I beg to move,
That an humble Address be presented to Her Majesty, praying that the National Health Service (General Dental Services) Amendment Regulations 1967 (S.I., 1967, No. 259), dated 22nd February, 1967, a copy of which was laid before this House on 1st March, be annulled.
We now move to a discussion of a very much more detailed Statutory Instrument, No. 259, although the same proviso applies as that which I mentioned when moving the previous Motion. I think there are some points which should be gone into. I understand that, in accordance with normal practice, the Minister has discussed these amendments with those principally concerned. I am sure that in essence they make a great deal of sense dealing, as the explanatory note says, with the remuneration by way of fee of those providing general dental services at health centres, making changes in the dental estimate form, and the question of dental assistants.
I start with a very small drafting point and I apologise at once to the Minister because I have not had an opportunity of doing what I normally regard as the usual courtesy of informing his office that I would raise this very detailed point. I make quite clear that I do not expect an immediate answer across the Floor of the House on this point. I raise it because I think it conceivable that it may be of assistance to him. I have a feeling that inadvertently he has amended rather more than he meant to do. That is rather a bold statement for any layman like myself to make, but it seems that that is what has happened.
If he looks at the parent Regulation 3 of 1964, he will see that this is amended by the Statutory Instrument before us by Article 2(2). I anticipate that the Minister intends that after the passing of this Statutory Instrument parent Regulation 3 is to open with the words:
The arrangements which a council are required by Section 40 of the Act to make with practitioners for the general dental service shall incorporate …
and then paragraphs (a) and (b). The form of words in the Statutory Instrument before us could at least have been
strongly argued to have taken out the introductory words. The words used in the Statutory Instrument before us are to the effect that there shall be a substitution for "sub paragraphs 1(a) and (b)", and I think that there is a strong presumption that the Minister has thereby inadvertently taken out the introductory words.
As I say, this is a highly detailed matter and I have not observed what I regard as the usual courtesy of notice to his office on it. I do not, therefore, ask for a reply now, but I should be grateful if the right hon. Gentleman would be kind enough to write to me to put my mind at rest.
My second point is one of complaint. This Statutory Instrument deals with three important and highly practical matters. For instance, the dental estimate form is one of the principal contacts which the dentist has with the Service as a whole. It has been most helpful up to now to have by far the greater part of the form incorporated in the 1964 Regulation. There has been only one amendment since, in 1965, dealing with the scale of remuneration, which was comparatively simple and easy to follow. Now, however, if the House approves this Instrument, the ordinary dentist and those who advise him will have to go through a great deal of cross-reference from one Instrument to the other.
I appreciate that any Minister is not always his own master in matters of this sort, but I make the plea—I have made it often before to other Ministers—that the Minister and those who advise him so competently should bear in mind the problems of the ordinary practitioner. It would be helpful now if we could have a consolidated set of Regulations so that the ordinary person could find out exactly what it all meant.
My next general point relates to assistants. This arises from page 19 of the parent Regulations, Regulation 12(3), which is amended by the Instrument now before us. The main change covers the situation where a dentist is operating in more than one area, and, in making the change, the right hon. Gentleman has slipped in two significant words. I think I know what the intention is, but this is a matter of importance to the general
practitioner and it would be helpful if the Minister made his intention explicit. He is now providing that a practitioner
shall not employ more than two assistants in all"—
the words "in all" are new—and he then goes on to provide for certain consents, and consents by more than one council.
I assume that what has been happening is that alert practitioners have appreciated that, if they are practising in an area covered by more than one council area, they are not clearly precluded by the Regulations as they stand at present from employing more than two assistants. In other words, they have done it—to put it in this way—on the strength of there being more than one council. It would be helpful if the Minister would make the point clear. Otherwise, the inclusion of the words "in all" becomes a little ominous.
We are always watchful for simple words inserted in legislation or Statutory Instruments. One constantly gets badly caught otherwise.
I am grateful for my hon. Friend's support. It behoves us all to keep a watchful eye on these matters, and it is a good thing if those who advise on drafting know that we shall be doing so.
I come now to the dental estimate form again. In the parent Regulations this is dealt with on page 16, and the Regulation now to be amended is Regulation 7(1,d). At first blush, the new provision seems rather curious. The Minister has used terms which largely follow what went before, but the practitioner is now to be allowed to sign his name to the form in his own handwriting, with his name and initials—which is what one would expect—but there then comes the new provision,
except where the Board allow him to use a shorter signature".
We should all be glad to know why.
I have an interest in this question because, although I am not a dentist—mercifully, there are some fates worse than death which one escapes, and I think that that would be one—I have what is probably one of the longest names in the House. If I were a dentist and subject to this Regulation, I should assume that I was required to sign my full and rather long name—which is not one I made up myself—whereas, under the new Regulation, the board will, apparently, be entitled to allow me to use a shorter signature. I am puzzled by this. What situation has the Minister in mind in which a dentist would be allowed by the board to sign in a shorter form? Would I be allowed to sign simply as "van"? In ordinary life, there are many times when I long to be able to shorten my name.
