Mr. Fintan Hourihan:

I thank the committee for the invitation to address the committee this morning. I am chief executive of the Irish Dental Association, IDA. I am joined by my colleagues, Dr. Eamon Croke, president; Dr. Caroline Robins, past president; and Dr. Will Rymer, chair of the GP committee.

This year, the association is 100 years old. Its history is intrinsically linked with the foundation of the Irish State and decisions made, for better or worse, by successive governments and policymakers over the 100 years. Oral and dental health form an essential part of general health and well-being, but our experience to date is that oral health is not prioritised in terms of promotion, funding or service delivery. My colleagues present today will tell the committee that diseases of the mouth and oral cavity have a significant impact on people in terms of pain, suffering, the impairment of function, productivity losses and reduced quality of life. From an economic perspective too, poor oral health costs. According to the Central Statistics Office, CSO, 80% of expenditure on dental care in Ireland is out-of-pocket expenditure. This tells us two things. It shows that State assistance towards the cost of dental care is extremely limited compared with other health conditions. More worrying, it shows that good oral health is strongly linked to socioeconomic status, with oral diseases and conditions disproportionately affecting poor and vulnerable members of society across the life cycle.

Unfortunately, none of this is new. Members will be all too familiar with the crumbling medical card scheme and the chronic delays in delivering the school screening programme, and we will address these issues, but staffing and resourcing in the dental sector is fast becoming an even bigger issue for patients in accessing dental care. Last September, we carried out research that showed in the starkest terms that the majority of vacancies in the dental sector cannot be filled. At that time, two thirds of practices that tried to recruit dentists in the previous 12 months could not fill the vacancy and neither could half of practices that attempted to recruit nurses or hygienists. These staff are essential to the effective running of dental practices and to ensuring access to dental care for those who need it in their communities. Two thirds of dentists said the staffing shortage was having an impact on patient access to dental care in their practice and two thirds said their capacity to treat emergency appointments had reduced in the past year. More recently, in April of this year, one in four dentists said they could not currently take on new private adult patients, while four out of five dentists said they did not have the capacity to take on any new patients, including children.

The situation is as stark, if not more so, in the public sector, where the HSE is obliged to provide care for children and for special care patients and an orthodontic service for children with severe orthodontic needs. Here, the recruitment and resourcing challenges arise from policy decisions which, as I stated, reflect the very low priority attached by the Department of Health and the HSE to the provision of dentistry.

The Minister for Health himself told us recently that the State has had a blind spot when it comes to dentistry and oral health. Our question to the committee today is what will it take for the State to open its eyes to the scale and urgency of the crisis that it consistently chooses to ignore in order that dental health is finally recognised as an integral part of general health. My colleagues will tell the committee in real terms that they cannot recruit enough dentists. They will say that their patients cannot get appointments quickly enough. I have no doubt that each member has come to today's meeting with stories from their own constituencies and communities about how difficult people are finding it to access care.

As part of the previous budget, the Government announced funding of €4.75 million to support the development of a new prevention-focused oral healthcare system for children aged from birth to seven years. We believe, first, that this is a tiny amount of spending directed at inappropriate reforms and we have fundamental concerns as to the likelihood of their delivery. We were not consulted or asked about the suitability of this type of reform prior to the oral health policy being published in 2019 or the latest budget announcement. In the period since, with no dialogue or consultation, we are increasingly concerned that this may be an attempt to shift political responsibility for children's oral health away from the public service, which is designed to target all patientsthrough the school screening service and into the private sector, where the onus will be on parents to ensure that their children receive adequate oral healthcare in line with clinical best practice. We appear to be moving from a system that essentially targets all children to one where only those who are interested and willing are going to show up.

Announcing this type of scheme without any consultation with the profession and expecting an already overstretched and understaffed private sector to have capacity to see this cohort of patients is a very ill-advised proposition, and certainly not at a cost that we estimate equates to approximately €10 per child. According to recent research by Amárach Consulting, 75% of dentists in private practice would find it "difficult" or "very difficult" to provide such a service for under-sevens. As dental practitioners, my colleagues can tell members that specialist care is required when treating children and that this should happen in a fully staffed public service to ensure that all children, regardless of socioeconomic status, receive early intervention. We again call on the Minister and his officials to sit down with the profession, listen to it and work together to resolve the shortcomings that would benefit the dental sector as a whole and, ultimately, deliver the best outcome for the patient. The unfortunate reality is that, sadly, without the political willingness, patients – in particular children and the most vulnerable – will continue to fall further behind with their oral health and will shoulder the burden of a system crumbling under decades of inaction and neglect.

