National Health Service (Dental Charges) Regulations 2005

My Lords, I also thank the Minister for the powerful way in which he explained the orders this evening. I remember him taking me aside after the last election and saying how pleased he was that he was not going to have so much to do with dentistry. I am not quite sure where it all went wrong. I also thank the noble Baroness, Lady Neuberger, for her amendment, which I support, and my noble friend Lord Howe for the many aspects of this order he has covered. Your Lordships will be delighted to hear that I have torn up most of what I was going to say, owing to the lateness of the hour, but there are one or two things I should like to clarify this evening. I commend the Government’s intention to change the system by which dentists are paid with a specific fee for a specific item of service, referred to as the ““treadmill””. I worked within this system from January 1966 for over 20 years. I should remind the House that dental practices are self-employed independent small businesses, and that the dentist is responsible for purchasing or leasing the premises. Highly specialised equipment, typically costing £40,000 for each treatment room, must be provided and maintained. The dentist is personally responsible for staffing the surgery with nurses and receptionists. He or she pays the specialised laboratories that manufacture crowns, bridges and dentures, and all the costs of implementing nationally agreed legislation, such as the Disability Discrimination Act, without any additional funding. All these costs are increasing year by year at an alarming rate. Implementation of health and safety legislation is a serious cost problem for all practices. NHS dentists do not receive grants or specific funding for equipment, materials or surgeries. Any capital investment is a personal choice, and is funded from the fees per item of service arrangement. With costs representing about 50 per cent of the total turnover, dentists have to work for half of their time to cover costs. I remember seeing between 30 and 60 patients every day. That was a treadmill. So what is new? The basis of the new system is that the contractor will complete a number of units of dental activity, as set by the local PCT, in return for monthly payments, based for the first three years on past gross turnover. In the transition from the current GDS system, the UDA requirement and contract value will be calculated according to the level of service activity and earnings in the current GDS, minus 5 per cent. The Department of Health claims that this will get dentists off the treadmill, but to me it sounds like another treadmill. Will this new treadmill not become even more onerous as the next three years are monitored and dentists are allocated a new quota for successive years? Will they be penalised financially if the total is not reached? The noble Baroness, Lady Neuberger, has reminded us that the British Dental Association and consumer groups have expressed concern about the incremental steps in the charge bands, which may well prove a barrier to accessing appropriate dental care. There is no specific encouragement to undertake preventive treatment, and I am concerned that patients may choose to wait for problems and then claim for an emergency course of treatment rather than incur a band 2 payment. The BDA and patient groups have not been informed how this new charging system will be explained to the public. For example, under the current system, an examination with X rays incurs a patient charge of £9.84, compared with £15.50 under the new system. These charges must be made clear to the public and justification given for the perceived increases. It is vital that the public are made aware that these charges are not directly part of the dentist’s income. The new system is supposed to be cost-neutral. I am sorry there is nothing in the regulations to address the issue of missed appointments or late cancellations. During the Standing Committee debate in another place the Minister accepted that this was a key issue for dentists, and suggested that, if there was a sudden and dramatic change in the number of missed appointments, it could be analysed with a six-month review. This is helpful, but the BDA believes that a cancellation charge should be included in the regulations to act as a deterrent, and that dentists should be able to claim UDAs for missed appointments or late cancellations. I should grateful if the Minister would confirm this. Neither the regulations nor the Explanatory Notes mention any arrangements for protecting the dentist against patient charge shortfalls. Ever since charging for treatment became part of the system, dentists have had to act as debt collectors for the NHS. PCTs may have a problem with uncollected NHS charges—or ““dentists’ bad debts””, as the DoH describes them. There is a good case for the PCT to assume responsibility for uncollected NHS charges as it does in every other area of the NHS. I was surprised to see that the Explanatory Notes, in paragraph 7.12, state:"““no dentists’ professional representative organisations or patients who responded to the consultation proposed an alternative system of patient charges””." This week I have spoken to Roger Matthews at Denplan and Quentin Skinner at DPAS (Dental Payment Administration Service). Denplan is the largest organiser of insurance-based capitation contracts. Both organisations cover patients for treatment and their average monthly charge is £15 or £16. Many dentists are moving to these and similar organisations to run their patient charging system. Denplan reports a 25 per cent annual increase year on year. The dentists can work at whatever level is preferred and all finances are taken out of their hands. No treatment bands, no UDAs, no money changing hands in the practice, no bad debts. But it is the dentist’s choice as to how the practice is run, and many prefer to stay with the NHS. I do not understand why the Department of Health did not consider a similar NHS insurance-based system, with free dental check-ups and assessment, identification of exempt patients and monthly payments determined from the total dental budget and an individual’s ability to pay. The difference between a capitation scheme and the Government’s UDA target system is that under capitation, if the workload is reduced by improving the patient’s oral health, the dentist can keep what is saved. This is why modified capitation delivers prevention while UDAs and fees for items do not. Genuinely, I wish the Government every success with their new system. Dentists want it to work. The dental organisations want it to work. But the way that it is intended to work must be clarified and explained to contractors and to their patients.