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Mr. Mike O'Brien:
I am grateful to the hon. Gentleman for giving way on that point because my hon. Friend the Member for Carlisle (Mr. Martlew) raised a question about how people access dentists. Before 1990, when registration payments were introduced, dentists kept lists of their patients for their own purposes. Many dentists now keep such lists and regularly write to their
patients for their own purposes. We are talking about a payment for registering-a payment to the dentist. Many dentists keep their lists anyway, and therefore people access and keep in contact with their dentist, who may write to them regularly to bring them in for check-ups and so on because they have their own list.
Norman Lamb: I note the Minister's point, but my central point is simply that many people, particularly those in rural areas, struggle to access an NHS dentist-whether or not they can register. We should all agree that that issue must be addressed.
The second issue that I shall deal with from the Steele report concerns the original claim from the 2006 contract-that its operation would take dentists off the treadmill and focus on prevention and oral health. In fact, the contract's focus has been on paying for activity. On page 5 of his report, Professor Steele says:
"So long as we see value for taxpayers' money as measured by the production of fillings, dentures, extractions or crowns, rather than improvements in oral health, it will be difficult to escape the cycle of intervention and repair that is the legacy of a different age.
Making the transition from dental activity to oral health as the outcome of the NHS dental service will be a challenge for everybody, but it is essential if NHS dentistry is to be aligned with the modern NHS."
The truth is that this contract has set back good dental health for some four years because of its failure to encourage and facilitate preventive work. Indeed, in many respects preventive work has been sidelined. The report says, on page 22:
"Perhaps the greatest surprise relates to the position of a scale and polish as part of a Band 1 charge. Many regular NHS patients told us they are paying privately for this treatment with a hygienist."
The Government can easily criticise the dental profession for that, but that is the reality as a result of the contract: it is not facilitating preventive health care under the NHS. Dentists have been overwhelmingly critical of the contract-a view reinforced and confirmed by the Steele report, which refers to 86 per cent. of dentists feeling that they are still, in effect, on the treadmill. That is not exactly an overwhelming vote of confidence in the Government's contract.
According to Professor Steele's vision for NHS dentistry, the focus should be ruthlessly on oral health-which was not ultimately a central feature of the contract-as well as on quality, prevention and continuity of care. On page 6, he says:
"The incentives for dentists are not as precisely aligned as they could be to a goal of oral health and consequently there are inefficiencies within NHS dentistry. The pathway we describe should be supported by an altered contractual structure for dentists. We therefore recommend that dental contracts are developed with much clearer incentives for improving health, improving access and improving quality."
Labour Members may simply refer again to the need for dentists to act with professionalism, but, as policymakers, we must surely ensure that the system incentivises the right things-preventive care and good oral health.
Steele argues-I am not entirely clear whether the Conservatives support him on this-that we should work to develop the current contractual framework instead of throwing it out and starting all over again.
Perhaps the Conservative spokesman can clarify their position on that in his closing remarks. If we throw the baby out with the bathwater and start all over again, there is a real danger that a further range of perverse consequences will follow that are hard to imagine at this stage. Professor Steele's central plea is to conduct a pilot and then apply the findings, which must surely be the way forward.
Mr. Mike O'Brien: May I confirm that, as I said in my opening comments, it is our intention to pilot? I agree that it is important that we take Steele's recommendations, pilot them, see how they work, and ensure that they work effectively. In other words, we too will learn the lessons. The hon. Gentleman makes a valid point, but unfortunately it appears that the Conservative Opposition are of the view that they do not need to pilot things because they have all the answers; I do not think they have.
Norman Lamb: To some extent I am reassured by that intervention, but in due course I will come to something that causes me concern about the Government's continuing approach, and the Minister might want to intervene on me again then.
