NHS: Dentistry Services

Baroness Barran Excerpts

Thursday 25th July 2019 Lords Chamber

[Baroness Barran (Con)]

My Lords, I congratulate my noble friend Lady Gardner on securing time for this important debate and all noble Lords who have contributed, although I feel, like the noble Lord, Lord Storey, that I am also on the subs bench. I have certainly learned a great deal from all today’s contributions.

I am genuinely pleased to have the opportunity to talk about NHS dentistry in England, but before I do I also thank my noble friends Lord Colwyn and Lady Gardner for their contributions to the NHS. I am delighted that our immigration services were enlightened enough to extend my noble friend Lady Gardner’s six-month visa many years ago.

This is a very serious and important area, and I know it is one that my noble friend is concerned about and has raised on several occasions. As we have heard put very eloquently across the House, poor oral health can have a devastating impact on an individual’s quality of life and an even greater impact on that of a child. We know that the two main dental diseases—dental caries or decay and periodontal or gum disease—can be almost eliminated by good tooth brushing, backed up by regular examinations by a dentist. As the noble Lord, Lord Storey, said, this is one of the most preventable areas of healthcare.

Noble Lords did not refer to—and I hope your Lordships will permit me briefly to comment on—the prevention Green Paper published on Monday, which included two important commitments on oral health. We will be consulting on two initiatives: water fluoridation and supervised toothbrushing. My noble friend Lord Colwyn referred to fluoridation. We aim to address the unwarranted variation in children’s oral health across the country.

[Lord Davies of Stamford (Lab)]

I am grateful to the Minister for giving way. Can she remind us how many years have gone by since the Government began to examine the issue of fluoridisation?

[Baroness Barran]

I am happy to write a response to that later.

Next year, we will consult on rolling out a school toothbrushing scheme in pre-school settings and primary schools in England. This would allow us to reach the most deprived children in the country aged between three and five, with the aim of reaching 30% of children in that age group by 2022. We will also be exploring ways of removing any funding barriers to fluoridating water, to encourage more areas that are interested to come forward with proposals.

Many noble Lords, including my noble friend Lady Gardner, talked about children’s oral health. We know that overall our children’s oral health has improved significantly, with the most recent data from 2015 showing that 75% of five year-olds in England are now decay free. Several noble Lords talked about children’s tooth extractions in hospitals due to decay. For children under 10, they have fallen slightly, by 2% between 2016-17 and 2017-18, but, encouragingly, for the under-fives extractions have fallen by 22% over the past five years, and there has been a steady decline over those five years. I am by no means denying that problems remain but am just trying to set a perspective. We want to keep that trend going.

Looking at some of the things that we are doing to address this, NHS England has developed schemes focused specifically on children in areas of high dental need. The Starting Well programme is aiming to improve the oral health outcomes for children in the most deprived areas, and is focusing on 13 high-priority areas, with the aim of increasing the provision of advice and interventions to all children under the age of five, particularly those who do not regularly visit a dentist. This will include outreach to children not currently in touch with dental practices. That is the focus in the most deprived areas. Also, to complement this, NHS England is developing the Starting Well Core, which aims to reach children between the ages of nought and two and is being offered to children anywhere in the country where commissioners decide that it is needed.

My noble friends Lord Colwyn and Lady Gardner and the noble Lord, Lord Storey, and the noble Baroness, Lady Jolly—perhaps everybody who has spoken—talked about challenges around access to NHS dentistry. Over 22 million adults were seen by a dentist in the two-year period ending in 2018, and 7 million children were seen by an NHS dentist in the 12-month period ending in 2018. Although those overall numbers are good, as noble Lords have pointed out, there are specific areas of the country known as “hot spots”—although I think they might be called “cold spots”—and it is vital that steps are taken to address these issues. NHS England is taking a number of actions to improve dental access nationally. These include, first, flexible commissioning to allow NHS commissioners to deliver a wider range of services from dental practices. That would include not just basic dental services but orthodontic services, which we think in turn will make NHS dentistry more attractive to new dentists.

That leads me on to the challenge of recruitment and retention. Again, if one looks at the numbers, there has been an increase in the dental workforce over the past five years. The noble Baroness, Lady Jolly, asked a question about the impact of Brexit on the workforce. In March 2019, we put in place legislation which ensures the continued recognition of European qualifications by all the professional regulators in the field. This means that EU staff who currently practise in the UK can continue to do so and that professionals qualified in the EEA and Switzerland can continue to apply for registration after exit day, deal or no deal.

NHS England is also working closely with Health Education England and a wide range of stakeholders to improve the career profile for dental professionals, allowing them greater flexibility to move between specialties. We are aware that some practices are handing back their contracts, and we recognise that there are stresses in the system. That underlines the importance of reforming the dental contract, as well as the measures we are taking to support professionals.

