Oireachtas Joint and Select Committees
Thursday, 28 March 2013
Joint Oireachtas Committee on Health and Children
State Dental Schemes: Discussion
I welcome Mr. Fintan Hourihan, chief executive of the Irish Dental Association, Ms Clare Dowling, employment and communications officer of the Irish Dental Association, Dr. Andrew Bolas, president of the Irish Dental Association, and Dr. Peter Gannon, chairman of the general practitioners' committee of the Irish Dental Association. I thank them for coming to our meeting this morning. We are glad that they were able to come in at such short notice and we appreciate their rearranging schedules to be here.
I remind members and those in the public gallery to switch off their mobile telephones rather than leaving them in silent mode because they interfere with broadcasting equipment and it is not fair to members of staff who have to put up with the interference in their headsets.
Our discussion this morning arises from a request from the Irish Dental Association to come before the committee. In correspondence with the committee the association has stated that it is worried and increasingly concerned about gum disease, loose teeth and extractions where it has not been possible to provide preventative treatments given the recent withdrawal of State support for patients. I thank Deputy Ó Caoláin for making this proposal at our meeting last week.
Before we commence I wish to remind members and witnesses that witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if a witness is directed by the committee to cease giving evidence in regard to a particular matter and continues to do so, the witness is entitled thereafter only to a qualified privilege in respect of his evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.
I call on Mr. Hourihan to make his opening remarks.
Mr. Fintan Hourihan:
I thank the Chairman and the committee for inviting us here. We are delighted to have the opportunity to address the committee. We have prepared a submission, which I believe has been circulated. I intend to speak only on parts of the submission, but we felt that as we had an opportunity to come before the committee we could in the submission address other issues about which questions are often asked. I intend to speak primarily about the State schemes and the services that the HSE provides for children.
In our executive summary we explain the critical importance of oral health and its connection to general health and summarise our main recommendations. I will start by reminding everyone that there are two State-funded schemes: the PRSI scheme - the dental treatment benefit scheme, as it is formally known - and the medical card scheme, the DTSS. Approximately 2 million taxpayers are entitled to benefit from the PRSI scheme funded by the social insurance fund. Since the budget of December 2009 the scheme has provided only one item of dental care, which is the annual oral examination. Prior to that - we will elaborate on this later - there was an extensive range of routine preventative and restorative treatments provided free or subsidised by the State. That has all been withdrawn.
In the case of the medical card scheme, the eligibility for medical card holders is increasing. In the December 2009 budget it was decided for the first time to cap the level of spending on the scheme. Similarly to the PRSI scheme - again, we will elaborate on this later - there was an extensive range of routine preventative and restorative treatments provided free to patients. That has been severely curtailed. It is now effectively an emergency pain relief scheme only. We feel that is causing profound difficulties for a very vulnerable cohort of patients, because oral health is a condition that is inextricably linked to social status.
I will talk about the difficulties in the public dental service later, but I wish first to make a point about dental care which we feel is often not properly understood. Dentists form one of the few groups of health professionals who do not receive any financial support from the State. They rely entirely on their own funds to set up in practice and to meet their running costs. Whereas the State spends €3.6 billion annually staffing and equipping hospital medicine, there is no comparable assistance provided for dental care in the community. Likewise, before a penny is spent on caring for medical card patients, GMS doctors in general practice can receive up to €100,000 per annum in grants towards employing nurses, secretaries and practice managers in rural locations, and there are pension payments available to doctors.
We consider that is entirely appropriate but again we would like to explain that none of that support is available to dentists. Likewise across the Border, dentists in Northern Ireland are entitled to extensive state supports. Dentists in the Republic do not receive a single cent towards the running of their practices. Given that they have to rely entirely on generating attendance and income to cover costs, most of which are fixed or State controlled, it is hardly surprising in these difficult times that with falling attendances practices are closing. We estimate there have been 1,500 redundancies in the sector in the past few years. This will never be noticed in the same way as the closure of a high profile multinational but the effects are just as real. Equally, entire classes of graduates are forced to emigrate because of the lack of viable opportunities. In spite of that, dentists are committed to providing care. They display their fees openly. They have reduced or frozen their fees and we believe that very often that is not properly understood or appreciated. We want to put what we are going to say in that context.
We estimate currently, as a result of the rationalisation within the sector there are probably still 8,000 people whose employment is directly or indirectly associated with the practice of dentistry in the Republic of Ireland. Many of the problems which impact on patients also impact on people who are employed in providing care for patients.
Members will note on page 9 of my presentation that the PRSI scheme was established in 1952. Everybody continues to pay their PRSI contribution into the Social Insurance Fund. However, in 2009 this scheme was restricted to one item, which is the annual oral examination or check-up. That had an immediate effect. Members will note there was an 87% cut in expenditure on the scheme from €69 million in 2008 to €9 million in 2011. We are not aware of any other part of the broader health service which has experienced such a cut. Ironically, while the benefits under the scheme have decreased, the rate of PRSI has increased. We consider it is particularly unfair for people who have paid PRSI contributions for a long period to find that they are now unable to avail of dental treatment. As I will go on to explain, that has a direct consequence in that people are not inclined to attend for treatment any more and that has an immediate knock-on effect in terms of their oral health. Members will note from the table on the bottom of page 9 that prior to 2010 an extensive range of treatments was provided by the State through this scheme including an oral examination, cleaning, gum cleaning, fillings, extractions, root canal treatments, X-rays, dentures, etc. These are all the essential routine items of care which we believe the State ought to consider restoring gradually over time.
