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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

DENTAL SERVICES

Thursday 21 FEBRUARY 2008

MS HELEN DELAITRE, MS KAREN ELLEY and MR ANDREW HARRIS

MS SUSIE SANDERSON, MR IAIN HATHORN and MR DAVID SMITH

Evidence heard in Public Questions 263 - 443

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 21 February 2008

Members present

Rt Hon Kevin Barron, in the Chair

Charlotte Atkins

Mr Peter Bone

Sandra Gidley

Dr Doug Naysmith

Mr Lee Scott

Dr Howard Stoate

Dr Richard Taylor

____________

Witnesses: Ms Helen Delaitre, Acting Head of Primary Care, Hillingdon PCT, Ms Karen Elley, Consultant Dental Public Health, Sandwell PCT, and Mr Andrew Harris, Primary Care Manager, Devon PCT, gave evidence.

Q263 Chairman: I welcome you to the second evidence session in our inquiry into dental services. For the sake of the record, perhaps you would introduce yourselves and the positions you hold.

Ms Elley: My name is Karen Elley, Consultant Dental Public Health for Sandwell Primary Care Trust.

Ms Delaitre: I am Helen Delaitre, acting Head of Primary Care at Hillingdon PCT.

Mr Harris: I am Andrew Harris, Primary Care Manager at Devon Primary Care Trust and lead for dentistry commissioning.

Q264 Chairman: Some of the questions to which you will be responding will be specific to individuals. I start the session by asking a general question of all of you. To what extent has the provision of dental services changed in your PCTs since April 2006?

Ms Elley: At the moment the level of provision is similar to that in April 2006. We have relatively good access to dental services within Sandwell. The provision has been in a steady state from 2006. I can go on to future plans, but I do not know whether you want me to do that at this stage.

Ms Delaitre: Our position is very similar. We lost one dentist through the changeover and that was a very small contract, so we have maintained steady state and it is very similar to Ms Elley's experience.

Mr Harris: We have begun to see an improving position but Devon started from a very low base in terms of NHS dentistry provision anyway. Certainly, in the first 12 months of the contract we have seen an increasing number of patients beginning to access NHS dentistry.

Q265 Chairman: One aspect of dentistry is that it has always been a little difficult to measure it in terms of what has been happening in the National Health Service. How did your PCTs go about assessing needs for dental services before the introduction of the new contract, and how do they continue to monitor needs? Are there differences here?

Ms Elley: In 2005 the Sandwell PCTs, of which there were three at that time, adopted a local oral health strategy which included a full needs assessment of all areas of dentistry: general dental service, hospitals and salaried dental services. It looked at total needs across the borough and provided a forward action plan for what it needed to do locally to address inequalities in provision in oral health. We did that at a stage when we knew the new contract was coming in. The new contract then gave us the tools to start implementing some of the change that we did not have under the old contract.

Ms Delaitre: It is exactly the same f or us. Our public health team led on the oral health needs assessment which clearly showed areas for future recommissioning of services to improve provision.

Mr Harris: We have a different approach. First, as a PCT when the new contract came in there were six smaller primary care trusts, so there were different arrangements in existence in terms of identifying needs. We reorganised into a single PCT in October 2006. A lot of what we have done today has been driven basically by access needs and demand from patients, and we are now in the process of developing an oral health strategy with public healthy input.

Q266 Dr Taylor: To pursue exactly that point, so many of the reorganisations in the health service have seemed to be rather difficult for people to cope with. You have told us that you went from six PCTs to one. What about Sandwell?

Ms Elley: Sandwell had three primary care trusts with one health authority originally. We have now merged into one primary care trust. I have always worked for all primary care trusts across Sandwell anyway, but obviously the managers in each organisation have changed.

Q267 Dr Taylor: You imply in your paper that you have a greater consultant dental public health establishment than is often the case. Does that mean you are better able to cope with commissioning than some other PCTs?

Ms Elley: I think various aspects are required for dental commissioning. Obviously, a good dental public health input is important in setting the strategy and identifying the needs, but there also needs to be a team and we very much work as a team. We need to work with commissioning managers and with finance managers, and throughout the organisation we have kept together a team which has had different members. It has been very important to keep together that team and we all have different perspectives. My manager colleagues say that they are pleased they have me - even the chief executive says that sometimes - because they need a public health focus as well as a manager input to facilitate change.

Q268 Dr Taylor: Do you believe that you have weathered the storm of three to one probably better than some others?

Ms Elley: I would not like to compare us with others. I will not say it has been easy. My finance colleague, myself and the senior commissioning manager have been the same throughout. A lot of the managers who have interfaced with general dental practitioners have changed. That is very difficult for both managers and practitioners, but we have been helped by having a stable team.

Q269 Dr Taylor: We have certainly heard comments from others that in some PCTs it has been left to very junior members of the PCT staff to make this happen. What about Hillingdon?

Ms Delaitre: We have probably been fortunate; we were not reconfigured.

Q270 Dr Taylor: You were one of the London ones that got away with it?

Ms Delaitre: Correct. We maintained the staff. I have been working in primary care since 2002, so there has been continuity there.

Q271 Dr Taylor: What we need to know from some of your dentists is whether the whole process has been pretty smooth since you did not have to merge.

Ms Delaitre: It certainly helped the situation. We were not diverted into working on reconfiguring and restaffing arrangements. Similarly, across the north west London sector we established a working group so we could share problems and new issues as they came along. We met on a monthly basis in readiness for implementing the new contract. That worked very well.

Q272 Dr Taylor: Ms Elley and Ms Delaitre - I do not know about Mr Harris - can probably answer my next question. We are trying to get at the proportion of the budget actually spent on dentistry.

Ms Elley: The proportion of the budget we were given?

Q273 Dr Taylor: Yes.

Ms Elley: It was not spent on anything else, if that is your question.

Q274 Dr Taylor: What is the proportion of the PCT's budget as a whole?

Ms Elley: I can tell you that we have spent £18 million this year on general dental services. I do not have at my fingertips the figure for the total spend of the PCT.

Q275 Dr Taylor: Do you know the exact number of dentistry staff, not just the number of bodies but the number of whole time equivalents? The Department of Health cannot tell us the number of whole time equivalents.

Ms Elley: I can tell you the whole time equivalents based on a local survey in 2005. Unfortunately, at that stage not every practice responded because there was no requirement for them to do so. Therefore, the data are incomplete. We are in the process of developing a West Midlands workforce survey. That is a model we have used before to count not just dentists but also dental therapists and dental nurses. It is a local initiative and I would certainly welcome a requirement to have national surveys of that kind.

Q276 Dr Taylor: Therefore, some time soon you will know the result of that to compare with 2005?

Ms Elley: The survey has not yet been done but when it is, yes.

Q277 Dr Taylor: One of our obvious recommendations is that that sort of exercise should be carried out nationally.

Ms Elley: I would support that.

Ms Delaitre: It would be very useful. I can tell you how many bodies we have but not whether they work full or part time.

Q278 Dr Taylor: It is absolutely ridiculous that we do not know, is it not?

Ms Delaitre: Absolutely.

Q279 Dr Taylor: What proportion of your PCT budget goes on those services?

Ms Delaitre: Our primary care budget is £75 million of which just under £10 million is for primary care dental services.

Q280 Dr Taylor: Are there any comments from your end?

Mr Harris: I do not know the full budget, but I can confirm that as a PCT we spent our full budget for dental services.

Q281 Dr Stoate: Ms Delaitre, I was interested in your experience in Hillingdon. Your submission says that the history of good collaboration between the commissioner and general dental practitioners has meant that many of the problems of the new arrangements reported elsewhere have not arisen in Hillingdon. What problems are you talking about, and how have you managed to avoid them?

Ms Delaitre: I have a dentist in Buckinghamshire whom I visited during this time. She said that she was not talking to her PCT and had a problem in negotiating what the contract envelope would look like. In Hillingdon where I have been in primary care for a number of years there has been a dental advisory and liaison group for 10 years-plus, and we also go to all the local dental committee meetings. That means we have maintained good relationships. In advance of the implementation of the contract we established a steering group with a number of local GDPs, not necessarily from the LDC, where we shared what we thought would be common issues and problems. We did that in an open and transparent manner, which I believe the dentists appreciated. Where we had perhaps funding issues or problems to overcome in terms of dentists who had atypical earnings in the reference period we could share those with the dentists so they understood upfront where and why we were making our decisions.

Q282 Dr Stoate: But you are also implying that others were not doing what you have been doing. Why do you think that was?

Ms Delaitre: Possibly it was because they had not had time to build up longer relationships and establish trust in the PCT's abilities to commission services appropriately with an understanding of the profession.

Q283 Dr Stoate: Are you saying that if PCTs got their act together we could avoid most of the problems of the new contract?

Ms Delaitre: No. They probably did get their act together, but it was a learning curve for everybody. Due to the fact that PCTs were also going through reconfigurations possibly they could not devote the time and effort it needed.

Q284 Dr Stoate: What I am getting at is whether the contract itself if flawed or whether it is just the relationships between the PCT and the practitioners that are flawed. If you are saying that the contract did not cause problems because you got it right does it mean that if everyone got it right the contract would be fine?

Ms Delaitre: I am not necessarily saying that.

Q285 Dr Stoate: Which bits do you think you have managed to achieve that others would not be able to achieve?

Ms Delaitre: I think it is just a matter of reassurance about the introduction of the new contract and given time we will see how it goes, because at the time a lot of dentists were saying they might leave immediately or would give three months to terminate. It was a question of seeing how it proceeded through the first year. They still had an opportunity to opt out of providing NHS care but there was no need for them to rush and do it at that time and they should work with us and see how we could achieve the contract together.

Q286 Dr Stoate: You also describe the collaboration between Hillingdon and seven other PCTs to provide out-of-hours dental care. How was it done previously? What has changed?

Ms Delaitre: Referring back to the north west London sector which comprises eight PCTs, previously GDPs had responsibility to provide out-of-hours care. When the new contract was introduced not all PCTs, including Hillingdon, had allocations in their budgets for emergency dental services. Therefore, we had a zero budget given to us and somehow had to provide care. Other PCTs in our sector were more fortunate and basically we piggy-backed onto the service they provided under an agreement that lasts until March/April 2009 at which time it will be reviewed. We shall probably make a financial contribution to that service.

Q287 Dr Stoate: Do you have any evidence that the new arrangements are more financially cost effective than the previous ones, or have you not got that far yet?

Ms Delaitre: I do not. For us it is financially beneficial because we are not paying, but I am sure that time will tell when next year we come to review the service.

Q288 Sandra Gidley: I have a question for Andrew Harris. We had a very interesting submission from the Devon PPI Forum which claims that as a PCT it allows some NHS dentists to exclude certain patient groups from treatment, particularly benefit claimants and the elderly. Why do you do that?

Mr Harris: We had a number of practitioners who worked under the old GDS contract and provided NHS services for only limited groups of patients, that is, children or perhaps children of exempt patients. Historically, their funding was based upon that pattern of service.

Q289 Sandra Gidley: To clarify, you had a historic situation of not providing adequate care for the elderly and benefit claimants?

