Dental Practitioners

Monday 29th November 2010 Commons Chamber

Motion made, and Question proposed, That this House do now adjourn.—(Bill Wiggin.)

22:00

Sir Paul Beresford (Mole Valley) (Con): I am particularly glad, Mr Speaker, that you are here this evening. I am also glad that my hon. Friend the Minister is on the Front Bench. I hope that he remains my hon. Friend by the end of the evening, but I have had some moments of doubt.

As my hon. Friend is aware, I have a declarable interest in this subject. I am a very part-time practising dentist. I am a member of the British Dental Association, the British Dental Bleaching Society and the British Academy of Cosmetic Dentistry, and I have a link with Lockton, a dental indemnity insurer.

Many of us in the real world of business had great hopes of the new Government, especially in the area of deregulation. Quangos were to be removed, or at least diminished in size, and bureaucracy was to be cut back. Indeed, many Departments have been spectacularly successful in this respect. The Minister’s Department has shown an early positive approach, with plans to remove primary care trusts. Sadly, the Care Quality Commission, which was set up by the previous Government, has slipped through the net. This organisation is now displaying a cancerous bureaucratic growth that I would have expected from the combination of the previous Labour Government working hand in hand with some overbearing Labour council.

In response to early consultation, members of the dental profession, particularly through their organisations, accepted that there should be regulation of the dental profession—they ought to, because there is plenty of that already—but they did not expect the monster that is now descending upon them. All dental professionals will be required to register with, and be regulated by, the CQC by April next year. The profession is being encouraged to do this online. The commission has made some efforts in that they undertook to warn dentists, and they even gave some dentists a registration number. Many dentists did not receive the notification; I am one of those. There are two stages that dentists need to complete. First, there is the enrolment form. To my mind, this form was relatively straightforward, but attached to it were barrel-loads of instructions—page upon page of confusing do’s and don’ts that were excessive and confusing. After registration is accepted, registrants need to complete the CQC permission and validation form.

Included in the second stage is a requirement for a Criminal Records Bureau check. Members of the dental profession are not required to obtain a standard CRB check but have to obtain an enhanced CRB check. This is the first example of the enormous bureaucracy and unnecessary duplication involved. It costs money and time to acquire. Forms have to be obtained, filled in and processed through one of the 100 or so Crown post offices. The Post Office is paid for the service by the dentist, as is the CRB. From time immemorial, the General Dental Council has kept a legal watchful eye over dentists in judicial matters. Any dentist who is convicted of a criminal charge is reported to the General Dental Council—that is simpler and involves only those very few members of the profession who are criminally convicted.

As a dentist and MP, I witnessed the uproar that the last Government caused among the dental profession with the change in the contract for NHS dentists. I have to warn the Minister that the CQC is causing the same uproar. The difference now is that the condemnation by individual dentists and by every organisation related to dentistry is universal. These range from the British Dental Association and all the other similar professional organisations through to, curiously, a group of solicitors called the Dental Law Partnership. The intriguing thing is that the Dental Law Partnership is a group of solicitors with dental training who specialise in suing dentists—but they are on side this time.

To quote Susie Sanderson of the British Dental Association, the CQC is currently seen as overbearing, inconsistent and duplicatory. The Health Department’s impact assessment of the regulation of primary, medical and dental care providers, on which the proposed regulation of dental professionals by the CQC was based, failed to identify any sound evidence to support the proposition that the existing regulation of dental professionals or the systems in which they work in England, were ineffective. There is no reliable evidence base for the proposition that the current regulation of the dental profession by the General Dental Council, among others, fails to regulate the system of dental care, nor is there any reliable evidence that failings of the GDC place patient care at risk.

The attitude of the CQC at its explanatory road shows around the country and at meetings has been seen by those who have attended—I do not include myself—as overbearing and dictatorial. To make matters worse, its responses to questions at those meetings and on its helplines have been inconsistent. There is an apparent lack of understanding of dentistry and the dental profession. Perhaps that was most clearly emphasised at a lecture, when one of the CQC’s senior members of staff failed to understand the difference between the British Dental Association and the General Dental Council.

Even more maddening is that most, if not virtually all, of the proposed outcomes or targets set by the CQC are duplicated in the existing regulations set out in the General Dental Council’s “Standards for Dental Professions” of May 2005. To exemplify that, I will list some of what the CQC calls outcomes—targets by any other name. Outcome 1 covers respect for individuals, outcome 2 is about consent to care and treatment and outcome 3 relates to fees. Those outcomes duplicate the GDC’s existing regulations: standards 1, 2 and 3 of “Standards for Dental Professionals” of May 2005, standards 1, 2 and 3 of “Principles of Patient Consent”, and standards 1, 2 and 3 of “Principles of Patient Confidentiality”. The same applies to the outcomes relating to personal care, treatment and support, safeguarding and safety, and to outcomes 7, 8, 9, 10 and 11—all are covered by the GDC. The same also applies to the three CQC outcomes on the suitability of staff quality and management.

