Mr. Fintan Hourihan:

I am the chief executive of the Irish Dental Association. I am joined by: Dr. O'Neill, the president of the association, who is a principal dental surgeon employed by the HSE; Dr. Robins, chair of our general practice committee and a Carlow-based practice owner who holds a medical card contract; and Dr. McAllister, our president-elect and a Dublin-based general practice dentist. We are delighted to appear before the committee and we welcome the members' interest in the concerns we have raised on behalf of dentists and patients over many years.

I propose to offer a brief explanation of the original scheme and the medical card scheme today, the difficulties which have prevented resolution of problems with the scheme, the possible options we see for reform of the scheme, and the priorities and approach we believe should be adopted as a matter of urgency.

Everybody accepts and, I hope, understands that oral health is an integral part of good general health. Difficulty in accessing dental care is recognised internationally as contributing to poorer oral health for lower income groups due to the high cost of delivery of dental care. In Ireland, the medical card scheme was originally designed under the legislation to provide basic dental care to those who met the income threshold provided for in the Health Act 1970 and subsequent legislation. The only other State supports to patients in accessing dental care are within the PRSI dental scheme, which subsidises dental examinations and a scale and polish, and tax rebates under the Med 2 scheme, which refunds advanced care for those who can afford to pay for treatment.

In the appendices, we explain the significant differences that exist as regards the operation of the schemes for medical card patients in medical and dental care and the disparity in financial supports provided to doctors and dentists treating the same cohort of patients.

I have also mentioned a very recent American study that shows the impact of the lack of priority afforded to oral health within primary care on the growth of inequities within different income groups. That is very true in Ireland as well. The Primary Care Collaborative, PCC, study, as it is known, is worthy of closer study. It states:

Oral conditions impact the body in myriad ways, and oral disease has been associated with worse outcomes across multiple health conditions and organ systems. The chronic inflammation associated with periodontal disease has been associated with worsened glycemic control among people with diabetes as well as increased risk of preterm birth. Older adults with missing teeth have worse nutrition and are more likely to have nutrient deficiencies. Poor oral health among people admitted to the hospital increases the risk of pneumonia. More importantly, the impact of poor oral health cannot be understood exclusively through potential association with other health conditions. Even without harmfully affecting other health conditions oral health problems can cause pain, discomfort and, in some cases, even death. Poor oral health impacts can also have an effect on employment prospects and an individual's self-confidence among many other economic, mental and social problems. All these problems are more tragic because dental disease is almost entirely preventable.

Historical differences in how oral healthcare is delivered and paid for have led to even larger inequities in oral health access and outcomes as compared to the rest of the healthcare system, according to the PCC study. That is very true in Ireland and elsewhere. The pre-existing gap in access to dental care based on income disparities has only served to widen in Ireland in the past few years. The current crisis in the medical card scheme is seeing an acceleration in the health divide between those who can and those who cannot afford to visit the dentist. The current scheme was introduced in 1994 and initially offered access to basic dental care for all those who had a medical card. It provided access to a dental examination, any fillings or extractions required, limited access to root canal treatment for front teeth and access to basic dentures. In essence, it provided reasonable access at the time to restore and maintain dental health.

Private dentists hold individual contracts with the HSE to provide care to eligible patients. Patients are entitled to be cared for and treated by any dentist holding a dental treatment services scheme, DTSS, contract. In 2010, 11 years ago, the HSE imposed unilateral cuts to the scheme to reduce expenditure. Those cuts were implemented without consulting the association, dentists or patients, despite the contract having an agreed committee to enable such consultations. Those cuts fundamentally altered the scheme from a demand-led scheme to a budget-led scheme. This was done by removing access for many patients to treatments under the scheme. It restricted access for the majority of patients to one examination annually, a maximum of two fillings irrespective of circumstances and access to as many extractions as are required. It no longer supports the oral health of medical card holders; rather it enables them to lose their teeth and to rely on dentures. Only those who have a significant medical condition from a narrow, prescribed range are enabled to access more treatment of items on application.

