Department of Health - Reforming NHS Dentistry: Ensuring effective management of risks (HC 167-I) Public Accounts Committee 14 Dec 2004

Evidence and Memoranda given by Dr Lester Ellman, Chairman of the General Dental Practice Committee, Sir Nigel Crisp KCB, Permanent Secretary for the Department of Health and Chief Executive of the National Health Service, Professor Raman Bedi, Chief Dental Office for England and Professor Aidan Halligan, Deputy Chief Medical Office for England.

Q6 Mr. Gerry Steinberg (City of Durham): How much does a dentist in the NHS earn?

Dr Ellman: Take home pay or gross?

Q7 Mr. Gerry Steinberg (City of Durham): Tell us both.

Dr Ellman: About £60,000 take home pay.

Q8 Mr. Gerry Steinberg (City of Durham): Very hard up. How much do they earn in the private sector?

Dr Ellman: Not very much more, in general about the same sort of money.

Q9 Mr. Gerry Steinberg (City of Durham): Long before discussions regarding the contracts had broken down huge numbers of dentists had left the NHS. So the idea that because the contracts had broken down means that there are more dentists leaving the NHS does not seem to hold water to me. You cannot get a dentist for love nor money; what is the reason for that?

Dr Ellman: Two reasons really. One is that there is a tremendous shortage of dentists, and the accelerated move away from NHS to some extent is more the reverse, that the NHS has moved away from them in so far as the uncertainty is causing great problems for them. They are all small businessmen; they all run a business.

Q10 Mr. Gerry Steinberg (City of Durham): Dr Ellman, I would put it to you that it has nothing to do with some of the arguments you have been putting forward. I was talking to a dentist recently and he confirmed what you said about an NHS dentist, confirmed between £50,000 and £60,000 a year. What he did not confirm was what you said to me, but he said he can earn between £100,000 and £150,000 a year when he goes private. So this frankly is rubbish that they earn the same and is misleading the Committee, in my view. The reason why they are leaving the NHS and leaving patients in despair is because they are going private and taking private patients, and they do not give a monkey's about their patients - they just take them off their lists and leave them, and if they cannot afford dentistry they do not get it. What we should be doing is saying that if you are trained by the NHS you work in the NHS and if you want to train to work in the private sector then train yourself and pay for yourself.

Dr Ellman: That is a viewpoint and I cannot argue with what you think you have been told. We have done our surveys and our surveys do not show that dentists earn that much more by going private. Most of them go private, when they do, in order to be able to spend more time with their patients and to make prevention much more of their life.

Mr. Gerry Steinberg (City of Durham): Dr Ellman, I do not want more time with my dentist, I want less time with my dentist - I would rather do anything than go to the dentist. All I know is that when I want to go to the dentist and I have toothache I want it putting right, and if I have a bad tooth I want it taken out. I do not want more time with my dentist, sitting chatting in the seat and giving me a service like that. What I want is treatment done on my teeth and out, and frankly I think it is hypocritical what you are saying, to be quite honest, in terms of putting all the emphasis on the government. I have no time for both of these last two governments who have clearly destroyed the NHS dentistry service, and it is an absolute disgrace the way we are today. That is not just this government, the last government as well - they have both destroyed it. But do not come and tell us that the dentists are all altruistic - they are not altruistic at all; what they are doing is looking for the biggest amount of money that they can make and that is why they are going into private practice. Thank you, Chair.

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Q114 Mr. Gerry Steinberg (City of Durham): This meeting is totally surreal. I cannot believe what I have been listening to because the story that you are giving me is totally different from the story that I get in my constituency, from the rest of the country, from people I have talked to. I have never known such complacency in all my life. The fact of the matter is that dentistry in this country is in meltdown, absolute meltdown. You cannot get an NHS dentist. It is all right for the Prime Minister to say, "Ring NHS Direct and you will get a dentist". How many people have rung NHS Direct?

Sir Nigel Crisp: 19,000 a month.

Mr. Gerry Steinberg (City of Durham): Do they all get dentists?

Q115 Chairman: Emergency.

Sir Nigel Crisp: Emergency and urgent.

Q116 Mr. Gerry Steinberg (City of Durham): Did they get a dentist?

Sir Nigel Crisp: For emergency and urgent. The figures we have got are something of the order of 94% get it within a short distance. I cannot remember the distance but they are able to access emergency or urgent treatment -----

Q117 Mr. Gerry Steinberg (City of Durham): What is "a short distance", Sir Nigel?

Sir Nigel Crisp: I need to come back to you on that.

Q118 Mr. Gerry Steinberg (City of Durham): You had better because I was talking to a Member of Parliament this afternoon and he told me that in his constituency they have to travel 70 miles to get an NHS dentist. Is that a short distance?

