§ 7.30 p.m.
§ Baroness Gardner of Parkes rose to ask Her Majesty's Government what plans they have to increase the training of dentists and dental nurses in dental sedation following the abolition of the use of general anaesthetics by general dental practitioners.
§ The noble Baroness said: My Lords, I graduated as a Bachelor of Dental Surgery from the University of Sydney and, like many other Australian dentists, came to England to help to meet the great NHS need. I was in general practice in London for 35 years.
§ The Sydney teaching was totally opposed to general anaesthesia in dental surgeries. Although our predecessor left the gas machine he had used on hundreds of patients, I never used it. It was the most basic I have ever seen; a museum piece. It had none of today's safety devices or flow meters. We did all our work under local anaesthetic.
§ I believe it was in the 1960s that intravenous sedation and intravenous anaesthesia became common. I wrote to the dental press opposing those. Correspondents replied to ask me what I knew about it. I realised I knew nothing. I decided to enrol for any and all courses available to dentists so that I would be able to oppose general anaesthesia more effectively. The more I learnt, the more I appreciated that the role for general anaesthesia in dental practice was to enable patients to have treatment.
§ The extreme example of dental fear which remains in my memory is of a patient who arrived on time for his appointment but was too terrified even to enter the building for an hour afterwards. He had one of the worst dental abscesses I have ever seen and was in great pain. I remarked on a bone sticking out of his hand. He told me he had broken it but had been too afraid to see a doctor. It had healed itself in that malformed shape. His fear was palpable and his need very great. A local anaesthetic would not work with such an abscess. The 230 tooth was extracted by the operator within 30 seconds; the abscess drained and the patient fully conscious again in three minutes. A week later the same man walked happily into the surgery and had his other treatment under local anaesthetic. His fear was fear of the unknown. He had never been to a dentist in his life. He became a good patient.
§ Over the years I have given thousands of anaesthetics, for other dentists, for extractions or fillings.
§ There is always a risk in general anaesthesia and I am not opposed to the banning of it from the dental surgery from December 2001, but it is essential that patients should continue to have a way of overcoming worry, anxiety and, in the worst cases, genuine fear of attending for dental treatment. The need for sedation will increase.
§ For a child's first visit to the dentist to be when he is in pain can be a damaging experience which can last for life. Sadly, the most under-privileged children whose parents are totally unaware of dental problems are the ones who suffer most in that way. The Minister knows that I feel strongly that only fluoridation of water can help those children and I have drawn his attention often to the difference in dental standards between the children in the West Midlands, with fluoridated water for many years, and the North West of England. I refer him to paragraphs 2.6 and 2.7 of Modernising NHS Dentistry. The water companies have already made clear that they want the Government to make it mandatory. Only then will they fluoridate the water supplies.
§ If a person has been awake all night with toothache, it is essential that urgent and immediate treatment be given for relief of pain. Clinics or hospitals able to treat the tooth or, if necessary, give a general anaesthetic for extraction, must be instantly available. For a dentist simply to provide tablets for pain relief is not enough. If it is true that 100 children a week were having emergency dental extractions in Blackburn last year, what is the position now? What will it be after general anaesthetics are completely banned in 2001? How will the Minister ensure that there are adequate numbers of specialist anaesthetists in hospitals able to deal immediately with emergencies? Can he assure me that those children will not be condemned to waiting longer in pain? And has he considered providing that specialist service within his new dental access centres?
§ If, as is certainly the case, the need for anxiety and fear control in the dental surgery can no longer be met by general anaesthesia, then training in other forms of sedation is essential. Dental sedation can vary widely from simple words of comfort and reassurance, through oral medication by tablets, to intravenous treatment. But at all times the patient's needs must be met, and safely.
§ There are too few courses available to dentists. A few NHS-funded Section 63 postgraduate courses are provided by local postgraduate deans—not nearly enough. Outside London only Newcastle provides postgraduate training. The Society for the Advancement of Anaesthesia in Dentistry (SAAD) 231 runs private courses for 60 dentists at a time at £400 each and for nurses at £200 each. Dentists meet those costs from their own pockets. The fact that they do so is an indication of the importance they attach to learning how to provide the best and safest sedation. There are simply not enough courses. All SAAD courses are full until the end of the year.
§ The Department of Health's publication, A Conscious Decision, makes clear that many patients will not seek dental treatment unless they can be sedated. It is suggested that dentists unskilled in sedation can refer patients to those who do offer sedation. That does not work as most of those practices have as many patients as they can cope with.
§ Intravenous sedation is effective and, used correctly, safe. However, there is a fine line between conscious sedation and anaesthesia. It is essential that the dentist or dental nurse providing sedation should know the drugs to use and the correct dosage to give. Retaining contact with the conscious patient at all times is the only guarantee that it remains sedation. Even relative analgesia, which uses gases for sedation, can pose risks, as gases have to be titrated to match each patient's needs.
