Child Dental Health

Debate between Alistair Burt and Graham Allen

Wednesday 3rd February 2016 Commons Chamber

[Alistair Burt]

This is possibly the fourth or fifth invitation that I have received from my hon. Friend to come to see different things in Northern Ireland, and he is right about every one. He finds in me a willing ear, and we will make a visit because there are several different things to see. Where devolved Administrations and the Department can learn from each other, that matters, and I will certainly take up my hon. Friend’s offer.

In older children there are challenges when comparing different countries, because of how the surveys are carried out. The available data still show that we have among the lowest rates of dental decay in Europe, but despite that solid progress we must do more. There is disparity of experience between the majority of children who suffer little or no tooth decay, and the minority who suffer decay that is sometimes considerable and can start in early life. In this House, we know the children who I am talking about—it is a depressingly familiar case. We can picture those children as we speak, as my hon. Friend the Member for Mole Valley described in the sometimes horrific parts of what he told the House. The fact that we know that such decay affects children in particular circumstances makes us weep.

Public Health England’s 2013 dental survey of three-year-olds found that of the children in England whose parents gave consent for their participation in the survey, 12% had already experienced dental decay. On average, those children had three teeth that were decayed, missing or filled. Their primary, or baby, teeth will only have just developed at that age, so it is highly distressing for the child, parents, and dental teams who need to treat them. Dental decay is the top cause of childhood admissions to hospitals in seven to nine-year-olds. In 2013-14, the total number of children admitted to hospital for extraction of decayed teeth in England was 63,196. Of those, 10,001 were nought to four-year-olds, and so would start school with missing teeth.

From April 2016, a new oral health indicator will be published in the NHS outcome framework based on the extraction of teeth in hospital in children aged 10 and under. That indicator will allow us to monitor the level of extractions, with the aim of reducing the number of children who need to be referred for extractions in the medium term. Extractions are a symptom of poor oral health, and the key is to tackle the cause of that. Today I commit that my officials will work with NHS England, Public Health England and local authorities to identify ways to reach those children most in need, and to ensure that they are able and encouraged to access high-quality preventive advice and treatment.

The good news is that the transfer of public health responsibilities to local authorities provides new opportunities for the improvement of children’s oral health. Local authorities are now statutorily obliged to provide or commission oral health promotion programmes to improve the health of the local population, to an extent that they consider appropriate in their areas. In order to support local authorities in exercising those responsibilities, Public Health England published “Local Authorities improving oral health: commissioning better oral health for children” in 2014. That document gives local authorities the latest evidence on what works to improve children’s oral health.

The commitment of the hon. Member for Nottingham North to early intervention and the improvement of children’s chances is noteworthy and well recognised in this House and beyond, and of course he can come to see me. I would be happy to discuss with him what he wants to promote in Nottingham, which sounds just the sort of initiative we need.

Public Health England is also addressing oral health in children as a priority as part of its “Best Start in Life” programme. That includes working with and learning from others, such as the “Childsmile” initiative in Scotland, to which my hon. Friend the Member for Mole Valley referred. It is important that health visitors—I know that the Public Health Minister takes a particular interest in their work—midwives, and the wider early years workforce have access to evidence-based oral health improvement training to enable them to support families to improve oral health.

Public Health England and the Royal College of Surgeons Faculty of Dental Practice are working with the Royal College of Paediatrics and Child Health to review the dental content of the red book—the personal child health record—to provide the most up-to-date evidence-based advice and support for parents and carers. The National Institute for Health and Care Excellence has also produced recent oral health guidance that makes recommendations on undertaking oral health needs assessments, developing a local strategy on oral health, and delivering community-based interventions and activities for all age groups, including children. Community initiatives to improve oral health include supervised fluoride tooth-brushing schemes, fluoride varnish schemes and water fluoridation.

I agree with my hon. Friend that water fluoridation is an effective way of reducing dental decay. However, as the House knows, the matter is not in my hands. Decisions on water fluoridation are best taken locally and local authorities now have responsibility for making proposals regarding any new fluoridation schemes. I am personally in favour. I think I am the only Member in the Chamber who remembers Ivan Lawrence and the spectacular debates we had on fluoridation in the 1980s. He made one of the longest speeches ever. Fluoridation was bitterly and hard-fought-for and I do not think there is any prospect of pushing the matter through the House at present. I am perfectly convinced by the science and that is my personal view, but this is a matter that must be taken on locally.

