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20 Dec 2000 : Column 92WH

NHS Dentistry

Mr. John Maxton (in the Chair) : Before Mr. Kidney rises, it may be for the convenience of those hon. Members who were not here earlier if I inform them that, as I am not one of the designated Deputy Speakers, I should be referred to as Mr. Maxton, not as Mr. Deputy Speaker.

11 am

Mr. David Kidney (Stafford): It is a great pleasure to open this important debate. It is timely for several reasons. First, it is a welcome opportunity for us to debate the Government's strategic plan, the White Paper entitled, "Modernising NHS Dentistry: Implementing the NHS Plan", which was published in September. Secondly, this week saw the publication of the report of the Review Body on Doctors' and Dentists' Remuneration and the Government's announcement of increases in fees and salaries for dentists from next April. Thirdly, the university of York recently published its study review on fluoride in drinking water, a matter that is of some interest to the residents of Stafford. I hope that the Chamber agrees that we have plenty to discuss.

My reason for asking for the debate is the recent decline in access to NHS dentistry in Stafford and in other parts of the country, a matter that is frequently raised by hon. Members at Question Time and in correspondence with Ministers. The Government's strategic plan charts that decline back to a change in the general dental services contract in 1990 and its effect on the attitude of dentists to NHS dental services, as opposed to their attitude to private services. In Stafford, dentists have voted with their feet by closing their NHS patient lists and refusing to take new NHS patients. The result has been that people have had difficulty finding an NHS dentist.

Mr. Philip Hammond (Runnymede and Weybridge): Looking back on the history of dentistry, I agree with much of what the hon. Gentleman says, but is it not the case that the new contract that was introduced in 1990 produced an increase in the amount of NHS work? It was in 1992, when the fees were cut, that we started to see a decrease in the amount of NHS work.

Mr. Kidney : Ironically, the strategic plan charts the rise in the number of dentists since 1990. It shows that there are more dentists today than there were in 1990, but that the proportion of NHS work that they undertake has decreased. I cannot agree with or contradict the hon. Gentleman's suggestion that the decline started in 1992. I observe simply that the Government's strategic plan points to the change in the contracts in 1990 as the start of the problem.

The phenomenon affected Stafford for the whole of the 1990s. It is a problem because it affects the level of oral health that the public can achieve. People such as I want to go to the dentist regularly, as part of a whole-care approach to keeping ourselves healthy. We like to have our oral health checked, to receive the dentist's advice and to benefit from the complementary contribution that the dentist can make to our efforts to ensure our general health. We do not want NHS dentists to deal only with emergencies, although emergency treatment is an important aspect of dental treatment.

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Since 1997, the Government have made efforts to improve access to NHS dentistry. A welcome and early addition to NHS dentistry funding was the investing in dentistry initiative, which started in 1997. Money is made available each year to help health authorities to improve the number and quality of NHS dentistry practices.

I acknowledge the contribution of South Staffordshire health authority in using that initiative to improve access to NHS dentistry. The authority prepared four different bids for money from that initiative, but only one of the bids was successful. On the other occasions there were difficulties with identifying suitable premises, or a suitable person to undertake NHS dentistry under the scheme. In the end, one scheme was agreed and one new NHS dental practice opened at Castlefields in Stafford, to which residents came in a great rush to register. To add to Stafford's woes, as soon as the period of restriction to allow concentration on NHS dentistry ended, that dentist announced that he was closing his NHS list for new patients--an event that was demoralising for people in Stafford.

The new plan is welcome and necessary and approaches the issues of oral health and equality in health treatment comprehensively, promising to act to end the unfairness that exists. The first of the important reforms is to make NHS Direct call centres the gateway to NHS dentistry. From anywhere in the country, people will be able to ring NHS Direct, ask where the nearest NHS dentist is and be directed there. That is a good addition to the NHS's overall services.

From next April, the country can have confidence in that scheme, but, already in Stafford, people can ring NHS Direct to get that information. It is pleasing to be able to tell the Chamber that there is an NHS Direct call centre in Stafford, based at Stafford hospital. It opened in October, created more than 100 new local jobs and serves more than 3 million residents in the west midlands.

That is all wonderful news but, on its own, it is not good enough. The health authority has a duty to advise callers where their nearest NHS dentist is and, at present, callers in Stafford will be told that the nearest dentist is in Rugely or Cannock, both of which are some 10 miles from Stafford.

There must be further reforms. The next welcome reform that is mentioned in the strategic plan is the introduction of dental access centres, at which people can receive treatment when they need it. A dental access surgery opened in Stafford in November--again, it is a great benefit to Stafford. People who cannot register with an NHS dentist can go there and receive dental treatment. That is deeply reassuring for my constituents but, without other improvements, it is not good enough.

Recently, after I had already requested this debate and learned that I had been given it, I received a letter--there is no question that the letter was the reason why I asked for the debate. Mrs. Hales, my constituent, was inquisitive about the new dental access centre and

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visited it. She found that treatment was available on the NHS for what she described as toothache and discomfort. She writes:

Mr. Hammond : To complete the picture, will the hon. Gentleman tell us how long Mrs. Hales and other good folk of Stafford must wait for an appointment at the access centre?

Mr. Kidney : Yes. When I said that Mrs. Hales was inquisitive and visited the centre, I meant that she could do that on the day that she chose, without having to wait in a queue. In fairness to the hon. Gentleman, I should make it clear that the centre opened only a month ago. It is a new and welcome facility in Stafford.

