§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Lawson.]
§ 10.13 p m.
§ Commander Anthony Courtney (Harrow, East)
I am grateful for the opportunity this evening of raising a matter which concerns the personal health and dental fitness of one of my constituents, Mr. Smith, and to draw attention to certain shortcomings in the dental part of the National Health Service which, I believe, as a result of Mr. Smith's experience, should be inquired into.
We are all proud of our National Health Service. On both sides of the House, we take credit for the steady development over the years of a service which is, perhaps, incomparable in the world today. In that I include the dental section of the National Health Service.
In passing, perhaps I might mention the high reputation enjoyed by the school dental service by its effect, demonstrable on all sides, on our children and by the tremendous work which continues to be done in that field.
With a reputation as high as it is throughout the world, it is all the more necessary that when an individual finds shortcomings in this Service he should declare them, and, if so minded, take his protests to a high level and have them answered. I find it a little distressing that my constituent, injured as I believe he has been in his dental fitness, should find it necessary eventually, in default of any other redress, to come to his Member of Parliament, which of course is why I am privileged to raise the matter on the Adjournment tonight.
Perhaps I could go into the sequence of events regarding Mr. Smith's case, because it is germane to my case. In October, 1963, Mr. Smith, in accordance with the custom of us all, went to his local dental practitioner, a Mr. Karl Joseph, also a constituent of mine. He had a sensitive tooth, which was diagnosed by Mr. Joseph, perfectly correctly I am sure, as being subject to undue pressure. In the technical jargon, the 346 bite was too great, and it was therefore filed down. Mr. Smith went off reasonably happy on the understanding that he should call at the surgery again a week later.
He went back to his dental practitioner a week later to have the tooth examined as he thought, and here perhaps I should digress for a moment to describe one of the conditions to be found in Mr. Joseph's surgery. Mr. Joseph likes music, as I do and as I am sure hon. Members on both sides do. He likes music while he works, and in his surgery he has a transistor radio which puts out what I believe is colloquially described as "pop" music. In fact, it is very noisy indeed. The point is that it makes communication between this dental practitioner and his patient somewhat difficult at times.
Mr. Smith understands that Mr. Joseph muttered something about the tooth under examination—the tooth which was now giving no trouble. I have to record, because I have inspected the evidence, that Mr. Smith was subjected to the extraction of a tooth on the spot. Imagine his surprise when, on the extraction being completed, and on being invited to look at himself in the dentist's mirror, he discovered that the wrong tooth had been extracted—not the sensitive tooth which he understood was under examination, but the tooth alongside it, to use a nautical phrase. It was maintained by the dentist that this had been made necessary by the necessity for Mr. Smith to have a lower denture fitted, because it was maintained by Mr. Joseph that the lower denture which Mr. Smith possessed was loose and did not fit very well. Here a rather odd fact occurs, because Mr. Smith is not accustomed to wearing a lower denture. Before this unfortunate extraction he had a full set of lower front teeth. It was not, therefore, necessary for him to have a lower denture and, ergo, not necessary for him to have a tooth extracted in order to facilitate the fitting of that lower denture.
After this episode Mr. Smith returned to Mr. Joseph and had an upper and a lower denture fitted, Mr. Joseph having stated that the upper denture which Mr. Smith normally wears was loose. This work was done and a charge of £5 was 347 made to Mr. Smith for it. Mr. Joseph had considered that a complete set of new dentures was necessary and had, therefore, fitted them.
Mr. Smith very soon discovered that his new dentures, fitted, as he believed, in error—he having suffered the loss of a tooth in the process—were extremely uncomfortable. In fact, they were such a bad fit as to be totally unwearable. He appealed—as I think he should have done, and as it is absolutely right that a man in his circumstances should do—to the Middlesex Executive Council. In due course he was asked to go to Watford and report to a dental surgeon, nominated by that council, to have his dentures examined. That dentist condemned the dentures and told Mr. Smith so, and reported back to the Middlesex Executive Council.
