Clause 157 - Provision of primary dental services

Health and Social Care (Community Health and Standards) Bill – in a Public Bill Committee at 8:55 am on 19th June 2003.

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Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon 8:55 am, 19th June 2003

I beg to move amendment No. 635, in clause 157 page 74 line 21 leave out

'to the extent that it considers it reasonable to do so'.

Photo of Peter Atkinson Peter Atkinson Conservative, Hexham

With this it will be convenient to discuss the following amendments: No. 629, in clause 157 page 74 line 22 after 'provide', insert

'and promote the development of'.

No. 636, in clause 157 page 74 line 23 at end insert

'in accordance with identified local need'.

No. 639, in clause 157 page 74 line 26 at end insert

'and will ensure that provision that is currently available under the existing system, including the care of those with special needs, and services such as orthodontics and oral surgery, will be secured.'.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I am delighted that we are finally, at least in this clause, discussing the role of commissioning. The Minister is aware of earlier exchanges during which regret was expressed at the fact that a great deal of this piece of legislation is designed to change structures and systems relating to the provision of service. This generally very welcome clause recognises the importance of commissioning, particularly local commissioning according to local decisions.

The amendments seek to examine more carefully the basis upon which commissioning decisions will be made. Proposed new section 16CA(1) does not give enough priority to the importance of first assessing local need and then commissioning services designed to meet it. Instead, it simply allows primary care trusts to judge what it is reasonable to commission. I should be grateful if the Minister would explain how that qualification, and the basis on which local commissioners have a duty to commission dental services, compare to the commissioning of other services by health authorities or their replacements under the National Health Service Act 1977. The comparison seems to be a fairly loose one, and it may be more appropriate to place a requirement in the Bill to deal with local need.

Dentistry, the provision of dental services and the level of public dental health vary considerably across the country. That variation is too great, which implies that there are pockets of great need. Commissioners may decide to increase the level of provision to a degree that they consider reasonable given all the circumstances. However, if that level comes nowhere near meeting the identified need, or if they do not take

steps to identify the needs of public dental health, health promotion, access to dental care, access to screening services and access to emergency and elective treatment, the commissioners may fall short.

In tabling amendment No. 635, the Liberal Democrats have the support of the Consumers Association, which requested that we raise the issue with the Government. It too recognises that access to dentistry is poor and that dental services are under great pressure in many areas. We have also heard from the British Dental Association that the share of funding for dentistry under the national arrangements has fallen from about 5 per cent. to nearer 3 per cent. of NHS spend. That constrains the ability of dental services to obtain sufficient resources to keep up with the level of need or demand, which is why the Committee and the Government have faced the problem of poor access to NHS dentistry.

Providing the ability for local commissioners to commission services and to be responsible for making contractual arrangements with providers—a matter to be dealt with in later clauses—is a sensible move away from a nationally negotiated and nationally organised system of contracting with dentists, and I support the Government in their intention. However, reference to need will be important.

We are concerned at the continuing failure to provide the ability for people to register with an NHS dentist. The Government made a limited pledge to ensure universal access to dentistry as much as possible. However, that really meant access in emergencies and did not result in people registering with dentists, as was the case before the drift away from NHS dentistry to private dentistry.

Primary care trusts should be required to identify the need for people to be registered with a dental practitioner, just as they register with a medical practitioner in primary care. Without that, there will not be the holistic and preventive care provided by dental practitioners that is an important part of dental health care, but simply a dental sickness service that deals with problems as they arise. There will not be the continuity of care that registration with an identified dental practitioner gives, and patients will not receive the advice that regular check-ups provide. Whether the practitioner is salaried or on a contract is immaterial; the question is whether that holistic care will exist.

If the Government were minded to look kindly on amendments Nos. 635 and 636 and consider the necessity to identify and cater for need, they would find that there was more pressure on local commissioners to ensure that they provided not just a holistic and preventive service, but one that was actually cost effective. If more dental disease were prevented by advice and appropriate evidence-based, effective screening techniques, and by dealing with problems early rather than in an emergency, the cost of dental care would ultimately be lower than if people were allowed to drift into problems that a firefighting system would rectify.

The wording of the clause is far too loose, because a PCT might consider it reasonable to maintain the current level of services and registrations. After all, the

Government consider that level to be adequate because they claim to have met their access pledge to dentistry. Members on both sides of the House know from their constituencies that current dental provision is simply inadequate, especially the levels of holistic and preventive work that I mentioned. The Government are running the risk of ensuring that commissioners continue to view dentistry and related care as a lower priority than other areas, and it is unreasonable to allow that to continue.

Photo of Andrew Murrison Andrew Murrison Conservative, Westbury

The Government have lived up to their 1999 pledge on dentistry, but does the hon. Gentleman agree that they have only partly done so, as they have fulfilled their pledge on emergency dentistry and but not on the bulk of dentistry care?

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Yes, the hon. Gentleman is agreeing with my earlier point that their pledge was limited in that it ensured greater access to only emergency treatment. Registration with dentists continues to fall, yet most people consider that good dental care involves the ability to register with a dentist, as one does with a GP, to ensure access to joined-up services, preventive work and advice on screening. The Government seem to want to provoke a firefighting mechanism by ensuring that there is a requirement only to provide access to emergency treatment or treatment when the patient deems it necessary, rather than encouraging the normal teamwork relationship between a patient and their registered dentist.

I hope that the Government have heard that point. I also hope that they recognise that the current wording is insufficient to safeguard the need to increase dentistry care. If PCTs argue that the current dental provision that the Government consider adequate—for which the access pledge has already been met—is acceptable, it would be reasonable not to seek to increase the degree of registration.

The clause does not recognise the degree of variation in dental services and in need. There is huge dental need in certain areas. It is important to debate whether other preventive measures, such as fluoridation, may be appropriate, but it is probably not fitting to do so during debates on this Bill. That whole debate is predicated on the unevenness of treatment.

The British Dental Association advised my colleagues and I on amendment No. 639, regarding the provision of specialist services. It is rather surprising that the British Dental Association, which has been involved closely with the Government in the negotiation of the contract and which, like us, generally supports these clauses, still has concerns. In tabling the amendment, I seek to clarify what specialist and special needs services will be available under the new system, because the Bill makes no specific provision for securing services for patients with special needs, who are among the most vulnerable people in our society. Dentists working in the community dental services have considerable experience in that area: they, and we, need assurance

that such care will continue to be provided and commissioned by primary care trusts under the new arrangements.

Similarly, patients who need orthodontic treatment and oral surgery must be assured that such services will be available in the future within a primary care setting. The General Dental Council, which regulates the profession, has recently set up specialist registers of those qualified to provide such services, and primary care trusts need to recognise the contribution that such specialists can make.

The Department of Health, through a supplement of the chief dental officer's digest from May 2003, states:

''There will also be an opportunity to ensure that developing dental specialities are given the right incentives to contribute to patient care''.