Mr Harris: Absolutely. It was a historic pattern of care that those dentists had chosen to provide under the GDS and which they were fully able to do under the old system. Therefore, they had a historic baseline of funding which reflected that level of service. Where that situation arose we had a choice. The choice was that if we required that practice to open up its provision to all groups of patients would that compromise the patients they were currently looking after? The position we have adopted since 1 April has been very clear: under any new service that we commission as a primary care trust and any contracts we renegotiation we shall expect all groups of patients to be offered a service.

Q290 Sandra Gidley: I do not completely understand why you did not seek an opportunity to improve the situation. The submission makes it quite clear that the effect on this group of citizens is a public disgrace and yet the PCTs seem content to allow that to continue.

Mr Harris: Devon comprised six different organisations at the time and therefore there were probably six slightly different approaches adopted, but the view taken, I believe in the majority of case, was that we had a level of funding to provide a service for this group of patients who were currently being provided for. Did we want that service to continue or for it to be widened to other groups of the population and find that those currently under care could not access the service? The decision was taken that that group of patients should continue to be looked after with the available funding.

Q291 Sandra Gidley: Have you commissioned anything since that has improved the situation?

Mr Harris: We have. We have looked across the whole county at where we have insufficient provision and where we need additional services we have been commissioning those services for all groups in the population.

Q292 Sandra Gidley: Can we put the new service into perspective? It could be a very small number of UDAs.

Mr Harris: I do not have the figure to hand but I can make it available. To put the restricted contracts into context, 7% of our dental budget was committed to restricted contracts or those limited to children or children of exempt patients. That was transferred across from the old system. We find that the activity in those restricted contracts is reducing, so there is funding coming out of those contracts and it is being reinvested in the provision of care for all groups of patients.

Q293 Charlotte Atkins: Was not the idea of the new contract that dentists would have to decide whether to go fully for an NHS situation or to go private and in a number of constituencies, including mine, there were many dentists who bribed parents to go private so that their children would be treated on the NHS? In my area basically dentists had to decide whether to stay with private contracts or go fully into the NHS. Why did you not do that in your area?

Mr Harris: I cannot explain. It was felt that given the time and the amount of work we had to do we wanted to get as many people into the contract as possible. We felt there was a real danger we would have a major lack of access for a significant group of our population if we did not contract with those practitioners.

Q294 Charlotte Atkins: I can understand perhaps doing that in the first few weeks, but we are now 18 or 20 months on. It seems to me that the continuation of the original contracts which allowed them to discriminate against certain groups they just did not want to treat is an absolute disgrace.

Mr Harris: Certainly, the PDS contracts can be renegotiated. Many of our contracts are coming up for renegotiation in the next 12 months. As a PCT we would certainly be reviewing the content of our contracts. The view is that in setting up new contracts we are putting in place services for all groups of the population.

Q295 Charlotte Atkins: Are you aware of other PCTs that have made similar decisions?

Mr Harris: Yes.

Q296 Charlotte Atkins: Where would they be?

Mr Harris: I cannot say specifically, but certainly talking to colleagues generally I understand that would have been the case in certain areas.

Q297 Dr Naysmith: I have a couple of questions for Ms Elley arising out of her submission, but before I come to that I wonder whether either of the other witness can help Mr Harris in the situation he is in which obviously does not apply in their areas.

Ms Elley: Within the West Midlands we made the decision that it was certainly preferable not to have contracts for specific groups of patients - child-only lists - and we did work well across that area on some of these issues. I am unsure whether any PCTs did break with that, but we certainly worked together to make sure there were not child-only lists, for instance.

Ms Delaitre: I think the original guidance suggested to PCTs that they should not offer GDPs non-comprehensive contracts, but that guidance was subsequently amended to allow that to happen at the discretion of PCTs. With the uncertainty of not knowing how many GDPs were continuing with an NHS contract it was felt that in some instances this might be allowed to continue until the end of the guaranteed income period when PCTs had the opportunity to recommission appropriately.

Q298 Mr Bone: You said that the guidance had changed. Which guidance, and by whom was it changed?

Ms Delaitre: The Department of Health's guidance.

Q299 Mr Bone: So, first they said that it should be comprehensive and they then changed it to what?

Ms Delaitre: To say that child-only services could be accepted in certain individual circumstances.

Q300 Dr Naysmith: Ms Elley, to return to the question I want to ask you, it is quite clear from the submission that you have been very positive about commissioning and the commissioning capability of Sandwell, yet your local dental committee has described the primary care trust's approach as "dictatorial" and accused you of ignoring local practitioners. How do you respond to that description?

Ms Elley: I have read that submission which says that we dictate and follow the policy of the Department of Health if there is a dispute. Yes, we do stick to national policy; if there is such a policy we follow it. It is not always particularly liked by some of the local dentists or local committee members, but if there is a national policy we have tended to stick with it. Having said that, we try to have a collaborative approach. We hope they feel that on an individual basis we collaborate. They do not necessarily like some of the outcomes. The new contract really introduces accountability into the general dental service in a way that was not there before; it allows the PCT to commission locally to meet need and that might not always suit what general dental practitioners locally would want to do. Previously, they could decide where they wanted to set up and what hours they wanted to work; if they wanted to increase their income they could work longer hours. That is now not allowed. I totally understand that from their point of view that is a problem, but from a patient and public health perspective the ability to direct service where there is a need is a good thing.

Q301 Dr Naysmith: Do you think the situation is improving in terms of relationships between you and the local dental committee?

Ms Elley: I do not think the relationship ever broke down. We have tried to be collaborative but that does not mean they always get the answer they want. To demonstrate that, originally we said we would not carry forward from the first and second years any activity over the 4% as was allowed under the contract, but, having listened to them, it was very difficult for them in the first year to model their activity and make sure they came in on the nose or within the 4% tolerance. Therefore, we listened and changed our behaviour. Where dentists had a robust plan to deliver that activity in the second year the PCT changed its policy position and said that, yes, that could be carried forward as long as there was a robust plan. Therefore, we have changed our behaviour. I hope they think that sometimes we try to listen.

Q302 Dr Naysmith: What kind of inappropriate provision were you attacking?

Ms Elley: It is more about new provision in areas of under-provision. Generally, we do not have a problem with access and, to go back to the contract of the 1990s when a lot of private dentistry developed, that has not happened to a great extent in Sandwell. We have areas of historic under-provision, however. Within the six towns in Sandwell some are better provided than others. The new contract will allow us to put more provision into areas that are under-provided. We have done that to a minor extent in, say, the Oldbury health centre where in a LIFT building we have established new dental services, including general dental services, salaried service and also a teaching facility for the dental schools to teach dental therapists. We have been able to make small changes like that. The 9% growth in the next financial year will allow us to commission new services through competitive tendering in areas of under-provision in Oldbury and Tipton. These are the areas identified in our oral health strategy.

Q303 Dr Naysmith: I am glad you mention Oldbury because I understand you have spent over £1 million on the new dental suite. You predicted that at least 4,000 patients would use that facility and so far you have got only 750. Does that mean good value for money?

Ms Elley: The £1 million was PCT money prior to the new contract, so that was the PCT investing money via a new LIFT premises to put it there, but not new dental contract money at all. We have combined a dental contract where a lady was on maternity leave in a test period and so we have invested to make up for what she would have earned in the test period that she would not otherwise have earned. That lady has chosen to work in the new health centre. The dental suite has been open only during this year and obviously it takes some time to get the patients in there. There has been recent media coverage. The dentist has been on local radio and in the local media saying that it is not full and there is NHS capacity here. There is an issue in that the public thinks there is a problem everywhere and we try to address that.

Q304 Dr Naysmith: Therefore, you expect to move towards 4,000?

Ms Elley: You cannot just switch on the number of patients in the day, albeit if there is really limited access you will do so, but we have wider access than a lot of places. We are trying to attract people who do not normally go to the dentist. It will take time but we are working on it.

Q305 Mr Bone: I grew up under both conservative and labour governments. We always had access to an NHS dentist. You never thought about it; the service was just there. My question is really about access. My first question is for every witness and when I come to my second question I will not ask for a response from the representative for the People's Republic of Sandwell and the dictatorship that exists there! Has patient access to NHS dentistry improved in your PCTs since April 2006? Can you also give an indication about the base level? Has it really fallen or gone up?

Ms Elley: It is about the same; it is around 72% or 73% in the past three years, so that is relatively high. It has not gone up yet. From the beginning of April we shall commission additional activity and it will go up. We believe that with the 9% extra funding it will go up even more.

Q306 Mr Bone: When the dictatorship says it will go up?

Ms Elley: I do not think Sandwell is a dictatorship.

Ms Delaitre: The position was similar to the rest of the London PCTs. We did not really have an access problem before, but, given the way access is now measured based on the number of patients seen in the previous 24 months, as of March 2006 there were 130,145 and at June 2007 it was 133,003 patients, so the number has gone up by 3,000 in the 24-month period.

Q307 Mr Bone: You are starting from a level of 70% or 50% NHS patients?

Ms Delaitre: 52%.

Q308 Mr Bone: If it is a 24-month period we have something of a problem because it overlaps?

Ms Delaitre: Absolutely.

Q309 Mr Bone: Do you have a feeling for what has happened since April 2006?

Ms Delaitre: It is difficult to say because it is too early to tell given that it is measured over 24 months. Maybe this time next year we will have a better feel for it. We plan for a 3% increase in access from April 2008 onwards given we have quite a large growth in patients.

Q310 Mr Bone: Ms Elley, you had a high rate to start with; it was 70%. In my area there was an enormous exit from NHS into private treatment, making access to an NHS dentist very difficult but also removing whole swathes of people because they took out private insurance, as I had to do. Did you not have any of that?

Ms Elley: We had one practice where the majority was private and for 1,000 patients in that practice the practitioner decided that he would not take up an NHS contract. For those 1,000 patients we needed to ensure there was provision elsewhere locally, so it was only one practice. Dentistry is a market and private dentistry will thrive in a market situation that allows it to thrive. Sandwell is a relatively deprived borough and consequently that is one of the reasons we have widespread NHS access because there is not a market for private dentistry.

Mr Harris: The background in Devon is probably very different because we have had very long-standing historical issues of access going back to the early 1990s when a number of dentists decided to privatise their practice. Using the old registration measure, the percentage of patients who accessed the service hovered around 45. In some areas of what is now Devon PCT it was as low as 27%. Therefore, we started from a very low base. In March 2006 about 49% of patients accessed a service. We are now approaching 51%, so we are seeing an increase as a result of the introduction of the new contract. Using the 24-month measure, we have seen over 9,000 additional patients treated in the first 12 months of the new contract. Again, that is probably only the tip of what we expect to see because we have commissioned a number of new services during 2007 and it will take a little time for those figures to come through and be reflected in the new two-year measure.

Q311 Mr Bone: You are commissioning new NHS dental services?

Mr Harris: Yes, particularly in areas where we have had long-standing difficulties. In a rural county such as Devon it takes only an individual practice in an isolated location to decide to move out of the NHS to create a problem. I have been involved in NHS dentistry for nearly 20 years. One of the great frustrations we had in the early 1990s was that if a dentist decided to take his practice out of the system the local NHS was left with a problem of access for its population but no means to deal with it because the funds sat in a central national pot of money and it could not do anything about it. The contract now gives us the opportunity to re-provide those services and that is what we are doing actively.