Therefore, we have NHS Direct and the dental access centres. What else is needed? As the British Dental Association points out, pay and conditions in general dental services are important factors. The Government's strategic plan recognises that and to some extent deals with it. More money has been allocated for NHS dentists through commitment payments. More money has been given to surgeries and to improve the NHS dental service generally. There is more emphasis on professional training and development. As I said earlier, we have had the news of next year's settlement for fees and salaries: an average increase of 3.9 per cent., with no staging, above inflation. That is all good news. The British Dental Association says, not unexpectedly, that that settlement will not be enough on its own, but interestingly the report of the Review Body on Doctors' and Dentists' Remuneration contains useful recommendations about the proposed commitment payments, to which I hope the Government will give serious attention.

The debate between the British Dental Association and the Government will continue. The Government have the right ideas for encouraging more dentists to devote more time to NHS dentistry. I hope that the Minister will comment on the anticipated improvements in access to NHS dentistry in places such as Stafford and on their likely time scale.

There are many other good elements of the strategic plan on which I do not intend to concentrate. However, I welcome those proposals, which give greater flexibility for health authorities and for delivering NHS dentistry. I also welcome the greater integration of community health dentistry with primary care providers. The discussion about better access to urgent out-of-hours treatment--there is a gap in the system in places such as Stafford--is helpful.

The fluoride debate rages hotly in the town of Stafford, where, generally speaking, the water does not contain fluoride. Most health professionals believe that

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it should, while a determined group of residents believe that it should not. I am somewhere between those positions. However, I have always put my cards on the table. My general view is the same as that of the Government. I believe that adding fluoride to drinking water at the optimum level, which most people accept is one part per million, improves dental health without harmful side effects.

Because the debate rages so hotly in Stafford and so many people refuse to accept that as a reasonable view, I was pleased when the Government announced the York review, which I hoped would produce authoritative conclusions that everybody accepted. Sadly, it did not. I was surprised that it found that the benefits were not as great as I had thought and that the incidence of the mottling of teeth, fluorosis, was higher than I had thought. Most significantly, the review team drew attention to the poor quality of some of the research. I quote from its conclusions:

As a result of reading those conclusions, I asked a parliamentary question about the Government's response. In an answer that I received at the beginning of the week from the Minister of State, Department of Health, my hon. Friend Member for Southampton, Itchen (Mr. Denham), I was told that the Government recognised that the report identified the need for more good-quality research. The Government have asked the Medical Research Council to advise on whether further research is required. I am obviously not the scientist advising the Government, but I would say that further research was required.

The Government tell me in their answer that they are consulting the water industry. Will the Under-Secretary of State confirm that no legislative action is expected for some time while those deliberations go on and while any research that is recommended by the Medical Research Council is carried out?

My concern is for oral health, especially among children. The Government have a good general health programme for improving health education, promoting healthy living and healthy diet, and reducing health inequalities. The assurance on fluoride that I seek from the Under-Secretary of State is that fluoridation is not seen as the one big idea to solve all the problems of oral health. I expect her to be able to give that assurance easily, bearing in mind the content of the fifth chapter of the strategic plan.

I want the Government to say that they are committed to education, advice and the reduction of inequalities in oral health. I want sufficient numbers of NHS dentists throughout the country to enable the profession and the public to play a full part in that agenda. The Government's plan contains all the right elements to achieve my aims and I look forward to hearing the Under-Secretary of State express her determination to put all the elements of the plan into practice.

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11.15 am

Ms Julia Drown (South Swindon): I am pleased to take part in the debate. Before the general election in 1997, national health service dentistry was one of the biggest issues raised with me on the streets and it has continued to be since. One reason why was that the situation in my constituency was especially bad. In 1997 under the Conservatives, no dentist in Swindon would take new NHS adults. Telephone lines received thousands of calls from people who wanted to register with an NHS dentist, but no one in Swindon would accept them.

Mr. Hammond : The hon. Lady emphasised that, in 1997 under the Conservative Government, no dentist in Swindon accepted NHS patients. Has not the hon. Member for Stafford (Mr. Kidney) told us that, in 2000, under this Government, no dentist in Stafford will take NHS patients?

Ms Drown : The hon. Gentleman is referring to the continuing problems in NHS dentistry, but it is clear that, under this Government, there has been huge enthusiasm and a huge initiative to restore NHS dentistry. There was no such plan under the Conservatives. Nothing took place to put the situation right. Before he intervened, I was about to say that it was good that I received an encouraging response as soon as I was elected and started to push the issue with Ministers.

I have been pleased that we have seen a huge change in NHS dentistry under this Government. That has happened through the Government investment in dentistry initiatives, the work of Wiltshire health authority and some individual dentists who have made proposals. There are four new practices, so we now have up to 19,000 places for NHS patients. I am delighted with the sea change in NHS dentistry in Swindon. Ministers do not receive enough thanks, so I want to thank them for their support for the people in Swindon. It is much appreciated. I regularly see constituents who are delighted that we now have NHS dentistry again in Swindon.

We have not only NHS dentists, but an emergency clinic. Before the hon. Member for Runnymede and Weybridge (Mr. Hammond) asks how long people have to wait to be treated there, I shall tell him that they do not have to wait. It has been open for several months. If people are in pain and in urgent need of help with their teeth, they get it. The clinic then encourages them to register with an NHS practice, or a private practice if they so wish, so that their teeth receive regular care and attention.

It is important to experiment with different ways of providing NHS dentistry because people fear dentists much more than they fear doctors, although I do not know why. Something in our psychology prevents a section of the population from registering with a dentist, although they would automatically register with a general practitioner. Those people keep taking the tablets and trying to put the pain out of their mind until things get desperate. Several of my friends avoid dentists until they have no alternative but to visit them. For that reason, experiments such as the emergency clinic are worth while and well worth spending funds on.