Members will note on page 10 that there are currently 1.4 million medical card holders eligible for this scheme. It is managed by the HSE and the care is provided by dentists in private practice. Dentists provide this treatment in their own self-funded practices on a fee per item basis. They are only paid when people show up. They do not block grant. It is not a capitation-based system.
Despite the surge in the number of medical card holders in recent years, the budget for the scheme was capped for the first time at the 2008 level of expenditure of €63 million. For the past two complete years for which we have official figures, the number of eligible persons increased by more than 17% and expenditure decreased by more than 41%. As members can imagine, that has had a very obvious effect on the extent of care provided.
Members will note on page 11 we provide a summary of the care that was previously available and the care that is currently available. In short, it is essentially an emergency pain relief scheme only. We believe that is not acceptable. This is not a Third World country. Next month it will be almost three years since the cutbacks were introduced and yet three years on the HSE has still failed to inform medical card holders of these cuts and has failed to give any sort of advice or warning regarding the implications of these cutbacks. Dentists deal with queries on a daily basis from patients who are trying to figure out to what they are entitled. Patients and even treating dentists are unsure of what is provided for. The availability of treatment is extremely subjective depending on the budget available and the individual funding available through the local HSE principal dental surgeon.
In addition to the unfair nature of the scheme, the cuts do not make any economic sense. Research has shown that the costs of poor dental health are largely borne by the most disadvantaged. In some cases this means people are living with painful and possibly unsightly dental issues which can cause or exacerbate other illnesses and reduce their capacity to get employment. Poor dental health and the inability to afford private health care undermines a person's ability to participate in the social and economic aspects of life.
I cite a study, which is not included in the submission, carried out in California which examined the cost of dental neglect. It found that the ounce of prevention by way of the oral examination is outweighed by a pound of cure, namely, that the cost of an emergency visit to the local hospital is 123 times greater. In other words, the cost of not having an oral examination is 123 times greater if a consequence of that is that one ends up having to attend a hospital for emergency care and treatment afterwards. There are similar comparable studies throughout the world. The great pity is that because we do not have research on this in Ireland we do not have up to date figures but the anecdotal evidence suggests that Irish patients and the population generally are suffering the same effect.
We in the Irish Dental Association regularly carry out surveys among our members and we commission surveys of the general public to establish what are the effects of these cuts. Members will note on page 13 that the most recent survey of dentists last November showed that 77% of dentists saw an increase of patients presenting in pain, 92% saw an increase in patients presenting with gum disease, nearly 90% saw an increase in patients presenting as emergencies, and there has been a comparable increase in patients presenting with dental infections and in patients presenting with multiple decayed teeth. We have commissioned research of the general public carried out on our behaviour by a research company, Behaviour and Attitudes. Members will note, on page 14, 29% of medical card holders had postponed dental treatment in the previous year due to the cuts to the scheme, 26% of medical card holders or a member of their family have missed time from work due to a dental problem, and 38% of medical card holders - which equates to more than 600,000 people - said they would visit their dentist less frequently from now on due to these restrictions and this compares to 14% in 2010.
Often where the HSE is no longer prepared to fund the filling of teeth, it is willing to fund, without limit, the number of extractions. The price of an extraction is not only the €40 that the HSE pays the dentist to take out a tooth. Patients who undergo multiple extractions lose supporting bone and tissue causing them to appear older beyond than years and confining them to a lifetime of denture-wearing, possibly at a far greater cost than the treatment required to save the teeth in the first instance.
The typical profile of patients is female, aged over 40 and wearing dentures, very often with poor diet and gum disease. One can imagine if in the morning one lost one's teeth what that would mean in terms of not being able to eat, converse, smile or talk to people. This scheme has the benefit of tipping the balance between a healthy lifestyle and ostracisation and poor health.
This scheme was first introduced in 1994 and there is clear evidence that it has had marked effect in improving the oral health, particularly of the most deprived, whose oral health tends to be worse in the first instance. At matters stand, the association and the profession cannot endorse this scheme; it is no longer fit for purpose and we want a new scheme introduced. In the short term we believe that even increasing the current funding of €63 million for the scheme to €80 million would not only enhance the oral health of vulnerable medical card patients but would save money for the State in the medium term. We suggest that key preventative treatments should be returned on a phased basis and in particular we would mention the scale and polish treatment for both the medical card and the PRSI schemes. We are aware that the Department believes that there are competition law restrictions and they have to be finally addressed. We have set out principles that should apply to a new scheme. We wrote to the Minister for Health in January of 2012 and we are ready and available to talk about a new scheme. Ironically, there is now talk of a universal health insurance for health services generally but we had a comparable scheme which was a form of universal health insurance; it was the PRSI scheme and it worked very successfully.
The State managed to control the costs, care was provided on a cost-effective basis and dentists and patients were happy with it.
The HSE public dental service operates the schools screening service. The policy is that children at primary school level should be seen at three intervals, in second, fourth and sixth class. As members will be aware, the orthodontic service aims to provide orthodontic treatment to children under the age of 16 based on clinical need. Unfortunately, many children in these groups are not being seen. In some areas children only receive their first dental screening in sixth class. That is due to the effect of the moratorium on recruitment and other cuts in the HSE. Even in the short time since March 2009, there has been an almost 20% reduction in the number of dentists working in the service. Likewise, there have been comparable reductions in the number of support staff – nurses, hygienists and administrative staff - in the dental service. When staff go on maternity leave, they are usually not replaced. There has been a massive reduction in the number of dentists available. The consequence is outlined in the list on page 17. For example, in Laois-Offaly, Galway, Kerry, parts of Cork and also in Cavan and Monaghan it has been the long-established practice in many areas that children are only seen for the first time in sixth class. The difficulty is that it is too late at that stage. Most evidence suggests that children should go to the dentist at the age of one or two years. The fact that they are only being seen at the age of 11, 12 or 13 means that much of the damage has already been done and it is far too late at that stage. Those children then have unfortunate experiences with dentists because they often require remedial treatment, which will obviously colour their view on attending the dentist from there on in.
