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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

DENTAL SERVICES

Thursday 28 February 2008

MR JOHN GREEN, MS JANE DAVIES-SLOWIK and MR MELVYN SMITH

MS SARAH ELWORTHY, MS MARGARET NAYLOR and MR DEREK WATSON

Evidence heard in Public Questions 444 - 640

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 28 February 2008

Members present

Rt Hon Kevin Barron, in the Chair

Mr Peter Bone

Jim Dowd

Sandra Gidley

Stephen Hesford

Dr Doug Naysmith

Dr Howard Stoate

Mr Robert Syms

Dr Richard Taylor

________________

Witnesses: Mr John Green, Director of Dental Public Health, Sheffield Primary Care Trust,

Ms Jane Davies-Slowik, Clinical Director, Salaried services, and Mr Melvyn Smith, Senior Lecturer Dental Public Health, gave evidence.

Q444 Chairman: Good morning and I welcome you to what is our third evidence session of our inquiry into Dental Services. Could I ask you to introduce yourselves and the position you hold for the record.?

Mr Green: I am John Green, consultant of Dental Public Health working in Sheffield PCT and in Yorkshire and Humber SHA.

Ms Davies-Slowik: I am Jane Davies-Slowik and I am here with 27 years of experience in Salaried Dental Services.

Mr Smith: I am Melvyn Smith and I am an ex-NHS consultant in Dental Public Health currently working part-time as a senior lecturer in Dental Public Health at the University of London.

Q445 Chairman: I have a general question to all of you about PCTs and Commissioning. We have been told that some PCTs have adequate dental health expertise but others do not. Do you agree and are PCTs making the most of the expertise at their disposal?

Mr Green: I think it is very variable around the country both in terms of availability and possibly the way in which specialists in Dental Public Health are used. Some, like myself, are very heavily involved in commissioning and others not so involved, but there are very large gaps in access to specialist help. The South West of England and the North East of England are particular areas where we have no colleagues at all.

Ms Davies-Slowik: I would say the same; it is very patchy across the country.

Mr Smith: I would agree. Also there is a difficulty in PCTs which share consultants in Dental Public Health where the consultant is not embedded in the PCT and therefore may be not available, or maybe decisions are made innocently without engaging the consultant. It is a problem where the consultants are shared across several organisations.

Q446 Chairman: It seems to be a general problem. What input did you and your colleagues play in assessing local dental needs before the contract was introduced? Was there any general assessment or how did it work?

Mr Green: Yes, most certainly. This is the core of what we do, whether that is through epidemiological surveys or by much more soft intelligence around patient involvement, feedback from patients, whatever that might be, is a central part of the role, and also not only identifying need but being advocates for that particularly for disadvantaged groups.

Ms Davies-Slowik: In terms of the salaried services, the salaried services are involved in collecting the epidemiological data for the surveys which goes to providing information to assess dental need.

Mr Smith: This assessment has been carried out for many years by Dental Public Health consultants and their colleagues in general practice and practice advisers as well working for health authorities and PCTs. What happened with the new contract was very much a kind of fixing of the existing levels of provision. Although it provided in the contract for growth in areas identified as having problems, the contract simply provided money to pay for the practices where they currently existed with some growth money but very often that was swallowed up in meeting the unexpected difference between the over-estimate in patient charge revenue and what actually was being delivered on the ground.

Q447 Dr Stoate: In both your submissions you seem to be quite pleased with the move towards a primary care-based provision yet you have both said that you are disappointed that the new structure has not really achieved full potential. What do you mean by that and what potential do you think has not been achieved and why has it not been achieved?

Mr Green: The potential would be - and you would probably expect me to say that - to take a more public health approach to the way that services are delivered, in that the practice would look at its practice population, try and assess who are the groups at risk and the problems and then applying prevention to those groups. Rather than dealing with individual patients but taking an overview, prevention, in that context, has much more meaning.

Q448 Dr Stoate: Why has that not happened? What has been the problem?

Mr Green: The problem has been that there has been a focus on activity, so units of dental activity were introduced to make sure that there was sufficient activity to provide care. That, in a way, has delayed a change in the culture of new contracts and has delayed that wider approach.

Q449 Dr Stoate: Is that a fundamental flaw with the contract that the UDA mechanism has not really allowed for enough preventative medicine? Is that what you are saying?

Mr Green: I would not say a flaw but is simply a feature of this transition phase.

Q450 Dr Stoate: Clearly it is a flaw. If events are happening and it is not happening and it is because of the UDA structure, clearly there must be something wrong.

Mr Green: I would have to concede that.

Mr Smith: What was useful was for the first time PCTs could look at the local problems and if they saw a gap, a deficiency in provision, then in theory they had the cash to do something about it. The problem has been, and quite rightly, to stabilise the dental work force. Little change has been able to be made away from investing in the practices which are there currently and doing the kinds of work that historically they have been doing and the patients they have historically been seeing. It is all about the availability, freeing up of money from the existing system to invest in the kind of ways that John has talked about. The other issue is, although the PCT had the money, they were using a national contract framework which had some inflexibility in it. I know there was a potential for making changes, to make things more preventively orientated, to try different models of service, and so on, but by and large the PCTs were simply delivering more of the same under a different kind of mechanism.

Q451 Dr Stoate: What we need to do as a committee is to try and make recommendations. You are saying again that it was supposed to produce more Public Health Dentistry but it has not done so. What would you like to see done differently to make sure that it does work in future?

Mr Smith: A disconnection of resources from activity measured by UDAs, because the PCTs have targets to meet in terms of UDAs and the UDAs are getting in the way of being as creative as PCTs perhaps could be.

Q452 Dr Stoate: What would you recommend that we did about it?

Mr Smith: I think the UDAs, as they are constructed, are a very crude averaging system for outputs. We should not be interested in outputs but rather more the clinical, if possible, outcomes, or at least some kind of health-related outcomes, which I think public health has been used to delivering in other contexts outside of dentistry.

Q453 Dr Stoate: You have both said that out of hours seems to have improved but in what way has it improved?

Mr Smith: The difference in out of hours is instead of individual practices taking responsibility for the practice populations, and perhaps half the population which did not have an out of hours service or where PCTs or health authorities had not provided a good service, there is now a focus on the importance and, in fact, a clear responsibility now with PCTs to provide the out of hours service. The difficulty has been that where the old health authority or the PCTs were not providing anything, and therefore were not getting national funding for it because that is how it was funded, if they had to create a new service they had to find new money out of that dental budget to do that and so there has been a financial consequence for those PCTs who did not inherit a good service.

Mr Green: One of the key things where we have seen improvements has been where there are specific dedicated help lines for the dental out of hours. Patients then do not phone NHS Direct in general but are directed to these lines and are often triaged by dental nurses or other people particularly skilled in dental issues. It is a much shorter process and is often, as is our case in Sheffield, linked directly to the dentist providing the out of hours care. They are hooked into slots and there is feedback to make sure that anybody with real urgent needs who may have missed slots is actually given some attention. That has been the key to our improvement.

Q454 Mr Bone: We recently needed an out of hours dentist on a Sunday and we did ring NHS Direct. There were two out of hours available but both of them were outside the county and therefore outside the PCT area. Is there no requirement on the PCT to provide out of hours treatment within its own PCT?

Mr Green: There is a requirement for them to make arrangements for out of hours care. Those arrangements may be on a wider scale than simply their own PCT. For instance - not that we do it in South Yorkshire - in a conurbation there is some sense in making sure there is cross-cover. We have two main centres in South Yorkshire, in Sheffield and Mexborough, Doncaster, and patients flow between those two depending on demand and so on. Northamptonshire is not a conurbation. I have lived there for 25 years and I know it very well. I am not quite sure what the arrangements are there. Certainly the PCT requirement is to make arrangements but they can be partnership arrangements.

Mr Smith: The fact sheet of the Department of Health actually required PCTs, almost at that level, to look at arrangements across PCTs because of the need for some kind of financial and technical efficiency in providing services so that dentists were not sitting there doing nothing and were covering a wide enough area to make that viable. The trade-off is the difficulty of travelling distances particularly on a Sunday when public transport services are poor. Certainly if PCTs are in arrangements with adjacent PCTs that was in line with the Department's guidance on out of hours services.

Q455 Mr Syms: It has been suggested that some PCTs have increased NHS dental provision by contracting services from inexperienced dentists and dentists who qualified overseas. Do you have any evidence to support or refute this suggestion and does it concern you?

Mr Green: It does concern me. Our experience is varied and it is either end of the spectrum. In South Yorkshire we recruited, through the Department of Health scheme, in Poland. I conducted a weekend recruitment event and was very impressed with the quality of people we had for interview and subsequently with their work for us in Rotherham. That is at one end of the spectrum. At the other end are the concerns where there is a skills gap, dentists coming to us from maybe Eastern Europe where their experience is more limited. It is not a question of their competence in what they are skilled in, it is a question of whether they have the full range of skills. For instance, Polish dentists are not taught how to do radiography. That is something we can fix, and we did fix, locally through post-graduate offers. The important thing is to identify where the skills gaps are and also through some sort of inductional training programme which we have attempted to do in our deanery. At the end of the day, if we are short of dentists and we have this movement of labour across Europe then it beholds us to make the best use we can of that and also improve the skills when we identify gaps.

Ms Davies-Slowik: I do not have any evidence from the point of view of the salaried services but in another role I work as retaining and returning adviser for the post-graduate office and part of that role is to support dentists from overseas. I think there are two sorts of dentists from overseas. There are overseas dentists from outside the EU who need to take a General Dental Council examination in order to come onto the register. Following that they need to have a period of vocational training or equivalent vocational training. They generally have to be supervised and have a vocational training number. The dentists from the EU, because of EU regulations, are not required to do vocational training. Just as I could go over to anywhere in Europe and work by being registered with the General Dental Council, they have no requirement to take an exam. The difference between these two is for the overseas dentists outside the EU they have the chance to have some supervised training and if they have any problems or deficiencies or any training needs these are met within a period of vocational training.

Mr Smith: We have always had dentists coming here from other countries: 40 years ago it was Australia; we have had people more recently from Sweden in quite large numbers in Essex where I work; South Africa we are getting quite a lot of people from; and now it is Eastern Europe with the broadening of Europe. It is not a new problem but some of the more recent difficulties, particularly around the recruitment that took place from Poland, maybe it was a rather hurried process to meet a target for 1,000 new full-time equivalent dentists in a very short order. Some of the work was commissioned from recruitment agencies and maybe we had people coming who did not know what to expect and did not quite understand the system. Some of the things which could have been done over there before the dentists arrived here, like occupational health clearances and so on, were not done. Contracts were based on Salaried Dental Services contracts rather than the general dental practice type of contract. It was done in very short order and there may be some technical problems which have made the dentists dissatisfied with the situation they found when they came here from Poland. Like John, the experience is like dentists from anywhere: there are good and bad, and very experienced and people with less experience. The problem may be fitting into the NHS system which is quite difficult for people to understand if they have been working in it for a short period of time.

