case of Dundee, and 1968 in the case of Glasgow. We are faced with the fact that the number of dentists in Scotland has been diminishing, whereas the number for Great Britain as a whole has been increasing. In 1956, there were 1,120 dentists practising in Scotland. In 1961, the number had fallen to 1,051. For Great Britain as a whole, in 1949 the number practising was 14,904. In 1962, the number was 16,619. That is an appreciable increase in Great Britain as a whole, but a diminution in Scotland. The diminution is greater because the increase for Great Britain as a whole covers the extra loss that has been experienced in Scotland. We are faced with a decreasing dental supply in an area which will not have its new dental col- leges until long after other areas have been satisfied.
It should be impresed on the Secretary of State for Scotland that expedition is necessary in the provision of these colleges if we are to provide in the remote areas of Scotland the full dental services for adults to which they were accustomed as children. To do this, we must seek closer co-operation with the dental profession than presently exists. I suggest that the dental profession can be kept in closer contact with executive councils, with the Minister and with local authorities if the information circulars sent to local authorities and executive councils are also sent officially to the Dental Association.
Much has been said about Recommendation No. 8. The Estimates Committee is in favour of amalgamating the Dental Estimates Board for England and Wales and the Scottish Dental Estimates Board. There is no doubt that amalgamation is the solution for all the dental disparities which cause much friction today in the service. In dealing with this recommendation, both Ministers sought to fling a little spanner in the works. They say this:
The Secretary of State for Scotland and the Minister consider that it would not, at the present time, be advantageous to transfer either the Scottish work to Eastbourne or the English and Welsh work to Edinburgh, or to establish a Board for Great Britain in some third location.
The Committee did not say anything about that. I did not think it was the business of the Committee to do any such thing. That is a matter of policy. It did not come strictly within our function. Why should we make reference to a third location? Had the Minister anything in his mind when he brought in the third location? Was it Ireland?
There are two places concerned—Scotland and England. I thought, perhaps in an over-simple fashion, that the location would be either in England or in Scotland. I did not think that there was a third location, unless a report which is still not completed and which, I believe, will be duly presented has something to say about a third location.
I must not discuss this in detail, except to say that there is no third location. There is only one location, if there is to be amalgamation, and that location would need to be Scotland.
Recommendation No. 11 has particular reference to Scotland. We are told this in the Government's observations:
…the Secretary of State has made special arrangements with a dentist who has just commenced practice at a new health centre in the new town of Cumbernauld, under which the dentist is being remunerated by way of fees and is paying a full economic rent for the accommodation and services provided.
That has the support of the Estimates Committee. It also has the strong support of the dental organisations. Is the right hon. Gentleman satisfied that the Secretary of State has sufficient powers to carry out this experiment fully? In other words, has the right hon. Gentleman powers in carrying out this experiment to enable him to treat the dentist as he can treat a doctor? The Minister knows that this practice is adopted regularly with doctors. The Secretary of State has full powers in the case of doctors. Will the Ministers satisfy themselves that they have to pursue no devious course in making this experiment in Cumbernauld? Can the Minister give me an idea of what the dentist is paying for his two-suite surgery in Cumbernauld? A figure of £600 a year has been suggested. Will the right hon. Gentleman either confirm that, or tell me the proper figure? If he wants to proceed further with this sort of experiment, the new town at Livingstone will provide him with further scope for this type of work which is highly commended by the Committee.
In Recommendation No. 15 we have a recommendation from the Estimates Committee for something which works very well in Scotland already. Most Scottish local authorities carry on an excellent consultant service in association with the hospital service.
I think that there has been a misunderstanding in connection with Recommendation No. 15. It states that
The responsible Departments should ascertain which local authorities have no ready access to orthodontic consultants in the Hospital Service.…
The Government's observations say:
Where such advice has to be obtained elsewhere than from a member of the authority's own dental staff…it should be sought from the nearest available hospital consultant.
That is a different point from the recommendation. In other words, the cases which we had in mind in making this recommendation were those where no hospital service was available, and I do not think that that has been answered correctly.
I felt a little worried when I read the Ministerial observations, because I had the same feeling as the hon. Member for Aldershot. I was referring to the recommendation and merely pointing out that this proposal already worked well in Scotland. That should give us greater confidence in presenting it, and I hope that the right hon. Gentleman will clarify the obscurity which surrounds his observation.
I come now to Recommendation No. 23. I shall say nothing about the hygienistsnor the auxiliaries. These are generally accepted by the Scottish dental profession. There are slight difficulties. For instance, the fee of 12s. 6d. for the scaling of teeth is felt to be insufficient because the hygienists are said not to work at the same speed as the dentists and, because of this smaller output, find it difficult to make the fee of 12s. 6d. a paying proposition.
Finally, I would like to consider the recommendation in which the Committee suggests introducing more refresher courses for dentists. The Minister of Health has accepted this recommendation, but the Secretary of State is considering the type of refresher courses which should be provided. When he has received advice, he will institute discussions with the universities and the dental schools about the provision of more refresher courses.
In this matter, existing conditions in Scotland are quite different from those in England. When a dentist goes on a refresher course in England, he gets his fare paid and he gets subsistence allowance and a locum is provided.
My hon. Friend will realise in a moment why I am pointing out what happens when an English dentist goes on a refresher course. I was saying that if a dentist practising in England takes a refresher course, he gets his fare paid, with subsistance allowance and a locum is supplied if the need demands it. I suppose that a locum would not be regarded as necessary if he were in a joint practice. However, in Scotland that system does not operate.
This is one of the dental disparities to which I referred in dealing with the amalgamation of the services in Britain. I hope that the Secretary of State will pay attention to this matter, for if the number of refresher courses in Scotland is increased, and more dentists take these courses, which everyone admits to be necessary, there should be no disparity between the treatment given to a dentist practising in Scotland and to one doing so in England.
That covers most of the recommendations about which I want to say a few words. There were one or two other matters which I might have ventured to mention, but I know that many hon. Members still want to take part in the debate. In the course of examining witnesses before the Committee, I raised one or two points of importance to people other than dentists, to those who sometimes, have to work in association with the dental service. I refer to what may happen after a tooth has been extracted and when post-extraction haemorrhage sets in.
Instead of the dentist treating it on his own, a doctor is often called in to do so. This sometimes creates unnecessary friction between the doctor and the dentist, because the doctor may be called out at difficult hours to deal with the aftermath of a dental extraction. This situation arises because, although the hours of availability of the dentist are posted up in post offices so that the public may know at what hours dental treatment can be obtained, the dentist himself is not bound to be in his surgery during those hours.
