NHS Dentists: Cumbria

Debate between Tim Farron and Lord Walney

Wednesday 3rd July 2019 Westminster Hall

[Tim Farron]

The hon. Gentleman makes a good point; in a moment I will come to some answers to those problems. The challenge is especially acute in rural communities when it comes to attracting and retaining dentists to work in NHS practices in places that are relatively close to people’s homes.

[John Woodcock (Barrow and Furness) (Ind)]

I congratulate the hon. Gentleman on securing this debate on all our behalves. The problem affects not just rural areas but more remote urban areas such as Barrow. Does he share my huge concern that people in Barrow face a 90-mile trip to Whitehaven if they want access to a new NHS dentist? That is the longest trip in England, for a town where more a third of young people suffer tooth decay, compared with 5% in more affluent areas.

[Tim Farron]

The hon. Gentleman makes an excellent point, which I will come to. He is absolutely right that the distance from the nearest available treatment affects urban as well as rural areas. It is a problem across the country that relates specifically to the NHS dental contract, which I will come to in a moment.

According to the most recent data available, taking a child living in Windermere to their nearest NHS dentist will involve a 60-mile round trip to Morecambe in Lancashire. That will mean a three to four-hour journey by public transport, with multiple changes. However, poor signposting by the NHS—it was not easy to decipher—means that that place is not obviously available. The nearest place advertising for new child NHS patients is in Appleby, which is an 87-mile round trip—two hours in the car or a five to six-hour round trip by public transport. It was only with the help of the British Dental Association that we managed to identify availability at the far-distant yet ever so slightly closer practice in Morecambe.

I am sure hon. Members will agree that this is beyond ridiculous. NHS dentistry is a public service. It should not take scouring the internet forensically with a fine-toothed comb and with the expert help of a national professional body to find a space for a child with an NHS dentist. That space has already been paid for through our taxes. Let us imagine for a moment the outrage if it were similarly impossible for people to get access to a GP.

For adults, the situation in Cumbria is even worse. I was appalled to discover that the nearest practice with available NHS provision for a new adult patient in Windermere involves a 98-mile round trip by car to Wigton—a six-hour round trip by public transport, involving three different trains and bus rides. The nearest practice that is adverting is even further away and involves a 104-mile trip, there and back, to Alston, taking over six hours by public transport. After that, the next option listed involved going 123 miles there and back to Blackpool.

Despite those obstacles, families in our communities are still trying to secure places at dental practices but are refused. In Sedbergh, Windermere, Grange, Ambleside and Kendal, dentists are working to their full capacity and even beyond, and are doing a brilliant job, but they simply do not have the numbers or the funding to meet demand. The Government have, cleverly or accidentally, dodged confronting the extent of the problem by doing away with official waiting lists. For the last six years, the NHS has held no waiting lists locally or nationally, and patients cannot depend on their clinical commissioning group or NHS England to support them in their quest to find a dentist who will treat them or their children. Will the Minister rectify that and ensure that reliable and up-to-date waiting lists are kept from now on?

We took the matter into our own hands locally. The Westmorland Gazette and I rang round our local dental surgeries to see whether there was availability, and found that in Kendal, not one of the 10 dental practices in our biggest town had a single space available for an NHS patient. Some 33% of new patients tried and failed to get a dentist appointment in the wider Morecambe bay CCG area last year. That is the equivalent of nearly 16,000 people. When we include those already on the books with a dentist, that figure rises to 18,000 people, and they are just the ones who have tried. That is a disgrace, and the situation is only getting worse.

The consequences should not be underestimated. Children across Cumbria have some of the worst dental health in England, with one in three suffering tooth decay by the age of five. In some areas, almost 20% of children under three have tooth decay, and a fifth have tooth decay when they are still toddlers. Often, that does long-term damage to their oral health before they even have the opportunity to make decisions for themselves. If children cannot see a dentist in a regular and timely way, preventable conditions become emergency conditions and the pressure is piled on NHS services, along with all their other responsibilities.

Nationally, tooth decay is the leading reason for hospital admissions among young children, despite being almost entirely preventable. In 2017-18, over 45,000 children were admitted to hospital to have multiple teeth extracted under general anaesthetic because of tooth decay. Children face completely unnecessary pain and distress, and the NHS faces a £36 million annual spend for that dental work. Dentistry in Cumbria is understaffed, underfunded and overstretched. Although this a local problem, it is a symptom of a systematic one, the effects of which are felt right across the country.

