Previous Section Back to Table of Contents Lords Hansard Home Page


Earl Howe: Amendment No. 430A, which stands in my name, differs only slightly from the amendment moved by my noble friend Lord Colwyn. I cannot add much to what he said, except to ask, on the assumption that the Minister agrees that a definition of "reasonable" is to be sought, who would be consulted and what benchmarks are there for making a judgment on it? It is a will-o'-the-wisp concept, but somehow we must get closer to it.

The dentistry objectives proclaimed by the Government are worthy in themselves, but they cannot be fulfilled without having sufficient dentists to perform the work. That is why I have tabled Amendment No. 432. Positive action is needed to ensure that enough dentists, dental nurses, dental hygienists and dental therapists are trained and in post to cater for the increasing levels of patient demand. That requires workforce planning.

I do not know whether the Minister is in a position to update the Committee on the department's workforce planning review, but she will know that that is seen as a key step towards addressing the concerns expressed by the modernisation board about capacity in the dental profession. As noble Lords have pointed out in recent debates on the subject, the British Dental Association has estimated that as many as 25 per cent more dental students are needed if we are to close the gap between supply and demand.

3 a.m.

Baroness Andrews: I feel that we have reached the sunlit uplands, occupied entirely by dentists. It is a great pleasure to hear from the noble Lord, Lord Colwyn, who has been such a faithful companion on this long journey over the past 12 hours.

The Government are committed to rebuilding and restoring NHS dentistry to improve the oral health of the nation. As the noble Lord pointed out, it has been a long time coming over the past decade, since the Bloomfield report, when so many in the profession have sought change and welcome the changes that we have introduced now. I know that the dentists in the House of Lords have lent their voice in support of that. The proposals represent the most radical reform of NHS dentistry since 1948. That is why we welcome the emphasis in the

20 Oct 2003 : Column 1457

amendment tabled by the noble Lord, Lord Colwyn, and others on the promotion of primary dental services and better oral health.

I do not want to rehearse the history. Let it suffice to say that the Government, the NHS and the BDA have worked hard to develop the proposals published in Options for Change in August 2002. The key recommendations were for an integrated, high quality primary dental service that was locally commissioned and responsive to the needs and wishes of patients. That is the way to address inequalities in health.

The most significant change, which addresses many of the issues raised, is that the existing duty in Section 35 of the 1977 Act so far has merely required a PCT to make arrangements for dental practitioners to provide dental services, where a dentist has agreed to undertake dental treatment.

Under Clause 166, PCTs will be given a new duty to provide or secure the provision of primary care dental services either through contracts with individual practices or by providing services themselves. That evidently significantly strengthens the PCT's role in local service provision. It is also entirely consistent with our intention to shift the balance of power to front-line staff. It will make a big difference to patients not least because we will be requiring dental health colleagues to assess local oral health needs in order to tackle long-standing oral health inequalities.

As noble Lords have said, for the first time since the foundation of the NHS, by breaking the link between fees based on items per service, primary care dentists will be given an opportunity to focus on prevention and health promotion as well as treatment. New contracts for dentists based not on items per service but on the full range and level of services available to patients will provide additional stability for practice incomes and a greater guarantee for patients and for the PCT. As the noble Earl, Lord Howe, said in his amendment, they will provide greater opportunities to engage the whole dental team and allow them to spend more time with patients.

For the first time, we will have a predictable level of service locally. We have been talking about concepts of reasonableness. That is very much a part of reasonableness that we have never had in the past. It will enable the PCT to provide up-to-date and accurate information for the public about the services for which it is responsible. For those reasons, because we believe that the whole thrust of what we are trying to achieve will promote dental public health in a way that meets the needs of our time—in fact it is long overdue—we do not feel that Amendment No. 432 is necessary, although we are sympathetic.

Amendment No. 431 would extend the PCT duty in relation to the provision of primary dental services by removing the qualification of reasonableness. Questions have been asked about what it means to

20 Oct 2003 : Column 1458

be reasonable. As my noble friend's letter to noble Lords explained and as was debated in the other place, the words,


    "to the extent that it considers necessary to meet all reasonable requirements",

have been carefully chosen because they mirror the current Secretary of State general duty under Section 2 of the 1977 Act to,


    "provide throughout England and Wales, to such extent as he considers necessary to meet all reasonable requirements".

However, I stress that the wording was amended in the other place in response to requests to bring the PCT duty unambiguously into line with that of the Secretary of State.

The most important test of reasonableness is to ensure that there is no postcode lottery. The PCT discretion will indeed be subject to national bench-marking—the noble Earl, Lord Howe, raised that issue—but with operational responsibility that will recognise variations in relation to local geography such as those between rural and urban areas for example. Time and distance standards will be used to measure compliance with the Prime Minister's pledge made some time ago about everybody being able to reach an NHS dentist. The distance travelled to reach a dentist practice, or time to wait for an urgent or routine dental appointment could be measured, because we are in the process of developing our criteria in this new scheme of things. We will be looking at ways of measuring and testing the concept of reasonableness.

I agree with Amendments Nos. 430E and 434A that publication of local bench-marking is desirable and I propose that it should be published. I agree that any local access targets should be agreed by the PCT during the public part of its board meeting. In that way, PCT decisions can be subject to public scrutiny. Indeed, Section 11 of the Health and Social Care Act 2001 places a duty on local health bodies to hold a public consultation on the proposed configuration. Users of those services need information to make a judgment about one of those services to meet the needs and wishes of people in the area. The performance of PCTs in relation to their new duty under Section 16CA will be a matter for performance management by the strategic health authority. I think that that meets the needs of transparency and openness.