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There has been a sea change in attitude, which has much to do with the Govt's constructive relationship with the British Dental Association and others. Shortly after I was elected, I spoke to a number of organisations and I was shocked by what I heard about the appalling relationship between the previous Government and dentists. I had never come across such a bad relationship between a professional organisation and the Government and I wondered whether it was reparable. I am pleased that some good work this summer produced the Government's new plan to modernise dentistry. There will always be complaints from individual dentists and it is the job of professional organisations to push the agenda forward, but the Government are developing the constructive relationship with the profession that is essential if dentist services are to be further developed.

Dentistry is of great concern to my constituents and I have done much work on the matter. I was surprised at the reaction of the British Dental Association to some of the Government initiatives, but we should remember where people are coming from. Only a couple of years ago, Members of Parliament were bombarded with BDA briefings that prompted fears that patients would be deregistered, which would be disastrous for them and for the dental profession. It was only when I raised the matter with the Minister that I learned that the problem could easily be solved by the dentists themselves. They had only to agree to re-register their patients and to encourage them to come back for more treatment and there would be no problem. Our constituents would stay on their dentists' books and the dentists would be funded for seeing their patients. We should always check what is really happening when we hear scare stories.

Dentistry fits well into the Government's public health agenda. Inequalities in people's dental health are only too visible. I have been in politics for some time. When I was a county councillor, I represented a ward with different socio-economic groups. The children in the relatively well-off part of the ward had bright, sparkling teeth and no problems, unlike the children in the working-class estate across the road. It shocked me that just crossing a road made such a huge difference because the two communities were served by the same health authority and dentists. The Government's agenda to tackle those inequalities is worth while.

I congratulate the Government on their agenda to modernise NHS dentistry and I urge them to continue to improve it. We must be able to assure constituents that they are receiving quality care. There have been worries about general practitioners, especially those who work in single practices. Some dentists also work in single practices, so there are fewer possible ways in which to pick up problems. However, whether a practice is single-dentist or multi-dentist, constituents need to know that quality checks are carried out to ensure a high-quality service. There have been some scandalous press reports about certain practices and that is a cause for concern among constituents. Therefore, I hope that the Minister will comment on how action taken through the modernising NHS dentistry initiative will ensure the quality of NHS dentistry that we deserve.

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The bureaucracy behind NHS dentistry has built up over the years. Can steps be taken to simplify paperwork and payments to dentists, so that more practice money can be spent on quality checks and on looking after people's teeth, and less on paperwork and associated checks?

The question of fluoride always comes up in such debates. We have spent years and years looking at that issue, but most of the evidence that I have seen supports taking action on water fluoridation. Not everyone will agree, but the British Dental Association has made clear its support for adjustment of the water supply in certain areas, so that at least 25 per cent. of the population can receive fluoridated water.

Mr. Hammond : I have listened to the hon. Lady's comments on fluoridation. She has acknowledged that certain people have strong objections to what is, in essence, compulsory medication. Does she agree that there are other ways to deliver fluoride to the population, particularly children? Will she join me in urging the Minister fully to investigate such alternative methods of ensuring that vulnerable people get adequate doses of fluoride, without resorting to compulsory water fluoridation?

Ms Drown : I accept that, in theory, there are other ways to give appropriate doses of fluoride. However, I am unsure whether they would in practice deliver fluoride to everyone, and I particularly doubt whether they would tackle the inequality agenda. It is clear that that issue must be looked at, but my wish is that we get on with matters. We could debate for ever which route to pursue. Meanwhile, children do not get fluoride. We will never reach agreement, but some action needs to be taken.

I have two final, brief points, the first of which concerns the funding, income and relative wealth of dentists. A question that always arises in such debates is whether dentists are poor people, working hard for no reward, or whether they are wealthy, have an easy life and therefore need no further support. I admit that I find it difficult to make my way through that maze. It is clear that some dentists who perform 100 per cent. or 95 per cent. of their work for the NHS have adequate incomes and provide a marvellous service. That is why it is sometimes said that it is housing costs in certain parts of the country that cause an NHS dentist to become a dentist in poverty. However, that is not the explanation. Some who do 95 per cent. of their work for the NHS and do the work to a good standard survive perfectly well on an adequate income with a good life style, but others say that it is impossible to support their families if they do NHS dentistry. I would welcome the Minister's comments on how to find our way through that maze, so that we can establish the reasonable level at which to support NHS dentists.

Although it seems to be kept hush-hush, most people in the dental sector agree that twice-yearly checks--on which the Government spend a lot of money--do not represent the best use of NHS resources. People do not like to say that, but most believe it to be so. We should be more open and face up to the fact that, if there is a more effective way of spending NHS resources to improve everybody's oral health, we must consider making the necessary changes.

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I want to see throughout the country what we already have in Swindon: good NHS dentistry. We need more, but I am delighted with what we already have. I thank the Minister and the Government for delivering that to Swindon. It has made a big difference. I look forward to even greater improvements in NHS dentistry.

11.30 am

Dr. Peter Brand (Isle of Wight): I am glad that we shall have adequate time to concentrate on the Minister's reply.

I congratulate the hon. Member for Stafford (Mr. Kidney) on initiating the debate. It is just over 12 months since we last discussed NHS dentistry in this Chamber, and this is a timely opportunity to revisit the subject--especially as we now have the Government's reply to last year's debate in the form of their document, "Modernising NHS Dentistry: Implementing the NHS Plan".

Mr. Hammond : Am I mistaken, or was that document promised us in April 1998 for the autumn of that year, which somewhat predates the debate that took place 12 months ago?

Dr. Brand : I am not one to pick holes in promises--they cannot always be delivered to the desired time scale. One of the points that I wish to make this morning is that the Government's document is not a very substantive answer to the questions that we raised last year.