Q456 Mr Syms: Do you think the department and PCTs have adequate measures in place to ensure competency of the overseas dentists? As we have already discussed a moment ago, you cannot stop them coming in to do a job but I suspect it is more is there sufficient training and money to ensure that the gaps in their particular skills or experience are brought up to a UK NHS level.

Mr Green: In terms of identification and doing something about it, PCTs do have powers to impose conditions on joining a performance list or remaining on it if they think they have concerns about skills or competence or whatever. There are powers which increasingly PCTs are becoming aware of and beginning to exercise. It has not been particularly clear, at least from my experience, but we are beginning to learn more about how we could do that. As far as the training, or remedial training, to fill those skills gaps, then there is a funding issue there because there is not an obvious source of funding. Post-graduate deans and deaneries do what they can but often they have to be funded by the individuals or by the practices who are attending or employing them. There is no central funding but it is coming from within the profession itself.

Ms Davies-Slowik: I would say that there is a system for assessing dentists' competencies against an agreed framework of competencies and this is done for the overseas dentists and people who do not have a VT number. There is a system for assessing competencies. If a period of supervised training is advised, then very often this is funded from within the practices or the individual dentist. There is not a pot of money available to do that.

Q457 Mr Syms: Is there sufficient money in the practices to cover this?

Ms Davies-Slowik: I cannot comment but it happens that dentists do have periods of supervised training and they get through and they are signed off as being competent.

Mr Smith: My experience, which is still quite recent, is that very often things like language competency was dealt with in a centralised way and there was a very clear requirement on PCTs to accept people who had met a certain level as regards language competencies. Similarly anybody who was appropriately qualified can practise and the PCT could not challenge, because it is a GDC issue, their competence in terms of their practising certificate. The problem then may arise if there is perceived to be a problem of performance. That would be the same as for any dentist wherever they were from and however long they had been qualified. The PCT then might have to put in remedial steps as a way of dealing with that. The difficulty then is a resource issue. It is a financial issue for the PCTs who do not have any money for it. Clearly it has been with deaneries and people responsible for training. The other resource issue is there are not necessarily the courses available in the dental schools, if that is what it takes, to be able to improve somebody's clinical skills in a certain area. There is a bit of a difficulty in meeting those training needs.

Q458 Chairman: Ten years ago any doctor coming in even from what we now call the European Union or the European Economic Area would have had to sit an English language test. That is not the case presumably for dentists coming from the EEA but is it the case for dentists coming from wider than the EEA.

Mr Smith: It is still the case that the PCT has to satisfy itself that there is language competence but that is determined by a central agreement, a national agreement from the Department, which says which tests can be used and what level has to be achieved.

Q459 Chairman: That is an employer's responsibility as opposed to a regulatory body's responsibility.

Mr Smith: It kicks in when people want to get onto the dental list of a PCT that certification has to be shown.

Ms Davies-Slowik: If the dentist comes from outside the EU area they have to take the language test.

Q460 Chairman: They have to do that as medical doctors would as well?

Ms Davies-Slowik: Yes, before they take their registration exam with the GDC.

Q461 Chairman: Coming from Poland, or anywhere else, it would be an employer's responsibility that they can communicate with patients in an adequate way.

Ms Davies-Slowik: I believe so.

Q462 Dr Naysmith: It has been fairly widely recognised that the new contracts had little, if anything, to encourage the provision of preventative care. John and Melvyn, in your replies to Dr Stoate a few minutes ago you made it clear that you agree that there is not much in it for promoting prevention. If we can look a little more closely, what type of preventative care should be provided? Would a QOF-type framework such as applies now to GPs provide at least one way of doing it or do you have other suggestions?

Mr Green: I just want to restate what I was stating earlier. Prevention, as a set of activities, is only of any point if it is set within a wider context of who actually needs it within a practice population. It is not doing it for everybody is the right thing because that certainly is not the right thing. Given that caveat then within it the sort of things might be anything from very active interventions, such as fluoride varnish application or other sorts of active application of fluoride, right the way through to supporting behaviour change. It could be smoking cessation. We have some practices that have smoking cessation clinics within the practice. It is a range of things but it is set within a philosophy of care for the practice population and care for the whole patient and deciding what they really need. It is providing the opportunity to adopt that mind set.

Q463 Dr Naysmith: That is quite opposed to the new contract. Under the old system people registered with a dentist and they went along regularly for check-ups. Now people are encouraged to come for a series of treatments and that is the end of it. How do you fit all this into the new system? I am not suggesting the old system worked that much better but it did work a little bit better.

Mr Green: When we were in the pilot schemes prior to 2006 then practices were able to do that. We created the space for them to adopt that approach and the reaction of patients was very, very positive. When they said "The dentist has more time for me", what was happening was that was the sort of evidence of a preventive approach. They were able to talk and encourage people to care for themselves better and things like that. That was a real bonus. The issue now has been that the focus on activity has squeezed those things out.

Q464 Dr Naysmith: Would a QOF-type system re-introduce that?

Mr Green: I think the thinking is going down that way. There are things to learn from QOF as well, the good and not so good things.

Q465 Dr Naysmith: Maybe it is not a good day to be talking about QOF.

Mr Green: The idea that you set aside part of the contract as well as part of the time for a preventive approach is key to it. The difficult thing is deciding how to do that whilst maintaining activity, whilst maintaining the charge revenue that goes with that activity. That is another issue of concern to PCTs, doing all of that, but from a public health point of view putting, for the sake of argument, 40% of the contract's efforts and reward into access and prevention or help patient outcomes or however you want to describe it is the way forward.

Q466 Dr Naysmith: It was not done properly before but partially with proper registration with a dentist as you have registration with a GP.

Mr Green: From a personal point of view, I would. I cannot say I have thought it right the way through but there seems some logic, leaving aside the rather temporary nature of the contract with the patient in the present arrangements, if you want a long-term relationship with patients you need some way of expressing that. The open-ended registration, which is what we have in medical practice, may be one way of doing that. Patients behave in that way. They think, as I do, I know who my dentist is who has always been there.

Mr Smith: Going back to the original question, although there are clearly some therapeutic interventions which we know work, like fluoride varnish applications, fissure sealants and so on, sadly although we know that some patients will respond to the dental team's help and assistance in terms of making behavioural changes the evidence for that is really quite thin in terms of the behaviour changes that we can show happen. There is some evidence around smoking cessation, the brief intervention which we know about in medical practice. In terms of dietary change, the evidence there is slim and it only reflects a short-term change in people's dietary habits. Similarly, despite the efforts of dentists and hygienists, people will soon relapse to oral hygiene measures which are less than perfect. That is why every time you go you will be reminded. It is about changing people's behaviour. The context of that is outside of the dental practice. Your remit here is to look at the dental contract and dental practices but you have to put it in the context of health promotion and what goes on elsewhere. Therefore, you have to be cautious of investing a lot of money into tying in dental practices when there might be other solutions, other ways of making bigger improvements - I know you have considered the role of schools, for instance - in terms of people's behaviour and empowerment to behave differently which would improve their oral health. This is the public health side of it. What I am saying is consider a focus which is not just based within the walls of the dental practice. It could be that dental practitioners have a role in that more publicly focused activity.

Ms Davies-Slowik: In some of the salaried services, in part of their public health input, they have oral health promotion staff who do things like work with health promoting schools and try to target interventions at populations at risk. The second thing I would like to say is that certainly for the patients that we see in salaried services the registration-type relationship with the dentist is really important in terms of knowing them and their habits and where they live, and it is very important in terms of the prevention and being there whenever you see them to reinforce that.

Q467 Dr Naysmith: It has been suggested that the NHS is carrying out fewer band 3 treatments now. Do you think that will lead to deterioration in the nation's dental health?

Mr Smith: If you look at what is within the band 3 treatment, crowns, bridges and dentures, then clearly if somebody needs a denture and cannot function for the lack of that denture then it will have a significant impact.

Q468 Dr Naysmith: Do you think it is a real observation?

Mr Smith: There is very real evidence, and maybe you heard it at the last session, that the amount of work going to laboratories, which is what this is about, is reducing. Whether we can manage without having a bridge to replace a missing tooth somewhere near the back of the mouth, maybe we could, but for those people where there is a clear need for functional restoration then that has a big oral health impact.

Mr Green: I would agree on that. I think there are some concerns from last week's evidence about some of the more inappropriate dentures that have been made in order to secure a band 3 reward. I did put in my written evidence that concerns about patients missing out on that, because the gap between band 2 and band 3, £40 or £294, is perceived as being very large, particularly older patients needing full dentures see that as a very large amount of money to find. I know because I talk to them from help lines and complaints and things.

Q469 Sandra Gidley: I am interested in whether there is any evidence that patients' quality of care has benefited in any way from the introduction of the new contract. Is there any evidence of that from your PCTs or is the reverse possibly the case?

Mr Green: I think the answer is it is too early to tell. It is difficult to get either a benefit or detriment at this stage from what is available to us in PCTs at the moment. We do work very closely with the dental reference officers from the dental services division and they are the ones who are the clinical monitors of care. I am not aware from our local reference officers of particular concerns that they have. There always have been variations in the way that people have provided care but there is nothing at the moment that is particularly unusual or any particular trends as far as we know.

Ms Davies-Slowik: I am not aware of any evidence.

Q470 Sandra Gidley: Melvyn, I think you said there was an inherent incentive in bands 2 and 3 for dentists to under-treat.

Mr Smith: I said the incentive was there; I did not say it was necessarily happening. Every system has a different set of incentives and you have to consider that when you are imposing a new system. Let us consider the case of somebody who needs a lot of treatment which falls into band 2, a mouth full of fillings not involving crowns and dentures, for instance. Clearly if a dentist can be rewarded in the same way for providing one filling as they can for providing ten fillings then there is an inherent incentive for that not to happen or, and this may be a different way of expressing the same issue, for that course of treatment to be split so that a claim can be made from the band 2 course of treatment somewhat later down the road and some other fillings done. That is just an inherent incentive in the system in the same way that capitation systems, for instance, have an incentive for under-treatment. The reason we have all this debate about dental contracts and what the contracts should look like and how the payment system should work is because nobody - and I feel some sympathy for those who have to think about it - has come up with a perfect system. There were calls for pilots going back to the beginning of this century and people were invited to bring good ideas to be tried as modernisation pilots but there was very little outside of the traditional capitation or fee for item, the kind of things that had already been tried. It is a good question but I do not think necessarily there is a good answer to it. There are incentives in whatever system you operate which are perverse or which would go counter to improving oral health.