The primary cause of the increasing problems with dental access in Cumbria and across England is the way that this Government choose to commission dentistry. The NHS dental contract is completely perverse. Based on units of dental activity, it sets quotas on the number of patients an NHS dentist can see and the number of dental procedures they can perform in any given year. If a dentist delivers more than they have been commissioned to do, not only are they not remunerated for the extra work, but they have to bear the cost of any materials used, any necessary laboratory work or other overheads from their own pockets.

That is not the only issue. Last November, I managed to secure the agreement of health bosses to increase the contracts of local NHS dentists in Kendal, so that they could see and treat more patients. It was great news—I thought. However, when NHS England contacted our local dentists, it found that not one of them was able to take up its offer because, as it told me,

“the practices are already working to capacity within the staffing resources they have available, reporting they are having difficulties recruiting additional staff.”

Additional resources were made available, but there were not the dentists to provide the service for local people.

The problem is at least in part the result of the contract, which pays a set amount for particular types of treatment, in some cases regardless of the number of teeth the dentist is treating. In practice, that means that a dentist gets paid an average of £75 for an entire course of treatment, including six fillings, three extractions and a root canal, but that is not enough to cover their overheads. They get paid exactly the same amount of money for a single filling. That acts as a serious disincentive for dentistry, full stop, but especially in more deprived areas, where evidence shows that more significant treatment is often required.

Perhaps the most significant issue with the current dental contract is that it totally fails to provide any serious recognition or budget for preventive work. The work of educating adults, parents and children to maintain good dental health receives no funding, despite the fact that that would significantly ease the burden on dentists and the NHS as a whole further down the line. Indeed, check-ups are the smallest and least-remunerated part of the unit of dental activity worksheet. As a consequence, there is no massive incentive to up the number that a dentist does.

None of that is helped by the Government’s decision to cut £500,000 in the last few months from Cumbria’s public health budget this year, undermining vital preventive work, especially in our schools. Nor does it help that we are currently in limbo when it comes to the future of emergency dental services under the soon to be defunct Cumbria Partnership NHS Foundation Trust. Will the Minister tell me which trust will be responsible for emergency dentistry in south Cumbria after October?

Morale among dentists practising in the NHS is at an all-time low. The latest British Dental Association membership survey shows that nearly three in five dental practitioners in England are planning to scale down or leave NHS work entirely in the next five years. Those with the highest NHS commitments are the most likely to want to leave. In recent months, I have received countless letters at an increasing rate from residents, many of them very elderly, asking where they can go for dental treatment, as their current dentist has gone private and they have effectively been kicked off the list. A lot of parents have contacted me saying that they have been asked to pay now that they have been kicked off their local dentist’s NHS list. If they pay, the dentist might provide NHS provision for their children. It strikes me that that is a form of bribery. Many parents cannot afford to pay for themselves just so their children can get free care. That is not right.

The current system also fails to use the skills of all dental staff to their full potential. The NHS dentist contract restricts the initiation of a course of treatment to dentists alone. I met the British Association of Dental Therapists, which explained that dentists often refer the patient to a therapist to carry out the treatment if it is within the remit of their qualification. The fact that that can be begun only by a dentist creates a bottleneck that prevents patients from receiving the treatment that they need when they need it. The dental therapists made the case to me—and, I believe, to the Government—for reforming the system to allow them to initiate a course of treatment, ease some of the burden on dentists, and enable patients to be seen more quickly. I ask the Minister to action that request, or at least to look into it as a matter of urgency.

I welcome the Government’s steps to reform the system by beginning to carry out a few pilots and trials in different forms of commissioning, but the pilots have not gone far enough, there are not many of them, and the proposed systems do not provide a complete break from the old “unit of dental activity” system. Rather, they blend it with new systems. In the face of the crisis that we have on our hands, I am afraid that a piecemeal change is simply not enough for the people of Cumbria. We need total system reform. The Government need to sit up, take notice and change the contract so that people get the dental treatment they need. The current system is unjust, not fair to dentists and patients, and not fit for purpose. It is not good enough for Cumbria.

