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Address in Reply to Her Majesty’s Most Gracious Speech

My Lords, the trouble with a debate such as this, with different speakers covering three or four major subjects, is that it loses the usual flow associated with the high-class debates in this Chamber. After that brief foray into education, I apologise for taking us straight back to healthcare. The Government have again outlined some bold healthcare policies in the gracious Speech and in the media in the past few weeks. I support a number of the proposals, and it is encouraging that the Government at last see the value of the role of the private sector in the provision of NHS healthcare. Although I fully accept that change and reform in our healthcare system take time, the Government have to their credit attempted to take some tough decisions, such as the Prime Minister’s recent pledge to offer more choice and personalised provision for patients. But that has not been followed through in all sections of healthcare. With healthcare professionals seemingly left out of that decision-making, there now seems even more indecision and uncertainty within the professions. That is no more true than in NHS dentistry. It will be no surprise that I want to confine my remarks solely to dentistry. I have been in practice for nearly 40 years, half of which were in the National Health Service. I want to use my experience to encourage the Government to consider a radical reform agenda for primary care dentistry, just as they have done for secondary, hospital-based healthcare. The Government have undoubtedly attempted to be radical in NHS dentistry, and it would be churlish not to say so. The passing of the Health and Social Care (Community Health and Standards) Act 2003, for example, represented some of the biggest changes to dental commissioning in the history of the NHS. I was happy to offer advice, and sometimes constructive criticism of the Government, during the legislative stages of the then Bill in this House, and was pleased by the details in the NHS dentistry: options for change White Paper of 2002, which clearly set out the way dentists would be able to get off the NHS treadmill of work. The Government have made strides towards changing a system that basically remains much as it was at the inception of the NHS in 1948, but that is also part of the problem. They seem unable to acknowledge that there are severe, endemic and terminal problems with the system. Queues for NHS dentistry seem to be the norm every time a new NHS practitioner opens his or her books to more patients, making the Prime Minister’s 1999 pledge on NHS dental access the most misplaced and inappropriate political soundbite ever. But it is the failure to get to grips with the cumbersome and gigantic system of NHS dentistry that is most telling. The changes offered only tinker at the edges of the problem. There is not enough radical, bold and brave thinking. I acknowledge that the Government have committed themselves to a huge increase in funding for the NHS, but that increase has not been felt across the   board. Last year, the Government’s own auditors, the National Audit Office, showed what the dental profession had been saying for many years—that NHS dentistry has historically been underfunded. The NAO’s report bears that out. NHS spending on high-street dentists per capita had increased by 9 per cent since 1990–91, compared with a 75 per cent per capita increase in overall NHS funding. The debate should not simply be about levels of headline funding but should be more radical. We need to think widely and consider future scenarios and possibilities. We need to make the tough decisions about better spending—not just more—and spending better in partnership with the private sector. In the discussions for the new NHS dental contract, the Government have publicly stated that they will guarantee all current income levels for NHS dentists for three years. That is welcome and has brought some measure of certainty to an increasingly uncertain process, but what happens after those three years? The Government have consistently dodged that question, and I fear that they have no idea what will happen either. They seem to be patching up the funding system as they go along. The personal dental service contract is another case in point. It was designed as a new type of contract—to move dentists away from item-of-service, piecemeal work to preventive-based, individually decided and tailored contracts. It was supposed to be a move away from a monolithic, ““one size fits all”” NHS contract, but in reality the Government have not been able to bring themselves to change the system that much after all. Those dentists who did mostly NHS work are shifting over to PDS, but the dentists doing more private work are not. A polarisation of the profession is now becoming much clearer. It could be said that all that PDS has done, on the face of it, is to replace one NHS system with another differently named, slightly different NHS system. It is better than the old contract, with the emphasis now on preventive-based dentistry, but it does not address the capacity issue within NHS dentistry. If increasing capacity was the Department of Health’s overarching aim, it has failed. That is not a very radical way to reform the system. Patient charges are central to the way in which the Government plan to reform—or not—NHS dentistry. Yet they have been sitting on the Cayton review of patient charges for more than a year, and there is now talk that the report has been quietly binned. That secretive and over-careful approach from the Department of Health is not the way to start a debate on how to proceed with this incredibly important aspect of reform. It shows yet again how the Government are looking at the issues in isolation. The Government need to do some serious thinking on what sort of service they want to achieve and how it is going to be paid for. NHS dentistry has not been free at   the point of delivery since 1951, despite this Government’s mantra that NHS systems remain ““free at the point of delivery””. But whether they are free or charged for becomes completely irrelevant if NHS dental services are simply not available, which is the reality for too many people today. So, taking the new Government at their word, I challenge them to have a serious debate about NHS dentistry and to think radically. For example, should we consider focusing NHS dentistry solely on free services for only particular groups of the population, such as children, people with special needs and older people? The consequence would be that today’s fee-paying adults would be taken out of NHS dental entitlement altogether. Should we reduce NHS dental care to a limited range of services, such as oral health assessments—that is, thorough check-ups—basic pain relief and fillings, and leave more complex treatments to be charged for? Should there be more use of dental patient insurance schemes—either state or corporate-run—with different levels of payment for different levels of service? I do not know the answers to those questions, but the Government need to start thinking in that wider manner. They need to pose those questions, and start a debate on where NHS dentistry is going and how it will be paid for. They promised in their election manifesto a ““fundamental review”” of the funding and scope of NHS dentistry, which I hope will cover the whole system and not merely certain parts of it. I said that I did not know the answers to the questions that I posed about which direction NHS dentistry should take and how it should be reformed, but on some aspects I can comment with authority, such as oral health. Good oral health, especially in children, is absolutely critical and plays a part in so many other social and health issues. If the Government are serious about showing themselves to be radical in their third term, tackling oral-health inequalities should be at the forefront of any future plans and public health strategies. The Government have made significant progress in that area, and I congratulate them particularly on the strong stance that they took in pressing for targeted water fluoridation to be put into statute. However, other areas can easily be tackled that would help to reduce some of the appalling oral-health inequalities that still exist in this country. Tackling what children eat and drink in our schools would be a good start. It is currently a very popular topic. Another aspect of improvement would be a better skill mix between dental professionals. At times, the dental profession has been guilty of not maximising the efficiencies of the whole dental team. Dental hygienists, therapists, technicians and nurses can all play a bigger role, but the Government have not offered much leadership or vision of how that skill mix can be expanded. Again, it is that sort of radical reform which is needed. The Government need to be bold and brave in their policy thinking. They need to expand the argument away from the narrow confines down which they are currently going of tinkering with parts of the system in isolation to everything else to prove that they are doing something about the problems. They should tackle the whole aspect of the system in one go. I hope that the Minister will react favourably to what I have outlined and bring my remarks to the attention of the appropriate Minister. I have attempted to be helpful to him by opening up those issues, but if the Government are serious about fulfilling their rhetoric on being radical in how NHS provision is delivered and structured, a good place to start would be NHS dentistry.