Mr. Fintan Hourihan:

I thank the Chairman and the committee for inviting us here. We are delighted to have the opportunity to address the committee. We have prepared a submission, which I believe has been circulated. I intend to speak only on parts of the submission, but we felt that as we had an opportunity to come before the committee we could in the submission address other issues about which questions are often asked. I intend to speak primarily about the State schemes and the services that the HSE provides for children.

In our executive summary we explain the critical importance of oral health and its connection to general health and summarise our main recommendations. I will start by reminding everyone that there are two State-funded schemes: the PRSI scheme - the dental treatment benefit scheme, as it is formally known - and the medical card scheme, the DTSS. Approximately 2 million taxpayers are entitled to benefit from the PRSI scheme funded by the social insurance fund. Since the budget of December 2009 the scheme has provided only one item of dental care, which is the annual oral examination. Prior to that - we will elaborate on this later - there was an extensive range of routine preventative and restorative treatments provided free or subsidised by the State. That has all been withdrawn.

In the case of the medical card scheme, the eligibility for medical card holders is increasing. In the December 2009 budget it was decided for the first time to cap the level of spending on the scheme. Similarly to the PRSI scheme - again, we will elaborate on this later - there was an extensive range of routine preventative and restorative treatments provided free to patients. That has been severely curtailed. It is now effectively an emergency pain relief scheme only. We feel that is causing profound difficulties for a very vulnerable cohort of patients, because oral health is a condition that is inextricably linked to social status.

I will talk about the difficulties in the public dental service later, but I wish first to make a point about dental care which we feel is often not properly understood. Dentists form one of the few groups of health professionals who do not receive any financial support from the State. They rely entirely on their own funds to set up in practice and to meet their running costs. Whereas the State spends €3.6 billion annually staffing and equipping hospital medicine, there is no comparable assistance provided for dental care in the community. Likewise, before a penny is spent on caring for medical card patients, GMS doctors in general practice can receive up to €100,000 per annum in grants towards employing nurses, secretaries and practice managers in rural locations, and there are pension payments available to doctors.

We consider that is entirely appropriate but again we would like to explain that none of that support is available to dentists. Likewise across the Border, dentists in Northern Ireland are entitled to extensive state supports. Dentists in the Republic do not receive a single cent towards the running of their practices. Given that they have to rely entirely on generating attendance and income to cover costs, most of which are fixed or State controlled, it is hardly surprising in these difficult times that with falling attendances practices are closing. We estimate there have been 1,500 redundancies in the sector in the past few years. This will never be noticed in the same way as the closure of a high profile multinational but the effects are just as real. Equally, entire classes of graduates are forced to emigrate because of the lack of viable opportunities. In spite of that, dentists are committed to providing care. They display their fees openly. They have reduced or frozen their fees and we believe that very often that is not properly understood or appreciated. We want to put what we are going to say in that context.

We estimate currently, as a result of the rationalisation within the sector there are probably still 8,000 people whose employment is directly or indirectly associated with the practice of dentistry in the Republic of Ireland. Many of the problems which impact on patients also impact on people who are employed in providing care for patients.

Members will note on page 9 of my presentation that the PRSI scheme was established in 1952. Everybody continues to pay their PRSI contribution into the Social Insurance Fund. However, in 2009 this scheme was restricted to one item, which is the annual oral examination or check-up. That had an immediate effect. Members will note there was an 87% cut in expenditure on the scheme from €69 million in 2008 to €9 million in 2011. We are not aware of any other part of the broader health service which has experienced such a cut. Ironically, while the benefits under the scheme have decreased, the rate of PRSI has increased. We consider it is particularly unfair for people who have paid PRSI contributions for a long period to find that they are now unable to avail of dental treatment. As I will go on to explain, that has a direct consequence in that people are not inclined to attend for treatment any more and that has an immediate knock-on effect in terms of their oral health. Members will note from the table on the bottom of page 9 that prior to 2010 an extensive range of treatments was provided by the State through this scheme including an oral examination, cleaning, gum cleaning, fillings, extractions, root canal treatments, X-rays, dentures, etc. These are all the essential routine items of care which we believe the State ought to consider restoring gradually over time.

Members will note on page 10 that there are currently 1.4 million medical card holders eligible for this scheme. It is managed by the HSE and the care is provided by dentists in private practice. Dentists provide this treatment in their own self-funded practices on a fee per item basis. They are only paid when people show up. They do not block grant. It is not a capitation-based system.

