National Health Service (Dental Charges) Regulations 2005

My Lords, the House will be grateful to the Minister for introducing the order which was described by the Government Whip’s Office as being of ““medium controversy””. To my mind, and especially after listening to the noble Baroness, it carries with it a considerable degree of controversy. I should like to set out for the Minister some of the reasons why it causes me as well as the dental profession a good deal of concern. My noble friend Lord Colwyn will be supplementing my remarks from his own perspective as a dentist. The new price bandings provided for in the regulations represent, as the Minister said, a radical departure from what we have had up to now. Like the noble Baroness, I am the first to acknowledge that a simplification of the current system is a thoroughly desirable thing. I have no quarrel with the general concept of what the Government are seeking to do. The problem I have is with the detail. The first thing that strikes you when you examine the new charging structure is that, for a very significant group of patients, the cost of going to the dentist will be a great deal higher than it is now. The entry point for having anything done to you at all will now be £15.50. At the next tier of the scale, for treatment, you will be charged £42.40, and by the Government’s own admission, three-quarters of patients falling into Band 2 will pay more than previously. The noble Baroness rightly mentioned the cost of denture repair, which is a further concern. It is no doubt true that, under the NICE guidelines, a lot of patients will not be visiting the dentist as often as they used to, but a lot will be. For many, £15.50 and £42.40 are significant sums. The first issue, then, is the affordability of the charges for those on fixed or low incomes, particularly the elderly. I cannot believe that the new bands will not have a very pronounced affect on the uptake of dental treatment among these groups, and that is a considerable worry. That is why, if we change the remuneration structure for dentists in this fundamental way, we ought to have some clear idea about how it will affect patient behaviour. Will it increase demand for dental services and, if so, from which segments of the population? Will it reduce demand and, if so, in what respects? I suspect that the Government, if they are honest, have no idea either way. That is a profoundly unsatisfactory state of affairs. If the new charges had been piloted in a few selected PDS practices—and I understand why that idea presented insuperable difficulties—we might have had quite good answers to those questions. But we do not. So, we must surely ask the Minister to institute some means of measuring the impact of these reforms in terms not only of dentists’ activity but also of improving access to dentistry. Will primary care trusts be obliged to collect this kind of data? The second thing that hits you when you look at the charging structure is the element of perverse incentive. One of the things that I had hoped to find in it was a recognition of the importance of preventive care. It has been a criticism of the dentists’ remuneration structure over many years that they have had an incentive to treat but no incentive to encourage patients to look after their own dental health in such a way as to make treatment unnecessary. How do the regulations recognise that concern? While the inevitable consequence of moving to a very much simpler pricing structure is that you move away from a strict fee-per-item approach, it is obvious that if patients realise that it will cost them the same to have three teeth filled as it will to have one tooth filled, they will be likely to want to cram in as many treatments as they can to a single visit. If that happens, the idea of dentists being able to spend time with patients talking about oral health promotion goes out of the window—the time will have gone. Similarly, if you say to patients that they can have emergency treatment for £15.50, which would normally cost them £42.40, what is that but a message to them not to bother to make regular appointments with their dentists or look after their teeth as carefully as they should? The Minister may say that he would not behave in that way and nor for that matter would I, but if you are of limited means and did not understand the importance of maintaining good oral health, which a lot of people do not, that is exactly what you might do. Personally, I can see a strong case for making the emergency charge band more expensive than is now proposed and the charge in band 1 slightly less expensive. As it is, I simply do not begin to see how the new charges will encourage people to adopt a preventive approach to oral healthcare. Perhaps the Minister will enlighten me on that. One of the other avowed aims of these arrangements is to improve clarity for both the public and dentists about the costs of NHS dental care. To be pedantic about it, I do not think that the costs of dentistry will be made any clearer to either side. The thing one hopes for is that there will be greater clarity on the price of dental treatment, but how will that happen? The one positive thing that you can say about the current system—complexity aside—is that it is at least transparent, but you can hardly say that about the proposed system, which needs explaining. Dentists have got to have an easy and effective way of communicating the tariffs to their patients. However, the BDA tells me that it is baffled by several elements of them even now. For example, the Minister in another place implied in Standing Committee that under band 1 the dentist is obliged to provide a set package of services for every single patient. Is that correct? If it is, it is not self-evident. That is why it is incumbent on the Department of Health to promulgate the details of these changes to patients and the public.  I would be grateful if the Minister could give us further and better particulars of how they plan to do that because the Minister in another place was pretty vague on the question. The noble Lord, Lord Warner, has helpfully expanded on the Government’s plans in the letter to the noble Lord, Lord Filkin, which he circulated today, but it would be useful to have the main points on the record. For all these reasons, I find myself in sympathy with the terms of the amendment tabled by the noble Baroness, Lady Neuberger. She is perfectly right that even if the new charging structure were not controversial in any particular and even if everyone agreed on it, it would still be necessary to have an effective communication strategy for patients because the new tariffs represent such a marked departure from the system in place at the moment. Patients need to understand that. I know that the Government believe in all sincerity that they have responded to the concerns of dentists constructively and that they have got the formula right. Despite that, I hope that, at the very least, the Minister will recognise that there are legitimate doubts out there that the formula is right, and in the light of those doubts we need his assurance that the effect of these regulations will be closely monitored and the new arrangements within them will be subject to review after an appropriate interval.