National Health Service (Dental Charges) (Amendment) Regulations 2023
(11 months, 2 weeks ago)
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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.
Lord Allan of Hallam (LD)
My Lords, I am very grateful to the noble Lord, Lord Hunt of Kings Heath, for giving us the opportunity to have this debate. I think he is having an even busier day than the Minister, given his contribution to the Illegal Migration Bill debate that we just had.
There are two real questions that people are asking about access to NHS dental services. The first is whether they can get an NHS dentist. That is something that we have debated in the context of other regulations along similar lines discussing the way in which the remuneration scheme works. The second question is about how much will it cost if they do get one—if they are the lucky few who can navigate through the system and find an NHS dentist, and that is what we are primarily discussing today.
It is also important to touch on dental deserts, particularly in rural and coastal areas. I hope that the Minister may also have some to say on availability. He has assured us in this House previously that the Government have ideas to try to improve the ability of NHS dentists generally, and I know he had some creative ideas about attracting dentists into under-served areas.
Having got through the barrier of finding an NHS dentist, we now need to think about the question of charges—a question that is entirely academic if you are unable to get one in the first place. The Government are proposing in these regulations an uplift—in common language, an increase, but they prefer to use “uplift”, which I think is supposed to sound a little softer— of 8.5%. I find that curious language. When I go to supermarkets they do not tell me that they are applying an uplift value to their prices; they apply an increase to their prices, but here we are told it is an uplift value.
In paragraphs 7.8 and 7.9 of the Explanatory Memorandum we get a lengthy and quite convoluted explanation of where that money goes, which makes it clear that patient charges make no direct contribution to the remuneration that the dentist receives. People out there may think that the payment they are making to the NHS goes to the dentist, but it does not. Again the Explanatory Memorandum makes it clear that there is intentionally no link between the contract price paid to the dentist and the contribution that the individual pays. Paragraph 7.8 states that the money is essential to improve access challenges, and that current and future work to improve NHS dentistry would be undermined by the risk of reduced funding if the patient charge revenue was lower. Yet, as we heard from the noble Lord, Lord Hunt, it is reported that there was a £400 million underspend in the NHS dentistry budget for last year, so I have a couple of questions for the Minister, a maths question and a logic question. The maths question is: will he confirm that £400 million is approximately five times as much as the £78 million in extra revenue that we are told that this 8.5% increase will achieve? In other words, if we were not to have the increase but were simply to roll the underspend into dentistry, we could cover five years of that additional revenue-raising from the underspend that already exists. The logic question is simply: how can we say logically in this paragraph that these charges are essential to improve NHS dentistry when we are not spending the money that is already available? Perhaps the Minister is going to make us all happy by confirming that that £400 million underspend is all going to be spent on NHS dentistry, in addition to the extra £78 million, but I suspect that is not going to be the case. Listening to the noble Lord, Lord Hunt, I wondered whether one of the solutions might be that the new charges should not be allowed to be levied unless and until all the existing budget has been spent. If there is going to be a £400 million underspend, perhaps the patient should benefit from that if the money is not going to be rolled back into NHS dentistry.
The overriding concern is one that the noble Lord, Lord Hunt, also referred to: that the long-term commitment from this Government to provide dentistry within the National Health Service just is not there. The right words are being spoken, but the actions are telling us a different story.
The Government’s own impact assessment notes, at paragraph 37, tell us:
“There remains uncertainty about whether higher patient dental charges would lead to lower levels of patient access”.
They say that, although the research is not clear,
“it is very likely that higher charges will reduce the number of patients seeking NHS dentistry services, relative to there being no patient charge uplift.”.
So, again, the Government’s own notes tell us that it is likely there will be reduced demand for NHS dentistry as a result of the charges that we are discussing today.
Paragraph 32 very tellingly talks about the relationship between NHS and private dentistry, which, of course, is an alternative in most parts of the country. It says:
“There is also a risk that increases in NHS charges could mean that the cost of NHS dental treatment becomes closer to prices of private dental care. Some patients may choose to receive private care if the cost differential is lower”.
