UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 289-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

DENTAL SERVICES

Thursday 7 February 2008

MR EDDIE CROUCH, MR JOHN RENSHAW and MR JOHN TAYLOR

MR BARRY COCKROFT, MR BEN DYSON and MR DAVID LYE

Evidence heard in Public Questions 1 - 262

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 7 February 2008

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Mr Peter Bone

Jim Dowd

Sandra Gidley

Stephen Hesford

Dr Doug Naysmith

Mr Lee Scott

Dr Howard Stoate

Dr Richard Taylor

________________

Witnesses: Mr Eddie Crouch and Mr John Renshaw, Challenge, and Mr John Taylor, former Chief Executive, Dental Practice Board (1987-2006), gave evidence.

Q1 Chairman: Good morning, gentlemen. Could I welcome you to the Health Committee. This is our first evidence session on our inquiry into dental services. I wonder if I could ask you for the record if you could give us your name and the position you hold?

Mr Crouch: My name is Eddie Crouch. I am Secretary of Birmingham Local Dental Committee and I am Chair this year of the annual conference of LDCs, local dental committees.

Mr Renshaw: I am John Renshaw. I am a general practitioner in Scarborough and I am one of the founder members of Challenge.

Mr Crouch: I am John Taylor. I was until two years ago the Chief Executive of the Dental Practice Board for England and Wales.

Q2 Chairman: John, could you give us a brief description of what Challenge is exactly?

Mr Renshaw: Challenge is a political pressure group that we created, Eddie and I and a friend of ours up in Teesside, Ian Gordon. We did not like what we were hearing from the profession in rebuttal and refutement of what was going on in dentistry and we challenged that and created a new organisation to try to argue the case in what we felt was a more robust manner.

Q3 Chairman: Thanks for that. Could I ask a general question to open this session to all of you? Do you accept that NHS dentistry required reform?

Mr Renshaw: Yes indeed. I do not think anybody would ever claim that the old system was perfect. There are very few systems in this world that are perfect, but the old system had some major advantages and one or two very serious disadvantages. I think the fact that the system had been around for 58 years or so and had been worked on constantly during that time meant that everybody who worked in the industry was familiar with the contract and how it operated. Familiarity does not always breed contempt; sometimes it breeds reassurance. What also was clear from the old system was that flexibility for developing and shrinking practices as and when it suited the practice and the patients who were wanting to use the service was a huge advantage which is missing from the current system. I think the biggest problem we all perceived was that the fee per item payment system was always seen as being potentially open to abuse. The trouble is, of course, that other systems may be just as open to abuse and we do see some evidence of that with the new system, the way it is being introduced. Yes, we would absolutely accept that the old system was flawed but I do not think that anybody, apart from the Department of Health, would say that the new system that has been introduced is an improvement.

Q4 Chairman: Would you both concur with that, Eddie and John?

Mr Crouch: From my own point of view the difficulty that I have had with the contract is that it has not allowed me to carry on providing NHS treatment for the amount of patients that I want to provide it for. The flexibility has not been there with the introduction of the contract and for me it has been a real hardship, turning patients away who were seeking my help. I find that most frustrating.

Mr Taylor: There are two parts to my answer. To administer payments to dentists was not difficult at all. To prevent and detect fraud and other forms of abuse the reform that I would have pursued would have been to increase the surveillance of the system, and I think with an increase in surveillance it would have been a very good system.

Q5 Chairman: So you think the changes should have been more of an auditing than a new contract?

Mr Renshaw: The tragedy from our point of view was that the new system was never tested at all. It was just introduced across the board without any consultation and nobody knew how it was going to fly. There had been some work on some new pilots on PDS and new ways of working, and the BDA at the time, when I was Chairman of the board, was very supportive of that work and we were hoping that that would produce some real evidence of new ways of working that would be better than the current system, but that was all swept aside and a new system was introduced without reference to anybody other than the department's internal systems, and the trouble is that nobody bought into it apart from the Department of Health.

Q6 Dr Stoate: The impression from the submissions we have received and what you have just said yourself, John, is that you seem to think that the new system was not sufficiently thought through. Which particular aspects were not thought through? Is there any way you can tell us what they did wrong?

Mr Renshaw: We have thought about this because we knew that this was likely to be the kind of question you would throw at us, and we ended up with a list so long that we thought we could not really give you the whole lot in one go, so I will just read you out some of the bullet points on the lack of forethought. The first thing was that the early work on PDS was simply discarded; that was thrown out as being of no value. There was no formal consultation with the profession. We believe that the duress that was placed on practitioners to sign this deal was grossly unfair. Basically, people were told, "Sign it and you are in. Do not sign it and you are out and you need not think you are coming back". That was basically the message that we were told.

Q7 Dr Stoate: From the department?

Mr Renshaw: From the department, yes. The PCTs at the time of this happening were undergoing internal reorganisation so they had their eye on a very different ball. PCTs were already overspent; they were in serious financial difficulties and did not have any play money to solve any local problems. They did not have anything left to do that. There were no roadshows for dentists to explain to them what was going to happen. The UDAs have never been tested. There was no time to argue about the UDAs as a concept. There was no chance to properly argue about individual UDA targets and contract figures. Funding was based on a snapshot view of practice finance at a particular year in time with no room for manoeuvre. I got caught with that. The number of charging bands and patients' charges were certainly worked on but had not been consulted on with the profession. Patient information arrived late. There was not any information for patients ahead of the change. The number of disputed contracts was in excess of 2,000 out of a sum of something like 9,200, which meant that they were really going to dispute the figures and the conclusions in them. The disputed contracts cost a fortune. It just goes on and on. The out-of-hours arrangements, which had been working perfectly, simply went into abeyance. There are virtually no out-of-hours arrangements in many places.

Q8 Dr Stoate: But apart from that it went fairly smoothly?

Mr Renshaw: Apart from that it was pretty good! The thing that concerns us more than anything else is the gulf between what the department says and everything that everybody else says. I am perfectly willing to concede that I might have a prejudiced view because I might as an individual have been badly done to in the changeover, but I do not think we have 3,000 members joined up to our campaign because I personally have been badly done to. Three thousand people to me says 3,000 people feel badly enough to go and join an organisation.

Q9 Dr Stoate: Can I just ask John Taylor, do you think the Dental Practice Board should have been more involved in the setting up of the new contracts?

Mr Taylor: No. I think we were well enough involved. The new work was going on roughly and it is our job to administer whatever politicians want; it is not our job to question. We can advise, of course, on our experience but we got the job done so we must have had enough involvement.

Q10 Dr Stoate: So as far as you are concerned you were sufficiently involved?

Mr Taylor: We were sufficiently involved to get the job done and the job was to be able to administer a system after 1 April 2006. We got that job done, so we must have been involved enough. It is not our part to question policy. It is our part to get the administration done.

Q11 Dr Stoate: That is very clear.

Mr Crouch: I would say quite the reverse, I am afraid. John obviously would be very loyal to his position but I personally as a dentist was unable to transmit any information to the Dental Practice Board until the summer of the new contract, three months late. There was no piloting or testing of the software that we were supposed to use. There were no discussions about how these forms should be filled in. Everything was thrust through. We had information given to us at the last minute. Patients were unsure of what system was working. We were not sure of what bands we were supposed to be ticking people into. The information that we could have sent we could not send through the software, so in the end we had to revert to a paper form to at least to keep things ticking along. There was a mad rush to introduce a system that clearly had not been thought through properly.

Mr Taylor: In the light of that could I just add one comment? All my nerve ends tell me that if you are going to introduce a new system you must test and test and test. We did not have the time to test our computer systems but, again, we have got to do the best we can. I would have preferred more time but that was not quite the question I thought you were asking me.

Q12 Dr Naysmith: Mr Renshaw, there is an alternative view to what you have just promulgated, which is that the BDA and dentists refused to engage in proper discussions with the department and eventually the department got fed up and said, "We are going to have a contract anyway". What do you think of that?

Mr Renshaw: It is a view but, of course, you would have to be listening to the Department of Health to take on that view.

Q13 Dr Naysmith: So you think there is no truth in that at all?

Mr Renshaw: None at all because that is a spun version of the truth.

Q14 Chairman: Why did everybody join Challenge then when they had got professional representation in the country?

Mr Renshaw: If you are claiming that the BDA were not doing their job properly -----

Q15 Chairman: No. Normally professional associations negotiate on behalf of the profession.

Mr Renshaw: Yes, they do.

Q16 Chairman: We have it with the rest of the medical profession, quite successfully, we are led to believe, but why in this case did it not happen and organisations like yours appear?

Mr Renshaw: I cannot help but feel that the association was left with some internal conflicts of interest with a number of members that it had working on both sides of this system and it was difficult for them to be as critical as we could be simply because we were representing just one particular group of practitioners who were the contract holders for the new system.

Q17 Dr Naysmith: So there was some alternative view within the representatives of the profession that they wanted to carry on talking perhaps, for whatever reason?

Mr Renshaw: I do not think there was, no.

Q18 Dr Naysmith: You have just said there was because of a conflict of interest. You just said there was.

Mr Renshaw: Yes, but the problem was that the willingness to challenge strongly was tempered by some internal conflicts of interest within the BDA. From our point of view those conflicts of interest did not affect the membership that we had. We did not feel that need to be more circumspect about our criticism. We thought we were entitled to make -----

Q19 Dr Naysmith: But what you have said is that there was no-one who was interested in talking about the new contract, basically, and that is not true.

Mr Renshaw: Are you talking about on the profession side or the -----

Q20 Dr Naysmith: That some members of the BDA were talking to the BDA and talking about getting this conflict of interest that you are talking about. There is a conflict of opinion as well. There were people on both sides -----

Mr Renshaw: You will never find 20,000 people -----

Q21 Dr Naysmith: I know that.

Mr Renshaw: You put five people in a room and if they are dentists you will get 27 opinions about what is the best way forward. The problem is that we will always find factions within professions. We represent a faction that was very unhappy about what was going on.

Q22 Dr Naysmith: That is not true of the whole profession.

Mr Renshaw: Not necessarily in our case, no.

Mr Crouch: I would like to comment on that. If you are having a dialogue with someone who is introducing something you would expect some dialogue to take place. There were many promises made about what the introduction of the new contract would do for the profession and for patients. None of those we thought was a real aspiration for what was being forced upon us, and therefore, if you are having a dialogue with someone, you would expect some give and take, and when there was no give and take it is not surprising that the BDA decided to walk away, because what is the point of them being there and giving advice if it is not listened to?

Mr Renshaw: The worst aspect of that was that the department were clearly going to use the fact that the BDA had been there as a justification that the profession had been involved and that therefore it was okay, guys, and the BDA clearly at that time was not agreeing with that and they felt that the only way they could get away from that was to walk away. You can ask them yourselves. They will be coming along later.

Dr Naysmith: We will do.

Q23 Charlotte Atkins: Is not the reason the department took this all-or-nothing approach, you are either in or out, that it was partly to stop the totally unacceptable practice of dentists bribing parents to take private dental treatment so that their children would be treated on the NHS?