Despite the surge in the number of medical card holders in recent years, the budget for the scheme was capped for the first time at the 2008 level of expenditure of €63 million. For the past two complete years for which we have official figures, the number of eligible persons increased by more than 17% and expenditure decreased by more than 41%. As members can imagine, that has had a very obvious effect on the extent of care provided.

Members will note on page 11 we provide a summary of the care that was previously available and the care that is currently available. In short, it is essentially an emergency pain relief scheme only. We believe that is not acceptable. This is not a Third World country. Next month it will be almost three years since the cutbacks were introduced and yet three years on the HSE has still failed to inform medical card holders of these cuts and has failed to give any sort of advice or warning regarding the implications of these cutbacks. Dentists deal with queries on a daily basis from patients who are trying to figure out to what they are entitled. Patients and even treating dentists are unsure of what is provided for. The availability of treatment is extremely subjective depending on the budget available and the individual funding available through the local HSE principal dental surgeon.

In addition to the unfair nature of the scheme, the cuts do not make any economic sense. Research has shown that the costs of poor dental health are largely borne by the most disadvantaged. In some cases this means people are living with painful and possibly unsightly dental issues which can cause or exacerbate other illnesses and reduce their capacity to get employment. Poor dental health and the inability to afford private health care undermines a person's ability to participate in the social and economic aspects of life.

I cite a study, which is not included in the submission, carried out in California which examined the cost of dental neglect. It found that the ounce of prevention by way of the oral examination is outweighed by a pound of cure, namely, that the cost of an emergency visit to the local hospital is 123 times greater. In other words, the cost of not having an oral examination is 123 times greater if a consequence of that is that one ends up having to attend a hospital for emergency care and treatment afterwards. There are similar comparable studies throughout the world. The great pity is that because we do not have research on this in Ireland we do not have up to date figures but the anecdotal evidence suggests that Irish patients and the population generally are suffering the same effect.

We in the Irish Dental Association regularly carry out surveys among our members and we commission surveys of the general public to establish what are the effects of these cuts. Members will note on page 13 that the most recent survey of dentists last November showed that 77% of dentists saw an increase of patients presenting in pain, 92% saw an increase in patients presenting with gum disease, nearly 90% saw an increase in patients presenting as emergencies, and there has been a comparable increase in patients presenting with dental infections and in patients presenting with multiple decayed teeth. We have commissioned research of the general public carried out on our behaviour by a research company, Behaviour and Attitudes. Members will note, on page 14, 29% of medical card holders had postponed dental treatment in the previous year due to the cuts to the scheme, 26% of medical card holders or a member of their family have missed time from work due to a dental problem, and 38% of medical card holders - which equates to more than 600,000 people - said they would visit their dentist less frequently from now on due to these restrictions and this compares to 14% in 2010.

Often where the HSE is no longer prepared to fund the filling of teeth, it is willing to fund, without limit, the number of extractions. The price of an extraction is not only the €40 that the HSE pays the dentist to take out a tooth. Patients who undergo multiple extractions lose supporting bone and tissue causing them to appear older beyond than years and confining them to a lifetime of denture-wearing, possibly at a far greater cost than the treatment required to save the teeth in the first instance.

The typical profile of patients is female, aged over 40 and wearing dentures, very often with poor diet and gum disease. One can imagine if in the morning one lost one's teeth what that would mean in terms of not being able to eat, converse, smile or talk to people. This scheme has the benefit of tipping the balance between a healthy lifestyle and ostracisation and poor health.

This scheme was first introduced in 1994 and there is clear evidence that it has had marked effect in improving the oral health, particularly of the most deprived, whose oral health tends to be worse in the first instance. At matters stand, the association and the profession cannot endorse this scheme; it is no longer fit for purpose and we want a new scheme introduced. In the short term we believe that even increasing the current funding of €63 million for the scheme to €80 million would not only enhance the oral health of vulnerable medical card patients but would save money for the State in the medium term. We suggest that key preventative treatments should be returned on a phased basis and in particular we would mention the scale and polish treatment for both the medical card and the PRSI schemes. We are aware that the Department believes that there are competition law restrictions and they have to be finally addressed. We have set out principles that should apply to a new scheme. We wrote to the Minister for Health in January of 2012 and we are ready and available to talk about a new scheme. Ironically, there is now talk of a universal health insurance for health services generally but we had a comparable scheme which was a form of universal health insurance; it was the PRSI scheme and it worked very successfully.

The State managed to control the costs, care was provided on a cost-effective basis and dentists and patients were happy with it.