Urgent action is needed to roll out a system that fairly rewards dentists for the work they do, includes incentives for preventive work and allows all dental practitioners to use their skills to their full capacity. If we want our NHS dentists to feel that their vital work is valued and not to feel encouraged to move into working privately or give up the profession altogether, we need to take swift, far-reaching action. We need a funding system that does not feel like a treadmill, that rewards preventive care and that is not riddled with unfairness, idiosyncrasies and perverse incentives.

Those of us living in Cumbria are seeing the colossal impact of the current system on the health of children and adults alike, and we are further affected by the huge distances that we have to travel to get care, if we are lucky enough to stumble across an NHS dentists with available space. My question to the Minister is this: what action will she take to provide my constituents with the NHS dental healthcare that they desperately need and that their taxes have already paid for?

Flooding in Cumbria

Debate between Tim Farron and Lord Walney

Tuesday 19th March 2019 Westminster Hall

[Tim Farron]

I thoroughly agree with all that the hon. Lady has said. The funding formula for Cumbria works massively against us in terms of both resilience and response to crises. I will talk later about the impact on mental health. The hon. Lady makes an extremely good point in that respect. The lasting consequences of flooding are very often huge when it comes to people’s wellbeing and their fear of what might come next.

We welcome the funding that we have got, but it is insufficient. Many areas, such as those that the hon. Lady has referred to in her own constituency, have not received that support. In my own community, we look at the failure to come forward with funding and support for places outside Kendal in particular. Windermere Road in Grange has flooded for many years, and only now has the Environment Agency been given approval to do a 12-month appraisal. We were expecting spades in the ground by now, not more chin stroking. I would appreciate the Minister’s intervention to ensure that the residents of Grange are not kept waiting for the flood protection that they desperately need. People will be reassured by tangible, visible construction and action, not by meetings and promises. The funding has been allocated for the scheme and plans have been made; we now need to move forward with actual delivery.

Flooding in the village of Holme, along Stainton Beck, in Burton and on the Strands at Milnthorpe remains unaddressed. Those places are on a list of flooding hotspots where action remains to be taken. The same is true of many other places throughout Cumbria. The Burneside and Middleton Hall bridges have been closed for more than three years, dividing and damaging communities. In the year and a half for which the Staveley bridge was closed, the community found itself cut off and isolated, without any financial support from the Government. Kendal’s bridges, including the Victoria bridge, were closed following Storm Desmond because of safety concerns. However, when Cumbria local enterprise partnership put in a bid for £25 million to make the county’s bridges and infrastructure more flood-resilient, it was rejected by the Government.

Meanwhile, the Government have failed to come forward with any plans for protections for the communities around Windermere: Bowness, Waterhead at Ambleside and Backbarrow in particular. Those communities have been completely ignored in the Government’s plans. They remain exposed and vulnerable, subject to whatever the weather throws at them next. Of all the businesses in Cumbria closed by Storm Desmond, more than one tenth were around Windermere lake.

[John Woodcock (Barrow and Furness) (Ind)]

I congratulate the hon. Gentleman on securing the debate and on the powerful case that he is making. It is extraordinary that when the Government can, at the stroke of a pen, assign £4 billion to a no-deal Brexit that it is in their unilateral power to stop, these relatively minor sums are not being spent even though they could alleviate the misery felt by thousands of our constituents. Does the hon. Gentleman agree with me and local businesses that the Government, in allocating money for alleviation schemes, should take more account of the impact on businesses?

[Tim Farron]

I agree with all that the hon. Gentleman has said. He makes an important point, which is very significant to his constituents, but also to mine around Windermere lake. Residences are affected, but so are dozens and dozens of businesses, all of which are the backbone of our local economy and have a massive impact on the wellbeing of local people. The Government must now take responsibility for the failure to invest in protecting those businesses. We cannot get away from the impact on families and businesses, which cannot plan for the future because they feel that they might get hit again. Even a modest downpour can trigger real panic in people of all ages, especially children. Flood prevention is about protecting not just properties, but the wellbeing and mental health of the people who live in them.