Mr Renshaw: The number of child patients who are being subjected to that kind of pressure I would imagine is very small. I have never seen any evidence of that going on. I know individually you can find practices where they were doing that.

Q24 Charlotte Atkins: Say you had evidence in my constituency?

Mr Renshaw: I am not saying it did not happen but I do not think it was ever a major problem, and if you look at the figures there are something like seven million patients still being treated as children on the NHS.

Q25 Charlotte Atkins: The body language, going round this committee, indicates very strongly that it is not a tiny problem; it actually is an extensive problem in some areas, certainly in my area. I only speak for my own constituency, but, judging by the nodding of heads around this committee, it is very clear that it was a widespread practice and people were forced into things like Denplan simply because otherwise their children would be left without NHS treatments.

Mr Renshaw: I beg to differ with you because I think that the big problem is not about what is going on with the children. Why are adults being taken out of the system? The answer has to be because the practice cannot make a living, it is not viable on the kind of money that the dentists were going to be getting for looking after the adult patients. If you then have the children, most dentists wanted to be able to keep on their child patients. If you look across the board -----

Q26 Charlotte Atkins: No, I am talking about the situation prior to the new contract, the situation which led the Department of Health to say, "You are either in the NHS or outside it". I am not talking about the new contract. I am talking about the situation before the new contract came in and why the department took the position they did, which was that you were either in, totally with the NHS, or you were outside. You could not have a situation where parents were being bribed to take out private dental treatment for themselves so that their children would have the benefit of NHS treatment.

Mr Crouch: My comment on that would be that initially, when the contract was placed out, within the terms of the contract it allowed practitioners not to discriminate against anyone that they took on as patients. The Department of Health had to change their position on that. Because of the fact that it had not been negotiated they had to allow practitioners to have child-only and selective contracts simply to get the thing in place, so if that was an issue that could have been sorted out with debate ahead of the introduction, but in effect they rushed through with the introduction with that problem still there and it is a lingering problem because these people are still having these lists and they will still have them up until 2009.

Q27 Charlotte Atkins: So do you think it is an unacceptable practice?

Mr Crouch: It does not happen in my particular area. I work in Birmingham.

Q28 Charlotte Atkins: Do you think it is an unacceptable practice?

Mr Crouch: I would be very horrified to think that people were bribing people to sign up to private plans simply by accepting their children. I think that is an unacceptable practice, yes.

Q29 Mr Bone: Does not Government, in a state-run health service, have the right to try and increase access to the NHS for dentistry, which is what was the driving force for this new contract? I suppose the question is, have they succeeded?

Mr Crouch: No, quite clearly, because even from their own figures a quarter of a million fewer people saw an NHS dentist in the first year of the contract.

Q30 Mr Bone: Okay. That is pretty clear. I am not allowed to agree but I do agree, but the issue was that also behind the Government's idea was, "You horrible dentists are not treating NHS patients in deprived areas", and they were trying to get more NHS access into areas where there was great poverty or real social problems. Have they succeeded in doing that?

Mr Crouch: No, quite clearly not. The problem with the introduction of the contract was that because it was untested and because it was not piloted every single PCT in the land was a million pounds short in their budget because of the patient charge problem. In my city six practices left the NHS in April 2006 and in January 2008 they replaced the service. They only replaced it then because for the first year of the contract they balanced the books with the million pounds' worth of dentistry they should have bought with the million pounds that they were short on the patient charge revenue. The idea that a dentist leaves the NHS and another dentist is purchased is admirable but in practice it does not work. Every single dentist who has under-performed in their contract has in some areas had money taken back off them. The PCT are not spending that on additional dentistry. They are not liaising with the local population on what services they want and this money is disappearing into the ether. It is no good having ring-fenced money if it is not accountable, and when we ask our PCT for accounts of how they have spent the budget for the first year we do not get any answers. It is all fudged and hidden.

Q31 Mr Bone: I think, Chairman, this is a very important point because in my area you have described exactly what has happened. All the dentists, dentists who have been in the NHS for years and years, decided they had to go private. There are no NHS dentists available in my constituency. You have to go out of the county to get an NHS dentist. I was forced to go on Denplan, as were thousands of other people, but what struck me as bizarre was, where on earth has all the money the PCT would have been paying to those NHS dentists gone? Have you any idea?

Mr Crouch: First of all, the whole way that the contract was introduced was based on historic funding so, if your area was always an area where it was difficult to access dentistry, unless there were huge amounts of extra money poured in where was that extra dentistry ever going to come from? That is the first point. The second point is that the introduction of the contract came when the finance people within the PCTs were trying to balance the books and that driver from the people within the finance department meant that the ethos of a new contract just did not happen from day one.

Q32 Mr Bone: So, given where we are now, what can be done to encourage NHS dentists into local PCTs? We are where we are so what can be done to improve the situation?

Mr Crouch: Obviously, the department will say that the extra 9% funding they have announced in the new spending review is a step forward in that direction and I probably would agree that some extra funding is definitely necessary and that will help. The problem is that there is a real difference in meaning between access, ie, getting in and sitting on the dental chair, and getting the quality of care that you really deserve when you get in there. There is a real difference with that. If it means that loads of people are not writing to MPs because they can get in and sit on the chair, but that once they get in the quality of care they get, because of the system that we are operating under, is not up to the standard, then extra money is not the solution. Extra money only works if the system changes to mean that patients get the quality of care they really deserve.

Q33 Mr Bone: Chairman, I understand we are under pressure of time but again that exactly mirrors what has happened with my constituency. Experienced dentists left the NHS. Inexperienced dentists came in and established new practices, but now the problem is not the access; it is the quality of service they are getting when they go to those new ones. Would salaried dentists be a viable option?

Mr Renshaw: If you go across the border into Scotland they have certainly looked very long and hard at introducing salaried practices and they have brought a lot of salaried people in, particularly into areas where populations are relatively scattered and where the normal model of practice will not work because it is not financially viable. The problem with it is that the output from a salaried practitioner is approximately 40% of the output from a contracted practitioner and therefore value for money is relatively poor, but on the other hand it is a very good answer if you have a particular situation where, for example, you might have high needs but there is a very low economic base which would not make a normal dental practice viable. You can take in there the salaried practitioner. Nobody has ever said, certainly I have never said, that salaried practitioners are of no value. They may not be the answer to the whole thing but in certain places they are a very good answer.

Q34 Mr Bone: My final point, and I do really know how you answer this in a few words, is that my dentist has spent many hours when he has been working on my teeth telling me why he has had to go outside the NHS, but what are the main factors why people who have been in the NHS for years and years, dedicated to the service, feel that they now have to go outside?

Mr Crouch: First of all, we have a cash limited service which puts different emphasis on the way that you prescribe for your patients. If you have a limited budget and also a target to hit, it is not the way that I was taught to do dentistry. I was taught to provide quality of care for my patients irrespective of any target, irrespective of how much budget I had. I wanted to provide the best for my patients. I understand that you must have cash restraints on any service but the amount of money that was being spent on dentistry before the new contract and now, the budget for dentistry never really exceeded what was already in the pot.

Mr Renshaw: Can I just explain my situation? I worked in the NHS for 37 years and I left when the new contract was introduced because I simply could not countenance it, and they made me an offer that was very easy to refuse, frankly, mainly because I got caught in the test period, having been engaged as Chairman of the BDA and taking a lot of my time away doing that so my practice had shrunk away, but then I had finished and I needed to go back to working and they were not prepared to accommodate me, so 37 years of my efforts on behalf of the NHS were simply --- well, two fingers was even less than I got. It was just very destabilising to have that happen after 37 years. What I was looking at in terms of what I wanted to do was maintaining standards. I wanted to be able to keep offering a sensible service to the people I was looking after. I had 1,000 patients registered at that time on the NHS. I refused to dumb down the quality of what I was offering and, frankly, if I had taken that contract, that is exactly what I would have had to do. I was not going to be able to do any preventive work, which I was managing to get a little bit of with the NHS as it stood, and all of a sudden every bit of the financial risk on the contract had shifted to me. I was the one that was taking all the financial risk and the PCT was simply prepared to walk away and say, "And if you do not meet the contract we will take the money back. We will not argue about it. We will just take it because we have got your money". I thought, "Does that really feel like a good deal for me after 37 years? No. I'm out", and I walked.

Q35 Stephen Hesford: Eddie, you said that no PCT steps in where dentists choose to go private; that is what you said. My experience in my constituency is quite the opposite.

Mr Crouch: I am not sure I said that.

Q36 Stephen Hesford: No, you did say that. It is quite the opposite and that is the way the scheme, as I understand it, is supposed to work. I will just give you a quick example: dentists about your age, about three or four years before retirement, yes?

Mr Renshaw: You have just insulted one of us!

Mr Crouch: I have got a hard time at the moment. I am really sorry!

Mr Renshaw: He has done a lot of mileage!

Stephen Hesford: Bear with me. Two examples, same situation: one coming up to retirement in unsuitable premises, upstairs, and the PCT said, "Look; you are single-handed. We want to replace your practice with somebody else". That dentist would not play ball, sent out letters to his patient group saying, "They are forcing me out. I want you to join up to Denplan". That is what he did. The PCT said, "You should not have done that. You are abusing your position. You either come and negotiate new premises or we will take the contract away", and he was not performing on his original contract, so he went private, but the PCT have persuaded another dentist to set up in his stead in different premises, better premises, ground floor access, all this sort of stuff, so they came and provisioned where he was. On your explanation that poor man was forced out and there would have been a gap, and the blame would be on the system, but the PCT stepped in.

Chairman: Hurry up, Stephen.

Q37 Stephen Hesford: But this is important, Chairman. The other example, and this comes to the age thing, both age examples, is that very few dentists in my area walked away from the contract, very few indeed.

Mr Renshaw: Could you tell us where that is?

Q38 Stephen Hesford: Wirral.

Mr Renshaw: Very heavy NHS commitment area.

Q39 Stephen Hesford: Yes. Very few walked away. The one that did walk away in my constituency disputed the new contract and appealed. The appeal failed, but he came to see me in my constituency, a senior man like you, and basically what he said to me was, "Do you know, at my age, Steve, I want to do less work for the same money", and that was what his dispute about the contract was. He wanted the system to pay him at a higher rate so he did not have to work harder at his age, "at my time of life", that is what he said to me. What do you say to that?

Mr Renshaw: There are 22,000 dentists out there who are offering a service of one description or another and we can go through the individual cases and give you evidence of individuals who are just as badly done to as you feel they were not badly done to. I am not going to argue that that did not happen because clearly it did. I am not going to call you a liar; it is not the case, but there are plenty of other cases, which we would say would be a preponderance, where the opposite has happened, where PCTs have taken the money that was saved by people leaving and have not, until much later, re-provided, and they have taken the money and they hope to set it against their overspends. They will deny it till their dying breath, of course, but that is what they do.

Q40 Chairman: I was going to ask you about that, because you said that there are PCTs in your area that are effectively not sticking to the ring-fencing of this money.