I find the plan a little complacent. It refers to increasing improvements in the oral health of the population, yet much of the evidence that it quotes is out of date. Measuring effectiveness in dental intervention through the number of remaining teeth in people over 65 or the amount of fillings and extractions in five-year-olds has a long tale to it. The evidence from my constituency, where we have undertaken regular surveys of schoolchildren, suggests that dental health is still deteriorating, not improving. From a purely public health point of view, it is important not to become complacent about the level of dentistry and dental health.

Two big issues are a cause for concern--outcomes, as in the dental health of the population, and the way in which people access NHS dentistry. In last year's debate, I asked the Minister to be more clear and honest about the direction that the Government are taking in delivering dental care to the population. They can do that in two ways--first, the traditional pattern of delivering care through the general dental practitioner service and, secondly, delivering care through a directly employed Government-organised dental service. The Government's paper refers to both of those methods, but does not emphasise which they are most trying to encourage. If we believe in the public health function of NHS dentistry, the access centres--the phone-and-go centres--that concentrate on dental pain and disasters are not the best way to serve the population.

The hon. Member for South Swindon (Ms Drown) said that there is a fear of dentists. There is not so much a fear of dentists--dentists are just as nice as doctors--as a fear of what they do. If dentists only drill holes and pull teeth out, that will not encourage the population to

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see them as relevant to their general health. As the hon. Lady correctly said, dentists solve acute problems that one sits on for as long as possible, hoping that they will go away. The result is traumatic intervention that literally leaves one spitting blood, and that is not the best way to encourage adults, let alone children or families, to consider dental health. As far as the NHS is concerned, contracts with general dental practitioners have not reflected that fear.

Dentistry has evolved away from the image of the clever manipulator who uses tools to pull teeth, to thinking people who look not only at the mouth but at the whole person, to see how they can help to maintain dental health in a healthy life style. As in medicine, it is no longer the prima donna big boss who does the manipulations, but a whole team that get involved: receptionists advise on access, toothbrushes and gadgets; dental hygienists have developed an enormous range of skills; dental nurse practitioners are invaluable people; of course, there are also dentists themselves. Encouraging access to that service is important, and the Government should be clear about the direction that they want to take. We have two-track access into dentistry, which means the Government can almost manipulate which track will come out on top. If the contract with the general dental practitioner does not allow the dental team to provide the service that they believe is right for national health service patients, they will not accept the deal that the Government offer.

Mr. Kidney : I am not quite clear whether the hon. Gentleman is posing an unfair choice for the Government by suggesting that they must choose one track or the other. Is it not true that both are relevant? Some people want to see their dentist regularly to receive the kind of advice that he mentioned, and I welcome that warmly. Other people do not want to see the dentist and do not want to be registered, but they would like the reassurance that treatment is available when they might need it.

Dr. Brand : That is a valid point. Of course that treatment should be available, but it should be available, even for those people who do not want to commit themselves, through a general dental practitioner. When people visit the dentist in emergency, they are most receptive to the message about preventative work. If they have a positive experience during an emergency--if that is possible--one may be able to persuade them to return. If emergency treatment is delivered through a separate agency, there is no support between preventive, maintenance and emergency work. That is why I find the direction that we are taking problematic.

I was talking about dentists moving away from NHS services. I do not think that that is primarily a matter of income. In some cases it is, but dentists can, by restricting what they do, by dealing in large numbers and by not concentrating on some of the time-consuming preventive and educational activity that a good dentist engages in, make an extremely good living in the national health service. Many dentists earn a great deal of money providing adequate service and good, acute interventionist services, but are failing the overall dental health of the population that they serve, because they have not engaged with the broader remit that should belong to a good dentist.

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The people who are moving away are those who want to engage in a more holistic approach--if I can use that term about dentistry--and who feel that they cannot do so under the current NHS regulations. The real challenge for the Government is not to entice them back with money provided as a sort of loyalty bonus. That is artificial and would probably be restricted to a small number of dentists--most likely those who are stuck grinding away at teeth anyway, and who are unlikely to change. We need to attract the modern-thinking, up-and-coming practitioners, and provide a deal for them that makes NHS dentistry not only financially rewarding but exciting and professionally fulfilling.

The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart ): As we have the time, I should be interested, given that the hon. Gentleman feels that our strategy lacks ambition and is a two-tier plan, if he would describe his vision of perfect national health service dentistry.

Dr. Brand : I am grateful for the opportunity to do that. The national health service should learn from good practice, whether abroad, in the private sector or in areas of the national health service. I do not doubt that a great deal of good practice is found in this country, but I am afraid that, with respect to primary care, preventive work and the full use of the dental team, most of it is in the private sector. Interestingly enough, however, many of the dentists doing that work, because they are ambitious, skilled and concerned people, also do a great deal of work within the secondary care sector for the national health service.

Ms Drown : Can the hon. Gentleman clarify whether what he is getting at, in his vision of holistic dentistry and wider use of the dental team, is relaxing the professional boundaries between dental auxiliaries, dental nurses and dentists, and the idea that assessing what each group can do might result in better care for patients and better use of NHS resources?

Dr. Brand : That is a valid point. Of course all members of the team should be recognised for their expertise. They should be enabled to fit in and should be adequately rewarded as team members. However, my real concern is that, in their discussions with the British Dental Association, the Government are too concerned with the manipulations that are carried out, instead of with the outcomes that are achieved. We can learn from some of the private sector insurers, who tend to think in terms of a package of care. They make an assessment and a payment is made. Irrespective of the amount of manipulation or the procedures that are carried out, a service is provided that suits the circumstances and the patient.