Mr. Smith was not satisfied with this. He preferred to go back himself to the Middlesex Executive Council. He had to proceed to Marylebone, in London, where he met the eight members of the Dental Service Committee of this Council. He was confronted by eight individuals who, he maintains—and one can well understand it in the circumstances—took up a somewhat hostile attitude towards his complaint. Only three of them were qualified dental practitioners. In fact, the committee seemed to be a trifle over-weighted with lay expertise. From this meeting Mr. Smith presumably emerged bloody but unbowed.
The case went further, because meanwhile the Executive Council had decreed that the £5 paid by Mr. Smith for these dentures, themselves fitted in error and ill-fitting, was to be returned to Mr. Smith, and that that amount was to be deducted from the remuneration accorded to Mr. Joseph. Mr. Smith—Briton of Britons—was still undeterred. He considered that he had been treated badly and said that he would take the case to the Minister. In due course he wrote to the Minister of Health setting out his case admirably and in detail.
I regret to say that the Minister replied to the effect that there were two alternatives—a decision on the clinical evidence available or an oral hearing of Mr. Smith's complaints. Looking at the case, I would have thought that the Minister would have conducted an oral hearing, 348 although I notice that there is a deterrent to such a procedure, in that the regulations provide that the Minister has power, in the event of such a hearing taking place, to award costs against either party to the appeal. I suggest that that is a form of pressure which can operate against an individual desiring an oral hearing of this kind.
In any case the oral hearing was refused, and in a final letter on 24th November the Minister told Mr. Smith that the case was considered closed and that there would be no further appeal. I believe that the following facts in this deplorable series of happenings establish at least that in the first place Mr. Joseph was in breach of his terms of service as a dentist.
I think that it is established in the minds of reasonable men that no permission was given by Mr. Smith at any time for the work on the teeth in his lower jaw, the extraction of this tooth and the fitting of the dentures about which he complained. Secondly, it would be a bit too much of a coincidence that the extraction of a neighbouring tooth should have been anything other than unnecessary. Surely, if a tooth had needed to be extracted, it should have been the sensitive one about which Mr. Smith had been to his dentist a week previously. In the opinion of the Watford dental nominee of the Middlesex Executive Council there was thoroughly bad workmanship in the new dentures supplied to Mr. Smith.
Mr. Smith has very properly exhausted all the channels available to him in seeking to redress his wrong, ending in this Chamber. Though there was this dereliction of duty—if I may so call it—by an officer of the National Health Service, there has been no cost whatever to the Service. I believe that no remuneration other than the £5 paid for the dentures has been withdrawn from the emoluments given to Mr. Joseph. Finally, my constituent has been subjected to considerable cost in time and money in following up this grievance about his dental treatment and, in particular, he has had to pay £3 10s. to another dentist to have proper dentures fitted which he could accept.
I submit, for the Minister's consideration, that the investigation and the procedure was autocratic and cumbrous. It 349 has meant travelling and expense for all the parties concerned. There is no evidence anywhere in the documents which I have seen that disciplinary action of any kind has been taken against Mr. Karl Joseph. There appears to be no guarantee that other patients of Mr. Joseph will not be subjected to the same "pop" music as afflicted the ears of Mr. Smith and resulted in the original misunderstanding by which his tooth was inadvertently extracted.
I think that the thanks of the Minister and this House are due to my constituent for raising this matter and that the very least the Minister could do, particularly as the service has not suffered any charge, would be to make an ex gratia payment to Mr. Smith in consideration of the pain, discomfort and trouble which he has suffered.
§ 10.29 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Sir Barnett Stross)
The hon. and gallant Member for Harrow, East (Commander Courtney) must have been misinformed about his constituent having all the teeth he should have had in his lower jaw. That is what the hon. and gallant Member inferred. I have here a diagram of the condition of Mr. Smith's teeth when he was examined by the dental officer, and it seems to me, if I read it rightly, that Mr. Smith had four teeth on the right side and five on the left and, therefore, could not have had all his lower teeth.
The hon. and gallant Member has put the case for his constituent firmly and clearly. He will not mind if I again go through the salient points, because there are perhaps slight differences of emphasis between us on this matter.
My history of the case is as follows. Mr. Smith wrote to the Middlesex Executive Council on 30th December, 1963, and he then complained that at a visit on 24th October, as we have heard, Mr. Joseph, the dentist, had extracted a sound tooth on the front of the lower jaw in mistake for the tooth next to it. This tooth had previously been giving the hon. and gallant Gentleman's constituent trouble. It had been painful.