This is a serious point. I can understand that there are practitioners, though probably not so many in the dental service, who help us immensely in this country but whose countries of origin are other than our own and who may well have very long names. The board may be happier in such cases to have a shorter signature. In the second place, I fully realise that the Minister does not wish to impose on the already heavily pressed dental profession more administration and form filling than he absolutely must. I should be glad to have an assurance that what is here provided w ill not be misused in some way.
In the fairly recent past, some dentists who have got absolutely fed up with the amount of administration in which they think they are involved have, as a matter of protest, signed their forms with a cross. I assume that the board had no intention to authorise that as a shorter signature. Will the Minister please tell us why he has put this provision in?
I have no other comments upon the dental estimate form save the one which I made earlier in my speech, that the unfortunate dentist trying to find his way through the provisions of the form will now have the fearful job of weaving between two separate Statutory Instruments.
My last point concerns what is, perhaps, the most important provision of all here—I warmly welcome it—namely, the amendments providing that general dental services at a health centre may be remunerated by fees as an alternative to salary. I have a particular interest in this because it is in areas such as designated new towns that health centres fill a most important rôle and, therefore, anything which assists in the provision of these services is to be welcomed. In my view, the powers which the Minister is now taking will assist to this end, but I should be glad to know what reason prompted the right hon. Gentleman to take them.
Was it pressure from the profession, or was it that the Board was finding difficulty in obtaining sufficient practitioners on the old basis? Is it that the Minister felt that it was wise to move to a system of fees rather than a salary basis? Has he perhaps come up against opposition from the profession? It would be very useful to know how the Minister's mind is working. As a consequence of the Regulations, does he expect a fairly substantial change-over from a salary to a fee basis? Those are matters we should be grateful to have fully explained, but I repeat that in principle and in general I very much favour the way in which the Minister's mind is clearly moving.
Only last week I paid a visit to my own charming, able and efficient dentist, and I commented to him that whereas everyone was glad to see his doctor almost everyone is reluctant to see his dentist. I should think that the dentist's must be one of the most unrewarding professions in terms of human relationships, but the dentist plays a vital part in our health services. The Statutory Instrument deals with three detailed but important aspects of their work. Although I am aware that the Minister's Parliamentary jaw is rather sore from the extractions of last week's local government elections, I hope that he will give an explanation.
I shall not deal with the final observation of the hon. Member for Wokingham (Mr. van Straubenzee), but I must tell him, in reply to his penultimate observation, that there is plenty of evidence that the reluctance to visit one's dentist is getting less and less as time passes, particularly among children. I visited a training establishment for dental ancillaries not very long ago in which there was a whole battery of dental surgeries dealing with children. I was there some time and I did not hear an exclamation of pain throughout my visit. All the children seemed perfectly happy, whether they were awaiting treatment or undergoing it.
The Regulations are the sixth set of Amendments to the consolidated General Dental Service Regulations, 1964. The hon. Gentleman made a fair point about consolidation. We are preparing a further consolidation which I hope will be laid before Parliament towards the end of June. There is a reason for the delay; the Dental Rates Study Group is considering recommendations on the scale of fees necessary to give effect to the revised target net income for 1967–68.
The hon. Gentleman very fairly said that he did not expect a reply this morning on the drafting point which he raised and which I should like to discuss with my legal advisers. As a layman, I never like to give interpretations of Parliamentary draftmanship, but I shall certainly write to the hon. Gentleman on the point.
The principal Amendment in the present set of Regulations is that which permits those dentists who are willing to provide general dental services at health centres to choose, with the agreement of the executive council concerned, whether to be paid by salary, as at present, or, if they prefer, by fee in the same way as dentists practising from their own surgeries.
Until these Amendment Regulations were introduced, dentists who wished to provide general dental services from a health centre could do so on a salaried basis only. For some years the profession have argued that this method of remuneration deterred dentists from taking up health centre practice; evidence suggests that this is probably the case, since at present there are only about seven dentists in England and Wales providing general dental services from health centres.
The growing interest of the medical profession in the development of health centres, which is illustrated by a very substantial increase in the number of health centres planned by local authorities over the next 10 years, and particularly the next five years, emphasised the need to remove, wherever possible, any disincentive to dentists providing general dental services from health centres. As the National Health Service Acts do not debar the Minister from making arrangements for dentists in health centres to be remunerated in the same way as dentists practising outside, I decided to amend the Regulations in the hope of encouraging more dentists to consider practising from health centres. The hon. Gentleman asked where the initiative came from, and I assure him that it was mine.
As it is not entirely clear whether my powers under the National Health Act enable me to permit dentists in health centres to accept private patients, I am advising executive councils that for the time being they should not enter into any arrangements for the provision of general dental services at health centres that will enable dentists to treat patients privately, though they will be able to provide more expensive treatment than is clinically necessary where a patient is willing to pay the difference in cost.