Amendment No. 639 would seek to secure that. The Minister will know that access to orthodontics and oral surgery is poor. Waiting times for orthodontics were traditionally not measured under the Government's waiting time statistics inherited from the Conservatives, and, therefore, there were particularly long waiting times in that service, as there were for a few other services such as chiropody. Indeed, the term foot and mouth disease might well apply to the failure of the system to measure the waiting times in those specialities. Therefore, due to the priority given to meeting waiting time targets, dentistry, chiropody and some other areas have fallen through the net, and waiting times have become too long.

There are people with complex needs who often have significant other health needs of which oral health is a component. In particular, some patients with congenital disease require effective access to these services both in secondary care and in primary care settings, especially as more expertise develops in primary care and the Government seek rightly to shift services into primary care for reasons of quality and access. If the Government are going to be consistent in that, they must give an assurance that primary care trusts will have a duty not only to commission and secure the services that are currently available for these groups of people with special needs, but to improve those services.

We may be able to cover access to dentistry in other areas, so I will not go into detail on that because you, Mr. Chairman, may see fit to have a clause stand part debate. However, there are issues concerning access to dentistry for other parts of the population, and I hope that we will have an opportunity to debate at some point, though perhaps not under these detailed amendments, what the Government intend to do to secure better access to dentistry in prisons and detention centres, and for some other groups.

I hope that the Government will look kindly on this group of amendments. They are tabled in a constructive manner to seek to ensure that primary care trusts are given the incentives that they need to ensure that dentistry is no longer the Cinderella service that it has been under the current arrangements.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I agree with the hon. Member for Oxford, West and Abingdon (Dr. Harris) that his amendments are a constructive way in which further information and guidance on the Government's intentions can be sought. I hope that the Minister will listen carefully to concerns, particularly as part 4 is an important and significant inclusion in primary legislation. To be accurate, the last work on this matter was done in 1977, so this is the first time in almost 30 years that a Government have taken a new approach to, and sought a greater insight into, the provision of dental services in this country.

It is apparent that since Nye Bevan set up the NHS in 1948, dental services have been a hybrid part of that service, and they have been greatly misunderstood by those who use them. In many ways Governments of all parties have used them as a whipping boy in the NHS, particularly when those Governments have experienced severe financial problems. That is why, by and large, the services have lost out.

I noticed that the hon. Member for Oxford, West and Abingdon mentioned briefly the question of access to the NHS. I am not quite as optimistic as he seems to be, because the pledge that the Prime Minister gave at the 1999 Labour party conference was not that access through registration with a local dentist would be ensured, but that within two years anyone would be able to ring up NHS Direct and be told the location of an NHS dentist in their area. That is very different from registering with one of those dentists, and the matter must be looked at.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I agree with the hon. Gentleman. I thought that I had made it clear that the Government's pledge on access to treatment was limited only to the accessibility of NHS dentists, and that that is not equivalent to ensuring that registration rates, which have been falling for years, turn the corner. Without registration one does not get, as I mentioned, the holistic and preventive care that is so important in avoiding dental problems.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I am grateful to the hon. Gentleman, and as I am in a benign mood, I will go along with him and accept that that is what he said.

Apart from giving the Committee an opportunity to improve the Bill so that there can be no misunderstanding or lack of progress, the amendments, just as importantly, will flush out more of the Government's intentions. Amendment No. 635 refers to proposed new section 16CA(1) in clause 157, which basically states that a primary care trust will now have a vital and significant role in the commissioning and, in effect, the provision of dental services in its region. That is in keeping with the Government's professed aim to decentralise the health service and make it more accountable and responsive to the needs of local communities. I have no problem whatsoever with that principle, and I think that the sooner that politicians end their day-to-day interference in the provision of dental services and health care the better.

I am not, however, convinced that what the Government propose for other areas of the health service—I shall not expand on those so as not to fall

foul of the relevance rule—will decentralise services to the extent that Ministers maintain. New subsection (1) states that a PCT

''must, to the extent that it considers it reasonable to do so, provide primary dental services''.

The amendment seeks to remove the words:

''to the extent that it considers it reasonable to do so''.

I do not understand why the Government have put that phrase in the Bill, because there is a danger that it will allow the status quo partly to continue under a different commissioning and provision regime.

What exactly does

''considers it reasonable to do so''

mean? I would appreciate it if the Minister elaborated on that in his remarks, and I hope that he reassures me. In theory, that could be a cop-out clause for PCTs. If they could argue that they do not provide a service, or do not provide it to the level that the local population might believe, they would be able to hide behind that expression. That weakens what the Government are proposing to do. However, I suspect that the Minister does not intend that to happen.

Photo of Gary Streeter Gary Streeter Shadow Minister (Foreign and Commonwealth Affairs) 9:15 am, 19th June 2003

Does my hon. Friend agree that another interpretation of the words

''to the extent that it considers it reasonable to do so''

is ''to the extent that it can afford to do so'', which lets off the hook not only PCTs but the Government? One can imagine that, for a PCT, a shortage of funding would be a good excuse for not making such a service available.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I am grateful to my hon. Friend, who anticipates a point that I will discuss in due course. I have been made aware by the Minister's sedentary comments that the debate has the potential to degenerate rather than remain at an intelligent level. I am not confident that that level will continue once the Minister begins to speak. I will say—to pray in aid my case—that the Minister should be a little cautious before he begins his misrepresentation and his rant about funding, because the Government have been in power for six years. One cannot constantly live solely in the past: defining what has happened between 1997—

Photo of Peter Atkinson Peter Atkinson Conservative, Hexham

Order. I remind the Committee that we are discussing the provision of primary dental services. I would be grateful if hon. Members could bear that in mind.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I am grateful for that guidance, which I accept. What I was eager to do, though wrongly, was to try to save the Committee from the Minister's rant, which I anticipate later.

Photo of Andy Burnham Andy Burnham Labour, Leigh

Labour Members may find it strange that a certain party seems to want more money to be spent on primary dental services. Removing the qualifying phrase in subsection (1)—

''to the extent that it considers it reasonable to do so''—

would render it meaningless because it would simply state:

''Each Primary Care Trust and Local Health Board must provide primary dental services within its area, or secure their provision within its area.''

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I am grateful to the hon. Gentleman, but I do not accept his argument. The phrase could throw an element of doubt into the procedures or introduce a barrier or excuse that PCTs would be able to hide behind. I will not argue with the hon. Gentleman, because if he believes that the amendment would render the subsection meaningless, which I do not, then presumably, rather than include a phrase that causes doubt, we should strengthen the subsection to remove any element of doubt.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Perhaps the hon. Gentleman could point out to the hon. Member for Leigh (Andy Burnham) that amendments Nos. 635 and 636, which would insert the words,

''in accordance with identified local need'',

are supposed to be taken together to reassure him that although part of the clause may be taken out, needs will be identified and met. If, as he believes, the removal of the qualifying phrase would make the subsection unreasonable, that would make it meaningful again.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I am very grateful to the hon. Gentleman, because again, like my hon. Friend the Member for South-West Devon (Mr. Gary Streeter), he has anticipated, in a different context, the point that I was going to make. Amendment No. 636—

Photo of Andy Burnham Andy Burnham Labour, Leigh

Will the hon. Gentleman give way?

