Examination of Witnesses (Questions 80
THURSDAY 15 FEBRUARY 2001
80. So in particular you would want to have
some incentives to get the likes of Dr Husband back up from the
South of England working in parts of Birmingham?
(Mrs Hamburger) Yes.
81. What will those incentives be?
(Mrs Hamburger) We can provide a very interesting
job in Birmingham. If anybody wishes to apply, they can now. I
genuinely think that interest in the job is of importance but
also I believe, and I know a number of consultants in the West
Midlands believe, if there were a package of incentives that was
not just a new fee scale that would help to bind dentists into
the NHS. So if you knew you were an NHS dentist, you knew you
could have access to occupational health services, you knew you
could have access to proper IM&T, you knew you could have
access to some of the group discounts that could be organised.
In the Health Authority we have already done that for things like
waste disposal. If we could have that put together as a package,
I think that would be quite attractive to people so people would
know what it was they would get from being an NHS dentist.
82. Obviously that is an issue for national
(Mrs Hamburger) Yes.
Dr Brand: That was a useful intervention.
Chairman: That is very kind of you.
83. One has to live with these things. I was
very interested in you saying that you can find very attractive
jobs for good dentists, and I am sure you are absolutely right,
but do you not feel that your ability to intervene extensively,
which tends to be through the employed service, through PMS, through
the community service, actually undermines the very viability
of the General Dental Service? Whilst the Government is looking
at solutions and giving you the job of finding solutions through
direct intervention, does that not mitigate against finding a
solution because the pressure is off the Government, because on
the whole I find people do not complain about not finding dental
hygienists, they complain because they cannot have their toothache
fixed, and once you take that pain out of the political agenda
you could then end up with a completely employed service? This
may well be appropriate in some parts of the country but I am
not sure that should be the solution. I have a real concern that
Government thinking has not been clear on this particular issue
and that we are actually seeing a re-nationalisation of dental
services by stealth.
(Mrs Hamburger) The efficiency of the General Dental
Service would mean that we would not get an adequate service if
we had an entirely salaried service, I have got no doubt about
that. In Birmingham we are going for a mixed economy.
84. Sorry, if the contract for the General Dental
Practitioners does not start reflecting the work that you want
them to do then you are not going to have them anyway.
(Mrs Hamburger) I do feel quite stronglythe
BDA and I are at one on thisthe fee scale does not encourage
the sort of work that is required in the current climate. I absolutely
agree, it was designed in 1948, it does not reflect the current
work that is required now and I would like it if we had something
that was different. I would like to go back because we have a
problem in Birmingham that predates the availability problem and
that is really what we are trying to address with the new levers
that we have, to try to even up oral health in Birmingham with
the levers that we have been given. The absolute availability
problem has not been severe in Birmingham, it is located in perhaps
two or three electoral wards, but we still have that inequity
in care and inequity in health, which is what we are trying to
address. We cannot do that without the General Dental Service.
We have had people with toothache in Birmingham for a long time
and dentistry has not been on the political agenda. I do not think
we should be using toothache to create pressure.
85. It certainly is on the political agenda.
(Ms Holland) It is now.
86. I most apologise to Cornwall and thank them
because I think we have just approached one of your dentists for
which we are very grateful! In rural areas do you see the same
problem and do you see that perhaps the more you do the less likely
it is that we sort out the general dental practitioner contract?
(Mr Tyas) I think that the two can work together and
that is what we are planning in Cornwall. We do not see a Personal
Dental Service salaried service being the whole answer; we never
have done. We see the need for strong independent dental practices
as well working within the NHS. We do believe we have all the
tools available to us if we are allowed to use them and we do
see the PDS scheme as the way forward. We held roadshows throughout
Cornwall and we have had 35 or 40 dentists coming along and they
are all interested in coming into a scheme that they feel will
provide them with sufficient remuneration to look after the number
of patients they are already looking after but to deal with them
in a slightly different way and to prioritise treatment where
it is necessary.
(Ms Holland) That is absolutely critical. It is back
to this issue about getting the workforce planning right, looking
at the mix of roles and team roles, and looking at doing thing
differently. You put all of that with all the levers that exist
now and we will have a mixed economy but which will be more sensitive
to the needs of local areas.