Mr Crouch: What I am not sure is whether they are because there is no transparency. It is public money that is being spent but at the end of the year maybe the PCTs could produce a budget for the population that they provide the service for to show exactly how much money they have spent, how much money has come in from the Department of Health and how much money has been delivered for the service.

Q41 Chairman: I thought you had said earlier that they were not using the money ring-fenced for dentistry.

Mr Crouch: Absolutely clear.

Q42 Chairman: I am going to ask you to give us a name and/or the evidence that that is taking place because we understand that that is not what should be happening, and I would like to see the evidence of that. Do you have it?

Mr Crouch: I have the evidence. I have the evidence from Birmingham East and North Primary Care Trust, that a million pounds' worth of NHS dentistry was forsaken on the introduction of the contract and it was only replaced in January 2008. If you claim that money spent on dentistry is the money that you balance the books with for the patient charge shortfall, then technically it is being spent on dentistry, I suppose, but it is not being spent on the delivery of service to the patients that it was supposed to provide the service for.

Q43 Chairman: If you have any further evidence on that and, John, if you have as well I would be more than happy to receive that to see whether or not that is taking place.

Mr Renshaw: One of the biggest problems we have is with the lack of transparency at PCT level and what they are spending. The fear has to be that the reason they will not tell us what they are doing is that they do not want us to know.

Chairman: Again, if you have any suspicions perhaps you could put that on paper and give it to us and we will investigate that.

Q44 Jim Dowd: That just cannot be true; otherwise Mr Crouch would not have said what he just said. Where did you get the evidence for that, if you are saying they are not telling you?

Mr Renshaw: No, because we know what has gone on in a particular PCT.

Q45 Jim Dowd: You cannot say, "We do not know what is going on" and then say, "We do know what is going on".

Mr Crouch: I can categorically say that I have the evidence because I know the practices that left the NHS and I know that the service that they have now trumpeted, which is a commission to one of the body corporates, opened in 2008 to provide that service. I have that evidence.

Q46 Chairman: There may be a problem. There is one in Rotherham and it has decided to go private and they are having to get the patients into other practices and you do not do that overnight and that has to be negotiated. These are small private businesses and they need to make it fit to the business plan. It does not mean to say that there is any intent to spend the money elsewhere. It might be the practicalities of transferring the money from one practice to another.

Mr Renshaw: Indeed.

Chairman: I have that but I also have expanding NHS dentistry because of that, I suppose, in a sense.

Mr Bone: I do think, Chairman, that it is varied around the country because in my case there were so many dentists that went private, the level of money the PCT must have saved was enormous and we have not seen that number of dentists open.

Chairman: Chase it up for us, Peter, because I have chased mine.

Mr Bone: Right; will do.

Chairman: We will have to move on now.

Q47 Dr Taylor: It is not actually moving on because it is still on PCT commissioning. Most of us have had our ears bent when we have been in the dental chair. My own dentist works for two different PCTs and one of them is good and one of them is bad. What we are looking for is evidence of the failing of the commissioning services. You have told us about lack of transparency and you are going to give us some evidence on that. In what other ways are they failing?

Mr Renshaw: The problem that we have had with PCTs is the variability of the quality of the managers who are dealing with these issues. Some of them are very good and I do not want anybody saying that we are saying all PCTs are bad because they are not; some are really quite good, but some of them are using the lowest level managers who really do not understand what they are doing and they are rambling around the country threatening people with legal action and all the rest of it. It just happened recently in East Yorkshire where a new head came in, started throwing his weight around, being difficult and threatening practices with all and sundry in legal terms if they did not behave themselves and do this, that and the other, and you think, "I am sorry, but you do not have a legal basis to start doing that. You have to start working within the rules", and the fact is this guy simply does not understand the rules but he is not the only one.

Q48 Dr Taylor: So, lack of transparency, variability of the quality of managers.

Mr Renshaw: Yes indeed; not enough of them.

Mr Crouch: Manpower. When people come into post they often stay there for a very short period of time. They build a rapport with the dentists of that particular area and then they get moved on to other things. Dentistry in most PCTs' budget is between 3% and 4% of their spend and therefore they feel that dentistry requires 3% or 4% of the manpower. Dentistry is a quite complex thing. There are 60 practices in one of the PCTs in my area and it is just too much for the people to go out and do their jobs properly. They have not got the manpower to do it. They do not go out and do mid-year reviews, they do not go out and do end of year reviews. They do not do anything that this contract is setup to do. They do not go out and consult with the profession about how the service can be developed. They do not go out and talk to the patients. None of the building blocks of this contract is possible with the structures that we have at the moment.

Q49 Dr Taylor: Thank you. We have already talked about gulfs between everybody's opinion of what is going on and the Department of Health. One is about the number of patients being seen because the department's figures suggest that there has been very little change. Are those wrong?

Mr Renshaw: The thing I would question about those figures is that what they have started to do is use two-year figures. We have never seen these appear before. Over the last 24 months a certain number of patients have been seen. Can I just remind you that the contract has not been in place for 24 months yet? The figures that we are being shown include the period when everybody was working like crazy to try and get people straightened out before the new contract started, so we have still got the overrun of that, and the data in my opinion are inflated, not because they have been inflated on purpose; do not get me wrong, I am not saying they are being deliberately inflated, but they are inflated by a period when the old contract was still in place where people were trying really hard to get everybody tidied up before the end of the old contract and the beginning of the new because we were told the best thing to do was get everything signed off so that we could have a nice clean break and start the new contract on the new system. Those figures in my opinion are highly dubious and certainly not worthy of consideration properly until the contract has been in place for two years and then it will start to make some sense.

Q50 Dr Taylor: Can we go to the numbers of dentists because the Government tell us the number of contracted dentists has risen, but you say that because of the lack of accurate and sophisticated data about whole-time equivalents the NHS has no idea how many dentists actually work in the service?

Mr Renshaw: They cannot tell you what the whole-time equivalent dental workforce is. I have never ever been able to find a figure and, believe you me, I have tried for the last ten years to find one. There is not one. I find that extremely frustrating, because from a planning point of view it is extremely difficult to try and work out what on earth we are going to try and do if we do not even have a clue how many dentists we have got.

Q51 Dr Taylor: Such a huge gap. In principle do you object to PCT commissioning or if they got it right would that be okay?

Mr Renshaw: PCT commissioning is in theory an excellent idea. I think the idea of local commissioning is relatively sound providing you have a decent national framework within which they can operate. What worries me is the variability of performance at PCT level which makes local commissioning look very bad where it is done very badly. Actually, it is done very well in some places and, of course, it does not tend to get noticed so much then.

Q52 Mr Scott: Can I just record my thanks, Chairman, for you allowing me to bring this forward as I have to attend the Chamber? I am particularly concerned about orthodontic services. Do you think there is a shortfall in orthodontic practitioners in England and, if you do, do you think the new contracts are by any chance going to address this shortfall?

Mr Crouch: My own particular circumstances are that I do provide an orthodontic service. I want to provide more orthodontic service. My own particular circumstances are that during this snapshot year, which affected orthodontics far worse than anywhere because orthodontic payments are over a much longer period of time and therefore, to take an arbitrary snapshot of funding without looking at any trends, without looking at the needs of the local population, has effectively frozen my orthodontic budget. I have gone from having no-one on my waiting list to nearly 700 patients in the first 18 months of the contract. I want to provide care for them. I do not want to be sitting there twiddling my thumbs, but I have been caught out by this inflexibility of the way the contract has been introduced. We have a real manpower shortage in orthodontics. We have a problem with the secondary service where this new 18-week rule will be unattainable completely within the orthodontic service. There is capacity to take some of that service out of secondary care into primary care and it has not been utilised because the PCTs did not have the flexibility to spend some of that money on enhancing the service. Orthodontics is my pet subject because it affected me so badly.

Q53 Mr Scott: Both Johns, are you in agreement?

Mr Renshaw: I am right with Eddie on this one. He is the orthodontist, not me.

Q54 Mr Scott: The British Orthodontic Society has made this clear but there are many orthodontists who are not working to capacity anyway because they simply cannot do so. I visited one servicing my own constituency where they told me that the main practitioner was not working full time, people working for him were only working part-time and their waiting lists are getting longer and longer. This is obviously a ridiculous state of affairs, particularly in children's cases. It is becoming too late for that treatment to work or even take place.

Mr Renshaw: There is a practice in my town where we managed to acquire a Finnish consultant in orthodontics who is excellent, really excellent, and he was providing a fantastic service. Up comes the contract. He had already arranged with the PCT to bring in a second orthodontic specialist, a specialist practitioner, not a GDP but a qualified orthodontist, the idea being to double up the capacity because they were beginning to mop up all of the excess treatment that was required in the area and they were doing a really good job, very popular. A Czechoslovakian guy comes in. All of a sudden, because of the contract, it is frozen in time; there is no more money, so we only have enough money for one of the orthodontists to work. The Finnish guy has kept the practice on, the Czechoslovakian guy is working there and doing a great job but within the constraints of what he is allowed to do, and the Finnish guy has gone back to Finland. What is that about? Somebody went to a lot of trouble to do that recruitment work and it cost a lot of money, and now all of a sudden it is just thrown out of the window and he is now talking about selling up the whole thing. I just despair.

Mr Crouch: My comment on that would be that there are certainly some areas of the country where orthodontists are working that are quite happy with the new contract because it gives them a lever now to suggest to the patients that they have that treatment privately. I work in a very deprived inner city area of Birmingham and even I have been approached by patients who say, "Please do not put me on the waiting list. How much will it cost me to get my child's teeth straightened?". I feel very bad about having to charge someone who is on income support for private orthodontics. That is not what I want to do. I want to provide that service.

Q55 Mr Scott: So basically the new contracts are letting down orthodontic services?

Mr Crouch: Completely.

Q56 Charlotte Atkins: Are you concerned that the new dental contract will lead to a deterioration in oral health in this country?

Mr Renshaw: I am.

Mr Crouch: Certainly I think the pressures within the contract to hit target are a driver. The Government and the Department of Health will say that the courses of treatment have become simpler but the patients that are coming through are exactly the same patients as we have always had. If they are trying to suggest that over-treatment was a problem in the first place then there may have been an element of truth in that in the profession but this driver that we have now is to provide simpler courses of treatment, and when you get the same reward for a simple bit of treatment and a more complex bit of treatment and at the end of the year you must hit a target and if you have not hit that target then funding will be taken away from you, there is inevitable pressure on the type of care that is provided. The Dental Laboratories Association will say that the amount of complex work has dropped dramatically and it is inevitable when you have a fixed budget to work with that you are cautious in how you spend that budget.

Mr Renshaw: We did some survey work amongst our membership at the end of March 2007 after 12 months of the new contract, and they were saying at that point that 67% of them were doing fewer root treatments than they had done previously, 75% were saying they were depressing the amount of cobalt chrome denture work they were doing, 85% were doing less multiple crown work than they were doing before, 85% were doing less bridge work. You can always argue about individuals but when you get mass information like this it is extremely difficult to argue that reducing the amount of bridge work by 85% across the board is somehow a good thing.

Q57 Charlotte Atkins: What was this survey?

