Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 80 - 95)



  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 Government?
  (Mrs Hamburger) Yes.

  Dr Brand: That was a useful intervention.

  Chairman: That is very kind of you.

Dr Brand

  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 strongly—the BDA and I are at one on this—the 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 going—giving 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 service—and the vast majority of dentists want to provide a good service for their patients—then 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.

Mrs Gordon

  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 information—and we are already talking about that—and 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 questions?

Dr Brand

  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 Anglia.
  (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 and the—

  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 not available.
  (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.

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