Q312 Mr Bone: Mr Harris, according to a survey in November 2007 there were still 7,700 patients waiting for NHS treatment.

Mr Harris: That is right. We have been operating a waiting list arrangement for patients simply because it is easier to allocate patients to a practice rather than that the first practice opens its doors and there is a flood of people and the practice cannot manage. We have 7,000 patients waiting.

Q313 Mr Bone: To stop you there, you say that these 7,700 patients are waiting?

Mr Harris: They have contacted the PCT and are awaiting NHS service.

Q314 Mr Bone: In my patch an NHS surgery was opened and people were queuing round the block and within 24 hours everything was full again. You go to the waiting list first?

Mr Harris: We encourage patients to come direct to the PCT and then work directly with the practice and allocate patients on a first come first served basis to the practice so the practice can manage the appointments booked for the patients. That has worked very successfully for us in Devon. I think the figure was 7,000 in October. In the past five and a half months we have allocated over 9,000 patients through this method, so we are seeing patients moving off our waiting list. People have been sitting there for 12 months in some cases and the wait is now coming down quite significantly - it is about six months - and that will continue as dental service capacity comes on line.

Q315 Mr Bone: What happens to these patients if they want urgent treatment?

Mr Harris: For those patients we have separate arrangements for urgent care. We have dental access centres in a number of locations across the county, so anyone who has an urgent problem can always be seen certainly within 24 hours if not the same day he or she contacts our services. They can go to dental access centres. We also have an out-of-hours service similar to the service my colleagues talked about, so if they have a requirement outside normal working hours or at weekends they can access a dentist.

Q316 Mr Bone: Therefore, you did not do what my PCT did, namely say that patients should go out of the county to find treatment?

Mr Harris: No.

Q317 Mr Bone: Ms Delaitre, your submission shows that patient access in Hillingdon has hardly increased, and you also start from a very low base. What has gone wrong?

Ms Delaitre: I do not think it has. The base is similar to the national average and to the London average.

Q318 Mr Bone: The national average is that only about 50% of people have access to NHS dentists?

Ms Delaitre: No - that are accessing them. It does not say "have access" but "accessing". We presume that the others opt to take private treatment. The capacity that we commission is slightly more than the demand, certainly from the 2006/07 contract team round.

Q319 Mr Bone: Nationally, it is half and half; half NHS and half private. Therefore, we have half-privatised dentistry within the National Health Service, but in Sandwell there is a very high NHS provision - 73% - so presumably for some areas access to NHS service must be as low as 25%?

Ms Delaitre: Possibly. I cannot comment. As my colleague Ms Elley said, it is an open market and patients can choose to access a dentist anywhere.

Q320 Mr Bone: They can choose in your area but not in mine; they have to go private because there is no NHS.

Ms Delaitre: Yes.

Q321 Charlotte Atkins: Ms Elley, your submission states that the number of patients seen in Sandwell increased by 10,000 from March 2006 to March 2007, but your local dental committee claims that the new system has introduced both rationing and waiting lists. What is your response to that?

Ms Elley: To my knowledge, we have no waiting list in Sandwell at the moment.

Q322 Charlotte Atkins: What about rationing?

Ms Elley: Most of the dentists were under-providing in the first year of the contract and they have elected and got plans to provide additional activity. There are one or two practices that are full and we can understand why they do not accept new patients, but there are no waiting lists in the others.

Q323 Charlotte Atkins: Did you claw back the money that was not used?

Ms Elley: Where there was no robust plan, yes. In most cases if they were not going to put up a plan they voluntarily gave back the money. I would not say "claw back" which sounds as though they did not want to return it.

Q324 Charlotte Atkins: But if there was a robust plan you did not claw back the money?

Ms Elley: No. Originally, the policy stance was that there would be claw back over 4% but we changed that to recognise they had difficulty in the first year to model their activity because it was as new for them as for us. Therefore, if they had a robust plan we allowed them to carry forward that activity to the next year and provide it this year. That was a one-off agreement, not something we would do recurrently. Because it was difficult for them we changed it and said that if they had a plan they could do it. Some people chose not to do it.

Q325 Charlotte Atkins: Obviously, you represent a relatively deprived area.

Ms Elley: Yes.

Q326 Charlotte Atkins: Sadly, there are people who choose not to access any dentist even if there is NHS capacity. Have you considered what some PCTs do, namely that when you commission a new dentist or practice you provide it with an incentive particularly to access the more deprived communities by suggesting, for example, that 70% of patients should come from deprived areas as opposed to 30% from the more affluent ones?

Ms Elley: I suppose that with Sandwell it is difficult to say "the more affluent". Relatively, there are some who are more affluent than others but certainly in some cases there is a wider variation between affluent and less affluent areas. We are certainly putting services into areas of historic under-provision knowing that local services are likely to attract the less affluent groups that are less mobile and so less able to travel into other areas. Therefore, it is done by the geographic nature of the area rather than incentivising particular groups.

Q327 Charlotte Atkins: Given there is a perverse incentive for dentists to focus on their more healthy clients, do you recognise the need to commission, persuade or encourage dentists to access those people who do not choose regularly to attend dental surgeries and, probably more important, for their children to attend?

Ms Elley: We do exactly that. Our oral health promotion unit is very much about making sure there is education and that systems are available so that those who are more deprived within the population and access these services less get to the dentist. It is done through promotion rather than a system to incentivise dentists. We have a scheme for nought to four year-old children where there is a very low uptake of care. We have a baby pack that goes out via health visitors when babies are very young. It is similar to the one in North Staffordshire which I set up when I was there. Mothers are encouraged to take their babies at an early age to get preventive care before there is disease. Similarly, for disadvantaged people with learning difficulties and ethnic minorities in particular there is a lot going on in particular communities via community development to make sure they access the service. It is not done necessarily from the service end but the public "people" end.

Q328 Charlotte Atkins: What happens when the children reach school age? What is done in school? We have not really covered what is done to encourage youngsters who are older to access dental provision?

Ms Elley: Similarly, oral health promotion and interventions are targeted at schools where there is a higher number of decayed, missing and filled teeth. They work with teachers and parents - certainly parents within special schools - and other agencies, for example healthy eating policies within schools, to provide health messages and increase the uptake of dental care. In schools it is very much a targeted approach.

Q329 Dr Taylor: I do not want you to pull your punches in any of your replies because we shall be coming to the dreaded subject of units of dental activity. You can be reassured that we have had only one response to the effect that UDAs are valid and that comes from the Department of Health. Everybody else is fairly critical, so please be as critical as you want. Are they a fair way of measuring the work of dentists?

Ms Elley: I will unpick what units of dental activity are. They are a way of paying according to the complexity of the particular course of treatment. I do not say that the UDA is the answer, but to pay dentists for more complicated courses of treatment is to me a good way of doing it. Whether the UDA is the right way to do it I do not know.

Q330 Dr Taylor: But they do not take account of the number of bits of complicated treatment that a dentist provides?

Ms Elley: The UDA is a measure. We can use the information we now get from the dental practice division not just about the UDA but the number of people who are treated. We also get exception reports about dentists. For example, if there are statistical outlyers on particular indicators they are flagged up by the dental practice division. That does not mean there is a problem with that particular dentist. It may mean that the dentist is in a particularly deprived area and therefore he does a lot more band 3 or band 2 than band 1 treatments, but it gives information which allows us to ask the question. We are then allowed to get the data split down by patient. For instance, if a dentist is doing a lot of band 3 treatments within a short period we are allowed to look at the patient data and can see what that is and we can get behind the data to get more than is revealed by the top line indicators. UDA is a start but it is not the only thing we look at. Certainly, for new activity we are not commissioning just on UDAs; we use UDAs because that is the contract currency, but we also believe that the number of people treated is important.

Q331 Dr Taylor: Did not the previous system give you more data than the current one?

Ms Elley: It certainly gave more data about lots of different items of treatment, and I very much welcome the change in April when we understand the forms will change and we shall get more detailed data.

Q332 Dr Taylor: That will improve things and take you some way back to the old system?

Ms Elley: Yes, but under the old system we did not get a lot of the data at PCT level. A lot of it was available on an individual basis to the dental practice division. Some of it came back to the PCT but under the new system we get a lot more information, the exception reports being an example of that. We know our local dentists and know where the areas of worse oral health are. To have that data and know about individual areas is beneficial.

Q333 Dr Taylor: That is an advantage of being a commissioner?

Ms Elley: Yes. Under the new system we get data; under the old system we did not. I think that the changes proposed will help us.

Ms Delaitre: It is good to have a quantitative measure but it is the qualitative measure that is missing. It is probably a good start. Certainly, it is something that is missing from our other primary care contracts when looking at value for money. Things like quality and health gain are matters that we should also be considering at the same time. The proposal to introduce a balanced score card might help to address those issue in terms of the overall care that a patient receives when he or she goes to the dentist.

Q334 Dr Taylor: I am sorry but to me "balanced score card" is some of the worst jargon.

Ms Delaitre: It is probably NHS jargon. A commissioner will use a number of indicators to look at the overall service provided by a contractor. There could be a variety of indicators.

Q335 Dr Taylor: Are there any views from Devon?

Mr Harris: Across Devon and Cornwall we had quite an extensive amount of PDS pilots going on prior to the new contract being introduced. One of the matters we learnt probably very early on was the lack of a measure, if you like, to determine what we would be getting for our funding of dental practices. UDA is a measure and certainly there are flaws within it. One of my particular concerns had been to do with recognising and identifying differing workloads that practitioners might or might not have depending on the group of patients they were looking after. In particular, you have alluded to a practitioner working in a significantly deprived area where the amount of work required to generate his three units of activity may be significantly greater than for a colleague down the road. At the moment we do not have the information behind that workload to be able to take account of that very easily when sitting down with a practitioner and looking at what he is providing. As my colleague Ms Elley says, with the enhanced data set that has been promised from 1 April we hope to have a much better indication of what practitioners are doing.

Q336 Dr Taylor: So, you are confident that it will be enhanced and you will have that sort of information?

Mr Harris: It will certainly provide us with a lot more information. We have gone from a system which gave us far too much information to a system that gives us next to nothing. As commissioners it is very difficult to understand exactly what practitioners are providing.

Q337 Dr Taylor: How do you think the value of the UDAs was calculated? Is there any basis for it? It seems to us to be a figure almost plucked out of the air. They cannot even multiply by three, can they?

Mr Harris: In our own patch we have had significant variants in values based on the historical patterns of treatment and income of practices. It ranges from as low as £14 at one end to as high as £30-plus at the other.

Q338 Dr Taylor: You are referring to different rates for a UDA?

Mr Harris: Yes.

Q339 Dr Taylor: Therefore, you are allowed flexibility?

Mr Harris: If we are talking about conversion from the old contract to the new one, each practitioner was guaranteed his historic funding for a level of work calculated on a UDA value.

Q340 Dr Taylor: For a particular period?