This is a profession in which consultation is still by appointment. Consequently, if there is any unexpected sequel to an extraction,"by appointment" still operates even when it is impossible to assign a time for attention which is urgently required. When the two Ministers are taking what my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) described as a hard look at the whole of this great organisation, I hope that they will look at the system by which hours of availability are made public, but which do not bind the dentist necessarily to be available at his surgery during those hours.
While we may say critical things about the service, and those employed in it, and the lack of planned Government expansion, especially in those parts of Scotland which I have mentioned, every one of us, either as a member of the Committee, as a member of the Government, or as a person practising in the dental profession, is animated by one desire—to strengthen the service and to widen its outlook in order that it may operate for the benefit of all the people of Britain irrespective of their location.
If I were to follow my hon. Friend the Member for Glasgow, Govan (Mr. Rankin) in his argument about the location of the Dental Estimates Board, I should soon be in trouble with my constituents. If it is to be concentrated, I hope that the suggestion put forward by the hon. Member for Aldershot (Sir E. Errington) might be followed and that it might be located in the North-East, but I do not think that on the Floor of the House at this moment we could come to a very satisfactory conclusion about a matter of that sort. Indeed, it is a comment on the sad state of our economy that my hon. Friend and I might be at cross-purposes over this.
I want to congratulate the members of the Committee and the hon. Member for Aldershot on the painstaking, thorough way in which they have gone into this very serious problem of the dental services. I should like to follow the hon. Member for Aldershot in his strictures on the Ministry of Education. Before I do so, I should like to say that wherever the school dental service is located and whatever steps are taken to improve the service for children, this is a matter which calls for the co-operation of a great many Departments, and that if it were to be allocated to the Ministry of Health that would by no means solve the problem.
The past record of the Ministry of Education in this respect is absolutely deplorable. When a witness was asked what staff the senior dental officer had, the answer to the Committee was,"He has not got a staff; he works on his own". Is it surprising, therefore, that local authorities, which are criticised by the Ministry of Education for not doing their stuff, do not consider the position of the senior dental officer of very much importance?
The facts are that about two-thirds of the chief dental officers in local authorities do not even attend the meetings at which their professional matters are being discussed. I think that the hon. Member for Aldershot was right when he said that there was very serious lack of drive in the Ministry of Education, both in regard to the way in which they look towards their professional staff, and the way in which they encourage dental officers in the local authorities. I am glad to se that the Parliamentary Secretary to the Ministry of Education has come in, because I was saying some nasty things about his Department. It is on this matter of encouraging dental health and encouraging publicity and propaganda that the comments of the Estimates Committee are very scathing.
In question No. 1460 a witness said to the Chairman of the General Dental Services Committee:
The whole picture of the dental health of schoolchildren is…a national scandal…
He goes on to say,
…we cannot get anyone to appreciate how bad it is.
I would think that qualification was a little hard. I and other hon. Members have raised this matter in the House many times. I asked the Library to find out how many times hon. Members had raised the matter of dental shortages. I find that in the last two years on no fewer than 10 occasions, by Questions,
by Adjournment debates and so on, hon. Members have drawn attention to these problems. The balance is three Conservatives, five Labour Members and one Liberal twice, which was a fair arrangement for the Liberals. This statement by responsible professional officers that the dental education of school children is a national scandal, demands far more of the Minister of Education than he has shown even in his answers to the recommendations of the Estimates Committee.
The Estimates Committee refers to the fact that if there were more nurses employed to support the school dental officers about 30 per cent. more work could be obtained from them. About a year ago there was a great fuss when the former Minister of Education, then Sir David Eccles, talked about auxiliaries in the schools. He diverted a whole debate to that subject, quite"off the cuff" without consultation with anyone concerned. It was purely a red herring. Had he concentrated attention on the use of auxiliaries in spheres where they were already being used he would have put his talents to a much better purpose.
I mentioned the question of nurses. Other hon. Members have referred to the need for more dental hygienists and the position there is laughable. There are only 11 employed in the school dental service and 24 in the general dental service, and there was a very cool response to Recommendation No. 22 from the Estimates Committee that the Health Department
should work out with the dental schools means of considerably increasing the training facilities for dental hygienists.
The observations are:
Inquiry is on foot to establish whether any further increase in output would be matched by reasonable prospects of employments. The expansion of training facilities depends on the outcome.
I should have thought that the Minister of Education would have made strong observations to the Minister of Health and told him that, of all the services where dental hygienists could be satisfactorily employed, the school service provided a situation where there would be a concentration of dental work and the utilisation of dental hygienists. Generally the same position applies in respect of dental auxiliaries and hon. Members have referred to this
I have a feeling that even in the profession of clerical assistants to the school dental service there is a far from adequate supply of clerks. The Estimates Committee refers to the inadequate organisation within the service and suggests that the hours during which school dentists operate in the holidays, surgery hours and supervision arrangements are far from satisfactory. It is not surprising that this is so when, just as in the general field of education, only recently has much regard been paid to statistics.
The same sort of thing operates in the Ministry of Education and the Ministry of Health in relation to the dental health of school children. The Estimates Committee was surprised that the Ministry of Education had no precise idea of the cost of the school dental service. There was an approximate figure of £4 million. In the statistics of the Ministry of Education regarding dental health there is a tiny paragraph tucked away, in which some basic figures are set out. But there is no attempt to make a refined statistical analysis to bring information to bear, at any rate on one side of the problem, in order that it may be isolated and a solution attempted.
The Estimates Committee referred to the absence of statistics regarding equipment. One witness said that most dental officers had the use of high-speed drills. But there was not a survey available so that the Ministry of Education could tell at once what sort of equipment there was in local authority clinics. I agree that the Ministry has accepted that it will review this matter and obtain information. But it is too bad that the information is not available and that the staff at the Ministry are not in a position to give advice to chief dental officers about equipment and to bring them up to date. I shall be glad if I can be told that I am wrong, but I cannot see how one chief officer at the Ministry can supervise 146 local authorities and make the necessary contacts.
I doubt whether the Estimates Committee is right in suggesting that it should be outside the scope of the Ministry of Eduction. I should have thought that the Ministry ought to be looking at this part of the service as a means of promoting officers in local authori- ties. One of the charges often levelled against the Ministry of Education—not so much in relation to inspectors, but chief administrative people—is that these people have no practical experience of local authority work. Here is a way in which a number of senior dental officers in counties and boroughs could be promoted to extremely useful jobs in the Ministry of Education. I hope that the establishment will be looked at and the whole system reorganised from the centre.
