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I must announce to the House that I have selected the amendment in the name of the Prime Minister and placed a 10-minute limit on Back-Bench speeches. May I also add that the amount of time available to Back Benchers will depend to a great extent on the restraint shown by the three Front-Bench spokesmen?
I beg to move,
That this House
supports the achievement of good oral health through the provision of NHS dentistry;
calls, therefore, on the Government to fulfil its commitment that everyone should have access to NHS dentistry;
is alarmed that the British Dental Association regards the new dental contract as 'a shambles' and is concerned that many dentists will reduce their commitment to NHS dentistry;
and further calls on the Government to withdraw the National Health Service (General Dental Services Contracts) Regulations 2005 and the National Health Service (Personal Dental Service Agreements) Regulations 2005 and immediately to re-open negotiations with the dental profession on dental services contracts which are piloted and linked to patient registration and capitation payments, support for preventative work and the achievement of good oral health.
In September 1999, the Prime Minister said that by 2001 everyone would have access to NHS dentistry just by calling NHS Direct. Six years after he made that pledge fewer people than ever are registered for NHS dentistry. In those six years we have seen queues forming outside the premises of NHS dentists who are opening up their registrations. We may not see that in future because the Government propose that people will not be able to queue outside NHS premises to be registered; they will have to register by letter or by telephone—queuing is too embarrassing. Indeed, the situation has now become so bad that the public are queuing outside private dentists.
Patients in Torbay are being told that they must not queue outside any new NHS dentist. I am advised that they have received letters informing them that it would be embarrassing for the primary care trust to have people queuing because it knows that so many people want dental treatment and that there are so few NHS dentists. Is that not outrageous?
It is outrageous.
I visited Torbay before the last general election and talked to the secretary of the local dental committee. If I recall correctly, the number of patients registered in south Devon was under 30 per cent.—among the lowest in the country. Indeed, the number in my constituency was also among the lowest in the country.
A Castle Point dentist and a local dental committee secretary, Mr. Foreman, states in a letter dated
"Under the terms of the new contract our CACV has been reduced by some 80 per cent. from our historic NHS gross average."
Dentists in Castle Point do a great job and we must fund them properly. We must stop ill-thought-out cuts. Does my hon. Friend agree that the Government's policy is a shambles and will reduce the number of NHS patients?
My hon. Friend is absolutely right. It is not only me who thinks that the policy is a shambles. The British Dental Association also thinks that it is a shambles. The association said that Ministers conducted the contract negotiations leading to a new dental contract with "extraordinary ineptitude". It described it as a "shambolic process". It has been a shambles. Over recent years, dentists have reduced their commitment to the NHS because they have been on a treadmill of drill and fill. We have known for years that change is necessary. That was why the Conservative Government, before the 1997 general election, introduced legislation that established primary care trusts and personal dental services contracts.
The Government have pursued a new dental contract based not on new ways of working but on targets. They propose a target-driven process that does not recognise the needs of the profession or of patients.
My hon. Friend and the Minister might be interested in an e-mail that I received a few days ago from a constituent. It reads:
"Since I moved to Ashford some 40 years ago I have attended the same dental practice. Last Tuesday, after my six-months check-up, I was advised that due to Government contract changes I would not be able to make a new appointment."
That is what dentists believe and that is what their patients believe. Contract changes are driving people away from the NHS.
I thank my hon. Friend for visiting the town of Hornsea in my constituency. As he knows, it is an isolated rural town. It is the largest town in the country without an A-road into it. The threat, when he visited the town, concerned community hospitals. That threat still remains. However, there are three dental practices in the town, two of which have announced in the past week that, thanks to the Government's shambolic handling of dental contracts, they are leaving the NHS. Seven thousand fewer of my constituents are now registered with NHS dentists than before the Prime Minister's promise was made.
I am grateful, Mr. Deputy Speaker, but I am grateful, too, to my hon. Friend Mr. Stuart for making that important point. Apart from persistent inequalities in terms of dental outcomes and dental health, inequality is increasingly apparent in terms of access to NHS dentistry, all of which is a condemnation of the Government.
I am grateful to the hon. Gentleman for reminding us of a previous Conservative Government with his reference to funding issues. On the "Today" programme this morning, the Leader of the Opposition confirmed that it was his party's policy to introduce a third fiscal rule—the proceeds of growth rule—which would mean that spending would fall as a percentage of gross domestic product under a Conservative Government. Does the hon. Gentleman expect the NHS and dentistry to be carved out of that rule, or does he expect it to apply to them too? If so, public spending would fall as a percentage of GDP on dentistry services.
I am grateful to the hon. Gentleman, whose point comes from the bottom of page 2 of the Labour party briefing—we will see if we reach the rest of those listed. One would have thought that the hon. Gentleman could at least write his own interventions. We made clear before the election what we intended to do about dentistry, and our proposals would have made an enormous difference. I do not know whether the hon. Gentleman in his previous occupations had occasion to read "Proposals for modern oral health", which was published in October 2004 by the Conservative party, but before the election we set out proposals based on registration
"to encourage an ongoing relationship for patients with a general dental practice."
The Government, however, propose to abolish registration. We proposed, too, a shift from fee-based remuneration to capitation. The Government propose to retain an activity-driven system, instead of introducing a system in which finances are driven by the number of patients on a practice list. We proposed a low-cost monthly payment scheme for non-exempt adults—the Government propose to increase the charges for patients—and oral health promotion focused on children. The Government, however have enabled primary care trusts—and, in some respects, they have encouraged them—to refuse children for treatment and exempt adult contracts for dentists. Finally, we proposed an
"evidence-based schedule for NHS dentistry designed by the National Institute for Clinical Excellence".
At least the Government have begun to introduce that proposal.
Will my hon. Friend include in his policies a commitment that the Government of the day should fund private dental care if someone is wholly unable to obtain NHS dentistry because none is available?
I am grateful to my right hon. and learned Friend, but I am not going to make that pledge. My objective, and the objective of the Conservative party, is to secure access to NHS dentistry for people in this country on an equitable basis. Inequalities of access have given rise to the need for a new contract. The purpose of the motion is to make the Government realise that it is the eleventh hour—it is one month to the day before the new dental contract comes into force. The profession are against the contract, and it profoundly disagreed with it in earlier discussions. The Government, however, refused to listen. In December last year, the British Dental Association literally walked away from the negotiations, and said that talking to the Government was akin to a one-way street. It talked to the Government, but the Government did not respond.
I am always anxious to contribute to debates secured by my hon. Friend. Does he agree that there is concern about oral health because of the lack of access to dentists, and that cancers of the mouth may increase and orthodontic provisions could be affected?
That is absolutely right. A central reason why dentists as a profession want to spend more time with patients is that they want to undertake proper preventive work and good oral health work. In the mechanics of the contracts, the Government have not taken proper account of the time that it takes for new orthodontic practices to establish their work. Practices across the country, including one in my own constituency, have written to me, because they have been offered a contract that dramatically underestimates the amount of work that they need to do. The base year or target year did not include their work because they had established themselves more recently.
The dentists walked away from negotiations with the Government, so the Government proceeded on the wrong basis. They did not introduce proposals based on registration or a capitation system. Their proposals did not encourage preventive work or promote good oral health. They should work with the profession, rather than against it. Not only is the profession against the Government, but this morning, Which? published a survey in which 79 per cent. of the public said that they do not trust the Government to improve dentistry in the next year. The profession and the public are saying the same thing, so the Government must think again. The motion is designed to make sure that they do so. The contract is a shambles, and it is not based on the primary dental services pilots. It does not include a UDA system. I apologise to the House. There are no Northern Ireland Members in the Chamber, but by "UDA" I mean "units of dental activity". The personal dental services contracts were not established on that basis, although the UDA system allows dentists to spend more time with patients and takes account of the size of patient lists. The Government would not proceed with such proposals, which is tragic.
Is it not irresponsible of the Government to introduce an untried and untested system, which is causing chaos throughout the United Kingdom, and will not achieve their aim of improving the quality of care for patients, securing access to dentistry and improving the nation's oral health?
My hon. Friend is right, and has captured the profession's view. I have already cited the British Dental Association, which has said:
"The new contract will not secure patient access, improve oral health or raise the quality of care."
Those are the things that we are supposed to target, but the Government are not setting out to achieve them. The contract is seriously flawed.
Leicestershire primary care trusts have a £6 million shortfall, so it will be impossible to deliver even the care that is available this year. That is on top of the complaints by the Leicestershire local dental committee, which is almost unanimously against the proposals, particularly the decision to charge on a treatment basis rather than per visit.
My hon. Friend is quite right. The pictures of people queuing for a dentist in the Leicester Mercury are testament to the difficulties that they are facing in the light of the withdrawal of services. The Secretary of State has not bothered to stay in the Chamber to discuss dentistry, but there are dental practices in her own constituency that have written to my hon. Friend Dr. Murrison to say that they have ceased to provide NHS dentistry. We need a new contract. Not only do practices find it impossible to secure contracts that will enable them to continue to look after their patients—90 per cent. have experienced difficulties with contract values—but, as I have said, they have lost the ability to charge for missed appointments. They can no longer offer services to exempt adults and children.
Well, there is a problem with which we must deal, as some dental practices say that adults can only register their children for NHS work if they enter into a private contract themselves. PCTs, however, have told practices that they cannot offer a contract to treat children and exempt adults on the NHS, whether or not the practice has made that condition. Children have therefore been thrown off NHS lists, even though their dentist is willing to offer NHS dentistry.
As the hon. Gentleman knows, because of demands in this House dentists were following exactly the practice that he outlined by saying, "We'll take your children on the NHS if you as parents go privately." There can still be children-only lists under the new system. I am sure that he agrees that if primary care trusts believe that it is better for dentists to offer services to children and parents at the same time, it is absolutely right that they have the discretion to do that.
As the BBC survey said this morning, 5 per cent. of primary care trusts are saying that one cannot have exempt adult and children-only lists. I know why they are resisting it—because then there is no patient income.
That brings me on to another essential point—charges. The British Dental Association has accused the Government of using the new contract as a revenue-raising measure contrary to the principles of the national health service, yet this is a Government who talk about a free NHS. In 2004–05, dental charge income was £465 million; in 2006–07, it will be £623 million. Those are the Government's own figures. I only received the latest figures this morning, having asked the question in November—we can only get information out of the Government by bringing this debate to the Floor of the House. That is a 28 per cent. real-terms increase in dental charge income. The Government's contribution to dentistry over those same two years is rising by just 9 per cent.
That is completely contrary to the Government's previous claim that the contribution made by patients towards the cost of dentistry would remain the same. In fact, it is rising—I have just stated the figures. There are three bands of charges. That is simpler, but not necessarily fairer. For example, a check-up will cost £15.50 instead of £5. Lord Warner, the Minister in the other place, said that 42 per cent. of patients get their treatment in band 2 and, of those, three quarters will pay more under the new system. That is what is going on—more charging and more costs for patients. Of course, the Government will parade the fact that £2.7 billion is being spent on dentistry, neglecting to say that the cost of dentistry to patients has increased by one third, on the Government's figures, in the space of two years.
Given the hon. Gentleman's concern about charges, does he agree that there is something unethical—indeed, perhaps involving a breach of data protection legislation—in dentists who are voluntarily opting out of the NHS writing to patients to advise them of private insurance arrangements without disclosing the benefits that they themselves stand to make? Is that appropriate?
I can understand that the hon. Gentleman is embarrassed that dentists are leaving the NHS and writing to their patients, but that is, regrettably, what is happening. They have a relationship with patients and are contacting them to give them details of what they are proposing to do. Instead of the hon. Gentleman criticising dentists, it would be better if he and his hon. Friends tried to work with them. The dentists we have talked to who are leaving NHS dentistry or reducing their commitment to it deeply regret having to do so.
The way forward is clear. Many dentists who sign up to the contract will do so reluctantly. They will be very unhappy with the straitjacket of activity targets that they are being put into. If they start to move beyond the 4 per cent. tolerances, they will find that they have no confidence that contract values will be honoured in future. They may well find that penalties are imposed on them. As time goes on, particularly as the income protection period expires, many will say that they are going to give up and go outside the NHS. A third of the dentists who got together in Birmingham at the local dental committee said that they would not sign the contract, and dentists in many other parts of the country are saying the same.
Instead of dentists reducing their commitment, we must go in the opposite direction. Their commitment to the NHS must be increased if we are to avoid recurring inequalities in access to dental care.
The hon. Gentleman has repeatedly mentioned inequalities. He is probably not aware that last week, in my constituency's most deprived ward of Coundon, a new health centre was opened with provision for two dental chairs, where there has never been a dentist before. His point is not borne out across the country as a whole.
I received an e-mail from a dentist in north-west London—I think that he was in the constituency of Frank Dobson—who was abandoning NHS dentistry and was deeply depressed about the Government's implementing of the new contracts. I am afraid that wherever one goes, including in north London, there are dentists who are going to do that. This morning the Minister and I discussed on the radio what is happening in Barnsley. I do not know whether any Members from Barnsley are here. That is not a wealthy area, but patients there have been queuing for private dentistry because their dentist has abandoned the NHS.
It is time for a new system. We know where the Government are heading because the Minister has made it perfectly clear in previous discussions. She is threatening dentists by saying that if they do not choose to do NHS work, she will find other dentists who will. There will be dentists coming in from Poland.
Perhaps, like me, my hon. Friend would like to disabuse Helen Goodman of the notion that everything is rosy in NHS dentistry. In my constituency, 34,000 patients have been deregistered, with a huge impact on lower income groups, older people and young families. What is worse is that the primary care trust has been forced into political posturing by operating a hotline that patients have to phone secretly to be told where the new NHS registrations are. That is spin under the NHS.
As my constituency is nearby, I have seen that that is indeed what is happening in my hon. Friend's constituency, where the enormous loss of NHS dentistry is affecting a large proportion of his constituents. I sympathise with him and agree with the support that he is giving to NHS dentistry in his constituency.
That is right. Only about 40 per cent. of non-exempt adults have access to NHS dentistry. Of course, the Government are going to abolish registration and manipulate the figures. They will say that increased numbers of people see an NHS dentist, but that does not mean that they are necessarily registered with them or have access as they did in the past on the basis of a long-term relationship.