Mr Renshaw: This was a survey of our members. We asked them to tell us a little bit about what they were doing so that we could get a glimpse, if you like, of what their performance was and what they were doing. We did not lead them. We gave them choices about were they doing a bit more, doing a bit less, whatever, and the figures were really alarming. We were astonished.

Q58 Charlotte Atkins: So your main concern from that survey is about the more complex work not being done. Is your concern also about having very little priority for preventative treatment in the contract, or are you more concerned about the fact that the more complex work is being crowded out of the system?

Mr Renshaw: The key issue with prevention is that you have to talk to the patient. It is not about doing things to them. If you cannot count it you cannot have it and the department will not pay for it. If I want to talk to a patient about looking at how they have got themselves into difficulties with their oral health and I am going to go through that with them it is going to take me 15, 20 minutes. I know that is not a lot but you do that 2,000 times a year and you have got a lot of money standing around doing nothing. If you want to try and do some preventive work with patients you really do need to have some time and it does have to be figured into the cost base of the practice.

Q59 Charlotte Atkins: So you are saying the previous contract -----?

Mr Renshaw: It was not there in the previous contract. I am not pretending that it was. One of the key things about the new one, however, was that it was supposed to be a key driver to increase the amount of preventive work. My view is, listening to the people that we represent, that it has not happened.

Q60 Charlotte Atkins: So there was no golden age in terms of preventative work?

Mr Renshaw: There never has been in the UK.

Q61 Charlotte Atkins: Except, of course, we hear that English children have the best oral health in Europe.

Mr Renshaw: If you really want an argument about that nonsense, that absolute piece of arrant nonsense, I would suggest you get some statistical advice on it because those figures are not comparable. Some of the figures that have been quoted are 15 years old and the 12-year olds are a snapshot view. I have to tell you: it is a very selective view which has been picked deliberately because it is the only one that shows that oral health in this country is any good.

Q62 Charlotte Atkins: So was it true 15 years ago?

Mr Renshaw: No.

Q63 Charlotte Atkins: And it is not true now?

Mr Renshaw: No.

Q64 Charlotte Atkins: So can you provide us with the statistical evidence to demonstrate that?

Mr Renshaw: Yes.

Q65 Charlotte Atkins: I do not know if that was in your submission.

Mr Crouch: No, it was not.

Q66 Charlotte Atkins: But you will supply that evidence to us?

Mr Renshaw: Yes.

Mr Crouch: Yes.

Q67 Charlotte Atkins: What is your view about the Secretary of State's announcement on Tuesday about the money for fluoridating the tap water supply?

Mr Renshaw: This is going to sound like heresy but I think that political boat sailed a long time ago.

Q68 Charlotte Atkins: Sailed a long time ago?

Mr Renshaw: It has gone. Fluoridation will never be accepted in this country in my view because it is a political dead duck. It has got nothing to do with the rights and wrongs of fluoridation. I just think politically it will never sail.

Q69 Charlotte Atkins: But Eddie is in Birmingham.

Mr Crouch: Yes.

Q70 Charlotte Atkins: And Birmingham's evidence is pretty uncontroversial, I would have thought, in terms of comparison with Manchester?

Mr Crouch: Absolutely. I appeared on Sky News on Tuesday pontificating on the benefits of the fluoridated water that we have had in Birmingham and I would say that the problems are that there is a huge lobby out there that is anti-mass medication. There are other ways in which fluoride can be applied and that could be introduced in various ways. There is some debate on whether it is the effect of fluoride toothpaste rather than fluoride in the water supply that has made the biggest difference and I think there is more evidence that needs to be found out for that, but certainly from what I see in Birmingham we come top of the league in dental health in the West Midlands every time there is a child dental health survey, so to me the evidence is clear.

Q71 Charlotte Atkins: If it was down to toothpaste how would you say there is a difference between Birmingham and Manchester?

Mr Crouch: That is right.

Q72 Charlotte Atkins: Should they just have more toothpaste in Manchester?

Mr Crouch: As I say, I think there is more evidence that needs to be sought on that.

Q73 Dr Naysmith: That evidence has been looked at over and over again.

Mr Renshaw: Yes, indeed.

Dr Naysmith: It is very clear that there is a difference between Manchester and other places that do not have fluoride in the water.

Q74 Charlotte Atkins: But I should just declare an interest as the Vice President of the British Fluoridation Society..

Mr Renshaw: The York review was not at all convincing. I have known Trevor Sheldon for a long time and they were not at all convinced that the evidence was there to back up either side. Do not get me wrong. I am absolutely pro-fluoridation.

Q75 Charlotte Atkins: You do not welcome the announcement then?

Mr Renshaw: The announcement is fine but it will not get you anywhere.

Q76 Charlotte Atkins: And you agree with that view of John Renshaw's?

Mr Crouch: I do not. Myself and John do not agree on everything.

Charlotte Atkins: I am glad to hear it.

Q77 Dr Naysmith: Does Challenge have a policy on it?

Mr Crouch: No! We can find one.

Q78 Charlotte Atkins: From your practical experience in Birmingham rather than the York study you recognise that there are benefits?

Mr Crouch: There are huge benefits but there are still huge pockets of inequality within Birmingham. In some of the areas that I work in I still see rampant problems with decay because of the fact that they are from the ethnic minorities, often shopkeepers who have a huge abundance of sweets. Fluoride may be one of the answers but obviously prevention and dietary advice and sugar control and various other things are so much more important as well.

Q79 Charlotte Atkins: What would you say the single most important issue is in terms of reducing inequalities in oral health?

Mr Crouch: Obviously, adding fluoride to the water supply allows people of low social background to have some element of fluoride if their parents cannot afford the drops and the mouth rinses and various other things. I am totally for fluoride.

Mr Renshaw: Can we just make the point though that the best oral health in Europe is in Scandinavia where they are not fluoridated? They have a very intensive campaign that runs with children from day one. They are really regimented into -----

Q80 Dr Stoate: But that is about deprivation and social inequality, which Scandinavia is extremely good at. We know that.

Mr Renshaw: But they have conquered the problem without using fluoride.

Q81 Dr Stoate: They have got a completely different social structure.

Mr Renshaw: Yes, they have.

Dr Stoate: This is slightly off the subject, Chairman. Look at America and the evidence is far more clearcut, but we are straying somewhat, Chairman.

Chairman: Can we move on?

Q82 Dr Naysmith: Sometimes people compare the provision of dental services with the provision of primary care services, doctors and so on, and the difference is obvious in one sense in that you go to the doctor when you feel unwell but you go to the dentist, or you used to do under the old contract, every six months, some sooner. Do you think that was necessary, that six months?

Mr Renshaw: It is interesting because, although people always claim they went every six months, if you look at the data they actually went about every nine months. If you are going to ask somebody, "How often do you go to the dentist?", they will say, "Oh, yes, I go every six months", but in fact the data from the DPB says no, they do not.

Q83 Dr Naysmith: In 2002 the Audit Commission said that they thought this was unnecessary.

Mr Renshaw: Yes, they did, and, of course, the NICE guidelines have been brought in to see whether a longer period between check-ups is appropriate for some people. Of course it is. It stands to reason. You cannot have a rule of thumb that says everybody goes every six months regardless. It is nonsense. People are not that regimented and they should not be.

Q84 Dr Naysmith: That aspect of the old system was unnecessary really, if people come along for an unnecessary scale and polish every six months.

Mr Renshaw: I think there is a big argument about the necessity for scale and polish. If you look at the level of periodontal disease in this country it is very hard to argue that more scale and polishes are not required. We are getting into the technicalaities of disease patterns here, which is fine, but they are not terribly wrapped up in the recall interval. The recall interval is really a preventive measure to try to reinforce the messages to the patients. If you look at the patients who come regularly on a six-monthly basis, they are generally speaking the better quality mouths that you see around. That is not every single one of them but on the whole they are very healthy individuals. The ones who come less often tend to be the ones who have the trouble, but there is a happy medium. I would suggest that we have been moving away from the six-monthly recall period for some time. NICE guidance has pushed it a little bit further and pushed the pace along a bit, and I certainly have a lot of patients who come in on an annual basis and they are perfectly happy with that and I am happy with it because I am not finding problems with them.

Q85 Dr Naysmith: But the NICE guidance also said there were some people, and possibly they were the people who most need dental treatment, who should come more frequently.

Mr Renshaw: Indeed.

Q86 Dr Naysmith: Do you think that is happening?

Mr Renshaw: Absolutely.

Q87 Dr Naysmith: It is the other way round, and I am looking at your statistics, that the ones who have the good mouths are probably those who come from the better-off parts of whichever society we are talking about.

Mr Renshaw: Indeed. It does not always follow.

Q88 Dr Naysmith: The ones who need to be encouraged to come are those from the more deprived areas. Do you think that is happening?

Mr Renshaw: That is right. It is not acceptable. It is a fact, is it not? We know that is where the problems are, but trying to get into those areas and get them to come to the dentist, and I do not want to be any part of dragooning people into going to see a dentist if they do not want to, is an uphill struggle. Even where access centres have been placed right in those areas their uptake is relatively low and it tends to be episodic visits. They come in when they have got toothache. Changing that culture is not going to happen overnight and what needs to be there is a strategy, if you like, a project, to try to get the population in those areas to value dental services and use them when they are available, and it is not going to happen simply because you go and plonk somebody in the middle of it.

Q89 Dr Naysmith: Okay, but what I am trying to get you to answer is, is there any element of the new contract which encourages what NICE was recommending rather than what happens with the system that you now operate, being almost outside of the NHS system?

Mr Renshaw: No. My view would be that the system as it stands now encourages regular visits, just like the old contract did.

Q90 Dr Naysmith: So it does not make any difference?

Mr Renshaw: I do not think so.

Q91 Jim Dowd: I used to go regularly to the dentist every six months or so and I now calculate that I have not been for nine years and I do not seem to be any the worse for it. I met my dentist a matter of fact just a fortnight ago at a dental committee.

Mr Renshaw: He says he is your dentist?

Q92 Jim Dowd: No, no, because he asked me to go and address the annual dinner of the local dental committee.

Mr Renshaw: So for a while he was your dentist?

Q93 Jim Dowd: It was the first time I had been in a room with him for such a long period without him inflicting great pain upon me, but could I just ask Mr Taylor, who has been very patient down the end there -----

Mr Taylor: I do not want to interrupt you but could I say something about the recalls because I mentioned the DPB data?

Q94 Chairman: I should have asked you.

Mr Taylor: At the time we are talking about the fee that the dentist got for an examination was time-bound at six months, so the dentist could only get a fee every six months. He could see the patient as often as he liked but he would only get a fee every six months, so the recall was fixed by the payment system. If you are talking about access you should look at the characteristic: how many people come back? Middle-class people do as they are told. If the dentist tells them to come back every six months they come back every six months. Other people may not. When you are looking at what actually happens you should look at the characteristic: how many people at six months, how many people at a year, how many people at two years? We did that all the time, but when the access comes up what do we know about access? We know a hell of a lot about access. Almost everybody in the population attends over a ten or 15-year period, almost everybody is in the NHS, but if you make it a ten-day period hardly anybody is in the NHS. To understand it you have probably got to define the terms and look at the figures.