Q471 Sandra Gidley: Has quality of care changed with the new contract?

Mr Smith: It is a bit early to tell if you are talking about clinical care. What we also need to do, and we could have got some information by now, is look at the quality of the patient experience: could they get treatment when they wanted it and when they came out of the surgery did they feel their problem had been sorted out. I do not know why that kind of monitoring, in terms of the patient experience and how they feel about treatments being offered, was not built in, in some way, to the new contract or new contract monitoring.

Q472 Sandra Gidley: If I could go back to the comment you made if somebody needed a number of fillings then a dentist would get paid the same amount for a course of one or ten so there may be an incentive to split it up, that would mean that the patient would pay more charges and the patient may not be aware of the way the fee structure currently operates. Do you think the new so-called simple fee structure is clear to patients and they are clear what they are getting?

Mr Smith: If you look at the situation of somebody who is a regular attender and therefore may have a need for a new filling identified every couple of years and they have that filling done then they have to pay a band 2 patient charge. If somebody is an irregular attender, perhaps less assiduous in looking after their teeth, then there is no financial incentive because they will have to pay that same band 2 charge. There may be an incentive there in the system for people to store up their problems and have everything done all in one go because, at the end, they are paying the same patient charge for it. Again, there is a disincentive. This is about the fee system rather than the UDA although it is tied to the UDA. People are trying to get better value for money by storing up their problems.

Mr Green: I would agree with that.

Q473 Sandra Gidley: Last week there was an admission from some of the PCTs who gave evidence that their dental services would suffer as a result of a shortfall in patient charge income. Is that something you can concur with?

Mr Green: Potentially it could be; it depends on the amount of impact. Speaking from my own experience, what happened in the first year was we had something approaching a £2 million shortfall on charge income. That has improved this year but it has not been eliminated. The PCT has put other money in to subsidise to make sure that services are maintained or expanded in some cases. It is variable and the ability of PCTs to do that, particularly those who have turned around, can be compromised.

Mr Smith: John has fallen into the trap which PCTs do of calling it a patient charge shortfall and regarding it as such. It was an overestimate by the Department of Health as to what patient charge revenue would be and it was never corrected.

Sandra Gidley: It is a bit like the GP contract but we will not go into that.

Q474 Jim Dowd: Can I apologise to our witnesses? I have a school party in an adjoining room. I had to spend some time with them and so I was away at the beginning of the session. Can you give us a brief background to the role of salaried dentists, how they work and where they work and your assessment of whether the changes of 2006 have had an impact on both the way they work and the services they provide?

Ms Davies-Slowik: The salaried services were set up a long time ago basically as the School Dental Service and then moved on to the Community Dental Service in response to high dental need. The Salaried Dental Service is now set up to be complementary to the General Dental Services so they work in tandem. They do the things that the General Dental Services do not do. The majority of them are all within PCTs, I think, or they are within the NHS system. They have developed very much on a local level to meet local needs so no two services are the same even in neighbouring PCTs. There are two sets of patients that they are there to treat: firstly, vulnerable groups or priority groups, so children whose parents do not go to the dentist who would not get treatment unless there was a service there for them; adults and children with disabilities, learning disabilities; patients that are inpatients in hospitals, mental health hospitals or rehab hospitals; and various groups like that who are outside the norm who would not normally go to general practice. The second group of patients are the safety net patients. A while ago salaried services set up to treat patients because of access problems, either with emergencies within dental access centres or normal treatment that the GDPs were not providing because of access. Does that answer your question?

Q475 Jim Dowd: There are a couple of points arising from that. The other part of my question was have you felt any effects of the changes on the community dental service?

Ms Davies-Slowik: Yes. It has been a big change for everybody. It is a huge change in the system. In my written submission I said I thought it had effects in four different areas and the first area was for the patients. I think the treatment of individual patients has not changed from salaried services so the patient is a patient whatever system they are in. The dentist would say no matter what the system, there is always the patient there and I do not think the treatment for the patient has changed. However, there have been increased referrals into the service by GDPs. There was a survey that the BDA did with clinical directors and there was a marked increase of referrals into the services which has a knock-on effect for the vulnerable groups that they might have to wait longer for treatment.

Q476 Jim Dowd: Do you think there have been appropriate referrals? I realise that is a subjective judgment.

Ms Davies-Slowik: Some of the comments made by the clinical directors in the survey have said they have noticed more patients with high treatment needs being referred in, so different patients from the normal ones.

Q477 Jim Dowd: Would it be your professional estimation that these are patients who used to be treated in the non-special sector?

Ms Davies-Slowik: In some cases.

Q478 Jim Dowd: Because of the pricing structure they are now referred to the specialist.

Ms Davies-Slowik: That is a possibility. The fact that services are commissioned as a whole to primary dental care has increased the profile of salaried services. I think GDPs know more that we exist and are more likely to refer anyway.

Q479 Jim Dowd: Has it resulted in increased investment, increased expenditure, in the specialist sector of community services?

Ms Davies-Slowik: Referring to the survey done by the BDA, there were a lot of services that were being reconfigured but my feeling is that it was mainly smaller services joining up. The worrying thing was that 30% of the clinical directors said that some of the posts were frozen at the time of the survey presumably because of the NHS spending problems and I have no evidence to say that the services have increased.

Q480 Jim Dowd: Was that part of the general issue over deficits rather than being specific to dentistry?

Ms Davies-Slowik: Yes.

Q481 Jim Dowd: Do you think the NHS generally makes enough use of specialist and salaried dental services?

Ms Davies-Slowik: Yes, but obviously it depends on individual circumstances. I think they are there to do a job. They are there to treat the most vulnerable sections of society and I think they do make good use of that.

Q482 Jim Dowd: What about their use in areas where there is a shortage of traditional dentists?

Ms Davies-Slowik: In some cases it is fine if it does not reduce the service to the most vulnerable people who cannot access treatment. In some cases there have been instances where the safety of the service has increased to the detriment of other patients.

Q483 Mr Syms: Some countries provide oral health care through publicly funded dental clinics staffed by salaried dentists and dental teams, such as Finland. Would you advocate an expansion of these arrangements in England and, if not, why not?

Ms Davies-Slowik: I think there are different services in different countries. The way the dental services are arranged is very different. For me the salaried services do the job they set out to do very well. I am not sure what the advantages are of going to full salaried services as you see in Finland.

Mr Green: The Scandinavian model tends to be salaried for focusing on children more than anything. In fact, that was the model here for many years. It is only from the late '60s or '70s onwards that general practitioners started to see children as part of the family unit. Having worked in what was once the School Dental Service for many years, in those days most of the child dental care was provided in the salaried service. I make no judgment about whether that was better or worse than what we have now; I do not think you can. As far as the salaried service now, the point of someone being on a salary is to give them the freedom from other concerns about business to focus on quite difficult challenging patients. That is the main justification and Jane has described that very well. The dental practice infrastructure we have has been created through a business approach and I do not think we could recreate that infrastructure now; it is not affordable. It is being funded mainly by the entrepreneurial world of practitioners. Also they have brought in other income from private practice offering a wider range of things and are able to be much lighter on their feet in terms of business than perhaps the NHS would be. At the end of the day, the practical answer is to do with whether it is really affordable. You decide it might be desirable but it is whether it is affordable. This is one of the great problems about comparing general practice with salaried practice. It is a completely different case load and this is why dental activity is so difficult to try to apply to salaried services. I have colleagues who work all day in the theatre with very challenging patients with mental handicap. They work all day and see two or three patients and end up with four UDAs. The average gain is 15 per session so it is not a sensible comparison.

Mr Smith: It is unfortunate that we use the term salaried dental services. What we are talking about is different models of provision. What is a family dental practice? It is a kind of environment with its own mix of private and NHS patients usually. It is run as a commercial business owned often by an individual who has invested a lot of money in the practice. On the other side we have maybe the need for more - institution is the wrong word. Maybe we are thinking of Darzi's polyclinics here: a differently structured service where people use it in a different way. They can drop into it. Maybe they are not traditional family dental practice users. There are different styles of service provision which suit people in different ways and probably we need both. How the people who work in them are paid in either system, whether they are paid an income every month or incentivised in some way, does not matter, it is more about the style of provision of the service. Whether it is somewhere on the high street people can drop into without any worries about feeling part of the practice, who are not interested in registration for instance. I would support registration but there may be people who do not want that kind of model. How people are paid is a bit of a side issue to developing a breadth of service. We might be talking about putting out of hours services in there. We might be talking about putting some specialised services in there. It is having different models of service to meet the needs of the population.

Q484 Dr Naysmith: Could I just follow that question up a little bit? Why could we not have a salaried service doing full dental services in a clinic?

Mr Smith: We do.

Q485 Dr Naysmith: But you said it suits different people. Actually what it does is it suits the practitioners to do it the way they do it. You have physiotherapists, pharmacists and nurses working in clinics being paid on a salary basis, why should it be any different for dentists?

Mr Smith: Absolutely right. If you talk to young under-graduates about what their aspirations are, some people would be very happy earning a salary and not having to worry about taking care of business and others would want to own their own premises, who want to diversify in their own way particularly in the private sector..

Q486 Dr Naysmith: There is not the opportunity to be a salaried dentist working in a clinic very much, it is not really offered. You are offered the traditional way of doing it and then for specialised services Jane operates in a different area.

Mr Smith: There is room for everything.

Q487 Dr Taylor: One of the many criticisms we have had of the new contracts is related to the poor collection of data. If I can go to Melvyn first, in your submission you have been very clear. NHS dental data is inadequate for strategic planning of dental services and preventive programmes. The old fee for item contract gave, as a by-product of the payment system, detailed information. Can you expand on how this is making life for Dental Public Health officials difficult?

Mr Smith: Can I give you an example of the headline measure that the Department of Health seem to have adopted, which is how many people have been seen in the last two years. We have a paradigm that we want to get people orally healthy, we want to give them fluoride in the water or put fluoride varnish in their mouths and empower them in schools about healthy choices around eating and cooking and all the rest of it, and people get good quality restorations which last for 20 years and not two or three years, then the measure we are looking for would be a reducing number of people walking through the surgery door. Yet the Department of Health have chosen the number of people visiting a dentist every two years as a performance measure for PCTs and they have to deliver more and more of that. That to me is an entirely perverse kind of method of counting the success of an oral Health Service. What we could have, and it is back to what I said before, are measures which are actually about the patient experience and how they feel about their dental care. If they have a toothache, can they get the service when they want it? On a Sunday, do they have to travel a million miles to get it? Those kinds of measures we do not collect. There has been no systematic approach within the new contract to say that is the kind of data set which would help us in planning services.

