Mr. Fintan Hourihan:

I am grateful for the invitation to address the committee. I am the chief executive of the Irish Dental Association. I am joined by my colleagues Dr. Boyd, Dr. Rymer and Dr. Robins. This is the third time we have been invited to address the committee during the lifetime of the current Dáil. We welcome its continued interest in the concerns we have consistently raised around the provision of dental care in Ireland.

Regrettably, we cannot report that the Government has afforded the necessary urgency or priority to dealing with the concerns we have consistently highlighted. The only hope we can cling to is that the World Health Organization has published a global oral health strategy, to which the Government is a signatory, that contains hugely ambitious targets to improve access to oral health. The association recognises the challenges and the opportunities the WHO targets present and we have published in recent weeks a comprehensive position paper which examines the implications of the WHO plan, assesses our readiness to meet those targets and identifies the necessary foundations and stepping stones needed to ensure successful reform in many areas.

We wish to address three challenges regarding the provision of dental care in Ireland, namely: first, our concerns about equitable access to dental care; second, the need to urgently address the concerns we hold in regard to patient safety; and, third, the workforce and capacity challenges we face and what the State can do to reduce the shortage of dental staff. The majority of dental care is provided by dentists to private patients. Over 80% of dental care is paid for as an out-of-pocket expense by patients, which raises a number of issues. As dental practices are very expensive to operate and dentists receive no subvention to meet their operating costs, unlike medical GPs, who receive €200 million in practice supports every year, their fees must be set at a level to cover their operating costs. For the patient, this means that dental care is an expensive cost and, potentially, this could make it unaffordable for many patients.

The State can help patients in meeting the costs of dental care by either subventing practice costs, which it has refused to do, or subsidising the cost incurred by patients through direct subsidy payments to patients or allowing patients to claim tax relief in order to reduce the cost involved. The Med 2 scheme did allow marginal rate tax relief, but this was restricted to standard rate relief in 2009, which had the effect of increasing the net cost to patients. We believe the State should review the operation of the Med 2 scheme to alleviate the cost to patients.

Dentists want to be able to provide care to all in their communities. For vulnerable or marginalised adults, the State has an important role to play in commissioning dental care to medical card patients and providing limited supports in return for PRSI contributions. Successive year-on-year polls conducted by our association show that over 90% of our members want to see a State scheme to assist access for lower income groups to dental care.

The medical card scheme has been spiralling into chaos over many years. There was a small rise in the number of treatments provided after the Minister increased payments to dentists last year, but barely one in four dentists participates in the scheme, and the number of patients seen is 35% less than in 2014. I checked the number of treatments. Whereas now barely 250,000 treatments are provided to patients, as far back as 2009, 15 years ago, 1.6 million treatments were provided to medical card patients. That is the perfect illustration of the decline of the scheme. Three years ago, in May 2021, the Minister, Deputy Donnelly, announced that he would instruct his officials to begin talks with the Irish Dental Association on a new scheme to replace the DTSS as a matter of urgency. We are still waiting for formal talks on a new scheme to begin. In the meantime, we have suggested an interim emergency scheme whereby HSE dental clinics would be opened at night and on weekends to allow public and private dentists to volunteer to see patients, but we are waiting for a response on that point also. In fact, we have commissioned and published a plethora of research and proposals to replace the current scheme with a far more effective model for medical card patients. Our experience with the medical card scheme is one of the many reasons dentists feel we are always one excuse or one more promise away from anything being done by the State to address problems which nobody disputes are real.

Persons who have temporary international protection or who are seeking asylum as refugees need care, which the State should fund or provide directly through its own dental service within the HSE. As I will go on to explain, the complete collapse in the HSE dental service, designed to provide care primarily for children and special care patients, means that the arrival of tens of thousands of vulnerable adults into dentists' clinics has placed huge stress on the system and on those who are employed to care for children and special care patients.

Thirty years ago, the Government published a plan which promised that children would be seen by a dentist at three different stages in their primary school days through the school screening service operated by the HSE. Our experience now is that many children are seen only once in primary school, usually in sixth class, which is way too late, or in some cases seen for the first time in secondary school, up to transition year in the case of Laois. In fact, we have now established that at least 100,000 primary school children were denied a dental appointment by the HSE dental service last year alone. That is less than 50% of the eligible cohort. That figure is also obscured by the fact that secondary school pupils being seen as a catch-up are also included in this data.

The reason fewer children are being seen is simple: the HSE dental service has been neglected and woefully understaffed. The number of dentists and dental team members in the HSE dental service has fallen by over 23% in the past decade, while the number of eligible patients has risen by the same amount. For some reason, dentistry in the HSE has been uniquely neglected. Between 2012 and 2021, the HSE increased the number of junior doctors by 52%, hospital consultants by 44%, administrators by 37% and nurses by 20%. I know medical and dental are often grouped together, but when dental is separated out, it is seen that the number of dentists employed by the HSE fell by 23% between 2006 and 2022. That is in stark contrast to the approach to employing staff by the HSE.

To compound these problems, access to operating theatres when patients require treatment under general anaesthesia, GA, has been severely diminished, primarily because of the failure to provide access to facilities, which were promised in Connolly Hospital, in Blanchardstown, following the closure of the GA clinic in St. James's Hospital ten years ago. That clinic had provided treatment under GA to 3,000 patients per annum. We now have very vulnerable patients waiting in many cases for years for treatment under general anaesthesia. They cannot be seen because of the problems in Connolly Hospital.