I must refer to the comments of the Estimates Committee relating to the productivity of dental officers in the school dental service. Here again, just as in education generally, one needs statistics about the situation to show what it really is. It would appear to be unsatisfactory. The Estimates Committee comment on it, but all the Committee can say is that it looked at the figures and found that there was extreme inequality between the efficiency of one local authority and another and that the general indication was that in the normal health service the productivity of dentists was improving. Yesterday I asked an official of the Dental Estimates Board to give me some indication of how the productivity of ordinary dentists had improved so that I could make a comparison. But I got only a vague answer and I was referred to an out-of-date Annual Report by the Ministry of Health. Both in the Ministry of Education and the Ministry of Health there is a greater need for an accurate appraisement of what the dentists are doing. It is quite scandalous that the number of children not receiving treatment is not known.
I wish to refer to what is the heart of the problem—the shortage of dentists. This has been known to the Ministry of Health and the Ministry of Education for a very long time. About a couple of years ago the University Grants Committee said that dental education had not progressed so far or so rapidly as it would have wished. This has been known for along time. Although the McNair Report was published in 1956, and although this situation is of longstanding, only now are the numbers of dentists entering the schools showing any improvement. One figure which I find alarming is that the proportion of dental students is a declining proportion of the total number of students and the number of women dental students is a declining proportion of the total number of women students.
This indicates a complete failure on the part of the Ministry of Education and the Ministry of Health to solve the problem. It is not a question of lack of recruits. One witness told the Committee that there is a long waiting list for the dental schools. The potential manpower is there, if the training could be provided. Training is the bottleneck. So we are in the position that the first McNair students will be coming out in 1968 and the target which was set in 1956 is likely to be reached only in 1973.
The University Grants Committee in another report drew attention to the inadequacies of dental research. I am told that those progressive dentists who wish to get into the academic field almost always go to the United States in order to get into the swim. There are nothing like enough hospital appointments for people who do this research and the hospitals are not doing enough dental research. In the Report of the University Grants Committee for 1960–61, which is the comparable period with the Report of the Estimates Committee, the number of advanced students in dentistry, dental surgery and orthodontics was 54. In the same year there were over 550 advanced students in history and archaeology. It is obvious that this country regards looking into the past as ten times more important than the study of the teeth of the children of the country.
Whatever organisation may be employed, whatever may be the arguments between the Ministers of Health and Education about the location of the dental service, there is no question that a radical improvement is required. One of the improvements lies with the Ministry of Education whatever organisation is adopted. Although I imagine that the Parliamentary Secretary will not be able to reply today, I hope that in the near future we shall get a report from the Ministry of Education about a more efficient organisation of the school dental service, more adequate statistics to illuminate the problem and a far greater drive in relation to the dental education of school children.
I wish to refer to one or two of the recommendations in the Report. Recommendation No. 1 refers to the problems of attracting general dental practitioners in the areas where there is a shortage. The Minister must know that when we were discussing the Health Service there was a plan to put doctors on basic salaries as well as capitation fees. May the question be looked at again from the point of view of dentists? There were certain administrative difficulties at the time. But it is a disgrace that in some areas there should be too many doctors and in other areas too few doctors and dentists. I believe that the best way to get dentists into the understaffed areas would be to set up more health centres. I believe that this is a fundamental solution to the problem.
Recommendation No. 4 refers to orthodontic treatment and the need to deal with the estimates more quickly. The House should realise that many of the people who send up orthodontic estimates, are not qualified orthodontists. I would never dream of treating an orthodontic patient, because I regard that as a specialist's job. Until we get a standard whereby we can measure a man's ability to do this work, there is bound to be considerable delay in passing estimates.
Recommendation No. 8 suggests that the Dental Estimates Boards for England and Wales and for Scotland should be amalgamated. I am all in favour of that if it leads to more efficiency, but, at the same time, I must point out that the Scottish Board has some advantages over the English Board. There is a more intimate service in Scotland and the Scottish dentist has more confidence in his Board than the English dentist has in his.
Again, while in England a large number of the estimates that dentists send up are examined and either passed or turned down by lay members of the staff of the Board, I understand that in Scotland all the estimates are examined by professional people. If, by amalgamating the two Boards, we got rid of the intimate relationship in Scotland and had a Civil Service staff passing estimates instead of having professional advisers doing so, that would be very dangerous to the good relations between the Board in Scotland and the profession. Incidentally, I should have declared my interest. I am, of course, a dentist.
Recommendation No. 21 deals with the education of dentists. It says that we
…should set up a standing joint committee, whose task should be to carry out an immediate review of the dental manpower position.
It is true that this manpower is declining in proportion to other professions, but, as my hon. Friend the Member for Bishop Auckland (Mr. Boyden) has said, this is not because not enough young people want to go into dentistry but because there are not enough places for them in the dental schools. There is nothing more degrading to a young man than to have to hawk himself around the country looking for a place in a school of dentistry. Sometimes he has to wait 12 months before he gets a place.
I said in the House many years ago, and have discussed it with leading dental surgeons, professors and teachers who agree, that dental education could be streamlined much more than it is. If the Minister would discuss this with leading teachers, he would find that we could perhaps cut the course by six months without lowering standards. Some of the subjects are of little value to the practising dental surgeon.
My hon. Friend the Member for Willesden, West (Mr. Pavitt), who made a very good speech, referred to the value of the addition of fluoride to water. There is no question about that. I am sure that no professional man would disagree. The Minister should use his influence with the local authorities to get them to speed up the addition of fluoride where it is necessary. There is not enough urgency in this. There have been adequate inquiries of all kinds and there is nothing to worry about over the health of the population. Every important medical authority agrees that the addition of a small percentage of fluoride would be a great advantage.
My hon. Friend the Member for Willesden, West made the important point that dentists, being paid on a scale of fees, are encouraged to look at then-profession not as a profession, but more as a commercial undertaking, and are apt to streamline and get as much as they can in their earlier years. It is true that much of the more intricate work nowadays cannot be done under the National Health Service on the present scale of fees, or otherwise the dentist would lose money. The fees are too low.
It is also true that when a man, at 45 or over, is at his peak of knowledge and technical ability—although perhaps not in speed—his income is apt to fall. This is a problem which is bound to arise on a scale of fees, but until we get a salaried service I do not see how we can overcome it. There again, the Minister should examine how the incomes of dentists are distributed. From my experience, I know that young dentists, very often just qualified, and being paid a percentage of their gross takings, are making much more money than the principals who are employing them. That is wrong.