I was hugely affected by what I saw and experienced on the morning after Storm Desmond, as we helped stricken people to empty their homes. I saw the forlorn Christmas decorations and sodden Christmas trees left out on the front garden or yard. I stood with people who had been made destitute. Barely able to afford to feed their children or pay the rent in the first place, they had forgone insurance because, frankly, they could not afford it, and they were left facing utter ruin. We cannot guarantee people that there will not be floods again, but we can massively reduce the risk. We can help people to give themselves permission to have confidence in the future and reassure their children, so that they can sleep easier at night.

A survey carried out by the Cumbria community recovery group reported that in the areas hit by the floods, a sense of vulnerability and loss of control was created, which re-emerged following further heavy rainfall of any kind. People reported anxiety and symptoms of post-traumatic stress disorder, which worsened further for those facing the loss of their employment, as well as their home.

For those flooded communities that have not received help—such as Grange, Windermere and Backbarrow—I ask the Minister to change the Government’s position and agree to intervene. There are deliverable schemes that will protect all those communities around England’s largest lake, as well as the community in Grange-over-Sands. I ask that she agrees to fund those as a priority.

The failure to hold water companies to account is a further area of concern. Despite the Kendal flood defences being built to withstand a one-in-100-year event, the water companies—in our case United Utilities—are only required to meet the standards for a one-in-30-year storm event. That is ludicrous. Millions of pounds are being spent on flood defences for our community, but the area will be just as vulnerable from surface water flooding. Surface water is one of the biggest factors to cause homes to be flooded in Cumbria over the last 10 years. On Steeles Row in Burneside, poor drainage means that residents have to deal with raw sewage overflowing into their homes and on to the street every time there is even a moderate downpour. I challenge the Minister to hold water companies, such as United Utilities, to account—to a one-in-100-year standard—so that homes receive the protection that they need.

Let us be clear that we are talking about not simply flood protection, but the mitigation of a human-created disaster—the consequences of climate change, which is more properly described as a climate catastrophe. The Government have moved away from renewable energy. They have changed feed-in tariffs, so that it is harder for businesses to invest in solar energy, while giving licences for fracking. The Guardian recently outed the Government as providing some of the heaviest bursaries for gas and oil companies. The cancellation of the Swansea tidal lagoon proves that the Government have stopped even pretending to care about climate change. Britain has the second-largest tidal range in the world, and yet we fail to use that natural, renewable resource to cut carbon and create jobs.

I want us to mitigate the consequences of our failure to tackle climate change in time to protect my communities from flooding, but I am also determined that the Government take the big strategic decisions to fight climate change. That requires a revolution in renewables and a push for energy self-sufficiency, which would protect our environment, boost our economy and give us vital energy security. I see no sign of any appetite for that from this Government. I was with students in Kendal last week, protesting against inaction on climate change. That was a reminder that the coming generation will not let us get away with it, and they are absolutely right not to.

Fire and Rescue Centres (North-West)

Debate between Tim Farron and Lord Walney

Tuesday 25th October 2011 Westminster Hall

[Tim Farron (Westmorland and Lonsdale) (LD)]

I am extremely grateful for this opportunity to discuss the future of Cumbria’s fire and rescue control centre. The proposal to close the control room and regionalise it in Warrington is of deep concern to my constituents in south Cumbria. It is a threat to public safety and a waste of public money.

It is a pleasure to serve under your chairmanship, Mr Howarth, and to see the Minister in his place. After our discussions about Cumbria county council’s botched single-status project, he might think that this is the latest in a long line of concerns over which he has no direct jurisdiction that I have brought to him. To add to his consternation, I am here in part to praise his actions and those of the coalition Government in this matter.

The previous Government proposed a centralised series of regional control centres for fire and rescue services, which would have led to a programme of forced closures and amalgamations of fire control centres, but after the coalition formed in May 2010, the new Government called off the project after a Public Accounts Committee report labelled it an expensive white elephant. That wise decision by the Government was welcomed in Westmorland and throughout Cumbria, and it should have been the end of the matter.

Sadly, however, Cumbria county council decided to ignore the Government’s sensible conclusions and proceed with the project anyway, planning to close the excellent control room in Cockermouth and keep faith instead with the white elephant in Warrington. The county council proposes in 2014 to merge all north-west fire and rescue service control centres into a single control room in Warrington, although the plans have received a severe setback after the announcement that the Merseyside services would be withdrawing from the project.