Mr Harris: It was based upon that period. Therefore, the UDA value would depend very much on what they did in that period and that is why you have a huge variation from as low as £14 to as high as over £30. In my opinion that would be the same in many areas.

Q341 Dr Taylor: You have lost me. I thought they were assessed only on the number of UDAs they did, not the actual value.

Mr Harris: There is inherent value because in the baseline period a practitioner would have earnings from the NHS and for that he would have done a certain amount of work. That work was converted into units of dental activity for that level of funding and that derived a unit of dental activity value for that practitioner.

Q342 Dr Taylor: The fact we are told that for band 1 the unit of dental activity is £15.90 is absolute rubbish?

Mr Harris: No; that is what the patient pays.

Dr Taylor: Maybe I am getting there.

Q343 Mr Bone: Therefore, dentists within the same PCT doing the same unit of dental work are paid vastly different sums of money?

Mr Harris: Yes, there will be variable rates.

Mr Bone: That is extraordinary.

Q344 Mr Scott: Evidence we have received suggests that the contract has led to far fewer complex (band 3) treatments. Should this be welcomed? Should we be concerned about the quality of care being given to patients?

Ms Delaitre: When we started to monitor what had happened since the introduction of the new contract we found a notable reduction in band 3 treatments. We have had claims from our patients that they have difficulty accessing endodontic work which is root canal treatment. I think that is an anomaly of the system and something that should perhaps be reviewed given that a dentist will save time by extracting a tooth rather than treating it. I think that is a concern. They are able to do that within their contracts, although given that in the reference period they were doing a certain amount of complex work without the data and detailed knowledge until April 2008 it is difficult to monitor it.

Mr Harris: There has been a reduction. In PDS pilots the experience was that there was a reduction in the amount of complex work being undertaken, and we have also seen that in the new contract. It is very difficult to draw a conclusion as to whether there were inherent incentives in the old system which generated higher than necessary or more complex work than under the old system or whether the incentives have tipped completely now. I agree with Ms Delaitre to a certain extent in that a dentist may feel that the reward is not there to do as many band 3 treatments as he did in the past.

Ms Elley: I very much agree with what has been said, but band 3 treatment does not always go down in the new contract. We have had contracts where band 3 treatments have gone up and we have had to follow it up to find aberrant patterns of behaviour where individuals are prescribed an upper denture in one course of treatment and a lower denture in another course of treatment. Obviously, that is not what is normally done. Again, the data have indicated that we should look at what the issues are, which is what we do.

Q345 Mr Scott: Are you aware of any reduction in band 3 being undertaken in the non-NHS sector?

Mr Harris: We would not be aware of that.

Q346 Mr Scott: What action do you take if a practice fails to meet its UDA targets? Do you automatically claw back the money previously given to dentists who fail to meet their UDA targets?

Ms Elley: I think I have covered that. If they had a plan we allowed them to carry forward in the first year, recognising that that was a difficult time for them.

Mr Harris: From our perspective, we have certainly met all our practitioners, particularly when there were early signs that they would be potentially failing in their contract, to see if there were any specific reasons why that had occurred. We followed an approach similar to that described by Ms Elley. We have not taken the hard and fast line that if they deliver less than the 4% shortfall we would not carry it over. If they have a good plan for making up that activity in the second year we have agreed that they should take it forward and make it up.

Q347 Mr Scott: Why does the work of vocational dental practitioners not count towards the total UDAs set for a particular practice, and do you think that is fair?

Ms Elley: There was a fact sheet produced in December 2005 on the way money would be allocated and information about the way vocational training would work under the new system. Vocational trainees are recruited into the practices by the deanery; they are not designated, if you like, by the primary care trust. There was a need for advice about how the money would follow the vocational trainee, if one wants to put it that way. The 2005/06 fact sheet said that dentists with vocational trainees would get additional money for their trainees' salaries, their training grants and the expenses of having them in that practice. It also said there would be a locally agreed number of UDAs additional to their contract for that money. It did not specify a number of UDAs; it said it was down to PCT negotiation. All our local dentists wanted the UDAs to be included within their existing contract value but obviously they would be given additional money for that value. Training is very dear to my heart. Training is supposed to be training and in the new era it is not supposed to be, as we have had with junior hospital doctors, just the provision of a new pair of hands; they are people in training. I am very much of the view that we should have a notional, not actual, number of UDAs so if they under-perform because they are slow or they are trainees it does not matter. If they over-perform they have done more but it is not then taken off their boss's contract and so there is no incentive for the dentist to drive the junior hard to make up his contract value. The 1,875 UDAs notional figure came out some time after the introduction of the new contract. It was originally left to PCTs but they were unhappy because they did not want to set different levels. Training is training and is national and the 1,875 UDAs were included in revised fact sheet 6 called fact sheet 6A, but it was some time after the new contract. Our local dentists did not like the fact that they could not balance them against their contract value.

Q348 Mr Scott: The UDA value contains an element for activity and an element for expenses and premises. Do you think there is a legal basis for claiming back the full UDA value?

Ms Delaitre: I am sorry but I do not understand the question. You are referring to claiming back the full UDA value?

Q349 Mr Scott: Yes. Do you think the full UDA value should be clawed back?

Ms Delaitre: If they do not meet their contract 100%?

Q350 Mr Scott: Yes.

Ms Delaitre: Yes, and we do claw all of it back below 96%.

Mr Harris: I agree. That is the approach we have taken.

Ms Elley: There is an issue about full cost and marginal cost and it works not only with under-performance but also over-performance and the commissioning of additional activity. Certainly, in commissioning extra activity if the premises are there you would not expect to pay for extra building unless there was a need for it, so our finance people do look at marginal rates.

Q351 Mr Bone: If you do not do your UDAs and claw back the full amount you are clawing back the fixed costs which the dentist has had to incur. Is that not grossly unfair?

Ms Elley: I think there should be one rule for over and one for under. I am a dentist and I tend to leave the marginal cost to our finance experts with whom we work.

Mr Bone: But you all claim back the full UDA.

Q352 Chairman: What is the relationship between UDAs and prevention?

Mr Harris: I think there is very little relationship between UDAs and prevention. I can talk only anecdotally but talking to practitioners, particularly those in the PDS pilots, many felt that the pilot arrangement encouraged them to work with patients to promote oral health. They feel that under the new system there is less time to devote to promotion and intervention.

Ms Delaitre: I tend to agree with that; there is really no incentive currently.

Ms Elley: I would want to incentivise the new contracts to do the preventive aspects. Delivering oral health is an available package and I would want new contracts to include that and funding for it within a practice. You can use UDAs to do prevention. We have had a pilot project for mouth guards. Children fracture their teeth when playing sports because they do not wear mouth guards. Mouth guards were never available on the NHS. In Sandwell we have had a limited pilot project where individual dentists have been able to provide up to 25 mouth guards to children at the greatest risk of fracturing their teeth given the nature of their teeth - whether or not they stick out - and also the sports they play. That was not available on the NHS but we have done it and remunerated it. Twelve UDAs are band 3 treatment for a limited number. I would not want to see that become widespread; otherwise, everybody in England would be walking round with mouth guards, but as a preventive measure for children in greatest need I believe that is a way to use the system.

Q353 Chairman: Where there is a population with a clear need because of its dental ill health is there any way you can use UDAs to do that, or would you need a different approach to bring onto the agenda the prevention of dental ill health?

Ms Elley: I would like to develop a quality and outcomes framework with remuneration like the general medical practice contracts. It is something that perhaps would be easier to do with the new practices we open or the additional activity we commission. I would want the new activity to include referrals to the smoking cessation services and remunerate for that kind of thing. At the moment we offer that to dentists and only one practice has taken it up. We have a local scheme but dentists have not taken it up. I would like to use that. There are ways to give money, whether for UDAs or another outcome, but as a developmental aspect it would be easier with new practices rather than existing ones.

Mr Harris: With our experience of PDS pilots we were able to support some practices to develop oral health educators to work with the local community linked into Sure Start schemes. They have worked with children and parent groups to include promotion. We have carried that forward under the contract. We have not put units of activity against it; we have made it a distinct element of the contract to be delivered in addition to their units of activity. There is a need for measures and you need different measures for that, but certainly the contract allows you to do those things.

Q354 Dr Stoate: As a practising GP I can confirm that QAF is quite a good way. It is not just about driving the amount of work; you can begin to look at the type of work people do, so QAF is a good tool and can be negotiated on an annual basis and tailored to meet specific needs, so I agree with Ms Elley that it offers a better solution and is fairer and more transparent. I want to talk about money. As I understand it, currently about 25% of income comes from patient charges and the rest from the department. Is that broadly correct? The department has acknowledged that there will be a shortfall this year of £159 million on patient charges and that must be a fairly serious worry for you. I know that Sandwell has reported a £92,000 shortfall on patient income this year. How has that affected you?

Ms Elley: When I made the submission to the Committee our finance people forecast that we would be about £90,000 under-collected on patient charges based on an £18 million budget. I went to check yesterday because I was sure the question would be asked. At the moment we project being £100,000 over, so it changes from month to month as patient charges come in. There is a seasonal cycle for people going to the dentist. Ours is not 25%. We have an expected patient charge of £3.5 million on £18 million.

Q355 Dr Stoate: It is an average of 25% and it does not apply to all of you.

Ms Elley: It depends on what proportion of the population is exempt and more of our people are exempt.

Q356 Dr Stoate: How is it affecting the other two PCTs? Has it made a big difference to you? Is there a big patient shortfall?

Ms Delaitre: We do have a large patient shortfall. Our expected income from patient charge revenue is 28% so it is higher than the average, and certainly we had a shortfall in funding last year. That was raised with our board right at the beginning of the year because we expected that to be the case having inherited the historic funding rather than funding according to need. We were fortunate in that the PCT expected that to happen and cushioned the effect in future years. If the situation continues that money will have to be taken from the dental allocation.

Q357 Dr Stoate: Has Devon had a problem?

Mr Harris: We have witnessed a significant shortfall in patient charges of over £1 million in the first year. We had a £33 million budget including patient charges and the shortfall we experienced was extremely high. I have looked at my colleagues across the South West and the percentage of shortfall has varied significantly, but the average is about 5%.

Q358 Dr Stoate: It is quite significant. The simple question is: what effect does that have on your ability to provide dental services?

Mr Harris: It means we have less funding to commit to dentistry.

Q359 Dr Stoate: Are you moving money from elsewhere in your budget, or do you just have to cut back on what you do in dentistry?

Ms Delaitre: Given that the dental budget is now ring fenced it will come from the ring fenced dental budget.

Q360 Dr Stoate: You are saying that that shortfall will impact on dental services?

Ms Delaitre: It will from 2007/08 onwards but last year it did not in that we were able to cushion the shortfall.

Q361 Dr Stoate: That is quite worrying. When the ring-fenced money effectively runs out after April 2009 what will each of you do? Will you guarantee the same level of dental services or be a bit less upfront about it?

Ms Elley: Currently, our PCT has no plans to strip the dental budget. We get additional money in 2008/09 and I shall work with the team to commit that money recurrently. Obviously, it is a possibility and one can never say never. Last time the Committee was asking whether or not people thought it a good idea to continue to ring-fence the money. As a dentist within the PCT I would have to say yes.

