Official Report (Hansard)
Date: Wednesday, 03 July 2013
Committee for Health, Social Services and Public Safety
Dental Services: British Dental Association Northern Ireland Briefing
The Chairperson: I welcome Peter Crooks and Claudette Christie. We apologise for keeping you waiting; we have just had a ministerial briefing on Transforming Your Care. The Committee agreed to take evidence from you and, afterwards, from the Department on the general dental service, following the Department's consultation. Thank you for the paper that you provided. I will hand over to you for a presentation and then we will open the floor to members' questions.
Mr Beggs: I declare an interest. I have relatives who are dentists.
The Chairperson: OK. The floor is yours, Peter.
Dr Peter Crooks (British Dental Association Northern Ireland): Sitting outside while waiting to come in was a bit like sitting in a dentist's waiting room. [Laughter.]
The Chairperson: Now you know how we feel.
Dr Crooks: I am the chair of the Northern Ireland Dental Practice Committee, which represents high street dentists throughout the Province. Beside me is Claudette Christie, director of the British Dental Association (BDA) Northern Ireland. Thank you for the opportunity to give evidence to the Committee on health service dentistry. You may recall that we appeared before you on 2 May 2012. We would like to thank the Committee for all its various inputs and engagement over the past year with the BDA and our members.
This morning, we became aware that the Department of Health, Social Services and Public Safety (DHSSPS) had revised its proposals, following the recent consultation. The changes are certainly welcome but the Department is still proposing substantial cuts to the dentistry budget, and we remain concerned about the impact that that will have on the service.
I would like to make three points, which we will then be happy to discuss with you. First, as I have said, DHSSPS has amended its proposals and moderated the scale of the proposed cuts, which goes some way towards addressing the profession's concerns about how oral health provision will be managed. However, although BDA welcomes that change, we emphasise that the amended proposals are still significant. The implementation of the public sector pay freeze means that funding for health service dentistry was frozen for the two years up to April 2013, except for a £250 award each year for staff earning under £21,000. However, the costs of providing the service have risen by 7% in each of those years, meaning that the dentists who provide the service have had to absorb the equivalent of a 14% funding shortfall over that period. The implementation of any further cuts would have profoundly damaging consequences for the service and, obviously, we will wish to discuss our concerns about that with the Department in the weeks ahead.
My second point is that, although the Department funds health service dentistry from different pots, with different payments going to dentists and each pot having a different title, it all ends up being used by dentists for the same thing: covering the costs of providing dental care. The DHSSPS still intends to phase out what is known as the commitment payment, which is an element of remuneration for dentists that was introduced in 2001 to recognise dentists' commitment to the health service and support their career progression. The reality for health service dentists is that the commitment payment is an important element in the overall funding package that they receive to provide the service. Phasing down and removing the commitment payment — indeed, removing any payment element — will inevitably have an impact on patient care and the viability of dental practices. Patients — your constituents — will be adversely affected, no matter the funding pot in which the Department makes the cuts.
My third point is that an indication of the true cost of providing health service dentistry comes from the personal dental services (PDS) contract, and, in comparison, general dental services (GDS) receives over 25% less funding per patient when orthodontic care is excluded. That figure surely highlights the existing pressure on GDS.
Unfortunately, Northern Ireland has long had a poor record on oral health. The last time we were here, the Chief Dental Officer told the Committee that dental health in the Province is in the bottom half of the European league table. Therefore, although we welcome the revisions that the DHSSPS has made to its proposals, it remains the case that the service is facing cuts. We want to continue to work with the Department on that issue, but it remains for you, the Committee, to be aware of the funding position of dentistry as it stands. Now, surely, is not the time to cut the funding of health service dentistry. We are happy to take questions.
The Chairperson: Thank you, Peter. Did you say that you received some new information this morning?
Dr Crooks: Yes.
The Chairperson: You said that the changes are welcome, but that there are still substantial cuts. What information was that?
Dr Claudette Christie (British Dental Association Northern Ireland): This morning, we received from the Department a summary of the responses to the consultation and its amended position on what had been proposed, which continues to be a package of cuts. However, they are not as onerous as what was originally intended. The position has changed, and we will be discussing —
The Chairperson: I know that the position has changed; I am just trying to work out what information you got and when. Can you give us a copy of that?
Dr Christie: Yes. The Department should be able to give you a copy of what we have. It is a summary of the responses and its position on them.
The Chairperson: Yes; we have the summary of the responses. You were told about that this morning?
Dr Christie: Yes.
Dr Crooks: It is dated June 2013, but we received it only this morning.
The Chairperson: We have a letter from the Minister. The departmental officials are here, so I take it that that is all connected. You have welcomed some of the changes but, as you say, there will still be substantial cuts to the budget. You suggested that there are discussions still to take place with the Department. Is there any suggestion that you can work through the problems in negotiations with the Department?
Dr Crooks: We have ongoing talks with the Department. It takes a wee while to arrange meetings, but we will certainly be continuing to draw its attention to the difficulties that dentists face.