The noble Lord, Lord Storey, asked about the transfer of UDAs—units of dental activity. The ability to transfer regionally is currently very limited, given the way they are set up, but the introduction of more flexible contracts and the new dental contracts being piloted will allow much greater emphasis on prevention, which many noble Lords have rightly raised. To pause on the new dental contract, it has now been evaluated and shown positive results. We have just taken on 28 more practices. I absolutely appreciate that there is frustration that the new contract has not been rolled out more quickly, but we are awaiting ministerial and NHS England sign-off on that.

The noble Baroness, Lady Masham, and the noble Lord, Lord Storey, talked about dental treatment for people with disabilities. Wherever possible, people with a disability who live in the community should be treated within a high-street dental practice. There is also a legal obligation for dental services to make reasonable adjustments to ensure that patients with a disability can use their services, in the same way as other people do. Where practices cannot make those adjustments, they have a duty to make arrangements for the patient to be referred to a more appropriate place to be treated.

The noble Baronesses, Lady Masham and Lady Wheeler, asked about clinical skills when treating citizens with a learning disability. NHS England has made a commitment in the long-term plan for the provision of dental services for those with a learning disability and autism. Part of that provision will ensure that clinicians have access to skills training, which many noble Lords also rightly raised.

The noble Baronesses, Lady Jolly, Lady Masham and Lady Wheeler, all talked about the CQC report and oral healthcare in care homes. The Government welcome the recent report, Smiling Matters. We are obviously concerned by its findings, which highlight the high percentage of people living in care homes, particularly those with dementia, who are just not getting the oral healthcare that they need. We are carefully considering the recommendations made in the report, together with Public Health England, NHS England and Health Education England. We will respond to the report later this year. The noble Baroness, Lady Jolly, asked about private care homes. I assume that a reflection on the status of private care homes will be part of our response.

The noble Baroness, Lady Masham, asked about dental treatment in prison services. NHS England remains committed to ensuring that oral health services for people in prisons are of the highest standard and that the availability of care is appropriate and timely. As part of that, NHS England is working with the British Dental Association and the National Association of Prison Dentistry UK to review the prison dentistry specification, which the noble Baroness asked about. It is expected that the revised specification will be ready for use from April 2020, after a period of consultation and the completion of the NHS England approval processes. We hope this will address some of the issues of inconsistency of care highlighted in the recent survey of prison dental services by Public Health England. As the noble Baroness rightly pointed out, this is part of wider health issues on the prison estate.

My noble friend Lord Colwyn and the noble Baroness, Lady Wheeler, asked about funding and dental charges. NHS England is required to commission services to meet local need so, for dentistry, decisions on priorities are made within the overall NHS budget, just as with other areas that NHS England commissions. Patient charges are an important contribution to the overall costs of the NHS. The above-inflation increases, referred to by the noble Baroness, Lady Wheeler, were driven by wider austerity measures and difficult financial circumstances. It is critical that no one is deterred from seeking care by cost and, as part of this year’s uplift, the department has committed to look further for evidence on whether patients have been adversely impacted, so that this can be considered next year and in any future decisions. The existing exemptions on charges, referred to by the noble Baroness, Lady Jolly, remain in place.

The noble Baroness, Lady Wheeler, also referred to penalty charge notices. She is aware that the Public Accounts Committee met on 1 July to discuss the use of penalty charge notices in healthcare. The Government announced then our intention to revise our current process for dealing with unpaid prescription and dental treatment charges. We are now introducing a three-stage process for penalty charge notices, and doing so as quickly as possible. This means that, in the first communication people receive from us telling them that they have not paid when we think they should have, we will invite them to get in touch and let us know if our information is wrong. A penalty charge notice would not be issued at this stage, but would if the person either is confirmed as ineligible for free treatment or does not respond to the initial communication.

This has been a fascinating debate for me. The noble Baroness, Lady Wheeler, asked about the commitment of the incoming Prime Minister. These are early days—I think he has quite a long to-do list—but I share her wish that addressing the issues that noble Lords have debated on the availability of dental services should be high on that to-do list. The noble Baroness also asked about the cross-government commitment to respond to vulnerable people as effectively as possible. We are clear that that continues.

I hope my responses have, in some way, reassured noble Lords that the Government remain committed to improving oral health in this country. Of those three strands, in prevention there will now be a renewed focus on tooth brushing and, I hope, flossing, given the amount of time my dentist spends talking to me about it. The others are fluoridation of water, our efforts to give more flexible contracts and improve education opportunities for the workforce, and our commissioning work, with greater emphasis on prevention in the dental contract and greater flexibility, so that local areas can respond to needs, particularly of the most vulnerable in their community. Shakespeare wrote in “Much Ado About Nothing”:

“For there was never yet philosopher

That could endure the toothache patiently”.

We do not want philosophers to have to endure toothache patiently. We do not want prisoners, the elderly, disabled or children to have to endure it patiently.

[Lord Storey]

Could the Minister drop me a note about dental milk, which I do not think she referred to, and how it might be developed in schools?

[Baroness Barran]

I am happy to do that. I intended to cover that through the fluoridation of water, which we hope is a universal response, rather than milk. If that is not sufficient, I will write to the noble Lord.