Q488 Dr Taylor: How could those be woven into it now?

Mr Smith: If you look at PCTs, they have data collected with the old GPASS and GPack system for ten years now about patient satisfaction. There is a continuing programme of NHS data collection about how people feel about their services: "Think about the last time you went to see your doctor. Did your doctor listen to your concerns?" Those are the kinds of measures which I think would help us to know if the local services were giving us what we needed and, if not, how we could change them to make them more responsive to user needs.

Q489 Dr Taylor: Are any PCTs putting these measures in place?

Mr Smith: They may well be. Those questions are being asked in terms of the generality of primary care provision but not specifically around dentistry.

Q490 Dr Taylor: Is this something we should recommend?

Mr Smith: It is done everywhere else across primary care. I do not know why it is not done for dentistry.

Mr Green: I agree with Melvyn about looking at patient outcomes: that is really what we are concerned about and the rest of it is all process data. The real outcome is whether the patient feels better and feels they have had a good service and their health is improved. That does go on although not to the extent that would be of most use to us. It is very high level data and does not go down to local neighbourhoods very well. I think that is important. Underpinning it we still do need to know whether we are winning or losing in terms of dental health. One of the concerns I have is about this decennial survey. We have been doing that for 40 years now. This will be the fourth time every ten years we have done it but it does not look as if it is going to happen.

Q491 Dr Taylor: We are going to ask you specifically about that in a moment. Can I move to Jane? Has there been any change in the way you record data?

Ms Davies-Slowik: Since the introduction of the dental contract, yes.

Q492 Dr Taylor: You would have the same criticism, would you, that the recording of data is much worse now?

Ms Davies-Slowik: Local PCTs sometimes have different ways of collecting data for the local services. Salaried services can have different performance measures. For example, some people might collect contacts which are just people through the door. Sometimes some PCTs use a measurement of case mix which was developed with the BDA which measures the sorts of patients that you have and weights the input to those patients. You do not have an overall view of things getting better or worse.

Q493 Dr Taylor: Previous witnesses have suggested that because of this poor data collection there is less probity assurances within the system and more scope for playing the system. Would you agree?

Mr Green: Potentially, yes. We have a lot less data now so it is very difficult to know what is actually done for the patient unless, of course, we do what is happening which is to go back and look at the record cards. A clear detailed record has to be made of every intervention the dentist has carried out so that is being picked up by the dental reference officer visits to the practice.

Q494 Dr Taylor: How feasible is that to look at a meaningful number of records?

Mr Green: That is a point. There is a capacity issue about how much and how often you can do that but it is certainly something that practitioners are aware of now and would have to make sure there are records to do. Something I ought to say which I do not think has come out today is from April we are about to have enhanced data sets which will give us much more capability to look at more sophisticated weighting of the sort of patient groups that practitioners are seeing, particularly new patients who need a lot more work. We will have the ability to identify that and see what the profile is of the practice. We have very little profile information under the new arrangements at the moment but that is a temporary phenomena.

Q495 Dr Taylor: One of our experts has just passed a very apt comment that these record cards which are examined are selected by the dentists themselves so they are not going to produce any of the bad ones.

Mr Green: You would be surprised. My reference officer colleagues tell me that someone who is perhaps underperforming is unaware of that.

Q496 Dr Taylor: Out of sheer ignorance they might produce some of the bad ones.

Mr Green: That is one conclusion.

Q497 Dr Taylor: Should it not be, as it was in the old days in hospitals, when we were inspected by the colleges you did not know which notes they were going to look at; they picked out an entirely random set. Should this not be the same?

Mr Green: I think so. It is the view of all of us in the PCT governance side of things that it ought to be a more random and probing process. We are taking it step by step. This was quite a big change we have been doing for two years now and I think everyone would think let us move on to the next step.

Mr Smith: I would challenge that statement in the sense that I can remember clinical governance started in the NHS in about 1999 and dentistry was kept entirely outside of it. There is no connection between the growth of clinical governance within PCTs which has been slow bringing on board the general medical practitioners took time but it happened but there was no connection between that process and that financial support and that resource in terms of audit, peer review and clinical governance developing within practices. None of that was taken into dental practices; it was kept entirely separate. The Dental Reference Service does not have a good technical relationship with the different PCTs and those responsible for clinical governance within it. Something would need to be done there to bring this tremendous resource we have in the Dental Reference Service more into the governance arrangements that already exist and are having to improve within PCTs.

Mr Green: There is a review going on in the Reference Service at the moment and we are contributing to that. These issues are coming up and are being addressed so we should see some changes there. I take a bit of issue with Melvyn about dental governance because I was involved in developing the national model which some PCTs have adopted. It is quite true about the range of what the Health Care Commission is concerned about and we have tried to translate that into a practical way of assessing the quality of care and the quality of the way in which dental businesses run. Again in Sheffield we have done a lot more work and taken it forwards further in helping practitioners to improve the way their businesses are running because that benefits them as well as the patients.

Q498 Dr Taylor: When the new data set comes in in April, is the completion of the activity data compulsory?

Mr Green: Yes. I cannot see it being anything else.

Q499 Dr Naysmith: A final couple of questions on the procedure that started in 1968 with the national ten yearly adult and child oral health surveys. We got lots of very valuable data from these surveys every ten years but the adult survey has been cancelled for 2008. What do you think, if anything, has been lost by the Department's decision?

Mr Smith: I do not think we have been very good at collecting data on adult oral health and oral health needs. My professional society has done a lot to promote the collection of school-based data, and that is done because it is easy to do, but what we have not done is looked for systematic collection of data on our adult population. The only way that is done systematically across the country is through these surveys. We should have good quality local data but we do not. It is expensive to collect. You can use the national data as a surrogate. We can look at the particular areas of the country we are in, compare it with London, or whatever region it might be, and see how we are doing against the trends that are occurring on this nationally collected data survey.

Q500 Dr Naysmith: You think we are losing something valuable with the adult data survey being abandoned.

Mr Smith: Yes, because without that we have nothing at all in terms of adult oral health. It was very useful data.

Mr Green: I do agree. I add to that what we were hoping when this 2008 survey was being talked about was that it would actually be able to give us more information a bit closer to home. At the moment it is in big super regions in the old days and we were hoping to get down to health regions or SHA regions, but that looks like being thwarted which is a great shame.

Q501 Dr Naysmith: Why do you think it is being abandoned?

Mr Green: I think cost has to come into it. It is a very labour intensive process to clinically examine about 5,000 or 6,000 subjects around the country to add to the interview and qualitative data that is gained as well. It is one of the reasons we do not do those surveys locally in any real way.

Q502 Dr Naysmith: If all the PCTs are collecting data, why do we need a national survey?

Mr Green: Because the data is coming from patients who attend the dentist. It is not looking at the total population so people who do not attend very often, people who are irregular attenders, do not figure and, therefore, it suppresses the scale of the disease levels.

Q503 Dr Naysmith: What is the kind of data that we will be losing?

Mr Green: Over time we have seen the number of people who are without any natural teeth fall from 37%, and we expected it to drop to well into single figures and getting towards 5% this time but we shall not know as things stand at the moment. That is one issue. That gives us an idea of what the likely need is going to be. As people age with all their natural teeth then the maintenance costs to them and the NHS is very considerable and gets even more the older we get. We need to have some idea of what that future workload is going to be. This again is the source of that data other than some sort of modelling exercise. The other bit of information if I can go back to the clinical surveys that are done on children, they are very important. I work in Lincolnshire which has been fluoridated for 35 years, or half of it has, and it gives us a measure of how we are doing and whether fluoridation is still working, which it is, and the degree to which children particularly are being disadvantaged by them not having fluoridation in the area in which they are. There are academic arguments about the evidence but the clinical evidence from dental practices day by day and schools' evidence we have is very clear.

Ms Davies-Slowik: Just on a very practical note to say how we would use the information, for example, as John was saying, over the years more people are keeping their teeth for longer and they are keeping more of their teeth and they are in not as good condition. It helps with planning services, for example, if we have an aging population with their own teeth who might have Alzheimers or be in nursing homes then it has a real impact on how we plan our services, what services we have to take to people and we have to transport them back into the surgery. It is really useful information.

Mr Smith: For example, if a PCT has to design a service for the housebound, older people, we need to know how many have dentures, how many have root fillings, to be able to design a service to meet that need. We do not have that data from anywhere else but the adult dental health survey.

Q504 Chairman: John, can I ask you, with your regional hat on, are PCTs collecting data of people who do not use services so they can make a proper needs assessment?

Mr Green: I suppose they are in a way. What they are looking at is in the past it is looking at registered and unregistered and it is now looking at those, as Melvyn says, who have been attending in the last two years and so on but that is very difficult data.

Q505 Chairman: There is no general population data on dental health care needs.

Mr Green: Some areas have done that in part of their PCT surveys but there is not a concerted consistent effort about all that. It might be a good time to make a point about registration or rather the attendance plan. Registration in the old scheme was a snapshot. Even though we may have had 65% of people attending, the reality was in any two or three year period it was more like 70% or 80% because of the turnover in practices. When we talk about the difficulty of universal registration, then it begins to make more sense because people who actually would be cared for are much larger than the percentage that were declared as registered at any one time. There is also a group of the population who for all sorts of reasons, and some of them very good reasons, only attend asymptomatically and do not want registration to come for that regular care. It is not quite the big step that you might think.

Q506 Chairman: Commissioning is patchy and we have heard evidence in past sessions how patchy it is. Budgets for commissioning are ring-fenced at the moment up until the end of the next financial year. Do you think that ring-fencing of those budgets has assisted in the commissioning of dental services under the new contract?

Mr Green: Yes, I do. It has given PCTs a clear message that this is what should be spent on dentistry and what should be devoted to that and many of them wherever they possibly can have done that, certainly in Yorkshire and Humber.

Q507 Chairman: Does it worry you that the cost commissioning is patchy? I do not know the Yorkshire picture that you have part responsibility for but does it worry you that ring-fencing will end at the end of the next financial year?

Mr Green: There is no certainty at the moment. The operating framework talks about extension being considered and I think that is part of the issue. If what we are looking to focus on now is access, then there needs to be some way of underpinning or focusing PCTs on achieving that aim. My reading of it is that government is probably more likely to continue that for a while. The important distinction to be made between ring-fencing as far as PCTs are concerned and protecting the contract values of dentists is that does end after three years and so on. PCTs are not likely to want to greatly undermine the stability of what they have achieved so far in dental practices.

Mr Smith: My concern would be if we have a continuation of emphasis on UDAs and increasingly more patients through the door over a two year period then the gain that PCTs might get involved in to take care of that would maybe compromise services like Jane's where the commissioners know the price of everything and the value of knowing. They would be looking for the cheapest possible way of delivering a new patient through the door in two years, which is not necessarily going to take care of the people in society who need to be looked after.