Diet is also key to improving children’s teeth and Public Health England published “Sugar reduction: the evidence for action” in October 2015. Studies indicate that higher consumption of sugar and sugar-containing foods and drinks is associated with a greater risk of dental caries in children—no surprise there. Evidence from the report showed that a number of levers could be successful, although I agree with my hon. Friend that it is unlikely that a single action alone would be effective in reducing sugar intake.

The evidence suggests that a broad, structured approach involving restrictions on price promotions and marketing, product reformulation, portion size reduction and price increases on unhealthy products, implemented in parallel, is likely to have the biggest impact. Positive changes to the food environment, such as the public sector procuring, providing and selling healthier foods, as well as information and education, are also needed to help to support people in making healthier choices.

Dentists have a key role to play. “Delivering Better Oral Health” is an evidence-based guide to prevention in dental practice. It provides clear advice for dental teams on preventive care and interventions that could be delivered in dental practice and school settings. Regular fluoride varnish is now advised by Public Health England for all children at risk of tooth decay.

For instance, the evidence shows that twice yearly application of fluoride varnish to children’s teeth—more often for children at risk—can have a positive impact on reducing dental decay. In 2014-15, for children, courses of treatment that included a fluoride varnish increased by 24.6% on the previous year to 3.4 million. Fluoride varnishes now equate to 30.9% of all child treatments, compared with 25.2% last year. This is encouraging progress.

There are many measures that can and should be taken in order to reduce the prevalence of decay in children, but we recognise it is unlikely that we will be able to eradicate entirely the causes or the effects of poor oral health in children. This means that the continued provision of high quality NHS primary dental services will continue to be an important part of ensuring that every child in England enjoys as high a standard of oral health as possible. NHS England has a duty to commission services to improve the health of the population and reduce inequalities—this is surely an issue of inequality—and also a statutory duty to commission primary dental services to meet local need. NHS England is committed to improving commissioning of primary care dentistry within the overall vision of the “Five Year Forward View”.

[Mr Allen]

The Prime Minister announced an excellent initiative on life chances less than two weeks ago. The cornerstone of that was improving parenting skills. Will the Minister’s Department ensure that feeding into that process there is, within the parenting programmes, stuff around health in general, but dental health in particular?

[Alistair Burt]

Yes. [Interruption.] Immediate information passed to me by the Minister with responsibility for public health indicates that that is a very positive initiative and we are indeed taking it up.

Overall, children’s access to NHS dentistry remains consistently high, with the number of children seen in the 24 months to September 2015 by an NHS dentist standing at 8 million, or 69.6% of the population. There are localised areas where children have access difficulties, but the more common problem is that the parents and carers of the children most at risk do not seek care until the child has developed some disease—this again emphasises the importance of health visitors and others in the process.

To help focus on prevention, the Government are committed to reforming the current system of primary care dentistry to improve access and oral health further. In line with the welcome improvements in oral health over the last 50 years, we need an approach in primary care dentistry that can provide a focus on prevention, while also incentivising treatment where needed.

That is why, following the piloting of the preventative clinical pathway, we are now prototyping a whole possible new system remunerated through a blend of quality, capitation and activity payments. The aim is to allow dentists to focus on prevention and, where appropriate, treatment, and how effective that could be for the children we are talking about. The new approach will be tested until at least 2017. We need to do a proper evaluation and, if successful, numbers will increase with a possibility of a national roll-out for 2018-19.

I hope I have been able to demonstrate the seriousness with which the Government take this subject—a seriousness that I know is accepted by the whole House. It comes back to some fundamental issues of inequality in health that are, as I said, depressingly familiar and which we are all absolutely dedicated to removing. The concept of total clearance for a child—I suspect that none of us has had to contemplate that in our personal lives, but it affects some of our constituents—is something that brings us all up short. I am grateful to my hon. Friend the Member for Mole Valley for raising this subject for debate.

Question put and agreed to.

Conception to Age 2: The First 1001 Days

Debate between Alistair Burt and Graham Allen

Thursday 17th December 2015 Commons Chamber

[Mr Graham Allen]

If the Minister is moving on from foetal alcohol syndrome, it is important to put it on the record again that, as of a couple of weeks ago, the attempt to have a prevalence study on foetal alcohol syndrome has not found funding. It is really important that we try to understand the issue in depth and get some evidence on how widespread it is. Will the Minister please consider looking at the matter in the light of the report he will receive today?

[Alistair Burt]

I take the hon. Gentleman’s point and I will raise it with the appropriate Minister.