It seems logical that, if a patient is confronted with real difficulty in getting an NHS dentist compared with getting a private dentist and if they understand that there is no real price differential, those two forces combined will act to steer people away from NHS dentistry towards private dentistry.
As I know the Minister and I have heard him speak on these issues before, I suspect he will say that this is not the Government’s intention—but we need more than words. We need evidence that we are not seeing a succession of measures leading inexorably in one direction: a direction in which dentistry ceases to be available on the NHS at a fair NHS price for people in large swathes of this country.
Baroness Merron (Lab)
My Lords, I am grateful to my noble friend Lord Hunt for tabling this regret Motion and speaking so clearly to it, describing for your Lordships’ House what this actually means for people by its effect on NHS dentistry.
I am glad to follow the noble Lord, Lord Allan, and I absolutely associate myself with his remarks about the word “uplift”. It is a very positive way of describing an increase in costs to those who need NHS dentistry. We should remind ourselves that this is why we are having this debate, not only about the costs but about the sorry reality of the state of NHS dentistry at present—and bearing in mind that all this takes place in the context of a cost of living crisis.
It is incumbent on us this evening to remind ourselves that poor oral health—which is where we end up when people do not look after their teeth because they cannot afford and/or cannot access NHS dentistry—does not just affect the teeth. It impacts on our general health and well-being; it affects what we can eat, how we communicate, and how and whether we can work, study and socialise with ease, and it affects our self-confidence. Yet it is right to say that tooth decay is largely preventable.
There is also a significant public health problem linked with considerable regional variation and inequality. A three year-old living in Yorkshire and the Humber is more than twice as likely to have dental decay as a three year-old who lives in the east of England; and one in three five year-olds in the north-west has experience of dental decay, compared to nearly one in five in the south-east of England. It would be helpful if the Minister could tell us: what is the Government’s aspiration in respect of NHS dentistry? That aspiration and the practical means to achieve it seem to have got rather lost on the way.
As we heard from my noble friend Lord Hunt, the last 13 years have seen dentists quitting in very considerable numbers. In 2021 alone, 2,000 quit the NHS, which represents almost 10% of all dentists employed in England. An estimated 4 million people cannot access NHS care, with some parts of the country now described as dental deserts, where remaining NHS dentists are not taking on new patients.
To secure a future, we need staff, which I will refer to later, and the equipment, technology and access to ensure that patients get the treatment they need. This raises a number of wider questions. We are spending less on dentistry per head of the population in the areas with the highest levels of deprivation. Statistics from the British Dental Association suggest, for example, that 1 million new or expectant mothers have lost access to dental care since the start of the pandemic. Could the Minister say what the Government are doing to prevent those on low incomes or in more vulnerable groups being disproportionately impacted?
Tooth extraction in hospital due to tooth decay remains the most common reason for hospital admissions in the six to 10 year-old age group, with an estimated cost of hospital admissions for children aged between nought and 19 for this intervention being some £33 million per year. What steps are being taken on early preventive action to reduce what has become a shameful situation?
We know that 91% of dental practices are not able to accept new adult patients in England and 80% are not able to accept new child patients. Millions are having to face the unpalatable options of waiting for months in agony, resorting to their own DIY dentistry, or stumping up for private dental fees they simply cannot afford. My question to the Minister is not just about what the Government are doing to tackle this crisis, but how did they allow it to get to this situation? From inadequate support for the prevention of oral ill health in childhood to dental deserts, net government spend on general dental practices in England has been cut by over one-third over the past decade. Again, perhaps the Minister could explain how the situation has been allowed to deteriorate to this extent.
We know that not enough is being done to recruit and retain dentists and dental care professionals. A recent British Dental Association member survey showed that more than nine in 10 owners of dental practices with a high NHS commitment found it difficult to recruit a dentist, with 43% of vacancies unfilled for more than six months.
On the workforce, there is a point I want to underline following the points raised by my noble friend Lord Hunt. In June last year the House of Commons Health and Social Care Committee reported the findings of its inquiry into the health and social care workforce. It found that the headcount—to underline this—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. While the register has the highest number of dentists, the number doing NHS work is decreasing. In 2021 alone there was a decrease of 951 dentists with NHS activity in England. That is the near equivalent of the whole intake target of dental students for the whole year. Perhaps the Minister could explain how this all stacks up.
