Dr. Dympna Kavanagh:

We absolutely had to address that issue. It took four separate phases to look at it. The first was commissioned and given to University College Cork by the reference group to look at the cost-benefit analysis of the various services. There was much international research on salaried services. We looked at the Scandinavian models and at introducing different types of models. They did not involve privatisation but public contracts in local communities. It was found that salaried services were best suited to providing services to vulnerable and special care services. For healthy patients in primary care, it was not as effective or efficient. There are multiple international studies in that regard. We looked at countries which were similar and there are theoretical constructs of it. The Dutch and Icelandic models are more similar culturally to where we are sitting and we examined those models closely.

The second stream looked at all insurance models internationally and what was successful and otherwise. It just did not look at the oral health outcomes of those models. Oral health is influenced by many other issues such as social determinism, disease and water fluoridation, and not just by the service. It looked at the uptake and the buy-in culturally from the countries involved. Insurance models work well in Ireland. We saw extremely good and fast outcomes from many of those models.

The final phase was done by the ESRI. It started examining various types of models such as mixed-payment models. This involved looking at a preventive package overlaid by a fee-for-item system and further overlaid by service level agreements. The reason we went down that model was because it was familiar to the public and it understood it more. The outcomes from such a model are good in a short period, particularly for a preventive-oriented scheme. It is good for the type of oral health we are experiencing at present, whereby the vast majority of children from middle to high-income families have good oral health. Then there is the smaller group of vulnerable persons.

We looked at the Medicaid model in America, whereby it increased access through practices. It found that ironically inequalities did not get worse but were much better for the high-risk and low-income groups when they got in early. The higher income groups did not tend to use it as much but it really benefitted lower income groups.

We undertook four separate phases because it is a significant change for us to undertake. We had to look at the economics. The Department of Public Expenditure and Reform certainly put us through our paces in that regard.