Examination of Witnesses (Questions 20
THURSDAY 15 FEBRUARY 2001
20. If you think of it you can come back in.
(Mr Renshaw) If you wanted to characterise the NHS
General Dental Service you could characterise it by saying that
the attitude of Government is "if you can't count it, you
are not going to get paid for it". It has to be countable,
it has to be seen, it has to be a filling, it has to be an extraction,
it has to be a denture. Preventive work, spending time talking
to patients, is not encouraged because it pays nothing. That is
the tragedy. What we have got at the moment is a world in 2001
where we have youngsters who are relatively orally healthy, we
have an ageing population who are keeping their teeth and bringing
problems to dentists which take a lot of sorting out, these are
really difficult problems, and we have a system of payment that
was generated and begun in 1948, which was a completely different
world from what we have got now. There is a mismatch there, a
very serious mismatch, between what we are facing now as a profession
and what we faced in 1948. Within the NHS we have still got a
payment system to match the 1948 situation. What the people who
have gone into the private sector have found is they can structure
a remuneration system for themselves that allows them to do the
kind of work they have always wanted to do, which is basically
about looking after patients, not drilling and filling and counting
and fees and all that sort of stuff. There is a real problem there.
21. Mr Bosley?
(Mr Bosley) Dentists have to run a business whether
they are National Health Service or whether they are private.
It has to be a business with a bottom line which makes sense ultimately
to their accountant and their bank manager. The business sense
of the National Health Service is to reward me with a fee of £11,
total fee from the state and the patient, for extracting a tooth,
which most people would regard as a significant act, event, in
their lives. On NHS figures that gives me 11 minutes to greet,
wash, treat, inject, take the tooth out, say goodbye and sterilise
the surgery for the next one. I cannot do it in 11 minutes. My
costings mean that £11 indicates that I should give the patient
four minutes to remain solvent. That is why I do not do it for
22. I am very interested in the de-registration
that is going on If we are concerned about this piecework mentality,
one would have thought that the registration system would be a
very good way of overcoming that, you could actually pay people
for long-term outcomes. I think you have demonstrated quite clearly
that the Department of Health at the moment is only interested
in turnover stuff and what you have done today rather than what
the results of your intervention are going to be like in five
or ten years' time. The registration scheme surely would have
allowed you to structure something which would have created a
commitment to the ongoing oral health of the patient. Was it the
funding of the scheme that was not right, or was it that it was
not underpinning what we all want to see, which is public health
(Mr Renshaw) Can I make clear right from the start
that successive adult health surveys have shown that despite everything
dentists in this country have managed to achieve a significant
improvement in oral health in this country for the whole population.
23. I am not arguing about that, I am looking
at your remuneration structure.
(Mr Renshaw) Despite the system rather than because
of the system. Registration was introduced as part of the new
contract in 1990 and was an innovative approach. I suspect at
that time it was meant to be the beginning of a move down that
track and it would develop further. If you go back to what I said
a few minutes ago, "if you can't count it, you are not going
to get paid for it", the problem seemed to be that the Department
of Health did not recognise what they were getting for their registration
payments, so they went cool on that. We have never seen any movement.
The fees for registration are really quite abysmally low, 60 pence
a month or something for an adult. You do not buy a lot for 60
pence but that is the kind of level that we are looking at. I
do not believe that we have ever really pushed the registration
approach in order to try and achieve something. If you look at
the private sector, one of the biggest players in the private
sector is a registration system, the Denplan system, which is
about regular care for a regular fixed amount of money, not based
on individual items of treatment. Registration can work, and it
does work successfully. There is mileage there. I think a lot
of dentists would be keen to see that looked at again. What has
not happened is we have not had a look back and a real consideration
of where the service should be going for the future, we have just
carried on doing exactly the same as we have done since 1948 with
a little bit of change but no real change of direction.