I have only a couple of minutes left, so I want to cover a couple of other things. Perinatal mental health is really important to me. I am disappointed that we have lost a couple of perinatal mother and baby units over the past few years. The increased emphasis on the issue is absolutely right. An NHS England working group is doing some intensive work on the £75 million that was committed in the last Budget to improve perinatal mental health services over the next five years. The report will come to me in the early weeks of January, as we look at the first tranche of that funding and then beyond. It is not as simple as just providing the units; it is about the community support care and everything else.

I was horrified by last week’s MBRRACE report. The association between people taking their own lives and perinatal mental health issues is very stark. Both of those issues are a very high priority for me. We will return in due course to say more about the detail. I offer the right hon. Member for North Norfolk that assurance.

Cities and Local Government Devolution Bill [Lords]

Debate between Alistair Burt and Graham Allen

Monday 7th December 2015 Commons Chamber

[Mr Graham Allen]

I would like to comment on this group, which includes my own amendment 60. It is relevant to what the hon. Member for Altrincham and Sale West (Mr Brady) has talked about in moving his new clause 9. My anxiety is that the welcome devolution that is taking place—the precedent of devolving health powers to localities is particularly welcome—suggests something of “the Empire striking back”, with the Whitehall Leviathan seeking to place a caveat on the devolution of health powers. What is being set up is the ability of the Secretary of State to revoke health functions from the relevant local authority.

I fear that somebody in the Department of Health might not approve of a devolution proposal within a given area. Let us say that the cities of Nottingham or Manchester—or indeed anywhere represented by hon. Members in their places for this evening’s debate—wished to do something innovative and interesting on public health because it matched the demography in the area. What it might not match, however, is the view of people in the Department of Health. Such people might have a one-size-fits-all masterplan that they would like to impose on everybody.

My difficulty is that if we allow the Secretary of State to pull back to the centre any of these powers, there will be no safeguard in law to prevent that from happening. The Secretary of State could attempt to launch an effort at devolution, but we see again and again what can happen when the dead hand of Whitehall lies upon local government and the charitable and voluntary sectors. A year could be granted to get on with it, with a local authority either allowed to raise its own money or be given some money. If, however, the Department does not like it, it could be pulled up by the roots.

[The Minister for Community and Social Care (Alistair Burt)]

I should not be, but I am tempted to respond. If that is the hon. Gentleman’s concern, why should the Secretary of State sign the order agreeing the devolution in the first place if it does not fit in with his masterplan? If he is going to take back the powers in due course, why would he give them away in the first place?

[Mr Allen]

The Secretary of State does have the power to pull back those experiments and those efforts at devolution. That is why I am bringing forward my proposal. If the Secretary of State is not concerned, he would have no worry about the ability of an independent panel to say, “Hang on—give these guys the amount of time they need to experiment” rather than have to deliver to a Whitehall timetable. That amounts to a contradiction in terms: devolution on the one hand, with the Secretary of State pulling things back into the centre on the other hand. My proposal—which I am sure the Minister can understand—is for the establishment of an independent panel, which would not consist of the Secretary of State and his advisers, but would include representatives of local government where the devolution was taking place and representatives of the national health service. That would enable the medical side to be looked at effectively, and separately from the Secretary of State. It would end the constant process that has driven devolution: the interference of Whitehall, often in the very short term, because someone somewhere in the Department of Health—some unknown person—does not like what is being done in the locality.

--- Later in debate ---

[Alistair Burt]

I rest my case with my hon. Friend: I believe that legislation currently provides the reassurance that he seeks. However, I undertake that, before the matter is concluded in the House of Lords, we will ensure that that assurance is there so that he is covered. He is absolutely right to make sure that his local authority has the opportunity to make representations when it needs to. I am sure that the legislation does that, but we will make doubly certain that it does.

[Mr Graham Allen]

It may well be that the current legislation covers this eventuality, but the Government’s amendment 34 makes it very clear that local government will not be consulted. If the hon. Member for Altrincham and Sale West (Mr Brady) would like quickly to peruse that amendment, he will see that local authorities will have no say whatever if devolved powers are taken back to the Department.

[Alistair Burt]

I will happily cover amendment 34 in a moment. Indeed, perhaps I should speak to that amendment before I turn to amendment 60, which has been tabled by the hon. Member for Nottingham North (Mr Allen), just to make it clear what amendment 34 is about.

Amendment 34 mirrors part of amendment 19 and amends clause 17 to provide that the requirements for combined authority and local authority consent do not apply to regulations revoking previous transfers of health service functions under clause 16. Proposed new subsections 1E and 1F, which amendment 19 would add to section 105A to be inserted by clause 7 into the Local Democracy, Economic Development and Construction Act 2009, also have the same effect in relation to health functions transfers under section 105A which are revoked.

This means that in the event that it becomes appropriate to restore NHS functions in a local area to NHS bodies, this can be achieved without the need for consent of the combined authority and local authorities concerned. This reflects the fundamental principles for health devolution, as reflected in clause 18, which builds on an amendment moved by Lord Warner in the other place, that the key responsibilities for the Secretary of State for Health and the NHS remain unchanged in any devolution arrangements. We envisage using the powers to revoke only in those circumstances where it was clear that duties and standards such as those referenced in clause 18 were not being met and that revoking the transfer was the best option to achieve the necessary improvement in performance.

The Secretary of State’s ability to use this power supports the key principle, which this House has already agreed and which the House of Lords was also insistent on, that nothing about devolution settlements will impinge on his duties in respect of the national health service, including the duty to promote a comprehensive health service, to exercise his functions with a view to securing continuous improvement in the quality of services and to have regard to the NHS constitution. The other procedural requirements and preliminary conditions will continue to apply, such as the requirement that the Minister making the regulations must consider that the instrument is likely to lead to an improvement in the exercise of the functions concerned, and that Parliament must approve the secondary legislation.

Let me explain in straightforward terms what this is about. The House has already agreed that it wants to retain the national health service, even if NHS functions are devolved to local authorities. That means that the duties of the Secretary of State in relation to the NHS remain absolute. As I said earlier, if the Secretary of State is to sign off these powers to commission services to a local authority, he has to be sure that doing so is in the best interests of healthcare and that the quality of healthcare will be improved. Otherwise, he just will not do it. There will not be any consent involved, or anything else; he just will not do it. However, if he signs it off, it means that he is satisfied that there will be an improvement in the quality of healthcare. Should that fail—should the NHS functions transferred to a new authority fail—it is the Secretary of State’s duty to take those powers back, because he is responsible for the delivery of NHS standards. If he cannot be satisfied, he is going to have to take these powers back. In the circumstances, it is possible that local authorities might disagree and want to challenge that, but his duties are absolute. That is why the requirement for consent is coming out. We are talking about a circumstance that nobody expects to happen. The Secretary of State is not going to devolve unless he is certain, but if he needs to take powers back to maintain his duties, he must have the power to do so. Even if he has to do so, the matter goes before the House, which makes up its mind on it. That is the basis of Government amendment 34 and the answer to amendment 60.

--- Later in debate ---

[Alistair Burt]

The hon. Gentleman is coming at this from the wrong point of view. He is coming at it from the point of view that the Secretary of State is deliberately pushing something towards an authority, but he is not—the authorities are asking him for something. He would not be doing that unless authorities came to him and said, “We want to do this.” The Secretary of State would not agree unless he thought it was in the best interests of healthcare, because it is not his personal judgment but his duty. If those functions are not performed properly, his ultimate duty, which the House has already agreed, must be to take the powers back. The hon. Gentleman is approaching it from the point of view that there is something malevolent about the Secretary of State which means he wants to challenge the authority. The duties he has, which are contained in statute and which the House says he must retain when NHS powers are devolved, are what impels the amendment, nothing else.

[Mr Allen]

rose—

[Alistair Burt]

I will give way one last time, but then I must finish dealing with the rest of the clauses.

[Mr Allen]

The Secretary of State may be doing the right thing—I am sure he would be, just as I am sure the local authority would think it was doing the right thing—but my amendment 60 and our new clause would allow there to be a local government representative and a medical NHS representative judging who is right in the decision about central power and local power. They, too, would make the right decision.

[Alistair Burt]

Let me turn to the independent panel idea in amendment 60, which the hon. Gentleman has tabled. The Bill provides an effective framework to support a more devolved, place-based approach to health and social care, while ensuring that there are appropriate safeguards in respect of the NHS and a clear line of accountability back to the Health Secretary. Our objectives for health devolution must be to improve the health and care outcomes for people residing in a particular local area. Clause 18 requires that where health functions are conferred by an order or regulations on a combined authority, provision must be made about standards and duties to be placed on that authority, including standards in the NHS constitution.