87. But you were saying that the national levers
are not applied to the right object always unless you can divert
a lot of the money that currently is being given out under General
Dental Services through PMS schemes instead. Which direction do
you think the Government ought to be goinggiving more money
to health authorities so that you can start influencing what happens
locally through PMS arrangements, or should the Government re-think
its current fee structure with General Dental Services? You are
going to say both.
(Ms Holland) It is both.
(Mr Scaife) Chairman, I think what we are grappling
with here is a paradox in that we have a piece rate system essentially
and we have market forces. Market forces understandably encourage
and entice general dental practitioners to work and live in more
affluent areas, and the piece rate system
88. Sorry, I do not understand that, with respect.
If it is purely fee-based on the "drill and fill" stuff,
you make a much better living as a National Health dentist in
a more deprived area because people's expectations are not that
high, you see a lot more holes, you may see bigger holes.
(Mr Scaife) We have had an explanation earlier this
morning that the way the system is designed, if one wants to make
money then you work in more affluent areas where dental health
is generally better and, of course, you can do some private practice
as well if you wish to.
89. I was talking about purely NHS income. The
real high earners in National Health Dentistry do not live in
leafy suburbs. There are very high earning dentists in leafy suburbs
because they do both
(Ms Scaife) There are some. If you provide a good
serviceand the vast majority of dentists want to provide
a good service for their patientsthen you have to take
the time it needs in order to deal with that which is in front
of you in the mouth. If you are working in deprived inner cities
generally, you are seeing much poorer dental health, you are having
to deal with huge cavities, lots of decay, you are having to deal
with lots of extractions and all the rest of it. It is a different
kind of practice if you are in a more affluent area. The point
I was trying to make is it is a piece rate system, there are market
forces and that encourages people to work in the more affluent
areas. Because it is a piece rate system, it is a relatively cheap
system compared to the salaried system that we have in the Personal
Community Dental Service where the pressure is not the same, where
you are providing a different kind of service, so it is something
of a paradox. What we do not have any discretion locally to take
account of is the fact that in significant parts of Birmingham
we have very considerable deprivation, significant dental health
problems, but we have a national system based on a piece rate
which is nationally determined. So it ties back, Chairman, to
what you were saying earlier in relation to General Medical Services,
and what happens with family doctors. Increasingly, Health Authorities
and health systems, with the development of primary care groups
and primary care trusts, the development of Personal Medical Service
pilots and so on, are finding appropriate local packages which
combine the benefits of cost-effectiveness and providing a high-quality
broadly-based service, but in relation to General Dental Services
we do not have the discretion to do that.
90. Mr Tyas, you mentioned earlier about NHS
Direct and its role or strategy. You have both been the holders
of the information about what is available to the public. Could
you say a bit more about whether you cope with that role well,
that people did access that information and how you see NHS Direct
taking over this role, and any difficulties that you have come
across so far or you think may happen about this and how you feel
that NHS Direct will be able to keep the information up-to-date
about costs and treatments, etcetera.
(Mr Tyas) As I said earlier, we have had the Dental
Help Line in Cornwall for ten years. It has been very well publicised
and it is very well used. We employ three staff on that and they
take, an average, 2,000 calls every month, roughly half of which
are people requiring dental treatment and 700 or 800 are people
looking for registration with an NHS dentist. We are working very
closely with NHS Direct South West. They are one of the members
of the dental pilot for NHS Direct. It has been a very valuable
addition to the services that we are able to offer during working
hours, nine to five. NHS Direct takes over at 5 o'clock and takes
the calls until nine the following morning, takes calls at the
weekend, passes those details back to us and between us we are
able to ensure that the service is provided within 24 hours where
the patients need it. It has been a great addition. We update
their information as we get any changes to the local dental availability.
We let NHS Direct know by e-mail and the information is going
out, as you probably know, on the Web very soon, so that information
is all available from Cornwall's point of view. We work seamlessly
with NHS Direct and it is successful.
(Ms Holland) There are two things for the future with
NHS Direct. One is that as technology improves there will be the
automatic ability to book the patient in, particularly into the
Personal Dental Services pilot when they ring. There is always
that anxiety for patients, that they have made contact, they have
been told they will get an appointment the next day but they have
not got it there and then. If we can get electronically that booking
system that will be a big improvement. The other thing will be
as NHS Direct moves into becoming Care Direct, which is one of
the plans for the future, for the South West to be able to keep
up to speed with not only the health issues but the total care
package, and to incorporate dentistry we will need a localised
sub-structure within NHS Direct. The central office for the South
West will otherwise need to be holding and updating such a huge
amount of informationand we are already talking about thatand
it is a localised, networked arrangement for Care Direct.