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I shall deal first with the previous intervention. Amendment No. 636 spells out that, among other things, it will be the responsibility of PCTs to provide a dental service in accordance with identified local need, which—

Photo of Andy Burnham Andy Burnham Labour, Leigh

Will the hon. Gentleman give way?

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

One minute.

Of course, that provision is crucial, because one of the main functions of PCTs is to identify local health needs or, in the case of this part of the Bill, dental health needs and to seek to commission treatment and care for patients.

Photo of Andy Burnham Andy Burnham Labour, Leigh

In accepting the amendments proposed by the hon. Member for Oxford, West and Abingdon, is the Conservative party supporting the notion that, in certain areas, the public sector should pay in full for dental services according to need? That would be the effect of amendment No. 636, and it would go completely against what the hon. Gentleman's party did when in office. The amendment would require the PCT to pay for all dental services according to local need.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

The hon. Gentleman is absolutely right, and, as I said at the beginning of my comments, if one is to have a health care system that includes dental care, one must respond to local needs. In many ways, this is about changing the way in which dental care is commissioned in an area and by whom.

The Government are using this part of the Bill in an imaginative way to devolve power to local PCTs, which is absolutely right. Sadly, we have not heard from the Minister yet, so we will have to wait to hear how he envisages the measures will work. However, as my hon. Friend the Member for South-West Devon stated, we do not know what will drive these reforms. Of course, spending drives the health systems in this country, and we will be very interested to hear how the Government will implement their proposals for funding that expenditure. Do they, for example, expect this innovation to be funded by their existing levels of expenditure, or do they think that the responsibilities and systems that they are imposing on PCTs will, in fact, generate more funding requirements from the existing NHS budget, and will they adjust their funding mechanisms accordingly?

We also do not know when the proposals will be implemented. We are at a loss because we are not familiar with all the Government's intentions for the exact working of the system and when it will be introduced. Will that be in the next 12 months or in two, three or four years?

Photo of Andy Burnham Andy Burnham Labour, Leigh

I hope that the hon. Gentleman will accept that Labour Members find it ironic that the Conservative party is making a major argument for huge expansion in NHS dentistry. Putting that aside, has the hon. Gentleman worked out how much the amendments would cost the NHS?

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

The hon. Gentleman is not taking in what I am saying. I welcome the fact that commissioning for dental care will be devolved to PCTs.

I welcome the fact that it will provide services at a local level. That is not in the Bill, but the hon. Member for Oxford, West and Abingdon is seeking through his amendment to include that commitment in the Bill.

However, until we hear from the Minister, we are in the dark about exactly how he expects the system to work on the ground, and whether he expects the system to work under the existing framework and arrangement. Alternatively, does the Minister envisage an expansion in the provision of dental care as a result of the changes in systems? As we all know, dental care is very different from most of the rest of NHS provision. It is split significantly between those who use the private sector for a variety of reasons, and those who have to, or choose to, use solely the NHS. Of course, even those who use the NHS do not, in most cases, receive a service that is free at the point of use. To return to my original point, that is because dental services have, almost since the beginning of the NHS—although not from day one—included an element of charging for a proportion of the cost of treatment.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Before the hon. Gentleman goes down that path, I would like to recognise that the hon. Member for Leigh made some important points, which I would have appreciated responding to in my own speech.

It is important to note that amendment No. 636 does not use the words ''all identified need''. It is not an unlimited spending commitment, but it is a

commitment to spending more. Liberal Democrats support the fact that extra resources are being made available. We also want the PCTs to be elected and to have tax-varying powers to meet the needs that they want to prioritise. The hon. Member for Leigh's point is a fair one to put to the Conservative party—it is quite political—but I hope that he recognises that the way that the amendment is worded does not provide for an unlimited spending commitment, and that Liberal Democrats at least have a democratic mechanism to respond to that.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

The hon. Gentleman is absolutely right. The amendment is not talking about ''all'', but ''the'' local need. It is in that context that I am making my comments, because I have been very careful in the course of my remarks not to give any commitment in any shape or form on spending. It is not appropriate in the context of the discussion of these amendments for us to do so.

I think—I say this with a degree of kindness—that the hon. Gentleman's intervention was too hard. I welcomed the first part of his intervention. However, vis-à-vis the second part of his intervention, I knew that it was only a matter of time before he jumped on the bandwagon and tried to turn this debate into a party-political dogfight, rather than maintaining the higher standards of intelligent debate on the provision of dental services.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I will not, because I wish to make progress and to conclude my remarks so that possibly the hon. Gentleman himself could make an invaluable contribution to our discussions; clearly he has an interest in and knowledge of dental services from his work on the Select Committee on Health.

I conclude with two points. First, with this part of the Bill the Government seek to achieve a significant change from the status quo and, in many ways, an overhaul and update of a system that was put in place when the provision of health care was in a different situation. In doing so, in many instances the Government raise more questions than answers. It is important that we hear what the Minister has to say, because I suspect that he will have an opportunity with these amendments not only to put flesh on the bones of this part of the Bill, but to inform us more about the way in which the Government intend this part of the legislation to work.

In dealing with the amendments and his proposals, the Minister must share with us when he anticipates the proposals being introduced. Moreover, how does he anticipate that the reforms will impact on the provision of dental care and its cost?

Photo of Andrew Murrison Andrew Murrison Conservative, Westbury 9:30 am, 19th June 2003

Most of my constituents' principal concern is the patchy provision of dental services. Amendment No. 635 would help to remove the possibility of that patchiness continuing. It is certainly the case that one can get different services in different areas. For the new section 16CA(1) to contain the phrase

''to the extent that it considers it reasonable to do so''

means that the service will continue to be provided as it is at present, so it would help if that phrase were deleted. In subsections (5) and (6) we see that regulations may define primary dental services and those that would be provided by contractors. At a lower level, the primary care trusts pass judgment, or comment, on that level of regulated provision and tweak it to suit local need. That is very good in theory but in practice would mean that there would continue to be a patchwork of services across the country that would vary from one primary care trust to another, and that would be wholly undesirable. Therefore the hon. Member for Oxford, West and Abingdon was right to table amendment No. 635, which would delete the phrase

''to the extent that it considers it reasonable to do so''.

Primary care trusts would be allowed to concentrate on those primary dental services that have been mandated by regulation. That would lead to more uniform primary dental services across the country, which most of my constituents want.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

First, I congratulate the hon. Member for Oxford, West and Abingdon on tabling the amendment. It has given us the opportunity to discuss what is, by common consent, a very important and significant part of the Bill. Those were the words of the hon. Member for West Chelmsford (Mr. Burns), and I agree with them.

It may have escaped the attention of anyone who was listening to the debate because of the words that were uttered, but part 4 of the Bill has been broadly welcomed. It is not the biggest shake-up of NHS dentistry in 30 years; it is the biggest shake-up since the NHS was established in 1945. It is a very important and significant area for the NHS. All of us know that our constituents experience problems in accessing NHS dental services, so it might be helpful for the Committee if I make it clear at the beginning that the clause is not about maintaining the status quo, but changing it. It is not about providing a covert mechanism for rationing, which is the usual approach of the hon. Member for Oxford, West and Abingdon to every such issue. It is about widening access to NHS dental services and providing a more up-to-date legal framework that will better allow primary care trusts to develop and plan those services strategically.