Ms Davies-Slowik: I worry that as the BDA survey said 30% of clinical directors said that their posts were frozen that if the money was not ring-fenced then the temptation would be to freeze. Actually some of them said that their posts had been disestablished. If you have got a dental service versus coronary care, and that is the sort of decisions that PCTs have to make, it is not difficult to see which one might win in that case. If funds are not ring-fenced then the danger is slowly but surely funding might leach away.

Chairman: Could I thank all of you for coming along and helping us with this inquiry.

Witnesses: Ms Sarah Elworthy, a Dentist working in Cranbrook, Kent; Ms Margaret Naylor, a Dentist with practices in Rotherham and Sheffield; and Mr Derek Watson, Chief Executive, Dental Practitioners' Association, gave evidence.

Chairman: Good morning. Could I welcome you to this third evidence session on our inquiry into Dental Services. I suppose I have an interest to declare here; one of the witnesses is my personal NHS dentist.

Jim Dowd: A chance for you to inflict some pain in return!

Chairman: No quips about "you can rinse your mouth out between questions" or "please take a chair", but I just thought I ought to declare that. We are going to start by talking about access, which has been the Government's big issue in relation to the new contract, and Peter is going to start with the first few questions.

Q508 Mr Bone: My questions really are for Margaret and Sarah, and perhaps I should say I am very pleased that you have come and put your head above the parapet because I understand some dentists were concerned about coming and giving witness to this Select Committee for fear of retribution from their PCTs, so it is very courageous of you to come. Access seems to me to be one of the crucial issues and we are getting different sorts of views expressed about access across the country. Have you taken on more NHS patients since the contract has come into force?

Ms Naylor: We have always taken on new patients. There has never been a pause in either of the practices where we have not taken on at one of the practices new patients, so we have just continued to take on new patients. The new contract has made no difference to us with regard to access.

Q509 Mr Bone: Right, so you are an NHS practice; you had the capacity to take on new patients; you have continued to do so; and it really has made no difference in your area?

Ms Naylor: It has made no difference to me.

Q510 Mr Bone: In your area have you seen some NHS dentists going over to private patients since the contract has been brought in?

Ms Naylor: Very few. A small proportion of single-handed dentists. The PCT would be able to give you the exact figures.

Q511 Mr Bone: But very small in your area?

Ms Naylor: Yes.

Q512 Chairman: What area is that?

Ms Naylor: I am a general dental practitioner in Rotherham and in Sheffield.

Q513 Mr Bone: Sarah, what about yourself, the same sort of questions: have you been taking on more NHS patients or fewer?

Ms Elworthy: I have had a slight increase in the number of patients that I have taken on.

Q514 Mr Bone: Do you do private work as well?

Ms Elworthy: Yes, I see adults under the private contract and children under the National Health Service up to the age of 18.

Q515 Mr Bone: Right, so you do not have any adult NHS patients?

Ms Elworthy: No.

Q516 Mr Bone: This is one of these problems where we come to working out whether you are an NHS dentist.

Ms Elworthy: I think I read in Derek's report that all dentists are private practitioners but some dentists have NHS contracts. I consider myself a general dental practitioner and I have an NHS contract to treat children.

Q517 Mr Bone: One of the things we are getting slightly hung up on as a Committee is whether we are increasing the number of NHS patients, but perhaps we are looking wrongly at that; should we just be saying is there a greater number of patients being seen either privately or on the NHS? Is it the total number that we should be looking at rather than getting very hung up whether the number in the NHS is going up or down?

Ms Elworthy: I do not know. Right from the beginning of the change in the contract I wanted to talk to the PCT about increasing access for adults, but with my business model and the model that they came up with it, it just was not financially viable for me to take on adult NHS patients.

Q518 Mr Bone: Just going back to you Margaret, obviously Sarah has a system where the adults are private and the children are NHS; is that the same in your practice?

Ms Naylor: No, over 95% of my patients are NHS, both adults and children.

Q519 Mr Bone: Sarah, which area are you?

Ms Elworthy: I am in Cranbrook in Kent.

Q520 Mr Bone: Do you know if your PCT has a waiting list for NHS patients?

Ms Elworthy: I have a waiting list for NHS patients.

Q521 Mr Bone: You do?

Ms Elworthy: Yes.

Q522 Mr Bone: Do you know the number?

Ms Elworthy: No, I am sorry, but I could get that for you.

Q523 Mr Bone: So in your particular case the patient applies to your practice to become an NHS patient and you say, "At the moment we are full"; is that the way it works?

Ms Elworthy: Yes. I have allocated funding for my child patients.

Q524 Mr Bone: This is children we are talking about in your case?

Ms Naylor: Yes, nought to 18 years.

Q525 Mr Bone: So you have got a children waiting list. Adults you can take on or are you full as well?

Ms Elworthy: There is a bit of a wait.

Q526 Mr Bone: So in terms of access there are people waiting just in your practice alone to get treatment?

Ms Elworthy: To be seen.

Q527 Mr Bone: What about you, Margaret, I think you have said you do not have a waiting list.

Ms Naylor: We do not have a waiting list.

Q528 Mr Bone: Because you are able to take people on.

Ms Naylor: Not always immediately. We may make them an appointment in two or three weeks but they will be given an appointment, they will not be put on a waiting list.

Q529 Mr Bone: It is a little concerning that people are still waiting to get treatment; how do you view registration, was that better or worse than the current situation?

Ms Naylor: I think registration was probably better for the patients because they had a sense of belonging and saying, "That is my dentist," and patients still believe they are registered and even though it is gone they say, "I am registered with you," so I think registration was better for the patient. With regard to the dentist, I do not think it really made any difference. I am quite happy not to have registration because what it does mean is that if we have any patients who have wasted a lot of time, once we have finished their course of treatment we have no onus on us to take them back on as a patient.

Q530 Mr Bone: Sarah, what about you on registration?

Ms Elworthy: I feel registration is very important, for one thing just for managing the workload so that I know how many patients I need to allow to care for, and the other is for the continuity of care model. Preventative dental practice is built on long-term relationships with patients and a course of treatment is not a finite thing: you may find somebody presents with no problems say at four years old and then it is educating the parents and the child to make sure they stay that way as they develop because they are going to get more prone to decay.

Q531 Mr Bone: You think preventative treatment would help if you had registration?

Ms Elworthy: I think long-term relationships with your patients are important.

Q532 Mr Bone: You are of course talking about children.

Ms Elworthy: And adults as well. People expect that. They come to our practice and they say, "We would like to register with your practice." You can talk to them until you are blue in the face that you are not allowed to keep a register and they just say, "Can I register?" and they think you are their dentist and they come back to you. Some people do not attend regularly but they still think of you as their dentist. I do not have an issue with that. I am always pleased that people come back because it is another opportunity to maybe help them become more regular attenders.

Q533 Stephen Hesford: I have a question really to Sarah. When did you cease to see adults for NHS treatment?

Ms Elworthy: I set my practice up in Cranbrook 12 years ago and I ceased seeing adults under the National Health Service when the contract was changed previously, I think it was 1992. In the practice at that time I continued to see exempt adults and children and then when I set my own practice up I made a decision that I could not continue to see adults as exempt adults because of the financial restrictions.

Q534 Stephen Hesford: Is there a waiting list for your private adults?

Ms Elworthy: Not so much a waiting list but it is quite a few weeks to get an appointment and I am beginning to think that may become an issue because I do not want to have too many people expecting me to look after them. I would rather have a smaller group of people that I look after really well; you cannot please all of the people all of the time.

Q535 Stephen Hesford: And your pattern of taking on, has that changed at all since this change of contract?

Ms Elworthy: Sorry, pattern of taking on?

Q536 Stephen Hesford: People wanting to come to you as an adult to receive care at your practice?

Ms Elworthy: I think people are pleased that I am still offering NHS care for children because some practices in the area are not offering NHS care for children, so that is a factor, yes.

Q537 Stephen Hesford: In my area, the PCT will not let someone do NHS children and private adults because they see that that is a kind of loss leader, that the reason practices want to do NHS children is to get the adults in, and so my PCT will not allow that to happen. What is your comment about that?

Ms Elworthy: Well, in my experience in my practice, if the adult patients were not happy with what they were receiving then I would not have so many adult patients. The ratio of child to adult patients is relatively small. I may see a mother who wants to register her children but then she will say to me, "I would like my husband to come to you," or, "I have recommended my sister-in-law", not because they feel they have to because I am seeing their children but because they genuinely like the service I provide.

Q538 Dr Taylor: This is absolutely fascinating because we are getting a picture of a north/south difference and I want to really try and explore how you negotiated your contracts with your PCTs. Sarah, from what you have said you could only negotiate a contract for children's care under the NHS because the contract you would have got for adults just would not have ---

Ms Elworthy: I did not have an existing adult contract. When they changed the contract ---

Q539 Dr Taylor: Did you try to negotiate one for adults?

Ms Elworthy: Yes, I asked what was available and what was available would not fit into my business model.

Q540 Dr Taylor: And was it purely and simply they were not prepared to pay what you required to provide the service?

Ms Elworthy: Yes.

Q541 Dr Taylor: So they have gone for a cheaper service than you would have provided for adults?

Ms Elworthy: I cannot comment on the adult service because I have not provided an NHS adult service.

Q542 Dr Taylor: Can you tell us who is providing the adult service in Cranbrook?

Ms Elworthy: Nobody.

Q543 Dr Taylor: Nobody?

Ms Elworthy: I believe one of my colleagues is still seeing some exempt adult patients.

Q544 Dr Taylor: Right. Margaret, obviously it was much much more satisfactory for you and you were able to negotiate a contract for all of dental care. How did that go?

Ms Naylor: We are committed to NHS dentistry and we have been since the inception of our practices so we have always worked within the NHS. We were one of the pilot schemes for the first PDS, which bears no relation ---

Q545 Dr Taylor: How did you persuade your PCT to accept your prices?

Ms Naylor: I do not think it was a question of persuading. I think that the PCTs, along with advice from the LDCs, gave us a price which we found acceptable.

Q546 Dr Taylor: You have said in the first few comments that really the new contract has made no difference to the way you work and yet in your submission you are really pretty damning of the contract because you say that the tendering process that favours the cheapest tender may provide low-quality treatment, the variability of UDA values penalises some dentists, et cetera, yet you have managed to work within it?

Ms Naylor: I do think all those things. To go through them point-by-point, the contract does penalise dentists that work in a poor socio-economic area with no fluoride because we will always be doing more courses of treatment, but it is early stages and we just have to see how this goes. We really had to take what contract was offered to us and see how it went. There was no pilot for this.