Outcome 14 requires practitioners to demonstrate that ongoing training is taking place. However, the GDC already regulates the professional development of dentists and other dental care professionals. Continuing professional development is compulsory for registered dentists and dental care professionals to remain registered with the GDC and be permitted to practice. Dentists must complete 250 hours of CPD every five years, of which 75 must be verifiable.

Outcome 17, on complaints against dentists, was a favourite of the Labour Government. It requires that there is a complaints and comments system, that there is support for complainants and that action is taken to address complaints. The General Dental Council also requires a practice to have a complaints procedure, so private practices and NHS practices are covered. An offshoot of the GDC, the Dental Complaints Service, deals specifically with patients’ complaints, whether in the national health service or private.

Outcome 10, on the safety and suitability of premises, duplicates matters under the jurisdiction of the Environment Agency, water companies and the Health and Safety Executive. The HSE has the power to enforce the requirement for practices to have a risk assessment. It also has jurisdiction over equipment and its use to ensure that it is properly maintained and serviced. I am sure that the Minister will have done some homework for tonight and will be aware that the fire prevention regulations also fall under CQC outcome 10.

[The Minister of State, Department of Health (Mr Simon Burns)]

indicated assent.

[Sir Paul Beresford]

The Minister is nodding sagely so perhaps I will believe him. The fire prevention regulations are enforced by the local fire authority and any CQC interest in that area is duplication. To my amazement, there is even duplication in the CQC requirements, some of which are addressed many times. For example, evidence that practices have appropriate confidentiality protocols in place must be provided to satisfy outcomes 1, 2, 6 and 21.

Dental providers must comply with 28 standards, but there is no guidance on what the CQC requires as evidence of compliance. Furthermore, it is unclear who the auditors of the process will be. To give an example provided by people who have lobbied me, the NHS Partners Network and the NHS Confederation state that generally, their members have been subject to mixed messages and unclear instructions from the CQC about what to expect from it. They say that in the current financial climate, such uncertainty is particularly difficult for their members and runs the risk of adding significantly to costs without yielding safety and quality benefits. The ultimate guillotine is having one’s practice shut down for failure to comply with a potential deadline of April next year, which is causing deep concern in the dental profession.

Finally, I turn to costs. The current situation is that there is no fee for CQC registration. In contrast, my fee to be paid this month to the General Dental Council is £576, the same as for the majority of dentists. However, the CQC is consulting on proposed fees, which it wishes to divide up depending on the size of a provider. The fees proposed are disproportionate, as the lowest fee is to be £1,500, for a provider with one location, such as my own small, part-time surgery, whereas £48,000 is to be charged for a provider with 101 or more locations.

One of the most glaringly ludicrous points is the extreme jump in fees from one level to another. For example, if a dental firm has 100 practices it will pay £24,000, but if it merely adds one more practice, its fees will double to £48,000. The situation has to be dealt with, and it is in the hands of the Minister and his colleagues to do so. The CQC is charging ahead blindly, apparently with little knowledge and with no response to concerns that have been expressed. It has finally agreed to sit down with the General Dental Council in the next week or two and discuss the potential duplications in registration costs.

I understand that there are organisations similar to the CQC in Wales and Scotland, and both appear to be working closely with the GDC without duplication. The result is that the annual cost to Welsh dentists for their organisation is not between £1,500 and £48,000, but probably in the region of £80 and certainly less than £100.

There is an opportunity for Ministers to act before it is too late, and before too much money is wasted. If necessary, the forthcoming Public Bodies Bill will enable Ministers to remove the CQC from its role of regulating dentists. I remind the Minister that all the problems that it is having with dentists, and dentists with it, are likely to be repeated, and more, in the case of general medical practitioners. They are next on the list.

I await the Minister’s considered response, and I hope that he will take a step back and promise to consider the points made by me and, in particular, by the many organisations that have lobbied on the matter. It would be helpful if there were a serious meeting between Ministers, the GDC, the CQC and the BDA. It is overdue.

22:12

[The Minister of State, Department of Health (Mr Simon Burns)]

I begin by congratulating my hon. Friend the Member for Mole Valley (Sir Paul Beresford) on securing this debate on an issue that I know is of some concern to him and other dentists throughout England. He said at the beginning of his comments that he was a friend of mine and hoped that he still would be by the end of my speech. I echo that, because I, too, hope that we are still on friendly, and hopefully speaking, terms by the end of the debate.