Part 4 makes several significant changes, and clause 157 is at the heart of those changes. The clause will place on primary care trusts and local health boards in Wales a new duty to commission dental services or provide them directly. There is no such explicit duty under the existing legislation, so existing legislation does not provide a robust-enough platform for developing NHS dental services. It is worth reminding ourselves, because no one has mentioned it yet, that section 35 of the 1977 Act merely requires primary care trusts to enable general dental services to be delivered when a dentist has agreed to provide such services. That is not a satisfactory basis on which to

develop the role of NHS dentistry to meet the needs of local communities.

No one is satisfied with the existing arrangements—we certainly are not. Thus, the new duty has been widely welcomed. Clause 157 will broadly shift the responsibility for commissioning NHS dentistry on to a basis similar to that of other medical services that primary care trusts are obligated to provide. This is an important new addition to the framework of NHS legislation.

The hon. Member for West Chelmsford said that he wanted to flush out my intentions. I am happy, if by doing so he can perhaps set aside some of the concerns that have been raised.

This group of amendments essentially addresses the concerns of the hon. Member for Oxford, West and Abingdon about the word ''reasonable'' in clause 157, which inserts new section 16CA in the 1977 legislation. It may be helpful to give a little background on this. The use of the word ''reasonable'' in new section 16CA(1) mirrors its usage in section 3 of the 1977 Act, which states:

''It is the Secretary of State's duty to provide throughout England and Wales, to such extent as he considers necessary to meet all reasonable requirements'',

a national health service. The duty in new section 16CA relates to the primary care trust area, and, as my hon. Friend the Member for Leigh made clear, without the test of reasonableness it would be difficult to interpret that provision succinctly. This is a new departure, so we must be as precise as possible. Given that, it would be unhelpful to inject an element of uncertainty into the precise parameters of the new duty.

With the greatest respect to the hon. Member for Oxford, West and Abingdon, his assessment of his own amendment is not accurate. It certainly was not helped by the clarification given by the hon. Member for West Chelmsford, who spoke in its favour.

Let me explain the fundamental difficulty with the amendment. Primary dental services are a description of what dentists do, rather than a service provided by the NHS itself. Therefore, his amendment would affect not only NHS dentistry, but private dentistry. It could be interpreted as meaning that the Liberal Democrats want primary care trusts to be put under a duty to promote the development of private dentistry. That may well be what the hon. Gentleman intends, but I suspect that he intended to provide a duty to develop NHS dentistry. However, that is not what his amendment proposes. This may well be a probing amendment, but I do not get the sense that it is.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I anticipated that the Government would take that approach. It is unfair to do so, because neither we, nor the Minister, oppose the ability of primary care trusts, and commissioning bodies in general, to commission services for the NHS from private dentistry. The Minister is saying that a need for private dentistry may be identified, and that it will somehow be the commissioners' role to ensure that people who feel a desperate need to pay privately

shall have that need met. That is not a fair interpretation of health need generally. I have never heard the Government mention, when they discuss health need in their many documents and consultation papers, the desperate need, and the right, of people to find services for which they can pay directly or through insurance. Therefore, the Minister's attack is a little unfair.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I am not trying to be unfair to the hon. Gentleman; I am simply telling him what his amendment proposes. There is a distinction between the two. As the hon. Gentleman well knows, we have no objection to encouraging a plurality of different health care providers—a concept to which the hon. Gentlemen is something of a late convert. It is a sensible way to maximise capacity and make it available to NHS patients, and it would be provided free at the point of use. That is not the issue. His amendment places a duty on primary care trusts to promote the development of private dental services.

Dr. Harris indicated dissent.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The hon. Gentleman shakes his head, but that simply confirms that he does not understand the purpose of the clause. If he were talking about general dental services, that would be a different story. However, he is talking about primary dental services, and that clearly includes private provision. I do not argue whether that is an appropriate way to provide treatment of NHS patients; it clearly is, and that is how it is currently provided. The question is whether that makes sense in terms of his proposals. It would be helpful if the hon. Gentleman would clarify whether or not this is a probing amendment.

He did not make that point in his introduction. We have to take the amendments at face value as a serious attempt to widen the commissioning responsibilities and duties of PCTs.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Would the Minister's claim that this seeks to promote private dentistry apply if amendment No. 635, which would delete the words

''to the extent that it considers it reasonable to do so'',

were rejected, and the words

''in accordance with identified local need''

were accepted? Would commissioners or providers be saved from having to secure and help the development of private dentistry by a test of ''reasonableness'', or by amendment No. 636, which talks about ''identified local need''? Perhaps if the Minister clarified that point the debate could progress.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

My concern is about the use of the words ''promote the development of'' in amendment No. 629, not about the deletion of the word ''reasonable''.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

That amendment is in the name of the hon. Member for Woodspring (Dr. Fox), and it is not an amendment to which I spoke. I spoke strictly to amendments Nos. 635 and 636. I assumed that it was incumbent on the hon. Member for West Chelmsford to speak to amendment No. 629.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The hon. Gentleman is quite right, and I apologise to him. Together, the amendments would

have the effect of promoting private dentistry. I should be directing my remarks to the hon. Member for West Chelmsford.

Photo of Jim Dowd Jim Dowd Labour, Lewisham West

I thank my right hon. Friend for showing the good manners that are so uncharacteristically lacking in his opposite number. The real weakness in amendment No. 636, which the hon. Member for Oxford, West and Abingdon seems to be advancing, is that it does not limit the number of people who could identify local need. The amendment does not restrict that role to the PCT, because it is so vague, it could mean that anyone in an area could identify local need, which the PCT would then be expected to meet.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I did address that point when I started to speak to the amendments, which feels like a lifetime ago. Amendment No. 636 would not aid the proper interpretation of clause 157 because it is so completely open-ended and, as my hon. Friend the Member for Leigh made clear, it would be difficult to determine the duty of PCTs.

I tried to say—for the sake of recalling the argument—that the hon. Member for Oxford, West and Abingdon was concerned about where the concept of reasonableness came from. I made it clear to him that it is broadly the Secretary of State's existing duty under section 3 of the 1977 Act. We are not importing an innovation or taking a back-door route to rationing. This is the current broad framework within which NHS services are commissioned and provided by the Secretary of State.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon 9:45 am, 19th June 2003

The Minister read from section 3 of the 1977 Act. However, I would be grateful if he read it again so that, in my response, I can get the wording exactly right. The wording in the Act is not the same as that in the Bill, because section 3(1) talks about the ''necessary''—a word that is not in clause 157—steps to secure reasonable requirements, and it lists those requirements. There is a difference between taking necessary steps to secure reasonable needs and doing something reasonably without any reference to its being necessary or to what those needs are.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The hon. Gentleman is scraping the bottom of the barrel with that approach. There is no substantive difference. Typically, he is making a mountain out of a molehill. I have no doubt whatsoever that this is a broadly comparable provision. The hon. Gentleman should not be developing his arguments along those lines.