One of the solutions is the development of the Health Service together with an industrial health service, which is just as important. Even the Labour Government were apt to concentrate on the Health Service and to ignore this aspect of what would be one of the major solutions. The only time I ever disagreed with the late Aneurin Bevan was on the question of a fully salaried dental service. After the war the young men coming out of the Armed Forces would have come into a salaried service, but, to get the good will of the profession as a whole, Mr. Bevan introduced the scale of fees instead.
Now I turn to the school dental service. I know that some people have been saying that the condition of our children's teeth is very bad, but it is not really as bad as it may seem. As I have said time and again in the House, many children go to the family dentist instead of to the school dentist. Whether that is a good or bad thing, there is something to be said for both sides.
That information would be useful. A lot of work might be involved in obtaining it, but it could be got because the relevant forms ask the date of birth of each child. I am not suggesting that it is a perfect scheme, and that all children's teeth are treated in this way. Suffice it to say that about 40 per cent, of my patients are school children and that this average is fairly common among dentists who are sincerely trying to work the dental service.
The school dental service should come under the Ministry of Health. It is true that little empires are created and that it is difficult to destroy them. We had some of these in the Armed Forces, with separate services for the Army, Navy and Air Force, all with their own establishments. In the school service the dental officer has so much book work to do that he does not have much time in which to carry out the real work of dentistry. In such a case a professional man's time is completely wasted.
One problem will not be removed until the services are brought under the Ministry of Health. I refer to cases where services are dependent on local authorities. Some of these are very good and efficient while others are a disgrace. I have visited school dental officers treating patients in rooms without running water and with almost no equipment, particularly in the country districts. If standardisation is to be achieved it will happen only under one Ministry.
The use of hygienists may make a contribution, but it will not be as important a contribution as some people imagine. Dental auxiliaries may be more important than hygienists; and I hope that hon. Members appreciate the difference between the two. An auxiliary can insert fillings into children's teeth whereas a hygienist can scale teeth, teach cleanliness, and so on. It is more important for the Ministry to go in for dental health propaganda in a big way.
This should be done not just when children attend school clinics or dentists' surgeries, but posters should be erected in schools, as is done in other countries, on hoardings and in all doctors' surgeries. The toothpaste manufacturers have a much better propaganda system than has the Ministry. Their propaganda is designed to sell toothpaste. Our problem is to encourage children to attend the dentist for treatment.
It is important to consider the question of the whole organisation of the Health Service, particularly that of the Dental Estimates Board. I raised this matter in the House recently and since doing so have checked my facts and believe them to be correct. The secretary of the Board is a civil servant and is responsible for the administration at Eastbourne. The Estimates Committee took evidence from the chairman—who is a dentist and quite an old man—and the secretary.
It is not clearly brought out in its Report that there is a growing tendency for more and more estimates to be approved or rejected by non-professional people. This causes disharmony between dentists and the Dental Estimates Board. It is surprising to realise how many niggling letters dentists receive from people who, obviously, do not know about what they are writing. I received one the other day. Why did not the Estimates Committee interview a member of the professional staff at Eastbourne?
I hope that the hon. Member will clearly understand that when the Committee went to Eastbourne its members not only saw two or three members of the professional staff, but went to their rooms and discussed matters with them. We asked anyone who wished to see us to come along and give evidence, but no one came forward. In those circumstances we went to see them. It is, therefore, quite untrue for the hon. Member to say that we did not visit the professional staff. I want him clearly to understand exactly what happened.
If the hon. Member had read the account of what was done he would have realised that evidence was not taken on our visit to Eastbourne. Had evidence been taken it would have appeared in our Report. A visit was paid to three or four members of the professional staff and some matters were discussed. I hope, therefore, that the hon. Member will not persist in what is wrong, for I can assure him that the Estimates Committee dealt faithfully with everything in its Report.
I will not persist with this point and I accept the hon. Member's word. I raised this matter only because I was approached by a considerable number, more than three or four, members of the professional staff, who informed me that they wanted to go to London to give evidence.
This is extremely important, because it is being suggested that we did not take evidence which would have helped us in the subcommittee. If the hon. Member is right, and he does know three or four people who wanted to give evidence, why did he not communicate that fact to me?
I did not communicate with the hon. Member, but I did with one of the members of the Committee. I thought that I was doing my part in doing that. However, since the hon. Member has made it clear that he went to the rooms of some members of the professional staff and discussed matters with them, I withdraw my remarks on this aspect.
Whatever the Report says about the Dental Estimates Board I can assure the House, from my close links with its staff, that it is not running efficiently. Its administrative costs are far too high and some estimates have been approved which should not have been. Others have been rejected when they should have been approved. Every dentist can make mistakes and insufficient treatment references are available to enable us to discover what is going on throughout the country. While the Report will make a contribution to the future of the Health Service there are one or two weaknesses in it and I hope that the Committee will press on and delve deeper into what is going on.
I was particularly interested in the discussion between my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird) and the hon. Member for Aldershot (Sir E. Errington) on establishing exactly how many children have their teeth regularly examined outside the school system. My children have never been to a school dentist. They go to the family dentist for regular attention, and I know that to be the case with many parents.
I do not know what arguments are adduced against the practice, but we find it useful, because one of the big problems is to get children to accept visits to the dentist as perfectly normal. I know that my dentist is extremely efficient, and my children go to him as part of the family. None the less, we should know the number of such child-rent, and perhaps the Minister can tell us whether there would be much difficulty to discover how many children are getting this regular treatment and attention.
The condition of children's teeth today appears to me to be appalling. The number of children whom I see who, at quite early ages, have two, three or four fillings seems to be unnecessary, and I cannot help feeling that no matter how much legislation we pass, or how many regulations are issued by Ministries, it is the parents who have the prime responsibility for looking after their children's teeth. I can look after the teeth of my children, and other parents can do the same if they are sufficiently interested. Unless parents accept that responsibility, any number of circulars and any amount of legislation will not solve the problem.
Yes, but there still remains the very good habit of cleaning the teeth twice a day. That takes a certain amount of time and, unless it is insisted on, children will not do it.
The difference in the facilities offered in dentists' surgeries and establishments in general is enormous. My own dentist provides light, airy conditions—and a constant service of the most appalling"canned" music which is, nevertheless, very popular with the children. This is not a matter of making a visit to the dentist pleasant for adults; it is a very real factor in the children's approach. Some of the places in which dentists practise are so dark, dismal and dreary that I am not at all surprised that children are as terrified of them as I am.
