Lord Storey
Main Page: Lord Storey (Liberal Democrat - Life peer)NHS: Dentistry Services
Lord Storey Excerpts
Lord Storey (LD)
My Lords, I thank the noble Baroness, Lady Gardner, for initiating this debate. I remember a similar debate in the Moses Room about two years ago. I knew nothing about dentists or dentistry, but I was on the subs bench and had to speak on the topic. I learned so much from that debate and I hope that that learning experience continues. I am conscious of the fact that I am among people who have given a lifetime to the profession. I also thank those organisations that sent some stunning briefings; particularly our own House of Lords Library and the Royal College of Paediatrics and Child Health.
The title of the debate concerns the availability of NHS dentistry. If you live in Barrow-in-Furness, it is a 90-mile round trip to see the dentist. It is the same in Whitehaven, Windermere, Bodmin and King’s Lynn. Morecambe is not exactly in a remote part of the country—I declare an interest in that my wife, like Thora Hird, is from Morecambe—yet it is a 61-mile round trip to see a dentist. It is the same in Plymouth. Tim Farron, the MP for Westmorland and Lonsdale, in a debate in the Commons in July this year, said that the situation “has reached breaking point”. For those who have to travel, it is not just the cost of going to the dentist, it is the cost in travel. Will the Minister, in replying, address those difficulties?
It seems to me that whether we are the fifth- or sixth-wealthiest country in the world, it is surely not acceptable that 31% to 41% of five year-olds across the UK have tooth decay. It is particularly unacceptable that those young people are concentrated in the most deprived communities of our country. Of course, we all know that tooth decay is the most common single reason that children aged between five and nine are admitted to hospital. Not only could we do something to sort out decay in children’s teeth—we will come to that in a moment and we will all have contributions to make—we could do something about waiting lists and waiting times in our hospitals. Just imagine the time we could free up if we did something about this, because tooth decay is entirely preventable.
NHS dentists struggle to see even 55% of the population in a one-year period. Lack of access to emergency dentistry is often seen as contributing to overcrowding in hospital accident and emergency departments. The British Dental Association claims that 380,000 patients a year with dental problems are approaching their general practitioner—what? We know that in England dentists are now paid in units of dental activity—UDAs; I learned about this last time, and I spoke to one of my colleagues. Typical values for these units are £20 to £35. They are paid at one unit for a band 1 course of treatment, three units for a band 2 course of treatment, and 12 units for a band 3 course of treatment. For many treatments, the rate of pay is below the cost of providing the treatment to a modern standard and, as a result, many dentists will refer patients for any unprofitable services. I raise this, and I hope the Minister can give more details, because I do not quite understand it.
I asked Adam, my dentist, “How do you ensure that more young people are treated by an NHS dentist?”. He replied, “Ah, Mike, the problem is UDAs”. Each practice is given so many UDAs to treat children, and when they are used up, they cannot treat any more children. The problem is that in affluent areas, dentists will have UDAs left, which will go back to the Treasury, but in deprived areas, the UDAs might finish after six, eight or nine months. Why can we not transfer the surplus UDAs from the affluent areas to those areas? I do not understand that, and I would be grateful if the Minister could explain it, making it simple for me—keep it simple for a simple person—so can I understand how we can use UDAs effectively to treat young people’s teeth.
Poor oral health can profoundly affect an infant or child’s health and well-being. A quarter of adults do not think that it matters if their child develops cavities in their baby teeth, and admit to a lack of knowledge about oral health. There is a common misconception that baby teeth do not matter. However, they are essential for speech, the structure of the space, and for holding space for adult teeth to grow into. Decay can lead to not only infection and discomfort but potential damage to the teeth below. It is therefore essential that parents take their children to the dentist as soon as possible and understand about tooth decay and good dental practices. That is why I regret the closure of Sure Start centres and the reduction in the number of children’s centres. Those were ideal places for parents to learn about the importance of not just dental care but baby teeth, and how parents should be encouraged to look after the child’s baby teeth for the very reasons I have given.
In recent years, although the number of children being seen by NHS dentists in England has increased, as we know, the number of adults has seen a falling- off. This decrease has partly been attributed to labour shortages in the NHS and dental practices, and dentists scaling down their commitment to the NHS or leaving entirely.
On the question of fluoridisation, as we know, fluoride is a mineral that prevents tooth decay and can be added to drinking water, salt or milk as a means to promote oral health. The excellent briefing from the House of Lords Library, which I do not need to repeat, explains how and where that is happening. However, I remember how, as a young head teacher, my progressive local authority—which was in fact Labour-controlled; should I say that?—introduced what was called dental milk, which had the correct amount of fluoride in it. That was a deprived community, with some of the worst dental problems in the region, and parents could choose between the dental milk in a green carton, or ordinary milk in a white carton. Guess what—99% of parents chose the dental milk, and the visiting hygienist said, “Mr Storey, your children’s teeth are improving year by year”.