Amendment No. 636—regardless of who the author is, and we can have a debate about that—would not help. It would introduce unfortunate ambiguity into the parameters of the new commissioning duty, and we can do without that. The real difficulty with the amendment, which stands in the name of the hon. Member for Oxford, West and Abingdon, is that it suggests that PCTs should provide services in accordance with identified local need. We expect a PCT to have regard to the needs of persons resident in its area, but as the hon. Gentleman knows, dental services have always been provided on the basis of catchment area rather than residential area. That

means that the public can access the service where it is most convenient, and we want that to continue.

It is at least arguable—probably more so than in the case of the words chosen by the hon. Gentleman—that amendment No. 636 would limit the service to what was required to meet the PCT's local health needs. I assume that the amendment is intended to cover the local resident population, rather than to those who want to use it wherever they are resident. Therefore, for that reason alone, it is not—

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

It is not my assumption; it is how the amendment can be reasonably interpreted. Even if I am wrong, it serves to illustrate the point that the amendment is not sufficiently well drafted.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Will the Minister explain the difference between catchment and resident population bases? It was not clear from his remarks. If he could do that, it might help me to respond to his interesting argument.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The catchment could be outside the PCT area, as is currently the case with NHS dental services. That is the difficulty with the amendment. Many commuters will register with an NHS dentist in Westminster because that is where they work and where they use services.

There is genuine difficulty with the amendment. I am not trying to make a mountain out of a molehill, but the new commissioning duty should be made as clear and simple as possible. I understand the hon. Gentleman's intentions; he wants PCTs to plan the provision of dental services, using their new statutory duties to commission in a way that meets the needs of local people. As I understand it, that is what the new commissioning responsibilities require them to do, so there is no issue. I say only that his amendment is unnecessary and its precise meaning is unclear. We do not know how it would affect historic patterns of registration with dental practitioners. I cannot support this group of amendments.

The hon. Member for West Chelmsford raised the subject of resources. With hindsight, he might acknowledge that that was not very clever, given that Labour Members know what happened to NHS dentistry when his lot were last in office. This refrain may sound familiar, but I am sure that he will understand why I use it: I do not think that anyone in the country believes that if the Tories were ever returned to power, they would suddenly reverse the changes that they made to NHS dentistry, or find that their policy was to spend significantly more on it. The hon. Gentleman will make no progress if that is the thrust of his argument.

The issue of resources is, however, important. It may help if I speak about that now, rather than being tempted to do so on every group of amendments. That would be tedious, although Labour Members would enjoy it. The changes to NHS dentistry in part 4 create a new legal platform within which those services can be provided. That is long overdue and widely welcomed. However, as I said earlier, we know that in some parts of the country it is difficult, especially for adults, to access NHS dental care. In some cases,

patients feel that they have to pay privately to see a dentist. That situation is not good, but we inherited it from the Conservative party.

Measures such as the establishment of personal dental services pilots, including dental access centres, have been taken to improve access to NHS dentistry, and they have done an excellent job in extending the range and reach of NHS dental services. However, more must be done. The proposals in the Bill underpin a modernised, high-quality primary dental service, provided through contracts between PCTs and dental practices. PCTs will have a duty to secure the provision of primary dental services, either through contracts with individual practices or by providing services directly. With those new responsibilities will come £1.2 billion of financial resources that are currently held centrally.

I make the important point that once the reformed system is in place, it will be possible, over time, to adjust NHS allocations to take account of the health inequalities that can only persist under the old system. I acknowledge that the existing funding arrangements are unsatisfactory. They reflect the varying willingness of dentists to treat, rather than the needs of the NHS to secure dentistry.

I can give the Committee the important guarantee that current spending will be protected. We will also take some short-term measures until the implementation of the Bill enables the NHS to address local historical anomalies, with additional funds being deployed to support PCTs as they get to grips with the new agenda.

In the longer term, allocations will need to take health needs into account, as general allocations currently do. In some areas that may mean that additional funding for dentistry will be available to PCTs so that they can begin to address the long-term oral health inequalities that many of them face. Clearly that would be taken into account in future allocations within the framework of the funding formula.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

I thank the Minister for such a detailed answer on this crucial matter, but can he advise us when the new system will come into force?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

Yes. We hope to have the new GDS contract operational by 2005, and we intend to commence the implementation and operation of the provisions as soon as possible. Perhaps we can return to the matter at hand.

Alongside the practice-based contracts, I want to move to a more preventive approach to the provision of dental services in much the same way as the Health Committee's report on access to NHS dentistry recommended. The Bill will end reliance on the fee-per-item-of-service method of paying dentists. Also, clause 158 will, for the first time since the foundation of the NHS, give dental GPs the opportunity to focus on prevention and health promotion as well as treatment. Those are important provisions.

The amendments in the name of the hon. Member for Oxford, West and Abingdon are unfounded, they

are not well drafted and they would not add clarity to the duties that we are placing on PCTs. The amendment in the name of the hon. Member for West Chelmsford would take us into similarly uncharted waters and create ambiguity that the NHS can do without.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

The Minister asked whether these were probing amendments. I may not have the necessary experience, but I did not think that it was a requirement to say at the outset whether an amendment was ''merely'' probing. I would hope that all amendments were probing. I sometimes wait to hear a Minister's response before I decide whether to press an amendment to a vote.

I do not accept the Minister's counter-arguments, perhaps because I have not understood them. That may be due to my deficiency in understanding or his deficiency in explaining. We will leave others to judge when reading Hansard.

The Minister said correctly that this is partly about rationing. The hon. Member for Leigh made that point too. My position is clear—there will always be rationing in a publicly funded cash-limited health service. The question is not whether there will be rationing. There are two key questions. First, how much rationing will there be? In other words, what services that are not available on the health service, or not available without a charge, do the health professional and the patient together think would be of net benefit to the patient?

Secondly, how explicit will that rationing be? There is, and has been, far too much rationing, and I have supported greater funds for the health service to reduce it. The Government's latest comprehensive spending review details the funding that they plan to put into the NHS. We argue that it is five or six years too late, but we accept that the level of extra funding is about right. I am at one with the Minister on the degree of rationing.

It is the failure to be explicit about rationing that concerns me. People should know what they will not be able to have, and they should not have the wool pulled over their eyes with the pretence that a treatment would not be beneficial, when it would be beneficial but simply cannot be afforded.

Citizens, voters and taxpayers should be empowered, so that when they know that something is not available because of a lack of resources, they can vote for politicians who are committed to the expansion of the necessary resources. Otherwise, not realising how much is unavailable to them, they may be duped into voting for tax-cutting, expenditure-cutting parties. The Government should find common cause with us on that, for their electoral well-being as well as ours. We take a generally similar view on the quantum of funding, whereas the Conservative party does not.

Unfortunately, the framing of the clause leads to fog rather than to clarity on rationing.