There is also the question of the extent to which the dental service is being utilised. We all accept that for quite a time there has been a serious shortage of dentists—about 6,000—and there are, as result, delays in some facets of dental treatment. The service for patients in pain is superb, but in the provision and repair of dentures there is an element of inconvenience and unpleasantness to the patient as a result of delay. I cannot help wondering whether the dental technician is being used to the full extent of his capacity.
We often hear in the House criticism of restrictive practices by trade union members in industry. I am very much opposed to restrictive practices wherever they may be, but here we have a large body of people, of whom a large number are members of trade unions who would themselves rather do a wider job—which, in my view, and that of many professional people, is within their capacity—but are prevented from doing it.
Section 42 of the Dentists Act, 1957, specifically prevents the General Dental Council from setting up a separate class of ancillary dental workers to undertake the fitting and insertion of dentures. That prevents the rapid service which is possible with the influx of the large number of people who can do the job under supervision, and causes unnecessary delay in the fitting and provision of dentures. It goes even further than that. There is a serious difficulty in obtaining good types of would-be dental technicians; first, because of the appallingly and disgracefully low rates of pay offered; and, secondly, because of the lack of a career structure and a professional objective.
P.T.B. Circular No. 143 sets out the scales of payment and qualifications of dental technicians. An all-round craftsman who has completed a five-year apprenticeship and is
…able to undertake the ordinary processes of dental laboratory without direct supervision.
and with four further years in the trade, can reach £605 per annum. That is not the sort of rate to produce people who are of great importance, and who are performing a job of some skill.
Let us take those in the real career structure. There is the senior technician who
…in addition to being a good all-round craftsman, is required systematically to carry out any specialised techniques of an advanced nature"—of an advanced nature:
in connection with anatomical articulation; design and construction of dentures in any
of the various accepted metals, cast or struck, including model surveying; crown and bridge fabrication, and orthodontic appliances…
That man, after six years, can reach the"magnificent" salary of £730 per annum. I do not make any party point here, but if these people are, as I think, extremely important to the dental service, we will not, and cannot, get sufficient numbers of good quality people who have served a full apprenticeship and are carrying responsibility, when these are the rewards and the career structure. To pay such people £730 a year is ridiculous.
At the very peak, there is the chief technician, with a total staff of 13 technicians working under him. This is obviously a man of some responsibility, but his absolute maximum—again, after he has worked another six years at the top—is £825 a year. Such salary scales are quite unrealistic if it is intended to have a good service of dental technicians. Dental technicians can play a big rôle at present in lifting some of the pressure from a very much overworked dental service, and some of the restricted practices that hedge their employment in this way could well be reviewed.
We hear a great deal about it when restrictive practices are applied in industry by the Boilermakers' Union, but these practices are no less offensive when applied by the General Dental Council. A case was reported in the Guardian at the end of last year where the General Dental Council was employing people to go round to see whether they could get illegally fitted with dentures by dental technicians. A case was reported, which was eventually taken to court, where a technician was charged with illegally supplying dentures because he was only a technician.
Things went rather amusingly astray because in court the agent provocateur employed by the Council admitted that he had obtained false teeth from the wrong person but said that he had also had two sets of teeth made by a dental surgeon and was unable to eat with them. He said of Mr. Holloway, the technician concerned:
I must say that those made by Mr. Holloway are far superior to the dentures made by the dentist.
The Council should be more careful in those whom it chooses to buy false teeth
by this means. It is clear that this work could be done by technicians, and where there is an enormous shortage of dentists there is no reason why it should not be done.
There is also the question of the people who are employed in the maxillo-facial service. This is a service developed out of two world wars and is now probably the best of its type in the world. There is one centre at least in every regional board area specifically to deal with damage to the face and facial structure as a result of injury, disease or congenital deformity.
It was thought at one stage after the last war that this service would become less and less needed. It is, I suppose, a rather ironic commentary on the world in which we live that now that the war is over, and all those people who were treated at East Grinstead and Hillend and various other places are no longer being treated, the number of people needing this treatment is rapidly and considerably increased as a result of damage done in road accidents. This is a first-rate and extremely important service of which the Ministry and all those connected with it are entitled to be proud.
It is also a service dependent upon a particular type of technician—a dental technician-plus. Difficulties are being experienced in securing a sufficient number of maxillo-facial technicians not because of the professional scope, but again because of salaries. These people have to do more than the ordinary technician and have to work in conjunction with oral surgeons. I should like to quote from a letter which the President of the Council of the British Association of Oral Surgeons recently sent to the Ministry and other people as well.
There is no secret about this. It says, in part:
The President and Council of the British Association of Oral Surgeons, who are themselves directly concerned in the treatment of maxillo-facial injuries, wish to emphasise in the strongest possible terms that unless immediate steps are taken to provide a salary structure comparable with other employees of the same type in the National Health Service,"—
and that would not be asking very much—
there will be a complete breakdown of the system which has been devised to deal with such injuries. This disaster will not merely be a temporary matter but will persist for
many years since technicians of the standard required cannot be trained overnight.
This is a very important facet of the dental service and it involves a comparatively small number of people who do not receive the kind of attention they deserve.
On this occasion, I hope that we may hear that while we will go on trying to recruit as many dentists as possible, and to get more dental students into our training hospitals, we will also see whether it is not possible to lift some of the less professionally qualified work from the dentists and widen the field of activity of the dental technicians, and, as a result, also improve the standard and the number of dental technicians.
I think that my hon. Friend the Member for Aldershot (Sir E. Errington), in opening the debate, was unduly modest in describing the range of the investigations of the sub-committee of the Estimates Committee. It was indeed a very wide-ranging investigation which covered most aspects of the dental services. It is true that it did not deal at all with the whole subject of remuneration. Although there have been references in the debate to dental remuneration, I intend in this respect to imitate the sub-committee, especially as dental remuneration has been the subject within the last three years of an agreement between the Government and the profession, on the basis of a Royal Commission Report, and has been reviewed in recent months by the Review Body, and as the rates are in the hands at the moment of the Dental Rates Study Group set up in pursuance of that agreement.
I feel, however, that one can only do justice to this important Report by supplying a wide background to the problems upon which the sub-committee more particularly concentrated. The whole dental scene has been dominated in recent years by the phenomenon of the great increase in the volume of treatment which has been made available in the general dental services.