My hon. Friend will know that the coalition Government do not believe in regulation for the sake of regulation. However, there are areas in which regulation is important for the interests of vulnerable people who are less able than others to defend their own interests. The provision of health care and adult social care services is one such area, and since 1 April 2009, the Care Quality Commission has been responsible for regulating those sectors under the Health and Social Care Act 2008.

The Government support the role of the CQC in ensuring that providers of health care and adult social care provide services that, at the very least, meet the essential levels of safety and quality that every patient and service user has a right to expect. I am sure that my hon. Friend would not argue with that, or with the enforcement powers that the CQC can use when providers fail to meet essential levels of safety and quality. He will be aware that the Government are committed to strengthening the CQC’s role as an effective regulator of health and adult social care services in England.

At the moment, NHS and private health care providers are registered by CQC under the 2008 Act, as are providers of adult social care. From April next year, providers of primary dental care and private ambulance services will also be registered. From April 2012, providers of primary medical care will be brought into the registration system.

There are a number of reasons why it is right to bring primary dental care providers into registration and to require them to meet essential levels of safety and quality. First, the current regulatory systems for dentists focus on the competence of the individual. However, how organisations and systems are managed is just as important in protecting the safety of patients. CQC registration will provide the framework to ensure that the provider, as well as the individuals within it, meet essential levels of safety and quality.

Secondly, increasingly complex treatments are being provided in primary care settings. For example, it is likely that more oral surgery will be carried out in primary care in future, and the General Dental Council has seen an increase in complaints about harm caused to patients by the placing of dental implants. Those developments make it even more important to ensure that providers have adequate systems in place to protect the safety of patients. Registration with the CQC will allow potential problems to be identified and addressed before they result in harm to patients.

[Sir Paul Beresford]

The Minister mentioned the GDC and complaints about dental implants. There has also been an increase in poor endodontic work, all of which can be dealt with adequately by the GDC. The situation does not need a huge, monolithic organisation such as the CQC.

[Mr Burns]

I am very grateful to my hon. Friend for making that point. If he will bear with me, I will, at a slightly later stage in the course of my remarks, address whether working together can minimise the level of overlap so that there is no unnecessary duplication.

Thirdly, registering primary dental care providers will ensure that the same levels of safety and quality are met irrespective of where care is provided. One patient could be treated in hospital where the quality and safety of their care is regulated by the CQC, while another receives the exact same treatment elsewhere without that same guarantee. Wholly private dental providers, treating some 7 million patients, are currently subject to no formal scrutiny of the service that they provide.

Finally—I know that my hon. Friend has raised this subject in the past—registration will provide greater controls on the decontamination of used dental instruments. Guidance on decontamination is set out in “Health Technical Memorandum 01-05”. Although that has no legal standing, the CQC can monitor whether providers, including those in the independent sector, meet its requirements by enforcing the cleanliness and infection control registration requirement.

It is the view not just of the Government that the registration of dentists will bring benefits; that view is shared by the dental profession. Responding to the consultation on registration of dental providers with the CQC in June 2008, the GDC said:

“We broadly welcome the establishment of the Care Quality Commission…Whilst we are responsible for the registration and regulation of the whole dental team, whether they work in the private or public sector, there has been no additional means of regulating wholly private dental services…up until now. We believe that this role can be covered by the CQC and would further enhance patient protection”.

The British Dental Association was equally supportive, saying:

“Wholly private providers are currently unregulated (beyond individual professional regulation) and we believe it is essential for this to be addressed.”

[Sir Paul Beresford]

I actually touched on that at the beginning of my short address. The Minister has to realise that the consultation came before the CQC moved into the area of dentistry, before the BDA realised what the CQC was going to do and before the monolithic and, what I called, almost cancerous growth of this organisation.

[Mr Burns]

I am grateful to my hon. Friend for that intervention. As far as I know, however, the BDA was aware at the time that dentists were going to be registered under the CQC, and as I see it, the comments on the consultation process were made in the knowledge of that information.

I know there has been concern among dentists about the potential impact of registration with the CQC, and my hon. Friend made an interesting and vigorous case highlighting what he perceived to be some of the problems. However, I have some sympathy with those dentists concerned that the process of registering with the CQC will be onerous and time consuming. I can assure him, however, that for the majority of dentists—those who already provide high-quality services—there will, to my mind, be no difficulty in meeting the essential levels of safety and quality.