It might be possible for the national health service to learn from the way that that funding can be structured. The present system, which is bob-a-job stuff, is open to manipulation and abuse. There is evidence that many more fillings are done than are necessary. It encourages sloppy thinking and over-intervention, rather than prevention, which is more important.

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Other than looking at the contract, and encouraging good-quality general dentistry within the NHS, the Government should consider access to NHS dentists. I am a great fan of NHS Direct, but it cannot deal with people's dental problems. It can only refer people to dentists if they exist. A national helpline is not very helpful if it refers people to a clinic some 20 miles away, so that a visit involves an expensive two-hour bus journey. Local solutions are much better and we should have some imaginative schemes during the interim period.

I am a great optimist, and I hope that the Government will get this matter sorted in the fullness of time. I hope that people will be able to use the dentists who are available. Some help with bus fares might be useful. My elderly constituents or those on low incomes would find it extremely difficult to get to a dentist now if it cost £8 or £10 in bus fares. Again, that is a great disincentive to a service that we want to encourage people to use.

As the hon. Member for South Swindon pointed out, dentistry, or the state of dentition, is probably one of the best measures of social disparity. If the social exclusion unit, which should have been called the social inclusion unit, took its job seriously, it could use it to measure almost directly how well off or connected a population is with the general welfare of the rest of the community. It is extremely sad to see four or five-year-olds with little black stumps and their parents not even concerned about the state of their teeth. They believe that that is how they should be, as they have always been like that.

It was not like that 15 years ago; we have gone downhill. That is not due only to non-access to dentistry, it is due also to diet. Sadly, the only way that people now clean their teeth is to soak them in Coca-Cola, which dissolves their teeth at the same time. We must recognise that, because special efforts are needed to find a dentist, to get there and to pay the bus fare, people tend not to visit dentists. They see their general practitioner who, on the whole, is pretty inadequate at dealing with oral problems.

That brings me to a further point, which is access to check-ups. The point is well made. Six-monthly check-ups for most people are irrelevant. There are some people who need three-monthly check-ups with a hygienist to ensure that they do not lose more of their teeth as they have gum disease. It is then part of a course of treatment as well as checking up. We correctly spend millions of pounds on taking cervical smears to avoid cervical cancers. Concomitantly, those tests pick up genitourinary problems; it is a useful way of finding chlamydia and other such diseases. However, we ignore the opportunities presented by having regular, free-access dental check-ups. More people die of oral cancers each year than now die of cancer of the cervix. We have a priority problem. We are abandoning the proper identification of some curable diseases because of a distrust--I do not know what motivates it--of the dental profession and of how it functions in the high street.

I usually think of the Government as wonderful people, but they seem still to have a dogmatic fear of what private contractors might get up to with

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Government money. At some stage, they will have to overcome that distrust. The Minister may be able to do just that.

Ms Stuart : I know that dentists are wonderful people, but before the hon. Gentleman goes too far in making comparisons between cervical cancer and oral cancer, he may like to tell the House a little more about the improvements in treatment and prevention that might result from early diagnosis. He suggests that screening for oral cancer could be as successful as screening for cervical cancer. Such a direct comparison may not stand up to analysis.

Dr. Brand : The Minister is testing my medical skills beyond what should be expected of the average general practitioner. However, she has the resources to answer that relevant question. We all know that the outcome for cancers that are diagnosed early are better than the outcome for cancers that have already presented symptoms. As a general rule, my argument stands. It would be extremely helpful if the Minister were to ask her officials and scientists to do some work on it. It would allow some evidence-based government, of which we are always in favour.

The hon. Member for Stafford made a good case for re-evaluating fluoridation. It is not clear-cut. The arguments for and against are both selective. The anti-fluoride lobby comes up with the most extraordinary bits of research--for instance, that wells in India are poisoned with natural fluoride. The pro-fluoride lobby tends draw on historical patterns of what has happened in two adjoining districts. However, those arguments may not be relevant to the debate.

I have no doubt that some dental decay, especially that seen in children in non-fluoridised areas, is the result of people not having access to fluoride supplements, access that is available to those who are better off, or who are at least better motivated. Those who do not own a toothbrush are unlikely to use fluoride toothpaste. We should consider other ways of delivering fluoride supplements--perhaps with school milk. It would be strange if the Government kept ducking the issue. There should be equity of access to such treatments if they are known to be helpful. At the moment, there is no equity.

Mr. Kidney : I gave my own opinion to show that I am not sitting on the fence, but is there a Liberal Democrat party policy on fluoride in drinking water? If not, does the hon. Gentleman have a personal opinion on the matter?

Dr. Brand : The party policy as expressed through party conferences is probably against standard fluoridisation. The health team in Parliament is in favour of it, on good public health grounds. As with embryology, abortion and hunting--which will be debated this afternoon--I suspect that we shall have a free vote with an indicative Whip. We do not go in for rigid regimentation; we believe that Members of Parliament ought to have their own view, and I hope that it is an informed view. The Government's job is to ensure that information is available in an accessible and balanced form.

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I think that I have filled up enough time and raised a number of issues to which I hope that the Minister can respond. Her Department's document, though helpful, is not a sufficiently strong pointer towards the Government's thinking. We must know whether they are going for direct services, such as the directly employed fire fighting and emergency services, or whether the direct access centres will be expanded to take a more holistic approach. That would be an alternative way of achieving what I think that we all want to see. There could be meaningful discussions with dentists, although not necessarily directly concerned with conditions of service and remuneration. The BDA is perhaps most concerned with those in the Committees with which the Minister deals. There is broader thinking to be done.