(Mrs Hamburger) We have had a very positive experience
so far with NHS Direct. We have been working with them quite closely
as we have been developing the PDS. We are working with them to
get started with provision for information on General Dental Services
from the beginning of the new financial year. We have undertaken
to collect a basic data set for them in the first instance, although
a fuller data set will be coming on stream later. We will be updating
those data sets on a very regular basis. They have arranged to
check with us when they get reports that our database is not correct
and we have undertaken to ask dentists to correct their database
when and if they need to. Obviously our system is untried as yet.
I would agree that NHS Direct would be a much better vehicle than
we have been so far as taking calls and redirecting people to
places where they can receive NHS care. We have had the ability
to be able to do that, we have received quite a lot of calls and
we have been able to place patients, but NHS Direct will be able
to deal with that in a much more effective way.
Chairman: Do any of my colleagues have further
91. Can I ask how much contact you have with
colleagues in other authorities? It is very wonderful to hear
how splendid everything is in Cornwall and Birmingham but that
is not the feedback I get from other parts of the country. The
next county but one, Somerset, seems to a total disaster as far
as the National Health Service is concerned, as are bits of East
(Mrs Hamburger) As Consultants in Dental Public Health
we have a very good regional network. There are areas within the
West Midlands that have quite severe difficulties with dental
access. My personal feeling, apart from the difficulties we have
discussed this morning about the fee scale, about the 1992 dispute
92. The fee scale or the fee structure?
(Mrs Hamburger) The fee structure.
93. I think there is a vital difference.
(Mrs Hamburger) It is an important difference, yes.
Apart from those, there is an underlying manpower difficulty which
needs to be addressed. We have been relatively good at recruiting
to the services that we have in Birmingham, it has been quite
hard work, and my fear is that we have shifted some of the problem
elsewhere. I would not like to take away from that, there is an
underlying manpower problem. I do not think there is an easy solution
and I would concur with the idea that we should examine that much
more closely and do some very positive work on that. We are quite
encouraged that there is a sub-group of the Modernising Dentistry
Steering Group looking at workforce, so we hope that there might
be some light on the horizon. That does need to be addressed.
94. Can I ask one quick question on an issue
that interests me in general terms, whether it has any relevance
to this inquiry I am not sure. Does telemedicine play any part
in dentistry? If it does, what future role may it play in the
implications of telemedicine and how we structure the service,
particularly in rural areas like Cornwall and the Isles of Scilly?
(Mrs Hamburger) It would be very difficult obviously
to do fillings over the wire.
95. I appreciate that.
(Mrs Hamburger) But in terms of supporting primary
care practitioners, I think there is an important role for telemedicine
which we would like to explore further in Birmingham and we are
generating some ideas now. Even within our urban situation with
a dental hospital in the centre of the city, for a General Dental
Practitioner to be able to get advice can sometimes be quite a
long winded affair and because the patients then have to be referred
in that can create a longer waiting list. There are considerable
openings there for us to explore, particularly with regard to
Orthodontics, advice on Oral Medicine, that could speed things
up and make the patient experience a great deal better, but it
does need an investment of IT and practice which currently is
(Ms Holland) For Cornwall, for telemedicine there
is already a developing and extending network that is very sophisticated
in the Isles of Scilly in terms of what we can beam back. Part
of this debate is also about working practice and team roles because
in a distributed and very poor county like Cornwall, if we cannot
get all the dentists we need, the question is: "what can
some of the other team members do with an immediate reference
point back to the dentist." That is something we are looking
at. On your comments about networks, yes there is a regional one
in the South West, yes there is a network of people who have been
involved in the Personal Dental Services pilots nationally but
the climate has to be right in each locality for some of that
learning to be taken on board.
Chairman: Can I thank you for a very interesting
session. It may be there are points you wish to put arising from
issues we have raised this morning. I certainly would be interested
in hearing more about the levers issue, what practical levers
may be made available to you as health authorities, I think that
is a very, very important area. In conclusion, we are most grateful
for your co-operation in this inquiry. Thank you very much.