The Chairperson: Breaking down where the cut in the budget will come from, if the Department goes ahead with it, will it mean that a dentist will have to take a smaller pay cheque? Will it not impact on services, but on wages?
Dr Christie: Dentists do not receive a wage; they receive funding for carrying out treatment for patients. Out of that, they meet all their costs, and the balance that is left is what they have for investment and pay purposes. All the funding that goes into dentistry has been frozen. That means that the money that dentists require for investment in capital or investment in revenue, plus the pay for their staff, is frozen. Effectively, practices had a 7% cut in funding last year and a 7% cut the previous year because of the way that that was delivered.
The Chairperson: Are you saying that all dentists do not receive a salary, or that those who own the practice do not?
Dr Christie: They are independent contractors, so their remuneration comes from carrying out particular treatments and having patients registered. They then meet all of the costs of the business. They are not salaried. Does that help?
The Chairperson: I am not sure. I will let other members come in, and I will come back on that point.
Mr McCarthy: It seems to me that dentistry is a very uncertain profession. Dentists depend on whatever work they get, and then that is paid for by the Department. It does not seem very satisfactory.
As you said today, the state of oral health in Northern Ireland is probably the lowest in the UK, perhaps in Europe.
Dr Crooks: As I recall, the Chief Dental Officer said that we were in the lower half of the European league table.
Mr McCarthy: That is bad in anyone's terms. If the proposals go ahead, that will get even worse, which is the last thing that any of us wants. As you say, all our constituents want the best possible treatment, but that will not happen if this goes ahead.
Dr Crooks: That is my fear. If the overall funding is fixed and the proposals go through, while costs continue to increase, the net income available to put into a practice and drive it forward into the 21st century will be severely curtailed. We want to provide the best service that we can for patients, but that will not be sustainable if there are increasing pressures every year.
Dr Christie: It is important to note that we will be going back to the Department for further discussions because a lot of these matters are contractual. What happened this morning is helpful, but a lot of work remains to be done to consider the impacts and out-turns.
The Chairperson: That is where I am looking for clarity. In the negotiations with the Department, is the issue the impact on services or the take-home pay of an individual dentist? Are you telling us that patient services will be impacted?
Dr Crooks: I cannot see how they will not be impacted. Regulatory requirements are placed on us, on decontamination, for example. That entails capital costs, running costs, and even staff salaries. Someone could come for an interview, and we may go through the process and tell them how much their pay will be. They could then go back to their own practice and say, "Mr Crooks is offering me a particular amount. Can you match that?" If that is matched, they may then come back and —
The Chairperson: I appreciate all that, but it is not —
Dr Crooks: All those costs go up and up.
The Chairperson: We were told a year ago that there was a possibility of orthodontic services being impacted. Are you suggesting or telling us that that sort of negotiation with the Department is finished, and that is the welcome part of it: there will not be an impact on direct services to patients accessing dental care?
Dr Crooks: Access to dental care has been very good. It went up by 30% in the past four or five years. Funding increased by about 20% over the same period. However, costs have gone up and up, and I cannot see how that will not have an impact.
The Chairperson: Officials from the Department are listening to this, and we will be hearing from them after you. I will bring in other members.
Mr McCarthy: I have to go, Chair. You cut me off. I had another question.
The Chairperson: I was a bit confused on that last point, and I want the departmental officials to be prepared.
Mr McCarthy: Could I ask one more question before I go?
The Chairperson: You can ask the question, then run. We will stay here. [Laughter.]
Mr McCarthy: Is the requirement for a dental practitioner to get approval from the Business Services Organisation to do certain work still in the proposals? That seems odd, to say the least.
Dr Crooks: We made a lot of representations on that issue. A lot of dentists contributed to the public consultation, and our understanding is that many expressed their concerns about that. Several of those proposals have now been changed. I have not had time even to read the document and have not received it. However, my understanding is that changes have been made that will make things a lot easier for dentists.
Mr McCarthy: Good.
Dr Crooks: The issue is not entirely out of the way, but things will be a lot easier if the revised proposals go through.
The Chairperson: You will be glad to know that the way our meeting was scheduled was not an accident. The running order was set on purpose so that departmental officials are listening to your concerns and we can address those with them.
Mr Dunne: My intended question was asked by Kieran. However, you have expressed concerns about orthodontics. Are you fairly satisfied that that issue has been addressed?
Dr Christie: Yes; I think we are comfortable that that has been addressed.
Mr Dunne: What is the position on orthodontics? That treatment is generally free for children, which is where the main workload would fall.
Dr Crooks: Yes. In the case of teenagers, when teeth have fully erupted they are easier to move through bone, and so on, in order to get them straightened up. That work tends to be done on children. However, many more adults are having orthodontic work. There is a proposal that the health service will pay for work in cases of more crowded teeth, but not for less crowded, more aesthetic work. That brings us into line with the rest of the UK. There will be a set level for that. It may not all work out just as easily as we are led to believe. There can be a grey area, and I know that, in other parts of the UK, dentists still have to apply for approval when they are not sure whether they are going to be paid at the end of the treatment. Some parents have expressed concern in cases where an orthodontist says that they cannot get treatment on the health service. They then ask for a second opinion, and the dentist applies for approval. Therefore, prior approval for orthodontic cases has not, by any means, been totally eradicated. There can still be a lot of difficult discussions with parents. I do not really accept the idea that prior approval will suddenly become much easier when orthodontics is taken out.
