Dr. John Marley:

I am the current dean of the Faculty of Dentistry at the Royal College of Surgeons in Ireland. Attending with me today is our vice dean, Professor Chris Lynch. I thank the committee for inviting us this morning to present on oral health policy in Ireland. I will first set out why were are here today and we will then be very happy to address questions the committee has.

The Faculty of Dentistry of the Royal College of Surgeons in Ireland was established in 1963. It is made up of dental specialists and consultants, senior academics and general dentists who provide education, accreditation of postgraduate educational programmes and assessments of qualified dentists both in Ireland and abroad. The faculty is Ireland’s leading centre for postgraduate dentistry examinations, with around 900 dentists from Ireland and abroad examined each year and more than 2,000 of its graduates working as dentists across Ireland and the world. Faculty representatives were invited to participate in a consultation day on the national oral health strategy which was held in Thomond Park in May 2015. This day consisted of general information sharing and discussion activity. I was formally invited to a meeting by Dr. Kavanagh, the chief dental officer, to meet her and the deans of the dental schools in Cork and Dublin on 7 November 2018. The group was informed that the publication of the oral health policy was imminent. At no time was the RCSI faculty invited to be represented on the scientific panel which was tasked with developing the policy.

As stakeholders with a significant interest in the delivery of quality oral and dental healthcare for the Irish population, the faculty has raised concerns on a number of issues. The first is the lack of a foundation year of dental training. Unlike our medical colleagues, for whom a pre-registration year, or intern year, is mandatory, newly qualified dentists are permitted to practice independently without the benefit of formal mentoring, clinical support, supervision and training in their first and pivotal year as a qualified dentist. Such a scheme exists in the UK for dentists who have trained in England, Scotland, Wales and Northern Ireland. We strongly support a mandatory year of foundation training for newly qualified dentists in Ireland. This would ensure that a dentist’s initial training requirements correspond to that of a medical graduate. As in the UK, it is envisaged that this training would take place in established practices. With regard to continuing professional development, we are concerned about the absence of legislation in Ireland to ensure and reassure the public that all dentists and their teams are subject to mandatory, lifelong learning and development through CPD. That would ensure that they continue to provide safe, effective and contemporary treatments for their patients throughout their working lives. There is a marked contrast to our medical and pharmacy colleagues in Ireland, where CPD and lifelong learning are an expected and mandatory requirement. In the UK, the equivalent scheme for dentists includes mandatory training, including in radiation protection, infection control, oral cancer detection and complaints handling.

We are also concerned regarding the lack of access to dental speciality and consultant training in Ireland. Currently, there are just two dental specialties recognised by the Irish Dental Council in Ireland, namely, orthodontics and oral surgery. There are a further 11 recognised dental disciplines in the UK and other jurisdictions. There are a small number of specialist training programmes in Ireland but, unlike medical training, these are self-funded by the trainees. There is also no formal mechanism for training dental consultants in the Republic of Ireland. Currently, there is no national body or forum where consultant dental training issues, including funding, can be discussed and progressed. On foot of section 86 of the Medical Practitioners Act 2007, the Health Service Executive has a number of responsibilities in relation to the development and co-ordination of specialist dental education and training and the subsequent alignment of this activity with dental workforce planning. We propose that this training be expanded to include all dental specialties and consultant level training and that, as is the case with medicine, this be funded by the HSE and Department of Health instead of personally by the trainees.

I turn to the impacts of the policy.

Dental foundation, DF, training provides an important transition for the newly qualified dentists from the sheltered environment of the dental school to that of the rigours and demands of general dental practice. It follows that with the absence of a foundation year of training, with protected time for learning and self-reflection in a supportive environment, the newly qualified dentist is immediately deep-dived into a complex environment of independent practice without the safety net of the support and guidance that could be provided and is provided to their medical peers. DF training has been established, in a mandatory arrangement, in the UK setting since the early 1990s.