§ Many years ago, as a member of the local dental committee, I had the duty of acting for a practitioner whose sedated patient had died in the surgery. It was a horrendous case and totally indefensible. With improved knowledge, different drugs, safety precautions and training I do not believe it could happen now. That was the case of a seven year-old child, the intravenous sedation being given under the Jorgensen technique—a cocktail of particularly potent and dangerous drugs. The practitioner had never used the technique before and had no properly trained assistant with him nor resuscitation equipment. He injected a full dose and, thinking it was not enough, fatally repeated the dose.
§ One good suggestion now put forward is that a "mentor" system be used for newly-trained sedationists. I favour that. The tragedy I described would not have occurred if a supervisor, experienced and aware of patient reaction, had been present for the trainee's first practical use of this complicated technique. Nowadays emergency equipment must be available in the surgery. The Poswillo report was excellent in establishing standards. Designed for general anaesthesia they apply well to intravenous sedation. Dentists are trained in basic life support techniques and have the necessary resuscitation equipment to hand, not just for treating sedated patients, but any patient, as an emergency, can arise at a dental surgery at any time. The dental team has to be trained and ready and, as in the case of fire drills, regular practice is necessary.
§ There are costs in terms of time and money in all these training procedures, and NHS fees have the effect of limiting the amount of time a practitioner can spend on any procedure. The General Dental Council recommends that dentists doing sedation must have had relevant postgraduate training and undertake regular, continuing education.232
§ The Government must not forget that the dental contract, introduced after agreement with the British Dental Association in 1990 was opposed by 63 per cent of the profession, who considered it unworkable. National Health Service dentistry has gone steadily downhill since then. The General Dental Practitioners Association is another body representative of many NHS dentists. It is important that the Government, if they want their new dental NHS plan to work, consult the BDA, the GDPA and, in the matter of sedation training, the SAAD. Are the Government going to ensure that more courses are available for NHS dentists and will they make a commitment to funding those courses?
§ I hope that we shall hear from the Minister that sedation techniques will be given the necessary priority and funding will be made available to ensure that anxiety or fear do not prevent patients from attending for necessary dental treatment.
§ 7.40 p.m.
§ Baroness Rendell of Babergh
My Lords, I want to begin by thanking the noble Baroness, Lady Gardner of Parkes, for initiating a debate on this most interesting subject. The noble Baroness is an expert on the subject and I am not.
I am not a dentist, but I have very likely been to the dentist more than any Member of your Lordships' House. And while I speak as best I can, largely from the patient's viewpoint, I hope noble Lords will forgive me if my terminology is not always correct.
The United Kingdom is the only country in the world where general anaesthesia is commonplace for dental treatment. Every year 350,000 British patients—mainly children—have their dental work carried out under general anaesthetic. This tradition may derive from the fact that the first anaesthesia used in any connection is thought to have been carried out by the dentist, William Thomas Morton, who in 1846 used ether to send a patient to sleep for a difficult tooth extraction.
However, according to the BBC's online network medical notes, modern techniques mean that no dental surgery requires more than local anaesthesia, perhaps used in combination with sedation. The prevailing belief is that general anaesthesia, which has been called "a practice out of time", helps those suffering from a true phobia of dentistry, of whom it is calculated there are between 6 and 14 per cent in this country. But experts tell us that "being put to sleep" is not the best way to overcome fear of the dentist. In fact, I believe that my own—I think I can say "dreadful"—problems with my teeth began with my childhood terror of what I saw as being forced to lose consciousness and being sent to sleep against my will. The result of two such experiences kept me from the dentist's surgery for years, so that when pain at last forced me to go—well, I shall not harrow your Lordships with details.
Perhaps the only way for someone like me to conquer dentist-phobia is to do what I was obliged to do if I was not to lose my teeth at an early age, as my 233 parents did. One has to make oneself attend for checkups so often that the dentist's surgery ceases to terrify and becomes commonplace. For me, sedation with Valium while my heart rate is monitored has become rather a pleasant experience. Indeed, I have sometimes, while having root canal treatment or a bone graft, done that which I would once have believed impossible and fallen asleep.
Only if the procedure is carried out in a hospital will general anaesthesia still be possible. This may continue to be the only option for children, often those from a socially deprived community who suffer from advanced tooth decay. Valium for conscious sedation can only be given to them orally, so my dentist tells me, in syrup form, which means a half-hour delay in a waiting room, a place which may already be unnerving, before it takes effect.
General anaesthesia for any medical procedures always carries a risk, as the noble Baroness, Lady Gardner, has told us, albeit a very small one. But if it is taken out of the dentist's surgery, as it will be, and conscious sedation finds its place in mainstream dentistry, a gap will inevitably be left in dental practice. This situation, as your Lordships have been told by the noble Baroness, is causing serious alarm among practitioners. Far from all dentists and dental nurses are competent to administer conscious sedation. The answer to safe sedation lies in first ensuring that students at least graduate fully aware of these important skills as part of overall pain and anxiety control.