Q362 Dr Stoate: You would like it to be ring-fenced but it will not be?

Ms Elley: As a dentist I would. Here I speak personally rather than for the PCT. There is no intention in April 2009 to start stripping out the money.

Q363 Dr Stoate: Does that apply also to the other witnesses?

Ms Delaitre: Absolutely. I am in the process of putting trajectories into the operating plan which is part of the annual cycle of planning. We are planning year on year for the next three years' growth in activity, which is what we have been asked to do.

Q364 Dr Stoate: Therefore, you are looking to improve things in the next three years?

Ms Delaitre: Yes.

Q365 Dr Stoate: What about Devon?

Mr Harris: Absolutely. We are starting from a less well off position and it is a very high profile matter of concern for both the public and our local Members of Parliament. We would certainly look to continue our commitment to dentistry.

Chairman: I thank all three witnesses very much for coming along and helping us in this session.

Witnesses: Ms Susie Sanderson, Chair, Executive Board, British Dental Association, Mr Iain Hathorn, Chairman, British Orthodontic Society, and Mr David Smith, Dental Laboratories Association, gave evidence.

Q366 Chairman: Welcome to the second evidence session of our inquiry into dental services. For the sake of the record, I ask you to introduce yourselves and the positions you hold.

Mr Smith: My name is David Smith and I am on the council of the Dental Laboratories Association. I am a dental technician and I have a laboratory in Exeter. I should like to focus today on what has happened to band 3 treatments in particular because that matter has the greatest effect on our members.

Ms Sanderson: I am Susie Sanderson, chair of the British Dental Association and also a practising GDP in Sheffield. We have two practices split almost equally between NHS and private provision, so I have a significant NHS contract. Thank you very much for inviting us to give evidence today. We welcome this opportunity.

Mr Hathorn: I am Iain Hathorn, chairman of the British Orthodontic Society. I am a former consultant orthodontist from Bristol working in a cleft lip and palate service in that area.

Q367 Chairman: Ms Sanderson, why did the BDA break off negotiations over the new agreements with the department? Did the BDA let down dentists by doing that?

Ms Sanderson: Taking the last point first, absolutely not - quite the contrary. At all times we have a representative structure which is very robust. We consult our members not only through that representative structure but also through surveys and consultations with members. The negotiations towards the new contract took quite a long time. Following the previous Health Committee's hearing, we started in 2001 with the Options for Change project. The BDA worked with the Department of Health and signed up very enthusiastically to the aims of Options for Change which looked at the local needs for dental care, explored different ways of remunerating dentists to deliver the provision of care and also make sure that the quality of care was robust and moved forward in that sort of direction. We thought they were very fine aims and worked with the Department of Health. The negotiations moved through the period when the Health and Social Care Act was launched upon us, rather in indecent haste as we thought at the time. That rather changed the complexity and concept of the discussions we were holding with the department at that time. We were very constructive and we thought we made sensible suggestions for a system that would work towards the aims of Options for Change. The field sites were beginning to work with the personal dental services. We suddenly found ourselves losing agreements that we understood had already been made about the new contract. We were told that it would be our job to sell the new contract to the profession, but at the same time our suggestions about a sensible way forward were not listened to either. It was more a discussion group than a negotiating team because negotiations had really stopped by that stage. We were making suggestions and listening on the other side was not very good, unfortunately. That team sought a mandate from its elected body which agreed it was time to make a public statement and said that things were not going in a way that was best first for patients but also dentists in the way they would deliver care to patients and at that point we walked away. We continued to have discussions with the Department of Health about several issues, for example decontamination and vocational training, so throughout that time we have maintained contact but the department removed any sort of conversation about the new contract and it was finally imposed. Recently, we have started to have perhaps better and more constructive relationships with the Department of Health and we look forward to making progress in that respect. We believe that local commissioning gives us huge opportunities as long as they are sensible and the profession and those who are to provide those services have some sort of input into it and changes are not dictated. At the same time, we have continued to support our members through the transition into the new contract. We know that one third of our members have contacted and on a one-to-one basis had advice from the British Dental Association. We have a regular journal and updates on contract issues. We hold tendering seminars which are always over-subscribed, so we are helping dentists to move towards local commissioning. We have worked with the primary care contracting team and provided information for local dental committees and advice sheets which, strangely enough, have also been welcomed by primary care trusts. Therefore, we have continued to engage. We found the transition into the new contract very disappointing.

Q368 Chairman: You will have seen the evidence we took quite recently from Challenge. Whilst it is a political pressure group, it said it was unhappy with the position of the BDA at that particular time. It argued that it was more representative of the profession in many ways. Do you believe that is the case?

Ms Sanderson: The leading light of Challenge is my predecessor who was chair at the time of the contract imposition, so he knows a lot about the process at that time. I think Challenge emerged out of frustration. The profession felt impotent and it was unable to withstand what has been described as the bullying tactics of the Department of Health in imposing the new contract. I think Challenge has proved to be a useful lobbying group alongside the very vigorous work of the BDA in raising awareness.

Q369 Charlotte Atkins: Ms Sanderson, do you believe that PCTs are up to the job of commissioning local dental services?

Ms Sanderson: It is very patchy. Taking the example of those having an interest in commissioning dental services over the years, today we have already heard of PCTs with joint working groups involving providers and sometimes patients as well. How welcome is that? To involve patients in choice about how dentistry can be commissioned is extremely valuable. Where it has been in place for a number of years the PCTs have had a head start. Where that is not so and the reconfigurations has disturbed the situation as we move into the new contract it has been very difficult. You have probably heard from three of the better ones today. There are other good ones and also those who are only just cottoning on to the issues of dentistry. We have not even started on proper local commissioning yet and we are still dealing with the transition through the historical activity into changing what should be a service properly aimed at local needs.

Q370 Charlotte Atkins: Do you think dentistry is a sufficient priority for PCTs? It is only a relatively small part of their overall budget. A lot of people decide not to access dentists and some PCTs take the view that if that is their choice it is not a big issue for them.

Ms Sanderson: I have evidence from my own PCT where it is a priority and it works very hard at making it such. It is a high priority within the operating framework as well, so we are encouraged by that. I think you are right. It is a very small part of the budget. Its priority has been raised by all sorts of means to push dentistry to the top of the public awareness agenda, and we have helped with that in the hope that it would become a priority. I think it is patchy.

Q371 Charlotte Atkins: From next year when PCTs take on the full commissioning role do you think they will be able to use that in a genuinely helpful way to assess local needs and then commission services which meet them rather than simply fill in gaps? I am referring to a deprived community, for instance, and paying more for UDAs to attract dentists to be interested in catering for a needy population.

Ms Sanderson: You explored earlier the unit of dental activity and already today you have unpicked one of the difficulties. It is inextricably linked to patient charge revenue and is a constantly changing unit. It is not a unit; it is different for everybody. There are four dentists in my practice. We have two practices and in each we have a different UDA value. That is crazy. We work alongside each other on the same cohort of community and yet the value of our units of dental activity varies by £2 in one case. If we continue to use only the unit of dental activity as the sole measure we have no chance whatever to make sure that dental provision is improved particularly in the disadvantaged cohorts of the population. I do not believe it is disrespectful to say that those parts of the community that do not normally access dental care tend to seek episodic care; quite often it is crisis management. Whereas in my view it is of paramount importance in my practice that we deliver prevention and ongoing care, it is quite difficult to manage episodic care in a business. It is almost impossible to plan to meet a target when patients do not turn up, or come on the wrong day, or arrive on a particular day and demand care because that is when the crisis has arisen. There must be some sort of imaginative contracting if we are to make real inroads into the dental inequalities in this country.

Q372 Charlotte Atkins: Would you rather see some sort of long-term registration of patients than the situation now where there is none under the contract?

Ms Sanderson: If you are aligning registration to continuing care, I would support anything which encourages patients to have a relationship with their dentist and the other way round. When you are sitting in your chair in the practice it is valuable to talk to patients. If I know the families I am treating I am aware which children I need to encourage to make sure that prevention is right; I know which parents have got it right and do not need to come quite so often and I can trust them to get on with it. That sort of interpersonal care and attention is crucial to make sure that the oral health of the population continues to improve. If registration helps that maybe that is a means of doing it, but the concept of continuing care is the important one.

Q373 Dr Naysmith: I have a series of questions about the supposed effects of the new contract on the dental profession. We have already talked a good deal about UDAs which you described in your evidence as a flawed measure of output, and clearly there has been a lot of evidence to that effect this morning. But you cannot be against the principle of measuring the activity of dentists, surely.

Ms Sanderson: No.

Q374 Dr Naysmith: In that case, how would you do it?

Ms Sanderson: There are various ways to measure and it is not just activity. The buzzword associated with this contract is "access". One of the questions which you see in our evidence is: what is access? Is it the number of times somebody goes to the dentist? Is it the amount of care the patient needs to make sure his or her oral health is corrected? What is it? There is no definition of access and measuring that on an ongoing basis is flawed.

Q375 Dr Naysmith: I am not really asking about access but how you pay dentists for what they do. What do you believe would be a fair measure to do that?

Ms Sanderson: Access is only one of those measures. There must be a level of monitoring. One of the beauties of the old contract, although I do not advocate that we go back to it, was that monitoring was very robust and we knew exactly what everybody was doing. You got paid for items. It must be much more imaginative so you pay for quality, prevention activity and healthcare outcomes. You pay for the number of patients that are seen but what is delivered to them and the outcomes are much more valuable.

Q376 Dr Naysmith: You accept that the old contract had a bias towards treatment rather than prevention?

Ms Sanderson: It measured treatment.

Q377 Dr Naysmith: There was very little in it which helped with prevention?

Ms Sanderson: There was nothing in it which supported prevention. That was one of the aims of Options for Change. Unfortunately, it has not been realised.

Q378 Dr Naysmith: Before we leave the UDAs, what effect do you think claw back has had on dentists who fail to meet the targets?

Ms Sanderson: There are two aspects to claw back: the threat of claw back and the anxiety about and reality of claw back. We have very painful and distressing examples of dentists with whom we have worked at the BDA being faced with significant claw back to the point where they have closed their practices and said they cannot manage any more.

Q379 Dr Naysmith: You have evidence of practices that have closed because of claw back?

Ms Sanderson: Yes, we have. In my own practice two of the partners have said they have had enough. One is aged 55 and is a very conscientious, experienced and effective NHS practitioner. That practitioner has just had enough and cannot face the anxiety of meeting targets on a day-to-day basis and the worry that there will be claw back at the end of the year.

Q380 Dr Naysmith: What has he or she done?

Ms Sanderson: She is taking early retirement. That is a huge loss to our practice because there is a big cohort of patients who trust and seek her care. She is always available for any new patients who turn up. We will miss that enormously. It is strange that 47% of dentists did not achieve 96% of their contracts in the first year. One could say that that is just the system bedding in, but with the threat of claw back and knowledge that that is a possibility it seems crazy that 47% of people who own their businesses and who are under threat of loss of money at the end of the year would not manage to do it more easily. It is just a demonstration that the system cannot at the moment seek to punish by taking money back from a dentist who has tried his or her best during the year.