The next impact results from the lack of legislation to mandate dental CPD. The Dental Council's code of practice pertaining to professional behaviour and dental ethics states that "all dentists have an obligation to maintain and update their knowledge and skills through CPD and the Dental Council decided to introduce its voluntary scheme." As a voluntary scheme, it follows that in the absence of mandatory, audited CPD, there is an increased potential for patients not to receive as good-quality care as they should expect and deserve. As occurs in other European jurisdictions, without this significant governance pillar, there is no formal mechanism for dentists to demonstrate to their patients that they are keeping their skills and knowledge up to date. While we know that all members of the dental team are appropriately trained and qualified at graduation, there needs to be a formal mechanism to allow them to keep their skills up to date, continue to know their limits and continue to be able to recognise when to refer patients appropriately.

With regard to the lack of access to funded higher specialist-consultant training, there are many implications for the current state of, or lack of, postgraduate dental training in Ireland. Fees payable for a three-year university-based specialist programme can be in the region of €100,000 and this is frequently a barrier to entry to such training. Talented young dentists who want a career in the public sector or academic dentistry in Ireland have only limited access to training programmes, unlike their medical peers. These young dentists are likely to leave Ireland to access these programmes of training in the UK, Europe or the USA, benefitting the dental health of other countries at our expense.

As there is no formal pathway for dentists to undertake consultant training in Ireland, any consultant appointments in Ireland are being made by equivalence which is determined by individual institutions in collaboration with external assessors as part of the selection-appointment process. This poses significant problems with appointments when specialists claim equivalence as a result of additional training. There is no clear mechanism to evaluate equivalence, which has resulted in competitions for consultant posts being abandoned. There are also concerns surrounding the quality assurance of training for individuals being considered for appointment to such posts.

Most dental consultants in Ireland are in their mid to late 50s or the early 60s. Many are expected to retire in the next three to five years. With no formal training and the difficulties with assessing equivalence, there is an existential risk to the dental service in terms of expertise, experience and delivery of undergraduate dentistry courses. Such considerations raise concerns about the training of the next generation of dentists, dental hygienists and dental nurses in Ireland as well as the leadership of dentistry in the 21st century.

I will now discuss the position in Ireland versus other jurisdictions. Within the UK, dental foundation training is administered by the 12 postgraduate deaneries in England and one each in Scotland, Wales and Northern Ireland, and currently there are in excess of 1,000 dental foundation trainees across the UK. Key exemplars of mandatory CPD requirement in Ireland are in medicine and pharmacy. In the UK, dental CPD is also mandatory and is overseen by the UK General Dental Council. Higher specialist and consultant training in all dental disciplines is available in the UK, which recognises 13 specialist lists.

Regarding reform proposals, for the foundation training year, the FoDRCSI supports a compulsory year of foundation training for newly qualified dentists. This would ensure that their immediate post-qualification training requirements correspond to that of a medical graduate. These posts should be salaried and would complement the oral health policy objective of equitable access to dental care for all. The FoDRCSI recommends the implementation of mandatory CPD through new legislation as a matter of urgency. There are several possible models including that of the General Dental Council of the UK. This will require new legislation. However, we feel that this development would be a significant external reassurance and oversight of the commitment of Irish dental team members to the safe delivery of quality oral health care for patients in Ireland.

In regard to specialist and consultant training, the FoDRCSI recommends an expansion of the current list of recognised specialties through new legislation as a matter of urgency. The FoDRCSI also recommends the creation a specific dental body which has, as its responsibility, the setting and quality assurance of consultant training programmes in all the dental specialties. The FoDRCSI would be happy to input to this body given its expertise in this field. This body would require ring-fenced funding so that both dental specialist and dental consultant training regains equivalency with medical consultant training.

The Faculty of Dentistry, RCSI, has laid out its concerns and recommendations for change. At the core of these issues is the need to maintain the quality of care and services provided to our patients. Professor Lynch and I are happy to respond to any further queries on the issues as outlined.