The HSE public dental service operates the schools screening service. The policy is that children at primary school level should be seen at three intervals, in second, fourth and sixth class. As members will be aware, the orthodontic service aims to provide orthodontic treatment to children under the age of 16 based on clinical need. Unfortunately, many children in these groups are not being seen. In some areas children only receive their first dental screening in sixth class. That is due to the effect of the moratorium on recruitment and other cuts in the HSE. Even in the short time since March 2009, there has been an almost 20% reduction in the number of dentists working in the service. Likewise, there have been comparable reductions in the number of support staff – nurses, hygienists and administrative staff - in the dental service. When staff go on maternity leave, they are usually not replaced. There has been a massive reduction in the number of dentists available. The consequence is outlined in the list on page 17. For example, in Laois-Offaly, Galway, Kerry, parts of Cork and also in Cavan and Monaghan it has been the long-established practice in many areas that children are only seen for the first time in sixth class. The difficulty is that it is too late at that stage. Most evidence suggests that children should go to the dentist at the age of one or two years. The fact that they are only being seen at the age of 11, 12 or 13 means that much of the damage has already been done and it is far too late at that stage. Those children then have unfortunate experiences with dentists because they often require remedial treatment, which will obviously colour their view on attending the dentist from there on in.

We are involved in talks with the HSE on reform of the public dental service and we have shown our commitment to reform, but we feel that the moratorium on recruitment must be lifted because no service can continue with 20% non-replacement of dentists and other staff. We also feel that consideration should be given to developing public private partnership models of service delivery to make best use of resources without undermining public service provision.

We are keenly aware, as are members, of the difficulties with orthodontic care and treatment. The waiting list figures are on page 19. Again, we have suggestions on how to deal with the problem. Previously, up to €85 million was assigned to the National Treatment Purchase Fund, but that is now with the advisory service in the Department of Health. There are obviously waiting lists not just for orthodontic treatment but for all aspects of dental care, and part of the funding should be diverted to dealing with that particular problem.

We also say there is a case for restoring the marginal rate tax relief for orthodontic and other specialist dental treatments. It was the case up to a number of years ago that marginal rate relief was available for medical and dental treatments, but that has now been restricted to the basic rate. It is clear that where people have no income they have no entitlement to claim tax relief. That is an anomaly that should be investigated. Perhaps a voucher system could be introduced or some modification of the existing system could be considered, because it would be of particular benefit in dealing with waiting lists.

We are also supportive of the introduction of orthodontic therapists to work with orthodontists in dealing with waiting lists. I accept issues arise about their scope of practice and training, which will have implications for dental schools also. We have detailed a number of other aspects of our submission for members. I am conscious of time so I will not go through everything in great detail. For example, we feel there is a huge untapped potential for dentists to help in health promotion and prevention. That is set out on pages 25 and 27. Many medical conditions can be seen and are more likely to be seen by a dentist. Currently, that is a resource that is not being availed of. We wish to mention also the great success of a voluntary initiative by the dental profession - namely, the mouth cancer awareness day, when dentists give their time free and invite patients for a chat and to explain the importance of regular attendance but also the dangers associated with neglecting the first signs of oral cancer, which is a type of cancer that can be successfully treated if diagnosed early. In fact, there have been 12 or 13 individuals who were successfully treated due to detection on mouth cancer awareness day. This is an increasingly common form of cancer and dentists have a critical role in detecting it and caring for and treating patients.

We also mention the need for a new dental Act. The committee will be aware that there have been changes in the legislation regulating the medical profession, pharmacists, nurses and other health care professions. We fully support a similar legislative change for the dental profession. We are also keenly aware of the fact that there is no direction within the Department of Health on dental care. There is no chief dental officer to offer the Minister guidance and advice, not only to verify what we say but also to conduct his or her own analysis and assess the consequences of the severe cuts to the dental schemes, and to shape, lead and introduce a new oral health policy, which is long overdue. There is no justification for not having a ministerial adviser in the Department. The Minister assures us the issue is being prioritised but we do not see any sign of the role being filled. The committee, the House and the country as a whole are being short-changed as a result.

I will conclude. My colleague, Dr. Gannon, is a practitioner in general practice in Knocknacarra in County Galway. He treats patients with medical cards and all other patients. Dr. Bolas works in the HSE in Sligo. He is an oral surgeon and a working dentist. My colleague, Ms Dowling, and I work in the Irish Dental Association. We thank members for the invitation and we hope the exchange has been of some benefit. We are happy to take any comments or questions.