A €5 million initiative was announced in the budget to address the school screening backlog - but no additional public service dentists are allowed to be hired with these funds. Instead, existing overworked and demoralised staff will be asked to volunteer to work additional hours at evenings and weekends. We also understand from the HSE that the Department of Health is prioritising these funds for adult medical card holders rather than children or special care patients.

In 2022, just under 100,000 children were seen under the school screening programme, which is less than half of those who should have been seen in second, fourth and sixth classes last year. Of those who are being seen, many are being seen late, with an almost ten-year backlog in accessing services in parts of the country where children only receive their first appointment when they are in their fourth year of secondary school. In addition, and for the purposes of today's presentation, we have collated other evidence, which illustrates clearly how patients have been neglected over the past two decades and the unacceptable neglect towards patients and the hostility shown to both public and private dentists.

First, there are currently two-year waiting lists for treatments requiring general anaesthetic, with dentists saying they are being forced to choose which children they believe are suffering the most pain and to treat them ahead of patients who may have already been waiting months or years.

Second, the number of public-only dentists in the HSE has dropped by almost a quarter over the past 15 years, down from 330 in 2006 to 254 in 2022. This means that the HSE would immediately need to hire 76 dentists at a minimum to bring the service back to the level it was at 15 years ago. There are now barely 600 dentists actively participating in the medical card scheme nationally for adults.

In regard to recruitment and resourcing, our survey found that one patient in six is waiting more than three months for an elective appointment, while more than half of patients are being forced to wait more than three months for specialist care. One quarter of dentists are currently not in a position to take on new private adult patients, while four out of five dentists surveyed said they do not have the capacity to take on any new patients, including children. Some 80% of our members who currently hold a contract say they are no longer able to take on or see new medical card patients. A total of 93% of dentists say that they would not rejoin or sign up to the medical card contract in its current form during talks on a new scheme.

In the absence of any engagement on these issues, we prepared a strategic workforce plan in April that outlines the scale of the problem and sets out a number of recommendations and solutions that we believe can address the issue. Our analysis shows that we need an extra 500 dentists across the public and private sectors to adequately meet the needs of a rising population and to replace retiring dentists. Among the measures to improve the supply of dentists, we recommended significant investment and expansion of the two dental schools in Cork and Dublin, the reintroduction of a foundation training scheme to facilitate new graduates, and changes to rules surrounding work permits. The dental schools in Cork and Dublin have not seen any significant expansion or investment in decades and, fundamentally, do not produce enough dentists or dental practitioners to meet the demand for care in Ireland. We are cautiously optimistic about what the recent announcement of increased college places by the Minister, Deputy Harris, and his Department means for Irish school leavers wishing to practice dentistry here in Ireland and most importantly, what this could mean for patients and people who have been struggling to access dental services and treatments right across the country. A simple and more effective measure that the Minister could take immediately is to provide sufficient funds to end the need for funding from students from outside the EEA. That would effectively mean that more places will be available for students from within the EEA. It would be far more effective and less expensive and it would bring more immediate benefit in terms of dealing with the problem.

I checked the breakdown of final-year students in the Cork Dental School. This is not in my presentation but I had a chance to check. Currently, within the final year, 25 of the students are from the EEA or the EU and 36 are from outside the EEA. The reason we see this in both the schools in Cork and Dublin is because the students from outside the EEA are paying of the magnitude of €45,000 to €55,000 per annum in fees. They are effectively cross-subsidising the other students. The most effective step that the Minister for Further and Higher Education, Research, Innovation and Science could take right now is to ensure that dental schools have enough funds in order that they do not need to reserve places for non-EEA students, which would mean that more local school leavers would be able to take up places in dental schools and, hopefully, more of them would be available to work here in Ireland when they graduate.