Q95 Dr Naysmith: There used to be the system, of course, where people registered with their dentist.

Mr Taylor: That was an intermediate thing, and I agree with this. One of the solutions to the problem is to put prevention into a capitation-type scheme and put the other things into a payment-by-results scheme, and that would have been an intermediate step, which is something we said at the DPB.

Dr Naysmith: That is a very interesting point. Thank you.

Q96 Jim Dowd: On that point, this committee interviewed Rosie Winterton before the contract was brought in and what we managed to establish then was that the only way of calculating who had a dentist and who did not was presentations within the last two years because you do not keep them on the books, so to speak, in the way that a GP does, and all they could really calculate was the number of people who had attended a dentist in the last two years.

Mr Taylor: But we know for ever. The thing about dentistry is that because we have the payment claims we know absolutely everything for ever, or for a very long period.

Mr Renshaw: And the tragedy of the new contract is that most of that has now been lost.

Q97 Jim Dowd: Okay, so that is the volume of activity, but could you just tell us what measurements there were to calculate the quality of dental care under the old system and can you say how it has changed things?

Mr Taylor: I do not know whether you know about the Dental Reference Service but the Dental Reference Service was set up about 1935 to keep an eye on the quality of dental services and it was run out of the Ministry of Health and into the Department of Health and the DPB took over the management of it but not the principles and duties of it in about 1990; I cannot remember exactly when. The Dental Reference Service examined on behalf of the Secretary of State, managed through the DPB, patients before a course of treatment and after a course of treatment, and so we knew within limits how many people we saw and what the standard of treatment was, so it was known.

Q98 Jim Dowd: You say it was. That system is no longer there?

Mr Taylor: As far as I know, and I have lost touch with this over the last couple of years, obviously, the role of the DRS has become pastoral, I think the word is. They visit dentists and they talk about things, but there was this hammering away at examining patients before and after treatment so that the necessity for it could be assessed and the standard could be assessed, and whether in fact it took place at all, of course, which is a matter of the proper use of public funds. We knew that and my argument was, and your committee many years ago at times would argue, that we should have more; the Dental Reference Service should have been strengthened. As I understand it, and I might be wrong here so I do not want to mislead you, it has effectively been withdrawn.

Q99 Dr Naysmith: I can confirm this, Chairman, because I used to be a member of the Family Practitioner Committee a few years back and there used to be evidence presented sometimes between the people you are talking about and practitioners who were in dispute about payments that had come before the FPC and all the things you are talking about were available, all the evidence of everything that had been done and independent people had examined them to see whether it had been properly done or not and all that information was available, which it is not any more, I dare say.

Mr Taylor: I do not know, but when I left the intention was that the DRS would take on a pastoral role.

Q100 Jim Dowd: You did say in your submission that the new contract had weakened the ability to provide quality assurance and to detect fraud.

Mr Taylor: Yes.

Q101 Jim Dowd: Could you expand on that?

Mr Taylor: I hope I did not make a submission. I put in some observations which I thought might be of help. The Dental Practice Board's job was was to examine whether public funds had been used as Parliament wanted them to be. Parliament would not know in detail what they wanted so we interpreted what we thought it was. That was our job. We had for that purpose two major things. One was all of the treatment data because the dentists could not get paid unless they told us what they were claiming for. They might not have done it, of course, but it might have been all sorts of things, so it was not only deliberate theft by deception, which is fraud, because that is a matter for the courts to decide, but it was also about use of public funds other than as Parliament would have wanted, and we could get from the data and from the Dental Reference Service because where we had a suspicion we could send a dentist to examine the patient to see whether it had happened and to what standard it had been done. Did I make that clear? I have talked a lot but I do not know whether I was saying very much.

Q102 Chairman: Can I just confirm, John, that your submission is not published with the first tranche of written submissions because it was not for publication but it has advised us and thank you very much for that.

Mr Taylor: I am quite happy about that. I was not trying to interfere. I was trying to help.

Q103 Chairman: Thanks for putting that question into the context of what you have done as well. Can I move on very briefly to dentists' workloads? John, your submission states that 47% of dentists fail to reach their units of dental activity as set by their PCT in 2006-07. Can you explain why?

Mr Renshaw: Yes, because the targets were too high in the first place. Our argument has been ever since the start of this that the way that the UDAs were calculated has never been explained. How the targets were arrived at has never been explained in my knowledge or anybody else's that I am aware of. I wrote a paper which I am perfectly happy to hand over for you, which explains a view of how the figures were wrong but I do not know how they were arrived at in the first place. Therefore, it is very difficult to be certain that the calculations that were used originally were wrong, but the fact is that if 47% of people fall below the target rate you have to assume either 47% of them are not trying or 47% of them had figures that were completely wrong.

Q104 Chairman: Were they not based on a two-year average of the activity that had taken place?

Mr Renshaw: In theory, yes, but in fact the system that was working at the time the figures were collected was one system and then you installed a new system and applied some kind of retrospective calculations of the new system back on to the old data and came up with a number. The number is very important because that is the target, and if you do not get to it they come back raiding the money. Our argument has been, "Please tell us how you arrived at those data because those targets are really important", and I have never in the last 18 months seen an explanation and nobody will admit how those figures were arrived at.

Q105 Chairman: They are just not realistic in your perspective?

Mr Renshaw: No.

Q106 Chairman: Do you agree with that, Eddie?

Mr Crouch: I would, yes. This comes on the back of the fact that the promise was that we would have 5% less work. That was the promise, that we would have 5% less work to do the prevention and yet the targets, as I perceive them, have been inflated. There are so many grey areas when treatment was submitted to the Dental Practice Board, and perhaps John might comment on this, such as, was that a piece of emergency treatment, which was 1.2 UDAs, or was that a piece of restoration work that required three UDAs? A significant amount of that within a practice make-up would inflate a target quite significantly and the statistics seem to show that people are finding it very hard to hit the target. Every dentist that I speak to says they are working harder under this new system than they were under the previous system, so the offer of 5% less work is not there and I think the contract was inflated, maybe - and this is cynical on my behalf - deliberately to improve the access problem.

Q107 Sandra Gidley: This is to John Renshaw and Eddie. Before 2006 dentists were paid according to the number of procedures they completed. It was a sort of piece-rate system. One of the reasons for change was supposedly that the old system encouraged unnecessary interventions. Would you agree with that?

Mr Renshaw: That was a perception, yes.

Q108 Sandra Gidley: You say that was a perception.

Mr Renshaw: Yes, because there is no evidence that it was true.

Mr Taylor: Do you mind if I -----

Mr Renshaw: Here is the man with the numbers.

Mr Taylor: There is no doubt that if you pay people by the item you get more items. Some of those items will be unnecessary and some of them will be shady. If you are going to intervene you might intervene earlier because you have a gap in your practice or you might intervene later because you are very busy, but there is an enormous amount of evidence that over-prescription was significant but small and by "small" I mean 2%, 3%, 4%, 5% of the total amount of money going to GDP. We have got tremendous evidence of that and in money that was £20-£80 million a year.

Mr Renshaw: But there is no doubt at all that in principle, as John says, quite rightly, that if you pay piecework rates you will get more pieces. That is the purpose of pieces. That is why the piecework rate was introduced in the first place, because they wanted loads and loads of work out of people, so the best way to do it is to pay them on a piece rate. The trouble is we have moved on from that now and we are now into a new era and we were, up till 18 months ago, carrying an old-fashioned payments system and we needed a new payments system. Nobody but nobody would argue that the old system was not creaking but the danger was in going for a completely new system that was untried and untested and that is our problem. It is not that the new system was introduced but that it was introduced without bothering to find out whether or not it was going to work or not. The testing that had been done had been done on an entirely different model. It was not on the model that was finally introduced and so we were left with the whole profession sailing 100% into a new system which was completely untried, and, of course, we have now found out that if 47% of them cannot make their targets there is something wrong with the system. It cannot possibly be right.

Mr Crouch: I would comment also that there is still no disincentive to sometimes potentially over-treat a patient because if you are falling behind on your target and a patient comes in and that is something that you might sit and look at and not intervene at that particular point, if you are behind on your target there must surely be an incentive to say, "I must do it now because at the end of the year if I do not do it I will not hit my target". If you introduce a system that is supposed to deal with that I do not think this is the system to deal with it.

Q109 Sandra Gidley: Is there not another direction this could go in as well because there has been some evidence submitted to show that work is not done to the same standard as before because the bandings are too broad, so it does not pay a dentist for doing what he or she would have done before and they will do something that will do but is probably not quite as acceptable to their patient?

Mr Renshaw: The purpose of a publicly-funded service in my view ought to be that patients should feel confident when they go to the service that they will be treated with respect and with due care. A payment system should not drive the provider of that care in any particular direction. It always ought to be absolutely neutral. Trying to find an absolutely neutral system is probably impossible but I cannot help feeling that what we have done is stagger from one very imperfect system to another very imperfect system and what is going to have to happen is that there is going to have to be another correction because what should have happened was that a test period should have been gone through to assess whether or not the new system was going to work and then have it modified to make it more suitable.

Q110 Sandra Gidley: Just to change tack slightly, we have heard how dentists are not meeting targets but how has their income been affected by these changes?

Mr Renshaw: It is a very serious effect. I have been doing some consultation work with some practitioners who have run into financial problems as a result of the contract and the sums of money being clawed back are enormous; they are very significant.

Q111 Sandra Gidley: Can you explain "clawed back"?

Mr Renshaw: "Clawed back" is getting the money back after the year has ended because you have not hit your target. I have to say that the first year was bad enough but I have a horrible feeling the way things are going that the second year is going to be significantly worse. The amounts being required to be repaid - and this is quite interesting if you think about the UDAs and the way they are structured - are that they are simply wanting back all the money for all the UDAs that were not performed. The trouble is that the UDA, if you like, the currency, in the way a practice operates is made up of two elements: the fixed cost element of providing the service and the treatment element of providing the treatment itself for the patient, and if you claw back all the money it comes straight off the dentist's bottom line, every penny of it. Nothing is then allowed for the expenses that were incurred in that year for running the practice despite the fact that those UDAs were not delivered. The expenses of the practice ran on regardless. The rent still had to be paid, the rates still had to be paid and a service was provided. It may not have been to the quality and quantity that was required but nevertheless the service was provided, so I think the effect is horrendous, absolutely horrendous.

Q112 Sandra Gidley: We have received relatively little evidence on that. It is probably the most unanswered question, so if you do have anything concrete we would be grateful.

Mr Renshaw: The trouble is that a lot of it is very personal stuff. It is not the kind of thing that people want being bandied around in public, to be asked to repay £230,000 out of a contract.

Q113 Sandra Gidley: I am sure it could be anonymised in some way.

Mr Crouch: The year 2006/2007 was an anomaly, because from my point of view as an orthodontist my income actually went up, and the reason it went up during that year was that I was paid for work in progress for moving from the old system to the new system, so I have had a balloon in my income which I am paying the tax for. My tax bill has gone up substantially this year because of my income going up, but that is not a true picture of the way things will develop.