Merseyside’s decision does two things. First, it undermines even further the viability of the regional model and plays havoc with the project’s finances. Secondly, it provides an entirely sensible alternative model. Merseyside has chosen instead to pursue a merger within the county with the control rooms of other Merseyside emergency services. Merseyside has recognised, as must we, that there is a financial imperative. It is completely necessary to make efficiency savings in a time of financial crisis, but Merseyside, unlike Cumbria, has demonstrated a bit of lateral thinking by choosing an option that saves money and keeps the service securely within the area, protecting public safety.

Although many are concentrating on the proposal to set up the regionalised centre in Warrington in 2014, we must remember that the closure of the Cockermouth control room will come much sooner, in June next summer. The county council plans pre-emptively to close its control centre in Cockermouth and outsource its work to the Cheshire fire authority. From next summer, 999 calls from Cumbria for fire and rescue emergency support will be answered in Winsford, more than 100 miles from most places in Cumbria—that is, if we are lucky. The Cheshire service, like many other authorities, has a resilience partner, its neighbouring service in north Wales. However, as hon. Members might be aware, the Welsh services plan to co-operate in a single service, meaning that Cheshire is looking for a new resilience partner. The favourites at the moment are Humberside and Buckinghamshire. That is where Cumbrians can expect their emergency calls to be answered by next summer, unless the county council changes its mind.

That is desperately worrying for all of us who believe that there are extremely good reasons for having a local control centre. I have no doubt that the people and technology in Winsford, Warrington, Wycombe or wherever Cumbria’s 999 calls might be answered will be excellent. I am in no way suggesting otherwise. However, it is also the case that the team at the Cockermouth centre are outstanding professionals who have shown immense dedication to our county week in, week out, particularly recently, when they have made an amazing difference by responding to catastrophic floods in 2009, the Grayrigg tragedy in 2007 and various other tragedies and near-tragedies off Cumbria’s coast, especially in Morecambe bay. It is peculiar for Cumbria county council to say thank you to those who have played a huge part in saving lives by outsourcing their jobs and moving their entire operation to the other end of the region.

The main reason why we must resist centralisation is that it will damage public safety. In more than 90% of cases, the regionalised system will provide an excellent response to people in emergency situations. Capable call handlers with a modern mapping system will scramble the right team to the right address swiftly and with the right result. However, some occasions seriously require local knowledge. For example, there are two Staveleys in my constituency and two Troutbecks and a Troutbeck Bridge in the county of Cumbria. Finsthwaite, where I was on Saturday, has three houses in the same postcode called Rose Cottage. A person sitting in Warrington or wherever, taking a panic-stricken call from someone in one of those places who cannot give an exact postcode or grid reference, will not know to ask critical supplementary questions such as “Which Staveley?” or “Is that the Rose Cottage by the church?” Such questions could save a life.

Even the best systems can only pinpoint a grid reference based on the nearest mobile phone mast when someone is out of range, which means that a grid reference given to the fire crew could be up to 18 miles away from the address where the emergency is taking place. I am not sure whether you have visited the Lake district recently, Mr Howarth, but getting a mobile phone signal is not always simple. Having a human being at the other end of the line who knows that there are two Staveleys 20 or so miles apart will save lives. There is no training like on-the-job training. Working in a control room where 100% of work relates to Cumbrian emergencies provides call handlers with the expertise needed to ensure a safe, specific and speedy response.

If Cumbria were to follow Merseyside’s lead and consider creating efficiencies by consolidating the control rooms of Cumbria’s emergency services, it could improve safety by exposing call handlers to the full range of Cumbria’s communities and to the geographical uniqueness of a county teeming with mountains, lakes and mountain passes, some of which are misnamed, being impassable. Meeting the needs of people in distress in our county involves understanding the county, the nature of road communications and the time distances as well as mileages involved.

This week, we started the inquest into the tragic death of Mrs Margaret Masson, who died in the Grayrigg derailment in February 2007. The emergency services’ response to that tragedy was instant, and one reason was that the Cumbria-based control room staff knew the nature of the area and, crucially, that it was right, for instance, to call out volunteer mountain rescue teams, which had the kit and the expertise to respond the most quickly. That is why the mountain rescue teams got there first. Would a call handler in Warrington have pictured the scene in their mind’s eye and have had enough experience of our area to know automatically that it was a job not just for the professionals of the fire service but for the expert volunteers of mountain rescue? I am not sure, but I am sure that that quick response, based on the call handlers’ local knowledge, prevented a worse tragedy and saved lives.