We are involved in talks with the HSE on reform of the public dental service and we have shown our commitment to reform, but we feel that the moratorium on recruitment must be lifted because no service can continue with 20% non-replacement of dentists and other staff. We also feel that consideration should be given to developing public private partnership models of service delivery to make best use of resources without undermining public service provision.
We are keenly aware, as are members, of the difficulties with orthodontic care and treatment. The waiting list figures are on page 19. Again, we have suggestions on how to deal with the problem. Previously, up to €85 million was assigned to the National Treatment Purchase Fund, but that is now with the advisory service in the Department of Health. There are obviously waiting lists not just for orthodontic treatment but for all aspects of dental care, and part of the funding should be diverted to dealing with that particular problem.
We also say there is a case for restoring the marginal rate tax relief for orthodontic and other specialist dental treatments. It was the case up to a number of years ago that marginal rate relief was available for medical and dental treatments, but that has now been restricted to the basic rate. It is clear that where people have no income they have no entitlement to claim tax relief. That is an anomaly that should be investigated. Perhaps a voucher system could be introduced or some modification of the existing system could be considered, because it would be of particular benefit in dealing with waiting lists.
We are also supportive of the introduction of orthodontic therapists to work with orthodontists in dealing with waiting lists. I accept issues arise about their scope of practice and training, which will have implications for dental schools also. We have detailed a number of other aspects of our submission for members. I am conscious of time so I will not go through everything in great detail. For example, we feel there is a huge untapped potential for dentists to help in health promotion and prevention. That is set out on pages 25 and 27. Many medical conditions can be seen and are more likely to be seen by a dentist. Currently, that is a resource that is not being availed of. We wish to mention also the great success of a voluntary initiative by the dental profession - namely, the mouth cancer awareness day, when dentists give their time free and invite patients for a chat and to explain the importance of regular attendance but also the dangers associated with neglecting the first signs of oral cancer, which is a type of cancer that can be successfully treated if diagnosed early. In fact, there have been 12 or 13 individuals who were successfully treated due to detection on mouth cancer awareness day. This is an increasingly common form of cancer and dentists have a critical role in detecting it and caring for and treating patients.
We also mention the need for a new dental Act. The committee will be aware that there have been changes in the legislation regulating the medical profession, pharmacists, nurses and other health care professions. We fully support a similar legislative change for the dental profession. We are also keenly aware of the fact that there is no direction within the Department of Health on dental care. There is no chief dental officer to offer the Minister guidance and advice, not only to verify what we say but also to conduct his or her own analysis and assess the consequences of the severe cuts to the dental schemes, and to shape, lead and introduce a new oral health policy, which is long overdue. There is no justification for not having a ministerial adviser in the Department. The Minister assures us the issue is being prioritised but we do not see any sign of the role being filled. The committee, the House and the country as a whole are being short-changed as a result.
I will conclude. My colleague, Dr. Gannon, is a practitioner in general practice in Knocknacarra in County Galway. He treats patients with medical cards and all other patients. Dr. Bolas works in the HSE in Sligo. He is an oral surgeon and a working dentist. My colleague, Ms Dowling, and I work in the Irish Dental Association. We thank members for the invitation and we hope the exchange has been of some benefit. We are happy to take any comments or questions.
I thank Mr. Hourihan for the presentation. We hope that members of the association will feel free to interact with committee members. In the absence of Fianna Fáil Deputies, Deputy Ó Caoláin can take the lead.
I join with the Chairman in welcoming all our guests this morning. Neither Mr. Hourihan nor I expected we would meet so soon when I made the proposition to accommodate a meeting at the earliest opportunity. I say "Well done" for stepping into the gap that opened up.
I have been exposed, particularly in recent years, to much of what Mr. Hourihan outlined this morning in terms of the impact on ordinary people. I am particularly concerned at the impact on young children whose lives are being blighted. It is only a number of weeks ago that I took the opportunity to meet with a senior colleague in Mr. Hourihan’s association in my constituency, with whom I have a respectful relationship, to discuss some of these matters. When Mr. Hourihan’s letter arrived it made every sense to follow through.
As I acknowledged last week, what I am exposed to is not unique. All Deputies and Senators recognise what Mr. Hourihan outlined. It is very depressing. I welcome the fact that he outlined a number of practical solutions. They will certainly not be a panacea but they could be pursued to address the difficulties that currently prevail. I refer in particular to proposed solutions Nos. 1 to 5 on pages 19 and 20. I propose that the committee forward them and commend them for consideration to the Minister. I put on record that logic dictates that we follow through on this excellent opportunity.
I do not propose to go over much of what Mr. Hourihan has put on the record; it would be only repetitious for me. I have highlighted a number of different sections to which, all too sadly, I can relate.
On a number of related areas, can Mr. Hourihan offer an explanation of the table entitled Orthodontic Treatment Waiting List 2012 on page 19? As somebody who resides and represents people within the north and north-eastern region, can Mr. Hourihan elaborate on the reason for the inordinate number of people on the waiting list within that region as against all of the others, with the exception of the mid-western region, or am I misreading the tabulated information on that graphic? I ask Mr. Hourihan to address that.
The fact that, in the main, children and young people in primary education are being seen perhaps once, and only in their final year, before progressing into adolescence and second-level education causes difficulties, particularly for those dependent on the GMS scheme - that is, families that are medical card holders.