It is deeply worrying that fewer children are getting access to NHS dentistry. This morning's Which? report said that 82 per cent. of the public think it extremely important that children get free dental treatment, but that too is being lost. The inequalities are dramatic. In some places, a quarter of adults have access to NHS dentistry, while in other places it is 60 per cent. That is deeply unacceptable in a national health service.
The Minister always used to say that we need a new way of working; well, we do. We need a new way of working that is not about dentists on a treadmill, particularly a new treadmill that is governed by primary care trusts, which, as the National Audit Office made clear, have none of the expertise necessary to put this new system in place. We cannot move towards the system that the Government seem to be proposing whereby patients have perverse incentives to delay treatment or present as urgent cases with pain because it will be cheaper than if they have the work done while not being in pain. We must have a system whereby the patient's relationship with their dentist is geared around preventive work and good oral health, patients know that they have security of access to NHS dentistry, and dentists are incentivised to offer NHS dentistry and to increase their commitment to NHS dentistry instead of reducing it.
The hon. Gentleman almost certainly knows that the deadline for the first return of contracts was yesterday. If people have not returned their contracts by yesterday, payments will be delayed by a month. The secretary of the Birmingham dental committee told me that 75 per cent. of NHS dentists had not returned their contracts by the deadline. Some may be returned this month but the figures show a massive reduction in the number of NHS dentists in Birmingham.
I understand the hon. Gentleman's point. We held discussions with the Birmingham dental committee, as he doubtless has. Dentists in Birmingham are rightly anxious and angry.
As I explained, we need a new way of working. However, we have made it clear that it is most important not only to commit ourselves to improving the NHS overall but to trusting NHS professionals. Happily, in this instance, the desires of the patients and the profession are exactly the same. Patients want a relationship with a dentist in which they have security of access and certainty that what is in their interests—good oral health—is being pursued, with their making a reasonable rather than an excessive contribution through charges. That is what we need. The motion calls for that, even at the last minute.
Two weeks ago, the Minister met representatives of the British Dental Association, who left the meeting deeply disappointed with its results. It is not too late for the Government to withdraw the contract, suspend the use of units of dental activity and work through a piloted system that is based on capitation. That is the way forward. I urge the Government to do that even now, and I urge the House to support the motion.
I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof:
"welcomes the Government's Oral Health Plan for England, which builds on major oral health improvements in the last 30 years, and the additional £368 million for improving dental services in England announced in July 2004;
recognises the Government's substantial achievements in improving the short and longer term supply of dentists for the NHS including recruiting the equivalent of an extra 1,459 whole-time dentists between April 2004 and October 2005, compared to the 1,000 extra dentists promised, and funding an additional 170 training places;
further recognises that the Government is investing £80 million in improving dental school facilities, and has approved the establishment of a new dental school in the South West Peninsula;
notes that the total number of primary care dentists in the NHS had increased to more than 21,000 by the end of October 2005, compared with 16,700 in 1997;
further welcomes the reduction in the maximum patient charge from £384 to £189 from 1st April;
further welcomes the new ways of working tested through Personal Dental Services pilots;
supports the framework for new dental contracts which will free up significantly more time to provide preventative care, remove the requirement for NHS dentists to treat patients on a fee for service basis and ensure that a committed NHS dentist can expect to earn on average around £80,000 a year;
and further welcomes the fact that, where dentists do not take up new contracts, primary care trusts will commission replacement services from other dentists."
Although the motion is flawed, it gives us the opportunity to debate NHS dentistry as we approach the implementation of the most significant reforms to dental services in the history of the NHS. It is worth reminding the House why we are making those changes to NHS dentistry. The current system provides no real stability for patients or the NHS. Under the traditional general dental services system, dentists can set up in practice where and when they wish and decide how much or how little NHS dentistry they wish to undertake. There have traditionally been no local budgets for dentistry. When dentists decide to reduce or abandon their NHS work, the NHS locally has no power to commission replacement services. I know that that has affected hon. Members of all parties and caused immense problems. That volatile system has not served patients well.
On top of that, the contract under which dentists have worked has been extremely unpopular with them, especially following changes that were introduced in the 1990s and the subsequent fee cuts. Let me remind hon. Members that the traditional way of paying dentists is based on payments for 400 individual items of service, for example, a filling, a crown or having a tooth out. That put the emphasis on invasive work rather than preventive treatment. As hon. Members have said in the House previously, it has been confusing for patients, who often did not understand what they were paying for on the NHS and what they were paying for privately. I am sure that many hon. Members have experienced constituents saying, "I've just paid £1,000 for treatment on the NHS." When they have come to me, I have told them that they could not have paid that amount because the maximum that they can currently pay on the NHS is £384. However, confusion between NHS and private treatment has occurred.
The dental profession, especially the British Dental Association, complained for many years about the treadmill effect of how dentists were paid. As I said, that put the emphasis on invasive rather than preventive treatment and was an incredibly bureaucratic system for dentists. Two dental schools were closed under the previous Administration. Again, that significantly reduced the numbers of dentists in training.
To tackle the genuine shortages in access to NHS dentistry, we have taken some immediate action.
I want to speak about clinical dental technicians, who specialise in making dentures, especially for senior citizens. The Minister knows that they are subject to a regulatory review by the General Dental Council and that they want to be brought within a new regulatory framework to remove the anomalous situation under which they have operated for many years. They have two key requests. First, they want a reasonable transition period. Secondly, if retraining must occur, they ask whether it can take place on a part-time basis in the United Kingdom to allow them to retrain in a way that does not destroy their livelihood. Does the Minister agree that that is reasonable and will she make that point to the GDC?
I hope that the hon. Gentleman understands that the GDC makes its own rules about what it considers to be appropriate training and registration requirements. However, he is right to point out that there are many opportunities under the new system not only for dental technicians but for dental therapists and hygienists. As we change the way in which dentistry is provided, we can increasingly make better use of different skills in the dental team. I believe that, when we consider the role of dental nurses and hygienists in future, they can increasingly take on some of the minor work that dentists currently do, leaving dentists to do the more complex work. However, I shall consider the hon. Gentleman's points and I am sure that the GDC will be aware of his comments.
The Minister was about to consider access. Will she clarify a point about the position after
The person who is currently registered with an NHS dentist will remain attached to that dentist on a dental list. That is not the same as registration because people currently fall off the register. We want to stop that because it has caused difficulties in the past. However, the person who is currently registered will remain attached to his dentist. I hope that the changes that we are introducing will free capacity and that the person next door who is not registered with a dentist can get registered. We are aiming for that. That is why it is so important that primary care trusts have the power to commission locally, examine the needs of their population and commission accordingly.
Since 1999, we have set up 53 dental access centres in areas where there was a clear shortage of NHS dentists. Those centres mostly provide urgent treatment but some provide routine treatment. Compared with 2003, we are now investing an extra £250 million every year in NHS dentistry, with a further £65 million to follow next year. We have recruited the equivalent of more than 1,400 whole-time dentists to work in areas with the greatest access challenges.
I am sorry that Mr. Lansley chose to denigrate the contribution of Polish dentists. In many areas of the country, they do an excellent job. In areas of particular shortage, we have been able to assist the position through careful international recruitment and carefully passing people on to those areas. I am sure that many Conservative Members are grateful for their contribution.
I am pleased that the Minister has acknowledged in the Chamber the tremendous work that Polish dentists do in the United Kingdom. Almost all the new dentists in Shrewsbury have come from Poland. I speak to many Polish NHS dentists in their mother tongue and they tell me that they will return to Poland after a couple of years. That is a tremendous problem.
I hope that I shall be able to reassure the hon. Gentleman later in my speech that there are dentists coming from all different quarters. NHS dentists are now offering to do more NHS work, and others are coming in through the international qualifying examination. Some of them may well wish to stay for only a short time, and that can be helpful in that they take different skills back to other parts of the European Union. I do not have a problem with that; it does not mean that we are going to experience a shortage. Indeed, in some ways, quite the opposite is the case.
When I was out on a Saturday morning recently knocking on doors, as we do at the weekends, I met a Swedish dentist who thanked us for helping with his planning permission. May I thank the Minister for the £28.4 million investment that has been made in Plymouth, and ask her how soon she expects the new dentists to come on stream following that extra investment in dental training?
Obviously it takes some time to train a dentist. We have recruited extra dentists over the past year, as well as announcing 170 more dental training places from September last year. In January, I announced the creation of a new dental training school in the south-west of England, and I suspect that that is what my hon. Friend was referring to. I was pleased that a good bid was put in by her area, and that we were able to make that announcement.
My hon. Friend is absolutely right. I believe that 12 new dentists have been recruited to his area recently. A dentist with a fairly high commitment to the NHS can expect to earn about £80,000 a year, with practice expenses on top of that. That is not a bad deal.
I am grateful to the Minister for working to bring 14 new dentists to my constituency. However, even with those new dentists, registrations have gone down since she came to the Isle of Wight. In two years' time, when the 24,000 people who have asked to register with those new dentists have done so, about 50,000 people in my constituency will still not be registered with an NHS dentist. Is that satisfactory?
As the hon. Gentleman said, I have visited his constituency. I know that there were considerable problems there, and I am glad that we have been able to assist him. His was one of the first areas that our support team went into to help with recruitment. I do not think that there were any NHS dentists there before that, but we managed to recruit eight into the area. I shall explain later how, under the present system, there will be room for extra capacity as the changes bed in, as well as the ability to have funding at local level to commission NHS dentistry if there are needs in the local area.
I want to explain how we are introducing a radical shake-up in regard to how NHS dentistry will be delivered in the long term. To go back to the basics of the plan, from April this year, primary care trusts will for the first time be able to commission and develop primary dental care services in ways that reflect the needs of their local populations. For the first time, they will have the financial power to commission new services when a dentist leaves the area or reduces their NHS commitment. That was one of the problems in the hon. Gentleman's constituency. For the first time, we will have a system of dental charges that is simple and transparent for patients, and a remuneration system that no longer encourages the drill and fill treadmill.
The new contract that we are offering to dentists will mean that a committed NHS dentist can expect to earn about £80,000 a year, with practice expenses on top of that. That £80,000 will be guaranteed for three years, for 5 per cent. less work. In return, dentists will be expected to carry out an agreed number of courses of treatment over the year—again, at least 5 per cent. below the levels in the old contract.
I am sure that dentists will be pleased to hear those figures. However, will the Minister explain how the technical application of the new contract has led to the situation in my constituency about which I wrote to the Secretary of State on
The way in which the contracts were calculated involved a reference period that ran from October 2004 to September 2005. During that time, the activity of the dentists was measured, along with the amount that they were paid during the period. The calculation should reflect those two figures, and produce the amount that the dentist would be offered, which would be guaranteed for three years. If a dentist has a problem with the calculation, they should pursue the dispute resolution procedure. However, the primary care trust might be able to identify the reason for the problem—the dentist might have taken on an associate during the year, for example. It is difficult for me to comment on individual cases, but there is a dispute resolution procedure to deal with problems with the amount in the contract.
Is there not a problem for practices such as the Caledonia practice in my constituency, which is expanding fast and has taken on two dentists since the end of the base-line period last September, but is now having to lay off those dentists because it cannot afford to pay them, given the amount that it is being offered? Will the Minister also confirm that a PCT is required by law to use any funds made available through the closure of a dental practice for dentistry and for no other purpose?
Yes, I will. The way in which the budgets have been given out is quite complicated, but I will try to explain it. During the reference period that I mentioned, an overall measurement was taken of the activity in a particular area. It is possible that, during that time, certain dentists might have worked for only half the year, because they had started up half-way through the reference period. Others might have closed during the period. The calculation took into account the balance between those that had opened and those that had closed, so that a dental practice that had opened half-way through the year would be able to use the money that had become available from one that had closed. So that would have added up. If, however, it did not add up in that way, extra money would be allocated, but it would not be able to meet every local circumstance. The instance that the hon. Gentleman has cited involves a dental practice expanding after the reference period. We had to have a cut-off point—[Hon. Members: "Why?"] Otherwise, it would not have been fair in terms of allocating the funds. The PCTs wanted to know the size of their budgets. We had that reference period so that we could make that calculation. On top of that I should say that £65 million has gone out to PCTs to ensure that there can be expansion. That is the difficulty that the hon. Gentleman might be facing. However, I should also say in relation to
May I move on? I am conscious that we are getting towards the time when Back-Bench Members will want to contribute.
Today's debate has shown that concerns have been voiced by some dentists about the changes, but that is not altogether surprising, because they are quite radical. New ways of working have proved popular in the personal dental services pilots, which cover some 30 per cent. of dentists.
To return to a point made by the hon. Member for South Cambridgeshire about a system of payment per head for those registered, we considered that suggestion during the piloting and found a lot of problems, not least because in some areas the number of treatments carried out fell by about 50 per cent., but without an equivalent increase in the number of people seen. Such a system also has a bias towards people with good oral health who would be taken on under it.
I quite understand why the hon. Gentleman is making that suggestion and I am more than happy to send him the data—[Interruption.] If he wants to intervene, I am perfectly happy to give way.
The National Audit Office report was very clear. Yes, there was a reduction in the number of treatments, because the drill-and-fill system had an incentive to overtreat. Of course the number of treatments reduced. We have to measure outcomes—that is what we should be doing—and the NAO was clear about the fact that the 10 per cent. reduction in treatments, on average, was none the less associated with no deterioration in the oral health of people on those patient lists.
But that is not the point about the system that the hon. Gentleman is suggesting. He is suggesting that each dentist be paid per patient. The difficulty with that, as I have said, is that we tried it in the pilot schemes and it effectively contained a bias towards taking on people with good oral health as opposed to those with a variety of types of oral health. I am perfectly happy to send him the data from those pilots so that he can look at them. All I am saying is that I can assure him that we considered and piloted that suggestion, but the evidence that came back suggested that it is not the right system.
That is quite astonishing, coming from the right hon. Gentleman. We have a lot of these problems—this is very well recognised—because of the contract changes and fee cuts made in the 1990s, as well as the closure of two dental schools. We are turning round the system that we inherited and introducing some changes.
I shall move on, because I want to make some remarks that I hope will help the House.