When I was at the dentist's last Thursday—where else?—I asked the dental nurse her views on taking a training course in sedation techniques. She was enthusiastic and agreed that it would interest her very much. Another dental nurse has since told me that she would enjoy expanding her horizons and taking on more responsibility in this way.
Dentists and dental nurses should also be psychologists in order to cope more effectively with anxious children and those who have grown into anxious adults. The Society for the Advancement of Anaesthesia in Dentistry, referred to by the noble Baroness, will this year hold its annual conference on the subject "The Anxious Child". One speaker attending, an expert on clinical hypnosis, claims that treating children under hypnosis reduces stress levels for both patient and practitioner. Another is a consultant health psychologist who works with plastic surgeons helping children cope with painful and invasive treatment. Then there is a doctor who has worked in the community dental service for 25 years, using inhalation sedation for most of that time, mainly for anxious children.
This seeming digression of mine is in fact pertinent, for I believe that the merits of conscious sedation against general anaesthesia cannot be examined without taking in the issue of patient fear. My grandchildren in the United States attend a dentist where the environment is so delightful and child-oriented, with so many diversions, games and so on provided during the waiting time, followed by an 234 encounter with a charming and likeable dentist in an attractive room, that fear of dentistry has never occurred to them. When we achieve similar conditions in the United Kingdom we shall have begun the task of raising a generation with perfect trouble-free teeth who may never need anaesthesia or sedation at all.
§ 7.46 p.m.
§ Lord Colwyn
My Lords, I, too, thank my noble friend Lady Gardner for introducing the debate and congratulate her on her good timing. This is the first debate on dentistry since the delayed Dental Strategy report, which promises £100 million to create new capacity for dentists to provide treatment on the NHS, to support the modernising of practices and enable everyone to find an NHS dentist by the end of next year.
The dental profession has always been at the forefront of efficient pain and anxiety control. As we heard from the noble Baroness, Lady Rendell, it was a dentist who administered the first ever general anaesthetic. I hope that the Minister will be able to confirm that funding will be made available to improve training for dentists at both under and postgraduate level, and to train ancillary staff in this important aspect of clinical expertise which has evolved from general anaesthesia.
I have several interests to declare which have prompted my asking the exact same Question as my noble friend on various occasions over the past two or three years. When general anaesthesia was first banned for operator/anaesthetists, then for two dentists working together and then totally in dental surgeries, I was unable to find any correlation between protection of the public—for that is what we are talking about—and the providers of the treatment. The Minister and his predecessor, the noble Baroness, Lady Hayman, and previous Ministers from both parties have answered my many questions on this subject for more than 30 years.
Between 1991 and 1999 there have been 12 deaths associated with general anaesthesia in dental surgeries. Only two of those regrettable deaths were caused by a dental practitioner. All 12, because they occurred during dental treatment, created massive interest in the media and resulted in the dental profession being severely criticised for incidents that are very rare and are predominantly caused by either medical practitioners or anaesthetists. I am sure that the Minister will not wish tonight to tell us how many anaesthetic deaths occur each day in our hospitals and clinics which do not receive any such media attention.
I have been a dental anaesthetist and provider of dental sedation for more than 33 years. I have administered something in the region of 60,000 anaesthetics and sedations and continue to provide a service for nervous patients using sedative techniques. I am the immediate past-president of the Society for the Advancement of Anaesthesia in Dentistry and was a member of the general anaesthetics/sedation review group of the General Dental Council.
235 There are significant numbers of actual and potential patients who have a genuine fear of dental treatment. This evening the noble Baroness, Lady Rendell, has provided graphic detail of that. I admit that I prefer to be sedated when my teeth are being treated. Since I started working on sedation there have been several working parties and reports: the report of a joint sub-committee on dental anaesthesia to the Central Health Services Council in 1967; the Wylie report on the working party on training in dental anaesthesia in 1978; the Seward report on training in dental anaesthesia in 1981; the Poswillo report in 1989, which caused the greatest upheaval; and, most recently, the report of a group chaired by the Chief Medical Officer and Chief Dental Officer entitled A Conscious Decision.
Each report has eroded the right of dentists, many with considerable experience, to work as they would wish and to administer general anaesthetics. The latest puts general anaesthesia where we all knew it would end up, in hospital, leaving conscious sedation where it belongs, in mainstream dentistry. The report also concludes that the answer to patient safety in conscious sedation lies in education at both undergraduate and postgraduate levels.
From the end of December 2001, all general anaesthesia in dentistry must be in district general hospitals, and current providers must meet rigorous standards. The report also defines "district general hospital" for the first time, which surely will have wide repercussions as to the way in which medicine is practised in this country. Perhaps the Minister can say when similar restrictions will be placed on medical practitioners who carry out procedures under general anaesthetic away from the intensive care facilities of a district general hospital.