Amendment No. 431 attempts to remove the reference to reasonableness. I do not accept that the PCT's duty under Section 16CA should be any different from that of the Secretary of State's duty under Section 3 or a PCT's duty under Section 16CC in relation to primary medical services. We therefore find it difficult to accept Amendment No. 431.

Amendment No. 433 raises the important issue of funding for the service. I should like to give the noble Baroness, Lady Barker, some reassurance on that. We acknowledge that the existing funding arrangements have been unsatisfactory. They reflect not the NHS's need to secure the needs of patients but the varying willingness of dentists to treat

20 Oct 2003 : Column 1459

patients. From now on PCTs will have a duty to secure the provision of primary dental services either through contracts with individual practices or by providing services themselves. With these new responsibilities will go the 1.2 billion (net of patient charges) of financial resources that are currently held centrally.

I make the important point that once the reformed system is in place it will be possible over time to adjust NHS allocations to take into account the health inequalities that persist under the old system. I can give the Committee the important guarantee that current spend will be protected. We are taking some short-term measures until the implementation of the Bill enables the NHS to address historical anomalies, with additional funds being deployed to support PCTs as they get to grips with the new agenda. I think that some of that funding was mentioned in the letter that we sent to noble Lords.

However, in the longer term allocations have to take into account oral health needs as well as other health needs in general allocations. This is a "once and for all" opportunity to do that. For some areas, that might mean relatively more funding for dentistry in future as PCTs begin to address the long-term oral health inequalities that some of them face. I think that the audit report showed very graphically the tremendous regional variation in the number of dental caries in children under five and young people. We must tackle that issue. So as my noble friend made clear in the letter to noble Lords, we will set a floor on the spending on primary dental services below which the PCT may not fall. By doing so, the financial resources allocated for dental services will be used for the purpose for which they were allocated.

An important feature of direct allocation of resources to the PCT is that should a provider reduce commitment to NHS services under the new scheme, the PCT will retain those funds to commission from an alternative provider. With those important reassurances, I hope that the noble Baroness will not press Amendment No. 433.

Amendment No. 434 suggests that PCTs should provide services in accordance with identified local need. However, it is implicit in the duty that PCTs will have regard to local needs. A most important feature of NHS dental services is that the public can use the service where most convenient, and for adults that may be where they work rather than where they live. The example of those who commute into London was given in another place. That is what we mean by catchment area rather than a residence area. It means that the dental services provided must reflect the needs of users of the service, not just its resident population. That is one of the great benefits of the service at the moment. So on those grounds I would suggest that Amendment No. 434 is unnecessary.

20 Oct 2003 : Column 1460

Amendment No. 435 requires PCTs to ensure that services which are currently provided are secured. The current treatment functions of the Community Dental Service will continue under PCT-provided primary dental services, PCTDS. Such services will include the provision of treatment to patients who might not otherwise seek treatment—for example, patients with special needs and patients with phobias as well as treatment on referral. Then we have the specialist elements such as orthodontics and minor oral surgery where CDS staff have developed skills. Over the years, the CDS has developed considerable expertise that we do not want to lose. However, integrating those treatment functions of the CDS under the new name "primary dental services" in the Bill will strengthen those functions rather than rely on guidance to PCTs which is the current basis. That, plus changing the way in which dentists are paid and moving away from item of service, will enable dentists providing services under a CDS contract to spend more time with their patients.

New powers under Section 16CA(2) will enable PCTs to commission specialist dental services, such as orthodontics, from experienced high street dentists, who are very accessible. That will ensure that the developing dental specialties are given the right opportunities to contribute to patient care because they will be able to pick up from appropriate referrals. Therefore, Amendment No. 435 is met by our intentions.

I have much sympathy for Amendment No. 436. A recurrent theme running through the Audit Commission report, the Office of Fair Trading report into private dentistry and Options for Change is that information about what services are available and how the public might access them is generally very poor and difficult to understand. We are committed to improving the patient experience of the NHS and to promoting patient choice by providing accurate and easily understood information about the services available and what patients might reasonably expect from them. That is why we have included the specific provision in subsection (3) of the proposed PCT duties in relation to primary dental services.

We have concluded that that is best dealt with through regulations. Requirements are bound to change over time as providers' abilities to provide information improve. Statistical information will change, as will ways of dealing with it through ICT and so forth. The regulations will contain a level of detail that justifies a regulation-making power. Subsection (3) makes provision for information about the primary dental services for which the PCT is responsible, and so, by definition, the NHS dental provision in its area.

The task of compiling information regarding non-NHS treatment for which the PCT has no statutory duty seems unreasonable to impose on PCTs. Our policy is that, in the first instance, complaints should be resolved through practice-based procedures. Information about complaints is better dealt with under GDS and PDS contract provision rather than

20 Oct 2003 : Column 1461

here. I can see no benefit in including examples where these are unnecessary. I therefore reject Amendment No. 436.

The noble Earl, Lord Howe, raised issues about workforce planning review and the increased need for dentists, in general. He is absolutely right. The workforce planning review is continuing its work. However, there are very positive signs—for example, the number of dental therapists has increased significantly. On looking at the capacity for this new service to meet the new needs of the dental service, two points can be made. First, it will encourage bigger practices and a better distribution of professional services with the development of ancillary professions and so on, which is very much to be welcomed.

Secondly, the fact that we are moving away from item of service will mean that the dental environment will become more positive and more preventive, which we hope will encourage young people to go into dentistry as a career because the work will be more satisfactory. In terms of capacity, there are some very positive points to make about workforce planning in the whole environment. With those assurances, I hope that the noble Lord will feel able to withdraw his amendment.


Next Section Back to Table of Contents Lords Hansard Home Page