As I have said, I know that, for some dentists, the changes are a fundamental shift from the traditional way of working. Understandably, they are quite nervous about that, so I have decided to set up an implementation group with representation from the profession, patients and the NHS to review the impact of the reforms and ensure that they are delivering their intended benefits, for patients and for dentists. I have invited representatives from the British Dental Association to join the group, and I hope that that is a way to reassure dentists that we are looking closely at the implementation of the reforms and ensuring that if any adjustments need to be made, they can be.
Will my hon. Friend include orthodontists in the group? As has been mentioned, there seem to be specific problems with how the lists will be compiled for orthodontists. It is only fair that those valuable servants be included.
I will certainly consider the point my hon. Friend raises, particularly perhaps with reference to the British Orthodontic Society, which we have been in discussions with recently. He is right to say that there have been problems with orthodontics, because obviously such services are offered over a number of years. If new practices have been set up, which we have been able to do because of the increased investment that we have put in, they might have had a short contract value during the reference period. Recently, we have again issued guidance to PCTs including principles such as current treatment having to be completed. They need to look at orthodontic requirements locally and ensure that there is proper commissioning. I acknowledge that this has been a problem, but we have tried to clarify it.
If I may, I shall move on, because it is important to say that we will not know until the end of this month precisely how many dentists are taking up the new contracts. However, the current view from PCTs is that the vast majority of contracts will be signed by
I should stress that, in the minority of cases where dentists choose not to take up the new contracts, the NHS will use the same funding to commission replacement services from other dentists. I am extremely confident that the NHS will generally be able to bring in new capacity very quickly. In the small number of cases where people say that they no longer want to remain with the NHS, we are finding that other dentists are coming forward to say that they want to expand their NHS provision.
Would the Minister like to tell us whether this alternative commissioning will be like the dental access centres? The average cost per patient episode, according to the Government's own figures, is £141 compared with £41 for high street dentists.
I am not sure that the hon. Gentleman has quite understood exactly how the new commissioning will take place. If a dentist chooses to leave the NHS, that money can be used by the PCT to provide what it feels is appropriate in the local area. If it feels it is appropriate to have a dental access centre, it can have one. However, it is more likely to want to commission dentistry from the existing dentists in the area.
I rather suspect that the name has something to do with the Minister's giving way. Will she estimate the number of new dentists who will be appointed? How many of those will be directly employed by the NHS and not work for traditional NHS practices? As my hon. Friend Mr. Lansley said a moment ago, the cost of providing treatment in that way is about twice the normal cost at present.
May I explain? Most dentists are independent contractors anyway. They are paid by the NHS. Some have greater commitments to the NHS than others, but there are no private NHS dentists, as it were. At the same time, some dental access centres often provide emergency treatment, which we would necessarily expect to be more expensive, and do not always charge fees as well.
We would expect there to be a range of providers who might want to come in. It would be for the PCT to decide which kind of provider it wanted to use, whether a direct one, one through the salaried service, or an independent contractor in the normal way. As I have said, large numbers of NHS dentists are keen to expand their commitment. We know that, because that is what local PCT dental representatives have been telling us. Something like 1,000 overseas dentists are currently sitting the international qualifying examination, and a number of dental corporate bodies, which have a track record in areas such as the constituency of my hon. Friend Mr. Martlew in Cumbria, have expressed an interest in establishing new practices, and are already taking up new NHS contracts.
The East Kent Coastal primary care trust has repeated the Minister's mantra that money "saved" by dentists leaving the national health service will be used to buy other dentists. The fact is that those other dentists do not exist. Existing dentists' lists are already full and have a backlog. Dentists in east Kent are closing or leaving the NHS. There is a gap, and children in particular are waiting for dentists. Where will those dentists come from?
I think that I just explained what the PCT is entitled to do, and probably will do, if there are not dentists in the area. For example, dental corporate bodies are keen to establish NHS dentistry, making use of some of the 1,000 dentists currently sitting the international qualifying examination. The hon. Gentleman must recognise that the money remains at local level so that the PCT can commission dentistry. There is no reason why it would not be able to do so. It has happened in other parts of the country, and I am confident that it could happen in his area, too.
I have explained how budgets were to be spent. The budgets that will be devolved to PCTs next year are around £315 million more than in 2003–04. As I have said, all existing NHS dentists are guaranteed contract values based on their NHS earnings during the reference period.
I also want to set the record straight with regard to two other misapprehensions about the reforms.
First, I am afraid that the British Dental Association, among others, has persisted in alleging that the reforms do not promote preventive dentistry. That goes against the clear evidence from personal dental services pilots showing that abolishing the fee-per-item system enables dentists to carry out simpler courses of treatment, with far fewer interventions and far more time to focus on preventive care.
Secondly, the new system of patient charges has been based on the recommendations of a working group chaired by Harry Cayton, National Director for Patients and the Public, including representatives from the British Dental Association among other stakeholders. The working group unanimously recommended a system based on three simple charge bands. At present, there are more than 400 separate charges for different items of treatment. [Interruption.]
I am grateful to the Minister. Will she therefore explain why the Cayton review recommended £11 for band 1, and she has £15.50; £27.50 for band 2, and she has £42.40; and £127.50 for band 3, and she has £189?
It is because the recommendations of the Cayton review on cost per band were meant to reflect the patient charges that would be raised during the time that it was produced—around January 2004, I think. Obviously, when we published it, we had to take into account the increased expenditure on NHS dentistry, and we wanted to raise the same amount in proportion in terms of NHS dentistry. The hon. Gentleman fails to mention over and over again that the maximum that can now be paid for NHS dentistry has been cut from £384 to £189, which particularly affects older and poorer people.
Surely there is something less than sincere about the position of Mr. Lansley. He talks about his concern for NHS charges, but earlier today was happy to support unscrupulous dentists who are exploiting elderly, vulnerable people. Where is the consistency?
Consistency has not been a hallmark of the contribution from the hon. Member for South Cambridgeshire today. As I have said, the new system makes it much easier for patients to distinguish between what they are paying for under the NHS and what they are paying for privately.
I want to finish by reminding the House of the broader objectives to which the reforms are designed to contribute. We want to support further improvements in oral health and reduce inequalities in oral health. We want to promote high-quality dentistry throughout the NHS. We want to improve access to services for NHS patients. I agree that the full benefits will not arise immediately.
I want the hon. Gentleman's primary care trust to ensure that there is appropriate provision locally. We can help support primary care trusts by providing them with extra money, which we have done, and a contract worked out with dentists that reduces bureaucracy and allows better care for patients, which we have done; and through measures such as the international qualifying exam to ensure that NHS dentistry can be provided locally The improvements in access will rely in part on the growing use that primary care trusts make of their new flexibilities under local commissioning. They will also rely on dentists adapting to new ways of working, which free up time, as we have seen from the pilots, and increase capacity to enable a greater number of patients to be seen.
A specific concern of dentists in my constituency is that devolved budgets appear to be ring-fenced for only three years. Hillingdon PCT is wrestling with a deficit of £25 million, and dentists are concerned that in time funds will simply be siphoned off from dentistry into other medical priorities. Does the Minister understand those concerns, and what reassurance can she give?
I am sure that the hon. Gentleman is pleased that there is ring-fencing for three years. Beyond that, I cannot predict or give guarantees. We have, however, ensured the ability to ring-fence, and introduced a duty on PCTs to provide dentistry to meet local needs. I hope that that is some reassurance.
I hope that right hon. and hon. Members will recognise the scale of what we have achieved, both in growing the dental work force and tackling some deep-rooted access problems. I hope that the House will welcome the reforms as providing a hugely more secure basis on which the NHS can build on improvements, working in partnership with patients and members of the dental profession. It would be irresponsible to halt the changes as the Opposition motion suggests. It would cause immense confusion to dentists, patients and the NHS, and take us right back to the bureaucratic drill-and-fill treadmill so disliked by the dental profession. The Opposition have offered no new ideas, only carping at the sidelines. I urge the House to reject their motion and to support the Government amendment.
D-day for NHS dental patients is rapidly approaching. The new financial year will bring many changes to dentistry—a new contract, new charges, and a new way of measuring dental activity—but the key question is, are patients really aware of the bombshell that could drop on them in the new financial year? For them, D-day will be deregistration day. On
How many dentists does the Minister estimate will not have signed the new contract by the deadline at the end of this month? How many does she believe will sign the contract, but at the same time formally enter into dispute proceedings? The Minister talks of "the vast majority", but a more specific figure would be appreciated.
"We wish to clarify that the figures referred to in that memorandum are not accepted as being a definitive correct representation of our earnings . . . in relation to the provision of NHS dental care . . . and that they represent only a provisional representation of our earnings and activity. For the avoidance of doubt, we reserve our right to initiate the statutory dispute procedures in respect of either the figures provided, or the basis on which those figures have been calculated."
How many dentists does the Minister estimate will enter into dispute proceedings at the same time as signing the initial agreement?
The hon. Lady represents an area with some of the lowest wages in the United Kingdom. Does she not think her constituents will find it a little strange that she appears to support the position of people who consider £80,000 a year to be an income not worth working very hard for?
I am sure that patients of NHS dentists will be more interested in the fact that the cost of check-ups and band 2 treatments will increase, and the fact that they may not be able to find an NHS dentist at all.
For 9,000 patients in my constituency, D-day—deregistration day—has already arrived. Last week, one of the biggest NHS dental surgeries in the constituency announced that its 9,000 adult NHS patients would either have to go elsewhere for NHS treatment, or have one week in which to decide whether to sign up for a direct debit plan and private treatment.
We would of course continue to negotiate the contract, which the British Dental Association has clearly rejected but which the Government seem to be pushing relentlessly, although it appears that many dentists will not sign it. According to the Minister, the vast majority may be signing. That could mean thousands of patients per dentist being denied access to NHS treatment.
The dental surgery that I mentioned has three dentists. They gave their reasons for withdrawing from the NHS, which were very specific. They said that
"a new NHS system is being proposed by the government and we have been unable to negotiate terms that we feel are in the best interests of our adult patients. We will therefore not be able to treat patients in the NHS from
My constituents who are affected are understandably shocked, and do not know what to do next. I have been inundated with correspondence from them, asking what they should do. For many, the choices are stark. One wrote:
"Can't afford the monthly fee offered—and this doesn't cover anything I need anyway".
"We are shocked that we had no previous knowledge and had not been consulted about this closure, and we are being forced into signing up within a week to a costly private scheme or losing all further treatment".
Those people do not feel that there will suddenly be a magic alternative.
Many of the dentists to whom I have spoken feel that they cannot offer their patients the level of service that they deserve under the current contract.
All over the country, as other Members have said, thousands of NHS patients are hearing similar bad news. Many of them do not realise that the Government's policy is creating the problem, at a time when NHS dentistry is already in crisis. Another of my constituents wrote:
"We do not know about the new government proposals mentioned in their letter that they are using as an excuse".
They clearly have not had time to read the new leaflet explaining the changes.
Ultimately, however, the patients do not care what is causing the problem. They may not know that dentistry's woes started with the Conservative Government's creation of the drill-and-fill treadmill, and the closure of two dental schools. They may not know that the breakdown in negotiations over the new contract has proved to be the final straw for many dentists. All they know is that they face losing their NHS provision, and it is not clear how they will find an affordable alternative.
Will the hon. Lady at least acknowledge that the new dental school that is coming to Plymouth will provide new dentists not only in Plymouth but in the wider south-west, including Cornwall?
In five years' time, once it is up and running, the dental school will provide new dentists, but there is no guarantee that they will enter the NHS. Moreover, if the current funding is based on levels of activity, there will be no vacancies for them in Cornwall even if they want to enter the NHS.
I am afraid I must make some progress.
Yet another horde of dentists look set to abandon the NHS, as they did in the early 1990s. The only difference is that a different political party is in power. The new contract does not mean more dentists for the NHS. Primary care trusts may have access to funds for alternative NHS dental surgery provision when existing dentists leave the NHS, but how does the Minister estimate that PCTs will be able to recruit enough dentists to fill the vacancies? In Cornwall 9,000 patients are being deregistered, while 14,000 are being deregistered in Cheltenham. How will those vacancies be filled? Where is the capacity for all the dentists who are so desperate to sign the new contract? Stockton-on-Tees already has eight vacancies. If more dentists refuse to sign the contract, the number of vacancies will increase.
The new contract does not automatically mean that more people will be treated in the NHS, because it is based on the existing number of dentists and their budgets. No assessment or investment has been made with a view to meeting previously unmet demand, and it is not clear how the Government will fulfil their 1999 pledge to give everyone access to an NHS dentist. That means that even in my constituency, which ought to benefit from a dental school, more cannot be spent on a net increase in the number of dentists or in NHS provision unless the Government are prepared to ensure that extra funds are available, and unless more dentists feel that the NHS offers a contract that is attractive to them.
There are plenty of new circumstances, but there is no improvement in the current dire situation. Millions of people are not registered with a dentist at all, and three quarters of those who are not registered with an NHS dentist say that they wish they were. Demand continues to outstrip supply by a significant amount, and the new contract will not change that fundamentally. The contract will also fail to provide patients who are lucky enough to receive treatment with better standards of treatment, and a stronger focus on preventive work.
The personal dental services pilot was popular because it allowed dentists to spend more time with their patients, and to focus on preventive advice as much as on treatment. It ended the drill-and-fill treadmill. Most of the dentists who are refusing to sign the new contract took part in the pilot, although it has been much vaunted as a reason for the contract. They feel that flexibility has been lost in the new general dental services contract because a new treadmill has been introduced: units of dental activity. It is another target-driven system that does not appear to be well understood on the ground either by dentists or primary care trusts, and it is essentially untested. It was not in the initial pilot.
Does the hon. Lady accept that we should be able to monitor and measure dental activity, given the amount that we spend on it locally? How would she monitor dental activity?
I would like the Department to monitor dentists on a full-time equivalent basis, rather than on a head-count basis. I have used this example before: I have spoken to a dentist who is on the NHS list and who has three NHS patients—his wife and two children.
Does my hon. Friend agree that the Minister's speech was strong on wishful thinking and weak on reality? The reality for my constituents in Chesterfield is that the wonderful new contract has driven dentists to leave the NHS. In recent weeks, a wave of my constituents have come to me to say that they have been given the choice between taking out expensive private medical insurance and looking for another dentist. However, when they look for another dentist, it is almost impossible to find any slack in the system that enables new NHS patients to be taken on.