Q547 Dr Taylor: We do realise that.

Ms Naylor: And they gave a figure which we felt we could work with, but that was our practice. There may be other practices in the area that are being paid less or being paid more that perhaps are happier or less happy.

Q548 Dr Taylor: Is it publicly known in an area what a UDA is valued at for the different practices?

Ms Naylor: I think so.

Q549 Dr Taylor: And within your area are they different?

Ms Naylor: Yes.

Q550 Dr Taylor: Markedly?

Ms Naylor: I cannot be definite, I cannot remember but it would be about £20 for some UDAs and will go up to about £28 for other UDAs. In different areas, for example in Macclesfield, there are dentists that are getting in excess of £40 per UDA and in Lincoln it can go down to as little as £16 per UDA.

Q551 Dr Taylor: We know that there was a test period that the UDAs were calculated on but how did it end up they were so widely different?

Ms Naylor: I never really understood that because we did not move from the old GDS system to the new contract. We had an intermediate step of what was laughingly called a pilot scheme. I am not quite sure how they historically got to it. I think what they did was they looked at what dentists had done in the past and whether they were a high crown/high volume/high value dentist and based their figures on those, so if you did very little crown work or bridge work and you did small fillings then you would be paid less.

Q552 Dr Taylor: Right, yes. Moving on, Sarah, I think it is in your submission that you say PCTs have a poor understanding of dental practice. Can you give us examples of that and how it affects you?

Ms Elworthy: Yes I have minuted the meeting I had with two people from the PCT. This was because I was not achieving the UDA values that I needed to achieve and I asked them for guidance. I said, "We are following the clinical protocols of good modern preventative dentistry and I do not see how I could increase my UDAs without compromising patient care." A couple of things came out of that. I had been looking at a CD-ROM Improving oral health with the new dental contract: make the new contract work for you and there was no mention of how to improve your UDAs on that (because that was what I was looking for) and when I asked the two gentlemen from the PCT what they thought about it, they had not even seen the CD and they did not know anything about it, so that was not particularly helpful. I also found it quite interesting that one of the gentlemen from the PCT asked why I felt it should be clinical guidance that I needed to increase my UDAs in changing clinical practice and I did feel that I would rather take advice from a clinician on how to change my clinical practice than a non-clinician.

Q553 Dr Taylor: Is your PCT one that was reorganised not that long ago?

Ms Elworthy: To be honest I do not know.

Q554 Dr Taylor: Is there a consultant in public health in the PCT?

Ms Elworthy: Yes, a very good consultant and I do know that he has been very supportive. I have to say although that was quite negative about my PCT, initially, if you go to back to implementation, I was aware the new contract was coming in and I decided to be proactive and I went to the PCT before the new contract came in. In actual fact, I wanted a PDS scheme and I was all set up - I think it might have been similar to something that you would have had, Margaret - to do that and then there was a general election and as I was about to sign a contract, the PDS scheme disappeared. We had made all the planning and all the set-up and Mr Allen(?), who is the Public Health Consultant for Kent was very supportive, I believe, when he was told of our bid. I am not completely against the PCT; I just feel they have got a very difficult job to do, and if they do not understand about dentistry it is going to make it even more difficult.

Q555 Dr Taylor: Margaret, did your PCT do better?

Ms Naylor: I think that both the PCTs I work for are pretty good and we have always had a lot of support and they have always been very approachable.

Q556 Dr Taylor: Margaret, I think it was in your submission you said that when PCTs have gone to tender for additional UDA provision they have often had multiple bids and had to select a preferred provider. This has usually been at the lowest price and this is where sometimes they bring in non-UK personnel. Is there any evidence that these people do not provide the same quality of care?

Ms Naylor: There is no evidence that they provide the same standard of care.

Q557 Dr Taylor: How do we get round that?

Ms Naylor: What concerns me is that a UK graduate will spend five years in dental school and everything will be checked by the GDC. They will come out of dental school and they cannot work in an NHS practice unless they have done a year in an approved practice with someone that has got the experience to guide them.

Q558 Dr Taylor: To know if they are okay.

Ms Naylor: To mentor them and to make sure they are okay and that they are not a danger to the public and that they provide good care.

Q559 Dr Taylor: So your worry is that these people are probably not trained to the same extent and not vetted afterwards?

Ms Naylor: Yes.

Dr Taylor: Thank you very much.

Q560 Chairman: Just one thing, when we were talking about UDAs and how much PCTs pay for UDAs, you said there are different rates in different PCTs maybe from one practice to another. Are there any differences within practices where you have got more than one dental practitioner?

Ms Naylor: There may be but I do not know of them.

Q561 Dr Naysmith: I was just going to bring Mr Watson in. You were nodding just now when you heard that question. Can you answer the Chairman's question?

Mr Watson: The UDA value was achieved originally by looking at dentists' historical treatment patterns, so if you take two dentists one of whom for example did several fillings in an average course of treatment and another dentist who perhaps did just a check-up and one filling in an average course of treatment because their patients were in general a lot healthier or perhaps because they were in the different area, the UDA values were derived simply by dividing the money for the average course of treatment by the unit value for that course. For the average course it would be three units for a band 2 course. Stick with me because once you understand this, it is the key to a tremendous amount.

Q562 Dr Naysmith: We are all slightly mixed up about this.

Mr Watson: Your first dentist for example, who would have been paid on average £90 per course, will end up with a UDA value of 30 per UDA because there are three UDAs so it is £90. Your other dentist who might have done £30 worth of treatment in an average course will get £10 per UDA because he on average does less per course.

Q563 Dr Naysmith: Can this be related to the quality of care provided in any meaningful way or is it just someone who works more quickly?

Mr Watson: It was related to the amount of care provided. It was designed to give dentists who historically did more treatment per course more money to pay for it, but the problem is that the dentist who generally does very little per course because his patients are healthy has no potential to improve and cut down on the amount of treatment he does, whereas the dentist who used to do ten fillings on every course immediately starts doing far fewer. There are all sorts of disparities but in answer to the question, yes, it is quite possible that dentists will be earning different amounts per UDA even within the same practice, yes.

Q564 Sandra Gidley: It was that point I wanted to pick up on because you said their workload is probably different because they have got a different cohort of patients who are healthier or in a different area, but to have the quite stark anomalies in the same practice that we heard about last week does seem to be a flaw in the system. How can two dentists within the same practice have such starkly different UDA bands?

Mr Watson: Because they will have different historical treatment patterns, so for example you may well have a practice owner who has been in situ for 20 or 30 years who has a number of patients who have been seeing him for 20 years who are very well controlled. He may have an associate who sees all the new patients - and this again is an issue with this contract - and the patients who come to see him will have very high treatment needs and therefore he is going to require a high UDA value to be able to deal with those patients that he has historically had to deal with.

Q565 Sandra Gidley: Should that not change over time though as they die off - which is no fault of the dentist I hasten to add!

Mr Watson: To a certain extent it is a facet of the three-year transitional period because post-April 2009 there will be some normalisation of UDA values. Once primary care trusts cease to have to pay units for historical reasons and they start to move into commissioning, they will then seek to commission, and the levels at which they commission will normalise, for want of a better word.

Q566 Sandra Gidley: That is going to be a nightmare presumably because all of those who will lose out under that will leave the NHS yet again, so we are going to see a further exodus of NHS dentists in the future possibly.

Mr Watson: We are for that reason and for a number of other reasons very worried about what might happen in April 2009 when the earnings guarantee comes to an end, yes.

Q567 Dr Naysmith: That was very helpful, Mr Watson, we can get back now to the couple of points I was going to raise with you out of your written submission. Why did you state in it that PCTs have a strong disincentive to expand provision?

Mr Watson: For two reasons. First of all, the intention of the contract was to expand provision in areas of high need and to put it bluntly, patients in high need tend not to contribute towards the cost of their treatment and, secondly, because during the period of the pilots, prior to April 2006, the Department of Health underwrote the patients' charge revenue for the pilot schemes and they basically said, "If we have got the calculations wrong and we have overestimated or whatever, we will underwrite any loss," and that guarantee finished on April 2006 so primary care trusts and local health boards no longer have that. Also in April 2006 the dental budget became limited. For the first time a limit was set on it and so primary care trusts who wished to expand provision have two problems. First of all, they are coming up against this budgetary control which they did not have before and, secondly, if they try and put provision where they would really like to in areas of high need, they suffer financially for it.

Q568 Dr Naysmith: So the so-called pilot was not really a pilot at all for what was about to happen?

Mr Watson: There were a number of pilots which paid dentists in various different ways but, as you have heard from various different people, people felt very strongly that the system which was eventually introduced was not one of the pilots. It may have been based on some wisdom which was gleaned collectively from the pilots but the system actually was not piloted. There were some technical problems with that relating to patients' charges because the regulations prior to 2006 prohibited patients paying for their NHS dentistry in one way in a pilot area and in another way in another area so there was no piloting of patients' charges possible. It is likely that it could not have been piloted in its exact form but a lot of people feel that it was not piloted in any form.

Q569 Dr Naysmith: Could I ask you a different question. Does it concern you that the Department will not be conducting the survey of adult oral health that it used to carry out every ten years?

Mr Watson: Yes, we are very concerned about that.

Q570 Dr Naysmith: If so, can you tell us why?

Mr Watson: Because the effect of the contract, and it is something which was telegraphed well before the contract came in, was that it was going to depress the amount of treatment that was being provided, and in fact to a large extent that was intended by the Department of Health. At the time they had a problem of access and without wishing to throw a tremendous amount of resources at the problem, they had a difficult tradeoff to make, and in the contract what they did was they traded off more treatments for less fillings, if you see what I mean, more courses of treatment each containing less, so for the patient going along to the dentist the good news was that they were more likely to be able to see a dentist and have a course of treatment but the bad news was that that course of treatment was going to contain less than it had done prior to April 2006. Because we said this would have an adverse effect on oral health we were obviously looking towards the data that they were going to collect to be able to see whether or not it had had a positive or negative impact. Of course we were very disappointed to find that they had for the most part ceased all collection of data post April 2006. In that data vacuum, which is something that the primary care trusts have felt acutely as well, the only thing we really had to fall back on was the certainty that in 2008 there would be a survey of oral health of the country and in fact if the system was a bad system, then it would show up. It may be slightly too early for it to show up but it would show up in that survey, so when we heard that the Department of Health had cancelled data collection right up to and including the ten yearly survey of adult health, we were very disappointed, yes.

Q571 Dr Naysmith: Just finally, you said it was telegraphed and they were going to balance this conundrum by doing less treatment within a course of treatment. How was it telegraphed? What do you mean by that?