The Secretary of State needs to be satisfied that revoking the transfer would lead to an improvement of statutory functions in that local area. He is under the same duties if he revokes as he is when he grants the powers in the first place. The revocation would need to be debated and approved by both Houses of Parliament, and the Secretary of State would be required to make available to Parliament a report concerning his decision, including what representations had been made to him in the process. That demonstrates that the decision to revoke transfer regulations would be taken only as a consequence of in-depth consideration, as well as engagement with local organisations, and with the support of Parliament. For that reason, I resist the requirement to convene a panel to review the decision, which would not only be unnecessary, but could be burdensome and costly, and could lead to delays just at the time when swift action was required to address fundamental performance issues.

The amendment is not necessary. The Secretary of State, in the exercise of his powers, already has to do what the hon. Gentleman is asking, but the need to move sometimes at speed means he needs to retain the powers; this is therefore covered, there is accountability to Parliament and the Secretary of State has to say exactly why he is doing it. It is straightforward: either he has the power to deliver his duties, or he does not, and he can do it without convening an independent panel to second-guess him. It is his responsibility, and if he exercises those powers unreasonably, there is judicial review, which means that a local authority is doubly protected.

[Mr Allen]

If a local authority, which understands its own demography—it knows its people and its inner-city and rural areas—makes a decision on a public health matter, such as fluoridation or free dental checks for three-year-olds, and the centre does not like it, the Minister can pull back that power, which has been given in what is meant to be a devolution Bill.

[Alistair Burt]

It is not about the centre not liking the decision. The Secretary of State has statutory duties that Parliament has given him. He has to exercise his power both to grant and revoke power based on those duties, not because he likes or does not like a decision. It is that statutory duty for which he is responsible that is so important. The House of Lords pressed that matter, but the House of Commons has accepted it. It is the maintenance of those duties that is so important. Liking or disliking a decision does not come into it.

Let me make further progress on the other amendments that the Government wish to push through. Amendment 35 is a further amendment to clause 18, which applies valuable safeguards to local devolution of health functions, including where certain functions and duties should continue to be held nationally. The clause was inserted in the Bill by an amendment tabled by Lord Warner in the other place and was amended in Committee in the Commons to give further definition and clarity to support its valuable principles. Clause 18 provides that regulatory functions of national bodies held in respect of health services will not be available for transfer to a combined or local authority.

Amendment 35 makes it clear that, in addition to NHS England’s responsibilities for assurance and review of clinical commissioning groups, all its supervisory and oversight functions set out in chapter A2 of part 2 of the National Health Service Act 2006 are out of scope of a transfer order. These include functions relating to CCGs’ institutional and constitutional arrangements, including their establishment.

Briefly, amendments 46, 47, 48 and 49 amend schedule 4, which makes amendments to the 2006 Act to provide a wider menu of flexible, voluntary options for local bodies, including combined authorities, to work with each other and with NHS England in respect of health functions.

One of the amendments introduced by schedule 4 includes provision under proposed new section 13ZA of the 2006 Act for new “devolved arrangements”, whereby NHS England is able to delegate its functions to a group of local commissioners exercising them together, or to make arrangements to exercise its functions jointly with that group. The group of local partners must consist of at least one clinical commissioning group and at least one combined authority or local authority, and the delegates or partners must exercise the function jointly.

Amendments 46, 47 and 48 are minor and technical amendments, which make it clear that “devolved arrangements” may relate to one or more of NHS England’s functions.

New clause 12, which was tabled by the hon. Member for Hemsworth, says:

“The Secretary of State must, within 15 months of this Act being passed, publish a review of health services devolved under the provisions of this Act.”

The review must include an assessment of how standards have been maintained, particularly of the quality and outcomes delivered by the devolved health service.

Maintaining the integrity of the NHS standards and ensuring that there is clear accountability for quality of outcomes is a key objective, as reflected by a number of vital safeguards provided for by the Bill. An order to confer health functions on a combined authority can only be made if a proposal to do so satisfies the Secretary of State that such a transfer will lead to the improvement of statutory functions.

As the House has debated a number of times, the requirements to monitor and regulate the functions that have been devolved remain exactly the same as if they had been with the NHS. It is the Secretary of State’s responsibility to ensure that the quality of services devolved is of NHS quality. For that reason, a full formal review is not necessary. There will be constant review of the quality of work done locally, and putting a formal review in the legislation is therefore not necessary. It is inconceivable that the authority delivering the functions on behalf of the NHS would not keep up a full review and the quality of regulatory work and monitoring work ensures that a full review is carried out in any case.

I hope that the new clauses will not be pressed to a vote and that I have been able to satisfy the House about the functions that need to be retained by the Secretary of State. I hope that the technical amendments will also be agreed to.