I regret that for all sorts of reasons—perhaps a fear of fluoridisation—dental milk is not as prevalent in our schools as it used to be. Could the Minister reflect on that issue and say what government might do about it? A study in Scotland—never mind my school in Knowsley—where a similar scheme was in place found that decay rates fell by 48% among five and 10 year-olds who were drinking dental milk. I know that there are legal problems, and so on, but it seems that we are silly not to have developed that opportunity.
Healthwatch produced a fascinating briefing. It states that one theme that has consistently cropped up is that of dentists lacking knowledge or training to be able to treat individuals with learning disabilities, autism or special needs. I had not thought about that, but I should have thought that part of a dentist’s training should be in treating people who are autistic or have a particular special need, or that there were, as there are in America, child-friendly practices and practices which can cope with people with special needs.
We can eradicate tooth decay. It is very simple to improve dental health. It need not be expensive. Most parents can afford to buy a toothbrush and toothpaste. Schools should be willing, particularly in the early years, to work with parents and children to develop good oral hygiene. I remember when the hygienist visited every school up and down the country every year to check the pupils’ teeth. No doubt the Minister will tell us about particular programmes that are operating. That is great, but we want it right across the country, not limited programmes. Why can we not go back to a system where the equivalent of the school nurse, the hygienist or the dentist comes into school and checks young people’s teeth to see what the damage is or what needs to be done and then works with the parents to ensure that children get the treatment they deserve?
I am not going to talk about sugar in food and drinks—I am sure that other noble Lords will raise that. Children should receive their first check-up as their first teeth come through, recorded on their personal child’s health record. Together, we can eliminate tooth decay from our country.
Baroness Barran
I am happy to write a response to that later.
Next year, we will consult on rolling out a school toothbrushing scheme in pre-school settings and primary schools in England. This would allow us to reach the most deprived children in the country aged between three and five, with the aim of reaching 30% of children in that age group by 2022. We will also be exploring ways of removing any funding barriers to fluoridating water, to encourage more areas that are interested to come forward with proposals.
Many noble Lords, including my noble friend Lady Gardner, talked about children’s oral health. We know that overall our children’s oral health has improved significantly, with the most recent data from 2015 showing that 75% of five year-olds in England are now decay free. Several noble Lords talked about children’s tooth extractions in hospitals due to decay. For children under 10, they have fallen slightly, by 2% between 2016-17 and 2017-18, but, encouragingly, for the under-fives extractions have fallen by 22% over the past five years, and there has been a steady decline over those five years. I am by no means denying that problems remain but am just trying to set a perspective. We want to keep that trend going.
Looking at some of the things that we are doing to address this, NHS England has developed schemes focused specifically on children in areas of high dental need. The Starting Well programme is aiming to improve the oral health outcomes for children in the most deprived areas, and is focusing on 13 high-priority areas, with the aim of increasing the provision of advice and interventions to all children under the age of five, particularly those who do not regularly visit a dentist. This will include outreach to children not currently in touch with dental practices. That is the focus in the most deprived areas. Also, to complement this, NHS England is developing the Starting Well Core, which aims to reach children between the ages of nought and two and is being offered to children anywhere in the country where commissioners decide that it is needed.
My noble friends Lord Colwyn and Lady Gardner and the noble Lord, Lord Storey, and the noble Baroness, Lady Jolly—perhaps everybody who has spoken—talked about challenges around access to NHS dentistry. Over 22 million adults were seen by a dentist in the two-year period ending in 2018, and 7 million children were seen by an NHS dentist in the 12-month period ending in 2018. Although those overall numbers are good, as noble Lords have pointed out, there are specific areas of the country known as “hot spots”—although I think they might be called “cold spots”—and it is vital that steps are taken to address these issues. NHS England is taking a number of actions to improve dental access nationally. These include, first, flexible commissioning to allow NHS commissioners to deliver a wider range of services from dental practices. That would include not just basic dental services but orthodontic services, which we think in turn will make NHS dentistry more attractive to new dentists.
That leads me on to the challenge of recruitment and retention. Again, if one looks at the numbers, there has been an increase in the dental workforce over the past five years. The noble Baroness, Lady Jolly, asked a question about the impact of Brexit on the workforce. In March 2019, we put in place legislation which ensures the continued recognition of European qualifications by all the professional regulators in the field. This means that EU staff who currently practise in the UK can continue to do so and that professionals qualified in the EEA and Switzerland can continue to apply for registration after exit day, deal or no deal.
NHS England is also working closely with Health Education England and a wide range of stakeholders to improve the career profile for dental professionals, allowing them greater flexibility to move between specialties. We are aware that some practices are handing back their contracts, and we recognise that there are stresses in the system. That underlines the importance of reforming the dental contract, as well as the measures we are taking to support professionals.