Mr Watson: What I mean when I say that is it was possible when the regulations were in their draft stage to do a reasonable amount of analysis of the system and its probable effects, and the probable effects of the contract were known, I would say, as early as April 2005 because, if you remember, it was due for introduction in April 2005 and it was then delayed six months and then delayed another six months so in effect it was delayed for the year, so probably 12 to 18 months before it was introduced, we had pointed out to the Department of Health the problems that they would have with it. When I say it was telegraphed, what I mean is that they had lots of notice of problems that we feel they subsequently have discovered for themselves.

Dr Naysmith: Thank you very much.

Q572 Sandra Gidley: A couple of practical questions to Sarah and Margaret. Sarah, you have already partly answered this because you referred to having trouble meeting your UDA targets. Did you actually meet your UDA targets for 2006-07 and how is it going this year? What action has the PCT taken? In your case, Sarah, it would appear to be nothing. I do not know if there is anything further you want to add?

Ms Elworthy: I did not meet my target for 2006-07. The last meeting I had, which I was talking about when I asked them to help me how to achieve my targets, I have not really had a response from.

Q573 Sandra Gidley: Was that in the 2006-07 year or this year?

Ms Elworthy: The last meeting was in January this year. No, sorry, that was in January 2007 --- no, that is not right. What I remember is that since last October I have not heard anything from them.

Q574 Sandra Gidley: Okay, so you have had no practical support from your PCT?

Ms Elworthy: They are not asking me about my UDAs and I am treating my patient base.

Q575 Sandra Gidley: Do you think PCTs should be tracking this a little more?

Ms Elworthy: They do not seem to be able to help me achieve my UDA targets.

Q576 Sandra Gidley: Margaret, how about you?

Ms Naylor: We met our target in the first year and we expect to meet our target this year.

Q577 Sandra Gidley: So you have not had a problem? Was that always the case that you were going to meet them or did it look as though you were going to fall behind at one point and you have had help?

Ms Naylor: We were certainly worried when we originally started and we did take on additional dental support, we had an additional dentist start with us.

Q578 Sandra Gidley: So you paid quite close attention to how it was going from an early stage?

Ms Naylor: Yes.

Q579 Sandra Gidley: A question to both of you again: do either of you now provide fewer band 3 treatments than you did before the new contract and, if so, why?

Ms Naylor: I cannot tell you because I do not have that data. In order to find out I would have to go through all the old lab invoices to find out how much we have done because whilst we have it on the computer it is not easily accessible because of the way that we send forms off now. You are either band 1, band 2 or band 3, and we have no idea what we do in each of those bands.

Q580 Sandra Gidley: Let me put it another way: have you noticed any difference in the way you might provide treatment to people particularly in the more complex band 3 treatments? Have your decisions and your options been changed by the financial restrictions upon you in what you have to do with band 3?

Ms Naylor: No, I do not think so. I think in an area like ours where there is a high dental need and a lot of patients, we have always looked carefully at what the patient needed and not done extensive work which may be unnecessary, like providing crowns on teeth which have no opposing teeth (you provide a crown at the back and it does not actually bite on anything). We have never done things like that. I am not sure it has made any difference but I cannot be definite.

Ms Elworthy: Because I treat children under 18 then it does not really feature.

Q581 Sandra Gidley: It does not really apply.

Ms Elworthy: Because I am really trying to prevent and conserve and unless it is acute trauma, and I can only think of two teenagers that I have had to supply replacement teeth to.

Q582 Sandra Gidley: We have had suggestions put to us that some dentists have been referring the more complex and difficult patients to the hospital because they do not feel the UDA system rewards them adequately. Would you have any sympathy with colleagues who do that?

Ms Elworthy: Totally.

Q583 Sandra Gidley: Margaret?

Ms Naylor: It is difficult. The phrase "swings and roundabouts" keeps coming up but if you are getting all the swings and none of the roundabouts then you may feel that you want to refer more, if you get particularly complex cases.

Ms Elworthy: You talk about UDAs influencing your treatment decisions - the way I set my model up was because of my historical knowledge of my clinical requirements, I knew how much surgery time I needed. I had been in the area for a while and I had a stable pattern of treatment, so once I knew what my finance was for the year (because that is one of the good things about the system, a regular monthly income) I now set certain amounts of surgery time for myself and my therapist and my hygienist and my oral health educators for looking after the children. We did judge that about right. When somebody walks through the door to see me I am not thinking, "How many UDAs will this generate?" all I am thinking is, "This person has got an appointment booked with me in my NHS clinical time; what is in the best interests of this patient for their treatment?" and we provide it. We have been monitoring our hours and this is when it can get very tricky because I am seeing children coming off the waiting list who have not had access to dental care for many years so I am now getting things like decay into adult teeth or into the nerve in the primary molar teeth, which is very difficult to manage and more time-consuming and of course will impact on the amount of surgery time that I have got to allow for.

Q584 Sandra Gidley: So you are starting to see a more complex case mix coming through in what was previously quite simple?

Ms Elworthy: Yes, and with our prevention, once they were rolling along we were not having people coming back with decay.

Q585 Sandra Gidley: It is interesting that you are doing a lot of prevention and you are struggling to meet your UDAs ---

Ms Elworthy: It is, is it not?

Q586 Sandra Gidley: Because it has been put to us that there is not space for adequate prevention in the new contract. Do you think the balance of the UDA system is right or should it be modified in some way?

Ms Elworthy: I have to say when I set up the PDS scheme I allowed for the amount of surgery time that I knew I needed for my steady children base and I have not considered or thought how the UDAs work because I knew from the beginning, I could tell by modelling it on my patient base, that I would not get my UDA target. I made that clear to the PCT right from the very beginning.

Q587 Sandra Gidley: Have you any suggestions as to how the UDA system could be modified?

Ms Elworthy: Listening to what people were saying earlier I think that it is a way of counting units of something, and obviously measurement is important, but there are different ways of measuring, and I think it needs a variety of things, I am talking about patient satisfaction surveys and quality assurance-type things. It needs a range of measurements.

Q588 Sandra Gidley: Margaret, would you like to see the UDA system modified in any way?

Ms Naylor: Yes I think so, in the same way as my colleague has oral health educators and therapists, we do as well, but I feel as though that is coming from us. We visit schools and playgroups with the oral health educators but that is our initiative; it is not an initiative from the PCT, so I think it would be nice to have it acknowledged if you are doing (as it should be being done) oral health education and also looking at diet.

Q589 Sandra Gidley: Derek, I have not included you in any of the other questions but, from your perspective, how would you like to see the UDAs modified?

Mr Watson: I think there needs to be a very quick adjustment to five or eight bands instead of three. To get every possible type of dental treatment into one of three bands was really going too far the wrong way. It would not necessarily have an impact on patient charges because you could take the band 2 and split it into band 2(a) and band 2(b), where the more complex intermediate restorative work would go into band 2(b). The patients' charge would be the same, it would be a band 2 charge whether it was 2(a) or 2(b) but at least it would give dentists faced with a patient who needs a reasonably large amount of work within band 2 to do it because it would come into band 2(b). What that would mean is instead of having a flat rate three units for band 2 you could perhaps have two units for band 2(a) and four units for band 2(b) so there would be a little bit of balancing of the units to be done. Similarly with band 3(a) and 3(b) where someone having one crown done would go into 3(a) and someone having two, three or four crowns would go into band 3(b). Instead of having a flat rate 12 units for band 3 you could have perhaps seven units for 3(a) and 15 units for 3(b). That is a simple thing which could be done very quickly. It is probably a little bit late for 1 April now but perhaps by 1 October, and it would go a tremendous way towards reliving the stress on the system to try and make it work.

Chairman: Jim, did you want to ask a question?

Q590 Jim Dowd: Well I did want to but Stephen asked one of my questions and Sandra asked another one of them! Can I just check with Ms Elworthy, the Cranbrook in which you practise, this is the one near Staplehurst with the golf course?

Ms Elworthy: That is right, yes.

Q591 Jim Dowd: Which is also one of the most prosperous parts of Kent, is it not? You may not be one of the most prosperous residents, but when Richard said he was noticing north/south divisions here, it is a far more complex arrangement. I do not know about Dinnington, Chairman, I am sure you do, and I not know if you have a golf course and it is the most prosperous part of Rotherham. You say in your submission that you find under the terms of the contract it is impossible to provide "patient centred effective dental care for children." Why do you say that?

Ms Elworthy: Because of the UDA system. For modern effective preventative dental care UDAs do not add up.

Q592 Jim Dowd: Despite your previous response to Sandra about whether they should be reformed, your view is really that they should be abolished?

Ms Elworthy: I am only talking about treating children. That is my area of National Health Service dentistry.

Q593 Jim Dowd: Where do adults in Cranbrook go who want an NHS dentist, Tunbridge Wells?

Ms Elworthy: Not in Cranbrook.

Q594 Jim Dowd: Where would they go; you have no idea?

Ms Elworthy: I do not know. We get a lot of phone calls and we refer them to NHS Direct.

Q595 Sandra Gidley: I think what I was planning to ask has partly been covered, it was about preventative care, and you alluded to that earlier, and I think Margaret picked up on that. I would be interested in what sort of preventative care you think ought to be provided as routine and how that can be incorporated into a decent system.

Ms Elworthy: I just want to refer back to what you are saying because most of the stuff that we do is only band 1. What you were saying about the sorts of things we want to do, for instance, for a child who comes in before the age of six, we will be wanting to take x-rays at about six when their adult molars are starting to erupt, and we would be wanting to apply fluoride varnishes to any vulnerable teeth, and we would want to apply fissure sealants to erupted first molar teeth. The evidence is very strong on how effective that is in preventing decay. All those come under band 1 treatment, so I could see a child and their mouth appears dentally fit and they can go out the door, or I can see a child and I can send them to my oral health educator for instruction in tooth brushing, making sure they are using the right toothpaste and brushing twice a day, all these very basic health messages which do need to get through to all ranges of society. Cranbrook is a middle-class area but we do have people, and I treat them, from lower socio-economic groups and we do care for them. We are not comfortable with this situation. I do not want to be in it. It is why I am here; I would not have bothered writing otherwise. I could have turned private if I wanted to, as you say, it would not have been that difficult. All the things that we want to do - and I will send my form off and still get one UDA, the same amount of money.

Q596 Sandra Gidley: Margaret, what type of preventative care do you think dentists should be providing?

Ms Naylor: I agree with my colleague. We should be providing for children at risk of all those things. If I have nice middle-class children who I know have a good diet and you can see that their oral hygiene is good, I can see the family is motivated and they will always look after their teeth, there is no point in doing fissure sealants unless there is a clinical reason. I think we probably take more of a judgment on it in the NHS but of course we see the cases of real dental deprivation in our area where almost every tooth in their head will be carious.

