National Health Service (Dental Charges) (Amendment) Regulations 2023

Lord Hunt of Kings Heath Excerpts

Monday 5th June 2023 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the increase of 8.5 per cent to patient charges under the National Health Service (Dental Charges) (Amendment) Regulations 2023 (SI 2023/367) (1) will be a considerable burden on NHS patients, and (2) will not help to improve access for NHS patients, including children and young people.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I know how eagerly noble Lords have anticipated our debate this evening. I should declare at the beginning my presidency of the Fluoridation Society and patronage of the National Water Fluoridation Alliance, so I can guarantee the House that I am not going to mention fluoridation again during tonight’s debate.

This is a critical time for NHS dentistry. The massive hike in charges of 8.5% in this SI seems to be a deliberate policy of discouraging patients who need care the most. Of course, it comes at a time when access to dentists has become increasingly difficult, with reports of patients resorting to DIY dentistry because they cannot get access to an NHS dentist. In August last year, the BBC reported that, based on a survey of 7,000 NHS practices, nine in 10 were not accepting new adult patients for treatment. The problem, of course, predates the pandemic, when enough dentistry was commissioned for only around half the population in England, and in many parts of the country access to NHS dental services was already very poor. It has now got worse.

Of course, the increasing cost burden on patients has been paired with a crisis of access. The General Dental Council found that the proportion of adults receiving dental care under the NHS fell from approximately half in 2013 to just over a third in 2021. The proportion of those over 15 years old receiving free NHS dental treatment fell from 31% in 2012 to 22% in 2017. According to the most recent GP Patient Survey, conducted in 2022, 12.9% of those surveyed said they had failed to get an NHS dental appointment in the last two years.

These access problems are obviously also linked to workforce challenges. In June 2022, the House of Commons Health and Social Care Committee reported that the headcount of primary care dentists in England providing NHS treatment or otherwise conducting NHS activity in 2020-21 was at its lowest level since 2013-14. The report said that although the GDC register has the largest number of dentists in its history, the number of dentists doing NHS work is decreasing. The BDA has told me that official data it secured shows that

“just 23,577 dentists performed NHS work in the 2022/23 financial year, down 695 on the previous year, and over 1,100 down on numbers pre-pandemic”,

which

“brings figures to levels not seen since 2012”.

The noble Lord referred to the NHS workforce plan in Oral Questions today. We certainly need a coherent long-term workforce plan for all dental professions, underpinned by data, starting with the regulator, the GDC, which counts dentists registered by full-time equivalent and not headcount. The basic fact is that we do not have enough dentists in this country willing to perform NHS treatments. At the moment, the shortfall can really only be met with overseas recruitment.

On that, I understand that the GDC has just announced that it is tripling the number of places on the first part of its overseas recruitment examination. However, there is no mention of part 2, which is the practical part of the process after candidates have passed part 1. Completely missing at the moment is anything being done to ease the blockages involved in getting an NHS number. Without that, newly registered dentists can work in the private sector immediately but not the NHS, making access to NHS dentistry even more problematic as private practices are more accessible to overseas recruits.

Dentistry has been subject to cuts unparalleled in the NHS. In real terms, net government spend on dentistry in England was cut by over a quarter between 2010 and 2020. The Prime Minister keeps making references to the £3 billion spent on dentistry, presumably implying that that is a growth figure. In fact, the budget was over £3 billion in 2015. In May 2022, the noble Lord, Lord Kamall, the Minister’s predecessor, told the House:

“The Government are working with NHS England and the British Dental Association to reform the current NHS dental system and to improve access for patients, tackling the challenges of the pandemic”—[Official Report, 24/5/22; col. 754.]


He also referred to an extra £50 million for additional activity and patient appointments. However, this is clearly not sufficient and a drop in the ocean. Actually, we have the remarkable situation whereby, as I understand it, we also have a likely £400 million underspend in the dental budget in the financial year just finished.

We then come to the issue of charges. In their Statement in March, the Government argued that this increase was necessary in order to continue to fund dental provision. They argued that the larger increase was necessary because dental patient charges had been frozen since December 2020. One contrasts that with the large underspending figure in the current dental budget. I simply do not see why the underspend figure could not be used to incentivise dentists to provide more NHS treatments. I understand that in the north-east there is a concept that follows the dental access centres, which we as a Government opened up and incentivised dentists to provide more NHS treatment. Some more imaginative leadership from the Government on this could use the money in a more effective way. We should not underestimate the real challenges for patients in finding access to a dentist where they are not eligible for financial support but do not have the resources to go private. For some people, this is a hugely disturbing and worrying challenge.