A situation arises regarding the issue of orthodontic address. Generally, the rule of thumb is that we do not address children below the age of 13; it is usually those over 13 years of age. I presume it has to do with development and so on, but I was recently very upset about the situation that exists for a number of young people who are going into second-level education having only reached their 12th birthdays. I ask that that be taken into account. I suggest that children are maturing at a much younger age nowadays than when I was a young person at school. Their awareness of many issues is way beyond anything I could have imagined at the same age but, as a result, they are very conscious of their appearance, which presents difficulties. Our committee is a health committee. It covers mental health. I have seen damage to both the health and the mental health of young people as a result of the failure in the first instance of all of us to find the proper formula to meet their needs. Mr. Hourihan might address that briefly.
My last two questions are not part of what Mr. Hourihan outlined but are to do with issues we have addressed previously. Has the Irish Dental Association had complaints on a geographic basis about the delay in the processing of dental treatment services scheme, DTSS, forms? I have had this reflected to me, and there seems to be a very different arrangement in some regions as against the speedy processing in the greater Dublin area, where it is a "one out, one back" system. In some areas around the country a form is sent to this address to go on to that address to come back to here and so on. That is ludicrous. It is about the application of common sense.
My last question is in tandem with that. A previous issue this committee has addressed is that of dental technicians. There is a qualification now for dental technicians which allows them to deal directly with the public in the provision of dentures and related work. That qualification, recognition and application of the regulatory standards does not apply across the board, yet there are a significant number of dental technicians not so regulated who are still dealing directly with the public rather than coming through the principal dental surgeon locally. What is the Irish Dental Association doing about that? Regulation is a major area of importance and concern to this committee across the board. It is about not only public confidence but public welfare. I would appreciate any comment the witnesses have to offer.
I welcome our visitors and thank Mr. Hourihan for his detailed presentation, which highlighted some of the difficulties and indicated solutions that the Irish Dental Association would favour. The presentation was very helpful in that regard.
The presentation details effectively with what amounts to the destruction of the two dental schemes in recent years. That was short-sighted, because the curtailment of these schemes affects the most disadvantaged sections of society, and it is necessary to ensure these schemes or improved schemes are put in place as soon as possible.
Clients come into my clinics to deal with three different areas, the first of which is the question of children being seen in the public service and, as Mr. Hourihan stated, being seen possibly only once very late in primary school or, in some cases, not seen at all. Another area is orthodontic treatment for children, specifically the narrow guidelines indicating whether a child is approved for orthodontic treatment and the huge cost of orthodontic treatment. The third area is the question of emergency attendance, whether at public or private dental services. It is difficult for members of the public, or myself, to understand what is or is not an emergency. One of the witnesses might indicate what would be considered an emergency.
The point made in the submission that there is no chief dental officer in the Department is important. On the question of consultation, negotiation and interaction with the Department, Mr. Hourihan stated that the initial contact regarding the schemes was as far back as January 2012. Has there been any contact, negotiation or consultation since then with the association regarding the replacement of these schemes or issues such as the appointment of a chief dental officer?
I will not repeat the issues raised but I want to echo the concerns raised by the previous speakers. I thank the witnesses for their presentation and the way they have laid it out in examining the challenges, but also for coming up with possible solutions. In the context of the position we are in currently, they have put forward realistic proposals.
I want to focus on a number of areas. First, oral cancer is not spoken about to a major extent and because it is not usually visible to most of us, it is only when someone attends a dentist that it is identified. Have the witnesses seen an increase in the incidence of oral cancer or an increase in the number of people being diagnosed later? What is the impact of that on their treatment and outcomes?
Regarding the schools programme and school screening, we have particular problems in the west. In Galway the issue has been long-fingered, and the position is not much better in Roscommon.
That has a considerable impact on the treatment of children, as indicated, and on their ability to get onto the waiting list for orthodontic treatment. Through no fault of the delegation, the submission contains the orthodontic waiting list figures for everywhere in the country except the western region, where circumstances are appalling and where children are waiting for two years and three months on average to see an orthodontist. Some 2,000 children are affected. Some 40% of posts in the western region are vacant, which is compounding the problem. As Deputy Ó Caoláin pointed out, this has a huge impact in terms of the victimisation of children in school. It leads to isolation and bullying. We know the impact of the latter on children.
It is really frustrating in my part of the country that a child on one side of the road must wait for two years and three months, if he is lucky, to be called for orthodontic treatment while a child on the other side of the road can obtain treatment in less than half that time because he so happens to live in the midlands region. The two children may sit beside each other in school and live across the road from each other, yet they are treated completely differently. I understood the HSE was established to deal with these anomalies but it seems to have compounded the problem. What are the delegates' suggestions for tackling the crisis in regard to orthodontic treatment and the impact it has on children's development into adults?
I thank Mr. Hourihan for his very comprehensive presentation. I want to touch on one or two points. Was there a dental officer in the Department of Health previously? How long is it since that individual has gone?
With regard to being financially innovative given the current budgetary constraints, a colleague of Mr. Hourihan’s was in contact with me recently to outline the system being introduced in the United States, which does not necessarily require the presence of a dentist. A dental nurse is in attendance and scanning and cloud computing are used, with the data being transmitted to a centre to be reviewed by qualified dental practitioners, who can then identify which cases need to be followed up. It is about the effective use of money. The person who was in contact with me goes to nursing homes rather than having residents in those homes come to the dental surgery. Thus, dental care can be provided within nursing homes. This is a time in which we need to be innovative and determine how to obtain value for money while at the same time providing a comprehensive service. We must ensure dental practitioners are remunerated adequately for the work they are doing.