Mr Watson: There was no prevention under the old system and there is really no prevention under the new system. The idea that this 5% reduction in workload was going to free dentists up to do prevention is just fanciful. That 5% was more than outweighed by other changes which took that 5% up straightaway. My view and the view of the association - and it is in our submission - is that there are systems which encourage prevention and they are systems within dentistry which have been well-demonstrated to produce oral health gain. It is no use measuring fillings, it is no use measuring courses of treatment, it is no use measuring patients' visits as it does in the strategic framework now. You have to measure and purchase oral health gain, and the best way to do that in dentistry is to have a system of registration, to make dentists accountable and responsible for the oral health of that cohort of patients, and lastly, as I say, you have to give them a financial stake, let us not beat about the bush, in any oral health gain made. If you did that, you could revolutionise dentistry and prevention in dentistry.

Sandra Gidley: Right, thank you.

Q597 Dr Naysmith: Mr Watson, you have been very helpful in suggesting ways of doing things this morning. How would you organise this financial stake in preventative dentistry?

Mr Watson: I will very quickly illustrate the two situations. At the moment if there is a certain level of disease in your patients and, let us say, you go out of your way to make them healthy and as a result many of them who would have had band 3 treatments end up having band 2 treatments and the band 2 patients end up having band 1 treatments, basically you are going to fail to hit your UDA target, that is what it boils down to. I think it has been amply illustrated that the very good dentists who really go the extra mile for their patients are really struggling under this system. The dentist who is a good preventative dentist is seen by the primary care trust as a failing dentist, one who has failed to hit their target. Under a system where a dentist was allowed to retain some of the money saved, let us say a dentist had £10,000 worth of treatment that was done on patients and because he is a good preventative dentist he then cut the cost of treating those patients down to £8,000, at the moment what happens is, as I say, that money will be clawed back. If you said to him, "For every £1,000 you save I will let you keep £500 and we will have £1,500 back to put into the general budget," that sort of system works.

Q598 Dr Naysmith: How are you going to measure it?

Mr Watson: You can do it on a population basis but it is not that difficult to categorise every dental patient into an oral health category. That is how it works in the modified capitation plans. You literally put every one of your patients on a scale of A to E, where A is great and E is a dental disaster, or you can give them a numerical value, and you just add the numbers up at the beginning of the year and you add the numbers up at the end and you can see how much they have improved.

Q599 Dr Naysmith: In your submission you also talked about a co-payment system as a possible mechanism in organising dentistry in the future. How would that work and in particular how would it help people under the age of 18 and adults who do not currently have to pay for their oral health?

Mr Watson: For them, things would not change.

Q600 Dr Naysmith: They would stay the same?

Mr Watson: Yes. In the submission we used the word "co-payment" and I think with hindsight that was probably the wrong word because co-payment implies that the patient is contributing toward the cost of their National Health Service treatment. We already have co-payment in dentistry, in fact it was the first co-payment that was brought in in the National Health Service.

Q601 Dr Naysmith: It could have been called a voucher system.

Mr Watson: I think the best way to think about it is direct payment, in the same way as already occurs in social care, so for example, let us take the example of someone who is being cared for by a relative at their own home but has to go into residential care for periods of respite care, what will happen is that person will be given a nominal amount, either directly or indirectly, to go into respite care and that will be adequate to go into respite care in a facility which has been inspected and is regarded by the primary care trust as adequate. Should that person choose to go elsewhere, it is understood that they will then pay the balance themselves and that is direct payment and that really does free people up to take their NHS subsidy wherever they like. The way it works is that if a patient goes to a dentist and under the present and future rules is exempt, they would simply self-certify as they do at the moment. If they go to a dentist and they are not exempt, then first of all they are free to go to any dentist they like and they can either complete the NHS form as they do at the moment, in which case the patient charge is netted off the dentist's remuneration or, as happens in other countries such as France, they take a statement from the dentist as to what has been done to the local post office and they get reimbursed through the local post office.

Q602 Dr Naysmith: I wanted to ask Sarah Elworthy about something that is maybe related to this in a funny sort of way. Do you treat any children as private patients?

Ms Elworthy: Yes.

Q603 Dr Naysmith: Is there any difference in the treatment that the two get?

Ms Elworthy: No.

Q604 Dr Naysmith: None at all?

Ms Elworthy: Sometimes I do not even know (because it is all happening on the computer behind me) whether I have got a private patient in the chair or a National Health Service patient, other than if I am aware what time of the day it is because I have NHS treatment areas.

Q605 Dr Naysmith: But there is nothing you can provide doing it privately that you cannot provide under the NHS?

Ms Elworthy: Some parents request non-metal fillings in their children's teeth and we do not provide that under the National Health Service.

Q606 Dr Naysmith: So that is quite an important difference?

Ms Elworthy: Very few, it does not feature a lot.

Q607 Dr Naysmith: But it might be important to the people.

Ms Elworthy: It is important to them which is why they request it but not a lot of people are requesting it.

Q608 Dr Naysmith: Does it make any clinical difference?

Ms Elworthy: The reason we recommend amalgam fillings in posterior teeth is because they last longer.

Q609 Mr Bone: Back to Mr Watson, I am very interested and encouraged in what you have said. We are not supposed to agree because it is an evidence session but I do agree with what you are saying. What has annoyed people in my area is they have had National Health dentists for years and years and suddenly they have all gone and they have to go privately. Most of them will have taken out insurance and what they say is, "I am paying my taxes for the NHS treatment but I am also paying for the insurance." For people who are not exempt for treatment, we have got this very strange situation in the NHS. The NHS is supposed to say "At the point of delivery you do not pay for the service" and that is clearly not what happens in NHS dentistry. Is there not a strong argument to say for non-exempt patients there should not be any NHS treatment whatsoever and therefore everyone should be in the same boat as effectively my constituents are and have to either co-pay as you say or provide some sort of social insurance?

Mr Watson: I think patients regard the provision of dentistry on the National Health Service as part of the compact they have with the Government by which they deduct national insurance, and I think to tell the vast majority of people in this country, the ones who demand treatment as opposed to need it if you like, that National Health Service is being taken over, politically would be very difficult. Obviously I would defer to your knowledge on that. The good thing about direct payment is that it gets round that problem of the patient who says "Why am I paying twice?" because they would not be paying twice.

Q610 Mr Bone: We are basically making the argument in a specific part of the NHS where there is already significant charging a voucher system would be a more equitable system?

Mr Watson: It would be completely equitable and, better than that, it actually fits in with the patients' collective consciousness on this matter because as a practising dentist myself for over 20 years, patients frequently used to come in and say to me, "I am entitled to National Health Service treatment, I want this done on the National Health Service but I would like nicer teeth on my denture or white filling material and I will just pay the difference," and we used to say, "You can't just pay the difference," and they would say, "Why can't I just pay the difference?" and we would say "Because you can't pay the difference"! That is all we are asking - that they should be allowed to pay the difference.

Q611 Chairman: Unlike a spectacle frame where you can pay the difference?

Mr Watson: Exactly.

Q612 Chairman: Could I pursue this a bit further with you because in your written submission your Association argues that the state should make a core contribution. Do you see that as being very much the cost of a treatment for a need of a patient in terms of needing help with a dental problem?

Mr Watson: Yes, I think it can be related to that patient's need and it would be equivalent to the cost of them obtaining the treatment from a facility which provides it to an adequate standard, yes.

Q613 Chairman: And the direct payment you are talking about or co-payment is in addition to that if you want something that some people would say would be more cosmetically pleasing?

Mr Watson: Yes, that would be an enhanced co-payment in effect.

Q614 Chairman: You also say in your submission that this could be done, as they do presently, where some dentists would work for core fees for patients who are fully remitted or exempt with one basic NHS service and there would be other practices where patients would need to make a larger co-payment? Why could it not happen in all practices?

Mr Watson: It would happen in all practices, but really the practice which is happy to work for the voucher cost, if you like, is the equivalent of the residential home that is happy to take people for the NHS tariff for that service, but the point is that in being able to reclaim what you are entitled to towards the cost of your dental treatment, you will not have to be restricted to going to those practices who provide that level of service. Technically, if you liked - and this does annoy some people - you could take a voucher to Harley Street and say, "I am entitled to £20 on the National Health Service and I will pay the other £980 or whatever myself"!

Q615 Chairman: Would you say that could potentially be an incentive to have access to NHS dentistry in any part of the United Kingdom, that a dentist would have to operate that system and therefore see NHS patients, including exempt NHS patients, running alongside being able to offer direct payment, you say, for this addition? Do you think your members would be happy for you to say that that is the new system and you will have to accept that?

Mr Watson: I think they would. I think that dentists would be very happy to accept this type of system in the same way as if you have a voucher for your NHS spectacles, lenses or whatever, where you will find that you can generally take that to any opticians. I think there would be very few dentists who would not want to co-operate with a system like this. I would go further and say that if a system like this was brought in I think it would be so popular with dentists that it would probably take dentistry off the news agenda full stop.

Q616 Chairman: Do you think it is a form of the state telling them that you shall see NHS patients, some who are exempt and some who may or may not have great need for care, and therefore would take time in their surgeries when they could be dealing with people who wanted a treatment that they were getting paid more, for want of better expression? Do you think they would easily accept things like that?

Mr Watson: Yes I do and the reason why I say that is the relevant words are cross-subsidy. It is shame Mrs Atkins is not here because I know she was particularly exercised about the issue of child-only lists and stuff. The reason why child-only lists came about was because it became uneconomical in certain high-cost areas to treat adults on the National Health Service, and the way those dentists continued to support those child patients was to cross-subsidise the children from the adults, so they used to take some money from the adult profit and put it towards the loss-making NHS child part. That attitude towards keeping the NHS going at a time when it really was not supporting itself, I think would mean that they would be able to integrate the National Health Service back into their private practices, yes.

Q617 Sandra Gidley: I am getting slightly twitchy about this direct payment idea. You used an analogy with opticians. There was a stage with opticians when the only NHS glasses you could get were something nobody in their right mind would wear until John Lennon made them trendy. Is there not a risk that under that sort of system what you would end up with is the NHS rather cannily deciding here is a solution, it would do the job, but most people would not want that in their mouth, they would want something else that had previously been provided and would it not drive down what the NHS provided?

Mr Watson: No, I do not think it would because children and exempt patients would still require treatment and therefore the amount of state subsidy would still have been to be adequate to provide treatment for those people who could not afford to co-pay. Really there would be a floor on the level of subsidy below which they could not go because then you would find a large number of people who were exempt would then not be able to find a dentist anywhere to do their work and that would not happen.

Q618 Jim Dowd: We had this discussion last week about whether you could buy Dolce and Gabbana crowns if we are going to have that kind of system. This alludes to a question Sandra asked earlier about the differences within practices, I certainly know of practices whe