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

May I have clarification about tax-cutting parties? I am under the impression that the hon. Gentleman has just

introduced a raft of policies that will involve cutting taxes.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Let me be a little clearer: this is about the quantum of resources and about how those resources are raised. The hon. Gentleman makes a fair point: in any tax-and-spend package, some taxes will be raised and others will be reduced. Our policy is to cut unfair taxes and to raise fairer taxes, so he is quite right. We are keen to cut unfair taxes. Let us not talk about tax cutting or tax raising, because one can get into silly arguments. The question is whether—

Photo of Peter Atkinson Peter Atkinson Conservative, Hexham

Order. That was good advice. I do not want a debate on tax cutting.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Quite so. The question is whether parties are committed to the quantum of resources, and the increase in resources, going into the health service. We voted for the rise in national insurance that the Government are using to fund the increase, but the Conservatives voted against it. That implies that the Conservative party is not in support of the additional resources. I hope that the hon. Gentleman accepts that that argument can be made and that there is, therefore, a question of rationing. How does one provide a greater level of services when one does not put in the resources?

As I said, the key issue with the amendment is whether rationing is explicit. If citizens, patients, consumers, voters and taxpayers are to understand what services are not available, it would help them if there was clear information on the level of need and on what services are provided. The next group of amendments provides the other part of that equation. This amendment seeks to ensure that primary care trusts look at identified need and then make decisions on what can be met, taking reasonableness into account. That is why amendment No. 636 stands on its own, in addition to whatever words the Government want to put in to ensure that there is a test of reasonableness—the rationing test—before meeting those resources. Amendment No. 636 ensures that any rationing becomes explicit.

The Minister was right to say that this is about rationing, and the hon. Member for Leigh was right to question the Conservatives about how they can support the amendments without at least supporting a significant increase in funding to give some scope for meeting—[Interruption]. Is the hon. Gentleman seeking to intervene?

Photo of Andy Burnham Andy Burnham Labour, Leigh

I was wondering whether the shadow Chancellor of the Exchequer would approve of the Conservative Front Bench support for these amendments this morning.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

It is slightly easier to put that question as an intervention, because, given the acoustics, it is hard to hear what is being said from a sedentary position. The question needs to be answered, but perhaps not in this forum. The rationing issue is clear, and I want to state clearly that the amendment is predicated on the basis of achieving greater explicitness. The Minister said—he sometimes says this and sometimes does not—that I am a late convert in relation to the plurality of providers. I have challenged him and his colleague to find any

statement in which I am on the record as saying that that I am opposed in principle to the provision of NHS services by non-NHS providers. I have opposed an increase, at the expense of NHS provision, in privately commissioned services, private pay-as-you-go services or insurance-based services, especially those that are subsidised by NHS money, such as the system recently proposed by the Conservatives.

Moreover, I am opposed to private health care being delivered through NHS services when it is against the interests of NHS users, because to jump the queue is unfair. Should the Minister continue to make this allegation, I should be grateful if he could find anything I have said to suggest that I do not support the mixed-provider message.

My main difficulty with the Minister's rejection of amendment No. 635 is that he thinks that the meaning of the words in subsection (1)

''to the extent that it considers it reasonable to do so,''

in relation to the provision, or the securing of the provision, of primary dental services, is equivalent to the general duty on the Secretary of State as set out in section 51 of the National Health Service Act 1977. I think it is the same as in section 3 of the Act. I invited the Minister to repeat the reference, but he was unable to do so. There is a difference, because the wording in that section concerns doing what is necessary, and makes the qualification of ''reasonable'' only after saying that he must do what is necessary to secure what is a reasonable need.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health) 10:00 am, 19th June 2003

The hon. Gentleman has misunderstood what section 16(6)(a)(i) provides. If he looks at it carefully he will understand that the primary care trust must provide those services that it considers reasonable so to do. The use of ''necessary'' that he is harking on about does not change that one iota.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

It may be that we must look at what the Minister has said and, at a later stage or in another place, table an amendment that has the exact wording that applies to the provision of general medical services. The Minister implied that the effect was the same and that to use the words that apply to the rest of the health service would make this clause unnecessarily complex. That is a debate that must take place when the wording is before the Committee. I accept that it is incumbent on Opposition parties to put those words in an amendment so that the Minister can argue with them.

Furthermore, the Minister argued that, because the wording was broadly comparable, we should not go down that path. However, when I have not been convinced by what he says, I am always sceptical when he urges me not to go down the path, because that suggests that he is not clear of his own ground.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I would be clearer about where the hon. Gentleman was coming from had he at any time during the passage of the Bill tabled an amendment to section 3 of the 1977 Act to make his point, but he has not done that.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

It is questionable whether an amendment would be in order. I should be grateful if the Minister could advise me on how I might do that, other than through a new clause. I accept that in order to deal fully with his response to this amendment and to test it we would have to bring back an amendment with the same wording as section 51—if that is the section to which he refers.

I did not understand the Minister's argument about catchment and resident populations, and I am not sure that he was convinced that that was a relevant argument. I am not sure from his two comments on it—one in response to my intervention—which arrangement exists now. Could the Minister clarify whether dental services are currently arranged on a resident or a catchment population basis? I should be grateful for his advice. I should also like clarity on the position of someone who comes to work at Westminster, lives in Westminster and wants to access an NHS dentist in Westminster. Will that person receive dental services on the basis of residency or catchment?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I made it clear that it is currently done on a catchment basis through reinvestments to general dental practitioners through the Dental Practice Board. The effect of this amendment—in crude terms—would be to prevent primary care trusts providing services on that basis. Instead they could provide them only to people who lived in their areas. That would be a retrograde step.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I now understand what the Minister is saying: catchment applies, by definition, to those who register with a dentist, rather than to a local resident population. School catchments imply a residency qualification, and that is why I was confused.

However, amendment No. 636 does not talk about local residents' needs, but local needs. As the Minister will know from other areas of the health service, many areas have a duty to provide health services for tourists. Indeed, such areas get extra funding under the weighted capitation allocations to meet the needs of tourists and commuters. He will also know that that is the case for Westminster, among other places. That is an example of local needs, but clearly not local residents' needs. Because the word ''resident'' is not in amendment No. 636, I understand his point, but I still do not think that it applies. It might have been easier to have the debate on wording that the Government have accepted in other areas of the health service. With that in mind, I beg to ask leave to withdraw amendment No. 635.

Amendment, by leave, withdrawn.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I beg to move amendment No. 637, in

clause 157, page 74, line 29, at end insert—


(a) details of all NHS dental provision in the area;

(b) details of overall available provision in the area; and

(c) details of the complaints procedure.'.

Photo of Peter Atkinson Peter Atkinson Conservative, Hexham

With this it will be convenient to discuss amendment No. 638, in

clause 159, page 76, leave out lines 9 and 10 and insert—

'(2) A general dental services contract must require the contractor or contractors to provide, for his or their patients, information about treatment charges, access to dental records, alternative local provision and the complaints procedure, and other such information.'.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

Amendment No. 637 also relates to clause 157. New section 16CA(3) reads:

''Each Primary Care Trust and Local Health Board must publish information about such matters as may be prescribed in relation to the primary dental services for which it makes provision under this section.''

I will deal with amendment No. 638 presently, which is an amendment to clause 159.