Mr Renshaw: That is why the second year will be worse, because the claw back will have more of an impact because the first year was protected to some extent by the run-off from the original contract.

Mr Crouch: One other important thing: plus the fact that a lot of PCTs dealt with the end of year of the first year by not clawing back the money but allowing the dentists to forward the target to the second year. It was difficult to achieve in the first year, it is equally going to be as difficult in the second year for quite a few people and, therefore, they will not be able to deliver the newer, higher target that they had previously.

Q114 Sandra Gidley: Why is it so patchy? Why have dentists not been able to achieve this in some areas, whereas in Dorset they ran out of UDAs and could not treat anybody? Are they more efficient in Dorset?

Mr Renshaw: This is the problem we have. Because we do not know how the figures are arrived at, it is very difficult to look at an individual area and say, "Obviously the reason for this is X." I am not aware that Dorset has any better oral health than anywhere else - I am sure it probably has excellent oral health, but I am not aware of any particular differences there - but if you go to parts of the West Riding of Yorkshire that I am more familiar with, there are plenty of areas there where everybody is hitting their target because, frankly, they have no alternative because they cannot afford not to, and they are being driven in a way that I am sure you and I would not be happy about. I am afraid, if you make the target, there is a danger that you may have been less than sensible about the way you have done it.

Mr Crouch: It could be, of course, that the funding that was given to Dorset, because of the way it was worked out because of the test year, was inadequate. That would be an argument that the Citizens Advice Bureau would make, that the introduction of the contract was based on the historic spend and not looking at the proper needs of the local population.

Q115 Sandra Gidley: We have talked about the impact on dentists' incomes, but actually, as politicians we are quite interested in what is better value for the taxpayer as well. John Taylor, would you like to comment on whether the new system represents better value?

Mr Taylor: As Mao Tse Tung said about the French Revolution, it is a bit early to tell. When I came into dentistry out of heavy engineering, everybody told me that the system in the United Kingdom delivered the highest productivity, adequate dentistry. Not brilliant - nobody is claiming there was not some range - but, overall, adequate dentistry at low unit cost, and I am a sceptic - I have seen a lot of dentistry - and I became convinced of that. I have been in all sorts of previous systems, a bit like our Chairman who I read about earlier, Dan, was an electrical fitter many, many years ago. I am a lot older than he is. I have been under all sorts of paper systems and all sides and I was entranced by this. That system, if you mean adequate dentistry at low unit cost and the interests of the dentist in getting the patient and treating them, was a super system. Whether that is what you want is another matter. It may be you want something else. Nobody has ever told me what the GPS is supposed to be for. So, we had a system which delivered high productivity, adequate dentistry, large quantities, low unit cost. Some dentists got very rich on it and, I think, that upset a lot of people, but the system was, in that sense, value for money. The new system might give you value for money. I do not know what the objectives of it are, so I do not know how we can tell, but this transition period is a false period and I do not think anybody should base their opinion on this three-year transition period. Dentists are watching, waiting and looking and adjusting themselves, and you will not find out until some time after that, maybe a year, two years, three years. That is when you should have your next inquiry to see has happened then. This is a false period to draw conclusions about.

Chairman: Thank you for that.

Q116 Dr Naysmith: You will be glad to hear, we are almost on the last lap. I have got a couple of questions for Mr Crouch and Mr Renshaw, but, first of all, I would like to ask Mr Taylor. When the question was asked earlier about a salaried service and salaried dentists, Mr Renshaw was rather dismissive and talked about 40% lower productivity. What do you think of a salaried service, Mr Taylor?

Mr Taylor: I am an old man and I have been around a long time. You get higher effort from self-employed people working on piece work than you do from salaried people.

Q117 Dr Naysmith: Do you getter quality work?

Mr Taylor: I think John said something about some jobs you cannot - a fitter on contract work. On some jobs you cannot make money and those jobs you give to some people who are meticulous and pay them a salary, but the bulk of work you get adequate quality. The thing about dentistry which is different from all the other medical people is the Dental Reference Service. We can check the quality, so we know we are getting adequate dentistry.

Q118 Dr Naysmith: Could there just be a possibility that someone who has been paid a salary was treating areas of the country where there was a lot more deprivation and a lot more difficult work and to compare them with the average dentist might not be a very fair comparison?

Mr Taylor: It might not be, but (and I think John's figures were slacking) we have got the community dental service, so we have known for a long time that there is a salaried service running alongside the contracted service.

Q119 Dr Naysmith: That tends to be for children's work though, does it not?

Mr Taylor: There are those factors, but my recollection, and I might wrong and John might be right, is about one sixth of the output from the salaried service.

Q120 Dr Naysmith: You are both agreed on that.

Mr Renshaw: The study I am referring to was done in Scotland and it was done on a straight comparison between salaried practitioners and general practitioners working in similar sorts of areas, and the work was done properly and the figure came out at 40%.

Q121 Dr Naysmith: I can see that you are not very keen on salaried service, are you?

Mr Renshaw: I think salaried service is fine. I do not have a problem. It is a good answer in the right circumstances. I am not sure it is the right answer for everything.

Mr Taylor: I do not think you can show that somebody working on a salary would be a better dentist, providing better quality work than somebody working for themselves. I really do not see how that could be. Let us say with people with a phobia, terrified of the dentist. If somebody working for me does not want to do that, goes to the community service, and it possibly takes longer, but I do not see that you would get better dentistry.

Q122 Dr Naysmith: We can check that. What I really want to get on to is the fact, Mr Renshaw, that in fact you have been here before.

Mr Renshaw: Yes; indeed.

Q123 Dr Naysmith: In 2001 you told this Committee that the relationships between dentists and the department were a running scar. That is how you described it at the time. This time you describe the relationship in your submission for this inquiry as "irretrievably damaged". What, in your opinion, do you think now?

Mr Renshaw: I think I was quoting somebody else as saying there were commentators who said the relationship was irretrievably damaged. I do not believe that that can be allowed to be maintained. We have to get back a working relationship between the department and the dentists, because if we do not get that back we are not going to have a service, we are not going to be able to make any progress, and at the moment---

Q124 Dr Naysmith: You think under the new arrangements, if we do not do something about it, then we are in for a real problem with the National Health Service dentists?

Mr Renshaw: I think maybe in April 2009, when the three-year so-called guaranteed income period comes to an end, there may well be a further water shed. If you look at the way private practice has developed in this country, there has been a series of water sheds, frankly, every single one of them precipitated by government action. If government takes another step like that, the move into the private sector will become, I think, irretrievable.

Q125 Dr Naysmith: What can we do about it? What particularly do you think can be done to encourage dentists to work for the National Health Service? Two or three important points and then I will ask Eddie for the last word?

Mr Renshaw: I think there are a few things that could be done. If anything, I think we are going to have to concentrate on the younger practitioners, because a lot of the people who are leaving are going to be the older men, like me, who are experienced and can hack it in the private sector probably. The younger ones are the ones who will be the life blood of the service for the foreseeable future and, although they may not have any alternative but to work in the NHS, I do not think what we should be looking for is a system where a bunch of disgruntled youngsters are coerced into working for the NHS. I think that is a very bad state of affairs to get into. That would be atrocious for patients - you really could not have a worse situation - but I think what we have got to do, and I think this has to start at the top of the department, we have to rebuild some faith in the fact that the Department of Health actually wants a dental service to survive and start behaving as though they want a dental service to survive, not just saying they want a dental service to survive. I think we have to look at the young graduates and start encouraging them to work in the NHS in circumstances that they want to espouse. They want to have the time to be able to do their work properly; they do not want to be placed under constraint of output straightaway. They want to be able to develop their skills so that you can get some of the work out of the secondary care sector and into the primary care sector so that the costs of that can be reduced. Patients get a better service that way. There are a lot of ways that you could look at that younger group and say, "We will help you to develop your life and your working practice over a lifetime within the NHS and we will encourage you to do that", but that has to be a lifetime commitment.

Q126 Dr Naysmith: Thank you. Mr Crouch?

Mr Crouch: I think, first of all, the Department of Health has to listen to the serious criticism of the system that we have got and work with the profession to cure some of the faults that are there. If that happens, then at least we are moving towards better service for patients. It is really my concern that we get a better service for patients. I think, if you are to rely on the primary care trusts to do some of the work in commissioning the service and getting the best service for the local population, then we need quality people working with the profession locally in that area. I am sure the Chief Dental Officer will come along and say that there are areas of the country where that has happened and it has worked really quite well. He will quote all the areas of the country where it is working, and they tend to be the areas where the PCTs have good managers, have a good understanding of the local area and they also work well with the profession. If that works, then that is at least a step in the right direction. Unfortunately, it not happening in many places.

Dr Naysmith: Thank you very much. That is very helpful.

Q127 Chairman: John, can I ask a final question to you. Quite a lot of what we read, in a sense, shows that some parts of the country do quite well out of NHS dentistry, and probably mine in South Yorkshire is one of them, maybe because of need and everything else, where some of us have a lot more private dentists. Is that related to income more than anything else?

Mr Renshaw: No, if you look at the data from Her Majesty's Revenue and Customs, who are the final arbiter on who is earning what, the difference between an NHS dentist and a private dentist, from the last figures I saw, was £600 a year, and I do not think anybody is going to claim that private dentists are making a fortune.

Q128 Chairman: I am not saying that. If we were to say to you: what do you think NHS dentists will be like in ten years time? In our area, Yorkshire and the Humber, income is rising. It has been quite low over the region in comparison with the South East, but income is rising. Is that likely to mean that we will see more private practice if income does rise in areas like ours?

Mr Renshaw: Yes, because the one thing that makes a private practice possible is an economic base locally where people have enough disposable income to be able to spend on that kind of treatment. It has to be a lifestyle choice in a lot of ways, private treatment.

Q129 Chairman: First of all, except for a very small group of people, we do not have free treatment on the NHS in this respect.

Mr Renshaw: No, you do not.

Q130 Chairman: It is not free at the point of need in as much as you need a filling; depending what your income is, you may have to pay for it.

Mr Renshaw: Quite a lot, yes.

Q131 Chairman: Where is the break? Maybe an NHS patient has cosmetic treatment in an NHS surgery and pays for it. Where is the break in all this?

Mr Renshaw: It is an interesting situation. We are in a fluid situation at the moment, are we not? It is influx. As far as I can see we have always had the top end private stuff, the fancy Harley Street prices that are telephone numbers. I do not know how on earth they get away with that kind of price, but, nevertheless, that is what people fixate on. They think £5,000 a tooth. That is nonsense; gibberish. What is emerging is a much more price conscious, private service which is saying, "We are a bit more expensive than the NHS, but we are not that much more expensive and we are trying to offer you a sensible product, not necessarily the high end stuff, and if you want some fancy stuff you can buy that from us as well, but we can offer you routine care at a sensible price." In an area where there is enough money for that to float (and we already have the evidence from Denplan: there are plenty of people around who are prepared, I would not say willing but prepared to pay a sensible price for their treatment), then I think that will gain ground and people will find that middle way. There is always going to be room for a middle way, and I think that is where it will be.