11.56 am

Mr. Philip Hammond (Runnymede and Weybridge): I am delighted to be in this Chamber for the first time since its reorganisation. I prefer it as it is now, because I like to see the whites of the Minister's eyes when I am speaking to her. I always found the former arrangement somewhat confusing because of the culture at Westminster. However, if the hon. Member for Isle of Wight (Dr. Brand) really thinks that the Government are wonderful people most of the time, he might like to sit in the corner next time, rather than so close to me.

Dr. Brand : They are like dentists, who are wonderful people, although I do not always approve of what they do to me. Some Ministers are also delightful, but I do not necessarily approve of everything that they do.

Mr. Hammond : I am sure that we all find the Minister personally delightful. Whether we approve of what she does may be another question. I am grateful to the hon. Member for Isle of Wight for saving us from the embarrassment of an early end to the debate by helpfully padding out its middle area.

I congratulate the hon. Member for Stafford (Mr. Kidney) on giving a balanced analysis of the problems facing NHS dentistry. In a measured way, he suggested some issues that the Minister might want to consider in taking the debate forward.

The hon. Member for South Swindon (Ms Drown) said that there were no initiatives in NHS dentistry under the previous Conservative Administration. I can understand the temptation to try to make this a party political issue, but she is not quite correct in saying that. For better or worse, there were initiatives under the previous Administration. In 1990, the new general dental services contract was introduced. Many of the issues that we are discussing and that the Government will want to address in future flow from that contract.

Ms Stuart : Will the hon. Gentleman acknowledge that insufficient piloting of the contracts resulted in a considerable deficit, which was part of the problem that we needed to address when we took office in 1997? There were initiatives, but does the hon. Gentleman think, with hindsight, that they were good initiatives?

Mr. Hammond : I have already said that the problem of declining NHS participation by dentists stems from

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the fee cut in 1992, rather than the contract itself. If I may, I shall say something later about what I think is the appropriate balance between capitation-based payments and fee-for-service-based payments, and how we might expect NHS dentistry to develop in future.

The hon. Member for South Swindon also talked about the Government's commitment to restoring NHS dentistry, and explained the baseline for that assessment. Whatever that commitment might be, it is not, however, to restore the general dental service model. In constant terms, spending on general dental services will be lower this year than in 1992-93. Of course, I acknowledge that there are additional expenditure items outside general dental services, and I shall return in a moment to the balance between GDS and other methods of providing NHS dentistry.

Ms Drown : I should clarify that I was saying that the Tories did nothing to deliver NHS dentistry in Swindon. Does the hon. Gentleman agree that the reality for Swindon is that there is now a Government who support the reintroduction of general dental services to the NHS? Project after project in Swindon has been supported, and I do not expect that such support will be limited. I hope that he agrees that it is in such circumstances that the Government want to see a return to NHS dentistry.

Mr. Hammond : I am grateful to the hon. Lady for making that point. I am no expert on what is happening in Swindon, and I am not familiar with the balance there between GDS and other forms of delivering NHS dentistry. The hon. Member for Isle of Wight touched on that point, and I shall ask the Minister about it in a moment.

I hope that this is not simply a sterile, party political issue. There are different ways in which to deliver NHS dental services, and to a significant extent, the jury is still out on some of the newer forms of providing access. The hon. Member for Isle of Wight noted that the Government's newer initiatives appear to focus on remedial, rather than preventive, work. As the hon. Member for Stafford suggested, they perhaps lack the facility for patient follow-up that was offered by traditional GDS methods. Here, there is a wider issue that relates to the way in which NHS services are delivered. Similar initiatives exist in respect of delivering primary medical care. The Government are experimenting with ways of delivering such care that differ from the traditional, general medical services model for general practitioners.

I am glad that the hon. Member for Isle of Wight also made the important point about the role of dental practitioners in the wider health care of the population. The majority of oral cancers are diagnosed by dental surgeons, and from that point of view, anything that reduces the number of people who routinely visit a dental practitioner must be bad.

I am unsure whether the comments of the hon. Member for Isle of Wight on the dental health of children bear detailed scrutiny. My understanding is that one of the bright lights in the NHS dentistry picture is that children's overall dental health is in fact robust, if not improving. That much, at least, we can grasp.

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The hon. Gentleman drew the distinction between general dental services and other methods of delivering NHS dentistry. Clearly, the Government's commitment to dentistry--whatever it may be--is not focused on restoring the traditional pattern of general dental services to enable them to deliver the percentage of NHS treatment that they did in the past. In 1992, 93 per cent. of treatment delivered through dental surgeons was NHS treatment. Now, the figure is 65 per cent. The Minister will correct me if I am wrong, but apparently the Government's stated commitment to increase access to NHS dentistry should not be read as a commitment to increase access to NHS dentistry through general dental services.

Why is that? Why have the Government determined, in relation to both GDS and general medical services, that it is more sensible to plough substantial sums of money into replicating facilities and infrastructure that already exist to provide stand-alone NHS-only facilities for patient access? Perhaps the Minister can point to a robust cost-benefit analysis suggesting that investing a large sum of money in new buildings where buildings already exist is more effective than using that same sum of money to persuade private dentists with mixed practices--both NHS and private work--to include a greater proportion of NHS work in the mix.

Creating a sort of dental apartheid, whereby people in some areas who need access to NHS dentists have to go to dental access centres or get their treatment through personal dental service schemes, is not the best way forward for patients or for the dental profession as a whole. It would probably be more cost-effective, and certainly more socially beneficial, to encourage by financial incentive dentists who are already largely engaged in mixed practice to take more NHS patients into their overall patient mix.

Ms Stuart : I would be interested to hear the hon. Gentleman's reaction to the Government's allocation of £28 million towards rewarding dentists' commitment to the NHS and £35 million towards modernising GDS practices, as well as improving access dental care and clinical governance. We are not only doing what he is asking, but doing more of it than his party would do were it to regain power--if we live that long.

