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.