One of the main current problems is the enormous variability in the quality of commissioning. I agree with the Minister that there are examples of very good practice, but according to most people the norm is that of not very good practice, in which commissioning has not been developed and the PCTs almost sideline dentistry and consider it of little central interest. That is part of the problem. In its paper published yesterday, the British Dental Association referred to the short tenure of staff. It stated that more than a quarter of PCT dental leads had been in post for less than a year, and the average was just 3.4 years. That turnover prevents any mature culture or understanding of the potential of commissioning from developing.
My hon. Friend the Member for Romsey (Sandra Gidley) made the point earlier than an enormous percentage of PCTs do not feel that they have enough scope to innovate under the contract. The examples of the few PCTs that have innovated suggest that there is scope to do that, but for some reason best practice has not spread around the country. There is therefore a significant shortfall in the quality of NHS dentistry compared with what is potentially achievable.
Along with a mass of poor quality PCT commissioning groups, there are none the less some PCTs that are doing really impressive, innovative work and making real progress. In Bradford, for example, the PCT has worked with the profession with collaboration as an important principle. It has developed a system that has less reliance on the measure of units of dental activity and created a blended contract with quality measures. That is possible under the existing contract, but most PCTs have not taken advantage of the scope available to them. The PCT in Bradford has developed effective care pathways, which are essential to proper treatment, particularly of those with poor oral health.
Salford is another PCT that has been proactive, and part of Birmingham is providing an impressive lead on dental public health. Accredited practices have been established there, and some of the money going to dentists is given on the basis of their practices achieving
quality and engaging in preventive work. Tower Hamlets PCT has also been doing good work. Those are the areas from which we ought to be learning what is possible in the way of good-quality preventive care and a focus on oral health. That practice needs to be spread out across the country. The approach has to be collaboration between dentists, PCTs and Government to pilot and then spread out good practice.
The concern that I referred to after the Minister's intervention relates to the dental access programme. It appears that the Department of Health is up to its old tricks again of not collaborating and of imposing an approach against the wishes of the profession. The BDA has specifically expressed its concerns to me, and no doubt to others. It states that the Department has attempted to design a new contract in a very short space of time, but that it is utterly controlling and far too prescriptive. It tells me that the Department started work on the new contract in April, but it was not until July that the BDA got to see it. That is precisely what we are all complaining about and why Steele complained so much about the need for collaboration rather than imposition from above.
The BDA says that the Department now appears reluctant to make further changes. It advised the Department in July-I believe that it met the Secretary of State-that it should use the existing contract, warts and all, to get the access programme running and then seek to effect improvements to it. Now we have got to the extraordinary and ridiculous position that the BDA is unable to endorse the new contract. Incredibly, practices that are tendering for the new contracts are unable to see them during the tendering process. How daft is that?
Despite its total frustration with the Department, however, the BDA stresses that it has an absolute commitment to engage with the Steele reforms and work with the Government. The Minister made the point in his intervention that the Government are determined to learn lessons and pilot schemes before introducing them. Will he look again at the access programme to ensure that it is introduced in collaboration with the BDA, rather than against resistance from it, which would be entirely counter-productive?
Mr. Mike O'Brien: Such contracts are a matter of negotiation. We cannot say to the BDA, or to any other organisation, "You've got a veto. If you don't like it, we're not going to have a contract like that." It was part of a negotiation in an attempt to get to an agreement. The hon. Gentleman is right that we need to learn lessons from how things were done in 2006 and we are intent upon doing so. There is a process of working through the issues from the Steele report and ensuring that we form a much better relationship with the BDA than we have had for at least a few years.
Norman Lamb: I hope I can take it from the Minister's comments that there will be a further attempt to reach agreement and to listen seriously. I appreciate that the BDA cannot impose a veto, but to get the best possible result, there needs to be proper, meaningful collaboration.
The Government have been guilty of imposing too much regarding health. They imposed the modernisation of medical careers and the fateful national IT programme,
with disastrous consequences, and they imposed the dental contract, which has set back the cause of preventive dental care for some four years. There is now an opportunity to get it right.