Among the 10 recommendations there is a requirement to follow the lead taken by the GDC's document Maintaining Standards which highlights the need for higher standards in resuscitation training throughout the profession and a requirement to collect data on fatal and non-fatal complications in both general anaesthesia and conscious sedation.
In August I tabled a Question for Written Answer (HL3770) and was informed by the Minister that no data was available on morbidity or private sector provision. The noble Lord promised that his department would take it forward, and I am delighted by the report's finding that the Royal College of Anaesthetists and the Society for the Advancement of Anaesthesia in Dentistry should undertake this study. Can the noble Lord tell me when that is likely to begin?
It is vital that the importance of undergraduate teaching in sedation is fully realised. If the teaching hospitals cannot yet produce new dentists who on graduation are competent to administer conscious sedation, at least they should be fully aware of the potential of those skills as part of overall pain and anxiety control for their patients. The dental schools are all working towards improved training in sedation techniques; some are doing better than others. In the 236 postgraduate field, standards also vary. I am proud of my association with the Society for the Advancement of Anaesthesia in Dentistry whose two courses each year for general dental practitioners and dental nurses are widely respected and almost full before they are advertised.
I am sure the Minister will tell us that there are plans to fund training in sedation, but I remind him that conscious sedation means that the patient remains awake; it is not an analgesic and local anaesthesia is still required. Patients may not lose consciousness.
In the days when a practitioner could prescribe the treatment that he or she considered best—for example, for the removal of decayed teeth to alleviate pain or for orthodontic reasons—it could be done safely in a few minutes under a one-minute general anaesthetic. That is now not possible. Apart from the very light sedation with nitrous oxide and oxygen, it is very difficult to sedate children with modern drugs and many cases must now be referred to hospital. In the past I have asked the Minister whether that will influence waiting lists, and I repeat that question this evening.
In conclusion, I am sure that in debating dental matters this evening the Minister will use this opportunity to confirm that, following publication of the report on fluoridation by the University of York, he will take immediate steps to ensure that water authorities add fluoride to all public water supplies. That simple move would at least take away some of the need for general anaesthesia in dentistry.
§ 7.54 p.m.
Lord Carlile of Berriew
My Lords, I join with others in congratulating the noble Baroness on securing a debate on such an important matter. I am puzzled as to why we do not debate dentistry a little more often in either House, willing as we always are to place the microscope on the rest of the medical profession. It would be good for dentists, their science and craft if we spent a little more time talking up the achievements of dentists, especially explaining that a little discomfort in the dentist's chair when young can spare us much pain on Thursday afternoons when we are older, as implied by the noble Baroness, Lady Rendell.
Apart from some years of concern and activity on the issue of medical and dental ethics, I claim no credentials for speaking in this debate other than the rather important one that from time to time I am a dental patient. I defer willingly to the technical expertise of at least two speakers in the debate so far, although I notice that the noble Lord, Lord Colwyn, did not declare as an interest—perhaps advisedly—his chairmanship of the Refreshment Sub-Committee. However, as the grandson of a hilariously entertaining orthodontist, I never thought the dentist to be an ogre. I vividly remember that the dentist father of my first school friend manufactured a denture for Dan, his springer spaniel. That led me to the early view that dentists were kind and, to say the least, versatile.
My general practitioner father used to administer general anaesthetics in that dentist's surgery. Both he and the dentist were experienced and skilled and, 237 fortunately, nothing went wrong. However, by the 1960s my father had decided that, whatever he had learnt about anaesthetics during his early training, which had been in the 1920s and during the second world war dealing with wounded soldiers, general anaesthetics were best left to people who did nothing else and in a proper clinical setting.
Nearly 40 years later we have the very welcome decision by the Government that general anaesthetics for dental treatment in England should, from January 2000, be administered only in hospitals. As a Welsh resident, I welcome that and seek an assurance from the Minister that that could be extended to Wales if adopted by the Welsh Assembly.
It will be helpful if the Minister reminds the House of the extra resources that hospital services will expend in providing those facilities at the beginning of 2002. Can he confirm that those resources will be provided as an addition to the relevant NHS budgets? Will he also assure us that the additional specialist and associate specialist clinicians and nurses will be fully funded by extra money so that there is no drag on other provision in the NHS?
1 suggest to the Minister that a continuing part of the Government's health education policy should be to educate children that dentistry does not hurt—or not much—that there is nothing to fear, and that awareness of what is happening during treatment is grown up and sensible. Surely, the prime aim should be a continuing reduction in general anaesthetics in dentistry whenever it can be avoided. The success of that aim would be assisted by a stronger commitment to conscious sedation which is referred to in the Question tabled by the noble Baroness. I shall not repeat what has already been said about the advantages of conscious sedation. However, I hope that, as part of a progressive approach, where children are sedated relative analgesia becomes the norm as it is elsewhere in countries with good dental health among their child populations.