I do not know whether we have done much work on education on dental care. It does not appear to be a priority within the Department. If there is no dental expert within the Department, the whole education programme automatically falls down. Perhaps the delegates could comment on the position on education and how Ireland compares with other EU countries, the United States and other countries within the OECD. Although we talk about education in regard to health issues, I am not sure whether we do so in regard to dental issues. How far behind other countries are we?
I thank Mr. Hourihan for his very comprehensive presentation.
I have two questions, one of which is on the voucher system. Will Mr. Hourihan elaborate on it? Could he also elaborate on value for money? It is well known that it is much cheaper to avail of dental health services in Northern Ireland, England and the rest of Europe than it is here. Can better value for money be provided here? We all acknowledge the country is in recession and that it is difficult to fund various services. I refer to ordinary dental services. Orthodontic treatment in this State is extraordinarily expensive. The cost is almost double or treble that in other countries. Could Mr. Hourihan comment on that?
Mr. Fintan Hourihan:
With regard to orthodontic treatment in the north east, I can only guess that the issue is related directly to the lack of dental staff. As the Deputy will be well aware, there has been a severe shortage of dentists in Cavan-Monaghan, of all places, irrespective of whether children require general or orthodontic treatment. I can only guess that this is reflected in the waiting list.
I will ask my colleague, Dr. Bolas, to respond to queries on the threshold and the criteria for orthodontic care.
With regard to clinical dental technicians, ours is not the regulatory body. The Dental Council is a separate entity so we do not have a role in regulating the profession. However, as an association, we fully support the registration of clinical dental technicians. We fully support the fact that they are engaged by the HSE and others. We, too, are concerned about technicians who do not have the necessary formal training. It is acquired at the expense of the individuals concerned, who must travel to Canada and elsewhere to obtain it. We share concerns that the system is not properly regulated. We hope there will be regulation and that increased enforcement powers will be given to the Dental Council as part of the new dental legislation, on which we expect consultation to begin very shortly.
With regard to the administration of the DTSS, we felt we could have spent a lot of time talking about the matter. General practitioners are experiencing considerable difficulties. Circumstances vary widely throughout the country. Essentially, this reflects the lack of resources in the public service to handle the correspondence from dentists. It also reflects the fact that there is now a budget ceiling for care provided to medical card patients. The HSE officials are told they can spend only so much so they must spend time exercising discretion in dealing with requests for care and treatment. The service is now an emergency service, essentially, and consequently some time is spent on deciding what constitutes an emergency. Deputy Healy asked whether there is a general definition in this regard. I am not sure that there is. A dentist may comment on that.
With regard to Deputy Mitchell O'Connor's comments on the voucher system, such a system has been introduced in other countries. Very often, people feel that if something is available free of charge, it is not availed of. Currently, under the medical card system and the PRSI arrangement, eight out of ten adults are entitled to a free checkup, yet fewer than a quarter actually avail of it. If people had an actual voucher, they might be more inclined to avail of the service. It would be easier to administer from the State's point of view and would be more cost-effective. It would not necessarily mean more expenditure, but we feel the current system, under which people have entitlements that they are not choosing to avail of, is not doing their-----
Mr. Fintan Hourihan:
Everyone would have an entitlement to a voucher and would physically receive one. We think it would be seen as a service that they have paid for in the case of PRSI employees and for which, in the case of medical card holders, they have an entitlement. They would be encouraged to visit their dentist. It would also have some benefits in terms of the administration of the system. Other countries have introduced these types of systems.
As regards value for money, the reason I spent so much time explaining the fact that there is no State support for dental care and that it must meet its costs fully by generating income, is because there is a perception that dental care is expensive. It is expensive all over the world. It is one of the most expensive areas of medical care and treatment. I would not accept that there are significant differences, although there can be between individuals. Very often, however, people will get a quotation in one jurisdiction and assume that it will cost the same or far more here, even though they may not necessarily have been to a dentist to get a quotation here. Even where there are differences, however, it simply reflects the cost of running a practice and the absence of State support.
We would tell people that, by all means, if they want to go abroad that is their prerogative but they should at least visit their local dentist first. From a value-for-money perspective, it is a short-sighted approach when somebody travels far away for treatment because if there are remedial or aftercare issues, they may find that it is far more expensive in the long run. We have plenty of experience of dentists close to the Border here who say that some of the fees they charge are lower than costs in Northern Ireland. That also reflects currency exchange rates. Dr. Gannon might wish to comment on this.
Dr. Peter Gannon:
That is true. I have been working as a dentist for about 15 years. When I started working there was a big cost difference between dental treatment North and South. That gap is very close now, however, and there is very little difference. In fact, a recent survey I saw in a national newspaper looked at four practices in the North and four in the South to compare prices. The cheapest one was in Dublin.
If one looks at the supports that a general dentist will get in the North in contrast to what I would get here, they do not pay commercial rates and their clinical waste is taken away. There are allowances for maternity leave and education, and there is locum cover if a dentist is not in the practice. Naturally, it will be more expensive for me to provide that care, so what I charge is based on how much it costs me to provide that care.
Looking across Europe and the world generally, there are huge differences in dental treatment costs. I have Irish patients who are now living in Canada or Australia and when they are home on holidays they come to me because I am much cheaper. Two weeks ago, a young man visited my practice from Norway. He reckoned that the price he paid me for a filling was about half what he would pay in Norway, so one will get that range of prices.
Where it is cheaper to provide dental treatment, the costs will be cheaper but the difference between North and South is a good deal less than it used to be. When people take the opportunity to compare different dentists' prices, they will find a lot more value within the Republic of Ireland than they used to in the past.
On a slightly different note, patients have said to me that dental practices are only open during working hours. Is there any way that their opening hours could be extended to help working people?
