National Health Service (Primary Dental Services) (Amendment) Regulations 2022
(1 year, 10 months ago)
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Lord Hunt of Kings Heath
That this House regrets that the changes to dental contracts in the National Health Service (Primary Dental Services) (Amendment) Regulations 2022 (SI 2022/1132) will not have a significant impact on improving access to dental treatment whilst current workforce shortages persist.
Relevant document:18th Report from the Secondary Legislation Scrutiny Committee
Lord Hunt of Kings Heath (Lab)
My Lords, it is good as ever to know that dentistry excites such interest amongst your Lordships. I am very grateful for those noble Lords who are going to take part in what I think is a very important debate tonight.
Like many aspects of the NHS, our dental services are under great pressure at the moment. Indeed, there are reports that some patients are resorting to DIY dentistry and removing their own teeth because they cannot get access to an NHS dentist. In August 2022, the BBC reported that, based on a survey of 7,000 NHS practices, nine out of 10 NHS dental practices across the UK were not accepting new adult patients for treatment under the NHS. The BDA believes that NHS dentistry is facing, as it calls it,
“facing an existential crisis with the service hanging by a thread”.
The problem predates the pandemic, but it has now reached an unprecedented scale. The BDA estimates that over 40 million dental appointments have been lost since the start of the pandemic. Those from low-income or vulnerable groups are being disproportionately impacted, with 1 million new or expectant mothers having lost access to care since the start. Dentistry has been subject to cuts unparalleled in the NHS; in real terms, estimates suggest that net government spend on dentistry in England was cut by over a quarter between 2010 and 2020. The BDA argues that chronic underfunding and the current NHS dental contract are to blame for long-standing problems with burnout, recruitment and retention. We know morale among NHS dentists is very low, and we are facing an exodus of them from NHS practice.
The regulations before us today are welcome, but they will not turn this around. Under the regulations, subdividing band 2—putting more complex treatments into categories 2b and 2c—should hopefully reward dentists’ time and input more accurately. More generally on access, I understand the NHS has started commissioning “access sessions”, remunerated using a sessional fee in practices with an NHS contract in the north-east, using existing flexibilities within the current regulations. I hear that this scheme has worked very well, and I congratulate the commissioners and providers on this. Can the Minister confirm this and say whether it is to be rolled out across the country? I certainly think that this should be a priority. Because it can be done under existing regulations, and because of the protracted delay in moving from the long pilot scheme we have had to a new contract, this surely is an area where Ministers could make some progress in the short term, provided they provide resources to the health service to do so.
We are debating one element of a package that was announced by the Chief Dental Officer last year, designed to improve access. Two weeks ago, we agreed on one of those planks—regulations which gave dental care professionals the ability to open new courses of NHS dental treatment when they are trained and competent to do so. I do not want to go over the ground again; I think that this is a significant change that should be applauded, but there are still blockages in making it work effectively.
First, under previous regulations, a DCP would have needed a performer number to open a course of treatment, and with that would have come associated pension benefits. I understand that, under the recently issued guidance from the NHS, the DCP has to demonstrate competence by entering their GDC registration number, but the dentist whose performer number appears on the NHS form signing this off actually accrues the pension benefit. That does not seem to me to be fair, it is potentially discriminatory, and I wonder if the Minister could give me some justification for that, perhaps in writing.
Secondly, work has been going on for over a decade to allow DCPs to give local anaesthetics without having the direction of a dentist. Can I ask when that is going to be implemented?
Thirdly, given that the current system of remuneration of our dental schools means that it is much more attractive financially to train dentists, will they be incentivised to train more DCPs? If not, how are we going to see a substantial increase in DCPs? If I may just take the Minister back to our debate two weeks ago and the decision to exclude overseas dentists from working as DCPs, I still fail to see the justification for that.
The third plank of the package announced by the Chief Dental Officer to improve access was in relation to NICE guidance published in 2004. The concept of six-monthly recalls is embedded in our society and among patients, but it is not evidence-based and recall intervals need to be tailored to risk—in some cases, six months may be appropriate, but not all. The time taken up by unnecessary recalls could be used to grow access, and I would like to know how the Government intend to make sure this guidance is complied with.
Putting this all together, it is inevitable we come back to the issue of the critical shortage of workforce. Opening new dental schools is clearly one solution—I would like to see that—but we know that it takes up to 10 years from taking the decision to open a new school to clinicians entering the workforce. We clearly do not have 10 years, so we need to train more dentists, but in the near-term we have got to make NHS dentistry a more attractive option to improve retention of existing clinicians, while also making it easier for overseas dentists to work in the NHS.