The Liberal Democrats' plea is that the Government learn the lessons from the past and work with the profession to secure a dental service that focuses on quality; prevention; areas of greatest need, to address the inequalities that we know exist; effective use of resources and ensuring that incentives move in the right direction; and, finally and critically, access for those who need NHS dentistry and who cannot afford the private alternative.
Mr. Deputy Speaker (Sir Alan Haselhurst): The House will be able to do its own maths. We have about 50 minutes-just under-and five Back-Bench Members are wishing to contribute. Perhaps everyone will bear that in mind.
Charlotte Atkins (Staffordshire, Moorlands) (Lab): The House's last debate about dental services took place in December 2008. It was on a report from the Select Committee on Health that followed an inquiry on which I persuaded the Committee to embark. The review that arose from the criticisms made in the report was brilliantly led by Professor Jimmy Steele who, as a clinician, teacher and researcher, had the breadth of vision to pull off a report that is comprehensive, authoritative and widely applauded. This debate gives us a good opportunity to consider what Steele said in his report. It is ironic that the planned Opposition day debate on dentistry in July was pulled in favour of a seemingly more newsworthy issue. Dentistry had to take a back seat.
Professor Steele nailed a few myths in his report. First, the media have told us that hordes of dentists have been so disgusted with the NHS contract that they have converted to 100 per cent. private practice. In fact, as Professor Steele says, the loss of NHS provision was very small indeed-just 4 per cent., which is hardly a mass exodus.
Secondly, we were told that no one could find an NHS dentist. Clearly, access to NHS dentistry is a problem. However, the Steele review found that it is not a universal problem, and that it is concentrated in some areas. The Which? survey, on which the Minister commented, demonstrated that 88 per cent. of people who wanted to access a dentist could do so.
Access to NHS dentistry is now firmly the responsibility of local PCTs. I applaud that, unlike the Opposition, because prior to that it was at the whim of individual dentists where they practised and whether they provided NHS services, private care or a mixture of the two. The PCTs have been given the responsibility to ensure that local demand is met. When they were first given the responsibility for commissioning, a lot of PCT mergers were happening, and that was unfortunate because the commissioning of dental health services was put on to the back burner. Dentistry did not get the priority in the NHS that it deserves-indeed, it never has done. More money has gone into dentistry, but it is still a very small part of the NHS budget even though dentistry is very important to people, not only because of the pain bad
teeth can cause, but because having a mouthful of such teeth-although, happily, fewer people do so these days-can cause a real lack of confidence. The PCTs are now getting their act together, but many challenges remain.
Yesterday a survey by the British Dental Association's local commissioning working group was published. Like the Steele review, it was initiated by the Health Committee's report. The survey found, as other hon. Members have said, that 60 per cent. of commissioners and 77 per cent. of local dental committee secretaries said that the national dental contract did not allow sufficient innovation and flexibility, so it is very good news that an effort is being made to introduce more innovation. We must work together to develop that innovation and flexibility.
The survey also contained some good news. There were positive attitudes towards liaison between practitioners and commissioners. Related research by the BDA identified a broad consensus on the priorities for dental commissioning-improving access, especially for new patients, and targeting areas of high deprivation. That would not happen if dentists were allowed to locate wherever they wanted, instead of the PCT being the driving force. We need to build on that consensus, and Professor Steele's report provides an excellent starting point.
The 2006 reforms addressed three key issues. The first gave responsibility for planning and securing NHS services to local PCTs, and that is really important. It means that the local health service can take account of local need. My PCT was very responsive to my concerns about one particular town, Biddulph, which did not have an NHS dentist, and we now have an excellent service there.
The second issue was patient charges. In the past, patients had to steer their way through 400 separate charges. Many could not tell whether they were receiving NHS treatment or private treatment, because the charging system was so complicated. In 2006, those charges were reduced to three bands. These were simpler and less confusing for patients, but they could provide perverse incentives for patients to store up their dental problems and delay visits to the dentist. We need to address that problem.