I am advised that relative analgesia has very wide safety margins, which obviously makes it advantageous in use with children. This means that the Government should engage with dentists through their representative bodies to ensure that proper fees and, where appropriate, capital grants or loans are paid to increase the practice of relative analgesia for children in this country.
I hope that the Minister will be able to confirm that when the new arrangements which remove all general anaesthetics into the hospitals come into practice, rural areas will not be disadvantaged. As he knows, rural areas have been poor relations with regard to NHS dentistry, and this has certainly been the case in the part of Wales where I live and which I represented in the other place for some years.
Finally, I should like to address some ethical considerations which are especially important in cases of anaesthetised and sedated patients. In Maintaining Standards, the ethical guidance issued to practitioners by the General Dental Council, there are set out commendably clear and firm standards for the 238 profession. As the noble Lord, Lord Colwyn., said, fortunately the cases in which deaths have occurred during anaesthesia in a dentist's surgery have been rare. Nevertheless, the general public have the expectation that any significant failures will be met by firm action. The few who do not practise responsibility for the competence of their whole teams, including their nurses, diminish the diligence and good reputation of the majority who do.
The taking of a full history, the obtaining of informed consent, the keeping of careful and contemporaneous records, the duty to act only within their range of fully trained competence, the willingness to refer elsewhere, the presence of a third party whenever treating children or sedating patients are all elementary examples of areas of failure that the profession must continue to police rigorously. So is incompetent sedation, however rarely it occurs.
I say that because, as never before, the self-regulation of the professions is under scrutiny and even threat. The medical and dental professions are well to the front of the firing line in that context. I trust that Her Majesty's Government will keep the effectiveness of the self-regulatory organisations and their willingness to change under review. I believe these professions will continue to adapt with the times and that self-regulation remains appropriate, albeit modified from its present form. But it should never be taken for granted that the professions are able to adapt in an acceptable way. That is why scrutiny is needed.
§ 8.2 p.m.
§ Earl Howe
My Lords, with the notable exception of my noble friend Lord Colwyn, there can be few noble Lords as well qualified as my noble friend Baroness Gardner to introduce a debate on dentistry, and she has done so in her customarily succinct and compelling way. This is without doubt an issue that has important ramifications for public health. As my noble friend has explained, there is cause for some considerable concern about it.
That concern does not relate directly to the Government's decision in July to remove dental general anaesthesia from dental practices. The British Dental Association has been calling for that to happen for some time. Indeed, anyone who has been even dimly aware from press reports of patients who have died as a result of receiving general anaesthetics in dentists' surgeries will have little doubt that the issue is one that needs to be addressed. The UK is one of only two countries in Europe that allows general anaesthetics to be given in the surgery.
Last year 48,500 general anaesthetics were administered in general dental practice in England on the NHS. It is a procedure that most of the time can be conducted perfectly safely. But from time to time there are tragedies. One death in a dentist's chair is one death too many. It is sensible and right that from the end of next year dental general anaesthetics should be carried out in a hospital setting, where there is all the necessary equipment for safe delivery of anaesthetics as well as ready access to emergency facilities.
239 Some in the profession maintain that far too many general anaesthetics are administered unnecessarily in dentistry, notwithstanding the fact that the number of such anaesthetics has fallen quite sharply over the past few years following guidance from the General Dental Council. Whether or not that is a valid judgment, it is obvious that the latest change of policy will serve to limit the availability of general anaesthetics in dentistry still further. It is important to realise that this will have consequences. There is a minority of patients—perhaps 10 per cent—for whom fear of pain during treatment is a major obstacle to going to the dentist. Some cannot even countenance the pain of having an injection for a local anaesthetic in the gum. Unless the anxiety of such patients can be alleviated, they will almost certainly not seek treatment at all.
Pain control by sedation is the well-tried route to achieving that. Sedation is of course safer than a general anaesthetic because the patient does not lose consciousness. Its importance in dental practice is therefore growing and likely to grow further. But, as my noble friend has explained so well, there is now a serious worry that too few British dentists receive adequate training in sedation techniques. An article by Leitch and Girdler in the British Dental Journal of 26th February of this year sets out the basis for that concern. In the light of questionnaires sent to the 16 dental schools in the UK and Ireland—13 of whom replied—a picture emerged of some serious variations in dental undergraduate teaching. At most schools students gained little or no hands-on experience in sedation. Only two schools had departments dedicated to the subject. New graduates felt that they were inadequately prepared in the practice of sedation. In two schools there were no lectures or seminars on it whatever.
The article lists some revealing comments by staff. One said:Sedation is seen as a separate subject, not as an adjunct to treatment".Another said:We need greater facilities to be able to implement hands-on training".Another said:Not enough teachers, insufficient time in the curriculum, inadequate facilities".From someone else:Insufficient time to supervise sedation".And again:The teaching is left to one department. There is a flat refusal to introduce sedation into other departments".Finally one said that sedation is "very under-funded".