As a result of this, new dentures had to be supplied, and Mr. Smith went on to complain that the new dentures were unsatisfactory. The Executive Council 350 then wrote to Mr. Joseph, the dentist, asking for his comments on this complaint. This is the usual form. The dentist replied saying that he had explained to Mr. Smith at an earlier visit that as his existing denture seemed no longer to be fitting properly—I presume this is the upper denture—if new dentures were to be fitted the front tooth concerned would have to come out as it was loose and that Mr. Smith agreed to this treatment.
The Executive Council then arranged for Mr. Smith to be examined by a regional dental officer of the Ministry. He reported that the dentures supplied by Mr. Joseph were unsatisfactory. He did not suggest that there was any need to extract any teeth, including the one which Mr. Smith said was unsound. The Executive Council——
§ Commander Courtney
Mr. Smith had complained of a sensitive tooth, but it had quietened down by the time he made his second visit and could no longer be considered as unsound.
§ Sir B. Stross
This, I understood, was his case. I am now giving the case as reported by the Executive Council.
The Executive Council then asked the dentist, who also received a copy of the dental officer's report, whether he was prepared to provide Mr. Smith with new dentures as recommended by the dental officer. But the dentist preferred to withdraw from the case. The hon. and gallant Gentleman knows what this means—that he would not charge for anything he had done. That is what "withdraw" means.
I should perhaps make it clear that in the course of these exchanges the Executive Council told Mr. Smith that the dentist was prepared to refund the statutory charge of £5. Moreover, Mr. Smith told the Executive Council that he was obtaining a new lower denture from another dentist. There was, therefore, no question at any time of these proceedings preventing Mr. Smith from securing necessary treatment. This is a point on which we must, I think, be agreed.
The Service Committee appointed a hearing—the hon. and gallant Gentleman has referred to it—at which both Mr. Smith and Mr. Joseph atttended. This was on 30th April. Both Mr. Smith and 351 Mr. Joseph gave oral evidence and Mr. Smith's teeth were again examined, this time by the dental practitioner members of the Committee. There were three of them, and, therefore, four dentists examined his teeth.
The Committee accepted Mr. Joseph's version of the events on 24th October, and although it considered that the dentures which he had supplied were unsatisfactory, it dismissed the case in view of the fact that Mr. Joseph was unwilling to continue treatment; it made the condition that the amount of the fee for the dentures should be withheld from Mr. Joseph's remuneration and that the £5 statutory charge should be repaid to Mr. Smith.
Mr. Smith appealed to the Minister of the day, and his appeal was allowed so far as it related to the dentures. This was on the ground that the dentist's withdrawal should not have been allowed to prejudice the complaint. The practical result, however, was the same—the amount of the fee was withheld from Mr. Joseph's remuneration and £5 was paid to Mr. Smith. The Minister felt obliged to dismiss Mr. Smith's appeal in so far as it related to his complaint that unnecessary work had been done because of the extraction of the wrong tooth. This is an important point to which I must now refer.
The hon. and gallant Member has complained that the handling of the case was characterised by, let us say, excessive bureaucracy and some muddle, perhaps, which involved time, expense and so on. In so far as this is not a reflection of Mr. Smith's dissatisfaction with the result expressing itself as a criticism of the procedure, I presume it arises from the considerable correspondence which has been entailed and the slow pace of events. Mr. Smith, admittedly, had to write many letters—we admit this—but the procedures require that both parties should, before the matter reaches the Service Committee, be entitled to state their own case and to comment on that put forward by the other party. The same procedure applies broadly on any appeal to the Minister from the decision of the Service Committee and Executive Council. This may take a certain amount of time—it does—but I am sure that the hon. and gallant Gentleman would agree with me that, regulations apart, no other method 352 of proceeding would accord with the requirements of natural justice. Both sides have to know what the other has said.
The family practitioner services which are provided under Part IV of the National Health Service Act, 1946, differ from the hospital and local authority services in that those providing the services are not employed by the authorities concerned. This is a great difference. These people work under contract with the Executive Councils to provide services as independent practitioners. It follows from this that there can be no question of Executive Councils exercising a discipline as an employer to deal with any shortcomings in the service. The fact that dentists are independent contractors is fundamental to an understanding of the purpose of Service Committees, and I turn to this for a moment now.