(Mr Ross) The registration system was a huge success
in 1990. We registered millions more patients than the Government
at the time expected and they had to pay out for it. We were rewarded
with what? Another fee cut. It sent out exactly the wrong message.
At the time they were not prepared to pay for what they could
not get, and they still are not.
Dr Brand: Is that because the balance between
the registration fee and your bob-a-job fee just is not right?
I have just been trying to work it out for General Medical Practitioners.
It is about 60 per cent of capitation in terms of registration
and 40 per cent as inducement payments which allows one to give
continuity of care. Have you any idea what the balance is like
for dentists? It is something that you could write to us about
and maybe we could find out for the General Medical Practitioners.
24. I want to pursue this point about access.
You have talked about geographical differences between the North
and South and I must say, coming from the South, that the migration
of dentists from the North will not be coming to my area and to
some of the points of deprivation in the inner cities. Clearly
there is a question of location and geographical area but there
are also different groups of patients and different categories
of care. I would like to explore what are the differences of access
for different groups of patients as well as the geographical issue
and how this might be addressed.
(Mr Bosley) May I speak? One of the effects of the
registration in 1992, in my opinion, was that practices registered
vast numbers of patients and became full up and were then unable
to offer access to emergency patients. It became easier to say
to a patient "I am sorry, I cannot look after you because
you are not registered here". I felt that registration was
a negative access for patients who just wanted a one-off job because
the regulations forbad the dentist from doing a full job without
taking the patient on and becoming two years committed.
25. Is there a difference of view as to what
constitutes emergency treatment?
(Mr Bosley) Yes. The National Health Service defines
emergency treatment and what one can do and very often it defines
the treatment as just being a dressing, so you can get rid of
the pain by doing a dressing but then the patient has to go and
find somebody else to put the filling in and this is nonsense.
To put the filling in you have to register the patient. If you
are full up, what do you do?
26. Is that view shared?
(Mr Ross) Not necessarily. I do not necessarily agree
either that the access problem is purely a North/South divide,
I think it can be an inner city and rural divide. I think the
access problem is different
27. Rich and poor presumably?
(Mr Ross) Rich and poor. I think the access problem
is different for children who generally have access to NHS Dentistry,
for fee paying adults who may not pay, and for the exempt patients
as well who may find it harder in certain areas to get access.
I think there are access problems within the branches of dentistry
itself because dentistry has changed and the NHS has not changed
over 50 years. Dentistry has moved on from extracting teeth and
replacing them with a bit of plastic to implants, whereas the
NHS is taking away bits of dentistry. They have taken away crowns,
they have taken away prevention and put in nothing, so there is
a void there which private practice is having to fill. The access
problem is a complex issue but, again, this strategy does not
really deal with those issues, the strategy only deals with pain
28. The private practice is not going to come
to the areas where patients are shooting up in the stairways outside.
(Dr Husband) They might if the incentives are there.
29. Sorry, do you mean private practice or do
you mean comprehensive treatment as is provided by the private
practitioners being made available to the National Health Service
if the NHS contract was right?
(Dr Husband) I think the NHS side of things.
30. Listening to what you have said, it strikes
me that the National Health Service has never really taken off
in dentistry or has somehow lost it half way through. The principle
that we are talking about today is one of basic inequality. We
are moving to a system of inequality and that worries me very
much. Clearly someone like yourself, Dr Husband, who has come
in relatively recently, really sees their future as treating those
people who can afford to pay for the service you provide. I am
sure you feel that would be wrong in principle for that to be
a national system. Have I got the right impression that you genuinely
feel that we have lost dentistry as a National Health Service
provision, that we no longer have that?
(Mr Renshaw) Yes.
31. It is also clear that you do not think the
Government's present strategy is going to turn things around at
(Mr Renshaw) I would agree with that. I am quite happy
with the content of the so-called strategy. It is not really a
strategy, it is more of an action plan to sort out the access
problem. In the short-term that will help and there are some good
ideas in there.
32. It is a short-term fix basically?
(Mr Renshaw) It is, yes.