Those remarks, and the findings generally, suggest that there is much to be done. For a long time the GDC has recommended that undergraduate and postgraduate dental students should have a sound knowledge of the theory and practice of sedation; that is to say, sedation by means of intravenous injection and by inhalation of gas and air. It has also recommended that there should be collaboration 240 between dental teachers and anaesthetic departments in dental schools. Not only does that not happen for the most part, but where sedation is taught, Leitch and Girdler found that the students believed they were getting an adequate education in the subject when in fact they were not. It is bad enough to know that you are ignorant. It is even worse to be ignorant and believe that you are adequately informed, not least because of the repercussions that that might have for patient.
I hope that the Minister will not say that it is for the dental profession to put its own house in order. If, as seems indisputable, there is a need to invest more money in sedation training, that cannot be done by the schools on their own. The common core curriculum now being considered by the Faculty of General Dental Practitioners needs to be encouraged and funded. I should be glad if the Minister could say what the Government are doing to provide improved funding for dental training. In particular, does he agree that there have been savings made in the NHS budget since the end of 1998 as a result of the decrease in general dental anaesthesia; and will he consider redirecting those savings into sedation training?
The Government have made much of their pledge to widen access to NHS dentists. That is an admirable objective. However, there is also an agenda to improve quality, not only in NHS dentistry but also in private dentistry. In the recent report by the Chief Medical Officer and Chief Dental Officer entitled A Conscious Decision, there are recommendations on promoting high standards of sedation and sedation training, and higher standards of resuscitation. It is noticeable that the Government's dental strategy pays scant acknowledgement to those recommendations.
A further and significant recommendation is that comparable standards should be maintained and enforced in NHS and private dental practice. My mind goes back to the debates we had on the Care Standards Bill only a few months ago when I argued the case for a single, overarching system of inspection and enforcement for both the NHS and the private sector. That case was not accepted by the Government, but the issue is still in sharp focus. I should be glad to hear from the Minister how he proposes to ensure that standards of care in both sectors are indeed comparable. Can he also say by what regulatory means general dental anaesthesia is to be banned from private dental surgeries?
The criticism of the Government's dental strategy voiced by the BDA, which I feel I have to echo, is that there is nothing all that new in it. What appears to be new is the funding element, but the £100 million announced for NHS dentistry turns out on further examination to include £40 million already announced earlier in the year. I worry that that will not be enough to tackle the underfunding of NHS dentistry, and especially the problem of poor retention of NHS dentists, about which the strategy document says very little. The danger, to my mind, is that the Government have raised expectations beyond what is realistically deliverable within the timescale that they have set for 241 the strategy. I hope that the Minister will be able to provide us with reassurance that the strategy is indeed comprehensive and that it is on track.
§ 8.10 p.m.
§ Lord Hunt of Kings Heath
My Lords, I pay tribute to the noble Baroness, Lady Gardner of Parkes, for giving us the opportunity to debate this issue. She has always taken a keen interest in NHS affairs generally and her expertise in dentistry is well known both in your Lordships' House and beyond. She shared with us her 35 years' experience in dentistry, which brought home to me the real fear experienced by some patients when they receive dental treatment and the skills of so many of our dentists in meeting that challenge.
It is good that we are able to debate dentistry today. I share the regret of the noble Lord, Lord Carlile, that we rarely have that opportunity. I certainly believe that we are well served by the dental profession and that we should see dentistry as being very much a core part of the National Health Service. I feel slightly pained that the noble Earl, Lord Howe, should say that there is nothing new in the dental strategy. It presents a cohesive set of proposals and intentions which will improve access for patients, improve quality, improve regulation and empower patients through better information. It seeks to ensure that health authorities are given a pivotal role in the future so that the strategy is delivered at local level.
One of the problems of the past few years is that dentistry has become rather disengaged from the NHS at local level. The NHS faces a major task in re-engaging with the profession and with local dental committees. It must also ensure that the contribution dentistry has to make to the wider NHS picture is fully recognised. I mention as one example the role of the health improvement programmes which represent the plans and programmes of the local health community in terms of both assessing health needs and ensuring that the services provided and the plans agreed meet those needs. I want to see dentistry being fully part of that process. It has been made abundantly clear to the NHS locally that engagement of the NHS with dentistry is to be a priority and that it can expect to be performance managed vigorously to ensure that that happens.