The noble Lord, Lord Storey, asked about the transfer of UDAs—units of dental activity. The ability to transfer regionally is currently very limited, given the way they are set up, but the introduction of more flexible contracts and the new dental contracts being piloted will allow much greater emphasis on prevention, which many noble Lords have rightly raised. To pause on the new dental contract, it has now been evaluated and shown positive results. We have just taken on 28 more practices. I absolutely appreciate that there is frustration that the new contract has not been rolled out more quickly, but we are awaiting ministerial and NHS England sign-off on that.
The noble Baroness, Lady Masham, and the noble Lord, Lord Storey, talked about dental treatment for people with disabilities. Wherever possible, people with a disability who live in the community should be treated within a high-street dental practice. There is also a legal obligation for dental services to make reasonable adjustments to ensure that patients with a disability can use their services, in the same way as other people do. Where practices cannot make those adjustments, they have a duty to make arrangements for the patient to be referred to a more appropriate place to be treated.
The noble Baronesses, Lady Masham and Lady Wheeler, asked about clinical skills when treating citizens with a learning disability. NHS England has made a commitment in the long-term plan for the provision of dental services for those with a learning disability and autism. Part of that provision will ensure that clinicians have access to skills training, which many noble Lords also rightly raised.
The noble Baronesses, Lady Jolly, Lady Masham and Lady Wheeler, all talked about the CQC report and oral healthcare in care homes. The Government welcome the recent report, Smiling Matters. We are obviously concerned by its findings, which highlight the high percentage of people living in care homes, particularly those with dementia, who are just not getting the oral healthcare that they need. We are carefully considering the recommendations made in the report, together with Public Health England, NHS England and Health Education England. We will respond to the report later this year. The noble Baroness, Lady Jolly, asked about private care homes. I assume that a reflection on the status of private care homes will be part of our response.
The noble Baroness, Lady Masham, asked about dental treatment in prison services. NHS England remains committed to ensuring that oral health services for people in prisons are of the highest standard and that the availability of care is appropriate and timely. As part of that, NHS England is working with the British Dental Association and the National Association of Prison Dentistry UK to review the prison dentistry specification, which the noble Baroness asked about. It is expected that the revised specification will be ready for use from April 2020, after a period of consultation and the completion of the NHS England approval processes. We hope this will address some of the issues of inconsistency of care highlighted in the recent survey of prison dental services by Public Health England. As the noble Baroness rightly pointed out, this is part of wider health issues on the prison estate.
My noble friend Lord Colwyn and the noble Baroness, Lady Wheeler, asked about funding and dental charges. NHS England is required to commission services to meet local need so, for dentistry, decisions on priorities are made within the overall NHS budget, just as with other areas that NHS England commissions. Patient charges are an important contribution to the overall costs of the NHS. The above-inflation increases, referred to by the noble Baroness, Lady Wheeler, were driven by wider austerity measures and difficult financial circumstances. It is critical that no one is deterred from seeking care by cost and, as part of this year’s uplift, the department has committed to look further for evidence on whether patients have been adversely impacted, so that this can be considered next year and in any future decisions. The existing exemptions on charges, referred to by the noble Baroness, Lady Jolly, remain in place.
The noble Baroness, Lady Wheeler, also referred to penalty charge notices. She is aware that the Public Accounts Committee met on 1 July to discuss the use of penalty charge notices in healthcare. The Government announced then our intention to revise our current process for dealing with unpaid prescription and dental treatment charges. We are now introducing a three-stage process for penalty charge notices, and doing so as quickly as possible. This means that, in the first communication people receive from us telling them that they have not paid when we think they should have, we will invite them to get in touch and let us know if our information is wrong. A penalty charge notice would not be issued at this stage, but would if the person either is confirmed as ineligible for free treatment or does not respond to the initial communication.
This has been a fascinating debate for me. The noble Baroness, Lady Wheeler, asked about the commitment of the incoming Prime Minister. These are early days—I think he has quite a long to-do list—but I share her wish that addressing the issues that noble Lords have debated on the availability of dental services should be high on that to-do list. The noble Baroness also asked about the cross-government commitment to respond to vulnerable people as effectively as possible. We are clear that that continues.
I hope my responses have, in some way, reassured noble Lords that the Government remain committed to improving oral health in this country. Of those three strands, in prevention there will now be a renewed focus on tooth brushing and, I hope, flossing, given the amount of time my dentist spends talking to me about it. The others are fluoridation of water, our efforts to give more flexible contracts and improve education opportunities for the workforce, and our commissioning work, with greater emphasis on prevention in the dental contract and greater flexibility, so that local areas can respond to needs, particularly of the most vulnerable in their community. Shakespeare wrote in “Much Ado About Nothing”:
“For there was never yet philosopher
That could endure the toothache patiently”.
We do not want philosophers to have to endure toothache patiently. We do not want prisoners, the elderly, disabled or children to have to endure it patiently.
Lord Storey
Could the Minister drop me a note about dental milk, which I do not think she referred to, and how it might be developed in schools?
Baroness Barran
I am happy to do that. I intended to cover that through the fluoridation of water, which we hope is a universal response, rather than milk. If that is not sufficient, I will write to the noble Lord.