Q381 Dr Naysmith: The Chief Dental Officer has told us that the new contract was showing signs of improving patient access in a number of areas. Do you agree with him?

Ms Sanderson: The figures are contrary to that. The figures are difficult to understand because there are two different sets of data. We started off with the 15-month data previous to the contract and we now have 20-month sets of data which start life before the beginning of the contract. The change management of this process is strange.

Q382 Dr Naysmith: I know that you were in the room earlier when we heard from Devon that things were getting better. Given that there were six PCTs being melded into one, it is perhaps not surprising that it did not work from scratch right away.

Ms Sanderson: That is right. Overall, we know from the department's own figures that there has been a drop of some quarter of a million in access, whatever "access" means.

Q383 Dr Naysmith: Do you have any evidence that experienced dentists are being lost to the National Health Service - you have just told us about one - to be replaced particularly by inexperienced dentists and dentists from overseas? John Renshaw said he was convinced that it was happening. Do you have evidence of that?

Ms Sanderson: I have some figures which happen to be on top of the pile of papers in front of me. We know that there was a peak in 2005 of 1,240 new registrations here from EU countries, and in 2007 the numbers are about the same. There is a little peak and trough. Therefore, there are more than 1,000 dentists coming in from EU countries and others from elsewhere. We are seen as an attractive place to come and work.

Q384 Dr Naysmith: Some of these could be experienced dentists, could they not?

Ms Sanderson: I absolutely accept that, but they are not experienced in UK dentistry. One of the fascinating things about UK dentistry is that it is extremely effective. In particular, under the old contract it could be proved that a huge amount of work was carried out effectively. It was also very cost-effective. The culture of UK dentistry is quite hard to grasp when you first arrive. I think that some PCTs and deaneries have made attempts at induction programmes, but it has been a bit of a culture shock.

Q385 Chairman: I accept what you say about the culture of the National Health Service not just in dentistry but in many other areas from the point of view of those who come from abroad. Some of these people have worked in practices where it has been very difficult to get dentists. In my own constituency which is very close to yours dentists have come in and worked within practices and been salaried by the PCT for people to access NHS dentists. It is not a situation where necessarily people have come and gained employment on their own, as it were, although there are some examples of that - and, as I recall, a few years ago a not very good example.

Ms Sanderson: Indeed. I think that as the bulge of new graduates comes out of our dental schools it will be important that they can come into the NHS. They have indicated in various surveys that that is what they want to do. I think it is very important that they are able to do that.

Q386 Dr Taylor: I should like to clarify something. I am still pretty confused about UDAs. I realise that patient charges account for only about 25% of remuneration, but you did refer to different values of UDA. Band 1 is £15.90; band 2 is £43.60; and band 3 is £194 up to a maximum of £384. Is that what you mean by the different values?

Ms Sanderson: No.

Chairman: They are the patient charges.

Dr Taylor: I know they are the patient charges.

Q387 Sandra Gidley: You are talking about what you are paid?

Ms Sanderson: Yes. The patient charges are linked to the number of UDAs delivered to the patient. For example, a check up is measured as one UDA and the patient pays at band 1 which is £15.90. If you move to the next section - I must be careful not to get confused - which includes any sort of fillings, root treatments and extractions, that is band 2 and that is £43.60. That rewards the dentist with three UDAs. It is not related to the patient charge in any sort of way; it will be related to the dentist's UDA value. Therefore, if you have a UDA value of, say, £20 the dentist will get £60 for carrying out that band 2 course of treatment and so it moves into the next one.

Q388 Dr Taylor: Is it up to each PCT to set the value of UDAs in that way?

Ms Sanderson: Historically, as we set off into the new contract the UDA values were determined by the previous activity of the dentist and previous contract value.

Q389 Dr Naysmith: It has been suggested in your evidence that vocational dental practitioners are unable to find employment. What is the reason for that?

Ms Sanderson: The real crisis is immediately post their vocational training year. During that year they are encouraged to build that sort of continuing care relationship with patients which is so important to the delivery of dental health and all the things that go alongside that, that is, the courage of the patients, faith in the dentist and their comfortableness in going to the dentist. Unfortunately, it is very difficult for those dentists to stay in their training practice because the PCTs are not able or willing to fund that additional place. Our practice is a training practice and the Chief Dental Officer is quite certain that training practices should take on new trainees. However, if there is capacity in that practice in terms of space it seems sensible to keep the vocational dental practitioner on there if there is patient need and the relationships have been built, and that is not happening.

Q390 Dr Naysmith: Why is it not happening? Could PCTs pay for this?

Ms Sanderson: If they chose to.

Q391 Dr Naysmith: Could dental practitioners make provision for it?

Ms Sanderson: If there is space in their practices to do that.

Q392 Dr Naysmith: Therefore, it really needs local agreement as we heard earlier in the session?

Ms Sanderson: That is right. The needs and oral health assessments are rather vestigial in sophistication as yet. You heard three different versions of it earlier.

Q393 Dr Naysmith: If local dental committees wanted to work closely with their PCTs they could improve the situation dramatically?

Ms Sanderson: Yes, absolutely.

Q394 Mr Scott: Mr Hathorn, you state in your submission that "the new arrangements perpetuate the inequality of orthodontic provision around England and Wales." Why do you say that?

Mr Hathorn: As at 1 April 2006 the new contract was obviously a capping process that froze the arrangements at that time. I think it was said earlier by the PCTs that the funding they received was based on activity in that area. There is no easy way to improve that. I refer to areas such as the North East about which we know and other areas of low dental provision. There is a compounding effect which says that OAs which general dental practitioners might be getting for their orthodontic contract have been converted into UDAs because there is a high need which makes it worse. In that particular area - often of high need - with the new 18-week pathway coming in there is a whole head of steam, in a sense, built up in hospital waiting lists which will effectively flood out into the market. We are aware there are certain reasonably well provided areas in the country. We have a report from Sheffield which gives us quite a good feel for where these areas are. The South East, where a lot of training takes place, is generally well provided as is Bristol, but in the North East and Midlands there are obvious areas of need and they are stuck. The existing funding is there but at a low level.

Q395 Mr Scott: Do you agree that there is one orthodontist for every 73,000 people in the country?

Mr Hathorn: Those figures derive from a European study covering 17 countries. We end up 15^th in the list. We are different from some other European countries in that we use our general dental practitioners to provide some orthodontics, particularly in geographically awkward areas where there is not enough population in certain spots to sustain a specialist practice. I think particularly of Cornwall. It just does not lend itself to big specialist practices. Therefore, we have this mix, but, yes, as a whole the specialist provision of orthodontists in the UK is low.

Q396 Mr Scott: To what extent has the introduction of the index of orthodontic treatment need led to rationing of NHS orthodontic treatment? Is the NHS denying children with need orthodontic treatment?

Mr Hathorn: As you have seen in our report, we welcome the introduction of the index of treatment need in that the very low end of the spectrum, say, the very mild malocclusions, simply do not get treatment. In truth that was always the case. Even in the days of DPBDV the very mild malocclusions were simply not supported, but the bar has been raised and it has gone up to 3.6 on the index of treatment need and that was done in large part because of numbers. In effect, it is a sort of rationing process but it also tended to move out groups of malocclusion which were on the lower end of the scale. If we have a limited resource we should be treating the more complex. One of the problems with any banded process is that there are people left in a grey area where there may be dispute as to whether they fall comfortably 3.6 and above and 3.6 below. I think that it has distinct pluses and it has been used within the hospital service for about 20 years because it was felt that it must focus on those patients with high need. I think it is just shifting the same emphasis into primary care.

Q397 Sandra Gidley: Mr Hathorn, you describe the way that PCTs introduced contracts with orthodontists as having had "disastrous consequences" particularly for newly-established practices.

Mr Hathorn: That refers to practices in transition or new ones working up. A very good example is the document from Ash Patel from the Birmingham area. In the period of the review process he had 500 patients under treatment but because he was not finishing cases at that time and the contract was based on the number of completions he was in essence given a contract for 80 cases. That is just unreal. If you read that particular submission, he was advised and encouraged by the consultant for dental public health that there was a need and he therefore set up in that period to try to get going. The background to that submission is that there is a three-year waiting list in the hospital, so there is a very significant need and yet the PCT for historic reasons gave 80 cases.

Q398 Sandra Gidley: Have any of those problems been addressed?

Mr Hathorn: In some parts of the country, yes. I think that in earlier discussions there was a range of ways to deal with problems with different PCTs. Some PCTs have been very thoughtful and sensitive to the need to change; some, as in Ash's case, have doggedly refused to make any change. When there is a clear need there are waiting lists locally and numbers of patients on hospital waiting lists. With the 18-week pathway kicking in this will bring out a large number of patients back into the general mix. I suspect that as MPs you will be getting considerable numbers of complaints from parents and patients.

Q399 Sandra Gidley: Interestingly, I have two PCT areas. From one I get a good number of complaints and from the other absolutely none. Do you have any inkling as to why some are so much better than others? Is it because they have motivated staff who have perhaps taken an interest in commissioning for some time? Is any of it financial pressures, or is it a mixture of the two? Is there a common theme emerging?

Mr Hathorn: Having listened to what was said last week - it has been echoed today - there is some demonstration that different PCTs take different approaches. There is no doubt at all that those which put dentistry in their thinking in terms of planning have done well. My belief is that something like Sandwell stands out as a perfect example of a good consultant dental public health working with the providers. The particular passion of the British Orthodontic Society is to encourage its members and providers to get together in networks - general dental practitioners, specialist orthodontists and consultant orthodontists - to work with the PCTs and negotiate and plan the future for the area. One of the pluses of the local provisioning process is that not every part of the country is the same and therefore this brings a new dimension to it. I believe it was said last week and echoed today that young members of staff on the management side keep changing. We saw six PCTs going down to one. A whole bunch of people once familiar with the dental input is lost to the system. Education and re-education goes on constantly and that is disruptive and not very helpful.

Q400 Sandra Gidley: One of my local orthodontists wrote to me and said that given her waiting list and the fact that she had to provide a check up the units of orthodontic activity that she had been assigned would go nowhere near meeting even the identified need with an IOTM of 3.6. Is that a universal problem or a local one?

Mr Hathorn: It is a widespread problem in the sense - I hope it answers your question - that the review process took place in 2004/05. Because orthodontic treatments take 18 months to two years the payments were made on a level of activity two years previously. We know from the appendix to the document that year on year there was a 10% increase in activity. In effect, the contract in 2006 was frozen on contract levels of 2004. There is widespread under-capacity in practice that were developing. I know examples of colleagues who have met their levels of UOAs in terms of new patients and are beginning to finish their cases for that year and to keep within the 4% levels they have to take days off.

Q401 Sandra Gidley: You have orthodontists who have to take days off when there is a huge need out there just because the commissioning is not right?

Mr Hathorn: Because historically orthodontics are two years behind. General dentistry was slightly different and there were all sorts of other tensions within general dentistry about whether or not that was a typical year for them, but for us it was based on a date two years previously and year on year there has been a 10% increase in activity which is not reflected in the new contracts. Those mature and well-established practices in steady state probably do not necessarily have a great deal of capacity, but there are significant numbers of practices that have capacity to take on more care.