The third issue that arose from the 2006 reforms was connected to the units of dental activity. Dentists rightly complain that UDAs have created a new treadmill, with a possible incentive to provide treatments that are clinically no better than a lower band alternative as a way of increasing their practice payments- [ Interruption. ] I am not suggesting that dentists are pulling teeth because it is financially advantageous for them to do so.
Professor Steele is right to propose more charging bands and a better continuity in the relationship between patients and dentists via a more formal registration system. The existing contract framework can be developed to allow payments for improving oral health, continuing care responsibility and better quality, as well as for increased activity. The Government must work with the profession and pilot these new incentives to ensure that any problems are quickly resolved.
I had the perfect preparation for this debate, because I visited my local dental practice, as a patient, just two weeks ago. I attend TLC 4 Smiles, in Leek, which has eight surgeries with four full-time dentists, as well as full-time hygienists and therapists. It covers about 20,000
patients and has existed for more than 10 years. I am glad to say that I signed up as its first NHS patient. On that occasion, my dentist was Dr. Sophie Mitchell. She is a delightful lady who gave me a complete and comprehensive examination-clearly checking for oral cancer-an assessment of my dental health and then a scale and polish. She had no idea who I was until, when she had finished, I started talking to her about the Steele review. I was amazed that she told me, quite voluntarily, that she had moved from being a 100 per cent. private dentist to a 100 per cent. NHS dentist. When I left, I was offered an appointment in a year's time. That is what we need from our NHS dentists: good access, prevention and high-quality provision for the whole family.
The Opposition motion proposes the reintroduction of school dental screening programmes. I agree with the hon. Member for North Norfolk (Norman Lamb) and the Minister that that is just window dressing. Those programmes have been proved to be ineffective, which is why they were stopped. If the Opposition are really interested in increasing preventive care, improving children's dental health and reducing dental health inequalities, they should be proposing to increase investment in Sure Start and similar initiatives and pushing the fluoridation of water supplies. Sure Start brings together health, education and social services to help pressurise mothers with children under four. It is the perfect vehicle to promote good, early oral hygiene alongside good access to NHS dentists. Fluoridation of water in Birmingham has provided huge benefits to children, compared with unfluoridated Manchester. The figures are very clear on the benefit of fluoridation.
Fluoride toothpaste has also made a significant difference, and I commend my local PCT, NHS North Staffordshire, for its work to promote good dental health. I have joined it in wet and windy supermarket car parks and in town centres where its representatives have engaged with shoppers on oral health issues. It also attended my recent health MOT days, which are events that I have organised to promote public health, and I am grateful to NHS North Staffordshire for having the forward thinking to provide the health professionals who carried out health checks, such as on blood pressure, body mass index, cholesterol and blood sugar levels. We had an amazing response. During the two MOTs that I organised, more than 800 people turned up, and the dental health team played an important role at the events. I put on the record my thanks to PCT chief executive Tony Bruce, to Lesley Goodburn and to all the health professionals, including health visitors and district nurses, who worked so hard to make those events such a success.
One of the criticisms in Professor Steele's report is that PCTs are no good at communicating with people about how to find a dentist. I am pleased to say that my PCT, having awarded a new NHS contract to two doctors in Biddulph-Mr. and Mrs. Keen-was very proactive in advising potential patients on how to sign up for that excellent NHS service.
Through my local newsletters I was able to hand Mr. and Mrs. Keen the names of about 500 families looking for an NHS dentist in Biddulph. Very quickly, they signed up thousands of patients, many of whom had not been to a dentist in years. One constituent-a man in his 40s-told me that he had not been to a dentist for well over 20 years, after a bad experience as
a youngster. However, the pain that he was in and the persuasion of his girlfriend finally led him to pluck up the courage to go. The Keens did such a fantastic job that he has never looked back. The Keens in Biddulph and TLC 4 Smiles in Leek are the modern face of NHS dentistry. As a Government we must do all that we can to support them.
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