On the matter of substance—we have heard much about this from the noble Lord, Lord Allan, as well as my noble friend Lord Hunt—at almost 500 practices across England the British Dental Association tells us that the amount paid by NHS patients was greater than the amount paid to that practice to provide NHS services. The analysis suggests that patients at those surgeries were topping up government funding by an estimated £2 million last year. It would be helpful to hear from the Minister how and in what way this makes sense.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
My Lords, I am pleased to respond to this debate on these regulations and to address the concerns about their impact on patients and access to dental treatment. I thank the noble Lord, Lord Hunt of Kings Heath, for securing this debate on this important matter, and I thank noble Lords on all sides of the House for their contributions to the constructive debate.
Dentistry is an important part of the NHS and we acknowledge the gravity of the challenges that some people have faced in accessing these services—and the real impact on the health service and A&E, and on young children, that the noble Baroness, Lady Merron, mentioned. So, to answer clearly the point of the noble Lord, Lord Hunt, about this not being about decreasing access, I say that access challenges are at the top of our minds. Hopefully, this speech will show that we have an aspiration to increase access to dentistry, as the noble Baroness, Lady Merron, said.
In July 2022, we announced a package of dental system improvements, having fully engaged, via the NHS, with the dental profession and patient representatives. These initial changes were aimed at improving information for patients, improving incentives in the contract to deliver more complex care and enabling the NHS to better work with the sector to ensure that dental care is delivered.
Most importantly of all, I will address the underspend head on. I appreciate the noble Lord’s maths, but I will be absolutely clear that we do not want the underspend; it is caused by dental surgeries that are not delivering on their contract. In many cases, they declare a number of UDAs to underpin their business and then try to sell in the private sector, ending up with an underdelivery at the end of the year. The changes that we introduced on 18 May were all about being able to adjust those contracts so that, where dentists underperform, we can remove those UDAs from them and redistribute them to those who are performing. So, effectively, I can say categorically that we are not trying to bank that £400 million—which is not the final number, I should say—or to bank an underspend; rather, we are trying to find ways to prevent that happening, because we absolutely accept that we want access to increase in all of this.
The dental patient price increase—I will not say “charges uplift”—is very much about generating money which will be used around the system. This is not a case of saying, “Oh, we’re going to try to bank the underspend and generate some more for us”; this is about trying to get to where people can afford to pay. Let us remember that 50% of people, including those in the most need, receive their dentistry completely free, so this is for the 50% or so of people who are in a position to afford it. Of course, since dental charges were last increased, we have had an increase in inflation of 17.9%, so what we are doing here is increasing those prices by only half that amount. This is about making sure that the money is there to fund an expansion of dentistry.
We consider that the 8.5% is a proportionate increase; it is about £2 on the cost of an NHS check-up. I reiterate that it is being paid only by those people who are in the best position to be able to afford it; we are making sure that those who cannot afford it continue to receive it free at the point of care. We know how important it is to provide the courses of treatment. We provided 8 million courses, 5.6 million of which were to children. The noble Lord, Lord Hunt, will be pleased to know that 54% of those are for fluoride treatments. We understand that it is vital that we provide those preventive measures to children.
To answer the noble Lord, Lord Allan, we know that we need to go further; the creative thinking has continued, and there will be further, wider-reaching changes to improve access to NHS dental care that we hope to announce shortly. I can say, hand on heart, that we are actively looking at ways to fund these increases. This is not about trying to bank underspend; this is about trying to make sure that those underspends are delivered. If those we are contracted with are not delivering it, we will find others who will do it. That is also where some of the creative ideas will come in.
Lord Allan of Hallam (LD)
I am curious about the point the Minister made about the underspend resulting, in a sense, from accounting practices—or, as I understood it, that people are seeking additional contracted amounts to boost the financial health of their dental practices. It is first time I have heard that. I wonder whether he thinks that that is a temporary phenomenon that will somehow come out of the system, or whether it is something that is inherent in the way the system has been established so that private dentists are contracting for blocks of NHS work.
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.