The experience of HTM 01-05 demonstrates this point. Before the introduction of the guidance, dentists raised concerns about the burden that complying with it would place on them. Only today, we have published the results of the dental national decontamination survey, showing that when HTM 01-05 was published in November 2009, about 70% of practices were already meeting the essential quality requirements for decontamination, with approximately a further 20% of practices very near the essential quality requirements. The remaining small minority of practices were not.

This experience will, I believe, be repeated with CQC registration. Most dental providers already give their patients a high-quality service and will find that they already meet the registration requirements. In those relatively small numbers of cases where dentists do not meet essential levels of safety and quality, registration with CQC will force them to improve. This is the purpose of regulation, and such an outcome would result in safer and better dental care for patients.

My hon. Friend has spoken about the potential for overlap in the role of the CQC and the General Dental Council in the registration of dentists, and he raised it again in his first intervention on me. I would like to address that point now. I read with interest the recent letter from a number of dentists in The Daily Telegraph making the same point as him. The CQC and the GDC are working closely to ensure that the roles of the two regulatory bodies are closely co-ordinated. Indeed, the two regulators have agreed and set out a memorandum of understanding that explains how they will co-ordinate their activities and share information to ensure that they do not duplicate actions and therefore create any risk of double jeopardy. It is vital that CQC registration complements the professional regulation of dentists by the GDC. The important word there is “complements”.

[Sir Paul Beresford]

I spoke to the president of the GDC last week, and she said they are having a meeting to discuss this for the first time. So the Minister’s information might have gone a little awry.

[Mr Burns]

I take on board what my hon. Friend says. However, the information I have been given, as I said earlier, is that the two regulators have agreed and set out a memorandum of understanding explaining how they will co-ordinate their activities and share information to ensure that they do not duplicate actions. I trust that that action is correct, I trust that they work closely together to achieve that aim, and I will certainly get back to him if—despite what I have been led to believe—that is not the case.

My hon. Friend also referred to the proposed level of registration fees for dental providers. As he is aware, the Care Quality Commission is currently consulting on its proposals for annual registration fees, which will apply to all providers, including dentists, from April next year. I would like to emphasise that they are proposals for consultation. I would certainly urge all dentists in England to make their views known to the CQC through the consultation process as soon as possible, and certainly before it ends, on 17 January. I heard what my hon. Friend said, and I have seen the consultation document. I can only repeat—and repeat quite vehemently—that it is important that all dentists take part in the consultation process and ensure that the CQC is fully aware of their views before it ends. I should also add that the CQC’s final fees scheme is subject to the consent of the Secretary of State. It would obviously be wrong of me to prejudge the consultation process or what will happen at its conclusion. All I can do is advise my hon. Friend and the profession to ensure that they lobby the CQC as part of the consultation, so that it is left in no doubt about the views and concerns of dentists on the issue.

My hon. Friend also mentioned Criminal Records Bureau checks, which I know have been a particular issue for some dentists. CRB checks are important to ensure that those responsible for the delivery of services are fit to do so. In earlier registration rounds, CRB checks have revealed convictions that were not otherwise declared. Those dentists who already have a CRB disclosure countersigned by their primary care trust can use it for CQC registration. I know that there have been practical problems with getting the required CRB checks carried out, and I understand the frustration that this has caused for some dentists. As a result, the CQC has increased to 100 the number of post offices that can process CRB disclosures on its behalf. That will go some way towards helping to deal with some of the practical difficulties experienced in getting a CRB check. The CQC is also exploring with Post Office Ltd the possibility of extending the service to the entire post office network.

Although there is a degree of anxiety among dentists about CQC registration, I hope—although I am not convinced—that I have reassured my hon. Friend that the majority of dentists, who already provide good services, have no need to fear CQC regulation. For the small number who do not provide a safe service, registration will provide an effective mechanism to bring about improvements for patients. Indeed, that is the very purpose of regulation.

In spite of the concerns, I am pleased to have been told by the CQC that the registration of primary dental care providers is so far proceeding smoothly. More than 7,000 dentists, including nearly 1,600 who operate solely in the private sector, have enrolled in the CQC’s registration process. The CQC has now invited those primary dental care providers to submit applications. I understand that the first completed application was returned to the CQC within three hours and that more than 400 applications for registration had been returned by the end of last week. With what I believe has been a good start, I am hopeful that the task of registering dental providers with the CQC will be completed on schedule by 1 April 2011, and that patients will have the assurance that whichever dental practice they use, whether NHS or private, they will receive care that meets essential levels of safety and quality.

Question put and agreed to.

22:29

House adjourned.