Dr. Andrew Bolas:
The committee will note that the table on page 19 lists two categories: grade 5 and grade 4. This is a historic way of assessing who needs orthodontic treatment. It is based on a UK guideline called the index of orthodontic treatment need. Those in category 5 are usually people who need surgical intervention where they have unerupted teeth or may have a cleft pallet or cleft lip. These are the extreme cases that need not just an orthodontist but also other inputs from an oral surgeon, such as myself.
Those in category 4 are what we would call - if I can use a layman's term - people with buck-teeth or crooked teeth. These people have a functional need for treatment. Within the grading system, a number of years ago everybody in category 5 and category 4 received treatment. The problem, however, was that huge numbers qualified for waiting lists. Therefore, the Department decided that only certain sub-categories in category 4 would qualify. People with crooked teeth had to have a very unpleasant condition before they would get past the goalposts.
Many of the statistics for the number of patients on waiting lists, even from anecdotal evidence of working in the HSE, are not strictly accurate. In the midlands area it is 175, for example, but the consultant orthodontist for the midlands moved to Cork in the middle of this period, so people were not being put on the waiting list.
I work in the Sligo-Leitrim region where we hold assessment days when we bring in 150 children on a single day. The consultant orthodontist will examine each child and decide who qualifies and who does not. We try to work on the principle that people are not waiting to see the orthodontist to go on another waiting list. It is much better to do it en masse and get them assessed, so they know whether or not they qualify. That gives patients the opportunity, if they can afford it, to seek private treatment if they do not qualify. It also gives a consultant the opportunity to tell us that a patient does not need to go on the waiting list, but that we could do the following treatment which would have a good result. We do a lot of interceptive orthodontics, taking out teeth to allow other teeth to grow.
As regards many waiting lists, there may be a consultant but he does not have any specialists working under him. There is an artificially large waiting list due to the manpower issue. The consultant is dealing with category 5 patients, while category 4 people are put on the long finger. As Deputy Naughten said, that was the case for a long time in Galway where there was no consultant. The specialists with orthodontic qualifications will not necessarily tackle cleft lips and cleft pallets, but they will deal with category 4 patients which is their bread and butter, so to speak.
I suppose the solution would be to have more orthodontic centres around the country with a consultant here and a consultant there. For instance, in Sligo we share a consultant with Donegal, so we only have him three days a week and he is gone for the other two days.
We only have him three days a week. It is also a question of providing him with the facility whereby he has more specialists working under him and a good number of aesthetically challenged patients get treatment in a timely fashion. That comes down to allowing the resources to be invested in dental schools to train people. Unfortunately, the way things are, as we train orthodontists, it is much more lucrative to be in private practice than to work for the HSE. In the UK, they used to fund the course and make the student sign up to a contract to provide two or three years' service to the State prior to embarking on his or her studies. That allowed the State to recoup the cost of the training by having the graduates treat those who were stuck on waiting lists. A little investment in orthodontics would go a long way.
Someone asked why we only deal with these things when people reach the age of 13. The development of the mouth is a bit like a car park. It is not until all the cars are in the car park that one can see what one has to deal with. Many orthodontists will not treat eight and nine year olds. They put them on a waiting list knowing they will have to wait for four years when they are 12 or 13. At that point, the whole mess will be dealt with at once. There is a school of thought that interceptive orthodontics, which involves fitting appliances to the young mouth as it is growing, has advantages. It is something we used to do. I joined the North-Western Health Board in 1997, at which time we did a lot of interceptive orthodontics. We put in retainers or space maintainers, which are removable appliances that allow the patient to manage his or her own situation. We do not have the manpower to do that now. We are too busy filling and extracting teeth to do the tasks that represent an investment in the future. It is a further argument for the moratorium to be lifted for dental staff. When it was initiated, an exception was applied to front-line speech and occupational therapists and physiotherapists. We are therapists also, but of teeth. That was forgotten.
My colleagues have mentioned the voucher system for orthodontics. Many consultants also have private practices. They work under the new consultant contracts. A voucher would go a long way for the category 4 patient or someone on a waiting list or who qualifies and needs but cannot afford private treatment. They are the ones who are bullied at school and have aesthetic issues. Many category 5 patients have teeth buried in their jaws, but their teeth look fine. No one knows they are badly off from an orthodontic point of view. No one will pick on Johnny at school because his canine tooth is impacted in the roof of his mouth. The treatment for an impacted tooth is to leave it and to avoid surgery where that will not improve the outlook or dental health of the patient. However, that category 5 patient takes a place on the waiting list before someone whose canine tooth is coming out sideways and at whom everybody points in the classroom. There is a great deal of peer pressure on category 4 patients. If one flicks on the television, every American child one sees has a fixed appliance. It is actually abnormal not to have one. That is what our kids are thinking about. I have had mothers ask me to put a fixed appliance on even though it will not do anything. It is just so that the child can appear in school with a fixed appliance and not be the only child without one. One would not do that, however, because there are oral health issues.
One of our problems is that we do not catch kids young enough. The European norm, including in the United Kingdom, is that children are encouraged to attend the dentist from the first sign of any baby teeth, particularly from the age of three or four. Even if the child is not sitting in the chair but is there to see a brother or sister get work done, it helps him or her to see that a dentist is not someone to be scared of. It gives the dentist the opportunity to tell the mother not to send a child to bed with a bottle of Ribena and to watch his or her diet. We have the highest consumption of sweets of any country in Europe. We want to catch children young enough and reinforce the message between the first and last visit. Children are covered to age 16, which will be when the last visit happens. We really only provide emergency treatment after age 14. Those children will become parents one day. What they learn as children becomes a habit and habits are learned from parents.