The BDA has said that the hike in charges

“won’t put a single penny into a struggling service”

or improve patient access to quality dental care. In essence, patients are being asked to pay more so that the Government can put less into the dental budget. We are talking about a huge differentiation between what happens in England and in the rest of the UK. A band 1 treatment, a check-up, will now cost £25.80 in England but just £14.70 in Wales. A band 3 treatment such as dentures will now cost £306.80 in England and just £203 in Wales. It is important to have some cohesion across the NHS in the United Kingdom and the differential in charges is really worrying.

The Government have described charges—no doubt the Minister will do so in his speech—as a patient’s contribution towards the cost of NHS care. However, it is clear that they are being used as a substitute for state investment, increasing as a proportion of total spend within a flat budget, thereby enabling Ministers to cut back government contributions. One wonders where this is all going to lead. Is this a signal that what the Government are doing is gradually withdrawing from any responsibility for NHS dentistry, leaving many members of the public desperately short of the ability to access a dentist?

The fact is that the UK now spends the lowest share of its health budget on dentistry of any European nation, according to OECD figures published in 2019. That is unsustainable and the dentistry service requires greater investment and leadership. I hope that this debate will provide some evidence to the Minister that the Government need to get a grip. I beg to move.

--- Later in debate ---

[Lord Markham (Con)]

I will try to unpack that point a bit more. A dentist can say, “Okay, I can provide so many UDAs over the course of the year”, and they will be contracted to do that. But there is then the situation whereby some of them—I am not saying all of them—having that banked in and knowing that they have the money to afford it, might go out to try to sell private healthcare, underpinned by that money. At the end of the year, if they have not delivered all the UDAs, then, in effect, the only reason that they have not delivered it is because they substituted that for private care work, resulting in that underspend, which we do not want.

That is what the changes we talked about in May were about: removing the UDAs from those persistent underdeliverers, for want of a better word, and having the capacity to give them to those who are persistent deliverers, so that we can increase their amounts by 110%. This is very much about taking away from those who are not delivering and giving to those who can, and also having money in the bank for some of the more creative ideas that Minister O’Brien is very focused on, and that we look forward to delivering. I can say, hand on heart, that is not about banking underspend; this is about making sure that we can redistribute it. These price increases—which, again, are half the rate of inflation—are for funding a dentistry plan through which we want to improve access; that is fundamental to all of this.

I hope that noble Lords understand a bit more where we are coming from and understand that it is an 8.5% increase versus 17% inflation. We are looking to recycle that increase and put it into more access for those who are not receiving it at the moment. I hope that noble Lords will see this in a better light and that it is all about increasing access.

In conclusion, as the noble Lord, Lord Hunt, mentions, it is important that patients can access NHS dental care and that it is affordable. No price increase is easy but we hope it is seen that this is a proportionate increase at less than half the rate of inflation and only for those 50% of people who are in a better position to pay. Most of all, this is part of a package of measures, of which more will be announced shortly, about expanding access to NHS dentistry—because I completely agree with the noble Baroness, Lady Merron, that it is vital to the health of our children, particularly, but to all the people in England.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister and for him attempting to explain the mystery of the dental contract, which has defeated many Ministers over many years. Explaining it in the way he did lends support to those who think we need a fundamental rethink about the way we remunerate dentists. I took part in some of the discussions with the profession which led up to the last contract and before that there was the contract in the 1990s. Essentially, it seems to me, each time there is a revenue envelope agreed with the Treasury on how much can be afforded for a new contract. The profession will always exceed performance in general because it is always based on a payment for a procedure, although efforts have been made to bring in incentives to treat the oral health of a person as a whole, more like the way in which GPs are remunerated. But at the end of the day, we still await a change in contractual arrangements which will provide the right incentives.

I am grateful to my noble friend for her support. She is right to say that at the heart of this is needing to know the Government’s aspiration for NHS dentistry. The Minister said that dentistry is an important part of the NHS, that he recognises the access challenges faced by the public and that we can await further announcements. I welcome that and hope that we can reset NHS dentistry on a much more positive route for the future.

In relation to charges, the contrast between the difficulty so many patients are having in getting access on the one hand and the 8.5% increase on the other is very difficult to understand and to support. Many of the people who rely on the NHS but do not get benefit support from the state are really caught by high inflation in general and dentistry charges is one more burden they have to face. That ultimately is what makes the proposal before us really rather worrying.

I hope this is an opportunity to reset our whole concept of NHS dentistry. I am very grateful to noble Lords who have supported the debate tonight and beg leave to withdraw my Motion.

Motion withdrawn.