One other issue was raised which is rather more general than the Question before the House today. It is a favourite subject of mine—fluoridation. As someone who lives in Birmingham, I am well aware of the dental benefits of fluoridation. As the noble Baroness rightly pointed out, perhaps the most vivid impact of fluoridation can be seen in Sandwell, which essentially is West Bromwich. It is one of the most deprived health communities in the country, yet it is in the top 10 in terms of oral health because of fluoridation. As noble Lords will know, a report by the York Centre was published less than a week ago. It showed that fluoridation of water helps to reduce tooth decay. It also indicated that from the research reviewed—hundreds of pieces of research world-wide were reviewed—no association could be found between water fluoridation and cancer, bone fracture or 242 Down's Syndrome, which is what had been alleged. The report did refer to a higher incidence of fluoride levels. My conclusion is that, certainly in areas of high tooth decay, health authorities should continue to see fluoridation as one option in their oral health strategy.
As far as concerns legislation, constructive discussions are taking place with the water companies. I think it better to wait to see the outcome of those discussions before we look at the potential for legislation.
The noble Baroness, Lady Gardner, referred to the real fear of patients and my noble friend Lady Rendell brought that vividly to our attention. We must all share the noble Baroness's ambition to see children visiting the dentist without fear. That is the challenge before us. In the past few years there has been considerable debate in relation to the use of general anaesthesia. It was in November 1998 that the General Dental Council issued ethical guidance which effectively prohibited dentists from providing general anaesthesia. That was prompted by a number of deaths, particularly of young children, that had occurred in the late 1990s and coincided with a small but definite rise in the number of general anaesthetics being administered for dental treatment.
Following the GDC ethical guidance, the numbers of general anaesthetics provided in high street, dental practices fell by about 80 per cent. What seems clear from that is that there has not been merely a straight and equal shift since 1998 from providing general anaesthesia to providing sedation as an alternative method of pain and anxiety control. What has clearly also happened has been a reappraisal by many dentists of the pain and anxiety relief measures needed for those patients who formerly were regarded as general anaesthetic cases. That has undoubtedly made for a safer environment in high street dentistry.
At this stage, perhaps I may refer to the speech of the noble Lord, Lord Colwyn. The noble Lord is a past president of SAAD. That has been at the forefront of pioneering training in all forms of dental anaesthesia and conscious sedation. As an experienced sedationist for dental treatment, the noble Lord has been a most valued member of the General Dental Council's working party on sedation. More recently, his advice to the council when amending its ethical guidance regarding general anaesthesia and sedation has been extremely helpful.
At the same time that the GDC announced its revised ethical guidance in 1998 my right honourable friend Alan Milburn, then Minister of State for Health, asked the Chief Dental Officer and the Chief Medical Officer to review the use of general anaesthesia and sedation for dental treatment. The report of that review, entitled A Conscious Decision, was published this summer and the Government have accepted its recommendations.
It was an extremely interesting review. It charted provision over the past 35 years, together with its accompanying mortality. It looked in detail at current provision and provided an analysis of its strengths and weaknesses. The review recommended unequivocally 243 that the provision of general anaesthesia for dental treatment should be confined to a hospital setting from 1st January 2002. The deadline was set because it was recognised that change could not be achieved in an orderly manner overnight.
The review considered that sedation when the patient is awake and can respond verbally is safer than general anaesthesia, but the administration of any drug which can alter the mental state of a person is associated with varying degrees of risk. As I stated earlier, we have not seen, nor would we necessarily expect there to be, a direct switch over to sedation for all previous general anaesthesia cases. It is important that verbal contact should be maintained with a patient. Furthermore, the report considered that any technique, including so-called "deep sedation", which was intended or was likely to render the patient unconscious at any time, should be regarded as general anaesthesia. We are particularly keen to maintain the downward pressure on the provision of general anaesthesia regardless of where it is provided while ensuring that pain and anxiety control for dental treatment is appropriate and clinically indicated.
This is not a matter only for government. I accept the point made by the noble Lord, Lord Carlile, that self-regulating professions such as medicine and dentistry also have a direct responsibility for patient protection. As matters of general good clinical practice, individual practitioners should be looking at their working methods to see how they can be improved, in particular when faced with patients who are disproportionately anxious. To that end, I very much agree with what my noble friend Lady Rendell had to say.
We are not aware of general problems as regards the provision of conscious sedation within the general dental services of the NHS, but if specific issues have arisen we shall be glad to be informed of them so that appropriate action can be taken.
Perhaps I may turn to the matter of postgraduate training because it is clearly an important point that arose several times during the debate. Postgraduate training in sedation has increased over the past decade and since 1991 it has been a priority topic for postgraduate training in the public sector. In 1998–99, almost 450 courses in England funded by the department through the National Centre for Continuing Post-graduate Education of Dentists were related to sedation. However, I wish to assure noble Lords that we are not complacent. We are already taking steps to increase the provision of training so that dentists are able to deliver conscious sedation that is both effective and safe for those who need it.
The review of general anaesthesia and sedation emphasised that, in the shorter term, we need to concentrate on the provision of practically-based courses. The NCCPED has established a group to assess the current provision of sedation training and to provide proposals for delivering an increase. The group is expected to report at the turn of the year, with 244 recommendations to the director of the NCCPED. That will then allow a year in which to increase the number of dentists trained in sedation.