I should like to illustrate this with a few figures. As far as possible, I will use Great Britain figures and my remarks are intended to apply, where the contrary is not stated, to both countries. On a number of detailed Scottish points, however, raised particularly by the hon. Member for Glasgow, Govan (Mr. Rankin), my hon. Friend the Under-secretary of State for Scotland will be communicating the answers to him.
In the nine years from 1953 to 1962, the number of courses of treatment given in the general dental services has risen from 9·4 million to 16·5 million. This is an increase of 75 per cent. over those nine years, or an average rate of increase of8 per cent. per annum, in the volume of treatment given. It is not without its importance, and it is not unsatisfactory, that in that total of treatment the proportion of emergency treatment has fallen appreciably—from 18½ per cent. to 13½ per cent.
This is the fundamental fact about the dental situation at present and in recent years. No one can say, of course, how long this remarkable trend will go on. One can only say that there is no sign at all of its ceasing. It is a trend which is bound to help to close the gap between the supply of dental treatment and the demand for it, whatever that gap may be. I do not think there are any means of estimating precisely what the extent of that deficiency is; but as the gap closes, a number of important effects may be expected. In particular, one may reasonably hope that it will help to reduce the disparities between different parts of the country to which attention has been drawn today.
It is quite true that these disparities are considerable. In London and south-east England there are 3,200 members of the population per dentist, whereas in the North Midlands the figure is almost exactly twice that—though, of course, even in areas such as the north Midlands or Scotland, where the proportion of population to dentists is relatively high, this tremendous increase in the volume of treatment given has enured to the benefit of the inhabitants. For example, in Scotland, although, as the hon. Member for Govan correctly said, there has been a certain reduction in the number of dentists in the general dental services, 45 per cent, more treatment was given last year than nine years earlier.
This remarkable increase in dental treatment in the general dental services has been achieved during a period in which the increase in the number of dentists in the services has been rela- tively small—only 9 per cent., or slightly under 1 per cent. per annum. It is, in fact, almost exclusively the phenomenon of an increase in the productivity of the dental profession—in the amount of effective treatment which a dentist is able to give.
When the subject of the supply and demand for dental treatment was last looked at comprehensively—in the McNair Report in 1956—that Report took no account at all of the factor of output in its calculations and recommendations. It made no allowance for, or even reference to, the possibility of increased output. As the House has been reminded, that Committee recommended that there should be an increase of25 per cent. in the number of dentists on the register. On the basis of that Report, a programme was drawn up to expand the capacity of the dental schools in Great Britain by somewhat over 300 places, thus raising them from about 600 to about 900. Of this programme the first 30 new places, including five in Scotland, come into use this year and a further 55 will come into use in 1965, although, owing to the length of the training, the effect will only be felt in terms of additional qualified dentists produced from the schools after a further interval of four or five years.
Meanwhile, however, since 1955, the year in which the McNair Committee was at work, recommending that there should be an increase of 25 per cent. in the number of dentists, the volume of treatment given in the general dental services has increased by over 50 per cent. A fact of this kind emphasises the extreme difficulty of long-range forecasting and planning in this field, and makes evident the wisdom of the recommendation of the Committee that there should be close and frequent reviews of the manpower situation. Indeed, this was already in hand. I fully accept the importance of keeping an open and critical mind on this subject and watching the position as it develops from year to year.
The right hon. Gentleman is making much of the increase in productivity, which he is perfectly entitled to do, but would he not agree that there might be another reason for the increase in output, namely, that conservation treatment of a rather impermanent nature may be creeping in and that, in fact, a smaller course of treatments of a more permanent nature might be better for the dental health of the nation?
The evidence is that the composition of the total volume of treatments given is moving in an advantageous way. As I pointed out, the element of emergency treatment is diminishing, while the element of conservative dentistry, which on the whole tends to be the more elaborate procedure, is increasing. So I think there is no reason to fear that the increase in volume is being accompanied by a deterioration in quality. Indeed, there is good reason to believe the contrary.
Before I come to look at the dental health and the dental treatment of school children and other priority classes against this general background of the increasing volume of dental treatment in the general dental services, I should like to refer, since reference has been made to it by a number of hon. Members, to the Dental Estimates Board, which plays so important a part in the control and management of the general dental services. I was glad that the Estimates Committee, after its careful investigation—and it certainly was a careful and probing investigation—gave the Board what the hon. Member for St. Pancras, North (Mr. K. Robinson) described as a"clean bill of health".
A number of the aspects to which the Estimates Committee drew attention certainly engage my continuing concern. The schedule of treatments requiring prior approval is something which is continually and critically examined, so that it can be kept to a minimum. The question of mechanisation—of maximum efficiency in the handling of the great mass of statistics and material with which the Board has to deal—is not one which is left without frequent reconsideration. My hon. Friend the Member for Bristol, North-East (Mr. Hopkins) referred to orthodontic treatment and to the question whether there was delay in the approval of estimates for orthodontic work. I think it is not an unreasonable situation where 92 per cent. of the cases with adequate information from the dental practitioner are cleared in two to three weeks. It was, therefore, justifiable for my right hon. Friend and myself to say that, upon the whole, orthodontic cases appear to be dealt with by the Boards with reasonable rapidity I should also like to correct a slip on the part of my fellow burgess for Wolverhampton, the hon. Member for Wolverhampton, North-East (Mr. Baird) by making it clear that an estimate is never disapproved by the Dental Estimates Board except on professional advice.
I feel, however, that the recommendation of the Committee for merging the two Boards would not produce the practical results which they hoped from it. Indeed, I am sure that it would, at any rate in the short run, have very much the reverse effect, because, whichever of the three theoretical possibilities that were earlier deployed was adopted, there would certainly have to be a big changeover of staff and a great dislocation in the work of the Boards. I think, too, that it would inevitably have the effect—particularly if the Scottish Board were to be moved over the Border—of reducing the intercourse and common understanding which is so necessary between the Board and the dental profession who have to work with it.
I come now to consider, against the general background which I have depicted, the treatment of the priority classes, the nursing and expectant mothers and children, whose treatment—this I emphasise—is shared between the general dental services and the local authority dental service. The developments in this field during the past five or ten years have been striking and point to big changes taking place.
I take, first, the expectant and nursing mothers. In the local authority service, in 1956, 51,000 such mothers were treated; in 1962, only 33,000 were treated. But in the general dental services, in 1956, they received over 500,000 courses of treatment and, in 1962, over 750,000.
For children, that is, children under 5 and children between 5 and 15, I must use England and Wales figures, because, although the figures for Scotland are available, they are divided at a different age-point and it is impossible, without unendurable complication, to give Great Britain figures. In England and Wales, in 1954, 65,000 children under 5 were treated in the local authority service, and this total had fallen to 54,000 in 1962. But in the general dental service the number of treatments had doubled, from 184,000 to 364,000. Again, the number of children of school age, that is, between their fifth and fifteenth birthday, treated in the local authority service fell from 1,494,000 in 1953 to 1,252,000 in 1962, But in the general dental service courses more than doubled—from just under 2 million in 1953 to approximately 4 million in 1962. A particularly gratifying feature relating to children of school age is that the proportion of emergency treatments—an indication that children have not had timely treatment or dental supervision—fell from one-quarter to one-eighth of the total number of courses of treatment.
These figures for dental treatment of school children show that in England and Wales, in 1962, well over 5 million courses of treatment altogether were given, in one service or the other, to the school children of this country. We know from general experience that about two-thirds of the children of these ages who are inspected are found to require dental treatment. Therefore, having in mind the fact that the number of children of those ages was 6·7 million in that year, it. is evident that a very high proportion of such children who need dental treatment are in fact receiving it from one part of the service or the other.
The situation which these statistics disclose—I apologise for their laborious character—is this. There has been overall a tremendous improvement in the dental treatment of the priority classes. Taking all treatment together, each group of the priority classes is receiving a far greater volume of dental attention than it was receiving relatively few years ago. But of this treatment, a minority only—and a declining minority—is being given by way of the local authority services.
It is dear, therefore—this was very fairly recognised by the Committee in, for instance, paragraph 70 of its Report—that the whole future and function of the local authority dental services has to be looked at carefully in the light of the changed and changing background. Before I suggest what may, in future, prove to be the main objectives of the local authority dental service, I want to discuss its manning in a little detail.
The manning of that service reached its lowest point in 1951, with only 808 whole-time equivalents in the local authority dental service of both countries together. In 1962, the figure had risen to 1,336—much more than in proportion to the increase in the number of school children. In fact, the increase has been particularly rapid in recent months. There was a big jump between 1961 and 1962, and the impression I have from visiting clinics in many parts of the country is that recruitment is continuing at an improved rate.
In defence of my own statistics, I must point out that it depends entirely upon one's starting point. I think that, during the last five or six years, it has been slightly less than the increase in the number of school children.
Yes, I know; but during the period which I took—from the lowest point to 1962—there was, in fact, a fairly rapid increase early in the decade and again at the end of the decade. Perhaps it is a warning to both of us against league tables.
It is important, however, to remember—this is one of the big things which has come out of this debate—that we must not look just at dental manpower in considering the local authority dental service. We have to look to an increase in supportive and ancillary manpower of all kinds. I was very grateful to the Estimates Committee for the very emphatic support which it gave to the development of a number of different forms of ancillary support which could, and should, be valuable in the local authority dental service. The Committee referred to dental hygienists. In the last year or two, there has been a sharp increase in the training facilities available for dental hygienists. It is to be hoped that local authorities will find growing opportunities for employing them in their services.
As regards dental auxiliaries, this development, as the House knows, is still in an experimental stage; but I hope that I am not presuming if I say, even in advance of the report to the General Dental Council, that the results of the experiment appear to me impressive and that the output of 60 trained dental auxiliaries per annum from the New Cross school is something which could be a very valuable reinforcement of the local authority dental services.
It is evident from what I have said that calculations of a requirement of 2,600 dentists in the local authority dental services, on the basis of it being the function of the local authority dental services to provide a comprehensive service of inspection and treatment for all school children—
Will my right hon. Friend clarify his phraseology? He is using the expression"local authority dental services", sometimes, I think, including the maternity services and sometimes confining it to the school service.
No. Wherever I have used the expression"local authority dental services", it has certainly been my intention to include both the services provided under health powers for children under 5 and the services provided in the school dental service. The staff, in effect, are one. I have, therefore, referred to the local authority services throughout when speaking of staffs.
Yes. The proportion which the work done in the priority dental service bears to the amount of work done in the school dental service is quite small; but I agree that the figure of 2,600, which I quoted, is a school dental service figure and was derived from calculations based upon numbers of school children.
But this figure rests on the assumption that it is the function of the school dental service to provide a comprehensive service of inspection and treatment for all school children. This no longer corresponds with the realities: it does not correspond with the changed sources from which school children are obtaining dental treatment, nor does it answer to the shift in the objectives and centre of gravity of the school dental service.
That service, so far as one can foresee, must always stand ready to provide treatment, and the giving of treatment must always be an appreciable part of the work of those who are employed in it. But its main objects for the future, against the background which I have sketched out, must be two. The first is to ensure complete coverage, that is to say, to ensure that there is no child between those ages who fails to obtain, in one way or another, the dental treatment needed. It must ensure a complete check upon the dental health of every child. It is an indication of the increasing relative importance of this objective in the school dental service that the proportion of inspections to treatments has been growing. In 1953 there were 3 million inspections, or twice as many as the number of treatments given, whereas in 1962 there were 4 million inspections, or three times as many as the number of treatments given.
The second objective which appears clearly to be indicated for the school dental service is the promotion of dental hygiene and dental health education.
I have not forgotten that point, and I shall deal with it, but at this stage I want to recognise the support which the profession, both individually and collectively, through its representative bodies, gives to just those objectives. We are indebted to the dental profession not only for the increase in the volume of treatments to which I have drawn attention—and it is the dental profession which has provided it—but for its enthusiasm in the cause of prevention and dental health education. This has always seemed to me to reflect great credit upon the profession.
One example is its support of fluoridation. The Estimates Committee sagely remarked, in paragraph 73, that
The provision of additional facilities for dental treatment is not the only means of improving the dental health of schoolchildren.
I venture to think that if it had been doing its work a few months later it might have included, among the other means of improving the dental health of school children, fluoridation—a measure which halves dental decay in children surely, safely and cheaply.
But this changed and changing rôle of the local authority dental service, and particularly of the school dental service, within the whole of the country's dental services, certainly calls for closer study of what is going on and for firmer guidance to local authorities on a national basis. This was one of the major conclusions of the Committee. It is one with which the Government cordially concur; and a number of methods recommended by the Committee towards this end will be applied.
In particular, however, the Committee recommended that in England and Wales responsibility for the school dental service should be transferred to my own Department. After careful consideration the Government have concluded that it would be a mistake to sever the dental health of school children from their general health—to sever the school dental service from the school medical service. In Scotland, although these two are on the other side of the dividing line, they are both together. The Government believe that the double objects of securing a closer integration between what is being done in the local authority services and what is being done in the general dental services, while retaining the link between the school dental and the school medical services, can best be carried out in another way.