Mr. Hammond : I shall ignore the last part of the Minister's remarks. As it is nearly Christmas, I allow her that little indulgence.

As the hon. Member for Isle of Wight said, the commitment payments to which the Minister referred are available only to dental practitioners who are already doing a large proportion of NHS work and have been doing so for some time. That gives the impression that the money is a reward for those who have "stayed loyal" to the NHS. The Minister is nodding, but I suggest that she should be trying instead to incentivise those who have not stayed loyal to the NHS to return and start to provide more treatment to NHS patients.

If we are to be pragmatic, we should use the limited amount of money that is available for NHS dentistry--we all accept that those resources are and always will be limited--in the way that best delivers access to NHS dental care. On what basis have the Government decided that dental access centres and personal dental

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services are the best use of those limited available resources, given that they both involve fairly substantial sums to duplicate infrastructure that is already available among dentists who provide general dental services? As the hon. Member for Stafford told us, the problem is not that there are no dentists, or that they do not have the premises, the staff or the equipment, but that they are not opening their lists to NHS patients. Relatively modest adjustments at the margin would surely change the economic balance for those dentists in mixed practice.

Will the Minister tell the House about the Government's view of mixed practice? Are they committed to maintaining a model of mixed practice in the future? Do they accept that it is beneficial for the service to maximise the choice of patients, so long as there is adequate access for NHS patients? Do they accept that it is for the good of everyone if NHS patients and private patients can be treated alongside each other in mixed practices? As some people might conclude from the focus on dental access centres, do the Government prefer to see the future model of the service as one of dedicated NHS facilities staffed by salaried dentists and technicians?

The problem with increasing the proportion of dental care delivered by salaried people--those employed by the NHS rather than through general dental services--is that it does not increase the number of dentists, or necessarily the number of dental man hours available. One discovers from talking to dentists in mixed practice, including the many with NHS patients who no longer seek to expand their NHS patient lists, that the principle reason for the closure of lists is not that the dentists are greedy, but that they feel unable to deliver adequate standards of care to NHS patients within the NHS remuneration structure. The hon. Member for Isle of Wight made that point.

Such dentists feel that they are being asked to run ever faster up an escalator going in the opposite direction. It is only by limiting the proportion of NHS patients in lists that dentists feel able to deliver something like an adequate service to them. Will the Minister tell us frankly whether there is a future for general dental services in the NHS, or do the Government see them as an historic aberration that they expect to fade away over time?

Is the Minister minded to think that, within the general dental services, the balance of emphasis between capitation payments and fees for item of service should be changed? Several hon. Members mentioned the perverse incentives that face dentists who are almost entirely dependent on fees per item of service. In some personal dental service pilots--I have the Ellesmere Port pilot in mind--the emphasis is on capitation payments, so that the dentists involved have an incentive to look after the overall oral health of their patients, rather than to treat in order to be paid.

I have three other specific questions for the Minister. Will she consider the problem of NHS patients finding that dentists willing to take them on make them suffer a long waiting time for a first appointment? Several people who have experienced that have suggested that it is somehow related to the way in which capitation payments work and are made. Many people think about signing on with a dentist only when they have an immediate problem. That system militates against

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patients registering with general dental practitioners because if they have to wait when they have a problem, they will probably consider going to one of the emergency centres or a dental access centre and then fail to register.

Will the Minister confirm that the Government want to increase the percentage of the population that is registered with a dental practitioner? Does she have any proposals to deal with the salary differential between dentists employed in delivering personal dental services and the community dental service, which the recent pay review body award has done nothing to address?

Finally, recognising that to some extent the root of the problem is the number of dental surgeons available--and we would all agree that our qualified manpower must be used to the best advantage of patients--what are the Government's plans for the registration of supplementary dental professionals, such as clinical dental technicians and dental therapists? How does she see the future development of the broader dental health team as a support to the limited number of dentists available to provide dental care?

12.16 pm

The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart ): I welcome you to the Chair, Mr. McWilliam. It has been an interesting and wide-ranging debate. I will try to draw it together a little. Should I inadvertently fail to address any points, I will be happy to get back to hon. Members.

I congratulate my hon. Friend the Member for Stafford (Mr. Kidney) on raising what is an important issue. We do not enjoy visiting dentists. It is not because of who they are, but because of what they do to us. For many years, NHS dentistry was almost a national pain service, rather than an integrated dental service. The question is: what are we doing about it? It is genuinely one of those cases where we have done a lot, but we recognise that there is a lot more to do. Duplicating past systems is not the way forward.

"Modernising NHS Dentistry: Implementing the NHS Plan" is a significant title. We have made dentistry a key element of the NHS again and we are modernising it. There have been big advances in practice. Dentistry was mentioned in the NHS plan in order to enshrine it there. The strategy comes with considerable amounts of money. It offers up to £100 million of new funding over this financial year and the next and concentrates on three major issues: improving access to NHS dentistry, improving the quality of services and improving oral health. I hope that that deals with the concerns of the hon. Member for Isle of Wight (Dr. Brand), who felt that the focus was not there and that we lacked ambition.

I reassure my hon. Friend the Member for Stafford that, after publishing the strategy and supporting it with money, we have every intention of driving its implementation forward. He mentioned the case of one of his constituents who asked for a check-up at an access centre. That should not have been refused. Something has gone wrong and we will take the matter up with the health authority.

Mr. Kidney : Let us be clear. My constituent Mrs. Hales did not say that the centre refused to check

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her teeth. She said that it could deal with toothache or discomfort, but could not sign her up for follow-up treatment.

Ms Stuart : I thank my hon. Friend for that intervention.