The obvious way to make NHS dentistry more attractive to dentists in the UK is by increasing the budget for NHS dentistry. Given the real-terms cuts that we have seen—a quarter since 2010—this is essential.
In the short term, overseas dental professionals are one key to addressing the workforce pressures and ensuring access to NHS dentistry. One way that we can achieve this quickly is by streamlining the GDC processes for accepting individuals on to the register. This can be done by the UK striking more mutual recognition agreements for dental qualifications with countries of comparable standards and creating more places for the overseas registration exam. The GDC’s current mutual recognition of EEA-qualified dentists is also vital in boosting short-term applicant supply; this must not be removed.
Then there is the performers list validation by experience process, which all dentists not qualifying in the UK must go through to practise in the NHS—it needs standardising, simplifying, and streamlining. Does the Minister agree?
We also need to look at the work dentists do. I was briefed by BUPA that 24,272 dentists did some NHS work in England in 2021-22, but 15% of the workforce—almost 4,000 dentists—did no more than one patient course of NHS treatment a month on average; that seems quite extraordinary. How can that be justified? Can the Minister confirm that dentists do keep their performer number active by that process, which means that their historically earned NHS pension is dynamised on an annual basis? How can that possibly be justified?
Finally, we want to hear from the Government what priority they give to NHS dentistry. I put it to the Minister: is he content to see the dismantling of the service with access problems, piling up the misery of millions of people, and the frightening growth in self-treatment? Let me remind him of the BDA’s belief that
“NHS dentistry is facing an existential threat and patients face a growing crisis in access, with the service hanging by a thread.”
Are the Government essentially saying that they are content for this to happen? If not, then we need to see concrete plans to increase resources and the workforce to ensure that patients who want NHS treatment can get it in a timely way, confident in the quality of care they receive.
When I was Minister for Dentistry from 1999 to 2003, the then Prime Minister Tony Blair made a pledge that any patient who wanted to see an NHS dentist would be able to do so—and we achieved it. It can be done with strong leadership and the support of the profession. I hope the Minister will tell us whether the Government are going to go down that route tonight. I beg to move.
Baroness Bennett of Manor Castle (GP)
My Lords, it is a pleasure to follow the noble Lord, Lord Hunt of Kings Heath. I thank him for securing this debate and for so clearly setting out the pressing issues around dental treatment. He set out the massive, chronic underfunding—a quarter down since 2010—and the workforce problems. As he said, the regulations we are debating are an extremely modest, if welcome, step to address that to a very small degree.
I will take this opportunity to take a somewhat broader view of dental health and raise a couple of issues that are arising from the crisis of the lack of NHS dental provision. My first point draws on the WHO Global Oral Health Status Report, which was published in November 2022. It stressed that most oral diseases are fundamentally preventable through addressing the social and behavioural determinants, with risk factors such as tobacco, alcohol and sugars that are shared with many other non-communicable diseases. So the first question I put to the Minister is: are the Government really taking seriously the issue of addressing good oral health and public health conditions, which would have so many other positives in terms of issues such as obesity, diabetes, et cetera? Are the Government looking at this in this kind of way?
Secondly, the WHO global strategy on oral health says:
“Achieving the highest attainable standard of oral health is a fundamental right of every human being.”
I will refer here to an article published in the Lancet Public Health on 11 December last year by Winkelmann and other authors, which looked around the world at the different classes of oral health coverage available. There are four: no coverage at all, limited coverage, partial coverage, and comprehensive coverage. The UK, I am afraid, falls in the second of those four increasing levels of coverage: limited coverage. We know that the Government like to claim to be world-leading in many contexts, so do they have an aspiration at least to reach the comprehensive or advanced level of coverage identified in that study, which would mean making dental treatment available to all and ensuing a high quality of preventive public health provision?
My third point is on the issue of dental health tourism. This was prompted to the front of my head again this morning by sitting in a Tube carriage in which I was facing adverts saying, “Get your teeth fixed—go to Turkey”. A couple of days ago, there were a number of horror stories about this across the tabloid newspapers. I am not picking on Turkey in particular, because I do not have the stats on how many people are going where and what problems are arising—but I do not believe that the Government have stats on what is happening with dental health tourism or those problems, either.
As I understand it, there is no reliable source of data on all outbound UK medical tourism, whether it be dental or other forms, but the ONS has estimated that 248,000 UK residents went abroad for medical treatment in 2019. I assume that quite a number of those treatments were probably dental. Indeed, in a recent article the Guardian quoted the editor-in-chief of the International Medical Travel Journal—it is interesting that there is a journal on such a thing—saying that this was going up fast. Are the Government going to collect any stats on both dental tourism and other forms of medical tourism? Are they going to publish those? Are they going to look into whether this is an issue, in which case the stats would clearly be a starting point? Does the Minister agree with me that when these operations go wrong overseas, we will end up seeing the UK dental health system and general health system ultimately having to pick up the pieces?