There is a real sense of uncertainty within the public dental service right now, especially given the Minister for Health's statement indicating his desire to develop a scheme which would see dental care for children up to seven years of age provided by private dentists. We welcome the commitment to improve access to dental care for children but we have serious doubts about the solution proposed by the Minister, especially when a viable scheme, the school screening service, is available but not resourced. Nine out of ten private dentists have told us they believe that the State should prioritise rebuilding the HSE dental service over launching a scheme for private dentists which the vast majority of dentists say they would not have the capacity to provide. We believe that, as an immediate measure, the Minister for Health should give a clear and unambiguous statement on the future of the HSE dental service and sanction the gradual rebuilding of the service to bring staffing levels back to where they were even before we saw a rapid rise in the number of eligible patients. The continued uncertainty is making it almost impossible in many cases to hire badly needed staff when the HSE allows the employment of dentists simply to replace those who retire or resign.

Concerns about patient safety have been thrown into sharp focus with several disturbing media investigations broadcast by the "RTÉ Investigates" team over the past 12 months. The association has consistently called for the 1985 Act to be updated and modernised to allow for the mandatory licensing and inspection of dental practices, among other changes. As it stands, the Dental Council does not have the relevant powers to conduct investigations, carry out inspections or issue sanctions in many cases where patient care is being jeopardised. The Government has modernised legislation as required by other health professions. Unfortunately, this has not been the case for dentistry. The "RTÉ Investigates" programme most recently broadcast outlined the shocking situation of the apparent illegal cross-border importation of controlled substances such as botulinum toxin, commonly known by its brand name, Botox, and other products, the sale of controlled substances to unqualified or unlicensed individuals and entities, and the use of those products by unqualified individuals.

We again ask that the Oireachtas prioritise reform of the Dentists Act 1985 or bring forward amendments via secondary legislation to bring the dental sector onto the same regulatory footing as that of general health. We also call for publication of the patient safety (licensing) Bill, in addition to reform of the Dentists Act 1985, to ensure that patient information and safety are of the highest quality and to allow for greater powers for the Health Information and Quality Authority, the HPRA, the Medical Council and all other relevant State regulatory bodies in order to ensure that the application of the law is thoroughly followed.

The single greatest impediment to improving access to dental care is the shortage of dentists and dental staff to provide such care. Our latest survey of members, published just last week, reveals that 65% of private dentists have been unable to recruit a candidate for dentist positions. Over half of dentists have been unable to recruit dental nurses. Not surprisingly, this means that there has been an impact on waiting times and access to dental care. Two thirds of dentists said the shortage of dental staff is impacting access and treatment. One quarter said they are currently not taking on any new adult patients. Nearly one in seven patients is now waiting over four months for a general dental appointment, that is, an appointment with a general dentist. This is an increase from one in 20 back in 2023. One third of patients are now waiting over four months for an appointment with a specialist. Again, we have seen those waiting lists double in the past 12 months.

There are several solutions needed to rectify the staff shortage, and we previously presented to this committee a detailed paper on the workforce issue. We acknowledge the welcome decision by the Government to fund extra undergraduate places to be provided by a new RCSI dental school in Dublin. However, the decision to cancel the building of a new dental school in Cork is profoundly worrying. We believe that, with some smart thinking and collaboration between the relevant Government Departments, UCC and the HSE, a funding solution should be possible which would allow not only a badly needed dental school to be built on a greenfield site but also expansion of the capacity in Cork University Hospital, on whose campus the current dental school is located. Last December, according to the National Treatment Purchase Fund, 30,000 adults and more than 5,000 children were on the outpatient waiting lists at CUH. If a solution can be found to allow the construction of a new dental school on a greenfield site, not only will it allow more dentists to be trained in a modern facility, but it will also allow expansion in capacity at the CUH campus. We hope that a win-win funding solution can be found without delay; otherwise we fear that there will be a reduced number of dental graduates from Cork due to safety concerns which have been expressed by the dean of the school in Cork, Professor Brady.

We are working with the Department of enterprise and hope that some changes can be made to the work permits regime which will allow the employment of more dental nurses and hygienists especially. Given that most dentists operate on a self-employed basis, the scope for engaging extra dentists from outside the EEA is limited. We will also seek to engage with the Department of Justice on visa arrangements.

A final change which could be made by the Minister for Health would be to authorise the recognition of dental specialties. Both the Dental Council and the Irish Dental Association have called for nine additional specialties to be recognised to bring us into line with the UK especially.

This would undoubtedly help in the recruitment of badly needed extra specialists and consultants, it would reward those dentists who pursue further training, usually at their own expense, and it would provide greater clarity to the public in deciding on their treatment options. There is so much we need to see done and the State has a central role to play in enabling greater access to dental care, in ensuring patient safety, and that we have as many dentists as we need to provide the highest standard of dental care and treatment our citizens expect. The Irish Dental Association is more than ready to play its part. We need the Government to move from talk and plans to engaging with the association and delivering the necessary reforms and resources we have clearly identified to realise the ambitious goals of the WHO global oral health strategy. We will be happy to answer any questions and thank the members of the committee for their attention.