The net effect is that any adult over the age of 16 can no longer access the dental care he or she requires to maintain dental health. In my document, I outline the treatments available prior to 2010 and those currently available. Biannual scale and polish, gum cleaning and periodontal treatment have been suspended, fillings are now restricted to two per annum and root canal treatment, dentures and denture repairs are all only available in emergency circumstances. An unlimited number of extractions are still allowed.

For the patient, it means a lifetime of embarrassment, decreased nutrition and loss of well-being. The association, as a party to the original agreement, has advocated on behalf of our members, and the patients who attend them, for many years. It is our view, and the expressed view of our members who are the dentists operating the scheme on a daily basis, that the State scheme for approximately 1.5 million eligible medical card patients is in crisis and on the brink of collapse.

The past year has seen an unprecedented number of dentists withdraw from the medical card scheme with serious repercussions for patients across the country. Total spending on the scheme fell from more than €63 million in 2017 to barely €40 million last year. The implication of this is that large numbers of patients are no longer accessing treatment as the scheme is a fee-per-item structure. A detailed breakdown of the impact of the cuts in spending on patient attendances by HSE community healthcare organisation, CHO, region, and an illustration of the reduced number of dental treatment services scheme, DTSS, contracts held by dentists by CHO region, has also been supplied to the committee.

The current sets of fees paid to dentists are in place since 2010 when fees were reduced under the financial emergency measures in the public interest, FEMPI, legislation. Any changes to fees require a decision by the Department of Health. There has been no review in the intervening period and no reversal of the cuts imposed. None of the items currently provided are economically viable in terms of the costs incurred by dentists caring for patients. Many of those treatments are no longer in line with modern best practice dental care. My colleagues will be happy to expand on that.

Last week, the committee heard from the HSE, which said that in a typical year just over 30% of the eligible population receive treatment through the scheme. Last year, the HSE said it fell to barely 22%, mainly due to the Covid-19 pandemic. The number of claims has fallen dramatically in the past number of years. In 2019, there were more than 1 million and, in 2020, there were less than 800,000. The number of contracts held by dentists nationwide fell by more than 30% between 2015 and 2020, from a figure of 1,847 to below 1,200. We believe that the current figures are significantly overstated due to many inactive contracts.

The fundamental changes in the structure of the scheme and the reduced number of participating dentists have had very significant impacts for patients. They are experiencing delays seeking treatment due to the reduced number of dentists participating and delays in accessing treatment while administrative decisions on whether to fund additional care are made. Patients are looking at increased travel time seeking treatment and in some cases are relying on the already underfunded public dental service to provide care in areas where DTSS contracts are particularly scarce.

What we are seeing, therefore, is an unprecedented crisis in dentistry and access to dental care for the most vulnerable of patients. In 2020, almost a quarter of participating dentists nationwide left the scheme. We see the scheme as no longer viable and that is the decision at which those dentists have also arrived. They simply cannot afford to continue to participate and this is leading to complete chaos. In the footnote to my statement, I mention the fact that the last straw for many dentists was when they were promised personal protective equipment, PPE, within seven days by the then Minister for Health last June and it still has not materialised. Many dentists said that was the last straw and it led them to resign.

The withdrawal of dentists is also affecting services provided by the HSE's own dental services, which are now faced with adult patients presenting when those same public services have seen a 24% reduction in staff at a time there has been a 20% increase in the number of eligible children seeking care from the HSE service. All these impacts are without considering the substantial impact of Covid-19 in providing dental care.

Not surprisingly, our members continue to voice their anger and disillusionment with the Government's lack of action on the matter. We have sought to engage with the Department of Health to redevelop the scheme over many years to no avail. Many of our members believe now that the refusal to acknowledge the reality of the crisis within the scheme and the general approach of the Department suggests a level of disrespect, if not contempt, for the profession, the importance of dental and oral health and the patients who rely on this scheme. It also shows scant regard or understanding of the impact of this crisis on vulnerable patients who are unable to afford access to a service that was defined as essential by the Government during the Covid-19 crisis.

Significant additional costs incurred by general dental practices during the pandemic have raised the costs of providing care to patients and have made the existing DTSS contracts completely unviable. Dentists want to be able to provide care for all patients but the Government is leaving them with little choice but to minimise their involvement or withdraw from this scheme.