The Service Committee procedure provides a means of investigating possible failures of practitioners to observe their terms of service under their contracts, and where breaches are found it provides for a withholding of remuneration to compensate for the failure, or, in appropriate cases, for steps to be taken to obviate future breaches, and also enables Executive Councils in certain circumstances to refund the statutory charges which patients have paid.
The procedure is not intended to provide redress for the patient. If the patient wishes—this is a point made by the hon. and gallant Gentleman—to press for damages against a practitioner, that is a matter for an ordinary civil claim in the courts, and it is wrong to ask the Ministry to offer an ex gratia payment in any case whatsoever, for it is up to the patient to take action, and he has this absolute right that no one can take away from him. I mention this only by way of explanation and to clarify what seems to be a misunderstanding on Mr. Smith's part, because he has raised the question of compensation for pain and discomfort that he suffered both in the letters setting out his appeal and in the letters that he has written after receiving the Minister's decision. As I have said, the aim of the Service Committee procedure is to arbitrate not between patient and practitioner but on the contract between the practitioner and the Executive Council as the body responsible for this part of the National Health Service.
353 It is with these considerations in mind that this case falls, I think, into its proper perspective. The hon. and gallant Gentleman has made clear that there were two aspects to it. There were two fairly distinct issues, first that the dentist extracted the wrong tooth, and secondly that the dentures were unsatisfactory. We have accepted that the dentures were unsatisfactory, and action was taken and Mr. Smith was vindicated, and another denture was supplied to him, and he is not financially, therefore, the loser. As to the matter of a tooth being extracted wrongfully, that has not been confirmed in our view, and it is for that reason that Mr. Smith failed in his appeal, and the Minister could not support him.
I may perhaps step outside the bounds of the case to point out that the provision of excessive and unnecessary treatment, if it were proved to have taken place, is regarded as a serious matter indeed. The staff in the Ministry and the Dental Estimates Board are especially concerned with its prevention and detection. In this case the allegation that this had happened was not, we consider, substantiated. The hon. and gallant Gentleman contended that some more serious action than withholding the amount of the fee payable for supplying the dentures should have been taken. We disagree with him, on the advice given to us.
This debate has been well worth while, and I am indebted to the hon. and gallant Gentleman for having raised the matter. Time is well spent in considering the proper functioning of the National Health Service or the rights of the individual. The hon. and gallant Gentleman prefaced his remarks by speaking in glowing terms about the National Health Service generally, and he knows that he and I are in absolute agreement about that. We hope to improve it further as time goes by. That is the aim of us all, for it is a noble Service and we hope that any complaints can always be brought to the Floor of the House.
354 The hon. and gallant Gentleman made the point that it was a pity that this case should have had to be brought. remember a former Minister, Aneurin Bevan, saying—it was either in Committee or on Second Reading of the original Measure—that every aching tooth has a right to cry out in pain on the Floor of the House of Commons. The hon. and gallant Gentleman has done that tonight, and, although I do not agree with him, he knows that I am glad that he has raised this issue.
§ Mr. Speaker
Order. The hon. and gallant Gentleman requires the leave of the House to speak again. He may get it. I do not know.
§ Commander Courtney
By leave, I have two points to put to the Minister. First, I wish to correct him in one respect, although I thank him for his kind remarks. Mr. Smith was, in fact, £3 10s. out of pocket on getting the new dentures to replace the faulty ones. Secondly, is it not a fact that when the Minister allows one party to a dispute like this to withdraw from the case, it is obligatory on the other party having accepted the justice of the case?
§ Sir B. Stross
I believe that another tooth was filled by the second dentist. Perhaps this, in part, would explain why there was a further expense. This was separate from the extraction or fitting of the dentures. On the question of withdrawing, it is a technical term meaning that he no longer wished to defend the quality of the service given by way of the dentures. That means that he did not ask for payment for them. Since it is a technical term, I do not think that the question which the hon. and gallant Gentleman asked me really arises.
§ Question put and agreed to.
§ Adjourned accordingly at seventeen minutes to Eleven o'clock.