I come now to my final point. Your Lordships’ House will shortly be engaging, I suspect at some considerable length, with the Levelling-up and Regeneration Bill. It is worth stressing how much dental health issues are a levelling-up issue. The south-west of England, Yorkshire and Humber and the north-west have the largest shortage of provision of NHS dental services, with 98% of practices in these areas refusing to accept new adult NHS patients, according to the latest figures I have been able to find.
I have raised a number of points, and I understand that the Minister may need to write to me on some of those. We sometimes have this sense that there is health, and then there is dental health. Indeed, the article I cited earlier stressed that the WHO is concerned that dental health is often seen as something that is done by private clinics in private places—but, of course, dental health is crucial to the health and well-being of a healthy population. We have, in so many different areas, a public health crisis in the UK. Dental health is one more of those areas, and it must not be left behind or neglected because of historic structural factors.
Lord Allan of Hallam (LD)
My Lords, I am grateful to the noble Lord, Lord Hunt, for ensuring that we have an opportunity to debate this important statutory instrument today. We benefit from his detailed analysis of problems in the dental sector.
The facts are laid bare in the Government’s own impact assessment, which says:
“NHS dentistry was a challenging area prior to the COVID-19 pandemic, with patient access proving difficult in some areas of the country … The COVID-19 pandemic exacerbated problems with patient access and created a backlog of patients seeking access to NHS dentistry.”
There is a recognition in that analysis that people being unable to access NHS dentistry is a long-standing problem. As other noble Lords have said, the statutory instrument is correctly aimed at addressing some aspects of that shortfall, and we would not oppose it as a contribution to solving the problem. However, we would ask the Minister, “Is this all you’ve got?”, given the clear and enormous gap between demand and supply.
The figures are dire. Again, the Government’s own impact assessment shows that the success rate for patients seeking an NHS dental appointment has fallen from 97% in 2012 to 82% in 2022 for people with an existing relationship with a dentist—so one in five of those who already have an NHS dentist relationship are not being seen. But for those trying to get their first NHS dental appointment, this has become almost impossible in many areas, with only 31% of those who had not been seen before successfully getting an appointment, compared with 77% of the same group in 2012. When we drill down into these national figures, we also see significant variation around the country, with some areas having become known as “dental deserts” because of the lack of dentists offering NHS treatments.
Turning again to the impact assessment, we see that it tells us that
“the North West has generally good access (but with pockets of poor access in rural areas), compared to the South West and East of England where access is generally poor, particularly in rural and coastal areas.”
This is a terrible indictment of what is supposed to be a nationally available essential service—one that is likely to have a disproportionate effect on deprived people who often need intensive dental care. The noble Baroness, Lady Bennett, also raised this point, quite rightly, in the context of the levelling-up agenda—or is it the gauging-up agenda? In any case, the agenda to deliver better services to people in historically deprived areas is critical to this understanding of the disparate access to dental care.
These changes are supposed to incentivise better provision of these intensive treatments but I note that again there is no statutory review clause in the instrument requiring the Government to produce data that will show their actual impact. I hope the Minister will want to commit to producing such a post-implementation evaluation in due course, even if that is not a statutory requirement. I am sure he will talk up the benefit of making these changes but the proof will be when we come back in a year or two and we can see whether there has been a change in the number of people able to access NHS dentistry and the number of treatments that were given.
As well as amending the payment scheme, this regulation places new requirements on dental practices to update information about their services for publication on the NHS website. This may seem weird, but I experienced a twinge of fond nostalgia as I read up on this section. It took me back to my first technology job, where I was responsible for producing the directories of primary care practitioners for what was then the Avon Family Health Services Authority. These consisted of papers in ring binders that listed each dental practice and its services for distribution to libraries and other public information points.
That was in the mid-1990s before the massive growth of the public internet, but I managed to get hold of some software called the NCSA HTTPd, an early web server, and I produced an HTML version of our directory for people in the local authority. All of those products are now long discontinued, as indeed is the country of Avon itself, so this is of historical rather than current interest. However, that may have been version 0.001 of the public directory that we now have on the NHS website.
Fast-forwarding to the present day, it will be no surprise that we support improvements to provision of information to the public such as those in the statutory instrument. However, that has to be complemented by improvements to the availability of services or we will simply see increased frustration as people are given better information about what they cannot have. Does the Minister have a response to people who will go to the NHS website and find that there are no dentists taking on NHS patients in their area?