The Irish Dental Association is the representative body for all dentists and was party to the negotiations which culminated in the introduction of the scheme in 1994. The need for redevelopment of the scheme has been long recognised. Negotiations on a revised scheme were abandoned 14 years ago, in 2007, when the then Department of Health and Children withdrew from the negotiations citing concerns about the role of the association having regard to competition law. We do not accept that there is any impediment to our participation in collective bargaining with the Department of Health and we have corresponded on and discussed this with the Department over a long period. In order to overcome any concerns on this issue, as recently as November we presented a modified version of the so-called framework agreement which was concluded in 2014 by the Department of Health and the Irish Medical Organisation, which represents doctors in general practice treating the same cohort of patients, to reflect the specific role of the Irish Dental Association in representing general dental practitioners. To date, we have not received a response to those proposals.

We stand ready to negotiate with the Department of Health. We successfully negotiated with the former Department of Employment Affairs and Social Protection in recent years on the extension of the PRSI dental scheme to eligible self-employed persons and the restoration of scale and polish entitlement in 2017. We are confident that we can engage constructively with the Department of Health if the threat of criminal sanction against the association is removed. The association is committed to promoting independent practice and has provided the committee with a copy of our independent practice policy paper, published as late as 2019. We recognise the need for support from the State in allowing low income and marginalised groups access to dental care within the context of promoting independent dental practice. However, the legitimacy and role of the association as the sole representative body for the dental profession must be recognised and secured within an appropriate framework agreement.

As the representative body, the Irish Dental Association believes that the priority in addressing the current crisis should be on ensuring proper access to dental care for those who face the greatest difficulty in meeting the cost of treatment. Any arrangement has to be economically viable for dentists and cannot have an administrative burden which delays patient care. There also must be clarity as regards care pathways for eligible patients. Patients or dentists should not be put in the position whereby they have to barter about the care to be provided.

We believe that a new approach is required to address the need to restore access to dental care for low income groups rather than more of the same with a failed model, as exemplified by the current system. We believe new models of access need to be examined, including a combination of some, or all, of the following approaches: application of a co-payment system similar to that used with the PRSI dental scheme; the use of use-it-or-lose-it vouchers funded by the State to encourage greater attendance of patients for dental examinations and, possibly, other preventative treatments of which there are examples in many countries; and expansion of the Med 2 tax relief scheme.

It was indicated by Department of Health representatives appearing before this committee last week that they favoured an interim solution prior to commencement of a root and branch review of the DTSS. Our members have been very clear in voicing the opinion that applying a shot of adrenaline to the current scheme is not an acceptable solution. It has been long accepted that a new dental scheme is required. We cannot wait for the pandemic to be over before comprehensive discussions commence. We are available to engage in discussions which, within an agreement timeframe, will produce an agreed long-term solution to the current crisis, but equally on the basis that any short-term interim solutions are credible and consistent with the principles outlined within this document and have a finite lifespan.

The legitimacy and role of the Irish Dental Association must be recognised and secured. Ultimately, we believe that the following principles must apply to any scheme or approach developed by the State. There must be a time limited review of any new arrangements. The complementary role of the public dental service must be recognised. There must be clear referral pathways agreed and adequately resourced within the public dental service. There needs to be clarity around the scope of treatment coverage for patients and dentists. Any changes in the scope of treatment must be reviewed regularly. It is vital that there is clarity as regards the State's responsibility to provide care to eligible patients where elements of a treatment plan are not covered. Any obligation resting on general dental practitioners and funded by the State must be clearly enunciated.

A demand-led approach cannot operate in tandem with caps on funding. Agreement must be reached on the maximum number of eligible patients any dentists can be required to care for and treat in any scheme. Bureaucratic overload must be avoided. The autonomy of dentists and dental practices must be recognised by the State along with the imperative of dental practices to secure the viability of their business. Professional fees must be structured in an economically viable manner, having regard to the operating costs incurred by dentists and with provision for regular review on an agreed basis. Unilateralism on the part of the State is not compatible with a collaborative approach to working with the profession. Finally, structured dialogue in any forums attended by State agencies and the IDA must be enabled along with agreed dispute resolution, grievance and disciplinary provisions.

I thank the committee for its interest. We will be pleased to address members' comments and queries.