That has been the experience in many other places. Of course, it is outcomes that are most important, rather than the treadmill of units of dental activity.
As we have heard, local dental committees report real concerns about the test year. The new UDA targets are based on the test year, but do not account for variances during the year, which could result in contract values that do not represent the NHS work that is undertaken. The system has not been piloted. I am pleased to hear that a review is to be conducted, but what will the Government do to implement the review group's recommendations? When will it be set up? Will it be in time for the introduction of the new contract on
Will we know whether more patients are accessing NHS treatment if it is courses of treatment, rather than registrations, that will be measured? What will happen to waiting lists at NHS dentists if people stay on the register permanently? Will we see a massive increase in registrations, with many patients struggling to get a check-up on the NHS within two, three or four years? Will there be any measurement of how long the average time is between check-ups for the average patient?
I will if the Minister will allow me to make some progress.
If that means that people will go longer between check-ups, how can that be squared with the Government's stated aim to shift their focus to preventive work? Under the new system, people will go to a dentist only if there is a problem.
Again, I do not think that the hon. Lady quite understands the system. The NICE guidelines have changed. It is up to the dentist to decide when a patient should come back. Some patients will have to come back within six months, but the point about the flexibility in the new way of working is that, if the dentist believes that the patient has good oral health and does not need to be seen for two years, that is when the patient would come back.
Of course, if there are not enough dentists, how will those patients be able to access the regular check-ups that they need?
That leads me on to the final changes, those to pricing structures—changes that, ultimately, the patients will notice. The price of a check-up will increase, surely deterring people from having regular check-ups, where not just caries but problems such as mouth cancers are detected, and where the preventive work that the Government claim is so important is performed.
The new pricing structure means that the median price will increase, even though the charges for the most expensive treatments will reduce. According to the BDA, three quarters of the 42 per cent. of patients who fall into the middle band will end up paying more than they did previously. That will lead to perverse incentives, where problems will be stored up, so that the treatment is more affordable and represents better value for money for the patient. I have raised that issue with the Minister in previous debates and she has refused to accept it, but I quote one of my constituents to emphasise the point:
"any problem that I have with my teeth I will now have to suffer as there is no way I can afford the charges."
People are coming to me saying, "If I understand the new charging system correctly, it makes better sense for me to wait until I need two or three fillings and I can pay for them under one band, through one course of treatment, rather than having them one at a time, and paying three times for the same treatment."
Primary care trusts are also concerned that the new charges and the new contracts will lead to even greater pressures being placed on emergency treatment centres. Previously, emergency treatment centres would accept only patients who were not registered with an NHS dentist. Now they will have to accept everyone. With emergency treatment cheaper than a band 2 course of treatment, there are concerns that people will wait until their problem is an emergency.
It is also unclear how many and how well people understand what the new charging structures are and how they will be affected by them. I understand that the new information leaflets have been sent to primary care trusts and are sitting in NHS dental surgeries. Have the Government estimated the penetration of those leaflets and what the level of understanding is now about the new charges, given that they will be put in place on
I hope that the hon. Lady realises that, under the new system, it is not just an ordinary check-up that is undertaken. It is an examination, plus preventive health advice, plus a scale and polish if necessary, plus any diagnostics, for example, X-rays. That all comes within the £15 range.
Of course, all the patients will know is that it is more expensive than last time. I would be interested to know how many leaflets have been produced, and how many have been sent to NHS and private dental surgeries, in case patients wish to switch to the NHS if they can. At what cost have they been produced? I understand that an evaluation report has been produced and I hope that the Minister will undertake to place it in the Library of the House.
The theme that sadly emerges is one of a series of unknowns. A series of fundamental changes are being introduced but there has not been adequate testing and piloting to determine the changes' knock-on effects individually, let alone in combination. For those reasons, it is hardly surprising that patients, dentists and primary care trusts are still unclear about what the new contract will represent and what impact it will have. Since the Government did not spend the time in advance of the changes assessing their impact, I am glad to hear that a review group will be set up, but will the Minister undertake to implement its recommendations?
The new contract and charging system has not produced the circumstances or incentives for patients to take a preventive approach to their health care. The cost of a basic check-up will increase, dentists will not have the time that they want to spend on preventive work, and it does not appear that more people will necessarily have access to NHS dentistry as a result of the changes. Ultimately, people will go for regular check-ups only if they can afford them, if they understand how the new system works, and if they can find an NHS dentist. It seems that many of the problems still remain essentially unresolved.
Before I get into my speech, I should like to thank all the hard-working dentists in my constituency and throughout the country who work well with the NHS. Sometimes, in my local skirmishes with some of my dentists, I have perhaps forgotten that.
Did not Julia Goldsworthy think it odd that the dentist whom she mentioned treated only his family on the NHS? Did she not think that that was a bit of sharp practice? Perhaps I am naive. Perhaps she can put his name on the record so we can all know who it is.
I have sat and watched the Opposition—the major Opposition, because there is no one here from Lloyd George's party. One of the Conservative Members who attended the debate was a Minister in the previous Government and a practising dentist. Mr. Redwood has just left, but he was in the Cabinet when the Conservative Government closed two dental schools. It is no good Conservative Members putting up their hands up and saying that that was 10 years ago. They did it and they also cut fees by 7 per cent. So do not imagine that dentists, even though they are angry with us, believe the Conservatives. They remember what being a dentist was like under the Conservatives. The haemorrhage of dentists away from the NHS started during their time in office, whether by accident or design; I leave Members to figure out which it was for themselves.
There was a severe problem in Carlisle when four dental practices decided to resign from the NHS. They resigned before they saw the contract, so that was not their reason for doing so. Mr. Lansley mentioned people queuing to sign up for private treatment, and that did indeed happen at a particular practice in my constituency. The dentist in charge of it sent out a letter saying, "If you don't queue up and sign up, bringing your bank details with you, you won't be able to get a place." That resulted in hundreds of my constituents queuing from 5.30 in the morning, waiting to sign up. [Interruption.] If the hon. Member for South Cambridgeshire will contain himself, I will get to the point. That dentist was even handing out raffle tickets in another part of Cumbria. He said that he was going to cut the list, and that those who did not sign up early would be unable to get on it.
A lady came to my constituency office on Friday and told me that she phoned that dentist four months later. The receptionist was over the moon that someone had actually phoned to ask whether they could sign up. In fact, the dentist had plenty of places left. Some dentists who have gone private will have a problem when—
The hon. Gentleman and I share a concern about animal welfare issues, and I want to make the serious point that, unfortunately, because of these changes, it is easier for my constituents' pet dogs to get dental treatment in Shropshire than it is for my constituents to get such treatment.
I do not know about the situation in the hon. Gentleman's constituency, but the reality is that in most cases—leaving aside the valuable work done by the Royal Society for the Prevention of Cruelty to Animals—those of us who take our animals to the vet have to pay for such treatment. I presume that pets in the hon. Gentleman's constituency are not treated on the NHS; if they are, there should perhaps be an inquiry.
The dental practice to which I was referring offered the caveat whereby the children of patients who signed up and set up a direct debit would be treated for free. That is an absolute disgrace. Unfortunately, neither the hon. Member for South Cambridgeshire nor Julia Goldsworthy condemned such practice; hopefully, they can put that right during the wind-ups.
Let us not be too concerned about dentists' earnings. Back Benchers are paid about £60,000 a year and most of us manage to live quite well on that. As the Minister said, an independent dentist with a good commitment to the NHS—and who probably does a little private work as well—earns in excess of £80,000 a year and gets a further £60,000 toward practice costs. A dentist who works for the NHS, but not as an independent contractor, could expect, after two years, to earn more than a Back-Bench MP—some £65,000—but with no practice costs. So dentists in my area, which is a low-wage area, are not badly paid.
The hon. Gentleman is very lucky that only four dentists in his constituency are refusing to take on NHS work. The NHS Direct website has a list of all the dentists in Bedfordshire and, as of today, 20 of those 41 dentists are refusing to accept any new NHS patients for treatment; of the remaining 21, only 11 will register children. So many of my constituents will be unable to find NHS treatment.
The hon. Lady is obviously a very good MP but I am sure that she does not represent all of Bedfordshire. To compare my constituency to Bedfordshire is to compare apples and pears, which is what the Conservatives usually do.
Let us look at why dentists are saying that they want to leave the NHS. They say that they do not understand the new contract and that they are concerned about the loss of independence, but the reality is that they realise that it is a question of supply and demand. They realise that they can make more in the private sector, and that they can probably work less hard for that money. Also—Members have yet to pick up on this point—they are being targeted by the insurance industry. They are being asked, "Don't you realise how much you could make if you use our particular plan?" Let us never forget that the insurance industry is the enemy of the NHS. Those who want to see where the big money in insurance is should go to America. We must treat with caution the private insurance companies working in this field.
The dental reforms are welcome. An extra £360 million or more is being spent on improving dental services, and when a dentist leaves the NHS, the primary care trust in question will retain the relevant funding. At this point, I should congratulate my local PCT—Opposition Members have offered little thanks to PCTs—which has worked hard to ensure that people can access NHS dentistry. In particular, I congratulate the senior manager, Michael Smillie, on the tremendous work that he has done. Last week, we announced the provision of eight new dentists in Carlisle and Penrith. They will take on 20,000 patients and in doing so will probably clear the waiting list. Extra dentists will also be provided in Workington and Whitehaven—I note that my hon. Friend Mr. Reed is in his place—so we are tackling the problem. It will not be solved in a day, and I am not saying that all dentists are happy with the contract, but the vast majority are working with it and people will see the difference.
The Minister has announced a new dental school—she kindly sent me a copy of the press release—for north Lancashire and Cumbria. That brand new facility, to be located at the Cumberland infirmary, will add to the excellent work already being done by its education centre. In training new dentists, it will thereby make up the shortfall. Be it dentists or doctors, the view is that, where they are trained is where they stay, so in four or five years' time we will have new dentists in our region. That said, I have no problem with dentists coming over from, for example, other parts of Europe. Patients tend not to have big conversations with their dentist.
I congratulate the Minister on the points that she made about the contract and I am glad that she has decided to review it. The Conservatives failed dentists when they were last in power, and they have failed to cost their current proposals. I doubt whether the people of this country, even if they are concerned about dentistry, will turn to the Conservatives.
It is fairly well known that I have a slight interest in this subject. The Conservative Whips certainly know that, and they took the risk that I might not be entirely on message.
I want to congratulate the Minister on two things. First, she has managed—almost, if not entirely, on her own—to upset just about every NHS dentist in general practice in the country. Secondly, the implementation group that she has set up sounds really positive. It is a mark of recognition, finally, that there are problems with the contract. Those problems may have more to do with perception, but they need to be looked at.
Most general dental practitioners doing NHS dentistry or offering a mixture of NHS and private treatment want to continue to provide that service. Earlier, we got an inkling of the degree of willingness on the part of the Government in that respect, and that is what is needed to make progress. Mr. Martlew said that there were some sharp dentists out there, but that is true of every profession. However, they are a minority: most dentists are straightforward people who want to provide a mixed service because they have to face their patients, to whom it is virtually impossible to say no.
I want to dodge most of the complaints usually raised in a debate such as this, and concentrate on a slightly different matter. The hon. Member for Carlisle spoke about what happened 10, 20 or 30 years ago, but there has been a dramatic change in the quality of dentistry on offer in this country. The teaching that dentists receive is vastly better, as is the quality of the materials that are available. Dentists are able to do much more for patients, but even more dramatic are the changes in what patients now demand. The things that people ask for are more the province of private dentistry than the NHS, and that means that dentists must be able to offer choice. That is the burden of my contribution, and it is something that I hope that the Minister will reflect on.
In that connection, I want to touch on two matters—the treadmill, and mixed provision. The Minister said that the treadmill had disappeared these days. Like everyone else, I expect that she will have received a letter from Dr. Adrian Kinnear-King, in Norfolk. In his very bitter letter, Dr. Kinnear-King says that he is a socialist, a long-standing member of the Labour party, and an NHS dentist. Although he seemed to be asking me for my personal help with the Labour party, I thought that I would telephone him anyway.
Dr. Kinnear-King has not signed his contract so far. In fact, he has not received one yet, but he has looked at some of its contents. He may decide not to sign it at all, but he says that there is no real treadmill under the present system. If he wants a break, he can take one, and he can also work a bit harder if that is what he wants to do. However, the introduction of targets that he has to meet means that he will get a phone call from the local PCT if he falls behind. He does not like the new contractual treadmill, or the way in which it has been introduced.
If Dr. Kinnear-King fails to meet his monthly UDA target, the PCT will want an explanation. Technically, it can claw back money from him, or take other action. I hope that most PCTs will wake up to reality and not be so draconian. They need to work with dentists who fail to meet their targets and find out why that has happened, as sometimes the fault lies with the proportions assigned in a mixed service.
I listened with care to the Liberal Democrat spokesperson, Julia Goldsworthy. This may upset her, but I can tell her that what she said is guaranteed to get dentists walking out of the NHS in droves. Dentists have some difficulties with the present system, as negotiating a change in the size of the contract or the mixture of services that it covers can take two or three months. I am sure that we can do better than that.
The Minister panned the Opposition motion, but it contains the vital proposal that
"everyone should have to access to NHS dentistry".
That commitment does not appear in the Government's amendment, even though it is extremely important.
I have something else for the hon. Member for Falmouth and Camborne to think about. A patient who presents to an NHS or mixed dentist suffering from pain in her lower-left third molar, for instance, will be offered a choice of treatments—NHS amalgam, for example, or the latest treatments using bonded composites, or a gold inlay, or an inlay-overlay in porcelain. Those might be her options, but what is important in the end is that the treatment gets done: that is what counts, not whether the treatment is NHS or private.
Under the new contract, the NHS amalgam option means that the dentist will achieve more UDAs. If he does not perform that treatment, he has fewer UDAs. As Dr. Kinnear-King notes in his letter, those UDAs have to be made up with other patients.
Nowadays, patients want choice. The more choice that they get, the more private dentists' fees will come down. If the fees are too high, the dentists will not fill their appointment books. That shows that the market can also work to the advantage of patients.