I hope that the Minister will not think it churlish if we say, “Thanks but not enough” in response to this instrument, and that he may have some additional remarks to make about what more the Government plan to do, especially in respect of creating the NHS dental workforce. I emphasise “NHS”; there are many areas where there is no shortage of dentists, but there is a shortage of dentists who are willing to work for the rates that the NHS is prepared to offer them. I hope that by making those improvements, we will be able to move on from where we are today, where seven out of 10 people in this country who try to get into the NHS dentistry system for the first time cannot find anyone to take them on.
Baroness Merron (Lab)
My Lords, I commend my noble friend Lord Hunt for such a thorough analysis and for bringing this debate before your Lordships’ House this evening. As ever, he brings his expertise, knowledge and incisive approach to this important subject: the provision, or lack of provision, of dentistry.
As we have heard, we have seen a quarter of the budget cut since 2010 and with dentistry, a complete failure to provide a proper service to the population of this country. We know that dentists suffer burnout and that there is difficulty in retaining and recruiting the dentists that we need, while insufficient numbers are in training. This is a toxic mix. We also know that even under the existing budget, even if it was utilised fully, funding is available to provide NHS dental services for only around half the population. We find ourselves in considerable difficulty.
Let us remind ourselves about this statutory instrument. It was drawn to the special attention of the House by the Joint Committee on Statutory Instruments in its report because the regulations are
“defectively drafted in two related respects.”
To look at the specifics of those, as the noble Lord, Lord Allan, also raised, I ask the Minister why it was not felt necessary in respect of primary dental service agreement changes to give a timeframe for dental practice profiles to be provided for the NHS website. Does this not, as the Joint Committee on Statutory Instruments criticised, insert a somewhat unacceptable level of uncertainty into the statute book? I look forward to the Minister’s comments on that point. Furthermore, in respect of the criticisms of this statutory instrument, can the Minister say why NHS England has received no steer within this as to what a “reasonable timeframe” is to take action against non-compliant contractors, which the JCSI concludes
“leaves this law unacceptably uncertain”?
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
My Lords, I start by declaring an interest: as I have mentioned before, my wife is a dentist, and so interested in this. She has been able to join us here, as part of a celebration for my father’s 80th birthday. Who knows why they would want to come and listen to me on such a night?
I thank the noble Lord, Lord Hunt, for securing the debate on this important matter and thank noble Lords for their contributions. We all agree that dentistry is a vitally important area. On the points made by the noble Baroness, Lady Bennett, I agree that health and oral health are indivisible. This is a key part of levelling up. I agree with the premise that these SIs are a start, not a finish—a point made by the noble Lord Allan.
I will try to address the points made by the noble Baroness, Lady Merron, about the defects of the SI. I am not defending some of the other things but I would like to think that this regret Motion and the one that we had the other day are more about having a debate because we think that we can do better, rather than disagreeing with the SIs themselves. If that is the case, I agree that they are the start and not the finish; there is definitely more that we want and need to do in this space. These regulations are a sensible first move. Some changes have been mentioned already tonight but the UDA changes—to put the minimum value in place and ensure that it more fairly reflects the complexities of some of the treatments—are steps that we worked with the BDA on. I think we would all agree that they are sensible steps.
I have also heard various variants on some dentists, for want of a better word, gaming NHS contracts. I have definitely seen some of that behaviour. I will need to take away some details on the points that the noble Lord, Lord Hunt, made about pension qualifications, but we generally recognise that that is going on. At the same time, the provisions within the SI to give more support, 110% or even more, to those who are properly contributing to the system are welcome. I hope that that would be generally agreed.
I hope that we would all agree that the other measures, such as using teams to get a better skill mix and DCPs to do more of that work, are sensible. I agree that we need to reduce those obstacles. I did not realise that we had the Tim Berners-Lee of the dentist directory among us today, but I hope that we would all agree that moves on dentistry website information are sensible, modest though they are. I know that water fluoridation is a great favourite of the noble Lord, Lord Hunt. We are making moves on it. On the changes we were discussing the other day on GDC international recruitment, the mutual recognition of qualifications is a good first step and should definitely be a way forward in easing access. There clearly has to be a better way forward on intelligent use of recalls, rather than those people who are already lucky enough to be with an NHS dentist automatically getting a six-monthly reminder. We all know that, in many cases, those appointments could be better used elsewhere.