Access to information about local dental services is clearly fundamental to enable consumers or patients to find appropriate dental care locally. As MPs, we know that access to information about local services is a high priority for people who come to see us who simply do not know where to find an NHS dentist. The Consumers Association found that to be the top priority for its members and consumers in a consumer health survey conducted in May 2001. An Office of Fair Trading consumers' survey found that 60 per cent. of those surveyed did not know where to find information about local dental services, which confirms the existing research on this issue.

In June 2001, the Consumers Association examined how NHS Direct provided information about NHS dental services and found that it was extremely patchy and generally poor. The Consumers Association told me that it has noted that there is no obligation on NHS Direct to provide information about private dental services. The Government may feel that it is not the job of the Government or the commissioning body to ensure that information is available about private dental services, and the Minister may want to comment on that.

There is clearly a problem with information, but without information about what is provided, we do not have the other half of what is required for an explicit system of rationing to ensure that people—patients, voters and taxpayers—know what they are voting for when they get it. Amendment No. 638 is important because there is a problem with the failure to provide consumers and patients with the necessary information.

The Office of Fair Trading report is relevant. It recommended that dentists should provide their patients and the population that they serve with clear information on indicative prices for common treatments, detailed treatment plans together with information on any other options and estimates of the likely costs, access to dental records and complaints procedure. Such information is fundamental to the delivery of a patient-centred service and to any notion of patient choice.

One would expect this to be sensible and to be observed by all dental practitioners, but the Office of Fair Trading report found that that was not the case, and that is extremely disappointing. There is a strong argument that dentists should inform consumers about the likely cost of NHS care and how to find an alternative dentist offering NHS treatment if they cease to offer it. Consumers tend not to look for a

different dentist, even if their usual dentist stops providing NHS care. I have had constituents whose dentists have stopped providing NHS care. They have been told that they can join Denplan or Dencare, but they have not been given the name of an alternative NHS dentist. That is not too much to ask.

These are genuine concerns, not only for us but also for the Consumers Association and the Office of Fair Trading. It is particularly important in an area such as dentistry where, historically, care has been provided by people who also have a private practice and, therefore, have a tremendous incentive to increase the market for that private care, particularly given that the rewards are so significantly better than their NHS remuneration and are always likely to be so. It is also important that this information is available where, in this particular area of health care, there is so much co-payment and co-charging. That is why dentistry is unique and why it creates a greater need for information so that consumers and patients may be absolutely clear, and to be made available not only by those who commission it, but also, in these cases, by those who provide it. I commend the amendments to the Committee.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I obviously have a great deal more sympathy for the hon. Member for Oxford, West and Abingdon on these amendments than I did with the other group of amendments that he moved. All of us, when talking to our constituents, have come across a generally recurring theme: the information about what NHS dentistry services are available and how the public might access them is often pretty poor and frequently difficult to understand. That is why the Government, in bringing forward new section 16CA(3), are very much in favour of greater consumer information and choice being made available. These are new duties on primary care trusts and local health boards to make this sort of information available to the public. I am sure that it was an omission on the hon. Gentleman's part not to say that he greatly welcomed the introduction of this new statutory provision.

The question is not whether we provide this information, because we should; the question is how we do it, and how we do it in the most effective way. We are thinking about dealing with this, as the clause makes clear, on the basis of regulations rather than through the Bill itself. We can argue that fairly and reasonably on several grounds. The requirements will inevitably change over time as providers' abilities to provide information improves. For example, in the future, it may be a requirement to make available certain statistical information that providers do not currently record. We should therefore look at alternative ways of ensuring that that information flow remains up to date. The danger of putting anything into primary legislation in the way in which the hon. Gentleman proposes is that it tends to get stuck in time.

I agree with the hon. Gentleman about the need for the sort of information that amendment No. 638 lists to be made available to members of the public. It may be helpful to him and the Committee if I make it clear

that our experience from over five years of piloting primary dental services is that this sort of information is best provided through national requirements, which local contracts must then contain.

Proposed new section 28O, which we shall come to later, will allow the Secretary of State to make regulations specifying mandatory contractual terms. The information required in the amendment will be covered by that type of provision.

We are also committed to learning from the field sites, several of which are concerned with improving the patient experience. The Modernisation Agency is setting up some 20 sites to test ideas that we want to incorporate into the dental service contract as it develops.

Amendment No. 638 seeks to replace new section 28L(2), which allows regulations to describe services

''by reference to the manner or circumstances in which they are provided.''

For example, the regulations could state that certain services could be provided on week days, perhaps between the crucial working hours of 9 am to 6 pm. Amendment No. 638 deals with completely different territory. However, I am sure that it is not intended to remove the flexibility that proposed new section 28L(2) will give with the exercise of powers conferred by proposed new section 28L(1). It is not a restricted provision; it attempts to ensure that there is a power to make regulations in cases where it would be helpful to patients and consumers.

I agree strongly with the hon. Gentleman's sentiments, and I know where he is coming from. This information should be made available. Regulations will ensure that that information is relevant and up to date. We can also consider mandatory contractual terms as a further platform for progressing such information exchange. I have only one argument with the hon. Gentleman, which is where we do it, not how we do it. For the reasons that I have given, it is better done through regulations and new contracts.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon 10:15 am, 19th June 2003

In the light of the Minister's positive response that this issue will be dealt with by regulations, and in some cases may go even further than that, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Photo of Jim Dowd Jim Dowd Labour, Lewisham West

Clause 157 largely enacts the provisions outlined in ''Options for Change'', and I want to examine some of the implications of the new commissioning regime. I was able to discuss the matter with the now Under-Secretary of State for Constitutional Affairs, my hon. Friend the Member for Tottenham (Mr. Lammy), when he appeared before the Select Committee on Health a few weeks ago as Under-Secretary of State for Health, a role which, sadly, from the Department of Health's point of view, he no longer holds. He was able to throw some light on how the system will operate, but I

should like the Minister to confirm a few points or let us have the Department's views on how it will operate.

The extensive discussion on PCTs and local health boards did not touch on how decisions will be made on what is reasonable with regard to the provision of private dental services. How much public consultation will there be? Will there be consultation with the broader public or will it be restricted to professional providers? Will an outline plan be published, on which consultation could be sought? Or will decisions on provision simply be taken and commissioned arrangements secured to support them?

I believe that the field test site programme is almost completely in place and that an implementation date for the new commissioning arrangements of April 2005 is still the aim. Will the Minister confirm that there are arrangements to allow that timetable to be met and that there is sufficient expertise available to people who are new to commissioning, not least the dentists themselves or those involved in the commissioning negotiation procedure? Would it not be better to have a simple default contract that could be negotiated rather than various PCTs having different contracts? I should be grateful to the Minister for an explanation of those issues.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon

I return to the issue that I flagged up earlier, which I hope the Minister will be able to address. How will the provision or commissioning of dental services by primary care trusts improve the services for certain vulnerable groups of people who are currently significantly underprovided for?