Does that refer to the dentist or the orthodontist? Surely, parents know without having to go to the dentist that providing Ribena or sugar in the doses we are talking about will lead to tooth decay.
Dr. Andrew Bolas:
It should be out there in other forums also. The public health nurse should deliver the message too but the best-placed person is a dentist, who can give the example. When the first cavity appears, the dentist can say to the mother, "Let me show you what has happened". Parents will often come in and say their children were born with weak teeth, when it was the bottle they went to bed with every night that was the problem. Parents do not understand, and the dentist becomes the bad guy for saying it is the parents' fault, not the child's. The child did nothing to progress the decay; it was what the parents were doing. We need an investment in the current generation to obtain a benefit for the next. That is the way forward.
Dr. Bolas instanced young males, but I am thinking of young females who are called "Nanny McPhee" at age 11 because of an abnormality. It is a label that will never be erased. It is something that requires earlier intervention. Whatever Dr. Bolas can do to encourage that earliest support saves a child or a young adult's life.
This has been a very interesting presentation, and I sincerely thank the witnesses for their work in preparing it. I commend the recommendations and ask that we forward them for the Minister's attention.
I thank the witnesses for coming here today. Some of the questions I was going to ask have been asked, so I will not repeat them.
As I expected, the witnesses painted a very bleak picture. I agree with Deputy Ó Caoláin on forwarding the recommendations to the Minister in the hope that he can respond, notwithstanding the fact that there is a €12 billion overspend this year despite the progress we have made in tackling our economic problems. Is there any way to construct an argument to say that if a certain amount were spent on dentistry for children, it would save the State money because there would be less intervention at a later stage? That is the sort of argument that must be put forward to win at the moment. I had intended to ask the question Deputy Mitchell O'Connor asked on the difference between costs in Ireland and those abroad, but the witnesses have addressed the issue. Scaling and polishing were mentioned. How much would it cost to reintroduce them in the schemes referred to?
How much would the reintroduction of scaling and polishing cost? Is there an obligation for dentists to list their fees? When one looks at a large number of children, some are going to be in a worse state than others. Is there a way some of those could be prioritised? Could the Minister devise some scheme that would focus on those with desperate needs for treatment?
I acknowledge the good work done on the ground by many dentists in local and primary care health centres. The availability of dental treatment at primary care centres has made a difference for young children. I agree with all that has been said about orthodontic services. In 1999 when I first entered politics, I was on the former Eastern Regional Health Authority when the waiting list time for orthodontic treatment was six and a half years. We have come some way but I am still concerned about waiting lists. Some children look different to other children in the classroom because of their teeth and, accordingly, it can affect them. The waiting time for treatment should be only a few months.
Hygiene begins at home and parents are the sole educators in this regard. I agree it is lacking in some households. My granddaughter who is two and a half brushes her teeth after she gets dressed every morning simply because she sees her mother doing it. As Dr. Bolas said, what parents do will be followed by their children. I do acknowledge that in poorer areas where people have less money there are problems.
I was not aware of the oral cancer awareness day. I have met several people in my area who had oral cancer and the disfiguration of their faces is shocking. Are more men affected than women and what age group is affected? How many children coming from schools actually attend their appointments? When I was bringing my children up, I always put a reminder for the date for a dentist appointment in a prominent place. I am concerned, however, that many parents miss their children's appointments. How much does a dentist receive for a check-up for a primary schoolchild? Is there a set fee?
I thank the delegation for its informative presentation which highlighted many problems but also offered solutions.
The report highlights sixth-class primary schoolchildren are often called for dental appointments only when they are in secondary school. I know that was the case with my daughter who was in first year in secondary school when she was called for an appointment. Should the Government take emergency measures to rectify this matter? The criteria for qualifying for orthodontic treatment are very strict. Accordingly, many 13 year olds who need treatment do not meet the criteria and have to attend private practices. Most parents cannot afford the enormous costs that go with the treatment and have to go on a waiting list. I know of cases where children are not called until they are 18. The voucher system suggested is well worth exploring. People with special needs also have to endure long waiting lists before they receive dental treatment.
The delegation said it was involved in talks about reform of the public dental service. Can it elaborate on this? Its report stated oral health care is now almost privatised. What would be the best practice model of an efficient and functioning public dental service?
How does Ireland compare with the number of dentists per head of population internationally? In every medical specialty we are so ludicrously low we are off the scale. What are the UK and continental averages for dentist per head of population?
Dr. Andrew Bolas:
My suspicion is that the incidence of oral cancer is increasing on a slow but steady basis. The confounding factors are alcohol consumption and smoking. I have noticed the patients referred to me are getting younger. The most recent case I saw a fortnight ago was a young girl 32 years of age. The beauty of oral cancer, so to speak, is that if it is caught early, the treatment can be done under local anaesthetic and is an excision of the area involved with dissolving stitches. However, once it gets to an advanced stage where one needs to borrow skin from other parts of the body or ribs or arms to replace bones, it becomes very disfiguring. When it gets to that stage, the first thing we examine is the patient's face. There is a social stigma almost attached to it.
People are presenting earlier with it. I have to give the credit for that to the Irish Dental Association and the Irish Cancer Society with its oral cancer awareness days. Also, with celebrities having it, some even dying of it, people have become more aware of it. Our biggest problem with the awareness day is that it is not supported by the Health Service Executive, HSE, or the Department of Health. It is purely down to the goodwill of the dentists doing it. We need to examine this because the incidence rates are comparable to other forms of cancer which get more air time.