Mr Dunne: Thank you. I welcome the progress that has been made between you and the Department. Hopefully, matters will be resolved satisfactorily.
Mr Brady: Thanks for the presentation. You mentioned the commitment payment. In my constituency, it was quite difficult for a few years to find a dentist who did NHS work. Since 2001, I think, the commitment payment has been in place to encourage dentists in their commitment to the National Health Service and to enable career progression. If that is removed — I am not asking you for a definitive answer, because it is probably speculation — is it possible, if not likely, that many more dentists will revert to private practice and that people trying to access NHS dentists will find themselves back in the situation that pertained 15 or 20 years ago?
Dr Crooks: That is a matter of speculation, but we know that about 77% of work carried out by dentists is NHS work, so that demonstrates the commitment of dentists to the NHS in Northern Ireland.
Mr Brady: But they are getting a payment at the moment in recognition of that. If the payment is removed, that commitment — I am not suggesting that dentists are not committed — may wane due to lesser remuneration because, obviously, your work depends on the number of patients, etc, and the commitment payment is an added bonus, in a sense.
Dr Crooks: It is tied in with the income.
Mr Brady: If the payment is removed, it is possible that dentists may go down an avenue where they can get more remuneration. It is a difficult and physically demanding job.
Dr Christie: We are clear that any element of remuneration that is cut will have an impact. That has to be considered.
Mr Brady: Yes. That is really the point I am making.
Dr Christie: We will want to consider that impact further with the Department.
Mr Brady: It is not an unlikely scenario, at least to some degree.
Dr Christie: It could have an impact in ways that you can anticipate or in other ways, but all of that has to be considered.
Dr Crooks: Given the overall picture of the economic situation, it is not so easy for people to put their hand in their back pocket.
Mr Brady: Absolutely. I agree with you totally on that.
The Chairperson: I want to bring Roy in, because members have other commitments, and I do not want to lose our quorum before we hear from the Department.
Mr Beggs: Inflation in the health service is widely accepted as being about 4% above ordinary inflation, so to speak. How did you estimate the figure of 7% in the dental sector over the past two years? How do you back that up, especially as there has been a wage freeze? Will you explain that?
Dr Christie: When we prepare evidence, we look at the balance between income and expenditure in dentistry. We then use a recognised formula that is produced by the Review Body on Doctors' and Dentists' Remuneration, which is the independent body that makes recommendations for doctors' and dentists' pay. That formula includes elements — I cannot tell you exactly what they are — such as cost inflation and increases in particular expenses associated with dental practice, including the wages paid to employees. It will look at three particular figures: one will be the one that you have talked about, which is inflation plus the healthcare costs; one will be the cost of wage inflation; and the other will probably be associated with the cost of consumables. You would then also have to consider, if you had a new resource allocation, that you have inescapable costs such as decontamination, where we absolutely have to make that expenditure. Any other business, when it has an increase in the cost that it meets, say through having to have a decontamination room, will say, "Well, I charge my clients, so I will increase the charge". You charge your clients in order to make amends for what you need to do to improve the service. We cannot do that, because our fees are fixed by the health service. So, that is one way to include it in the pay equation if there is a new, inescapable cost. That is how it is done.
Mr Beggs: Has it been widely recognised that these additional costs were all essential and needed?
Dr Christie: Yes, because they are legislatively bound, bound in good practice or bound in recommendations from the Department, so they are inescapable.
Mr Beggs: They are inescapable, but are they sensible, coming from the Department?
Dr Christie: Having decontamination in your dental practice is not a choice; it is a reality.
Dr Crooks: It is essential for the safety of patients.
Dr Christie: It meets good practice and governance. The Minister talked about record-keeping and about how he wanted to make sure that nurses were able to take good records. However, he did not want to take them away from patients in order to make them take good records. All of those things have to be met.
Mr Beggs: My final question is about the new proposal, and I appreciate that you may not even have seen the details as yet. How will it impact on patients?
Dr Crooks: I would like to think that it will be better for our treatment of patients. I do not want to repeat everything I said last year when we met the Health Committee, but if someone comes in with a sore back tooth, it will mean that we will not have to wait for approval to complete the course of treatment, which we would have had to do in the initial proposals if someone had a sore back tooth and we had to carry out a root-canal treatment. We could do the emergency treatment, but we would have had to write for approval or permission to complete the entire course of treatment, not only on that one tooth but everything else that the patient may require. That is not going to be the case, and that is very welcome. Being able to provide scaling and polishing for patients more regularly is very welcome and will certainly help the oral care of the patients. What I understand these changed proposals to be will help our patient care.
The Chairperson: Thank you very much. You are more than welcome to sit in the Public Gallery and listen to the Department.