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Debate on the Address

My Lords, the gracious Speech refers to a commitment to providing a healthcare system organised around the needs of the patient and thus it enables me once again to draw noble Lords' attention to the current situation affecting the provision of NHS dental services. The Minister will know, as did his predecessors—I see that the noble Lord, Lord Warner, has just left the Chamber because he has heard all this before—that I support the concept of change in NHS dentistry and have commended the Government for their courage in tackling a dental service that has long needed revision, an end to the fee-per-item-of-service treadmill and help for the less well-off. But the dental profession, which is providing the service, does not believe that the new contract is working. The Government need more courage to consider changes; they need to undertake urgent discussions with the profession and all providers of NHS dental services so as to put the contract back on course. In 1999, the Prime Minister pledged that by September 2001 everyone would have access to an NHS dentist, no matter where they lived. In March 2006, on the eve of the new contract, 46.2 per cent of patients were registered with an NHS dentist. There are no figures for registration since the new contract, so it is difficult to assess the number of patients who now have regular dental care. The new contract was introduced to improve access, but recent surveys have shown that only one in five NHS dentists is taking new NHS patients and that four out of five restrict access in some way. Most dentists believe that the new dental contract has failed to make it easier for patients to get an NHS appointment and that the quality of care that patients receive has got worse. According to the recent Dentistry Watch survey, commissioned by the Commission for Patient and Public Involvement in Health and published on 15 October 2007, about 20 per cent of all patients are declining treatment because of the cost and about half of all patients simply do not understand the charges system. The new contract in 2006 gave primary care trusts responsibility for commissioning NHS dental services using a fixed budget set by central government. The National Audit Office has cast doubt on the ability of the PCTs to commission dental services. It found that the PCTs had little experience of high street dentistry and would need to ensure priority for the delivery of appropriate contracting arrangements, expertise and resources. The contract was not fully negotiated with the profession, to the extent that 1,649 dentists withdrew from the NHS between March and June 2006, just as the new contract was implemented. According to figures published by the Department of Health on 23 August this year, patient charge revenue generated only £475 million instead of the expected £634 million, resulting in a £159 million shortfall in the dental budget. It may be helpful to noble Lords if I explain that, under the system of dental charges introduced on 1 April 2006, the previous list of 400 individual charges was reduced to three price bands: band 1 at a cost of £15.90 for a basic examination, radiographs and cleaning; band 2 at £43.60 for single or multiple fillings, extractions or root canal work; and band 3 at a cost of £194.00 if construction work such as crowns is included. The new system means that the minimum charge for a treatment, which was previously £6, has risen more than two and a half times. The money paid to dentists, which is dependent on the number of units of dental activity accumulated, does not reflect the amount of work carried out. For example, dentists receive the same amount of UDAs from the primary care trust for treating a patient regardless of whether they do two fillings or 10. The number of UDAs awarded is not necessarily related to the time taken to complete the treatments. I understand that this can create a swings-and-roundabouts situation but it is not conducive to carrying out the best possible treatment for each patient. At a meeting of the Westminster Diet & Health Forum on Tuesday this week, I mentioned that 1.4 million fewer people receive NHS dentistry than did at the start of the new contract. I was corrected by Dr Barry Cockcroft, the Chief Dental Officer, who told me that access over the two-year period has remained broadly stable, with a 0.1 per cent fall of 47,000 according to the latest Department of Health statistics. I have the highest regard for the Chief Dental Officer, who is a brilliant champion and defender of the changes made by the Government. He has worked for 27 years in NHS general practice and has been closely involved with local dental committees and the task groups that formed the basis of the Options for Change report. His skills in the negotiation, explanation and implementation of the new contract are commendable, but sadly the views of the Government, the Department of Health and Dr Cockcroft are at variance with those of most of the dental profession. Most dentists want to work for the NHS to provide a quality, preventive dental service, but the contract is seen as being flawed and this opportunity is being denied. The Government have created a system based not on prevention but on a new treadmill, creating the unnecessarily prescriptive system of monitoring output via units of dental activity. Specific oral health advice, spending time with patients and advising on diet, smoking, drinking and good personal oral health regimes, does not attract any units, although I am aware that next week all practices will be sent information on evidence-based prevention and primary care and how this should be provided under the dental contract. I think that when the Minister, the noble Lord, Lord Darzi, made his recent statement on obesity, he agreed with me that the dental profession should be in the front line in providing advice to patients on nutrition and diet. Good oral health is vital for good general health. Promoting the potential of fluoride either in toothpaste or by targeted water fluoridation will reduce tooth decay significantly. I should be grateful if the Minister could confirm the Government's continued support and funding for the British Fluoridation Society. The British Dental Association is suggesting that a range of performance indicators should monitor dentists' activity, rather than reliance on the UDA as a predominant indicator. These should be agreed locally between the PCT and dentist contractor, based on the practice profile and the needs of local patients. Indicators may include numbers of patients seen and time and provision of additional services in conjunction with UDA monitoring. Rather than relying on 25 per cent of the dental commissioning budget coming from an unpredictable amount of patient charge revenue, PCTs should receive their dental commissioning budget in full. This would provide PCTs with financial certainty and allow them to commission the maximum amount of NHS dental services. I welcome the announcement that the Health Select Committee in another place will undertake an inquiry into dental contracts, including the general dental contract and the NHS personal dental services agreement. I welcome also the publication on 1 November of the London Assembly report on NHS dental care in London. It highlights concerns over the way in which NHS dentistry is delivered and calls for the department to revise the contract to encourage preventive care. Oral health across England varies widely and London is at the bottom of the list. In his Statement on obesity on 17 October, the noble Lord, Lord Darzi, said that he might look at the allocation of UDAs in respect of prevention. The report calls for revision of the dental contract to see how it might be possible to build preventive care into the equation. If the noble Lord, Lord Darzi, is responsible for that, I congratulate him. The Government need to trust the profession and to make the profession feel part of the NHS family. The Minister will be aware of the number of times that I have drawn attention to the absence of any reference to the dental service in government NHS policy. About 120,000 people work in NHS dentistry, including dentists, nurses, receptionists, practice managers, technicians and members of the community and hospital service. They should be consulted and represented and their contribution should be recognised. I shall look forward to hearing the Government's plan for the future.