In a circular to local health authorities on health centres which I hope to issue shortly I shall make it clear that dentists in health centres who choose to be paid by fee will be free to agree in consultation with the Executive Council and local dental committee the extent to which equipment, materials and services shall be provided by the local authority on a repayment basis. Thus if a dentist prefers to install his own dental chair, employ his own nurse and technician or use a commercial laboratory of his own choosing he will be free to do so. On the other hand, should he prefer the local authority to provide all equipment, services, staff and laboratory facilities it may do so. He will, of course, be required to pay the full economic cost of any services provided. This is because the scale of fees incorporated in the General Dental Service Regulations are designed to yield not only the target average net income recommended by the Review Body but practice expenses as well.
The development which this Regulation makes possible is, I believe, very attractive for the younger dentist, for he will be able in the years when dentists' earnings tend to be at their highest to build up a substantial practice without having to worry about servicing and repaying bank or other loans. I understand from my recent discussions with the British Dental Association that some young entrants to the profession are reluctant to incur the heavy capital commitments needed to set up a practice on their own account. At the same time, the dentist who comes into the health centre will benefit from contact and exchange of views with his medical, pharmaceutical and nursing colleagues who will be working in the same building.
I appreciate that the profession is disturbed at the present embargo on private practice from health centres and believes that because of it few dentists will be willing even now to come into health centres. I hope that their fears will prove to be unfounded. Nevertheless, my mind is not closed to the possibility of permitting some private practice, but as amending legislation will be necessary before present arrangements can be modified to allow this I want to consider the whole question very carefully.
I have to bear in mind that in some parts of the country there are dentists, albeit a small proportion of those working in the general dental services, who are unwilling to provide the full range of treatments that should be available under the service. Clearly I could not accept such a situation in health centres that are financed by public funds primarily for the provision of National Health Services. A situation in which a health centre dentist refused to provide a set of dentures for a National Health Service patient who needed them could not be tolerated. It seems essential to me, therefore, that those who come into health centres must be prepared to offer the full range of treatment available under the National Health Service that is needed by the patients they accept and that they themselves are competent to provide.
There is nothing in the new arrangements to prevent a dental partnership, or a single-handed dentist for that matter, from coming to an arrangement with an executive council to provide general dental services at a health centre on a part-time basis while still retaining surgery premises elsewhere. Nor is there arty reason why a dentist in a health centre should not, with the consent of the executive council, bring in a partner or enter a separate part-time contract with the local health or education authority to provide treatment under the priority or school dental services at the health centre.
It is my aim that the new arrangements shall be as flexible as possible and shall insure that the facilities at health centres are used as much as possible for the maximum number of N.H.S. patients. At the same time, I would only encourage health authorities to provide accommodation for dentists in health centres in places where there is a demand for such facilities.
That is the main amendment in the Regulations. There are others, primarily designed to tidy up and clarify certain points of doubt. As the hon. Member said, there are some slight changes in the dental estimate form and the way in which it must be filled in by dentists.
As to his question about a shorter signature, I am told that the Board has to be certain that the signature is that of the practitioner and not a simple mark or initial which could readily be imitated by an employee of the dentist or some other person. The Board must be satisfied that the shorter signature can be allowed without carrying such a risk. I imagine that, if a dentist had a signature as long as the hon. Gentleman's or longer, he could arrange with the Dental Estimates Board to sign something else.
Opportunity has been taken to resolve doubts where executive councils have power to hear a complaint from a patient that a dentist has charged him for failing to keep an appointment without good reason. In future, executive councils will not deal with such complaints, which are essentially matters for the civil courts to determine.
For some years, with the profession's agreement, the number of assistants employed by a dentist providing general dental services has been limited to two. The hon. Gentleman is right to say that the Regulations did not make it clear beyond doubt that this was the maximum for each principal, irrespective of the number of executive council areas in which he practised. We have corrected any misapprehension on this point. It is not a change in practice but merely a clarification.
I have also amended the Regulations to bring them into line with the recent amendment of the General Medical Service Regulations, which provide for executive councils rather than dentists to pay general medical practitioners a fee for the arrest of haemorrhage.
At the request of the profession, the term "occasional treatment" has been substituted for "emergency treatment" as a description of certain treatment that may be done by a dentist without the prior approval of the Dental Estimates Board. I have also amended the conditions governing the use of materials to require that acrylic teeth supplied in the general dental services shall conform to a recently published British Standard. In the light of these explanations, I hope that the hon. Gentleman will feel able to ask leave to withdraw the Motion.
I am grateful for the Minister's painstaking explanations. My only reservation is that we shall want to look more closely at the admittedly thorny question of the treatment of private patients at health centres. I was interested to hear the right hon. Gentleman say that his mind is not closed to an extension here. As the matter is under examination, it is clearly not appropriate now to go into it further. In the light of his explanations, therefore, I ask leave to withdraw the Motion.