Q132 Chairman: And income will drive that, you think, all the time?

Mr Renshaw: I think so, yes.

Q133 Jim Dowd: I was looking on the Net the other day and I came across a dentist based, I think, in Budapest. They were advertising for patients. If you cannot find an NHS dentist or you think that private dentistry is too expensive, they will actually fly you out to Budapest, do the principal work there and arrange for any follow-up work in the UK, if need be. In your experience, are many people susceptible to that?

Mr Renshaw: It has certainly grown, because it is built on a complete lie and it is built on a lie of how much those things cost in this country. They always quote Harley Street prices, and actually, if you shop around a bit in his country, you usually get it cheaper. Frankly, if you are going to Budapest, get off the plane in Budapest, get on another plane and go to San Paulo in Brazil, because Brazil is the cheapest place in the world for dentistry, and the other one is Beijing.

Q134 Chairman: Can I thank all three of you very much indeed. A very lively session we have had, the first one on this inquiry. I am afraid we have run over substantially on the time we were going to have.

Mr Renshaw: Our apologies, Chairman.

Chairman: I think there were good reasons for that. Thank you very much.

Witnesses: Dr Barry Cockcroft, Chief Dental Officer, Mr Ben Dyson, Director of Primary Care, and Mr David Lye, Head of Dentistry and Eye Care Services, Department of Health, gave evidence.

Q135 Chairman: Good morning gentlemen. It is nearly good afternoon. I am sorry that we have run over time a little bit. We will try to have some sharper questions next and possibly sharper answers as well! If you do not disagree with what has been said in answer to a question, you do not have to repeat it, please. Could I first of all ask you to give us your names and the position that you currently hold, for the record, please?

Mr Dyson: I am Ben Dyson; I am Director of Primary Care for the Department of Heath.

Dr Cockcroft: I am Barry Cockcroft; I am the Chief Dental Officer for England.

Mr Lye: I am David Lye; I am Head of the Dental and Eye Care branch of the Department of Health.

Q136 Chairman: Once again, thank you and sorry for the delay. Your submission states that the first 18 months of the new contract has demonstrated beyond doubt that the system is workable and working. I have to say, the overwhelming number of submissions that we have received at this stage suggest quite the opposite of that. Indeed, when we received the written submissions which we have published - I showed this earlier - the temptation would have been to write to everybody else and say, "Are you sure you have got this right? Because you are completely out of line with what the Department of Health say." I wonder if you could account for or just explain why you think there is this disparity in terms of people's response to the new contract?

Dr Cockcroft: I think there are two things to say, first of all. One is that there is a misconception that, just by moving from the old contract to the new contract, everything is automatically sorted, and that is clearly never going to happen. The issue is about having to recommission to give the PCTs a sound basis for reforming dental services. The old system, which was the cause of the issue and, of course, the famous pictures in Scarborough and all that sort of stuff, was under the old system. What we are saying is there needs to be a sound system that enables PCTs to grip the agenda and improve access to dental services. What we are saying now is that in areas where that has happened we have got clear evidence that PCTs are able to grow services in some of most challenged areas (and Eddie referred to them - the Isle of Wight, Devon, Lincoln, Milton Keynes) where PCTs had real problems and, where they were more engaged, have been able, using this new system, to transform the nature of local services. I think I would also agree that the engagement with primary care trusts has been varied, and that is one of the reasons why we included Improving Access to Dental Services and the Operating Framework before Christmas to try and guide and help or support PCTs where they really want to focus on these issues. Some of them have done incredibly well, some of them have done okay and some of them have let it slip a little bit. I think we need to get them all performing at the top level. The evidence I heard more or less implied that, if we do that, this system actually works, and we are taking a slightly longer view. The other thing I would pick up from what was said just previously, and I cannot remember the quote exactly but John said the thing that dentists really hate is the absolute flexibility to grow services or reduce services, and that is the exact thing, in the old context, that caused the problems. Dentists could often increase or reduce the amount of NHS dental services they did, and the NHS had no means of countering that. What the new system does is it gives the PCTs a duty to commission services. It also gives them a budget to do it. The thing that John said the dentists did not like, which from my point of view I do not think is that true now, talking on behalf of patients, is the very thing that means this contract is in the best interests of patients. I think it also has to work for dentists and I think it has to work for all sides. What we are saying is we are moving in the right direction; we are moving in the right direction quicker in some areas than others. On the whole, through a difficult transition period where PCTs have been in a reconfiguration situation, I think they have done remarkably well. We think access is relatively stable. John doubted the validity of the access figures. They are information centre data; we think they are accurate. They look back two years, and in that two-year period was the transition period where we have already said we lost 3.6% of service. If you transfer that into patient numbers, although it was not measured exactly the same, that is actually about 960,000 patients. So to actually keep relatively stable through a period that includes that period, when we know we have lost that amount of service, I think is actually quite an achievement.

Q137 Chairman: Is access the main criteria that we should use to judge the contract?

Dr Cockcroft: I think it is measurable criteria. For me personally as Chief Dental Officer, that is absolutely not the only criteria. It is about numbers of people that can access services. From my point of view as Chief Dental Officer, I want to improve the oral health of the country. As you said, we have the lowest rates of dental decay in Europe - that is World Health Organisation figures, by the way, it is not flaky data - comparable with the best in the world, but there are big inequalities which we need to tackle and I think the fluoridation stuff on Monday tackles that inequality.

Q138 Chairman: We may come on to that in a few minutes. Quite clearly, the picture prior to 2006 has not been good, and from some of the written evidence it has not been good for decades now, in terms of the relationship between the department and the profession. Do you think that these new reforms have made what was probably a bad situation worse?

Dr Cockcroft: In terms of relations with the profession?

Q139 Chairman: Yes.

Dr Cockcroft: One of my aims and objectives for the next couple of years, I have described it as "peace for the profession". I was described by Susie Sanderson, who is John's replacement at the BDA, as the most accessible Chief Dental Officer there has ever been, and one of the things I do in my job is go out on a regular basis and meet as many ordinary dentists as I possibly can, and I am opening two new practices in Oxfordshire tomorrow. I think the transition was a very difficult period for everybody in very difficult circumstances, with money being tight and PCTs being reconfigured. If we end up with a situation that works for patients and does not work for dentists, that is not going to be a successful, long-term, sustainable system. The BDA, who I know are not giving evidence today, have recently had a meeting with the Minister about how we work looking forward. I think that meeting is very constructive. I met Eddie and a whole number of representatives at the Annual Conference of Local Dental Committees a couple of weeks ago, and I think Eddie in his notes said it was a very constructive meeting and, clearly, living in a period of constant tension and aggravation between us and the dentists is certainly not what I intend to do. When I go out I sometimes get a much more grassroots view of the contract, and it is often much less aggravated than you get from political leaders. The other thing, of course, is that every time you go out to tender for a new contract there are lots of people who are due to provide services, so it is not putting people off, people are actually wanting to provide more services under these new arrangements. I think we have got rid of the old system with some of the things that damaged patients' interests. We have to develop what we have got now as a sound basis, but the omens, I think are good, because where it is working, it is working well.

Q140 Dr Taylor: I want to pick up on that. What you are really saying is the new system is the right one and is successful because it is working in some places. Where it is not working you are blaming PCTs and you are blaming management. We need some evidence to say exactly where it is working, because we have got the Citizens Advice Bureau survey, we have got the Commission for Patients Public Involvement in Health overview and the Dentistry Watch campaign, which point very much the other way. We have got your report, which actually is pretty anodyne and does not really give much detail at all of what is happening. What we really need is to know exactly where it is working in detail - which PCTs. Is that possible?

Dr Cockcroft: I think it is working two ways in terms of access.

Q141 Dr Taylor: I do not want it now. I want a geographical list across the country of where everybody is happy with it.

Dr Cockcroft: I am not sure that is---

Dr Taylor: That is what you are implying.

Q142 Dr Stoate: I think it is going to be a short list!

Dr Cockcroft: I did not say everybody was happy. I am not sure how you would do that survey.

Mr Dyson: What we are saying is that we still believe very strongly that this provides a much better basis than the previous system to enable PCTs to grow services and to develop services so that they meet the needs of local populations. We can provide evidence - in fact evidence is already publicly available - to show, by PCT movement, the number of people accessing dental services. You can track from that areas where access has improved or access has gone down since the introduction of the new arrangements, but it is important not to look at that information in isolation. What you also need to look at is the developing plans that PCTs have for commissioning new services. Many PCTs will acknowledge there were problems in that first, very difficult transitional year of the new arrangements, and they would also acknowledge that they were somewhat slow at putting in place new services, but they are doing that. The number of services commissioned by PCTS is growing pretty much by the month.

Q143 Dr Taylor: You probably heard the first lot of witnesses. One them said we had staggered from one imperfect system to another. What we really want to know is why there were not any pilot trials of this: because these were suggested by the National Audit Office, Challenge, the people we have just had referred to the personal dental pilot sites and they felt that these should be revisited and perceived failures ironed out. So, why did you rush into it, because really, sitting on this Committee for some time, it has been the fault with most of the Government reforms that they have been rushed into without piloting. Why have you not learned the lesson and tried to pilot something?

Dr Cockcroft: I do not think that is accurate. I came into this, and I was in general practice for 27 years, and I was a PDS pilot from 1998. There was an original wave, then there was a second wave, then there was a third wave, then the Modernisation Agency field sites and there we rolled out PDS. You do not pilot what works, you pilot a range of issues, a range of models, and look at what works and what did not, and there were some things that we learnt from PDS that clearly did work, were appropriate. The reduction in complex course of treatment was clearly learnt from PDS piloting and it has been reproduced within the new contracts. We also learnt very clearly that you cannot have a system that does not have some form of monitoring. John, quite rightly, said if you have a currency, you will get that currency delivered. "Item of service" was an inappropriate currency in an ever improving oral health system, and if you go to the non-monitored capitation based scheme, the risk always is that people get registered but do not always get the appropriate treatment, and courses of treatment, which is what this is, is an attempt to find a middle line between an output-based item of service, which is clearly inappropriate in the oral health situation, to a capitation based scheme, which is very difficult to do nationally, but also you need some monitoring to see what activity goes on within that.

Q144 Dr Taylor: One of our previous witnesses in his written submission was very complimentary about the amount of information that was available under the old contract, and he went on to say, "As a result, in the GDS, more than anywhere else in the NHS, it was possible to know. It would have been possible to conduct experiments and pilot studies and pursue a practical phased introduction of the new arrangements. This would have made it easier, quicker and cheaper to recover if things looked like going wrong." I find it very hard to be convinced why---

Dr Cockcroft: I think the concept of a phased introduction would have been an absolutely logistical nightmare, certainly in terms of patients' charges, because it was illegal to have different patients' charges in different parts of the country at any one time, so you had to change patients' charges in one go.

Q145 Dr Taylor: By law you could not have phased it in; you had to do the big bang?

