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—