Sir Nigel Crisp: No, that is not. The point that I made earlier, which was not remotely complacent, in response to your Chairman was that we are not doing as well as we want to.

Q119 Mr. Gerry Steinberg (City of Durham): That is complacent, you are not doing it as well as you want. I had three people last week who could not get a dentist.

Sir Nigel Crisp: Did they try NHS Direct?

Q120 Mr. Gerry Steinberg (City of Durham): They came to me and I told them to go to NHS Direct. I also mentioned it to the PCT. We have not got one dentist in my constituency who is taking new NHS patients, not one. My dentist told me a fortnight ago that he is no longer going to take NHS patients, so for you to come along and say that everything seems to be okay and this damn new contract is going to solve everything, that is not right. People cannot get a dentist.

Sir Nigel Crisp: I am not remotely saying that everything is okay today. I said earlier that people are not getting a dentist, which is why we recruiting a thousand -----

Q121 Mr. Gerry Steinberg (City of Durham): It is easier to win the National Lottery than to get a dentist.

Sir Nigel Crisp: It is 14 million to one on the National Lottery. It would be a good quotation on Today.

Q122 Mr. Gerry Steinberg (City of Durham): Exactly.

Sir Nigel Crisp: It is not 14 million to 1 to get an NHS dentist.

Q123 Mr. Gerry Steinberg (City of Durham): You ask my constituents who cannot get one whether it is easier to win the National Lottery or not and they will say there is no difference.

Sir Nigel Crisp: Can I be clear what I have been saying, which is that if you use NHS Direct you can get access to emergency and urgent care.

Q124 Mr. Gerry Steinberg (City of Durham): But that is not good enough. I want to be able to ring up a dentist, as I have done for 55 years, at least, my parents did it for me and then me since, and for my own kids to be able to ring up a dentist and say, "I have got toothache. Can I come and see you?", and they say, "When can you come?". Now you have got to ring up NHS Direct, who many people have never even heard of for a start, and then they have to travel 70 miles to get treatment. Also, we were told by the previous witness that no dentist would turn away kids. He is living in cloud cuckoo land because kids are being turned away in my constituency. I had a woman phone me up and say that she could not get a dentist for a small child of about five or six and NHS Direct eventually found her one. That is not what NHS dentistry is all about. It is about people having access to a dentist.

Sir Nigel Crisp: I absolutely agree with you, which is why -----

Q125 Mr. Gerry Steinberg (City of Durham): Then why do you not do something about it?

Sir Nigel Crisp: We are.

Q126 Mr. Gerry Steinberg (City of Durham): You are not, though. Nothing is being done at all.

Sir Nigel Crisp: Your colleague to your right made the point that we do not want to over-treat people. We want to introduce a contract which ensures that people have got good dental health. The other thing in this report is that we have got very much improving oral health, the best figures for children in Europe.

Q127 Mr. Gerry Steinberg (City of Durham): That is fine. If you look at paragraph 2.30, it says, "... the British Dental Association surveyed 25,000 dentists and reported that 60% of the 7,500 dentists who responded would either reduce their provision of NHS services or opt out of the NHS altogether". We are talking about 60% of dentists who are thinking of leaving the NHS or reducing capacity.

Sir Nigel Crisp: You are thinking of 60% of 30% if you read those figures. A third of the dentists responded and 60% of those who responded -----

Q128 Mr. Gerry Steinberg (City of Durham): We can assume that the two-thirds who did not respond are probably in the same boat.

Sir Nigel Crisp: I do not know about that. We have got 2,500 dentists and getting up to 20% who are opting for the new arrangements.

Mr. Gerry Steinberg (City of Durham): It is a bit like the government saying if 50% do not vote that that is a vote for them. That does not follow.

The Committee suspended from 5.31 p.m. to 5.40 p.m. for a division in the House

Q129 Chairman: Sir Nigel, can you complete your answer please?

Sir Nigel Crisp: I have forgotten the question. I beg your pardon: what I wanted to say was that we said something earlier about bad debts which we do not think is right. Can I send you a note on that?

Chairman: Of course you can.

Q130 Mr. Gerry Steinberg (City of Durham): I brought up paragraph 2.30 on page 36 and we were having an argument about whether or not it is two-thirds or a third. It is irrelevant really, is it not? Regardless of what the statistics are, the fact of the matter if that if that number of dentists are going to drop out of the system you are going to be woefully short of dentists. As I said before, we are almost in a meltdown situation and that seems to substantiate it. You are hoping to recruit a thousand dentists if I remember correctly, but a thousand is not even going to make a difference to the ones who have dropped out, let alone add further dentists to the system.