Q402 Sandra Gidley: You alluded earlier to areas of low provision, so presumably the commissioning in those places is based on a historic low provision anyway.

Mr Hathorn: Absolutely.

Q403 Sandra Gidley: Therefore, the problem is perpetuated.

Mr Hathorn: It is made worse. It is one of the reasons why we put it high on our list of concerns. Unlike the BDA's frustration, we did negotiate with the department and we do not have a problem with the nature of the contract itself or the way it is paid, but we have serious problems in terms of how we ensure there is a more even provision because it has been frozen at one point in time. Good areas are fine; the poor areas are badly off.

Q404 Sandra Gidley: Have any managed local orthodontic clinical networks been established?

Mr Hathorn: Yes, fairly widely. I will not say that they have always been as effective as they would like to be, but they are beginning in many areas. I know that a number of them have started in Yorkshire. I can speak only for Bristol in particular where a colleague is leading the team. One of the exciting parts of it is that for the first time ever we have general practitioners alongside specialists and hospitals talking together about community service and beginning to work together in a way that is potentially much more constructive. The Bristol lead PCT has done a very robust needs assessment of the amount of orthodontics to be provided and it has been modelled on 35% which is near the high need indicator in the child dental health survey. It also modelled it on 30% lower, thinking perhaps that it was over-provided, and found out that the 30% model is pretty much what they are providing. They also have modest waiting lists. The modelling process is already happening in certain parts and if it is done properly it will be to the benefit of the local community. Our major concern, which you may have picked up from the document, is that we believe the means of calculating it is flawed. The Department of Health has said that there is a known 34% which equates to levels 4 and 5, so they are high need patients. But they also asked parents whether they thought their children needed orthodontics. Without any knowledge of the problem, 50% said that perhaps not given the hassle, but that has been used as a divider to say that because 50% of parents do not believe there is a need that 34% can be modelled down and divided by two to reach 15%. If that happens it will provide a ridiculous needs assessment. I am reassured that in the Bristol setting the calculation has been made based on that original figure. We already have evidence from a member that another PCT is using that model of thinking of a number and dividing it by two.

Q405 Dr Naysmith: I can confirm as a Bristol MP that a lot of good things happen in Bristol. I know the commissioner for dental services very well. Does the money for orthodontics come from the same ring-fenced budget as that for general dental services?

Mr Hathorn: Certainly for the time being. The two are together within dentistry as a whole.

Q406 Dr Naysmith: Therefore, in some places they are really competing for limited funds?

Mr Hathorn: That was the point I made in response to the original question put by Mr Scott. In the areas of under-provision of dentistry as a whole it is sometimes robbing Peter to pay Paul, and we certainly have evidence that that occurs. In desperation to try to encourage better dental provision orthodontic provision suffers.

Q407 Mr Scott: Mr Hathorn, does a newly-qualified orthodontist have difficulty in finding work?

Mr Hathorn: It is certainly not as easy to find jobs as it used to be and many struggle to piece together jobs in differing practices, picking up bits of contracts here and there. Some specialist practitioners have gone almost straight into private practice. They have been trained in the health service and out of desperation have simply gone off independently to work. Ms Sanderson refers to the desperate waste. If you train good people to lose them from the system is an appalling waste of people power. There are problems because there are no neat new contracts. I have referred to the North East. If in the North East you trained up specialists with a view to giving them a contract in that region it would give them some hope for the future and give that area the very thing it wants which is more balanced provision. I believe that with planning the difficulty they experience could be resolved.

Q408 Mr Scott: My own area is Redbridge. I suppose an alternative is to tell people to go to Bristol which is obviously the land of milk and money.

Mr Hathorn: It is certainly not that.

Q409 Mr Scott: Taking into account that constituents come to me regularly with children who have to wait up to 18 months or beyond to start treatment, is it fair to say that in some cases when those children do start treatment the situation has deteriorated to such a level that it makes it much more difficult or impossible to treat them?

Mr Hathorn: In the introduction to our piece patient growth and the developing child is a key part of good treatment because it is best done in a growing child. There is a window of opportunity. I think it is more likely that in three years someone might be kicked out for not being the right age or being too old. Yes, there are potential problems. My real worry is that we already have a system that is frozen in time two years back. Once the 18-week pathway kicks in there will be a lot of patients coming out of hospital waiting lists and into the marketplace. Where do they go for treatment?

Q410 Mr Scott: My final short question can perhaps be answered yes or no. Do you say that this contract is letting down children?

Mr Hathorn: In particular respects it certainly is letting down children. In some areas there are examples of reasonable provision. It is not quite yes or no. In some areas it is "yes" for one bit but it is definitely not working for others.

Q411 Sandra Gidley: You have alluded a couple of times to the 18-week pathway having an impact. Can you clarify exactly how that will impact on primary care?

Mr Hathorn: If we take an area that is under-provided, a hospital secondary care department often has quite a long waiting list. We have made a recent check and some colleagues have waiting lists of six years which essentially is meaningless in the context of the question asked earlier. People fall off, are too old, get fed up and move on. But the 18-week pathway is being introduced for all disciplines - medicines, dentistry and the whole thing - so when a patient is first seen treatment must be commenced within 18 weeks. It is no longer acceptable to have what is for us an outpatient waiting list. Patients once seen need to be treated.

Q412 Sandra Gidley: Are you saying that the hospital consultants will basically chuck everybody out into primary care so they can meet their 18-week target?

Mr Hathorn: No. I put it differently. Hospital colleagues will treat as many patients as they can and will take on limited numbers just to backfill, that is, as a patient finishes a new one comes in. They will not be able to have waiting lists of any shape or description, which means that at the moment there is a hidden problem within outpatient waiting lists which has not been reviewed in DoH terms. This has always existed and it will now flush out the problem and exacerbate the inequality of provision.

Q413 Sandra Gidley: Would it also have the knock-on effect that orthodontists who work in the community would have to pick up more complex work which might previously have been carried out by the hospital service? They might be taking on work outside their usual scope of expertise. I do not say they are not up to it, but custom and practice means they would not have dealt with those cases.

Mr Hathorn: I would expect not. Most of those in the community orthodontic service are specialist registered colleagues and therefore they are able as in a practice setting to treat the full spectrum. I do not expect specialists in primary care either in practice or in the community to take up the really severe cases - the cleft and open palates and multiple missing teeth - which the hospital is there to treat. What will happen is that a whole raft of patients will go out. Where the community exists it will perhaps have to take on some more cases, but they are also getting into contract settings and so they too have their own limitations. We will not find one flooded because it simply does not have the contract ability to take on the additional patients. The real sad consequence is that you as MPs will hear from more patients who are concerned that they simply do not get treatment.

Q414 Sandra Gidley: Have you made any estimate of how many patients this will affect?

Mr Hathorn: We do not have numbers. We know the range of waiting lists because our consultant group in preparation for discussion with the department in May produced that range which in some parts goes up to six or seven years. There are very big numbers of patients hidden on waiting lists at the moment.

Q415 Sandra Gidley: Mr Smith, you have been waiting very patiently. In your submission you state that the new dental contract has resulted in less complex treatment being provided by dentists and this has led to a reduction in the quality of care provided. How do you substantiate that claim?

Mr Smith: We looked at the overall decrease in band 3 treatments. The courses of treatment on our figures showed a reduction of at least 44% and the department's figures found that under the previous scheme treatments under band 3 were about 8% of courses of treatment, whereas under the new contract the courses of treatment according to their own figures were about 4% or 4.5%. That is just using the broad figure of band 3. Within band 3 there were a huge number of items of treatment. Within that we have found, based on our own statistics, that the more complex treatments have disappeared. Things like complex dentures - metal ones - and bridge work have almost disappeared. There has been an 80% to 90% reduction in this type of item being manufactured by laboratories. There have been reductions in all manufactured items from laboratories except for the simplest plastic dentures where there has been an increase.

Q416 Sandra Gidley: You are saying that the way dentists treat their patients has changed as a result of the new contract?

Mr Smith: Yes. There are drivers in the system. We have talked about drivers that supposedly over-provide; now we have drivers that under-provide. Dentists fully accept that dental practices are private businesses and have to make a profit, pay the salaries of staff and so on. Within the system there is nothing to encourage multiple treatments - the treatment of four, five or six teeth - or those cases where patients need more intervention and complex treatment. There is nothing to reward or adequately to pay dentists for doing this type of treatment.

Q417 Sandra Gidley: The bottom line is that they are not getting paid for it and so they are not doing it?

Mr Smith: That is one way of putting it.

Q418 Sandra Gidley: You also report an increase in private work of about 18% but that does not seem to make up the difference. Obviously, some switch to the private system because that is what they want; they make a decision about whether that is right or wrong. What is happening to the others?

Mr Smith: There is no natural situation between NHS and private work. Everybody in dentistry finds the way it is provided is quite a difficult or complex thing to breach. The system is definitely not transparent and so patients also do not understand what is available on the National Health Service and what is available only privately. This becomes a very complex discussion and what is happening is not easy to tease out of the system. All we can tell you is what is happening based on what we are producing, and certainly we have not had a volume increase in the amount of private work to replace the lost NHS work.

Q419 Sandra Gidley: Can one argue it the other way? Can it be said that the old contract encouraged dentists to do some of the more complex work but now they will look at a solution that does the job? It may not be the most attractive-looking thing - if you want that you pay for it privately - but from a dental health point of view it fits the bill.

Mr Smith: "Fitting the bill" is an interesting euphemism. When one invests in people's oral health in many cases it is a long-term investment. We want the treatment to have a long-term benefit for the patient, which is the whole point of doing it. Many treatments are inexpensive but have only a short-term benefit; some treatments are more costly but have a much longer-term benefit to the patient and overall are perhaps better value for money. It depends on whether you measure it today or over a long period of time. John Renshaw said that one wanted dentists to be in a neutral position when it came to prescribing so they do what is in the best interests of their patients at all times and money does not cloud the issue as to which way to do it, other than whether or not it is affordable.

Q420 Chairman: Mr Smith, you said that fewer bridges were being made than before. Is not the advent of implants one of the reasons why fewer bridges are being produced now?

Mr Smith: First, one has to put something on top of an implant. An implant is just something put into the bone in the oral cavity and something goes on top of that. Often that is a bridge or crown unit. Certainly, implant work would not change that type of work; it would probably have the opposite effect and increase the number.

Q421 Chairman: You referred to an increase in the production of simple plastic dentures. I remember being lobbied in this job a couple of years ago. It was not concerned directly with this inquiry. Given what is said now about UDAs there will be a plethora of people coming in for a denture with a single tooth on it because the dentist gets the same amount for that as an outcome, as it were, as he does for putting on a cap. Do you see evidence of that?

Mr Smith: This is the only increase we have found. There has been a massive increase in the number of one tooth partial dentures. Such dentures were things one hardly ever saw. I learned to do them in dental school. Apart from the odd situation where you would make a temporary denture for a short period you hardly ever saw them. We are now making them in vast numbers; they have increased by 76%. Nobody on this table would say that that is the best long-term treatment plan for any patient who has a missing tooth.