As mentioned, we all agree that these measures are just the start and definitely not the finish. The steps we need to introduce have to centre around supply and workforce. On when the workforce strategy will be published, fairly advanced drafts are being circulated, as I mentioned the other day. A lot of work has been and is being done in that space. While I cannot give a precise date, I think it will be in the not-too-distant future—let me put it that way. We recognise that more needs to be done on it. As the House has heard me say before, a lot of that is around the flexibility between qualifications and having much more of a modular, escalator-type approach. For instance, it surely makes sense for a dentist to be qualified as a nurse along the way, two years in, and then to be able to start work in the dentistry profession and hone their skills, rather than supplementing their income down at Wetherspoon’s as they finish the rest of the course. I think we all agree that those have to be sensible measures, and I know this is very much the direction of travel being worked on.
The critical element is dental deserts. We all know this is the nut that we have to crack. When I have conversations with colleagues normally, having a bit of knowledge can sometimes be a dangerous thing. In this instance, I try to describe it. I ask them to think about a situation where we want a dentist who has probably been there for about 10 years and is in their mid-30s. We might say, “We would now like you to set up your own practice.” The dentist says, “Great, I’d like that. I’m up for that.” We say, “And in an NHS dental desert, because that’s where we need it.” The dentist says, “That’s good, I really want that. What do I have to do?” We say, “Well, raise 400 grand to set up a practice; set up payroll so you can employ six to eight people; start marketing yourselves; fit it all out, get the chairs, and off you go.” They say, “Hang on a moment, I’m a dentist. I’m good at being a dentist. I’ve done it for 10 years, and I think that qualifies me. I’m not in a position to go out there and set up a dental practice like that.” So, I think there is recognition that, if we are really going to move the dial in that area, we have to give them far more help and support: the know-how, some of the funding, the whole package. Clearly, if you are going to get that support, you need to be committed to doing it in that area, but that is the kind of direction of travel that I know colleagues are working on. So while I portray a personal view in terms of my feelings towards it, I know that is very much recognised by colleagues in the House.
Lord Hunt of Kings Heath (Lab)
My Lords, I am very grateful to noble Lords who have taken part in this short debate. As the Minister mentioned fluoridation, I should just remind the House that I am president of the British Fluoridation Society and patron of the National Water Fluoridation Alliance. I agreed with the noble Baroness, Lady Bennett, when she talked about the WHO and preventative measures. The single most important measure would be to introduce fluoridation where it is not present at the moment. I was delighted when the Government took powers back to themselves to do this. I know that progress is being made: I just urge the Government to speed it up.
I also say to the noble Baroness, Lady Bennett, that she is right to identify the levelling-up Bill. It is a long Bill, but there is room for more amendments in relation to health. There are some already, but I would encourage her to think about that. She and the noble Lord, Lord Allan, raised the issue of the south-west. I had a meeting today with Stonewater, a very large social housing provider, which is very concerned about the lack of housing in the south-west. I would definitely make the link between housing and health, which is a very important issue if we are serious about levelling up.
The noble Lord was right to identify that these problems started before the pandemic, and that we are now facing particular issues, but the underlying structural issues are still not being dealt with. I also agree with him about post-implementation evaluation. I hope that the Minister, when he responds in writing, might be able to say something about that.
My noble friend Lady Merron was absolutely right to hone in on retention and recruitment. Although there are various initiatives, at the moment I do not think enough is being done to retain the profession within NHS dentistry. We need to do very much more about that. Her point about practice information going on the NHS website is really important, and I hope that the Government will respond to it.
Ultimately, it comes back to prioritisation and money, and I was grateful for what the Minister said. I am delighted that his wife is present to hear our debate, and indeed that he is celebrating his father’s 80th birthday. It reminded me that I took my wife with me—for a romantic 50th birthday celebration—to address the Pharmaceutical Services Negotiating Committee dinner. She has never forgotten that or forgiven me for that great sin, nor has she forgiven Alan Milburn for making me do it.
Anyway, the point is that we come back to the workforce strategy, because without a properly funded workforce strategy, with numbers, we will not get anywhere. In the meantime, there is still a lot that can be done to streamline GDC processes, recruit dentists from overseas and, crucially, give dentists currently in the profession but not doing NHS work some confidence that it will be worth their while to do NHS dentistry.
I was very interested in the point the Minister made about the cost for dentists coming into NHS dentistry and starting a new practice. He will, of course, have been interested in what Wes Streeting had to say about the future of primary care. He came in for some criticism for suggesting that maybe the current model of GP partnerships might not always be the right one. He is absolutely right that we have to think rather radically about how we will develop primary care in the future.
The argument for a proper strategy for dental access for NHS patients is very persuasive indeed. Having said that, I thank noble Lords and beg leave to withdraw my Motion.