Dr. Kinnear-King offers a better example of that. He says that a patient who comes in with teeth that are intact but badly stained—perhaps by tetracycline, for example—is likely to give him a big, broad, ugly smile. When I asked him what he would do as treatment, he said that he would get out his screaming diamond burr and apply it at 500,000 revs. He would use it to tear around the tooth enamel and put on 16 sparkling new NHS porcelain veneers—
I am sorry to upset the hon. Lady. My voice is not pitched high enough to make what I am saying even more emphatic. The process that I am describing would secure lots of UDAs, and the dentist would have to do it all again after a few years, when the gingiva had moved. Once more, he would achieve lots more UDAs, but what that dentist would want ideally is to be able to offer the patient an opportunity to go for private treatment as well. The best treatment would be to spend hours carefully bleaching her teeth. That would leave her with a broad and beautiful smile, intact teeth, and no need to repeat the treatment.
However, Dr. Kinnear-King says that he feels that he cannot undertake the bleaching treatment, because he is looking over his shoulder at the avalanche that is the monthly UDA total. Somehow, the Government have to change the position that dentists find themselves in.
In his letter, Dr. Kinnear-King says that he is a solid socialist, but that he is seriously considering not signing the contract. He intends to go private, but says that he will keep the fees down so that he can offer his patients the service that they need. As I remember from my own experience as a full-time dentist, the problem is that some people cannot afford even low fees.
The Minister's implementation team will have to look very carefully at how the mixture of NHS and private treatment can be introduced. It must also find a way to ease the treadmill, or dentists will continue to walk away from the NHS. We have enough dentists, and will soon have more than enough, but they must be encouraged to stay with the NHS. The present contract, and the way that it has been implemented, is achieving the exact opposite of that.
I hope that I can help the hon. Lady. Many dentists are moving into the private sector, but I assure her that most patients feel more pain from the white envelope containing their bill than they do from the treatment that they receive.
I thank the hon. Lady for that.
The problems associated with getting dental treatment cause more people to come to my surgeries, write to me and send me e-mails than just about any other issue. Their concern is mainly generated by letters that they have received from their dentists explaining that they are no longer taking on NHS patients or are opting out of the NHS. It is important, therefore, to consider why we are introducing these reforms to dentistry.
Everyone, even the Tories, would agree that there are not enough dentists, that provision is unequal, that access is difficult and that the Government are trying to respond to the concerns of both the public and dentists. Everyone, even the Tories, wants better access to treatment and to promote good oral health. We have heard a lot today about the difficulties that people have experienced, but we have heard almost nothing from the Opposition on proposals for changes that they readily admit are very necessary.
I do not deny that we are in a difficult situation. Almost all the dentists in my constituency have already decided not to sign the NHS contract and I agree that we need to do more to attract dentists to stay in the NHS. However, would not our time be better spent today discussing some constructive proposals and ideas on how to do that?
The Government have always worked on the principle that prevention is better than cure. We want to ensure that dental recall periods are based on clinical need, rather than on automatic six-month check-ups. We want to free up dentists' time to see a range of patients and provide additional NHS services, such as promoting oral health.
I have terrible teeth and have been to many dentists, so I have met far more dentists in a professional capacity than I would want to. All of them, without exception, are committed to providing oral health care and preventive medicine to the highest standard. However, preventive measures are increasingly being hampered by sweets in supermarkets and it is surprising that that has not been mentioned yet today. It was not until recently, when I took my two-year-old shopping, that I noticed a whole bank of sweets, at adult knee-level, lining the channel to the supermarket check-out. Everyone knows that sugar and sweets cause tooth decay, so why is that still happening?
I understand that there was a private Member's Bill on children's food, which the Government did not support. Would the measures in that Bill have helped to alleviate the problem that the hon. Lady describes?
I understand that we are adopting similar measures. What I would really like to know is why the Opposition have not made any mention of the link between sweets in supermarkets and reforms in dentistry. It sounds a trivial matter, but it is very important when we are discussing preventive medicine. Our oral health plan at least takes a more holistic approach to prevention by aiming to improve oral health and to reduce health inequalities. We propose to do that by increasing the use of fluoride to help to prevent tooth decay, improving diets and reducing sugar intake. I hope that my hon. Friend the Minister will meet the parents jury of the Chuck Snacks Off the Checkout! Campaign, which I intend to join. We will also encourage preventive dental care; aim to reduce smoking to tackle oral cancer—the ban on smoking in public places will go a long way to achieving that—increase early detection of mouth cancer; and reduce dental injuries such as those caused by contact sports. I have heard no positive or constructive proposals from the Opposition to match those ambitious plans.
I do not claim that everything in dentistry is fine, but I would rather look for ways to improve the situation. I will meet the chief executive of my primary care trust in north-east Derbyshire and dentists in my constituency to find a local solution. These reforms coincide with the reorganisation of primary care trusts. Let us ensure that the outcome of our reforms will enable PCTs to place with an NHS dentist anyone who wants one.
Poor people are more likely to have poor oral health. Poor people are not in a position to pay for private dental care. We do not want to exacerbate inequalities but to ensure that everyone has access to an NHS dentist. Oral health is too important to be used for political point-scoring, so let us hear some good ideas.
I shall make a short speech, because I have one simple point to make. I have some 78,000 people in my constituency and, on the whole, no NHS dentists, so those people have nowhere to go. It is not a question of the NHS being free at the point of delivery: it is failing at the point of delivery. There are no NHS dentists. The Minister knows that we have had busloads of Polish dentists coming to set up in south Devon, and we now have a few of those, but on the whole there are no NHS dentists. That is the first problem that the Minister must address.
The issue is not about having high-powered discussions about drilling people's teeth out. There are no NHS dentists to drill people's teeth out. I must declare an interest, in that my hon. Friend Sir Paul Beresford is my dentist. He is an experienced and very skilled dentist. I hope that the House will excuse the slight lisp with which I speak, which is because of a slight problem we have had. My hon. Friend's concern is the care of patients and the access that they have to treatment. What do I say to a garage forecourt man who, when I spoke to him the other day, had a very swollen cheek? I asked him what was wrong and he said that he had an abscess. He said that he could not afford to go to the dentist, because they are all private in our area. He said that he had gone to the doctor—that service is free at the point of delivery—and got some antibiotics to try to reduce the swelling. I know how painful an abscess is and the necessity of immediate treatment, so it is criminal that the NHS system does not work in our area.
What should small children and elderly people do? I have the ninth oldest constituency in the country—not the Member of Parliament, but the constituents—and they are one of the groups of people that need quick access to dentists. Because I have a large rural constituency—it runs 30 or so miles one way and 40 or so the other—we have no adequate public transport. What do we say to such people? We are supposed to be the fourth or fifth—I think that the Chinese have just overtaken us—richest country in the world.
I do not wish to get into the detail of the contracts, but I wish to ask the Minister whether dentists will end up like opticians, who are now outside the NHS. Everybody applauds the Minister's frankness and her integrity, but is it really the Government's intention to get rid of NHS dentistry that is free at the point of delivery? If not, why do we make it so complicated? What are these units of dental activity? Does it depend on the dentists themselves being very active? It is another example of weasel words—the Government are wonderful at using them. Does it mean that if the dentist rushes around his consulting room, he gets an extra point? Or is it based on something more that he does for the patient?
Can the Minister tell me why one dental practice in Plymouth is being offered £22 per unit of dental activity, when the next-door dental practice—I know them both, although I have not used them both—is offered only £14 per UDA? What is wrong with the £14 UDA dentist? Will people who go to the £22 UDA dentist get better dentistry? The Minister is trying to marry two services that are irreconcilable—a salaried service and an individual, private service. The result is that few people will be offered free services by their dentist.
Is my hon. Friend aware that the problem in his constituency, which is contiguous with mine, is in fact Devon-wide? I have just been sent an e-mail from a Devonshire dentist who tells me that in north Devon
"2 practices have already deregistered for adult patients. 3 practices are now on the brink of refusing to sign the new contract."
In my constituency, no dentist is accepting national health service patients. The situation is the same across the entire county.
People will clearly be able to tell which constituents come from Devon; they will all have black teeth and swollen cheeks. They will all be suffering from bad teeth because Devon does not have NHS dentists. This is not just about Totnes; my constituency covers parts of five local authorities—the Dartmoor national park, Devon county council, Teignbridge district council, South Hams district council and the Torbay unitary authority. They all have the same problem.
I understand why the Minister is no longer in her place; she can no longer face us. What are we to say to people in Torridge and West Devon and in Totnes? From what Natascha Engel said, if she had visited only NHS dentists she would probably have no teeth left—perhaps she does not. We cannot tell a nation of 60 million people, including children and the elderly, that the NHS is free at the point of delivery and then produce the wicked joke that there are no dentists.
What do I say to my constituents? The Minister knows about my concerns, because I have written to her over and over again about one person after another. I am embarrassed to represent an area in the world's fifth-largest economy and tell my constituents that they cannot have free dental health provision.
I am impressed by my PCTs, which are responsible and highly committed organisations. The snag is that they cannot find dentists. I do not know whether something is wrong with the contract. In any case, I am not concerned about the machinery, but about every person I see in the street who is in pain. I represent them, so I say to the Minister that she must do something about the contract so that people can receive free dental care. She must provide the dentists. I do not mind if she brings in busloads of Bulgarians or Romanians. She can bring them in from any country in Europe. She misunderstood my earlier question—I do not object. The Prime Minister misunderstood me too, but he regularly misunderstands my questions. The point is: what are we going to do about the situation? I cannot represent a constituency when I know that people will continue to be in pain and will have to find money that they do not have to pay for private dentistry.
I apologise to the House as I shall have to be discourteous and leave soon after speaking. I have a ministerial meeting at 3 o'clock on a pressing constituency matter, but I shall try to return for the wind-ups so that I can hear the ministerial response.
Over the past six months, I have convened meetings of London dentists. We have held two meetings at the House of Commons, as well as meetings with individual groups of dentists elsewhere. One of the meetings in the House was in November and the other in February, and I am grateful to the Minister for the access that she gave to civil servants, who attended one of the meetings, and also for the correspondence she provided that enabled us to share information about the new contract procedures with the dentists.
Like many dentists, I welcome the Government's policies with regard to the additional resources and their commitment to dentistry. I was impressed by the parliamentary Labour party briefing and can understand why on this occasion it was circulated more widely than usual, given the additional resources it described, including the £368 million for improving dental services in July 2004, the 19 per cent. increase since 2003–04 and the nearly 1,500 new dentists. I welcome all that, but I want to raise issues about the method of introduction of the new contract, especially the timing, some of which relate to London and others specifically to my constituency.
My colleague, Mr. Hurd, has pointed out that the contract is being introduced in our area at a time when Hillingdon primary care trust is struggling with a deficit of £25 million. It looks as though the amount may be nearer £30 million—it varies week by week. That has resulted in an inability to manage change generally and impedes the introduction of the new contract. We are on our third chief executive in less than four months—and counting. The PCT's struggles with its deficit have led to problems in the introduction of the contract.
I welcome the Minister's statement about the implementation group and the review mechanism, which is a real breakthrough and was one of my recommendations. However, the Department may need to intervene in some instances—such as Hillingdon and other parts of London—where there has been a failure to manage the introduction of the contract effectively. I have two brief examples of the impact on my constituency.
The first relates to the Hayes dental practice in Station road, Hayes, where Dr. Stern has encountered a problem to which the Minister referred earlier, although it was not addressed locally in the way that she described. Last year, during the reference period, two of Dr. Stern's colleagues left and he was unable to recruit for some time. As a result, the PCT's assessment of his activity and income levels was not an accurate reflection. In December, he thought that he had held a co-operative meeting with the PCT. He contacted it regularly after that but heard nothing about the contract. On
"You will be aware that you need to have signed the contract and confirmed this to us by no later than midday on Friday 24th."
So he was given only 24 hours. Furthermore, when he read the contract he discovered that it did not take into account the representations that he made about staffing and activity levels during the reference period, so his income will not be as before and he will have to lay off staff, including not only his dentist colleagues but also support staff.
I accept what the Minister said about appeal procedures, but that dentist thought that he had gone through that process during his negotiations with the PCT. The Department may have to intervene in such cases, where the PCT is clearly struggling to manage the introduction of the new contract.
The second example affects colleagues in Hillingdon and Ealing and relates to the orthodontics centre in Northolt opened by Sarinda Kumar over the past 12 months. We all welcomed the centre, to which the dentists involved committed significant personal outlay, raising capital of about £450,000. However, because the centre opened mid-year, the contract value is not sufficient to reflect the new service it provides. As far as I am aware, there has not been much response from local PCTs in terms of recognising those needs.
The orthodontics service at Hillingdon hospital has also suffered due to the PCT cuts, which relates to a general point about the priority accorded to dental services in several PCTs. There seems to be a lack of sufficient specialist advice from local dentists in the PCT and a failure to acknowledge the need to involve them fully in discussions about the roll-out of services generally and in consultations about the implementation of the contract.
Other general matters were raised that were not specific to my constituency or London overall. There is a concern that the units of dental activity do not fully reflect the importance of prevention. There may well be a need in the review process to find out whether a specific, separate UDA is necessary for prevention and dental health promotion.
Does the hon. Gentleman agree that, if a charge of £183 is levied for a single crown and precisely the same charge is levied for doing six crowns, the incentive for those whose teeth are becoming bad will be to wait until they are sufficiently bad to maximise the value for money that they get from the charge that they pay?
Such issues may well arise during the review process, because the one thing that neither the Government nor any of us want to do is to provide any disincentive to people turning up for health treatments.
Another concern was raised by the London dentists. PCTs obviously set their own targets and the budgets are allocated and then capped. The concern is that, particularly in areas such as mine and in London, PCTs will put pressure on individual practices to increase their income to a certain level from charging. In other words, that is a perverse incentive in the system, thus undermining NHS work as well.
There are concerns about children and exempt patient contracts, which will be determined by PCTs. Given the lack of local engagement with adequate dentistry advice and support, the decision-making process on how such contracts are allocated needs to be closely reviewed by the Department in the first year of operation.
A number of dentists have said that they must introduce new computer systems at considerable cost. The information that we received from yesterday's meeting is that those costs range from about £10,000—with one practice, it was £35,000—and that the allocation that they receive goes nowhere near recovering those costs. In fact, less than 10 per cent. is recovered in some instances and a lot less than that in many others. That will impact on the overall delivery of service.
I believe that the Government have exceptionally good intentions. There is real commitment, and it has been backed by resources. I congratulate the Minister on her personal commitment to the development of dentistry policy. We would not have come this far in the allocation and investment of resources and the priority for dentistry without her personal commitment, but those intentions are being frustrated in many constituencies, particularly mine, because of the financial crisis in the PCTs themselves.
I accept that an element of ring-fencing has gone on for three years, but the concern—it was raised by the hon. Member for Ruislip-Northwood—is that beyond those three years, no matter what statutory duties are placed on PCTs, dentistry will be a soft option when prioritising expenditure. The Government will need to monitor the situation closely over the next six to 12 months in particular. In special circumstances, such as mine, direct intervention by the Department may be needed if the system is seen to be failing and we are losing NHS dentists.
I welcome the implementation group review and the structure that has been announced today, but I suggest that, first, the review should report in six months and then in 12 months, and that that information comes before the House. We could then have another debate—not on an Opposition day, which sometimes degenerate into knockabout rather than real debate—on that report to find out what adjustments need to be made to the system. There is a commitment on both sides of the House: we want dentistry to improve in this country, but we want it to do so in a way that brings people with us. I do not think that dentists are convinced about the system. If we introduce the appropriate adjustments as we learn from experience, we will be able to retain people in the NHS and to work together to improve the system overall for all our constituents.
I realise that time is marching on, so I will keep my comments as short as possible.
I empathise with Natascha Engel. I, too, have lost my two front teeth, although I did so by failing to obey the first rule of cricket: "Always keep your eye on the ball."
I am unsure where in this country the Government are fulfilling their pledge of access for all to an NHS dentist—perhaps in Liverpool or Doncaster, but certainly not in Milton Keynes. Indeed, in an answer to a question posed back in June by my hon. Friend Mr. Turner, who is not in his place, we discovered that just 62 per cent. of children and 39 per cent. of adults—an overall rate of just 45 per cent. of people—are registered with a dentist in Milton Keynes. The figure is down considerably—in fact, 10 per cent. or some 20,000 people—since 1997. That is an extraordinarily low figure. If just 45 per cent. of the population of Milton Keynes is registered with a dentist, about 122,000 people in my city are not.
Perhaps the Minister believes—I am sure that she does not—that my constituents simply do not want to register with a dentist. If so, I point her to a recent survey carried out by Milton Keynes PCT showing that 79 per cent. of people who are not registered with an NHS dentist would like to do so—a fact that is backed up by my overflowing postbag of correspondence from many constituents who have written to me on the issue. For example, my constituent, Mrs. Byrne, who wrote to me only this week, is representative of many young mothers when she says:
"I have a 9 month old son and I am 7 months pregnant, I have been advised to go to the dentist for a check up but unfortunately cannot find one in Milton Keynes. My son's first teeth are now through and I need a dentist for him too. I am quite disgusted that I have an NHS maternity exemption certificate so that I can go to the dentist but the NHS are not providing the dentists for myself and many other people in my situation to attend."
Perhaps the Minister, who seems to suggest that training dentists is one, if not the main solution to the problem, believes that my constituents are simply not looking hard enough for a dentist. If so, perhaps she would like to meet my constituent, Mrs. Carter, who in an e-mail this week says:
"I desperately need an NHS dentist who will accept my two children, my husband and myself as new patients and I have phoned every number on the list provided by the PCT and none of them are taking on new NHS patients. I refuse to go private as my husband and I have paid far too much in National Insurance to have to pay for it again."
That raises an interesting question about national insurance contributions to which I will return in a moment, but is it really that hard to get a dentist in Milton Keynes?
Like many people in Milton Keynes, I am not registered with a dentist. Indeed, I am tempted to ask my hon. Friend Sir Paul Beresford, who is no longer in his place, whether he will start accepting NHS patients, but I sense that that would probably be unfair. I was able to find just one practice that was happy to accept new patients, but there is a catch: they must be under the age of 18 and they would qualify only if both parents were involved. However, I accept that that has been addressed.
As a Back-Bench Conservative MP who may feel that we have absolutely no influence in the House, I am delighted that my very first question in the House was to the Minister on this subject. I asked her back in June whether, effectively, she had replaced the access-for-all-to-an-NHS-dentist policy with a buy-two-get-one-free policy. So I am delighted—I am sure that the people of Milton Keynes are, too—that I seem to have had some impact on the House.
If I were a cynic, I would ask whether, in reality, the Government are pursuing their policy in the hope that people will perhaps get used to going private and therefore not want an NHS dentist, with possible effects on funding dentistry in the future. So who is to blame? I am sure the Government are keen to blame dentists, but I am afraid that I do not blame them. Having talked to my local dentists, it is clear to me that they are doing the very best that they can in extremely difficult circumstances. They do not want to turn away NHS patients, but seem to have little choice.
Dentists have serious concerns, some of which have already been raised by my hon. Friends, so I will focus on just two—first, the time scale for the new contracts. Certainly, in Milton Keynes at least, they were given their contracts just eight days ago, yet they were expected to return the first draft by yesterday. The second concern is the security of the new contracts. Although they will last for three years initially and have been ring-fenced, there appears to be little security beyond that point. For example, if an associate leaves a practice, there is absolutely no guarantee that the PCT must award a contract to the same practice. It is therefore very difficult for dentists to plan the expansion of their practices beyond the three-year period. I should be grateful to the Minister if she considered that issue.
Perhaps we should blame our local primary care trusts, but to be fair to Milton Keynes primary care trust, which is being forced to swim against the tide because of an ever-increasing population, it is at least trying to address the problem, although the early signs are that the results of its efforts are, at best, mixed. It sent out a mixture of practice and individual contracts, but 20 per cent. of dentists have so far refused to accept a contract. As of yesterday, 40 per cent. of dentists had not returned their contracts, and at least a third of the dentists who had returned and accepted their contracts had done so in dispute while waiting for further negotiations with the PCT. Those statistics are hardly encouraging. Given the rapidly growing population of Milton Keynes, Milton Keynes PCT is one of the hardest pressed primary care trusts in the country, although I am confident that it will try to do the right thing when funding dentistry in Milton Keynes.
My hon. Friend has obviously had extensive conversations with his primary care trust. Has it given him any indication of the possible implications of the 12-monthly block payments that are coming through on its funding and deficit next year?
My hon. Friend makes a valuable point. There is deep concern about that matter in Milton Keynes, as I am sure there is in his constituency. Although I am confident that my primary care trust, which is staffed by excellent people, will try to do the right thing, I am worried that once we get beyond the three-year ring-fenced period, there will be a temptation to divert funds for dentistry elsewhere. I hope that the Minister will ensure that that does not happen.
Finally, may I pass on a question that many of my constituents are keen that I should ask the Minister? Given that they have paid their national insurance contributions yet failed to get an NHS dentist, will she give them their money back?
It is a pleasure to follow my hon. Friend Mr. Lancaster, who gave us several examples of problems in his constituency that are reflected in mine. The Government's proposals on NHS dentistry are characterised by being target driven, centralised and shambolic, although perhaps we should not be surprised because that is a description of their general approach to the NHS. Several Labour Members focused their comments on the relatively high salaries of dentists, but it should be noted that Conservative Members are worried about access for patients, which should be the focus of the Government.
I want to talk especially about younger dentists because the proposals have been presented as representing a bright future for NHS dentistry. However, is that the case? I suggest that they are yet another nail in the coffin for NHS dentists, especially young dentists. I concede that funding, recruitment and the number of training places have increased, which is welcome, but how will that affect in practice young dentists who want to be part of the supposed bright future? Will my constituents get proper access to a dentist? I suggest that the contract is an obstacle to any of the relatively good progress that has been made and a road block for young dentists.
Let us consider the situation for young women dentists, especially those who are young mothers. One of my constituents, Mrs. Surabaskaran, has told me about her experiences, which are no doubt replicated throughout the country. She is an NHS dentist who graduated in dentistry in 1998 from Kings college school of medicine and dentistry and looked forward to a future in the NHS. She was on maternity leave for five months during the relevant period over which her contract value was calculated, and has been in negotiation with the PCT to get an appropriate contract value. However, her maternity leave has been wholly discounted, so she has effectively been left with a contract that would be worth half her salary. Although she has 2,000 patients on her list, there is a risk that she will be forced out of the NHS because the PCT has stonewalled by saying that it has insufficient funds to address the situation.
The Minister might well point out that the framework proposals said:
"Allowances will be made where the practice has carried a vacancy"— for example, due to maternity leave. It was suggested that allowances could be made for dentists who were
"increasing or reducing, or planning to increase or reduce the amount of NHS care they provide" during the relevant period. However, despite all the good intentions in "Framework proposals for primary dental services in England in 2005", the reality is that a young dentist such as Mrs. Surabaskaran is being left short when negotiating her contract because the local PCT refuses to award a contract with the value that she should properly have.
As the PCT has said no to Mrs. Surabaskaran, she must use the dispute resolution procedure for the contract and go to the Secretary of State. However, where will that leave her? Will she be guaranteed a better value than that which she has been offered? Given that the contract should have been signed yesterday, she faces the precarious predicament of endangering not only her future career in the NHS, but the 2,000 patients who are on her list. Is the process for dispute resolution appropriate? Should the Secretary of State be the binding determinant of a contract? Such a procedure might be appropriate in different parts of the NHS, but should the Secretary of State make decisions about a party who is a sub-contractor risking private capital? Again, the controlling hand—the dead hand—of the Government is at the heart of the proposals. We have heard that D-day has passed, so many NHS dentists, especially young dentists, face chaos.
Mr. Lancaster said a moment ago that a three-year contract was not sufficient, although these days most people would be happy with a three-year contract. However, Mr. Burrowes seems to be saying that the contract should have no obligations and that there should be no mechanism to resolve disputes. Is he seriously saying that we should simply pay the money and give no further attention to what happens? Does he think that that would be credible?
The debate is about the proposals that the Government have put in place. I hope that the hon. Gentleman agrees that there has been discrimination against a young dentist who has been on maternity leave. She has been left with a bureaucratic and centralised resolution process. She effectively must choose between not continuing to provide NHS care, or meeting the needs of her 2,000 NHS patients.
I want the Minister to hear the words of Mrs. Surabaskaran loud and clear. She says:
"If the dispute is not resolved speedily with due consideration for my maternity leave I will be forced to seek a job in the private sector."
However, she does not wish to do that.
In the circumstances that the hon. Gentleman describes, I believe that his constituent could sign the contract with a note to say that there is a dispute about some aspects of it.
I am grateful to the Minister for that point, but my constituent has no guarantee that she will receive her due reward. She runs the risk of being given a contract with a value that is half what it should be. Neither she, nor any other NHS dentist, has an individual contract guarantee.
We must also consider the situation facing graduates. We have to welcome the fact that 100 extra dental school places were announced on
"The current NHS access problem"— the concern is not so much about salaries or training places, but NHS access—
"is caused by the large gap between the terms and conditions offered by the NHS and those in the private sector. This has led to an outflow of dentists from the NHS which has been exacerbated by the prospect of an inflexible and inefficient new NHS contract in April 2006 which is generally expected to make working in the NHS less desirable to most dentists."
That is the case, particularly for vocational dental practitioners. How do they fare with this contract? If one looks at the detail of the contract, one sees that all revenue associated with vocational training will be put on hold during the relevant period and will be removed from the contract value. The employment of vocational dental practitioners will essentially be at the behest of the primary care trust. We have heard already of deficits among PCTs, and the situation is the same in my constituency. It is fair to suggest that the first to feel the squeeze in the PCTs' capacity to deliver NHS dentistry will be vocational dental practitioners, who will be unable to find a place to pursue their training. Many a dental practice is not receiving, in its units of dental activity, any recognition of vocational dental practice. The PCTs do not have to provide that recognition. They have been asked by the Government to do so, but there is no specific requirement to take any account of the vocational route that we would wish many people to follow.
Finally, I turn to the care given to patients. It is at the heart of the motion, which refers to support for preventive work and the achievement of good oral health. The Minister says that it is all about preventive care, but what is the reality? As dentists in my constituency tell me, no real value is given to preventive treatment in the UDA system. Root canal treatment is worth three points, as is extraction. Root canal treatment usually takes three 45-minute visits, while extraction takes half an hour, so there will be an incentive to take out a tooth rather than give root canal treatment, despite their having the same UDA value of three points. Dental repairs too, will come straight out of the dentist's salary, so there will be an incentive to fit fewer crowns and more fillings. The contract looks more to points than to patients.
I should conclude because I have gone way over the time—eight minutes—that dental practitioners will be allowed by the contract for an examination, X-ray, and scale and polish. The question is not so much whether there will be time for NHS dentists to give quality care but whether there will be any access at all to NHS dentists.
I am grateful to Her Majesty's official Opposition for initiating this debate, the second on this subject. The first was last October and was initiated by the Liberal Democrats. We were told then by the Minister that we should wait until the new contracts had come out to see what would happen. I have to tell her that in my constituency it is no longer a case of saying that NHS dentistry is in crisis; NHS dentistry simply does not exist. In 1997, 58 per cent. of the population was registered with an NHS dentist. Last year, that figure had dropped to 35 per cent. The Minister herself admitted, when I questioned her, that that is not progress. I have asked on numerous occasions, both verbally and in writing, what she will do to improve the situation.
Since Christmas, the situation in Rochdale has got worse. Last December, residents received letters from the last remaining full-time NHS practice informing them that from
I listened very carefully to the Minister to see what the new contract could offer us. She talked about what it will mean to existing dentists, particularly with regard to the reference year. How does that create new money to enable Rochdale PCT to employ more dentists? It does nothing in that regard. The dentists have to be in the system already, receiving NHS money; no NHS money will be transferred to non-existent "ghost" dentists.
We have heard a lot about access, which is the key point. The hon. Gentleman has described what is happening in his constituency, and that has been the tale throughout the House. One question that the Minister has to answer today is how many dentists who had previously resigned from the NHS will come back to the NHS under this contract. Surely the answer is zero, and that is a failure of access.
I agree entirely. The situation in the borough of Rochdale will get worse because dentists in the Heywood and Middleton constituency—I think that there are eight—have said that they, too, have no intention of signing the new contract. A borough that already has a very poor record of dental health will be left with virtually no NHS dentists. Yes, we have a walk-in centre, and it is fully committed, but it is doing nothing in the way of preventive work. It simply cannot cope with that on top of the emergencies that it deals with.
In the past 12 months, we have seen new dental practices open in neighbouring areas, such as Radcliffe and Bury. People in my constituency have queued from 5 o'clock in the morning to get themselves on the list at those practices. A dentist from Zimbabwe recently opened a practice in the neighbouring constituency of Oldham, East and Saddleworth, and within four days his list was full. Rochdale needs 10 dentists to treat those people who cannot afford to go to a private dentist.
When the Balderstone surgery announced that it was pulling out of the NHS, a constituent came to see me. He said that he had been told bluntly that if he wanted to stay with the practice he had to be prepared to pay £15 a month. There is no way that that gentleman could afford that sort of money. I wrote to the PCT, pointing out the situation with the last remaining NHS practice and asking what it was going to do and what advice it could give me to pass on to my constituent. The advice was laughable; it was to look at the website. When one looks at the website—not everyone has access to the web—one asks, "Where are the dentists for Rochdale?" They simply do not exist. I really am sick of hearing talk about this new contract and what it is supposed to deliver, when the few dentists left in the NHS are being driven out as a result of the obsession with targets.
We need to hear concrete proposals from the Government to address real shortages. I have been asking since May, when I was elected, what the Minister will do to deal with the crisis in my constituency. Everything that she has done so far has made the situation worse. In the next few years, we will see a dramatic rise in dental ill-health; we will see more expensive treatment having to be carried out; and we will see people's general dental health deteriorating greatly. That is not why the NHS was created. It is not what the Prime Minister promised us back in 1999, when he said that everyone who wanted an NHS dentist would have one within two years. The reality is that fewer and fewer people in my constituency have access to a dentist.
I have asked for a meeting with the Minister. I invite her to come to Rochdale and explain to people why we cannot get NHS dentists in the constituency. They deserve answers and we ought to have them now.
I applaud the Minister's courage in coming to the Chamber for the debate, given that there is opposition on all Benches, including the Labour Benches, and opposition outside the House to the Government's proposals.
I praise the work of dentists throughout Shropshire, especially in my constituency. I praise also the professionals who work in orthodontics and dentistry at the Princess Royal hospital in my constituency. They all provide a valuable and vital health service for my constituents.
I note that the Government have tried to shift the blame from them to primary care trusts and to dentists. However, it is the Government who will be funding PCTs. Those trusts, with scarce resources, will have to apportion dental contracts accordingly. Given that Shropshire County PCT and Telford and Wrekin PCT are already struggling financially, that does not hold out much hope for my constituents with dental problems for the months ahead. That is clearly of concern to them and to me.
I remind the Minister of the Prime Minister's comments at Question Time today—that we should trust professionals. We have heard that mantra over many months. We were told in the context of the Terrorism Bill that we must trust the professionals. We were told, "The police are asking for X and we should give them X." Why is it that on this issue the Government are not prepared to listen to the professionals? Let us listen to the words of the British Dental Association. It says:
"The Government's aims of securing patient access, improving oral health and raising the quality of patient care will not be achieved by the imposition of this target-driven NHS contract."
If the Government are serious about listening to professionals, let us see them listen to dental professionals on this point.
I am tempted to go down that route. I know that Labour Members do not want us to address serious issues on dental care. That being so, I shall stick to the substantive points that other Members have raised. I shall be happy to discuss the point that the hon. Gentleman has raised outside the Chamber at a later stage, at his cost, over a cup of tea.
It has been said that it is the poor who will suffer, and that is absolutely right; and that the elderly will suffer as a result of the proposed changes, and that is absolutely right. In addition, everyday families and single people—in fact, everybody—are likely to suffer in the light of the proposed changes.
The Minister has reminded us of the number of dentists entering or opting in to NHS contracts. The overall net figure, including those who have opted out of NHS contracts over the past few months, or who are likely to do so, shows that there will be a drain away from the NHS. There will be fewer dentists providing NHS treatment. I accept that some centres have opened, and I know that in the neighbouring constituency to mine—Telford—there will be a new centre, but that will not meet the needs of all the constituents in Shropshire. The demand will not be met. Unfortunately, there is a net loss overall.
I wish to reinforce the point that the hon. Gentleman has just made. When I spoke to my primary care trust last year, it was putting various measures in place—no doubt applauded by the Minister—and hoped to achieve 21,000 new NHS registrations. When I met the members of the trust only a week ago, they told me that they were expecting 14,000 fewer registrations because of the likely impact of the new contract. This is NHS dentistry in crisis.
Absolutely; crisis is an appropriate word. We have a crisis in health care generally, and it is not the fault of the professionals who are working in our hospitals, our dental practices and our primary care sector. On so many of these issues, the fault lies with the Government. We have seen today Ministers smiling and taking these issues lightly, no doubt with extremely healthy teeth. They should take these issues far more seriously and look after my constituents who are unable to access NHS dentists.
The Minister might be aware—I have discussed this previously with her—that the nearest dentist for some of my constituents in, for example, the wonderful market town of Shifnal, is as far away as Lichfield. It is totally unacceptable that young mothers, often having to use public transport, have to change two or three times to access the NHS. As my hon. Friend Mr. Lancaster rightly said, given that people have paid their taxes, the very least that they might expect is the standard of NHS dental care that they enjoyed over many years. There has been criticism of past Conservative Governments, but at least people could register under the previous Conservative Government with an NHS dentist. People will not be able to do so given the present proposals.
I recognise that my colleague is a distinguished Member on health matters. Unfortunately, one other Member wishes to speak in the debate. That being so, I shall give way on another occasion, perhaps.
Many orthodontists in my constituency have concerns. We are likely to lose an orthodontist place at the Princess Royal hospital, which will result in people waiting even longer to receive orthodontic treatment. Orthodontics should not be an aside to general dental services. There are 550 patients who access orthodontic care at the Princess Royal hospital. They will be unable to access future care if we do not replace the orthodontic practitioner that we have lost over recent weeks. That will lead to a decrease in oral health. As I said earlier in an intervention, I think that in the long term we shall see an increase in gingivitis. Sadly, we may even see an increase in cancers of the mouth that are not picked up by dentists and orthodontists.
In conclusion—I am rushing through to try to be helpful to other Members—the Minister said that the Government would review dental and orthodontic contracts once they had been in place for some months. I ask the Minister for that review prior to the introduction of the contracts. If she is to consult the professionals then, why does not she listen to their advice now? Surely that is a logical position to take.
My constituents are being disfranchised as a result of the Government's policy. They are likely to be more disfranchised from access to NHS dentists as a result of the policies in the new dental contracts. This flies in the face of the Prime Minister's saying in September that all people will have access to an NHS dentist within two years. Clearly, we and my constituents have yet again been misled by the Prime Minister on a key health issue.
I shall be brief. We have had an interesting debate, and many hon. Members have made my points for me.
I shall draw on the Welsh experience, not just because it is St. David's day, but because many of the things that we have experienced in Wales are now being experienced in England. What has happened in my constituency offers a glimpse of what Members representing English constituencies will face. Pembrokeshire has the lowest rate of adult access to NHS dentistry in England and Wales. Just 15 per cent. of adults are registered with an NHS dentist, and 85 per cent. do not have access to NHS dentistry, which has all but collapsed in west Wales. One by one, dentists have exited the NHS, so their patients have had to sign up to private schemes.
In the past two years, the Pembrokeshire local health board, which is responsible for commissioning, has made great efforts to tackle the problem, to the extent that it has employed dentists directly, but it has fought against the tide. I do not wish to be partisan, but it should be placed on the record that all of this has happened on Labour's watch. What would have happened if the people of Pembrokeshire had been told in 1997 that within eight years they would witness the almost wholesale destruction of NHS dental services?
It is a little disingenuous of the hon. Gentleman to say that all of this has happened on Labour's watch, because the peak in NHS dentistry registration occurred in 1992. It started to fall because of the new contract introduced by the last Conservative Government.
My memory may fail me, but I do not recall people queuing from 5 o'clock in the morning to sign up with a dentist under a Conservative Government. The truth is that NHS dentistry has all but collapsed in parts of the country under the present Government. Labour Members ought to be extremely concerned about the trends in my constituency developing in constituencies that they represent. My constituency had a Labour majority of 9,000 at the end of the 1990s, but as NHS dentistry unravelled so did that majority.
Few issues galvanise so many people from so many different backgrounds as the NHS. The Labour party should understand that better than anyone, as it claims to be the party of the NHS. The NHS serves everyone, and people are attached to it, so they are rightly angry when they wake up one day and find that their NHS dental service, for which they helped to pay, no longer exists and they are required to sign up for a private sector service.
In conclusion, the new contract represents a massive missed opportunity to reinvigorate NHS dentistry. Not one dentist to whom I have spoken in Wales or England believes that the clock can be turned back, and they are very pessimistic indeed about the future of NHS dentistry in this country. The truth is that the NHS dental service is dying under the Labour Government.
We have had an instructive debate this afternoon, with a total of 11 Back-Bench speeches, all of high quality. I have received reams of correspondence from dentists about the new contract—none of it is complimentary. Ministers will be particularly interested in messages I have received from Leicester, Doncaster, Liverpool and Birmingham. Most of them use parliamentary language, but some do not. I should like to begin by sharing one that I have just received from Doncaster, as I know that Ms Winterton will be interested in it:
"As of 1020 hours Doncaster time, we have not received a contract . . . I can state with a fair degree of confidence 100 per cent. of dentists in Doncaster have not agreed to the new contract."
The Minister made great play of apparent demands from patients for a simplified, more transparent charging mechanism, but I can honestly say that I have not met a single constituent who is exercised about the complexities of the charging system. However, like my hon. Friends the Members for Totnes (Mr. Steen), for North-East Milton Keynes (Mr. Lancaster) and for The Wrekin (Mark Pritchard), as well as Paul Rowen, I have received shedloads of letters about deteriorating access to NHS dentistry. That is not surprising, because in the strategic health authority area serving my constituents only 25 per cent. of people are registered with an NHS dentist. I am horrified to hear that in the constituency of my hon. Friend Mr. Crabb the figure is even lower at 15 per cent.
As constituency MPs, we know—and Citizens Advice recently confirmed it—that access to NHS dentistry is of overwhelming concern to dental patients, despite the Prime Minister's famous pledge in 1991, which, I note, is not reiterated in the Government amendment to our motion. The contract is set to make matters much worse. Community Dental Centres is a group of nine major dental practices in the west country that cares for 100,000 patients. It announced yesterday that unless there are changes to the contract it is likely to pull out of NHS dentistry. It points out, as did the London local dental committees that I met last night with John McDonnell and my hon. Friend Mr. Hurd, that payments will be based on dental activity, which is not the same as dental care. Activity implies the treadmill, which is precisely what we thought Ministers were keen to remove. Dentists want to offer care to patients, not activity, and the Minister ought to know the difference between the two.
The consumer organisation, Which?, and the National Audit Office appear united in their belief that primary care trusts are simply not up to managing the new contract. Which? has asked for a clear audit framework to measure the impact of the changes. That would at least allow us to draw breath and reconsider after a few months or a year. I am pleased to hear that the Minister is going to put in place a review group and implementation team. I hope that it meets in six months' time and in 12 months' time and that at each of those points, as the hon. Member for Hayes and Harlington suggested, there is a report that is debated in this place.
What is the Minister doing about contractual arrangements for practices that have grown in the test year? Yesterday, I met a full-time NHS dentist from south-west London who is preparing to sack three members of staff on
"The financial disaster we are facing is due to the methodology adopted by the Department of Health for deriving contract values for orthodontic practices."
On the same theme, a Birmingham dentist writes:
"One Dentist in South Birmingham extended his practice to 6 Dentists last year from 3 to accommodate the extra patients seeking NHS treatment, he has been told his budget is such that the 6 dentists must work part time or 3 must leave, as his funding is based on the period when he had 3 dentists. This will leave about 4000 patients without a Dentist."
Clearly, at this late stage there is considerable confusion about how the anomalies that the test year will introduce are to be resolved. This is the eleventh hour.
I am assuming that moneys released from the many dentists who opt out will be reallocated to the few who are expanding their services or to the Government's massively expensive dental access centres. However, practices willing to expand have not been told that that is the case. Can the Minister offer us a time scale? Why are we getting reports that the few high street dentists still willing to take NHS patients are being turned down if there is a dental access centre nearby, despite the big cost disparity? I suspect that it is because dental access centres are a Government pet project that must be supported at all costs.
More concerns emerge from Birmingham on the subject of out-of-hours cover. It appears that the contract, taken with PCT deficits, will mean that post-
I have had a raft of messages from dentists over the past six weeks or so. I will read just a few of them. They would fill two box files and, sadly, time does not permit me to read them all. A dentist from Coventry writes to me with more than a hint of desperation:
"Three of my best friends with over 80 years of NHS experience between them have sent out their conversion letters."
That is, conversion to private practice. He continues:
"These are dentists who have stuck with the system until now. There are many hanging on there by their finger tips hoping this disaster will be stopped on Wednesday. They are torn because of feeling for their patients."
He signs off,
"Best of luck on Wednesday."
A dentist from Yorkshire says, typically more briefly:
"if these reforms come in I doubt there will be an NHS dental service worthy of the name in 3 years."
A general dental practitioner from Colchester writes:
"We will reduce our NHS commitment. Accordingly, letters will go out to my NHS kids/exempts shortly, and my associate will keep what little NHS funding remains, prior to a move to private practice within 12 months. It's the only solution that I can come up with that allows me to keep people in a job. The alternative is to make everybody redundant!"
That raises an important point because, in Committee, the Minister said that primary care trusts could provide children-only contracts. However, since children and exempt adults do not pay the 80 per cent. contribution, how will PCTs that operate with massive deficits manage to provide such targeted contracts? The contracts that they let will depend heavily on the 80 per cent. co-payment.
The contract is clearly too rigid. The British Dental Association rightly believes that dentists will overdo their UDAs for safety, yet there is no way to claim for them. If they undershoot, they will face penalties. Despite the assurances in Committee, the contracts that have emerged appear to allow for the tailing off of services towards the end of a year and for some jockeying to approximate as closely as possible the target number of UDAs. There is a parallel in the way in which PCTs finesse hospital treatment when funds run out at the end of the financial year. That is no way to manage patients.
Ministers claim that the new contract will encourage a more preventive, health-promotion focus. How will that happen when the cost of the band 1 episode on which Ministers rely for health promotion will be at least twice the current cost? Nothing in the contract rewards the use of dental hygienists, whose services may become the preserve of private patients. I am sure that that was not the Minister's intention last year when she opened the school for complementary professions to dentistry in Portsmouth, which I had the pleasure of visiting last week.
Several dentists have written about the perversities that the Government's interpretation of the Cayton report introduced. Earlier, we heard the Minister's explanation of the difference between the Cayton report and what we are now offered, and the extraordinary 40 per cent. uplift. Perhaps the Under-Secretary will expand on precisely what the Minister meant in her justification of the difference.
We know that the cost of a basic filling will increase substantially and that a mouthful of fillings will cost the same as one. Clearly, the articulate and well-briefed patient will be able to obtain several items at once from band 2 while those who are less adept at using the system may lose out. There will be a tendency for dentists to offer simpler and quicker treatments in band 2 and only the guileful patient will be capable of pushing for more. Inevitably, that will widen oral health inequalities.
Doubtless the Government will continue to blame previous Governments, local health care managers and practically anyone else they can think of for the chaos over which they preside. An insightful dentist wrote to me earlier this year. He said:
"I believe you are after information about how the government are making a complete shambles of this new NHS dental contract."
That is quite right. The writer continues:
"What tickles me is, after 7 years, they are still trying to blame the previous Tory government. That's a bit like blaming potholes in the roads on the Romans."
Mr. Martlew might like to note that point.
I am delighted that the hon. Gentleman rose to that cue. Does he seriously suggest that a decision that the university grants committee made 19 years ago is germane to the argument today? I do not think so—let us knock that one on the head. The debate is not only about the number of dentists—the hon. Gentleman knows that full well—but about how they are employed. The contract will make the position substantially worse and that is the reason for the debate.
The catalogue of disillusion and dissatisfaction continues. A husband and wife dental team in the midlands wrote:
"We are now . . . having to accept a contract that has not been fully piloted in its present form contrary to what the DOH keeps indicating. I could go into details but suffice to say I have never met so many colleagues that are disenchanted with the proposed contract and are considering cutting back or leaving the NHS in all the years since qualifying."
There is more foreboding—I could go on and on, but time is short and I hope that the Under-Secretary will have something useful to say in a few moments.
The accounts that we are receiving suggest that many dentists will sign up at the last minute as a stop-gap to allow them time to make plans, which will probably involve leaving the service. Concern about the systematic miscalculation of UDAs is a recurring theme of the correspondence that I received. The perception that the proposals will establish a new treadmill is one of the principal causes of dissatisfaction among NHS dentists. Sadly, that could have been ironed out if the new arrangements had been adequately piloted.
In my five years as a Member of Parliament, I have never received so much correspondence or attended so many meetings about a single issue. One has to be pretty dedicated to the service to be an NHS dentist, given the attractions of more lucrative private work, yet the Government appear to have alienated them all. That is quite an achievement.
This has been a rich debate, and if a single theme has emerged from it, it is that there is a need for reform. So this debate, on the eve of the most significant reforms to dental services in the history of the NHS, is indeed timely.
Important progress has been made in the provision of NHS dentistry since 1997. For example, there has been a 22 per cent. increase in the number of dentists in the system since then, from just over 16,000 in 1997 to about 20,000 in 2005. That is good news, but it is obviously not enough because many of them will not be working full-time in the NHS. Many of them will extend their private sector commitments rather than their NHS commitments, so we must take registrations into account as well. The number of registrations has gone up by 305,000 since 1998; it has increased in four of the six years for which we have records. The number of dental interventions has also gone up.
I need to respond to many valuable points, so I will not give way at the moment. If I have time nearer 4 o'clock, I will of course give way then.
None of the increases that I mentioned has happened by accident. They have occurred because investment in NHS dentistry has risen substantially over the past few years. Indeed, it has gone up by 20 per cent., or £250 million, in the past couple of years. The Government have also recognised, however, that there are parts of the country in which an enormous amount more needs to be done. We therefore commissioned a report into the viability of the future work force, which in turn prompted our announcement of unprecedented investment.
We have heard today that there is still an enormous amount to do, and the Minister of State set out a programme of reform that rests on three foundations. The first involves a new role for local health professionals working in primary care trusts to take a lead in commissioning services, and new arrangements to ensure that, when dentists leave the NHS, the money is recycled back into the NHS. From April this year, those health professionals will have the freedom to run budgets of about £1.7 billion. The second involves the big increase in the number of dentists being trained and recruited. The third is that we are seeking to change the relationship between the NHS and dentists with a new contract that will end the treadmill and encourage prevention. It will also encourage more dentists up and down the country to serve the NHS.
Sir Paul Beresford spoke with great insight and intelligence, as he always does on these matters, and I welcome his congratulations on some of the proposals that my hon. Friend set out. He said that the present system was not a treadmill. That was the opinion of one of his friends, but I think that the hon. Gentleman secretly believes that it is a treadmill. We must ask ourselves whether it is unreasonable for the NHS to agree to a certain amount of activity in return for writing cheques for £80,000 a year. Looking at the national picture, we shall be writing cheques for £2.3 billion worth of dental services, and it is not unreasonable to ask for a few specifics in return.
The hon. Gentleman asked a number of important questions about whether there would be monthly targets and whether the PCT would be breathing down his friend's neck. There will not be monthly targets, and it is important to remember that the contract has been set in such a way as to ensure that dentists undertake 5 per cent. less work. It therefore represents a decisive move against the treadmill. We would, however, like to know the name of the hon. Gentleman's socialist dentist friend. Given what is happening, it will be important to ensure that his party membership is being paid by direct debit.
The hon. Gentleman underlined the importance of the monitoring group that my hon. Friend the Minister of State announced, and I welcome his congratulations on that move. More broadly, NHS dentists, no matter who is in their chair, have to offer what is clinically necessary.
Mr. Steen, who is not in his place, is an excellent advert for the hon. Member for Mole Valley. The hon. Member for Totnes did not say whether the treatment he received from his colleague was on the NHS, but in a thoroughly reasonable speech he highlighted concerns that underline the need for the reforms we are making—more investment, more recruitment and putting more people in training.
The hon. Gentleman called for free care, but NHS care has not been completely free for some years, not even in Devon. The important point for him to pick up in Hansard is that the budget for NHS services next year will be ring-fenced. I think his PCT is Torbay, where there is a ring-fenced budget of £6.3 million for commissioning dental services next year.
Mr. Lancaster underlined the need for more dentists, which is an argument on which we would agree, but he should do more to challenge dentists locally who are refusing to register children. He questioned the number who might sign up to their contract by the end of the month. We shall see, as my hon. Friend the Minister of State said.
We expect the vast majority of dentists to sign the new contract, and the point I would make to the hon. Gentleman about contract length is that contracts are a two-way deal. Many dentists do not want a contract of more than three years. Of course, the new general dental services contracts are an open-ended commitment, but the work that local health professionals will be doing in his area will be made substantially easier by the £8.2 million they will have to commission dental services next year.
My hon. Friend the Minister of State was able helpfully to highlight a number of aspects of the contract, in particular the issue of the abnormal reference year, which was referred to by Mr. Burrowes. He mentioned the example of a dentist who had taken maternity leave. She must take up the dispute resolution procedure with her PCT; it is important that she do so.
I hope the hon. Gentleman accepts that it is not possible for my hon. Friend, formidable though she is, to negotiate every single contract personally. That is why she has to set a framework and rely to some extent on local professionals to operate within it. I should also say, if it is helpful to the hon. Gentleman, that my hon. Friend can sign and earmark the disputed clauses for later resolution.
Mark Pritchard made a number of points about listening to professionals. That is an important aspect that was highlighted in a document published yesterday, to which I shall refer in a moment, but, far from dentists not being listened to, the new system is virtually identical to that developed with the BDA two years ago. Far from blaming PCTs, we are putting more power in the hands of local professionals to negotiate local arrangements. What is more, they are doing a good job.
In the hon. Gentleman's area, my hon. Friend tells me, there are new dentists arriving. He mentioned the centre that is opening just across the constituency border, where about 40,000 registrations will be available. That is part, I am glad to say, of a national pattern, and about 1,100 new dentists were recruited between April 2004 and April 2005.
The hon. Gentleman made an interesting point. If I might be permitted a detour through the registration statistics under the last Conservative Government, he said that he is proud of that record, but I remind him that in the last four years under that Government registrations fell by 2.1 million.
Paul Rowen highlighted the shortage of local dentists in his constituency—an issue that I think has been acknowledged. He made a number of points about the contract, the number of dentists in training and PCT responsibilities, all of which are incredibly important in taking things forward in his constituency. Rochdale's PCT has not one, but 20 NHS contracts and £4.3 million to commission services next year. He also criticised targets, but when we are writing cheques to a dentist for £80,000 it is not unreasonable to ask for a few things in return.
My hon. Friend Mr. Martlew spoke with great experience of health services. Usefully, he reminded us about our inheritance. He also reminded us helpfully of the struggles of living on £80,000. I extend my congratulations to his PCT, which is doing a good job locally. The fact that he has eight new dentists and 20,000 new registrations locally shows that progress is beginning to be seen in many parts of the country.
My hon. Friend Natascha Engel echoed the point about the need for reform and the lack of constructive criticism this afternoon. She was right to highlight the problems of shopping with toddlers, especially as one gets closer to the checkout. I have three children under the age of five, and I find that the only secure way of getting through a checkout is to put them in the trolley, where their little hands cannot reach through the bars. She made the important point that the reforms that we have introduced dovetail with a broader public health strategy.
My hon. Friend John McDonnell, who, I am glad to see, has returned to his place, raised a number of important issues in an intelligent and thought-provoking speech. Where PCTs are wrestling with important issues, it will be of some comfort to know that money is ring-fenced for dentistry. He also raised the issue of the abnormal reference year. His PCT has the flexibility to discuss that in review with local dentists. As my hon. Friend the Minister of State said in reply to some interventions, dentists can sign contracts but mark disputed terms, which can be resolved later in dispute resolution. He was right to underline the importance of the implementation group—
It would be exceptionally helpful to the London dentists who have been meeting regularly if the Minister would consider a meeting with them to raise some of those general concerns.
I will pass that request on to my hon. Friend the Minister of State, and I am sure that she would be delighted to meet London dentists.
Julia Goldsworthy made a number of useful criticisms, although we did not hear much in the way of substance or constructive alternatives. I know that the ballot for the leadership of her party is taking place shortly, and I put on record my best wishes to all those candidates who remain in the field. I hope that whoever triumphs—if that is the word I am looking for—moves rapidly to fill in the blank sheet that he has been bequeathed.
I suppose that I was looking for a slightly more forensic analysis from the hon. Lady. I know from the Electoral Commission's quarterly returns that the largest single donor to the Liberal Democrats in one quarter of last year was a company called Alpha Healthcare, so no doubt any future leader will be able to draw on a body of valuable expertise. She mentioned Birmingham, which I must mention as it is my home town. I got in touch with the Birmingham Mail yesterday, and in my experience it is right about most things. In the survey that it conducted of 175 dentists, between three and five dentists had definitively rejected the new contract—about 3.5 per cent. according to my maths. I look forward to progress over the rest of the month.
The hon. Lady also spoke about dentists being insufficiently remunerated. Again, I do not think that £80,000 is bad.
I will plough on, because I must finish my response.
I was slightly concerned that many of the concerns of the hon. Member for Falmouth and Camborne were riddled with misapprehension, not just about NICE guidance but about charging bands.
That lack of substance was not echoed by the Conservative party, however, which has been producing many interesting press releases, speeches and pamphlets. I have one here, which has on it an excellent picture of Mr. Lansley looking thoughtful. It is called "Built to Last", which is a phrase that might acquire some interest. It was published yesterday, and set out some important principles. Principle four was that public services for everyone must be guaranteed by the state—hear, hear. Principle one, however, was that the proceeds of growth will be shared between public services and low taxes. It will be interesting to see how the tension between those two points is played out.
I will not dwell on the fact that it was the Conservative party that cut fees by 7 per cent., or on the fact that registrations under it fell by 2.1 million. We have already heard about the closure of two dental schools, but I think it important to note the analysis behind that decision. At the time, the then Secretary of State for Health said that there would be a possible serious oversupply of dentists in the future unless the present rate of students admitted was reduced. Given that analytical foresight, I am not sure that "built to last" is the right phrase.
Question accordingly negatived.
Question, That the proposed words be there added, put forthwith, pursuant to
Mr Deputy Speaker forthwith declared the main Question, as amended, to be agreed to.
That this House welcomes the Government's Oral Health Plan for England, which builds on major oral health improvements in the last 30 years, and the additional £368 million for improving dental services in England announced in July 2004; recognises the Government's substantial achievements in improving the short and longer term supply of dentists for the NHS including recruiting the equivalent of an extra 1,459 whole-time dentists between April 2004 and October 2005, compared to the 1,000 extra dentists promised, and funding an additional 170 training places; further recognises that the Government is investing £80 million in improving dental school facilities, and has approved the establishment of a new dental school in the South West Peninsula; notes that the total number of primary care dentists in the NHS had increased to more than 21,000 by the end of October 2005, compared with 16,700 in 1997; further welcomes the reduction in the maximum patient charge from £384 to £189 from 1st April; further welcomes the new ways of working tested through Personal Dental Services pilots; supports the framework for new dental contracts which will free up significantly more time to provide preventative care, remove the requirement for NHS dentists to treat patients on a fee for service basis and ensure that a committed NHS dentist can expect to earn on average around £80,000 a year; and further welcomes the fact that, where dentists do not take up new contracts, primary care trusts will commission replacement services from other dentists.