Sir Nigel Crisp: Can I draw your attention to page 45 of the report, which is the other side of this argument, if I may put it like that, where you see a very interesting curve on that graph. This is the number of dentists who have not filled in a form on the questionnaire to their association. This is the number of dentists who have voted with their feet and signed up contracts. You can see the angle of that increase there, and these figures are September 2004, and they are people who have signed up. The figures I mentioned earlier were the people who have expressed an interest in signing up. There is a considerable body of opinion out there who are wanting to sign up to the new arrangements.

Q131 Mr. Gerry Steinberg (City of Durham): That is fine.

Sir Nigel Crisp: It is.

Q132 Mr. Gerry Steinberg (City of Durham): But at the end of the day the number who are wanting to sign up and the number who will sign up are still going to be woefully short of the number of dentists that you need. That is obvious.

Sir Nigel Crisp: No, I do not think it is because the first one was a vote and that you can take your view as to how likely you think the people in that survey will follow that through with action. This is what dentists are doing in practice. In addition to that I am happy to get in at some point the description of how we are going to secure the thousand more dentists we believe we need, because we believe we need a thousand more.

Q133 Mr. Gerry Steinberg (City of Durham): Somebody else can answer that question because I want to move on. I think the whole thing is summed up on page 13 in figure 3. You are making great play on that thing that you have just shown me to take it as proof of what is going to happen. I look at figure 3 and think to myself, "No wonder national dentistry is in the state that it is in today" because if you have a look at the spending that has gone on since 1991, not just by this government but the previous government, we are spending, according to this, less now than we were in 1992, 12 years ago.

Sir Nigel Crisp: Yes.

Q134 Mr. Gerry Steinberg (City of Durham): So how on earth can the system manage and how can all the problems that most of us have outlined that have taken place recently be solved when frankly it is quite clear that it is just a matter of resources?

Sir Nigel Crisp: Two things. First, as it says here somewhere, that figure from 0305 goes up very sharply by 19%. The next figure on the curve goes up 19%. What you will know from the last 100 of these committee hearings on health is that there are a number of areas where we have put in much more than the average: cancer, for example, and coronary heart disease. There is a whole series of areas where we have put in much more expenditure. Dentistry has stayed flat, I absolutely agree with you, and that is a significant part of the problem, but we are now coming to the point where we are going to invest a lot more money in dentistry and in the next two years, again as this report says, it goes up by 19% which is higher than the increase in spending during that period.

Q135 Mr. Gerry Steinberg (City of Durham): Sir Nigel, that is all well and good, but really -----

Sir Nigel Crisp: And true.

Q136 Mr. Gerry Steinberg (City of Durham): It could well be true and the Today programme will probably say that as well, but the fact of the matter is that it has taken you and Professor Bedi and Professor Halligan --- I do not know how long you have been in your jobs but if I had had this graph when I started my job I would have looked at it and said, "It is quite obvious why we have got no National Health dentistry because there is no money going in". In fact, in 1996 it almost disappeared off the graph. I am surprised we have any dentists at all.

Sir Nigel Crisp: I am sorry. You are absolutely right that we have not increased the expenditure in dentistry at the same pace as we have increased it in areas that we have given higher priority to and that is why it is below the average increase in spending, but we need to rectify that. There are a number of other features that have happened over that 14-year period, including the discussion that was raised earlier about -----

Mr. Gerry Steinberg (City of Durham): How much have a Permanent Secretary's wages gone up in that time?

Chairman: I do not think that is a fair question.

Q137 Mr. Gerry Steinberg (City of Durham): I was being a little bit facetious.

Professor Bedi: Can I make a comment, Nigel? This graph is exactly why we are doing the reforms, because the low level is because the dentists determine how much NHS dentistry and how much activities they draw from the open-ended public expenditure, so the commentary there is that we need these people because of the present system and the way it works.

Q138 Mr. Gerry Steinberg (City of Durham): Why has it taken ten years, Professor, to work out that you need these reforms? If you look at 1993/1994, the expenditure had gone down considerably and it has never really increased since, so it has taken ten years for somebody to come up with this magnificent view that something needs to be done. In the meantime people cannot get a dentist.

Sir Nigel Crisp: Dentists are very important and the ability to get dentists is fantastically important. What has happened over this period is that in that first ten years there was lack of clarity about what needed to be done because oral health was improving very fast and it was not clear how many dentists were needed. A lot of work has happened since 1998. The other point worth making is that we have spent the increased money in the NHS on things which have been seen as a higher priority at the time, like cancer and coronary heart disease. I do notice, for example, that this committee has not examined dentistry in its last 100 sittings. We have given it the same -----

Chairman: That is a bit of a mean shot.

Mr. Gerry Steinberg (City of Durham): You just decided your fate there.

This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee. Neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.