I do not have detailed briefing notes about the situation in the Prison Service, and I know that the Prison Service had a separate health care system from the NHS until recently when it was finally announced, after a long time, that there would be an effective merger. However, it has been generally acknowledged in various reports by the chief inspector of prisons that the provision of dental health care—and even access to emergency treatment, let alone preventive work—is appalling in prisons. There may be historical reasons for that: perhaps it was not felt unreasonable in the past that people in prison should suffer toothache. However, it is a miserable thing to have to suffer, and poor dental health has significant implications for infection, particularly systemic infections and infections of heart valves, and for the general health of the patient or person concerned.

There is now plenty of research that shows that the poor provision of dental health care in prisons creates major problems for people who have been in prison, and a significant financial burden on the NHS, which has to pick up the pieces. I should be grateful if the Minister would take the opportunity to assure me that there will be some thinking about that matter when primary care trusts take over responsibility for the provision and commissioning of NHS dentistry, and that either specific duties will be imposed on them with regard to prisons—there is very little lobbying of them by people in prisons—or there will be some other mechanism.

The second area that I am concerned about is people who are not in prison and are not criminals but who are otherwise in detention. In my constituency the Campsfield house immigration centre has a number of people detained, sometimes for very long periods even though that was not the intention. Some of them, not unsurprisingly, have dental health care needs, and I understand that the detention centre has only been able to avail itself of the services of one community dental practitioner once a fortnight because of the extent of rationing. I do not see how it is compatible with human rights for people to be left in that situation. I know this because people who have been in detention there have contacted me while in detention or after their release. How can it be compatible with basic decency for people to be left for weeks, shut off from the outside world, not having been convicted of an offence and unable to obtain access to the dental health care that they need? People in the outside world with relatively trivial complaints can simply go to the dental practitioner with whom they are registered or get access to some of the community dental services and personal dental services schemes that the Government have introduced.

This is something that I feel strongly about. I will not go into any more detail, but I seek an assurance from the Minister that he is aware of the problem and that it will be dealt with, not only through the Bill, but in general even before this measure reaches the statute book.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

As we have realised during discussions on this clause, we are talking about a significant revamping and overhauling of the provision of primary dental services. But there is one area that we have not really touched on, about which the BDA is particularly concerned, I think with some justification.

I should like to raise the issue of dental service staffing so that the Minister is aware of our thinking. As we shall discover as we progress through the amendments to this part, the Government envisage not simply overhauling the commissioning process but specifying an expansion in the duties and services provided. Such expansion, however, requires a sufficient number of properly trained dentists and dental nurses, hygienists and therapists. Will the Minister explain how he will plan for future staffing in the dental service to fulfil the Government's aims as set out in the clause?

Photo of Peter Atkinson Peter Atkinson Conservative, Hexham

Order. The hon. Gentleman is anticipating later clauses. Perhaps the Minister will bear that in mind when he responds.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

You are absolutely right, Mr. Atkinson, but it may help to flag up that concern now so that when we reach that stage of the Bill, the Minister will be aware of the issue and able to answer in detail.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I can assure the hon. Gentleman that I have come fully briefed for this debate; he need not worry about that.

My hon. Friend the Member for Lewisham (Jim Dowd) asked three important questions, and I shall try

to deal with each in turn. First, he asked about preparations for the new general dental service contract. As he knows, some 20 sites with approximately 100 dental practices will be involved in testing the contract. They are preparing to start on 1 October. I am assured that all arrangements are proceeding satisfactorily, and our intention is to begin to test those new arrangements on that date. The Government have made it clear that they want those provisions and the new contract to start in April 2005, and that remains our strong intention. It is the Department's job to ensure that that timetable is observed.

Secondly, my hon. Friend asked about the default contract. Clause 160 provides for that, and it is not optional; provision must be made for a default contract in the interim period. We shall activate that provision, so dentists need not worry in that regard. Thirdly, my hon. Friend raised the important issue of the PCTs' new commissioning responsibilities. He asked whether I thought it appropriate for PCTs or local health boards simply to make decisions and then publish their strategies. That would not be appropriate; it is the responsibility of PCTs to consult widely on their new commissioning responsibilities and to develop their local dental strategies in an open and transparent way.

For many years, the NHS has been a secret society wherein plans are made and announced, and people have to take them or leave them. That is absolutely not how the new NHS will operate. This is an opportunity for local PCTs to consult widely on the development of their services, particularly dental services. Section 11 of the Health and Social Care Act 2001 requires proper public consultation on any significant change to service delivery, and that will apply as much to dental services as to other parts of the NHS. Those are all significant gains for transparency and openness, and I hope that my hon. Friend is reassured.

I apologise to the hon. Member for Oxford, West and Abingdon for not referring to prisons earlier. The new commissioning responsibilities for PCTs will apply to prisons in their area, so they will have a responsibility to make reasonable provision in that regard. I am not aware of the particular problems at Campsfield detention centre, but I shall make inquiries and write to the hon. Gentleman if he has concerns.

Photo of Evan Harris Evan Harris Liberal Democrat, Oxford West and Abingdon 10:30 am, 19th June 2003

I do not want to retread the ground of amendment No. 635, but does the Minister think that the current provision for prisons is reasonable? If it is not, could PCTs be criticised for continuing with the current provision rather than increasing it? I am talking in general terms. The problem lies with the use of the word ''reasonable''. PCTs may consider it reasonable not to offer much of a service to people who have fallen foul of the law. That is why prison health care is so appalling, as is commonly recognised. I hope that the Minister will state his view of the current state of dental health care in prisons.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

It is for PCTs to make those determinations in their own area. I could not say whether dental provision in every prison and detention

centre is sufficient, and I would not want to volunteer an opinion about that. It is not in my capacity to do so. However, it is important that PCTs look carefully at their new responsibilities and plan accordingly. I do not doubt that there could be an improvement in dental provision in many parts of the Prison Service, and I look forward to that happening.

The hon. Member for West Chelmsford also raised some important issues. If we want to expand and improve NHS dentistry, we must ensure that there are dentists, hygienists and therapists to work in the NHS and support this policy, which we have outlined on previous occasions. He will be aware, as the BDA is, that we are currently reviewing the work force requirements for dentists and other health care professionals. We want to ensure that we have proper, strategic long-term planning.

The hon. Gentleman will be aware that we have already provided for an additional 150 training places for dental therapists to be established next year. That is the first instalment of the long-term approach that must be taken by the Government, the NHS and the higher and further education providers to make sure that we have an adequately skilled and sufficiently large group of workers to ensure that NHS dentistry can continue to play the role that we want it to play.

Photo of Simon Burns Simon Burns Shadow Spokesperson (Health)

The Minister will be aware that the work force review to which he referred was commissioned by the Department of Health in 2001. When does he anticipate that its results will be published?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I hope that we can do that soon. It depends on the work that is done and the progress that has been made. It is a very important piece of work. As the hon. Gentleman will know from his time in the NHS, work force planning has not been one of our greatest strengths. It is a complicated field, and we have never performed very well in the past, so we are now trying to plan effectively. I am sure that the hon. Gentleman is one of those who would counsel us to ensure that we get it right this time rather than rushing something out. That is how we used to do it, and it is not how we want to do things in future.

Question put and agreed to.

Clause 157 ordered to stand part of the Bill.