33. Not a long-term plan?
(Mr Renshaw) That is right. There is no long-term
planning in there, absolutely none. There is no looking at the
workforce, there is no looking at the remuneration system, there
is no looking at distribution, there is nothing. But it is not
meant to be that. What we are hoping to be able to persuade the
Department of Health to do is to say "if we help you to try
to get over the short-term problems of access and people ringing
up wanting treatment for toothache, fine, but can we please at
long last stop this concentration on the here and now and starting
looking at where this profession and this service ought to be
in ten or 15 years' time?" We have not been allowed to do
that. The reason we have got a split within the profession, if
you like, is because the people who moved into the private sector
have actually done that, they have decided for themselves that
they are not prepared to put up with this carry on any longer
and they are moving out and doing for themselves the thing they
want to do for their patients, which is look after them holistically
and on a whole body basis. The tragedy of it is because the Government
will not fund that, the only people who can afford that kind of
care are the worried middle class well, sadly. Do you want to
make a note of that?
John Austin: Okay, there is the issue about
the fee structure and the method of remuneration, but is a service
based upon independent contractors necessarily the right way to
address the needs of, say, the inner city areas? What is your
feeling about a salaried NHS Dentistry profession?
34. Can I add to that. We have had this debate
with hospital doctors and consultants in particular where the
Government at one point were putting forward this idea of a six
or seven year commitment to the National Health Service. What
about something like that to adequately reward the dentists who
come into the National Health Service by committing them on a
contract basis to so many years' service directly in the NHS?
Is that something that could be seriously looked at if you were
happy with the reward structure?
(Mr Ross) I think what you have to remember is that
there are substantial differences between doctors and dentists.
Dental practices are fully funded by ourselves.
35. I understand that. All I am saying is in
principle is that a runner as far as you are concerned? We could
have people contracted to work with NHS patients to overcome the
problem that we have been talking about where Dr Husband works
in the North but migrates to the South and leaves us Northerners
behind because there is more money in the South of England. Can
we not get people committed to work in the North by virtue of
some restructuring on the commitment to training and proper rewards,
in other words getting a National Health Service dentistry provision,
which we have not got?
(Mr Ross) If you went down an entirely different path
36. What would that path be? We are trying to
tease out the different options.
(Mr Ross) If you went down the path of buying over
dental practices, which maybe is what the strategy is implying
(Mr Ross) There will be nationalisation of dentistry.
Maybe that is what this strategy is implying for the future, that
the NHS will buy over practices and run practices. What the strategy
forgets is that the most cost-effective access centres are our
own practices. It has been shown time and time again that General
Dental Practitioners run the most cost-effective service. If we
were paid properly then there would be no access problem. The
access problem is entirely of the Government's making and the
Department of Health's making. On the more specific point of emergency
dental treatment, those fees and regulations are so appalling
that they just do not bear thinking about. The dressing fee is
something like £3. It can take 20 minutes to do a dressing.
That has to be looked at specifically, and we are quite willing
to help you on that. That is why the emergency situation is so
bad and it really is poor.
38. Could I just come back to the point Mr Bosley
was making about access to emergency treatment. You take the view
that registration may have exacerbated the problem?
(Mr Bosley) I do not think it helped.
39. Is there a general feeling that access to
emergency care has deteriorated and whether the current proposals
and practice of out of hours care is addressing that? Lastly,
what is the role of the hospital in emergency treatment procedures?
(Mr Bosley) A hospital largely has no role in dental
emergency treatment and if they did there would be queues around
the corner because the patients do not pay when they go to hospital,
they pay when they come to me under the National Health Service.
Hospitals have little function apart from acute trauma. Since
1992, as I say in my evidence, I have been on bleep call all the
time that I am not in work. My professional commitment to out
of hours emergency service is great. When I was a younger dentist
I would have to get the kids out of bed to go and treat patients
in the night. That is no way to run an emergency service.