Q422 Chairman: Is that related to the new contract?

Mr Smith: Definitely.

Q423 Chairman: What percentage of dental laboratories are members of your association?

Mr Smith: We have over 1,000 members and that probably accounts for about 85% of the manufactured work. We have members over the whole of the United Kingdom.

Q424 Charlotte Atkins: Clearly, you are not happy with the way the UDA system is working for you. What are the solutions? Should patients in future pay dental laboratories direct and also for their NHS treatment? Do you think you need to get out of the straitjacket of the UDA system?

Mr Smith: We should have a system of transparency so that patients have an understanding of what it is they are being treated with and the value or cost of that treatment. The patient should be in the driving seat as to the choices of treatment available. Dentistry is slightly different from many medical treatments in the sense there are several options as to what can be done in a particular case when we come to more complex dentistry. Therefore, the dentist is the neutral prescriber and is empowering the patient with information about what those choices mean for that patient. When one brings in drivers like UDA one sees how they affect that process. We would like to see some process where the patient was back in the system and the choices made were ones in which the patient was involved with an understanding of the cost implication of making those choices.

Q425 Charlotte Atkins: What about patients who are exempt from NHS charges? You said that the patient should know the cost implications. How does that work in the case of a patient who is exempt from all charges?

Mr Smith: What we must not do is prevent patients who even where exempt are restricted in their choice. We will want those patients to have an element of choice as well. The question is how the NHS chooses to subsidise that choice and how one does that is a political decision. I still believe that every patient should be involved in the choice process in some way.

Q426 Charlotte Atkins: What would be your preferred option?

Mr Smith: The option would be that the NHS should subsidise an amount towards the treatment and when the patient discusses the choices with the dentist he or she can make an informed choice as between the most basic treatment or a much more complex option.

Q427 Charlotte Atkins: Do you think that given PCTs commission dental services they should also commission work from dental laboratories?

Mr Smith: There is no reason why dental laboratories and PCTs cannot work together and negotiate contracts between them.

Q428 Charlotte Atkins: Do you think that would work better than the present system?

Mr Smith: It would probably make prescribing more neutral.

Q429 Dr Taylor: The evidence of the Dental Technologists Association, not yours, was that there was a drift of dental laboratory work abroad. Is there any evidence to back that up? Do you have any idea of the scale of the problem?

Mr Smith: I went on a fact-finding mission to Shanghai at the end of last year to discover in China what evidence there was as to that. It was very interesting to see how they are gearing themselves up to be a provider of this type of treatment for the world, but at the moment the vast majority of the work they produce goes to the United States and mainland Europe. The NHS has in some ways protected us from that because there is no real cost advantage at the moment in using China. When we looked at the costings of some of the treatments by the time it was shipped there and returned it was found it was possible to source the work in the UK for a similar price. We found no evidence in any of the laboratories we visited in China of any work being done for the UK. I do not say that none of it is done there, but it is certainly not enough to hit our radar yet. I do not believe that at the moment it is a big issue although it will be.

Q430 Dr Taylor: Ms Sanderson, are you aware of dentists sending work abroad like that?

Ms Sanderson: I am aware that it happens.

Q431 Dr Taylor: But not as a major problem?

Ms Sanderson: I am not aware of the scale of it. I was just reflecting that all three of the labs I use for crown, bridge and denture work are within two miles of my practice. For me, it is absolutely paramount that I have that a relationship with the technician who is making the work for the patient. Sometimes the patient goes and presents himself to the technician and says, "This is my smile. Now you can see what you are going to do the work for." It is absolutely crucial that you have that sort of relationship. Dentistry is a team event. Although there may be moves to send work abroad when looking at the style of dentistry I deliver it is important that I know my technicians and they know me.

Mr Smith: The new contract has already had a detrimental effect on the employment of dental technicians in the UK, but at the moment I do not attribute that to overseas work.

Q432 Dr Taylor: The same memorandum from the Dental Technologists Association says that from August 2008 they will be required to be on a recognised course or to hold a current registrable qualification. Has that not been the case until now?

Mr Smith: No. Registration is new for all DCPs and comes into effect on 13 July.

Q433 Dr Taylor: Quite naturally, they suggest that there should be some help with training and the continuing professional development that they will need.

Mr Smith: Yes. Because of the effects of the contract and the loss of work the situation now is that technicians are being made redundant, laboratories are closing and recruitment into the profession is being affected quite significantly.

Q434 Dr Taylor: The association tells us that Scotland has looked at this and is funding education for dental technologists?

Mr Smith: Scotland has introduced an extremely good VT programme for dental technicians similar to the one in England for dentists. It is very successful and highly regarded by everybody involved. We have approached the Department of Health about it but I am afraid it has fallen on deaf ears at the moment.

Q435 Dr Taylor: Is that something we should look at and perhaps recommend?

Mr Smith: Yes. The department used to help with a very small bursary to laboratories to help with training. Our training is a little different in that we work with our hands. There is the academic as well as the technical side of training which you can get only within a laboratory. That small bursary has also been removed and we get no funding at all from the department for training technicians.

Mr Hathorn: I agree that both technicians and dental nurses will have to register for the first time. They will be expected to do continuing professional education and they will struggle. Many practices or hospital departments do not necessarily give much support. The model in Scotland that Mr Smith mentions, which sounds a very good one, is one where some commitment is made to help with continuing training.

Q436 Dr Taylor: At the moment the dental nurse who is at the right-hand side of the dentist, or whatever, does not need a registrable qualification at all?

Mr Hathorn: No.

Q437 Chairman: Ms Sanderson, we come from the same part of the land as it were. When we took evidence on this issue earlier I asked about dentistry in future. One of the issues in terms of the build-up of private dentistry, not just insurance, is the ability of people to afford multi-pay policies and to go beyond what the National Health Service currently provides. Many of the latter cases occur in what we call National Health Service dentistry at the moment. Where do you believe dentistry will be in 10 years' time? We are talking now about access. You said earlier that you were involved in two dental practices, one private and one NHS. Which one will still be around in 10 years' time, or will both still be around?

Ms Sanderson: To make one slight correction, one is exclusively NHS and the other is a mixture of private and NHS.

Q438 Chairman: I was intending to pursue that.

Ms Sanderson: I hope to be able to carry on with that sort of model. It really depends on making sure the NHS continues to be an attractive place to provide dental services and to have dental services provided for you and there are quality measures and a real commitment on the part of national government but also local primary care trusts so that dentists are able to continue to provide comfortable, safe choices and options within whatever sector they deliver care. My hope for the future is that dentistry will continue to make inroads into the oral health of the nation. The Department of Health said that the current contract was intended to produce simpler courses of treatment. How one defines "simpler courses of treatment" we are beginning to unpick. What it will do to the oral health of the nation in the long term disturbs me. There are all sorts of different ways to provide care for a person's tooth. The long-term outcome is really important and we need to keep an eye on it. The 10-yearly adult dental health survey was under threat until recently. I understand that it is now back on the cards, but it is being delayed. Unless we keep an eye on what is going on and make sure we are ahead of the game in monitoring I fear for the diversity of care in the country. I think it is moving apart.

Q439 Chairman: If South Yorkshire gets richer - my constituency is richer now than it was a decade ago - will people be more likely to get private dental care?

Ms Sanderson: Do you mean by that question that more private care will be offered, or that they will choose to do that?

Q440 Chairman: It is a marketplace and the question is: what is affordable? Some areas are probably richer than South Yorkshire; there are a lot more private dentists than traditional NHS dentists. NHS dentistry has gone out of fashion. I do not suggest that that should happen, but what if the market does drive that? Where will you be in your work in 10 years' time in South Yorkshire if it gets richer and more people go to the wholly private side of your practice as opposed to the National Health Service side?

Ms Sanderson: It has to be driven by the need for high quality comprehensive care for all. That comes at a cost and choice comes at a cost. Where the split lies in future years depends on who decides to buy those services. Disposable income buys choice in holidays, schools, cars and it also buys choice in dentistry at the moment. I would like to see that choice available right across the board, but it comes with a cost, and that applies also to services provided under the NHS.

Q441 Chairman: Charlotte Atkins referred earlier in asking questions of Mr Smith to the NHS paying for part of the treatment. Let us say an NHS patient wants a different type of denture or something that is not necessarily medically needed but is cosmetic. A lot of people now go to dentists for cosmetic and not medical reasons. Do you believe that access to dentistry for those people who do not want a better denture or different crowns from those the state will pay for would be better served if there was some sort of system where people could go along to any dentist, whether or not there was a register, and access what the state provided and if they wanted more than the state provision there would be part payment by them? Would that be more likely to secure access to dentistry in years to come, as opposed to letting the market continue to dominate in some parts of the country exactly what type of dentistry is available?

Ms Sanderson: There needs to be clarity about what is available. How that is funded is probably a political decision. My personal view is that all NHS services should be available to everybody.

Q442 Chairman: I do not dispute that at all. I agree entirely with what the Government is doing in its intention under the contract. What we do as a committee is a different matter. The question I pose to you is: looking at dentistry in 10 years' time, would the situation be one where people went for treatment initially but then wanted cosmetic treatment - something that the state would not and should not pay for - but what the state was obliged to pay for as part of that treatment could be set off against the cost of the cosmetic side of it? It would be a political decision. The reason I put it to you in that truncated way is to discover whether it is more likely to mean that everybody will have access to dentistry because dentists will not opt to cease seeing one group of people any more because they are old, or anybody who has to do with the national health, because they are setting up dental practices in the town as wholly private businesses. That is why I pose the question. Would we break down that type of situation? That situation is now happening in South Yorkshire and in my borough. Ten years ago I would not have thought people would be taking that type of decision.

Mr Smith: But are you not assuming, therefore, that the National Health Service always provides best value for money? I disagree with that. With the patient contribution now standing at £193, some of the items of treatment we are providing cost considerably less than that. If you take a crown, the patient's contribution for each one was somewhere in the region of £60. The patient is now expected to pay £193. Therefore, the value for money element in all this has disappeared because patients are now paying a lot of money for a little amount of basic treatment.

Q443 Chairman: They could go into the private sector. If dentistry moves as it has done in some parts of the United Kingdom into practically a wholly private sector - we have a geographical problem about NHS patients accessing treatment - it does not answer that problem in the medium to long term, does it?

Mr Hathorn: One of the questions asked of the three previous witnesses from PCTs was to do with ring fencing. I believe that once ring fencing is significantly removed and even patchy and differing versions of PCTs commit to dentistry to a high level in, say, the South West and to a low level in the North East I just worry that there is no longer central direction and we may have mini-states. I worry that the more private practices there are in orthodontics and general dentistry those without the money will just disappear over the horizon. A fortnight ago there was talk of fluoridation. That is one of the things back on the agenda. We should be doing things to target young patients who do not have the resources for private dentistry. Birmingham is a living, screaming example of how good it could be if we could get it around. The real worry is that with this patchiness we might find that PCTs act like mini-states and do one thing here and something else somewhere else.

Chairman: Thank you. We hope to bring out our report in the not too distant future.