As the House knows, at present the same individual is the Chief Medical Officer of my Ministry and of the Ministry of Education. On this analogy, I have arranged with my right hon. Friend the Minister of Education that my Chief Dental Officer will in future act also for the Minister of Education, so that there will be the same link of personal responsibility as there is on the medical side. Moreover, the senior dental officer of my Ministry who is at present responsible for advising local authorities on the priority dental service will perform the same function for the school dental service. The staff at the Ministry of Education working under the senior dental officer is also to be strengthened by two additional dental officers. I am sure that the effect of these measures will be to bring closer together the school dental service, the priority dental service and the general dental service, and to promote the more purposeful direction of the local authority dental services towards those objectives which the changed background of the dental services as a whole indicates as being the right ones.
When the Government considered that they did not wish to separate the school dental services from the school medical services, did they also consider the possibility of the right hon. Gentleman's Ministry taking over the complete medical services and the dental services?
What I am concerned to point out today is that the recommendation of the Estimates Committee, as it stands, would have the undesirable effect of severing these two services. The way which is being taken will bring the school dental service into a much closer connection with the rest of the dental services and will assist in giving a much more purposeful and closer guidance to the school dental service.
I end as I began, by referring to the extraordinarily wide and thorough investigation which the Committee carried out. The House will understand what I mean when I say that merely to count up the recommendations accepted, modified or rejected and to look at the rather official phraseology in which observations are traditionally couched can give no indication of the value which a Department draws from the work of an Estimates sub-committee or from a Report such as the House has been discussing today.
I know that I speak for my right hon. Friend the Secretary of State for Scotland and my right hon. Friend the Minister of Education as well as myself when I say that we, as well as the House, feel ourselves to be greatly in the debt of the Estimates Committee for this Report.
I should like to ask my right hon. Friend a question. One would like to read and consider carefully the figures which he has given. The point which I desire to make, however, is that very often the figures of National Health Service children's attendances may be misleading in view of the fact that a number of parents believe that their children should have regular attention, which means that they may go as often as two, three or four times in the year.
Therefore, I hope that nothing that my right hon. Friend has said on the figures will alter the position at page xxxv of the Report, where it states:
In the view of Your Committee it is desirable that steps should be taken to produce more accurate figures, so that a clearer picture
can be obtained of what happens to those school children who are inspected but not treated or not even inspected by school dental officers.
I accept my hon. Friend's point that one cannot at present precisely marry the figures of courses of treatment given to children between the ages of 5 and 15 in the general dental service with the number of such children treated in the school dental service. It will, however, be found, I think, that the deduction which I drew from the figures—some of which were later than those which could be available to the subcommittee—substantiates my conclusion that a high proportion of the children of school age who need dental treatment are already receiving it. I entirely accept, nevertheless, that we need to know more, so that the school dental service can perform its function of ensuring complete coverage.
Before turning to the subject of dental services, I should like to say something in response to the remarks made earlier in the debate by my hon. Friend the Member for Bristol, North-East (Mr. Hopkins). Speaking generally of the work of the Estimates Committee, my hon. Friend expressed the hope that subcommittees might have more expert advice and assistance at their disposal.
As Chairman of the full Committee, I merely want to say that in my view it would be a great mistake if we indulged in empire building and tried to make ourselves too authoritative and expert. A large part of the value of the Estimates Committee consists of the fact that it is a sort of jury, a collection of, we hope, intelligent laymen, but laymen at all events. Our value largely resides in our very inexpertness, because it enables us to"stick out our necks" and make suggestions and recommendations which can be considered and, possibly, rejected by Departments and by Ministers without creating an impossible situation, the sort of situation that would be created if we spoke with greater authority. I have not myself noticed that any Ministry has felt particularly inhibited in rejecting our recommendations, least of all the Ministry of Health
Having said that, I should like to say a few words about the subject of the debate. First, I thank my right hon. Friend the Minister of Health for his exceedingly friendly approach to the work of the Estimates Committee. We have not always had a friendly approach from his Department and I hope that this is a sign—it would be a welcome one—that the Ministry of Health will pay careful attention to what the Estimates Committee, with the best of intentions, recommends and will not reject everything out of hand. I am not simply counting up numbers of recommendations which have been accepted or rejected when I say that.
This debate has been valuable, particularly because I do not believe that our recommendations would have had the same sympathetic consideration from the Department if it had not been possible to debate the Report in the House. I therefore take this opportunity of emphasising the great significance that the Estimates Committee attaches to its right to have two whole days' or four half days' debate in the course of the Session, a right which has only recently been established.
Speaking as a non-expert and as one who was not able to attend all the meetings of the sub-committee, I believe that by far the most valuable of our suggestions was that of placing the school dental service under the Ministry of Health. I am not altogether happy about my right hon. Friend's approach and decision in that matter. I was surprised, for example, that he appeared to claim credit for the fact that the general dental service was doing most of the work of the school dental service. A large part of my right hon. Friend's speech almost boasted of that.
The plain fact is, as the evidence proves, that the school dental service is breaking down. As a department of the Ministry of Education it has either to be ended or mended. I am sorry that my hon. Friend the Parliamentary Secretary to the Ministry of Education is not speaking today, although I quite understand that he would have had a difficult task. It is not the fault of that Department—the school dental service is not really its proper sphere of activity—but, certainly, the Department has not carried it off very successfully.
I welcome the changes—I do not like to call them concessions—which were announced during the last few minutes by my right hon. Friend. Is he quite sure, however, that he is not simply propping up and perpetuating an anomaly? Is it not reasonable and logical—although I always suspect logic—that health should be treated as one subject under one Ministry? Why should a Ministry like the Ministry of Education, which has no expert knowledge on health matters, have to go to another Department, the Ministry of Health, and borrow the services of its experts so that health and dental services for children should persist under the roof of the Ministry of Education? There is, I think, more in this attitude of the Government than meets the eye. Little empires have been created and there is a reluctance to dismantle them.
It is decay, but no change, I fear.
However, I do not want to be ungenerous. Speaking for the Estimates Committee, I am truly grateful to the Minister of Health for his kind references to us and for the way in which he has given careful consideration to our recommendations. Even though I may not agree with all his conclusions, I have no doubt whatever that the consideration has been careful and sympathetic. It augurs well for future relations between my right hon. Friend's Department and the Estimates Committee.