The hon. Member for Runnymede and Weybridge (Mr. Hammond) questions whether our commitment to access is good value for money. I wonder what he will think about dental access centres after the next round of bidding; there is already one in Woking and there may be some near his constituency. I do not know whether he will welcome them or say that the money would be better spent on something else.

Mr. Hammond : I was not trying to be confrontational. I was merely asking the Minister whether the decision to go for dental access centres rather than to reinforce general dental services was based on a robust cost-benefit analysis, or was part of the Government's instinct to do things differently.

Ms Stuart : The Government considered all the problems, one of which is access and the various means of getting people to dentists. I was struck by the suggestion that our proposals would mean the end of general dental services. Would we have invested £35 million on modernising GDS practices if that were so? The strategy must be seen as a combination of improving the quality of the service and the access to it. It is not a matter of the Government saying yet again that they have inherited a problem. In this case, we really have inherited a problem.

When the Government came to office, about 2 million people who wanted NHS care could not get it. In what other modern, primary care service would that have been possible or acceptable? That is the reason for our strategy. It is not just a question of the number of dentists. The hon. Member for Runnymede and Weybridge seemed to imply that we could increase access by increasing the number of dentists, but the number of dentists has gone up. What has gone down is their commitment to the NHS. More dentists are working in general dental services than ever before--about 18,000 are working in GDS, an increase of more than 1,600 since 1997.

The real problem is that some dentists worked under the 1990 contract system, which was introduced without being properly piloted. That system had significant drawbacks for oral health, NHS dentistry and expenditure. It resulted in an overspend of about £200 million, which eventually had to be written off. The contract was based on unsound activity forecasts and resulted in a 7 per cent. fee cut, which left many dentists increasing their commitment to the private sector. The problems started with the 1990 contract, which led to the 1992 changes to try to remedy those problems.

Mr. Hammond : The Minister said that the number of dentists has gone up. Will she confirm that, under this Government, the intake of pre-clinical students to United Kingdom dental schools has fallen from 937 in 1996-97 to 877 in 1999-2000?

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Ms Stuart : I can check the figures, but the problem is not one of capacity, if the hon. Gentleman is suggesting that we do not have enough dentists. The problem involves the focus on NHS work. In some areas where there is a shortage, the problem may be the skill mix, rather than registration.

Mr. Hammond : I am merely responding to the Prime Minister's commitment that, by September 2001, anyone who wants access to NHS dentistry will get it. The BDA said that at least 1,000 additional dentists would be required to deliver that commitment. It is the BDA's suggestion, not mine.

Ms Stuart : We must make it more attractive for dentists to make a commitment to NHS work. The problem is that, for the past 10 years, dentists have shifted to doing more private work, and the number of dentists working part-time has increased. That is the reason for most of the access problems that we still have today. What are we doing to change that?

The investing in dentistry scheme, which ran from 1997 to 1999, offered dentists grants, so that they could expand their practices and treat more NHS patients. The scheme is still bearing fruit. The £10 million in grants that has been approved is expected to generate up to two thirds of a million more patient registrations with dentists.

The scheme was moderately successful in south Staffordshire. Patients in a number of locations were once again able to receive NHS treatment. I know that there were problems of recruitment to the Stafford practice. It had been offered funds to expand, but the expansion could not go ahead, which meant that the practice did not receive the funding. In general, however, health authorities' contracts with dentists include specific repayment clauses in the event of the terms on which the grant was awarded not being fulfilled.

The hon. Member for Isle of Wight was concerned about the relationship of the personal dental service to public health. He may want to study the pilot schemes that took place under the personal dental service programme because they dealt in a focused way with the situation that he described. The East London and the City health authority personal dental service not only uses dental therapy in general practice, but, because it has low dental manpower and, more important, a socially deprived, mobile and ethnically diverse population, aims to improve access and to deal with inequalities in oral health provision, with an emphasis on improving the oral health of children. In the Warwickshire health authority area, particularly in Rugby, primary dental care is designed to encourage dentists to work within the NHS and to encourage the registration and treatment of new adult patients. The PDS model is responding to real needs and idiosyncrasies.

Dr. Brand : Can we be assured that those exciting pilot projects will be evaluated and could form the basis for a more flexible contract with general dental services providers? Does the Under-Secretary of State not

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recognise that the direct access clinics may be undermining some of the efforts that are being made in those projects?

Ms Stuart : Of course the projects will be evaluated. More important--it is horses for courses--we should consider the needs of an area and then deal with them. There is not one model that is right for every area. The hon. Gentleman mentioned the treatment of oral cancer and cervical cancer. There is no clear evidence that the early detection of oral cancer leads to a significantly better outcome, but he may be delighted to hear that setting up a screening programme for oral cancer, particularly for the over-40 higher risk group, is under active consideration by the UK national screening committee. We are not ignoring the matter, but giving it careful consideration.

I need to say something about fluoridisation, particularly as my daytime job is as a fellow west midlands Member of Parliament. The question of what the Government should do is hotly debated and tempers can get terribly frayed. The evidence from the York study was not as clear as people would have liked. We have therefore asked the Medical Research Council to do some more studies. However, it is clear that no area will decide one way or the other without careful consultation, because dental health can be improved in other ways, particularly for children. Fluoridisation may not be the chosen route, but that chapter is not closed.

Hon. Members queried our commitment to ensuring oral health, particularly for children, but the issue goes much wider than dentistry. Our work with health action zones and health living centres in education is the way forward. I hope that hon. Members will realise that we have recognised the problem, particularly with respect to achieving equity. We have begun to deal with that in many, I hope, innovative ways, including increasing physical access and introducing more flexible structures, but there is still some way to go.

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