[John Woodcock (Barrow and Furness) (Lab/Co-op)]

I congratulate my neighbour, the hon. Member for Westmorland and Lonsdale (Tim Farron), on securing this debate. He makes some strong points. Does he agree that part of the problem is the impossible position in which local authorities such as Cumbria county council have been put by the scale of the reductions that they are being forced to make across the piece? They are being forced to consider efficiencies such as the £300,000 saving that the proposals will generate.

[Tim Farron]

The hon. Gentleman makes a fair point. Without doubt, all local authorities face huge pressure, because of the pressure on public finances. I simply make the case that the situation in Merseyside is no harder than that in Cumbria, and Merseyside has thought of an intelligent way through it. I am sure that all involved are not jumping for joy at having to make a difficult decision—merging control rooms is never easy—but, even at the hardest of times, whoever is to blame, it is possible to think laterally and to try to ensure that the service in the county is protected. The hon. Gentleman makes a fair point, but that does not let Cumbria off the hook, given Merseyside’s rather more intelligent response.

Having spoken to members of the Fire Brigades Union in Cumbria and to other fire and rescue staff, I know that they strongly oppose the proposals, because, as I am sure we all know, it is the firefighters themselves who rely more than anybody else on the accuracy and professionalism of the Cumbrian-based call handlers to get them to the right place, with the right information and at the right time. They know that a control centre 100 miles away, however fantastic and professional it will be, cannot be as reliable or responsible as a centre committed to Cumbria, focused on our county and understanding its quirks.

This is a rare opportunity for me to be critical of the coalition—the Labour-Conservative coalition in Carlisle that runs Cumbria county council. I will qualify that, however, by saying that I am proud to represent a county where six MPs—only two of us are present—from all three parties work closely together, not just on this issue but on others. I know that my colleagues share my deep concern on the issue, even if we might not always come to exactly the same conclusions. I think that there is exasperation across the county—including all three parties and, more importantly, in the community—about the county council’s decision to resist all attempts to get it to rethink.

The recent decision of the Merseyside authority to turn its back on this wasteful project seems to have been ignored. Only a fortnight ago, the county council’s own overview and scrutiny committee, chaired by Jo Stephenson, the county councillor for Windermere, discussed the project, objected to it, for the reasons that I have outlined—the objections came from all three parties—and strongly recommended that the cabinet of the county council think again. The cabinet responded in less than 24 hours, without any time to consider the committee’s recommendations, and obstinately proclaimed that it was not for turning. I am sure that the Minister will understand our extreme frustration. There are intelligent, safer and more efficient alternatives, yet the county has so far refused to countenance them.

As someone who believes that decisions such as this should be taken at a local level—not least because it means that voters know exactly who to blame at the next local election—I do not want the Minister to intervene and override the county council. He could not, even if he wanted to, and even if he could, he absolutely should not, in the interests of democracy and localism. I would, however, like him to help us all the same.

The Government rightly withdrew their backing for the national programme of regionalised control centres. The logic behind that decision was right. I would be immensely grateful if, as a result of this debate, the Minister wrote to the leader of Cumbria county council to explain why he feels—indeed, why this Government feel—that such a move is inefficient, wasteful and a threat to public safety. If it wants to ignore his advice, as well as that of many of the county’s MPs and the vast majority of Cumbria’s citizens, it can do so, but it will, of course, face consequences. An intervention by the Minister would do no harm and would be very welcome, especially given that all I am asking him to do is restate what he said about this flawed proposal last year.

We are not saying no to any reform or restructuring, but we want the county to use its imagination and value the unique nature of our county. It is a county where fire and rescue means a lot more even than our excellent fire brigade—it means mountain rescue, such as the teams in Kendal, Ambleside and the Langdales, and inshore rescue, such as the bay search and rescue team in Flookburgh. Ours is a county in which understanding all that is essential in responding to people in acute distress. By all means, let us look at how we can consolidate our emergency control centres in Cumbria, but do not go down a route of regionalisation that will cost more money and could easily cost lives.