As regards the issue of dental nurses, again I very much agree with the noble Baroness, Lady Gardner, and my noble friend Lady Rendell on the role played by dental nurses. Ethical guidance issued by the GDC in May 1999 states that all staff must be trained in the use of conscious sedation and as a team in the management of sedation-related complications. This is of particular importance where the dentist is combining his normal role with that of a sedationist. The report A Conscious Decision recommends that an assistant to the sedationist should be present throughout the course of dental sedation. Furthermore, dental nurses are of crucial importance should there be a catastrophic collapse of the patient. While it is intended that dental nurses should be registered with the GDC and we would certainly want to see training needs considered in that context, in the short term we also wish to see what recommendations are to be made for dental nurses in respect of sedation training needs by the NCCPED working party.
The noble Lord, Lord Colwyn, and the noble Earl, Lord Howe, mentioned the training of undergraduate dentists. Again, I do not think there is any doubt that at present the situation is somewhat patchy at best in UK dental schools. We accept that, in the longer term, this must be addressed more comprehensively within the curricula. That has to be the way forward. On graduation, dentists and dental staff must have sufficient knowledge of, and reasonable experience in, the use of sedation techniques, as well as knowledge of their personal limitations, what further training they may require and when they should refer more complex cases. In that respect, two documents have recently been published by the Dental Sedation Teachers Group. One sets out guidelines for teachers while the other sets a standard for the competent graduate. Those are to be commended.
A number of points were made concerning the ability of dentists to undertake such training—not in terms of the number of courses but in terms of their abilities as dentists to be able to take it on. Clearly, the context in which that has to be considered is so as to ensure that we establish an environment in which clinical quality flourishes. That is why we shall introduce clinical governance to dentistry through three main routes. First, we shall ensure that all dentists participate in clinical audit and peer review. Secondly, we shall increase investment in continuing professional development so that dentists committed to the NHS receive support for the 15 hours of verifiable training they will need to undertake each year to meet the GDC's recertification requirements. Thirdly, we shall implement the other measures which the GDC wishes to take to strengthen the self regulation of dentistry. If I have sufficient time, I shall return to the issues raised by the noble Lord, Lord Carlile, in relation to the GDC.
245 I was asked about waiting times in dental specialties. I am glad to report to the House that, when comparing the quarter ending in June 1999 to the quarter ending in June 2000, the number of outpatients kept waiting for 13 weeks or more for treatment by the dental specialties declined by 15.2 per cent. That compares to a reduction for all medical and dental specialties of 8.3 per cent. However, we shall need to keep that under review in terms of any extra demand which is likely to be placed on hospital services.
The noble Baroness, Lady Gardner, raised the issue of the North-West and I believe that she specifically mentioned Blackburn. I have not received any specific reports of difficulties in that area, but I am very willing to look into the matter if the noble Baroness would care to furnish me with further information.
The noble Lord, Lord Carlile, asked about the situation in Wales. I am not sure that I am allowed to say anything about Wales; indeed, I am quite sure that I am not allowed to do so. However, I understand that the president of the GDC opened a new facility for the training of undergraduates and postgraduates in conscious sedation at Cardiff Dental School. Furthermore, I take the point raised by the noble Lord as regards rural areas. That is as relevant an issue in England as it is in Wales.
The noble Lord, Lord Colwyn, asked about the study. SAAD will shortly be submitting a proposal. Officials at the department will be discussing the issue with the Royal College of Anaesthetists later this month. I hope that we shall be able to make progress as soon as possible. The noble Lord also asked about restrictions on medical practitioners. Interestingly, in the report from the CMO/CDO, the issue was referred to obliquely. Of course, the remit of the group was to look at general anaesthesia for dental treatment. It concentrated on that, but it did go on to express the hope that other procedures which carry similar levels of risk will come to have in place the same standards. If evidence is produced that other procedures carry similar levels of risk as those of general anaesthesia for dental treatment, we would consider that and make our decisions on an individual basis.
The noble Lord, Lord Carlile, also raised the issue of relative analgesia. All I would say here is that I agree that it is the preferred method of conscious sedation for most children. As regards resources, all I would say is that the context in which we are discussing this must be the record amount of resources that this Government are putting into the National Health Service over the next four years, which in real terms will allow it to grow by a third.
In regard to the important issue of self-regulation, the GDC has submitted a range of proposals to strengthen self-regulation. We are preparing the necessary legislation to put these improvements into effect. The GDC is also working on proposals for the investigation of complaints about private dentistry which fall short of serious professional misconduct.
246 I thank all noble Lords for their contributions to an excellent debate. We should perhaps have more debates about dentistry. I hope that I have assured the House that we are very much alive to the need to ensure that appropriate training is in place for both dental practitioners and dental nurses and that we shall keep the matter under close review.