Dentists are beyond frustrated at the endless broken promises and false dawns promised by successive health Ministers and the Department of Health. The collapse of the medical card scheme is the perfect example. The Minister, Deputy Stephen Donnelly, is the sixth Minister for Health to hold office since the Department walked out of talks on a new scheme, 15 years ago. It is astonishing to think that in 2023, an oral healthcare scheme that fails to offer the same standard of care to the most vulnerable and economically disadvantaged in our communities still exists.

Last year, the association supported an independently commissioned research report, prepared by Professor Ciaran O'Neill of Queen's University Belfast, that outlined a proposal to improve access to dental care for medical card patients. This would take the form of a voucher scheme, which would offer between €100 and €500 towards dental care and would have a total cost per annum of approximately €108 million and €232.5 million, respectively. For context, the spend on the medical card scheme in 2021 was €39.6 million, rising in 2022 to €49.4 million, which is an awful long way from the €86 million that was spent in 2009. The extra €10 million being made available this year is nowhere near enough to solve the underlying problems associated with the scheme.

I remind the committee that this scheme was established by the Department of Health in 1994, predating both the Internet and mobile phones. Perversely, it dictates what materials dentists can use and what procedures can be carried out. Only extractions are unlimited. Could members imagine having no clinical autonomy to make decisions that are in a patient's best interest?

It should not matter whether you are a medical card patient or not but it does. Imagine walking into a doctor's surgery with a broken leg and being told the only available option to you because of your socioeconomic status is amputation. A more cynical person might argue that the system is weighted towards cost containment over good oral health by providing an accelerated pathway to extraction for those who cannot afford or access the alternative. As policy makers, we implore members to join us in saying "enough is enough". Immediate talks on a better system must begin immediately.

Following the financial crisis of 2008, reimbursement levels to dentists were reduced and treatments available to medical card holders were suspended or available in emergency cases only. This has not substantially changed in the 15 years since. The Minister and Department, however, will say that he has increased funding of the DTSS. He will say that some limited treatments have been reintroduced and that the numbers of contracted dentists have actually increased in recent months but when you examine the expenditure more closely, you will see that what the Minister and Department are portraying is nothing but a glossy veneer on an otherwise rotting tooth with barely 600 dentists now operating this scheme for 1.5 million adults nationally. This is the equivalent of one dentist per 2,500 patients. I checked the HSE website yesterday. What it confirmed to me is that 80,000 fewer medical card patients were treated in the first half of 2023 compared to the first half of 2017. This is 80,000 fewer patients. The truth is that there has been no meaningful engagement with the profession on this or any issues nor with the Irish Dental Association as its representative. Legislation to regulate dentistry, which protects patients and ensures the highest standards of education and training of dentists, has been promised for many years but when the opportunity arose recently to bring mandatory professional education for dental professionals in line with other healthcare practitioners and international best practice, the Minister would not and did not support the inclusion of this amendment in the Regulated Health Professions Bill 2022. What remains now is antiquated legislation dating back to 1985, while the legislation regulating medicine, nursing, pharmacy, and veterinary medicine has been overhauled and modernised. I would note here that, despite the harsh message we have delivered today, we thank this committee for its efforts in raising this both as an agenda item and directly with the Minister.

As a profession, dentists have felt sidelined and ignored by successive Governments for more than a decade - contracted to provide an extremely limited and wholly restrictive service to some of the most vulnerable and economically disadvantaged people in our communities. We are the representative body for dentists and the only advocates on behalf of the patients served by dentists. Our members can deliver change and want to see better access to dental care for all the community but change can only happen through political willingness and we have yet to see that from Government. The recent vote of no confidence in the Minister by dentists at our AGM in May shows how broken their trust is in a system and service that has no capacity and no conviction to reform. As an association representing more than 1,800 public service and private sector dentists, we would welcome this committee’s support in pushing the Government to prioritise dentistry as an urgent national healthcare matter. We need to reform how care is delivered but we also need more dentists and dental team members to meet the growing demand for dental care as well as the huge unmet need. We need to see commitments, we need to see pathways and we need to see progress. Above all, we need the committee's support as a coalition of the willing to be part of these discussions and in developing the best pathway forward for everyone. As we have cause to reflect on the past 100 years of dentistry in Ireland, we understand that we all have a choice to either learn from the past and change or allow history to continue to repeat itself. We hope that our policy makers do likewise.