Dr Cockcroft: You could not have people in different parts of the country paying different charges for the same thing in different areas. It was a legal thing. When I set up my PDS in 1998 I spent a whole week developing a new system of patients' charges and then I was told by the Department of Health I could not do it legally.

Q146 Dr Taylor: In the period before it started, did you talk to any people about piloting it? Did you take advice on that?

Dr Cockcroft: We had been having discussions with the British Dental Association. They made it very clear that they could not negotiate because dentists are independent contractors and they would have to make their own decisions, but we were talking about this for quite a long period of time. There was a little mini group set up which tried to look at what a currency might be, and that group arrived at the concept of weighted courses of treatment, and we actually got as far as having a draft agreement, which included weighted courses of treatment, but then the relationship deteriorated and it did not go forward in that case. So they have been very involved in developing the concept of weighted courses of treatment over quite a long period of time.

Q147 Dr Naysmith: Before we leave that, you say they were involved, but they say they were involved for a bit but you did not listen to anything they said. That is the message which comes from that. Did you take any notice of what they were saying?

Dr Cockcroft: We certainly did. We spent several years talking to them trying to go forward, and they fed in. At times it got very difficult and at times we did not accept some of the things that they said, but we certainly spent a long time listening to them. In terms of patients' charges, they were on the working group which came up with a new patient charging system which produced unanimous recommendations. So, they were involved, but we did not always agree with what they said.

Q148 Dr Naysmith: Did you sometimes agree?

Dr Cockcroft: Sometimes we did.

Q149 Sandra Gidley: I am increasingly uncomfortable. We are talking about access and I have to challenge your statement that the queues were all under the old system. The only reason you do not have queues under the new system is that you cannot now register with a dentist, so there is no point in queuing. I think we need to get that straight. According to the department's 2002 Options for Change paper, one of the stated aims of the contract was to improve patient access to NHS dentists. Most of our submissions seem to say that this has not happened.

Dr Cockcroft: What I said right at the beginning, we are not going to change access in one month, we are going to improve it gradually over a period of a year or two or three. It takes time to do that, to commission new services. I know in your own constituency the PCT got four tenders out, or they have got tenders now for four services, including Romsey, West Leigh---

Q150 Sandra Gidley: Yes, but only because I suggested that. They were going to do it over a whole geographical area, which would have left no dentist in Romsey.

Dr Cockcroft: We asked all PCTs to do a needs assessment in their area. People talked about the delay between loss of service and recommissioning. The PCTs should not just recommission what was there before blandly, because there may have been a surfeit of people in one area and not in another; so before you go ahead and tender we asked PCTs to do a needs assessment. So you can either do it very quickly and make it more comfortable for me sitting in this sort of area, or you can take a bit of time, do it properly and base it on needs. Like I say, in areas where the need was quite glaringly obvious, then people moved very quickly. In other areas, some PCTs have not moved as quickly as others. We clearly accept that. We are doing everything we can to support them to get a primary care contract.

Q151 Sandra Gidley: There is something here I am not quite understanding. We heard in the previous session that the money allocated to a particular PCT was based on historical provision; so in areas where it was good there was a lot of money; in areas where it was less good, some deprived areas, I would contend my part of Hampshire, the money stayed the same. Given that, where is this magic pot of money coming from to commission new services? All that has been done in Hampshire is to recommission the unused UDAs, so I cannot see how that is improving access.

Dr Cockcroft: We put some money into the early PDS pilots where they were targeted at areas with high access and we invited PCTs and dentists to bid for that. What we have now done, with the inclusion of the Operating Framework, we have also increased dental budgets by 11% from next April, so now there is a lot more free capacity or free finance for people to do that.

Q152 Sandra Gidley: Is that across the board or has that been target at areas of need?

Dr Cockcroft: 9% goes to PCTs and 2% goes to strategic health authorities to focus on specific access issues or issues of service that might be better dealt with at a strategic health authority level, like commissioning orthodontic services across three or four PCTs rather than just putting it into one PCT. That money, as you say, goes out. It is in the Operating Framework and it goes out from 1 April. I am much happier putting that money in now than I might have been before we did this: because if we put a lot of extra money in over the transition period, within experienced PCTs I think we might have spent that money and not quite got so much benefit for the public and patient out of it; people might well have bought off difficult issues. I am very happy with that money going out now, and it is a real chance to expand the services.

Q153 Sandra Gidley: So, it is up to strategic health authorities whether more of that money is targeted on---

Dr Cockcroft: Nine percent PCTs, 2% SHAs.

Q154 Sandra Gidley: Why does access seem to be a particular problem in some socially deprived areas in particular?

Dr Cockcroft: Historically the areas where access has been most difficult has usually not been in socially deprived areas, it has been in the more affluent areas where dentists were more easily able to move into Denplan and things like that, where patients could actually afford it. I do not know the local circumstances in terms of deprived areas in your area.

Mr Lye: There is an issue about people not actually accessing services in deprived communities even where services are available. The Greater London Authority report which was published in November gave a very favourable picture of the availability of NHS dentistry in London, and it is probably better in London than anywhere else, but there was still a problem that people were not accessing the services. So there is another issue, which is what we can do and what primary care trusts can do to actually try and improve awareness of access and to look at innovative ways of taking services out to deprived communities. Barry was talking about what we are trying to do to try and improve relations with the BDA, and one of the things that we are talking about is joint work that we can do with them to look at ways of doing innovative outreach services to get precisely to those deprived communities, especially to children in deprived communities.

Dr Cockcroft: I think one of the bad things over the last couple of years is in quite a few areas there is access but people make the assumption that there is not access and do not take it up, and that is certainly an issue in London, I think.

Q155 Sandra Gidley: Recently published figures in Scotland show that they seem to have both increased the number of NHS dentists and the patients registered. There seem to be a success story there. Could we be learning from them?

Dr Cockcroft: I would not want to comment on what Scotland are doing, but certainly in certain areas of Scotland we have got huge waiting lists and people not able to access care. What Scotland do is not my issue. The great benefit of our system is that it is locally commissioned so that the NHS controls where NHS services go for patients. If you lead a system where dentists decide where the service is located, how much there is, how little there is, you are still at risk of the same sort of problem that happened in our old contract here where you created the dental deserts that the Citizens Advice Bureau spoke about.

Q156 Sandra Gidley: A final question about data. The evidence submitted by Challenge suggests that the department lacks accurate and sophisticated data. We heard evidence earlier that previously there was a lot of information available and we are in danger of losing some of that which is quite valuable. We also heard that it is impossible to have a clear picture of the number of whole-time equivalent dentists working in the NHS. We seem to have those figures from everybody else.

Dr Cockcroft: The issue about whole-time equivalent dentists is that some dentists work largely in the NHS and part private, some dentists work largely private and a small bit of the NHS, although a lot of those people left. A good example would be around the change from the two contracts. In 2006 about 1,000 dentists rejected contracts. It was 3.6% of service. It was certainly significant, indicating that those people had not got a very large NHS commitment, in general - some obviously had. What we do know, and the most important thing for patients, is the amount of service commissioned, and that is looking-forward data rather than the access data which always looks back. We have announced today, the commissioned activity is enough to provide extra care for about 180,000 patients just in the last three months. Obviously there is an issue about commissioning and delivery, and that is what we have to support PCTs in. John talked about the data on "item of service", and I think it is quite right that dental practise years ago on "item of service" had very accurate data about how many fillings were provided and what they did, but I do not think that data was in any way related to oral health. Especially now, as we have got far, far less decay, the one thing we would not want to do is encourage more intervention. We are also introducing from April an enhanced clinical data set. We have recognised (and the NHS has asked us) that we need a bit more detail to know what is going on within these bands and these courses of treatment; so we are introducing a very simple enhanced clinical data set from April which will include what is in band one, what is in band two and what is in band three, and that is for the benefit of both dentists, so they can demonstrate what they are doing, and PCTs to know what they are commissioning.

Q157 Sandra Gidley: Will it be possible to compare what is going with the old system, because that is what people are really interested in?

Dr Cockcroft: Broadly, but not individually by every single type of filling, but you will know how many fillings, how many extractions, how many root fillings, how many crowns. The reduction in intervention, broadly, is a good thing. One of the learnings from PDS pilots from a long time ago is that if you reduce the item of service incentive you get a reduced level of activity; and there was some research done by the National Audit Office on my own practice compared to another one in a similar area. We had a reduction of about 15-18%, I think, and there was no difference in the level of oral health between our practice, where there had been a reduction in activity, and a comparable practice - I think they did it in the evening - where they continued on the item of service basis. It was a very small survey, but there was no discernable indication that because you had done less activity oral health was in any way damaged.

Q158 Charlotte Atkins: Ministers have already admitted that commissioning by PCTs has to become stronger, so why do you think, therefore, that they are going to be good at commissioning dental services when dental services represent such a small part of their budget?

Mr Dyson: The kind of competences, skills and disciplines involved in commissioning good dental services are actually quite similar to those involved in commissioning other health services. The commissioning framework that the department has now developed takes PCTs through a commissioning cycle which begins by assessing the needs of local patients and then works through how you engage with clinicians locally, how you engage with patients and the public locally, how you review service provision and how you develop new services, both by working with existing providers and, where necessary, by procuring new services. Although there are some distinct challenges, inevitably, in dealing with an area like dentistry, those competences, those skills, those disciplines are actually broadly the same as any other area of NHS provision; so we believe very firmly that by skilling up PCTs to become better commissioners of health services generally, they should also be in a much stronger position to develop dental services.

Mr Lye: Can I add to that, because there are, obviously, some specific issues in dentistry as well, and one of the things that we do as a branch is we have a contract with Primary Care Contracting, which is a consultancy run within the NHS and it is NHS people who run it, specifically to work on developing commissioning of dentistry. In the last year, for example, they have produced all sorts of guidance on practice visits, on how to deal with contract breaches and frauds, just on the management of commissioning, on how to carry out needs assessment, on clinical governance, specific guidance on the 18-weeks target and the specialties where the 18-weeks target applies, and we will be rolling forward that contract next year as well. So we are trying to provide specific advice and development for PCTs to help them develop their commissioning.

Q159 Charlotte Atkins: But surely you need some sort of needs assessment before you can decide what dental services should be commissioned.

Mr Dyson: Yes.

Q160 Charlotte Atkins: It seems to me that does not really happen?

Dr Cockcroft: Many of the SHAs, in working with their PCTs to discuss how they are going to develop services, have asked all their PCTs to come up with a needs assessment and a commissioning plan to take things forward, so that is happening at the moment.

Q161 Charlotte Atkins: Many of them have not. Most SHAs are more interested in PCTs getting into the black than they were into---. I do not think it is funny, because actually a lot of people in my constituency cannot access a NHS dentist and, what is more, because you are basing everything on historical dental activity, it means that where you have a rubbish service in the past you have a rubbish service in the future. That is the problem, is it not?

Dr Cockcroft: Yes, but your PCT particularly is commissioning services within that area to meet the need.

Q162 Charlotte Atkins: Do you know why?

Dr Cockcroft: