NHS Dentistry

Opposition Day — [17th Allotted Day] – in the House of Commons at 4:10 pm on 14th October 2009.

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Photo of Sylvia Heal Sylvia Heal Deputy Speaker 4:10 pm, 14th October 2009

I advise the House that Mr. Speaker has selected the amendment in the name of the Prime Minister.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health 4:37 pm, 14th October 2009

I beg to move,

That this House
supports maximising public access to NHS dentistry;
notes that under the Government's new contract considerable numbers of patients now do not have access to an NHS dentist;
believes the dental contract imposed by the Government is not adequately meeting its objectives for improving oral health or access to dentistry;
recognises that any future contractual arrangements should be appropriately consulted on and piloted;
calls for stronger incentives for dentists to carry out preventative care;
recognises the opportunity to bring about better patient care by ensuring the best treatments are provided at the appropriate time and by fostering the stability that will allow new investment in NHS practices;
supports an approach to NHS dentistry focused on preventative care;
further believes that the oral health of children should be protected by re-introducing dental screening programmes in schools;
and further supports the introduction of patient registration, allied to capitation-based funding rather than fee-for-service, restoring a relationship between patient and dentist conducive to an improvement in long-term oral health.

The House may not know it, but this is a 10th anniversary debate. Ten years ago, in September 1999, Tony Blair told the Labour party conference:

"Everyone will have access to an NHS dentist within two years."

The Labour party conference a couple of weeks ago might have done well to remember that the nature of promises from Labour Governments is that they are not delivered. In fact, the record shows a loss of access. After the introduction of the new contract, the number of people accessing NHS dentistry fell by 1 million. Some 7.5 million people are not going to an NHS dentist, because it is hard to find one. Fewer children are accessing NHS dentistry-more than 100,000 fewer than before the new dental contract. Dental caries is now the third most common reason for children's admission to hospital.

What is the public's view of the state of NHS dentistry? The British social attitudes survey shows that only 42 per cent. of the public are satisfied with NHS dentistry, compared with a 76 per cent. satisfaction rate with the general practitioner service-although the Government constantly claim that we should be dissatisfied with that service. No doubt the Minister will attempt to pretend that the public are satisfied with NHS dentistry, but they are not.

Promise after promise on NHS dentistry has not been kept. After every failure, the Government make a new set of promises that, in their heart of hearts, they know they will not be around to keep. Their latest promise is to deliver access for everyone who seeks it by March 2011 at the latest. There is no evidence of how they intend to achieve that.

The Government knew that NHS dentistry needed change, and in preparation for the new dental contract, they rightly piloted new schemes. The personal dental services contracts were designed around the proposition that instead of the dentist treadmill-under which dentists were paid fees for services-dentists would be paid on a capitated basis for the number of patients registered. The idea was to incentivise dentists for encouraging good oral health, rather than simply for activity. But what happened? The PDS contracts were examined by the Audit Commission, which concluded that patient charge income had fallen by 30 per cent. as a consequence of the pilots, because there were fewer treatments. The Government should have said, "Well, that's worked then. We wanted to incentivise not just treatment, but good oral health, and a consequence of that will be a reduction in the number of treatments that are chargeable to patients." But no, completely the opposite happened. They said, "Well, we can't have that. We can't have the economic viability of the NHS dental service being undermined by the fact that patients aren't paying enough," so they scrapped the PDS pilots and imposed a new contract on the dental profession that had not been piloted. Contrary to the dental profession's expectation that it would be able to get off the dental treadmill, it remained on it, only with the primary care trusts, instead of it, in charge of the speed of the treadmill. We have ended up, therefore, with a continuing activity-based contract, and one that, owing to the way in which it was imposed and the nature of the contractual provisions, actually led to a substantial reduction in the number of dentists willing to sign up to the contract.

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Photo of Stephen Hesford Stephen Hesford Labour, Wirral West

The reverse is true in my constituency, where three new dental practices have opened in the past year-I had the honour of opening all three. The hon. Gentleman's experience of the new contract is considerably different from mine.

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M

Lucky Mr Hesford! Please come to Herefordshire and tell us how to get on an NHS panel.

Submitted by Mike Evans

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The hon. Gentleman must explain why nationally the number of dentists choosing to enter a direct contractual relationship with their PCT has fallen by 7 per cent. in the past year-it involves only 31.8 per cent. of dentists. I freely acknowledge that there are more dentists in this country than ever before, but that is not the point. The point is this: how many dentists are willing to be NHS dentists? And how many of those who are NHS dentists find that the access provided to their patients in the locality is not as good as it used to be?

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I will not give way. I tell the hon. Gentleman, and other Labour Members, that the Health Committee produced a report last year into dentistry. The report said that there were four criteria-not its criteria, but the Government's-for the new contract, namely access, clinical quality, NHS commissioning and improving dentists' working lives. I remind Labour Members what the Select Committee report said about those four criteria. On access, it stated:

"The Department's original goal that patient access to dental services would improve from April 2006 has not been realised."

On clinical quality, it stated:

"While the Department argued that the new contract would improve preventive care, this was disputed by dentists who claimed that the new contract failed to provide the time and the financial incentive to do so."

On commissioning, it stated:

"The Minister admitted that PCT commissioning of dental services has been poor."

On improving dentists' working lives, it stated:

"The new remuneration system based on UDAs"- units of dental activity-

"has proved extremely unpopular with dentists."

Does the hon. Gentleman want to respond?

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Photo of Stephen Hesford Stephen Hesford Labour, Wirral West

To make it clear, not only is the experience on the ground in my constituency different from what the hon. Gentleman is describing, but the new dental practices are NHS dental practices.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I do not know what point the hon. Gentleman is trying to make. I have new NHS dental practices in my constituency. The Minister might even have a note about them to use later in the debate. That is not the point. The point is this: what is the overall picture? That picture is very clear. The number of people accessing NHS dentistry after the introduction of the new contract in April 2006 fell by 1 million. It has now recovered by about 500,000. That is across the country. I do not think that those figures are disputed. The point is that even now-three and a half years after the contract was introduced-access to NHS dentistry is poorer than when that access was one of the central criteria.

Many people think that they have access to an NHS dentist-I suspect that many in the House think that they have such access. However, if they went to their NHS dentist, especially if they did so in the first quarter of the calendar year-the last quarter of a financial year-they would find dentists who have reached their UDA limit and that their dentist is not their dentist at all, because registration has gone away. We do not have "our" NHS dentist; we have access to NHS dentistry on sufferance of the local primary care trust.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

Is it not the case that the Steele report confirms the problems with access? Access is variable around the country, particularly in rural areas, where it is often very difficult, which rather confirms the hon. Gentleman's point.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I am grateful to the hon. Gentleman, who helpfully points me towards the next thing to add to the picture, which is the review undertaken by Professor Jimmy Steele.

Before I do that, however, let me remind the House that one of the Select Committee's conclusions was:

"We recommend that patient registration be reinstated because dental care is most effective when delivered over time and as part of a trusting dentist-patient relationship."

When Government Members start snorting about the fact that people do not have access to an NHS dentist because they are no longer registered with an NHS dentist, they need to get up to speed. That is what their Government have done to dentistry in their contract. They have removed registration. The Government effectively admitted the failure of their contract by establishing the review under Professor Steele within three years of introducing the contract.

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Photo of Andrew Murrison Andrew Murrison Shadow Minister (Defence)

Does my hon. Friend agree that the Government completely missed the point about registration? The value of registration is that it encourages prevention, because dentists develop long-term relationships with their patients, which incentivises good practice and oral hygiene and inevitably leads to better mouths with better teeth in them. That produces less onerous work for dentists, who will practise prevention instinctively if their patients are registered.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

My hon. Friend is exactly right, and I appreciated the time that he and I spent working on the issue in years past. Indeed, when the new contract was introduced, we argued that registration was precisely the basis on which it should be structured. We have now reached the point where the new contract not only does not incentivise prevention in the way that it should, but has incentivised treatment in a way that is completely counter-productive. For example, a dentist might have the option either to fill a tooth and repair it or simply to extract it. The structure of incentives in the contract points towards extraction, which is why there has been a significant increase in the number of extractions.

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Photo of Paul Beresford Paul Beresford Conservative, Mole Valley

Does my hon. Friend agree that registration is the best proof of access? Whether the patient goes ahead with national health treatment or chooses an alternative, private treatment, it is that access coming from registration that counts.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I am grateful to my hon. Friend, who brings his extensive personal knowledge as a dentist to the issues. He will know, because it has been his experience in his professional practice, that the relationship between a patient and their dentist is a critical part of delivering good quality care.

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Photo of Eric Martlew Eric Martlew Labour, Carlisle

I will check in Hansard, but I think that the hon. Gentleman just said that dentists will pull teeth out instead of filling them because they get more money for that. Is that really what he is saying about our dentists? I am sure that that is on the record.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

It is, and my hon. Friend Mike Penning, who knows these things well, will produce some data to support it when he speaks.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I will give way to the hon. Gentleman in a moment, but he has mentioned the Steele report and, although I will not go on about it at length, I want to make this point. The Steele review said:

"Making the transition from dental activity to oral health as the outcome of the NHS dental service will be a challenge for everybody, but it is essential if NHS dentistry is to be aligned with the modern NHS."

The message from the Steele report is that we need to move from an activity-based contract to one that incentivises good oral health. I hope that the Liberal Democrats now support that.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

We very much support that approach, but let me refer back to the hon. Gentleman's comments about perverse incentives. He talked about the increase in extractions, but is it not also the case that there appears to be a perverse incentive against doing complex work such as root canal fillings, which appears to have lead to a deskilling of the dental profession, with a lot of dentists simply no longer doing that work?

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I do not disagree with that, and my hon. Friend the Member for Hemel Hempstead will certainly want to elaborate on that point when he replies to the debate later.

The Steele report identified that the current contract was based on activity and was therefore misguided, and that we needed to move to a contract based on prioritising and incentivising good oral health and preventive care. However, there is no plan to move from A to B. We have consistently made it clear that it is our objective to make that move to a contract based on registration and capitation that incentivises quality and outcomes rather than simply focusing on activity. I want to say a few words on how we propose to do that.

There are two parts to our proposal. First, we propose to take immediate steps to ameliorate the problems in the existing contract. Secondly, we propose a more fundamental phase of reform. The immediate steps, under the current structure of units of dental activity, would enable preventive care to be incentivised. We know that every £1 spent on giving a patient preventive dental treatment can save at least £8 in subsequent curative work. We need to support children with information and advice on how to look after their teeth. I have read the Department's toolkit to support that activity, but we need to make it more systematically available. That is why we will restore school dental checks for every child, which have been surreptitiously phased out by primary care trusts since 2007. We will also enable children to continue to access NHS services through child-only contracts.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

I am sure that the hon. Gentleman is aware of the studies that have looked at school screening. In particular, is he aware of the study undertaken in 2002 by the oral health unit? It concluded that screening did not improve dental health in the target child population, that it did not increase dental attendance among those who had screened positive, that it did little to improve the dental health of those who had screened positive and that it tended to exacerbate social division. There is not much academic support or support in the dental profession for the hon. Gentleman's proposal.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The hon. Gentleman and the Government need to recognise this point. In their amendment to our motion, the Government claim that children's oral health in England is already among the best in the world. The evidence for that is the 2003 child dental health survey. We have not had such a survey since 2003, however, and we will not have one until 2013. We know, however, that children are presenting at hospital with dental caries, and that that is the third most common reason why children are admitted to hospital. In 2001-02, just before the last child dental health survey, that did not feature among the five most frequently reported diagnoses when children presented. We also know that children are not accessing NHS dentistry to the extent that they did. Significant numbers of children are therefore not seeing a dentist, and we need to ensure that that changes. It is perfectly obvious from looking at the Department's toolkit to support better oral health among children that there needs to be a focus to bring about that change. School dental checks, if they are integrated into the local commissioning of dental services, could do that.

The third thing that we need to do rapidly is to give people more access to NHS dentistry. That is not just about insisting that the PCTs issue more UDAs, or about simply piling money into the system-valuable though that might be. The issue is about winning more capacity from within existing resources. For example, there are unnecessary recalls, including cases of people finding their treatment being divided between a first attendance and a subsequent one more than three months later. The chief dental officer himself rightly criticised that practice, identifying it as a result of one of the perverse incentives in the current contract. Without such practices, we could be looking at a potential capacity for 2.3 million people to access NHS dentistry. We are not even assuming half that figure in our plan to give 1 million more people access to NHS dentistry by eliminating such unnecessary recalls.

We also need to get more out of dentists' working hours. We are therefore going to return to dentists the power to charge patients who repeatedly miss appointments. Five per cent. do so on a regular basis, and 1.8 million courses of treatment are wasted. If only a quarter of that waste were remove by this measure, it would enable 100,000 more patients to be treated.

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Photo of Eric Martlew Eric Martlew Labour, Carlisle

If I accept what the hon. Gentleman says on this issue, does he accept that the same principle should apply to general practitioners?

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

No, I do not. Dentists already have a mechanism for charging patients. Since the late 1940s, there has been a clear expectation that the system of co-payment applies to NHS dentistry, but not to other NHS services-and I have no intention of changing that.

We need additional fundamental reforms so that we can move to a new registration-based contract with payments linked to the good oral health of patients through a capitation system properly adjusted for the patients being looked after-I recognise the Liberal Democrat point about the need to incentivise dentists in areas where oral health is poorest-while also providing a proper incentive for preventive care, as my hon. Friend Dr. Murrison has mentioned.

We also need to bring more dental professionals back to the NHS, which is why we have proposed-I am glad to say that the Liberal Democrats recently supported us-that NHS or state-trained dentists, who cost about £170,000 each, should be required to work in the NHS for at least five years. We need generally smarter commissioning where we open it up, so that people can access preventive work. I am particularly pleased to confirm today that we will widen access to preventive advice and treatment by removing the regulation that prevents a dental hygienist from seeing a patient if the patient is not directly referred by a dentist. We are seeking to empower the whole dental team to work together to deliver innovative and preventive advice strategies.

The Government, far from listening to the Steele review and moving in that direction, unfortunately appear to be moving in the wrong direction. At the time the Government received the Steele report earlier in the summer, they had started work on implementing not that review, but their own draft access contract-contrary to what is expressed in their amendment to our motion about meaningful consultation and

"working with the dentistry profession and other stakeholders".

This is yet another example of an activity-based contract focused on a narrow objective rather than on good oral health as a whole, which will not support preventive care as it should. It has so failed to engage the profession that the British Dental Association has advised its members not to sign the new contract.

I am not often minded to read with much care the amendments that Ministers table in response to our motions in Opposition debates, as they tend to be far too self-congratulatory. This particular amendment, however, seems to make a whole series of claims that are simply not justified-they are plain wrong. The Government are not working "through careful piloting" on either the current dental contract or their new proposed draft access contract. They are not working together with clinicians as they should. They claim that

"children's oral health in England is... among the best in the world", but the evidence of recent years since the last child dental health survey points to a significant loss of access and dental problems among children. They talk about

"access for all... by March 2011", but that is risible in the light of their utter failure to deliver improved access over the past decade.

The Government told everyone that they would offer access to NHS dentistry, but they failed. They talked about prevention, but they incentivised only treatment. The dental treadmill is just rolling forward in exactly the same way as it always did. No doubt money has been poured into the system. The Minister will doubtless talk about the level of inputs in dentistry, but the issue is not about inputs but outcomes. Once again, it is a familiar story from this Government: it is all about how much money has been spent and never about the proper structure of reform or the outcomes being achieved. The Government are pursuing that flawed approach all over again. Once more, we need a new approach to access and quality that is based on outcomes and results and not simply on processes. We need proper incentives for prevention and for delivering good oral health, working with professionals rather than against them. By those mechanisms, we will reverse the long and slow death of NHS dentistry.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health 4:59 pm, 14th October 2009

I beg to move an amendment, to leave out from "NHS dentistry" to the end of the Question and add:

"welcomes Professor Steele's review report and its endorsement that the principle of local commissioning introduced by the 2006 reforms provides a firm basis on which to develop NHS dentistry;
agrees with the vision set out in the review of improving incentives to support dentists in delivering access and quality;
acknowledges the Government's commitment to working with the dentistry profession and other stakeholders to ensure through careful piloting that it implements the recommendations in a way that delivers the best possible system for patients, dentists and the NHS;
acknowledges that children's oral health in England is already among the best in the world;
welcomes the commitment of the NHS to deliver access for all who seek it by March 2011 at the latest, supported by some £2 billion in central funding for dentistry, and understands that access is now growing again;
notes that in the last four quarters the number of people seeing an NHS dentist in the previous 24-month period has grown by 720,000;
further notes that the dental workforce is growing, with 655 more dentists working in the NHS in 2007-08 and a further 528 in 2008-09;
and recognises the support that the dental access programme of the Department of Health is providing to clinicians and managers to help them rapidly expand NHS dental services where necessary.".

In 1997 we inherited an NHS that was on its knees and in a mess, and NHS dentistry was part of a system that was struggling. In 1991 two dentistry schools were closed by the Conservative Government. The number of dentists in the country was seriously down, and there were enormous problems.

Mr. Lansley disparaged the idea of looking at the record of his own party in government, and I understand why he does not want to look back. All that I can say to those who may be watching this debate is that we do not need to listen to the rhetoric, because we can look at the book. We can look at the history. We can look at what the Conservatives did to the NHS last time. We can look at the way in which they left it-and we can know that, if they are re-elected, they will do exactly the same again. This Government, on the other hand, are committed to providing access to high-quality dental care for everyone who wants it, and we are committed to providing it through the national health service.

Dental access has improved for the whole of the last year, with 720,000 more NHS patients seen by NHS dentists. The Steele review, which we set up, has been accepted and welcomed by the British Dental Association. We have increased spending, and yes, spending is important. The hon. Gentleman may not think that it is important, and he may well feel that his Government would be free to make the cuts in the NHS that they made on the last occasion, but we take the view that increased spending on dentistry is necessary. It was up by 11 per cent. in 2008-09, and it is up by 8.5 per cent. this year. This year funding is running at £2.25 billion net of patient charges. Since 2004 it has risen by 70 per cent.: that is £900 million more in six years. Let me say to any dentists who happen perchance to read the report of this debate that they will be able to look back and see what the Conservatives did last time, and to compare it with what this Government have done in terms of putting money into dentistry.

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Photo of Andrew Murrison Andrew Murrison Shadow Minister (Defence)

Does the Minister not understand that dentists feel deeply demoralised? Nine years after the 1997 general election, the Government undertook wholesale reform of the system; just three years after that, they are winding the clock back to the previous position, and dentists are entitled to ask what on earth is going on. Such changes-welcome though they must be, because the Minister's system has clearly failed-must be seen as deeply demoralising to the dental profession, so perhaps the Minister would like to apologise.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

Perhaps I would like to congratulate the Government on the fact that 850 dental students are expected to graduate next summer, an increase of 25 per cent. since 2005. I think that that is worth saying. I also think it may be worthy of a little congratulation that there were 655 more dentists in the NHS in 2007-08 than in the previous year, and 528 more in 2008-09 than in the previous year.

Yes, it is true that much is changing in the NHS, and much of the change constitutes improvement. Significantly more dentists are graduating, and more dentists are coming into the NHS. That is a good record. As part of our expansion programme we have created two new dental schools, which opened in 2007 in the south-west and central Lancashire. That has reversed the Conservatives' closure of dental schools which was announced in 1987 and completed in 1992, and which caused a shortage of dentists in the early 1990s, when there were fewer of them than there are today.

The hon. Member for South Cambridgeshire made an extraordinary and, indeed, candid speech. In fact, he was so candid that he seemed to me to impugn the professionalism of every dentist in the country, saying that they were prepared to extract teeth with no clinical justification. He has been offered the chance to retract that statement, and he is shaking his head now: he does not retract it. I do not think that impugning dentists is a satisfactory way for someone who thinks that he may at some point be a Secretary of State to proceed.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

Does the Minister accept Steele's conclusion that the incentives for dentists are not precisely aligned with the goal of oral health, which constitutes a fundamental flaw in the contract?

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

Let me just say the following about the way we have structured some of the charges and the funding. Previously, the funding levels and the charges patients paid were enormously complicated. We have simplified the whole process. We have a choice here. We can have multiple variations in the charging system so everything is charged at different rates for different sorts of systems. Frankly, that will create massive bureaucracy for dentists and massive complication for patients. Alternatively, we can simplify the system so that people can understand what they have to do. In that case, we have to rely on-let me make this very clear-the professionalism of the dentistry profession to ensure they are doing what is clinically necessary. We have taken the view that most dentists are in the job because they want to do the best for their patients-it is clearly a different view from that of the Conservative Front-Bench team but it is the view we take-and we have therefore decided that we need to have an appropriate system of charging and remuneration to take that into account.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I shall give way once more, after which I will want to make some significant progress.

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

Does the Minister accept that the system has been oversimplified, thus leading to cases such as that of a constituent of mine who was told she could choose which tooth to have repaired and would have to wait six months to have the next one done? Thankfully, that is being investigated. I would hope it is a rare case, but nevertheless some dentists do seem to be forced down that path, as a direct result of an oversimplified system.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I do not accept that dentists are being forced down that path. There will always be some in such professions who do not do what is clinically appropriate and do not use the system as it ought to be used-I put that at its mildest, perhaps. However, we believe it is important to recognise that the dentistry profession has responsibilities, standards and professional organisations that seek to regulate it. We need to ensure that we have a system that not only makes sure that we have a good quality of care-and we have to rely on professionalism for that-but that also has a charging structure that is not overly bureaucratic. It appears that some in the Opposition want to introduce such an overly bureaucratic charging system, however.

In the years since the foundation of the NHS, dental health in our country has improved massively. I want to make it clear, however, that registration was not one of the reasons for that massive improvement. Registration payments were introduced only in 1990. There was continuity of care before that, and, broadly, there has been continuity of care in recent years. Therefore, before the hon. Member for South Cambridgeshire over-emphasises the importance of the registration issue, he had better check the historical facts. Registration is, in fact, just a payment system. Continuity of care is what matters. That is what Steele said; that is what he recommended we should ensure happens, and that is what we are seeking to put in place.

Let us look back to see how NHS dentistry has changed things in this country. In 1948, half of all adults had no natural teeth at all. By 1968, the NHS had cut the proportion to 40 per cent., and 10 years ago it had fallen to 11 per cent. We are about to start the next national adult dental health survey and we expect this figure to have fallen still further to about 6 per cent.

Let me give another example. Thirty-five years ago, more than 90 per cent. of all 12-year-olds in England had tooth decay. Today, that proportion is lower than 40 per cent. In fact-I do maintain this-our older children have some of the lowest rates of tooth decay in Europe, and they are comparable with the best in the world, including those of the United States. We can always do better, however.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I will give way to the hon. Gentleman a little later, but if he will forgive me, I want to make some progress now as I am conscious that several Back Benchers want to contribute to the debate.

The best decisions are those that are made as close to the patient as possible. In 2006, in line with the rest of the health service, we reformed NHS dentistry. The new system gave power to primary care trusts to commission the right dentistry services for their communities. PCTs have provided incentives to encourage prevention and improve quality, but in some areas progress has been too patchy and too slow. Therefore, in December 2008, the then Secretary of State for Health asked Professor Jimmy Steele to conduct a review of the new contract, which he published in June. I am delighted to say that the review joined the Select Committee on Health in strongly supporting the principle of local commissioning, providing a firm basis for the future of NHS dentistry.

The review also showed the range of services that are needed. It showed that the different generations need different types of dental care and that, rather than simply drilling and filling, maintaining oral health and preventing decay and disease must increasingly be a priority. I did agree with some of the points raised by the hon. Member for South Cambridgeshire, and it appears that we are at one on ensuring that we prevent decay and treat maintaining oral health as a high priority. On the basis that I have set out, the Government wholeheartedly welcome Professor Steele's review. We will be rigorously testing its recommendations through pilots across the UK-there will certainly be pilots across England-over the coming months.

I am pleased to say that the British Dental Association, patient groups and other stakeholders have welcomed the review. The Government have shared their implementation plans with the BDA and others, and they will be playing their part in delivering them. We have made a good start. Professor Steele recommended that we should develop measures for monitoring the quality of dental services, and we are developing a set of key performance indicators for all new contracts under the dental health programme. The work has already begun to develop clinical pathways and procedures to ensure that all new patients receive an assessment of their oral health and the treatment that they need.

It is important that we ensure that oral health improves. The level of tooth decay among 12-year-olds in the UK is at its lowest ever and is among the best in European countries, although inequalities remain. We want every child to access dental services, but all the evidence shows that, contrary to what the hon. Gentleman suggests, mandatory school screening is not the way to achieve that. That is what the research considered by the National Screening Committee showed; children in deprived areas, who are most likely to be shown to need treatment, were found to be the least likely to be taken to a dental practice to receive the treatment that they need. In other words, the suggestion sounds good, but we need to examine this issue in a much more effective way.

If we really want to deal with the issues associated with child tooth decay, we will find that the better way to do so is to ensure that we have fluoridated water supplies and that we make changes in the way in which dental health is examined to ensure that we target those in the most deprived areas for the additional help and support that they need. We are examining ways in which we can identify and put help into areas where there are the most problems.

In addition, we have begun to look at the way to improve the information available to patients on NHS Choices so that, as Professor Steele recommended, patients have accurate and up-to-date information about what NHS dentistry entitles them to do and how they can best access it. We are working with the NHS Business Services Authority to improve the data that we collect from dentists, which was another of Professor Steele's recommendations. That will provide a better sense of the nature and quality of services that dentists are providing. I know that dentists did not like the 2006 contract that was introduced, but I hope that the way in which the review was conducted and the way in which its recommendations will be implemented will help to heal some of those wounds, because we want to work with the dental profession as we pilot and evaluate the changes. I promised to give way to Sir Paul Beresford, so I shall do so now.

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Photo of Paul Beresford Paul Beresford Conservative, Mole Valley

I am pleased that the Minister has finally got round to mentioning fluoride, because fluoridation in the water supply and in toothpaste has been the biggest single factor, over and above any dentistry, that has brought about the change that he is proclaiming as an asset to his Government. He ought to realise that countries that have a school dental service are teaching children to use fluoride toothpaste as well as the inspection. That is the biggest advantage and that is where some countries, particularly New Zealand, have moved ahead. He ought to look at those results before he comes out with a condemnation of what has been suggested.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I will look at those results. We are prepared to look at the evidence and to make judgments based on it. It is important that when we get independent reports that suggest that spending £17 million on NHS dentists going into schools is not the best way of spending that money, we consider the evidence and base our policy on it rather than on some historical view that that was a nice thing that might perhaps be popular. We need to base things on the evidence.

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Photo of Bill Wiggin Bill Wiggin Opposition Whip (Commons)

I am particularly interested in what the Minister said about continuity of care. Will he take the opportunity to look at what is going on in Herefordshire? I decided to test the NHS for myself and waited in the queue. I eventually got to the front and had a filling, which fell out two weeks later. I still cannot see a dentist to get it put back in again. Unless people are in pain, it is almost impossible to see a dentist. I am sure that that is not what the Minister wanted, and if there is something that he can do, I know that my constituents will be deeply grateful.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

Only a Conservative MP can say, "I decided to test the NHS by using it." The hon. Gentleman symbolises where the Conservative party is on this issue. Fillings sometimes come out. I hope that he will be able to access a good NHS dentist who will ensure that he can get an appointment. I suspect that the best approach will be to go back to the person who originally did the work to ensure that it is done in a way that means that it does not come out.

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M

What a totally predictable response by the Minister, Mike O'Brien. He should apply for a job with Michael O'Leary on Ryanair. Let me say right away I am not a political animal and hold no allegiance to either the Labour or Conservative parties. However, I do live in...

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Photo of Charlotte Atkins Charlotte Atkins Labour, Staffordshire Moorlands

Would not the Minister accept that the best way to promote oral health among children is to start very early? For instance, we could start in the many Sure Start centres up and down the country that bring together health, education and social services. Mothers can then work with their children to instil good oral health right from the start. Unfortunately, the Opposition are committed to closing down those centres, not expanding them.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

My hon. Friend is right, and she presents a much more coherent argument than the Opposition have. As the hon. Member for South Cambridgeshire quoted the British Dental Association during his speech, may I point out that the BDA does not support mandatory school screening? It agrees with the National Screening Committee's decision. Given the comments made by the hon. Gentleman, it is worth adding that the BDA, in a report on local commissioning that was published yesterday, gave a positive picture of the opportunities offered by local commissioning, which he derides. It states that there are

"some truly excellent examples of innovation on the part of commissioning teams around the country".

It found

"very positive attitudes towards liaison between practitioners and commissioners".

I want to see whether we can build on that to make NHS dentistry as good as we want it to be.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I shall give way twice more, and then I am going to close. I shall give way to the hon. Gentleman first.

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Photo of Julian Lewis Julian Lewis Shadow Minister (Defence)

The Minister has nailed his colours to the mast in favour of fluoridation. Does he accept the principle that no community should have its water fluoridated if a majority of the members of the community do not wish its water to be fluoridated?

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

We need to make judgments on fluoridation based on the evidence. Stories always go round that can frighten people, and we have seen in this country a whole series of scare stories about vaccinations that resulted in a significant number of people being frightened out of giving those vaccinations to their children. We need to ensure that we consider the evidence, that we base our judgments on the clinical evidence and that we ensure, too-

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

Let me answer Dr. Lewis, and then I will give way. As far as vaccination was concerned, there were some stories and as a result we are paying the price. We need to ensure that we consider the evidence on fluoridation and make judgments based on that evidence. We have already seen that there have been some moves towards fluoridation in the water supply, particularly in Southampton, although that is the subject of a judicial examination.

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

The Minister mentioned the commissioning report and he slightly cherry-picked the results, but he must have been disappointed to read that 60 per cent. of dental leads and 77 per cent. of local dental committee secretaries agreed or strongly agreed that the national contract did not allow as much innovation as they would have liked. What steps does he think need to be taken to address that problem?

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

Far from being concerned by that, I welcome the fact that the BDA is saying that we must do more in relation to innovation and quality so that we improve some of the better ideas coming out of dentistry. That means that we have to look at the contract and make sure that it encourages innovation and best practice.

If I may be critical of the NHS for a moment, there is something that the service as a whole, and not just dentistry, is bad at. There are lots of examples of good practice in parts of the NHS, including in dentistry, with good ideas and work in both management and clinical practice, but those examples are not spread as quickly as they should be. I think that Sandra Gidley has made a sensible comment. We need to take it on board and respond in a positive way.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The Minister will know, not least from what my hon. Friend Sir Paul Beresford said, that there are Conservative Members who agree with the principle of fluoridation. However, the point is not that we should judge the evidence that suggests that it makes a positive contribution, but that the legislation makes it clear that there should be a process of public consultation. There was such a process in Southampton and Hampshire, but it began with the strategic health authority setting out the evidence in support of fluoridation and it ended with the SHA saying that it remained convinced by the same evidence.

The consultation process therefore added nothing at all: what is the point of consultation when a decision has been made already? The Minister and the health authorities need to think about that again and accept that, if evidence is to be presented in a public consultation process, people must be given a more objective opportunity-either through a referendum or some other means-to make their views known.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

The difference between the hon. Gentleman and me on this is not as great as he makes out. I agree that the people who make decisions must take on board the views expressed by local people in the public consultation process. The process is not a referendum-

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

By the sound of it, the hon. Gentleman is committing the Conservative Front-Bench team to referendums all over the country. I believe that, when local people are consulted, those who make decisions need to take on board the views that are expressed-and, indeed, the votes that are taken-by people in local areas. Those views are important, and the people who make decisions must consider them and give them due weight, but they are not binding in the way that a referendum would be.

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Photo of Julian Lewis Julian Lewis Shadow Minister (Defence)

The Minister is very kind to give way again, but 72 per cent. of respondents to the consultation said no to fluoridation, even though the local PCT had sent out a great many postcards, first-class postage paid, to get people to say yes when they replied. Presumably, if 72 per cent. of people saying no can be ignored, the same would be true of 82, 92 or even 100 per cent. What is the meaning of a consultation when an SHA can tell the overwhelming proportion of people saying no that the answer is nevertheless yes?

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

People who have to make a decision have to give due weight to the views of local people. They must ensure that all the arguments are taken into account, and that the views of local people are reflected but, in the end, they still have to make the decision.

I should have known, when I mentioned fluoridation, that we would get the reaction that we did from the reactionary side of the House. Fluoridation is an issue that, like Europe, produces an immediate reaction.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

The Conservatives are proposing referendums once again. They want one on Europe, and now they seem committed to one on fluoridation as well. The important point is that we are working with the dentistry profession. There were difficulties following the 2006 contract-I do not dispute that for a moment-but we are now working with the dentistry profession to ensure that we produce a system of NHS dentistry that is right for England and the whole UK.

The Government are committed to providing high-quality dentistry for everyone who wants it. As I have said, in the past two years, we have increased funding by some 20 per cent., or about £385 million a year. Although about 90 per cent. of dentists continued with the NHS after the new contract was introduced in 2006, others did not. That led to an initial fall in the number of people able to access an NHS dentist-a fall that is now quickly being reversed. New practices are opening across the country. The Conservative Opposition would like to paint a picture in which things are the same as they were two years ago, but that simply is not the case. In fact, if Opposition Front Benchers want to see for themselves, I invite them to go round the corner from the House of Commons to Horseferry road, where a dentist's has opened today.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

The Minister wants Conservative MPs and Front Benchers to go and see dental surgeries, but can he explain why, when I asked in a freedom of information request when, in the past 12 months, a Government Health Minister of any description had last gone to see an NHS dentist, the answer was that zero had done so?

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I have certainly accessed my NHS dentist in the past 12 months. [Interruption.] I gather that the Under-Secretary of State for Health, my hon. Friend Ann Keen, has done so, too. We probably visit such practices in a way that the hon. Gentleman, and some of his Back-Bench colleagues, do not, in the sense that perhaps they do not use NHS dentists in the way that most of us do. However, that is not the key point.

What needs to improve is access. A Which? survey published in June 2009 showed that nine out of 10 people who tried to get an NHS dentist in the past two years were able to do so. With more dentists in the NHS last year, dentists delivered an extra 1.4 million courses of treatment, and I am confident that access will continue on its current track of improvement. All 10 strategic health authorities have now committed themselves to giving everyone who wants it access to an NHS dentist by March 2011 at the latest.

The Steele review made a range of recommendations on how to improve the incentives to promote access and quality. We welcomed its recommendations on developing contracts that encourage dentists to take on new patients and to provide them with high-quality continuing care. The right to continuing care, in a system that promotes quality, is key to Professor Steele's vision, and we know that patients and dentists value that right. That is why the new practices being developed under the access programme will pilot some of the review's recommendations. Existing practices will be invited to volunteer for pilots incorporating Professor Steele's full recommendations from next spring. We were encouraged to hear that as soon as the review was published, informal expressions of interest started to come in from the NHS and front-line dentists' practices.

Prevention and quality are two of the most important principles in today's NHS, and the review will help us further to embed those principles in the dental system. In 2007 we produced the world's first guide to evidence-based prevention in primary dental care. We published a second edition this year, and we are already seeing the benefits. The prescription of high-concentration fluoride toothpaste has risen by almost 250 per cent. in one year, and fluoride varnishes are being used much more than ever before. Our focus on prevention is starting to work, and we will ensure that the new pilots that I have described will include preventive dentistry.

The Labour party founded the NHS. We have tripled funding to the service as a whole and we want dentistry in the NHS to succeed. By working with the profession to deliver the recommendations of the Steele review, within the framework of the 2006 reforms, I believe that we can ensure that it does succeed.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health 5:29 pm, 14th October 2009

The Liberal Democrats will support the motion tonight. We will support it, first, because it is rightly critical of access under the current contract. The Minister referred to statistics suggesting that 90 per cent. of patients are able to access dentists, but the fact that there are 10 per cent. who cannot should be a cause for concern. As my hon. Friend Mr. Leech said to me, if that was the case with access to GPs, there would be an outcry. For people who cannot access an NHS dentist, that creates a very real problem and the Government should not be satisfied with the current levels of access.

The motion is right to stress the importance of piloting before introducing change, something that the Government failed to do when they introduced the contract. That is one reason why it was so much resented by the dental profession. The motion is right also about the objectives. The objective should be improving oral health and introducing incentives for preventive care. The Minister rightly pointed out the importance of all dentists behaving professionally, but it must surely make sense for the system to ensure that the incentives are in the right direction to encourage and incentivise dentists to do the right thing. The motion is also right in identifying the need for an element of capitation-based funding and patient registration, and the importance of establishing a long-term relationship.

However, the motion falls short in two important respects. First, it says nothing about oral health inequalities. That is an issue of fundamental importance, about which we on the Liberal Democrat Benches feel very strongly. Resources should be targeted at areas of greatest need, and the motion is silent on that. Secondly, on the face of it, the proposal to reintroduce dental screening programmes in schools looks appealing, but it is wrong and should not be introduced. If we are moving into an era where public finances are stretched and where we have to ensure that every penny is spent effectively, the Conservatives should think again about this. All the evidence suggests that school dental screening is ineffective in achieving the objectives.

I have already referred to the survey undertaken by the oral health unit in 2002, but that is not the only research. There was a report in 2006 which concluded that the majority of the children studied

"derived little benefit from the school dental screening programme in terms of attending the dentist, and receiving treatment for their carious permanent teeth. School dental screening also fails to address inequalities in the prevalence of untreated disease and utilisation dental services."

An even more recent survey in 2008 concluded:

"The evidence from the UK and elsewhere is that while the concept of dental screening is attractive to policymakers, there is no scientific evidence that it leads to improvements in health, either for individual children or for the child population."

The Conservatives should think again. They are committing resources to something that has no evidence base to it whatsoever.

This debate follows on from the Steele report in June. The Government deserve credit-it was an inspired move by the previous Secretary of State to appoint Jimmy Steele to undertake the review. It has been an independent process that has managed to secure the trust and respect of the dental profession and it has been stronger because of that. The recommendations of the report have secured widespread support. But the outcome of that report should embarrass Ministers, because it demonstrates that their repeated claims, made here on the Floor of the House, that the contract was working were nonsense. Back in 2007, the then Health Minister, now the Minister for Regional Economic Development and Co-ordination, Ms Winterton, said:

"We know that NHS dentistry is expanding, and that new contract is working."-[ Hansard, 26 June 2007; Vol. 462, c. 154.]

The former Secretary of State for Health said in February 2008:

"Access to NHS dentistry is getting better all the time."-[ Hansard, 5 February 2008; Vol. 471, c. 772.]

Those comments fly in the face of reality, and now the authoritative Steele report, which the Government accept, demonstrates that many claims by Ministers and the resistance to any challenge to the workings of the contract were nonsense.

Professor Steele highlights a number of issues. First, he points out that access is variable. In many parts of the country, access is fine and people can get to an NHS dentist, but in many other areas that is not the case. Steele makes particular reference to rural areas, where, according to a Which? survey that the report mentions, just 29 per cent. of dentists are taking on new NHS patients. We should be concerned about that. It compares with 46 per cent. of dentists in urban areas.

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Photo of Eric Martlew Eric Martlew Labour, Carlisle

I hear what the hon. Gentleman says about rural areas, but if we take my constituency for example, people from rural areas go to the city to register. Is that not the case in many areas?

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

They may access dentists in urban areas, but they cannot register because they are not allowed to. However, many older people in rural areas, including my constituency, struggle to get to an NHS dentist, and that problem needs to be addressed. Everyone accepts that some people cannot access an NHS dentist, but Professor Steele says that for such older people, the problem is of great concern.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

I am grateful to the hon. Gentleman for giving way on that point because my hon. Friend Mr. Martlew raised a question about how people access dentists. Before 1990, when registration payments were introduced, dentists kept lists of their patients for their own purposes. Many dentists now keep such lists and regularly write to their patients for their own purposes. We are talking about a payment for registering-a payment to the dentist. Many dentists keep their lists anyway, and therefore people access and keep in contact with their dentist, who may write to them regularly to bring them in for check-ups and so on because they have their own list.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

I note the Minister's point, but my central point is simply that many people, particularly those in rural areas, struggle to access an NHS dentist-whether or not they can register. We should all agree that that issue must be addressed.

The second issue that I shall deal with from the Steele report concerns the original claim from the 2006 contract-that its operation would take dentists off the treadmill and focus on prevention and oral health. In fact, the contract's focus has been on paying for activity. On page 5 of his report, Professor Steele says:

"So long as we see value for taxpayers' money as measured by the production of fillings, dentures, extractions or crowns, rather than improvements in oral health, it will be difficult to escape the cycle of intervention and repair that is the legacy of a different age.

Making the transition from dental activity to oral health as the outcome of the NHS dental service will be a challenge for everybody, but it is essential if NHS dentistry is to be aligned with the modern NHS."

In other words, he is saying that the contract fails to achieve that. That shows that its introduction was an enormous mistake.

The truth is that this contract has set back good dental health for some four years because of its failure to encourage and facilitate preventive work. Indeed, in many respects preventive work has been sidelined. The report says, on page 22:

"Perhaps the greatest surprise relates to the position of a scale and polish as part of a Band 1 charge. Many regular NHS patients told us they are paying privately for this treatment with a hygienist."

The Government can easily criticise the dental profession for that, but that is the reality as a result of the contract: it is not facilitating preventive health care under the NHS. Dentists have been overwhelmingly critical of the contract-a view reinforced and confirmed by the Steele report, which refers to 86 per cent. of dentists feeling that they are still, in effect, on the treadmill. That is not exactly an overwhelming vote of confidence in the Government's contract.

According to Professor Steele's vision for NHS dentistry, the focus should be ruthlessly on oral health-which was not ultimately a central feature of the contract-as well as on quality, prevention and continuity of care. On page 6, he says:

"The incentives for dentists are not as precisely aligned as they could be to a goal of oral health and consequently there are inefficiencies within NHS dentistry. The pathway we describe should be supported by an altered contractual structure for dentists. We therefore recommend that dental contracts are developed with much clearer incentives for improving health, improving access and improving quality."

Labour Members may simply refer again to the need for dentists to act with professionalism, but, as policymakers, we must surely ensure that the system incentivises the right things-preventive care and good oral health.

Steele argues-I am not entirely clear whether the Conservatives support him on this-that we should work to develop the current contractual framework instead of throwing it out and starting all over again. Perhaps the Conservative spokesman can clarify their position on that in his closing remarks. If we throw the baby out with the bathwater and start all over again, there is a real danger that a further range of perverse consequences will follow that are hard to imagine at this stage. Professor Steele's central plea is to conduct a pilot and then apply the findings, which must surely be the way forward.

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

May I confirm that, as I said in my opening comments, it is our intention to pilot? I agree that it is important that we take Steele's recommendations, pilot them, see how they work, and ensure that they work effectively. In other words, we too will learn the lessons. The hon. Gentleman makes a valid point, but unfortunately it appears that the Conservative Opposition are of the view that they do not need to pilot things because they have all the answers; I do not think they have.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

To some extent I am reassured by that intervention, but in due course I will come to something that causes me concern about the Government's continuing approach, and the Minister might want to intervene on me again then.

One of the main current problems is the enormous variability in the quality of commissioning. I agree with the Minister that there are examples of very good practice, but according to most people the norm is that of not very good practice, in which commissioning has not been developed and the PCTs almost sideline dentistry and consider it of little central interest. That is part of the problem. In its paper published yesterday, the British Dental Association referred to the short tenure of staff. It stated that more than a quarter of PCT dental leads had been in post for less than a year, and the average was just 3.4 years. That turnover prevents any mature culture or understanding of the potential of commissioning from developing.

My hon. Friend Sandra Gidley made the point earlier than an enormous percentage of PCTs do not feel that they have enough scope to innovate under the contract. The examples of the few PCTs that have innovated suggest that there is scope to do that, but for some reason best practice has not spread around the country. There is therefore a significant shortfall in the quality of NHS dentistry compared with what is potentially achievable.

Along with a mass of poor quality PCT commissioning groups, there are none the less some PCTs that are doing really impressive, innovative work and making real progress. In Bradford, for example, the PCT has worked with the profession with collaboration as an important principle. It has developed a system that has less reliance on the measure of units of dental activity and created a blended contract with quality measures. That is possible under the existing contract, but most PCTs have not taken advantage of the scope available to them. The PCT in Bradford has developed effective care pathways, which are essential to proper treatment, particularly of those with poor oral health.

Salford is another PCT that has been proactive, and part of Birmingham is providing an impressive lead on dental public health. Accredited practices have been established there, and some of the money going to dentists is given on the basis of their practices achieving quality and engaging in preventive work. Tower Hamlets PCT has also been doing good work. Those are the areas from which we ought to be learning what is possible in the way of good-quality preventive care and a focus on oral health. That practice needs to be spread out across the country. The approach has to be collaboration between dentists, PCTs and Government to pilot and then spread out good practice.

The concern that I referred to after the Minister's intervention relates to the dental access programme. It appears that the Department of Health is up to its old tricks again of not collaborating and of imposing an approach against the wishes of the profession. The BDA has specifically expressed its concerns to me, and no doubt to others. It states that the Department has attempted to design a new contract in a very short space of time, but that it is utterly controlling and far too prescriptive. It tells me that the Department started work on the new contract in April, but it was not until July that the BDA got to see it. That is precisely what we are all complaining about and why Steele complained so much about the need for collaboration rather than imposition from above.

The BDA says that the Department now appears reluctant to make further changes. It advised the Department in July-I believe that it met the Secretary of State-that it should use the existing contract, warts and all, to get the access programme running and then seek to effect improvements to it. Now we have got to the extraordinary and ridiculous position that the BDA is unable to endorse the new contract. Incredibly, practices that are tendering for the new contracts are unable to see them during the tendering process. How daft is that?

Despite its total frustration with the Department, however, the BDA stresses that it has an absolute commitment to engage with the Steele reforms and work with the Government. The Minister made the point in his intervention that the Government are determined to learn lessons and pilot schemes before introducing them. Will he look again at the access programme to ensure that it is introduced in collaboration with the BDA, rather than against resistance from it, which would be entirely counter-productive?

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Photo of Mike O'Brien Mike O'Brien Minister of State (Health Services), Department of Health

Such contracts are a matter of negotiation. We cannot say to the BDA, or to any other organisation, "You've got a veto. If you don't like it, we're not going to have a contract like that." It was part of a negotiation in an attempt to get to an agreement. The hon. Gentleman is right that we need to learn lessons from how things were done in 2006 and we are intent upon doing so. There is a process of working through the issues from the Steele report and ensuring that we form a much better relationship with the BDA than we have had for at least a few years.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

I hope I can take it from the Minister's comments that there will be a further attempt to reach agreement and to listen seriously. I appreciate that the BDA cannot impose a veto, but to get the best possible result, there needs to be proper, meaningful collaboration.

The Government have been guilty of imposing too much regarding health. They imposed the modernisation of medical careers and the fateful national IT programme, with disastrous consequences, and they imposed the dental contract, which has set back the cause of preventive dental care for some four years. There is now an opportunity to get it right.

The Liberal Democrats' plea is that the Government learn the lessons from the past and work with the profession to secure a dental service that focuses on quality; prevention; areas of greatest need, to address the inequalities that we know exist; effective use of resources and ensuring that incentives move in the right direction; and, finally and critically, access for those who need NHS dentistry and who cannot afford the private alternative.

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Photo of Alan Haselhurst Alan Haselhurst Deputy Speaker and Chairman of Ways and Means

The House will be able to do its own maths. We have about 50 minutes-just under-and five Back-Bench Members are wishing to contribute. Perhaps everyone will bear that in mind.

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Photo of Charlotte Atkins Charlotte Atkins Labour, Staffordshire Moorlands 5:52 pm, 14th October 2009

The House's last debate about dental services took place in December 2008. It was on a report from the Select Committee on Health that followed an inquiry on which I persuaded the Committee to embark. The review that arose from the criticisms made in the report was brilliantly led by Professor Jimmy Steele who, as a clinician, teacher and researcher, had the breadth of vision to pull off a report that is comprehensive, authoritative and widely applauded. This debate gives us a good opportunity to consider what Steele said in his report. It is ironic that the planned Opposition day debate on dentistry in July was pulled in favour of a seemingly more newsworthy issue. Dentistry had to take a back seat.

Professor Steele nailed a few myths in his report. First, the media have told us that hordes of dentists have been so disgusted with the NHS contract that they have converted to 100 per cent. private practice. In fact, as Professor Steele says, the loss of NHS provision was very small indeed-just 4 per cent., which is hardly a mass exodus.

Secondly, we were told that no one could find an NHS dentist. Clearly, access to NHS dentistry is a problem. However, the Steele review found that it is not a universal problem, and that it is concentrated in some areas. The Which? survey, on which the Minister commented, demonstrated that 88 per cent. of people who wanted to access a dentist could do so.

Access to NHS dentistry is now firmly the responsibility of local PCTs. I applaud that, unlike the Opposition, because prior to that it was at the whim of individual dentists where they practised and whether they provided NHS services, private care or a mixture of the two. The PCTs have been given the responsibility to ensure that local demand is met. When they were first given the responsibility for commissioning, a lot of PCT mergers were happening, and that was unfortunate because the commissioning of dental health services was put on to the back burner. Dentistry did not get the priority in the NHS that it deserves-indeed, it never has done. More money has gone into dentistry, but it is still a very small part of the NHS budget even though dentistry is very important to people, not only because of the pain bad teeth can cause, but because having a mouthful of such teeth-although, happily, fewer people do so these days-can cause a real lack of confidence. The PCTs are now getting their act together, but many challenges remain.

Yesterday a survey by the British Dental Association's local commissioning working group was published. Like the Steele review, it was initiated by the Health Committee's report. The survey found, as other hon. Members have said, that 60 per cent. of commissioners and 77 per cent. of local dental committee secretaries said that the national dental contract did not allow sufficient innovation and flexibility, so it is very good news that an effort is being made to introduce more innovation. We must work together to develop that innovation and flexibility.

The survey also contained some good news. There were positive attitudes towards liaison between practitioners and commissioners. Related research by the BDA identified a broad consensus on the priorities for dental commissioning-improving access, especially for new patients, and targeting areas of high deprivation. That would not happen if dentists were allowed to locate wherever they wanted, instead of the PCT being the driving force. We need to build on that consensus, and Professor Steele's report provides an excellent starting point.

The 2006 reforms addressed three key issues. The first gave responsibility for planning and securing NHS services to local PCTs, and that is really important. It means that the local health service can take account of local need. My PCT was very responsive to my concerns about one particular town, Biddulph, which did not have an NHS dentist, and we now have an excellent service there.

The second issue was patient charges. In the past, patients had to steer their way through 400 separate charges. Many could not tell whether they were receiving NHS treatment or private treatment, because the charging system was so complicated. In 2006, those charges were reduced to three bands. These were simpler and less confusing for patients, but they could provide perverse incentives for patients to store up their dental problems and delay visits to the dentist. We need to address that problem.

The third issue that arose from the 2006 reforms was connected to the units of dental activity. Dentists rightly complain that UDAs have created a new treadmill, with a possible incentive to provide treatments that are clinically no better than a lower band alternative as a way of increasing their practice payments- [ Interruption. ] I am not suggesting that dentists are pulling teeth because it is financially advantageous for them to do so.

Professor Steele is right to propose more charging bands and a better continuity in the relationship between patients and dentists via a more formal registration system. The existing contract framework can be developed to allow payments for improving oral health, continuing care responsibility and better quality, as well as for increased activity. The Government must work with the profession and pilot these new incentives to ensure that any problems are quickly resolved.

I had the perfect preparation for this debate, because I visited my local dental practice, as a patient, just two weeks ago. I attend TLC 4 Smiles, in Leek, which has eight surgeries with four full-time dentists, as well as full-time hygienists and therapists. It covers about 20,000 patients and has existed for more than 10 years. I am glad to say that I signed up as its first NHS patient. On that occasion, my dentist was Dr. Sophie Mitchell. She is a delightful lady who gave me a complete and comprehensive examination-clearly checking for oral cancer-an assessment of my dental health and then a scale and polish. She had no idea who I was until, when she had finished, I started talking to her about the Steele review. I was amazed that she told me, quite voluntarily, that she had moved from being a 100 per cent. private dentist to a 100 per cent. NHS dentist. When I left, I was offered an appointment in a year's time. That is what we need from our NHS dentists: good access, prevention and high-quality provision for the whole family.

The Opposition motion proposes the reintroduction of school dental screening programmes. I agree with Norman Lamb and the Minister that that is just window dressing. Those programmes have been proved to be ineffective, which is why they were stopped. If the Opposition are really interested in increasing preventive care, improving children's dental health and reducing dental health inequalities, they should be proposing to increase investment in Sure Start and similar initiatives and pushing the fluoridation of water supplies. Sure Start brings together health, education and social services to help pressurise mothers with children under four. It is the perfect vehicle to promote good, early oral hygiene alongside good access to NHS dentists. Fluoridation of water in Birmingham has provided huge benefits to children, compared with unfluoridated Manchester. The figures are very clear on the benefit of fluoridation.

Fluoride toothpaste has also made a significant difference, and I commend my local PCT, NHS North Staffordshire, for its work to promote good dental health. I have joined it in wet and windy supermarket car parks and in town centres where its representatives have engaged with shoppers on oral health issues. It also attended my recent health MOT days, which are events that I have organised to promote public health, and I am grateful to NHS North Staffordshire for having the forward thinking to provide the health professionals who carried out health checks, such as on blood pressure, body mass index, cholesterol and blood sugar levels. We had an amazing response. During the two MOTs that I organised, more than 800 people turned up, and the dental health team played an important role at the events. I put on the record my thanks to PCT chief executive Tony Bruce, to Lesley Goodburn and to all the health professionals, including health visitors and district nurses, who worked so hard to make those events such a success.

One of the criticisms in Professor Steele's report is that PCTs are no good at communicating with people about how to find a dentist. I am pleased to say that my PCT, having awarded a new NHS contract to two doctors in Biddulph-Mr. and Mrs. Keen-was very proactive in advising potential patients on how to sign up for that excellent NHS service.

Through my local newsletters I was able to hand Mr. and Mrs. Keen the names of about 500 families looking for an NHS dentist in Biddulph. Very quickly, they signed up thousands of patients, many of whom had not been to a dentist in years. One constituent-a man in his 40s-told me that he had not been to a dentist for well over 20 years, after a bad experience as a youngster. However, the pain that he was in and the persuasion of his girlfriend finally led him to pluck up the courage to go. The Keens did such a fantastic job that he has never looked back. The Keens in Biddulph and TLC 4 Smiles in Leek are the modern face of NHS dentistry. As a Government we must do all that we can to support them.

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Photo of Paul Beresford Paul Beresford Conservative, Mole Valley 6:05 pm, 14th October 2009

I will be mindful of your point that I will have to scurry along a little, Mr. Deputy Speaker.

I should point out first that I have a declared interest. I was going to be succinct and not touch on fluoride, but I can hear a hobby horse being saddled up in the Chamber just along from me, and I am bothered that my hon. Friend Dr. Lewis will have the blinkers on himself rather than the horse. In this case I support the Minister, which is probably damaging for him. He is absolutely correct: the case that was raised in the intervention was a consultation. Consultation is a normal approach for local government and the NHS in many areas throughout the country. There is an ongoing consultation in my area about the hospitals and hospital services. That is the correct way to do things, and the Water Act 2003 was adapted as it went through so that that approach would be adopted.

In the case of fluoride there is a good reason for that, which is, as the Minister lightly touched on, that the scare tactics and extraordinary stories used by the opponents of fluoride frighten people. I have been in the field for some considerable time and I have heard accusations that fluoride makes people sterile-accusations which make every man deeply worried-that it is used as a poison, that it makes the tea taste strong or weak, or just different, and so on. In the consultation, therefore, as in most local government consultations, the responses were checked to see whether they were valid.

Perhaps the silliest example is from some years ago, when a friend of mine was discussing fluoride at a big public meeting. He came through with all the statistics and so on, but at the conclusion of the meeting a gentleman got up near the back of the hall and said that he had been doing his own research too. He had researched a coastal town without fluoride, where predominantly elderly people lived, and a new town with fluoride, where mostly young people lived. He said that the VD rate in the young town was higher than in the old town, and that, therefore, putting fluoride in the water supply led to venereal disease. The disturbing thing was the number of people in the hall who seemed to agree with that rather weird synopsis of the decision.

To get back to today's debate, there is much that I do not have to say, because my hon. Friend Mr. Lansley, backed to some degree by Norman Lamb, has covered many of the points. The dentists are very upset. As the Minister accepted, many of them opted out, hedging over signing the contract. His predecessor set up an implementation panel that is supposed to ease the way through, but we have not heard anything about that.

Local commissioning has become the done thing. There were 300 PCTs, but they were reduced to about 150, which caused chaos. Most of the PCT officials were complete dental novices and there was considerable confusion. Many PCTs are now doing their own thing-I suppose that we could call it 150 variations on a theme. The extra bureaucratic cost of all those little PCT units struggling to do their own thing on a muddled contract seems obvious.

One of the problems is that dentists are paid by units of dental activity, which are allocated, probably by a non-dentist, in ranges of supposed difficulty of task. How one could get the same UDA for a molar root canal, which probably takes an hour and a half to complete properly, assuming that it is not sitting on an infection, and for the alternative solution, namely 15 minutes for an extraction, is beyond imagination.

In addition, after asking to get away from the treadmill, dentists found not only that they were still on it, but that it had an allocation of UDAs. Some of those UDAs were low and, as my hon. Friend the Member for South Cambridgeshire pointed out, the dentists completed the tasks early, then turned patients away because they had run out of UDAs. Perhaps more seriously, however, others failed to meet their targets. They suffered clawbacks, and the deficits were loaded on to the contract target for the following year. That is worse than any treadmill that they might have been on before.

A number of dentists have had considerable financial difficulties, and the realisation that many of the UDAs had different values in different practices only added to the confusion and discontent. Oddly enough, most people-including dentists-do not like being paid lower rates than their colleagues for performing identical tasks. I understand that a few primary care trusts are correctly trying to iron out that problem, but many have not bothered.

The new, untried contract has been mentioned-the so-called Warburton access programme. Understandably at this stage, the British Dental Association is advising against any dentist signing it. As I understand it, dentists feel that the new contract gives the PCTs even greater control over dental ownership and practice. Research by a number of the dental media, such as Dentistry magazine, suggests that the relationship between many PCTs and dentists in many areas is extremely poor.

Because of the contract's structure, a dentist gains the same number of UDAs for a patient who needs one filling as for a patient who needs 15. There is therefore an understandable reluctance among dentists to tackle new patients who might present with extremely complex work. The amount of more complex work being undertaken has therefore dropped, and many of the NHS laboratories that provide back-up services are suffering a rather cool freeze.

It must be said that some dentists and some PCTs appear to have made the system work. Indeed, some have been so successful that they have been accused of working the system, rather than making the system work. The comments about "gaming" that have come out of Richmond House are not helpful. Added to that, dentists are feeling somewhat persecuted because, when they look over their shoulders, they see that the General Dental Council-the policing organisation-has 24 members, yet only three of them are dentists or have dental experience. They also see that the National Institute for Health and Clinical Excellence, the quango that has proclaimed on dental recall intervals, does not even have a dentist among its ranks.

In England, NHS dentistry is a world-class mess. I firmly believe that we need a public dental service. Ministers, however, measure access by the numbers of treatments. I believe that the measure should be the number of dentists who offer NHS dentistry as a choice for patients. Registration would enable such a count, and that would be the case whether the patient chose NHS treatment or private care. That is the key point: the patient should have the choice. A decayed tooth filled with an NHS amalgam or with a private porcelain inlay is still a restored tooth.

There is much world-class dentistry provided in this country. Much of it is leading-edge advanced dentistry. We have world-class dental schools training students in world-class dentistry. They are producing porcelain and composite restorations, and beautiful world-class endodontics with microscopes and rotary nickel titanium instruments. They also produce carefully crafted obturations, inlays, onlays, all porcelain restorations and implants. The sad thing is that, given the present system, those students will move out into the real world of UDA targets, amalgams, high-speed endodontics and extractions. We need to bring back choice for patients. The blinkered view that just because it is the NHS it is best completely blocks the patient's opportunity for choice. I hope that those on both Front Benches will think very carefully about that.

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Photo of Eric Martlew Eric Martlew Labour, Carlisle 6:14 pm, 14th October 2009

Thank you for calling me to speak, Mr. Deputy Speaker. If you think I am going on too long, you can remind me to sit down.

The last time that I spoke on dentistry was in the spring of 2006, when my constituency had a major problem of dentists opting out. There was one disgraceful incident in which a dentist who had done so wrote to his patients and told them that they had to come and apply the next day, and that if they did not, they would not get on to his list. He was actually giving out raffle tickets to the lucky ones who were going to stay with him.

Since then, however, things have improved greatly. We now have about 10 new dentists in Carlisle and Penrith, with more on the west coast. We have a large practice staffed by European dentists right next to my office in the centre of the city. They are not Polish, but German. The reason why the Germans are coming over here is that they can make more money working for the NHS in this country than they can working as dentists in Germany.

We have progressed greatly, and I was particularly pleased to receive an invite to the opening of the Carlisle dental centre on 25 February this year, which I will always remember. It is not only a multi-million pound emergency centre, but part of the Cumbria and Lancashire dental school, so we are now training dentists for this rural area. One of the arguments for training there is, "Where they train, they settle." In contrast to the Conservatives, who closed two dental schools, we have opened two of them, so things have improved greatly-and rightly so. I worry about what would happen if a Conservative Administration came in, because we know that they started the rot when they broke the contracts of NHS dentists-I know that that goes back a long time-and closed the dental schools. We have to ensure that that does not happen again.

Fluoridation, which is an issue that angers me, has been discussed. I agree with Sir Paul Beresford on that subject. I remember that this issue was on the agenda when I was the chairman of a health authority more than 32 years ago, when I suspect that the hon. Gentleman was training as a student dentist. I suspect that he was told that fluoride improved the health of children's teeth, yet we have done almost nothing about it.

On the west side of Cumbria, fluoride has been in the water for 40 or 50 years, and people are not dying early-if they were, it would probably be blamed on Sellafield rather than fluoride anyhow! The reality and fact is that fluoride improves the health of children's teeth. I suspect that most Tory Back Benchers would argue that fluoride should not be put in the water, yet it is a scientific fact that it works. My Government, however, have also failed to get this issue brought forward as it should have been. We should have encouraged water authorities to increase fluoridation year on year, but we have stalled. I remember voting in favour of fluoridation on a free vote in this Chamber about three or four years ago, but I suspect that no real progress has been made since then. Consultation will be used as an excuse for doing nothing. We must move forward on this issue.

I shall speak briefly about charges, which have not been much mentioned. In fact, my hon. Friend Charlotte Atkins mentioned them, but not in the context of how charges put people off going to the dentist. It is difficult to go to the dentist anyhow in that we know it is likely to be painful, but finding that there is a charge makes it worse, which shows the difference between the GP service and the NHS dental service. It may always have been the case, but we have to remember that some working people in this country simply cannot afford to pay the charges, so they will put off going to the dentist as long as they possibly can and then go to the emergency services.

In an ideal world, I would stand up to say that if we are serious about universal access, we should abolish these charges. If I look to the future, however, I see other major priorities for the NHS and financial constraints on Government spending. Although this has been done to some extent, my appeal to the Minister is to give some assurance in her reply that a Labour Government will acknowledge the fact that many people find it very difficult to pay those charges, never mind going private. The hon. Member for Mole Valley spoke about patient choice-choosing to go private or choosing to go to the NHS-but if people do not have the money, there is no choice.

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Photo of Paul Beresford Paul Beresford Conservative, Mole Valley

When I started working in the NHS in this country, in east London, there were no fees. When the fees were introduced, patients started to question the work. They began to ask whether it had to be done, why it had to be done, why if it had been done last time it had to be done again, and so forth. The introduction of fees brought about monitoring of the dentist by the patient, and therefore it was a very good thing.

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Photo of Eric Martlew Eric Martlew Labour, Carlisle

I suspect that those who questioned whether the work needed to be done were those who could afford to go and see the hon. Gentleman. That is the point. I fear that a Conservative Government will take the view that this is an area in which they can put up the charges. We have already heard one Member say that he had experimented with NHS dentistry. My fear is that the Conservatives will raise the charges, because they are not really convinced that we need NHS dentistry. I suspect that most of them opt for private treatment.

We need an assurance from the Government that they will bear in mind the level of charges. I know that since 1997 we have kept them down, but we must bear in mind what people can afford, and the least that we can do is freeze charges for the foreseeable future.

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Photo of Julian Lewis Julian Lewis Shadow Minister (Defence) 6:21 pm, 14th October 2009

I do not know which of the following two slogans resonates more with you, Mr. Deputy Speaker, but I know which resonates more with me. There is "The people will decide" on the one hand, and there is "The people do not know what is good for them" on the other. "The people will decide" is the slogan that the Prime Minister used when he visited Southampton and was asked whether fluoridation would be imposed on the city of Southampton-and, by extension because of various configurations of the pipework, on 8,000 of my constituents in the town of Totton as well. It was a banner headline: "The people will decide".

Well, the people tried to decide. They responded to the consultation on fluoridation in very large numbers, and, as I said earlier in an intervention, 72 per cent. of respondents decided that they did not wish their water supply to be fluoridated. The strategic health authority, however, decided differently. Its members do not live in the area affected by the proposed fluoridation, apart from, I think, one member of the board. This was supposed to be a decision for local people, but those non-local people decided that although 72 per cent. of respondents did not want the water supply to be fluoridated, fluoridated it would be. One thing that the leader of my party keeps saying-there is a resonant effect on society whenever he says it-is that people do not like being taken for fools. It does not matter whether politicians are attempting to fool them over dodgy weapons dossiers, dodgy expenses systems or dodgy consultations, but they do not like it.

If the case for fluoridation of the water supply is as scientifically strong as its advocates make out, its advocates have been singularly unsuccessful in persuading people to agree with them. It may be that my hon. Friend Sir Paul Beresford thinks that I am blinkered because I do not believe in mass medication via the water supply, and it may be that he thinks that my constituents are foolish and believe all sorts of old wives' tales because they reject it; but, in a democracy, it is up to him and people who think like him, and people who think like the Minister of State, to persuade the people to do what they think is right. I am sure that the Minister believes passionately that it will help people to have their water medicated with fluoride. For all I know, he may be right-for all I know, he may be hopelessly wrong-but I am sure that he believes passionately that it is in the interests of people to re-elect a Labour Government at the next general election.

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Photo of Julian Lewis Julian Lewis Shadow Minister (Defence)

No, I will not. I am sorry, but the hon. Gentleman has had his go, and I have very little time.

I am sure that the Minister believes that passionately, just as my hon. Friends believe passionately that it is in the interests of the people to kick out this failing Government and elect the Conservatives. The one thing that we agree on in those contexts is that if we want those things to happen, we must persuade the people. We must give them the choice and the final say. What is more, if we are telling them that we are giving them the final say, we should give them the final say and not cheat them.

After the Prime Minister came to Southampton, and after the decision was nevertheless taken that fluoridation was going to occur in our water supply, I tabled a parliamentary question, which was answered by the Minister who will wind up this debate. I asked what the Prime Minister meant when he said that local people will decide this question. The response was as follows:

"The Prime Minister's statement serves to highlight the legislative requirements contained in section 89 of the Water Industry Act 1991 whereby a strategic health authority must 'consult and ascertain opinion' before requesting a water undertaker to increase the fluoride content of a water supply."-[ Hansard, 22 June 2009; Vol. 494, c. 722W.]

When one looks more closely at the regulations concerned, one is made aware of the Water Fluoridation (Consultation) (England) Regulations 2005, and in particular regulation 5, which reads like something straight out of Orwell's "1984":

"A Strategic Health Authority shall not proceed with any step regarding fluoridation arrangements that falls within section 89(2) of the Act unless, having regard to the extent of support for the proposal and the cogency of the arguments advanced, the Authority are satisfied that the health arguments in favour of proceeding with the proposal outweigh all arguments against proceeding."

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Photo of Julian Lewis Julian Lewis Shadow Minister (Defence)

My hon. Friend says "hear, hear", which is fine, but in that case why bother to consult at all, because what that really means is that the health authority knows best? If 72 per cent. of people say no but the health authority says yes, the health authority gets its way. If 82 per cent., 92 per cent., 99 per cent. or 100 per cent. of the people say no, my hon. Friend, the Minister and the people who think like them say, "Tough luck chaps"-and chapesses in these equalitarian times-"you're going to get it anyway." That is utterly unacceptable, and it is undemocratic.

We on my side of the argument are denounced as reactionaries. Well, it is interesting to see the company we are in when we are denounced as such. I am a Conservative-I am, indeed, a right-of-centre Conservative-but Mr. John Spottiswoode, one of the most articulate and outspoken opponents of this locally, is a candidate for the Green party. Councillor David Harrison, the Totton county councillor, and Sandra Gidley, who is not in her place at present, are also not usually regarded as reactionaries; they are, in fact, rather prominent and articulate Liberal Democrats. The Hampshire county council overview and scrutiny committee is made up of a highly qualified collection of people, and it is seriously worried about the way in which this consultation has been carried out.

Most interestingly of all, however, Mr. Denham, a member of the Cabinet of course, and Dr. Whitehead have both said that although they are personally in favour of fluoridation, they believe that a stop should be put to the process because of the lack of public support. I am not cynical enough to think that those two Labour politicians are saying such a thing just because there is a general election coming next year. I reject that view-I am sure that they are saying that out of principle. They are saying it out of principle, and so are we.

I shall conclude by referring to the letter I was delighted to receive recently from my hon. Friend Mike Penning, who will wind up for the Conservatives. He wrote that he was "happy to clarify" our position on this issue. He stated:

"there are serious questions to be raised about the methodologies employed" in the consultation and that

"public consent is vital to the implementation of any compulsory fluoridation scheme. Communities should have to give their approval for any proposal before it is permitted to go ahead".

That is the position of the Conservatives, whether or not every individual dentist on my own party Benches chooses to endorse it.

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Photo of Colin Breed Colin Breed Shadow Treasury Minister 6:29 pm, 14th October 2009

I am pleased that so many areas of this country have had their access to dentistry improved, but that improvement has not been the experience of people in Cornwall, particularly those in South-East Cornwall, who for more than the past 10 years have seen a declining service in NHS dentistry. More and more dentists have retired and not been replaced, and many have left to go into private practice. The declining and appalling service that we have experienced has been raised in this House on many occasions, and it has been brought to the attention of the primary care trust. Even in its most recent strategy, it failed to put this service in its top 10 priorities.

Some people who move to Cornwall, because it is such a nice place, suddenly discover that they cannot get an NHS dentist and decide, therefore, to hang on to what they have. As a result, some people travel back on a regular basis from Cornwall to north Devon, Reading, Bristol, Somerset and other places to see their dentist because they cannot access a dentist locally-the waiting lists prevent their doing so. That is not to say that we have not been given anything recently. Some emergency dental services have been provided-someone who is in dire pain and dire need might get in, within 24 or 48 hours, to receive some emergency services-but that is not good enough for people who want a proper NHS service. I am also pleased about the new dental school at the Peninsula medical school. I hope that-I think that there have been indications about this in the past-the fact that new dentists are being trained there might encourage them to stay after their training and, thus, build up the dentist population in Cornwall. I hope that that will happen through the NHS-if there is a compulsion for them to do NHS work when they have finished training, that might assist. However, there is no guarantee that they will remain NHS dentists or that they will remain in the area.

It was no surprise that during the summer the last NHS dentist in Saltash in my constituency, which is the sixth largest town in Cornwall, left the NHS and went private. I just want to read part of a letter sent to me by the dentist, to whom I wrote asking for an explanation, which sums up precisely what so many have said today:

"I have worked as an NHS dentist for 20 years, and had always imagined I would carry on working for the NHS for my whole working life. I would consider myself a caring professional, and I hope many of my patients would back me up in this statement. I had warned the PCT that I may have to go private if they could not help, unfortunately I think they may have wanted to rely on my better nature not to change at all."

The dentist continues by saying that at a meeting with the PCT's commissioning and performance manager in June, he

"asked if it was possible to have a child only [0 to 18 years] NHS contract and they declined. I also asked the PCT for an NHS contract to continue seeing those adults who were exempt from NHS payment charges [those receiving state benefits] and they declined this also. The targets that the PCT were asking us to achieve were unrealistic and we also want to spend more time with each patient, discussing prevention of oral problems and how to look after one's mouth. I thought long and hard...but...I had...to leave".

Unfortunately, that has been the experience of far too many dentists in Cornwall, particularly those in South-East Cornwall. The Minister of State, Department of Health, Mr. O'Brien, is not in his place, but he was suggesting that he might visit. I would welcome the visit to Cornwall of any health Minister-they could meet me or any of my colleagues-so that we can hunt down greater access to dentists. Greater access is simply not true down in Cornwall, and it has not been for years. It is about time equality of access was actually addressed.

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Photo of Mike Penning Mike Penning Shadow Minister (Health) 6:33 pm, 14th October 2009

It is a pleasure to sum up on behalf of Her Majesty's Opposition on such an important debate, which has taken up so much of my time since I became a Front Bencher. As we have heard, dentistry does not take up the largest part of the NHS budget-some £2.7 billion of some £110 billion is spent on NHS dentistry annually in this country-but it is something that affects nearly everybody in this country, whether or not they go private. I shall return to the comments made by Mr. Martlew about where I go for my dentistry in a moment, although I must say that he clearly does not know me very well.

The shadow Secretary of State summed up very well the problems within NHS dentistry, which explain why this debate has been chosen by Her Majesty's Opposition so quickly after the summer recess. That was done-I shall come on to this in more detail in a moment-because we welcomed the Steele review, which the Government accepted in full. I asked the Under-Secretary whether she accepted it in full, and she said yes. The Steele review is there, and I welcome it. I have spoken to Professor Steele since he published his review and I think that it was a very important way to look forward. It is visionary-it has similarities to Lord Darzi's review in that respect-although it perhaps does not have the detail that we were looking for about how we should implement some of those ideas. We have those ideas, and the shadow Secretary of State laid them out earlier.

I want to touch on some areas to do with our policy on dentistry that we did not have a chance to discuss earlier and I also want to make comments on the contributions made by each individual Member who has spoken in the debate this afternoon. This has been a sensible debate. I have to admit that some of the comments that I have heard about how brilliant the availability of NHS dentistry around the country is seem to be anomalous to the letters and correspondence that I get and the comments I hear from dentists. As we heard earlier, provision is patchy and in some parts of the country it works well whereas in some parts of the country it is appalling. How can that be right in an NHS in the 21st century?

Let us consider some of the comments that were made during the debate. I have been on the platform many times with Norman Lamb to discuss dentistry. I was slightly surprised when he said that he did not quite know whether we were going to get rid of the contract, keep it, twist it or do whatever else with it. I have stood on the platform with him many times and said that the contract in its present form is unworkable, that it is a damaged brand and that it needs to be phased out. We intend to phase in the new contract alongside it. We will pilot the hours-the pilot is important-but we will not ignore the pilot, as the Government did in 2006 and appear to have done again now, and force something on dentists.

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Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health

I am grateful for that sort of clarification. It was merely that the hon. Gentleman said that he accepted Steele's recommendations, and Steele says that we should build on the existing contract framework, develop it and, if necessary, make some changes to regulations. Essentially, he says that we should build on what is there at the moment. Is the hon. Gentleman saying that that is not the approach that he would take?

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

I have said that there are very good things within Steele, but that how we implement what he is saying is much more difficult than simply saying, "I have a vision." We do not feel that one could leave the contract in this form, discredited as it is within the profession and around the country-it is discredited not only with patients but with dentists too. It is absolutely right to say that if we came in on day one and scrapped it, there would be chaos-there would. There is chaos in parts of the country now, but there would be more chaos. The new scheme needs to be phased in and to be piloted and dentists need to know from day one where we are going and we need to work with them, unlike what is happening at the moment.

Let me touch on the school inspections, which have been commented on by my hon. Friends the Members for South Cambridgeshire (Mr. Lansley) and for Mole Valley (Sir Paul Beresford). If we only do school inspections and nothing else-if a dentist merely walks into a school, looks at a child's oral health and walks back out again-there is no point doing it. That is not what we are proposing. It has to be based on education, and on training for people in the schools and for the nurses in the schools. We also need to look inside that child's mouth-in many cases, sadly, they will never have had any oral expert look at their oral hygiene at all.

I say to hon. Members and to people around the country-I have said it to the British Dental Association, too, so it is no secret-that if they think that it is acceptable for children in our schools today to have abscesses and rotting teeth at such an early age and for us to do nothing about it, they should come up with another idea-

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

I hear a comment from a sedentary position that it is just about fluoride. It is not just about fluoride. There has been enough fluoride in toothpaste in this country for many years.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

No, thank you. The hon. Gentleman has said enough from a sedentary position.

If school inspections are so wrong, how come one in seven primary care trusts in this country still carry them out? They have made the decision to put their money where their mouth is and to still do that. That is very important.

I also listened carefully to Charlotte Atkins, with whom I served on the Select Committee. I congratulate her on convincing the Committee to look into dentistry. I would have thought that it would have been an easy process-I would have thought that all Members of the Committee would have realised what a crisis there was.

The important part of the hon. Lady's speech was her understanding of the problems with the unit of dental activity. The Select Committee saw the problems in having such a small group of bands. It is not good for the patient, because they do not understand exactly what they are paying for when they hear of someone who had a lot less treatment paying exactly the same. The bands have to be expanded, as we have said, but they also exert a perverse influence on dentists. What should they be interested in when they look inside a person's mouth-oral hygiene, or how much money the job will cost and how much they will get? I know that the Health Committee looked at that, because it was one of the biggest worries expressed by dentists.

It cannot be right that dentists get paid the same to do one filling, or six. The money has to be based on the activity that is undertaken. Earlier, and again from a sedentary position, the hon. Member for Carlisle made it clear that he was worried that more extractions than fillings are carried out these days. In fact, there has been a 45 per cent. reduction in the amount of root canal work done in this country since the new contract came in.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

No, you have had your opportunity already. There are more extractions and fewer fillings now: those are the facts, as given in evidence to the Health Committee. That Labour-dominated Select Committee produced a devastating report about dentistry in this country.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

If you want to get on the Health Committee, I suggest that you talk to your Whips. Then you can contribute in a better way.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

Thank you very much, Mr. Deputy-I am sorry, I mean Mr. Speaker. Perhaps "Deputy" is another word that I should not use too often.

My hon. Friend the Member for Mole Valley knows so much about dentistry that sometimes it is very difficult for me to talk to him about these matters. He probably knows more about them than anyone else in the House, and I was very interested when he said that dentists were less worried about what happened when they ran out of UDA than they were about the money that is then clawed back. Although they may want to treat the new patients that come to them, the fact that they do not have enough UDA means that they are not able to.

It is astonishing to me that, in the past nine months, we should have had two debates about the types of contracts that are out there yet hon. Members and the public still do not realise that, unless they are having treatment, they are not registered with an NHS dentist. In his report, Professor Steele made it absolutely and categorically clear that registration was crucial. He said:

"We recommend that patients register in a continuing care relationship."

However, you cannot have such a relationship if the dentist is not responsible for continuing care. If you only go to him when you have problems, he is not responsible for your continuing care. That is why registration is so important, and why we need to make sure that dentists, like GPs, are responsible for people's preventive care.

Earlier, the hon. Member for Carlisle said, again from a sedentary position, "I bet he's always gone to a private dentist," but-

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Photo of Eric Martlew Eric Martlew Labour, Carlisle

On a point of order, Mr. Speaker. That is not true. I did not say that about the hon. Gentleman.

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Photo of John Bercow John Bercow Chair, Members Estimate Committee, Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons, Speaker of the House of Commons

I am grateful to the hon. Gentleman, but I suspect that that represents a point of debate to which Mike Penning may or may not wish to respond.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

Where people in this country go to the dentist is a matter for them, and I happen to be lucky enough to have an NHS dentist. In fact, most of the time my dental hygiene was looked after by Her Majesty's armed forces. That care was not private either.

In many parts of the country, people do not have the choice to go and see an NHS dentist. There is no point in being delusional about the fact that NHS dental provision is good in some parts of the country and bad in others. Sadly, the current system is fundamentally failing millions of people who would prefer to have an NHS dentist looking after their continuing oral hygiene needs.

My hon. Friend Dr. Lewis defended local democracy to the hilt. He read out the relevant correspondence and my hon. Friend the Member for South Cambridgeshire, the shadow Secretary of State, set out our party's position on these matters. However, one specific thing would help to ensure that an awful lot more children got to see an NHS dentist-the removal of the ban that the Government introduced that prevents children from being seen only on the NHS.

In a perfect world, NHS dentists would be available to everyone who wanted to see one, but the crisis is most serious when it comes to children. For a large proportion of the adult population, the damage has been done already, but children's dental care is the crisis area and that is why we would allow NHS-only contracts for children. That would have the important effect of encouraging dentists back into the NHS. We do not have a shortage of dentists in this country: what we have is a shortage of dentists willing to work in the NHS. Those are the facts.

We train huge numbers of dentists. In his opening remarks, the Minister told the House how many dentists are being trained in this country at the taxpayer's expense, but as the hon. Member for Staffordshire, Moorlands said, they may not even stay in the NHS. We train them very well, with some of the best-probably the best-training in the world, but once they have done that training, they can walk away from the NHS and the taxpayers who pay for it. We must ask them to stay at least partly within the NHS; it is important that we do so. This has been an important debate. I am pleased that so many Back Benchers have-

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

I have said no. I have indicated the position of my party throughout the debate. There has been a long time for everybody to participate. With a minute to go, I shall defend the statement that the NHS must be there for everybody. NHS dentists must be there for those who wish to have an NHS dentist. That is not the position today, but it will be under a Conservative Government.

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Photo of Ann Keen Ann Keen Parliamentary Under-Secretary, Department of Health 6:45 pm, 14th October 2009

I thank hon. Members for the high quality of this evening's debate. We may often disagree on the specifics of policy, but I hope that we none the less share a commitment to providing high-quality national health service dentistry to everyone who wants it. Dentistry has come a long way in recent years, although we all know that there is still further to go. The Government believe that the best decisions are those made closest to the ground. That principle of devolved, local decision making is at the heart of everything that is happening in the national health service today, and at the heart of NHS dentistry.

The new contract in 2006 gave primary care trusts the power and the responsibility to shape local dentistry services to fit the specific needs of their communities. Many have risen to that new challenge and are providing excellent NHS dental services. I could give many examples; some have been given in the Chamber this evening. South Tyneside primary care trust, like much of the north-east, has a history of ensuring good access to NHS dentistry, but now the PCT is working with local dentists to improve the quality and efficiency of the services that it provides. The aim is to improve services for patients while providing best value for money.

Although places such as South Tyneside are good, other areas are not as good, as we have heard today. Where progress is uneven, we need to go further. That is where Professor Jimmy Steele's review has proved so valuable. It has helped us to understand further the modern landscape of dentistry and the needs of the population, and that the focus of modern dentistry must be on prevention, the maintenance of oral health and quality. It also helps us to understand that different generations can have very different needs. We are asking our dentists for different approaches in light of that. We are starting to test the recommendations. PCTs that tender for new contacts so as to increase access to dental services are starting to place qualitative measures in their contracts. Depending on the results of piloting, we will start to roll out the Steele recommendations on quality to all contracts for dental services.

In the past two years, funding for NHS dentistry has increased by the best part of £400 million a year. That is extra money going to the front line, and that gives more people better access to high-quality dental care. However, the issue is not only about spending more; it is about spending better. The national dental access programme is helping PCTs to get the most out of existing services, looking at how things are organised on the ground and offering advice and guidance on how they can be improved within existing budgets.

The last time I stood at this Dispatch Box to debate dentistry was in December last year. I assured the House that access to NHS dentistry was about to increase. If I remember correctly, the Opposition did not share my confidence. Well, I am delighted to say that I was correct. The NHS information centre's latest statistics show that the number of people who have been able to see an NHS dentist has risen by 720,000 over the past year. I hope the House will believe me now when I say that the growth in access will continue in the years to come. We are on course to achieve and, indeed, surpass the Opposition's rather unambitious target of an extra 1 million people. Trust the Government and this party to do the job properly. Trust this nurse. People should always trust the nurse when she is telling them what we will achieve.

We are well on the way towards replacing the access lost when a minority of dentists decided not to accept the new contracts in 2006, but we aim to go much further. Every strategic health authority is committed to making sure that by March 2011 everyone who wants a dentist can access an NHS dentist. We are committed to implementing Professor Steele's recommendations to improve both the quality of dentistry for patients and the working lives of dentists.

In the time that we have left, I will endeavour to answer as many as possible of the questions that hon. Members raised. As is traditional, if I fail to answer any questions we will write to the Members who participated in the debate. Norman Lamb, speaking from the Front Bench for the Liberals, made a positive contribution and spoke about quality, prevention and inequalities. He reminded us of the importance of good negotiations with the BDA, and I take note.

My hon. Friend Charlotte Atkins, who is known for championing dentistry in the House, and in particular fluoridation, spoke about TLC 4 Smiles for herself. She also mentioned a Mr. and Mrs. Keen, who were making a valued contribution to dentistry in her area. May I say to all in the House and to any journalists who may be present that I have only the one job. On this occasion I can also vouch for my hon. Friend Alan Keen.

Sir Paul Beresford, who spoke from his experience as a dentist and brought much experience to the Health Committee and the all-party group on dentistry, referred to the BDA survey. That survey also stated that relations between PCTs and dentists was very good indeed, citing 87 per cent. of cases that were reported. That report was published yesterday and we should acknowledge its findings.

I thank my hon. Friend Mr. Martlew for his comments on the improvements that have been made. He mentioned the important matter of charges, which is dear to the hearts of all Members, especially those on the Labour Benches. All children and about 30 per cent. of adults are exempt from charges.

Dr. Lewis raised with typical forcefulness and passion the subject of regulations. I should point out that those regulations were passed in the House on a free vote. I cannot go further as the matter is subject to a judicial review.

Mr. Breed highlighted important topics. From next spring the PCT responsible for Saltash is commissioning new services that will offer care to all sections of the population. He also mentioned that the new dental school in the south-west peninsula, part of the development of a dental education centre, is under construction in Truro. For the first time, dentists will be trained in Cornwall.

Speaking from the Opposition Front Bench, Mike Penning stated that should the Conservatives be in government, dentists would be required to work in the NHS. I should be grateful if he would explain how long they would be required to do so and how he intends to achieve that.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

If someone is trained by the NHS at taxpayers' expense, they will have to have a built-in loyalty to the NHS. We have said, and not just today, that they will have to work in some shape or form for five years in the NHS in order to pay back its contribution to their training.

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Photo of Ann Keen Ann Keen Parliamentary Under-Secretary, Department of Health

Those are very interesting comments, indeed. That proposal is similar, of course, to registration, because registration was in fact a payment to register. Our dentists today recall patients, and they have continuity of care.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

We have been very clear about our proposal and have made it before: a five-year tie-in for NHS, state-trained dentists so that they remain in the NHS. The Liberal Democrats agree with us, and it is practised in Scotland. Will Ministers agree with that proposal?

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Photo of Ann Keen Ann Keen Parliamentary Under-Secretary, Department of Health

The registration was a payment. What we are still able to do is-

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Photo of Eric Martlew Eric Martlew Labour, Carlisle

I am sorry to interrupt my hon. Friend, but the Opposition would not give way to me. Does she know anything about the policy on making dentists work for five years? Will it apply to doctors as well? Would that not seem fair? Are the Conservatives going to make doctors work for five years for the NHS?

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Photo of Ann Keen Ann Keen Parliamentary Under-Secretary, Department of Health

My hon. Friend makes an excellent point. The proposal is certainly news to Government FrontBenchers today, but I think that we should expand on it; perhaps it is something that we should look at. It will be interesting to see how negotiations on it go with the BDA. Perhaps the Opposition will keep us informed, because much has been said today about the professionalism of our dentists. In fact, accusations have been made about the number of extractions that are deemed unnecessary.

We admire our dentists and congratulate not only them on the real hard work that they do, but all the team who play such a role, including hygienists and, in particular, dental nurses. We note also their approach to health inequalities and their serious work with us and Professor Steele to implement the new contract. I have heard nothing from Opposition Members about inequalities.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

In my speech I made it very clear that we want people to have greater access to preventive care, and we have made it clear that we will allow people to visit dental hygienists without the requirement of a dentist's referral via a prescription. Will the Minister agree with that proposal?

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Photo of Ann Keen Ann Keen Parliamentary Under-Secretary, Department of Health

I am not sure that the hon. Gentleman would be able to achieve that, because regulation might come into play. He cannot make such statements just to please himself this evening; he has to be able to fulfil them. [ Interruption. ] I am sorry, but he does have to look at his subject area again, because it is just not possible to make that proposal tonight.

We are talking about a team of people who work in our primary care system and are respected and valued in the community. Interesting points have been made today about dentists being asked to work up to five years for the NHS, and it would be very interesting to see how that might be expanded to include other health professionals and members of the health service work force.

We want to congratulate all the dentists who have worked with the contract. It was a difficult contract to introduce, and it has been difficult for some people to implement, but our PCTs, along with our commissioners, are working for dentistry to be accessible for all. We have made a commitment that by 2011 all those who want a dentist will have access to a dentist.

We have heard tonight, yet again, from a Conservative party that pays lip service to everything-

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Photo of Patrick McLoughlin Patrick McLoughlin Shadow Chief Whip (Commons), Opposition Chief Whip (Commons)

claimed to move the closure (Standing Order No. 36).

Question put forthwith, That the Question be now put.

Question agreed to.

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Question put accordingly (Standing Order No. 31(2)), That the original words stand part of the Question.

The House divided: Ayes 210, Noes 277.

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Question accordingly negatived.

Question put forthwith (Standing Order No. 31(2)), That the proposed words be there added.

Question agreed to.

Main Question, as amended, put and agreed to.

Resolved,

That this House welcomes Professor Steele's review report and its endorsement that the principle of local commissioning introduced by the 2006 reforms provides a firm basis on which to develop NHS dentistry; agrees with the vision set out in the review of improving incentives to support dentists in delivering access and quality; acknowledges the Government's commitment to working with the dentistry profession and other stakeholders to ensure through careful piloting that it implements the recommendations in a way that delivers the best possible system for patients, dentists and the NHS; acknowledges that children's oral health in England is already among the best in the world; welcomes the commitment of the NHS to deliver access for all who seek it by March 2011 at the latest, supported by some £2 billion in central funding for dentistry, and understands that access is now growing again; notes that in the last four quarters the number of people seeing an NHS dentist in the previous 24-month period has grown by 720,000; further notes that the dental workforce is growing, with 655 more dentists working in the NHS in 2007-08 and a further 528 in 2008-09; and recognises the support that the dental access programme of the Department of Health is providing to clinicians and managers to help them rapidly expand NHS dental services where necessary.

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