School screening depends on the area. Geography dictates health care. In some areas, they attend the schools to examine the children in the class. Time wise that is probably the most effective way because then one knows who to call back to the clinic for treatment. The problem is that not everywhere has enough staff to go out to the schools so they have to call them to the clinics which takes longer. It means the children have to be brought out of school.
Parents often have to leave work to facilitate the appointment. The non-appearance rates also vary. In some weeks virtually nobody shows up and we are ringing around to find patients. I worked in County Leitrim for a period of time and if it happened to be a good week for cutting hay there was no point in sending out appointments. We also tend to avoid certain age groups during exam times.
In regard to the high cost of orthodontics, it is a modern reality in Ireland that the credit union treats many of the patients and even orthodontists will advertise that they allow instalment payments. However, it becomes a tough decision for parents when the choice is between paying an instalment for orthodontics or purchasing groceries.
There is a significant problem in getting theatre time in hospitals to treat patients with special needs. This is where many of the long waiting lists arise. There is a further failure in that insufficient people are trained in special care dentistry in order to proved the requisite treatments. The task is assigned to a senior dentist in a particular HSE area but he or she may not have formally trained in this area and is working on an experience basis rather than an academic basis. We found to our detriment that the packages handed out last year to encourage early retirement often removed the most senior people in dental departments. In many cases these individuals were the special needs dentists and they have not been replaced.
I will ask my colleague, Dr. Peter Gannon, to speak about models of best practice. As he works in general practice, he will be better positioned to comment on who we should resemble.
Dr. Peter Gannon:
Various types of model exist. We tend to look to Europe in the main because it seems to provide the best access to the most people. Generally the European model provides state support for those who need it and people pay more of the cost of their dental care as their means allow. This is backed up by a public dental service that tends to look after certain age groups, such as children, and special needs groups.
We operated a similar system in Ireland until the cuts were introduced several years ago. I have found that many people tend to come to my practice less often now that the supports are no longer being offered. The schemes that were formerly in place focused on fairly simple preventive treatments, such as cleaning teeth and fillings. Despite all the talk of complicated dental treatments, implants and root canal treatments, these aforementioned treatments comprise more than 95% of my work. I know the patients who take fantastic care of their teeth and young people and teenagers will never need complicated or expensive treatment. That is where people are saving money. By offering regular simple treatments we can send a personal message to people in terms of showing them where they may be missing out in cleaning their teeth and pointing out their particular problems. They are more likely to take on board a personal message than the general message about not eating sweets and brushing teeth.
In regard to the cost of reintroducing scaling and polishing, the cost for the last year in which these treatments were allowed under the general medical card scheme was in the region of €5 million. That is the most simple preventive treatment we carry out but it makes a big difference to individuals' gum health in the long term. The prevention of gum disease leads to fewer extractions and dentures down the line. People are inclined to attend for such treatments because they do not mind getting their teeth cleaned, which allows us to impart a personal message. If they come regularly they are more inclined to take better care of their teeth. If they know they are going to see the dentist in a month's time they are inclined to clean their teeth properly.
Mr. Fintan Hourihan:
The post holder would give strategic direction and advice to the Minister on the best deployment of resources and offer advice on emerging scientific developments. A dentist is appointed to look after the HSE and the public service component but that is a limited cohort of the overall population. In the same way as there is a chief medical officer, a chief dental officer is also required.
Mr. Fintan Hourihan:
It has stated simply that it must cut numbers. We argue that the savings for the system and the benefits for patients would be far greater than the cost of employing a chief dental officer. It is embarrassing when we go to international meetings to admit that Ireland is the only country without a chief dental officer. There is no justification for that.
Mr. Fintan Hourihan:
We would greatly appreciate that. We wrote to the Minister of Health about the DTSS in 2012 but unfortunately there has been no engagement. As with other contracts and schemes, the Department is hiding behind competition law even though the last Attorney General stated there is no reason the Department cannot negotiate with representative bodies. We would like that to happen sooner rather than later.
Dentists are obliged to display their fees. The association actively supports and promotes this practice and surveys have shown that fees are displayed in 98% or 99% of cases.
A question was asked about fees paid for seeing primary school children. Obviously there is no fee if they are seen by the HSE but the Deputy may have been asking about private visits.
Mr. Fintan Hourihan:
The fees are usually four figure sums. Prioritisation is already being done on the basis of what could best be described as rationing because of the drastic cuts in the public service. It is difficult to see how any further prioritisation can take place without some relaxation of the moratorium.
The backdrop to the reform of the HSE public dental service was that the HSE commissioned a firm of management consultants to examine how the service was structured. It was previously structured on the basis of what were the 32 community care areas in the days of the health boards. The ensuing report suggested that certain services be consolidated or amalgamated and that a national oral health office be established within the HSE. This has happened and we participated in the process. Dentists have taken on a lot of extra work without additional remuneration. One of the key components of the report was the recommendation that the moratorium on recruitment be lifted.
By contrast, what has happened since that report came out is that the numbers have decreased by 20% in net terms. In some parts of the country one will find it is far greater, but, as I said earlier, one will also find that dentists who retire, leave permanently or take maternity leave are not being replaced, and nor are their nurses or hygienists. That is practically the entire explanation for the problems one is seeing in terms of waiting lists and screening not taking place until sixth class. Very often the orthodontic waiting lists can be misleading, because by the time people get to see the orthodontist they have other dental problems which need to be treated, cured and cared for before they can proceed with orthodontic treatment. Bad and all as the figures look, the situation is worse.
The figures we have provided are based on parliamentary questions but those figures are not representative of the actual situation. Dentists in some parts of the country have said to me that the waiting lists are far worse than stated in the replies to parliamentary questions. I have been called to task for the figures we have put out. I have explained they are based on parliamentary questions but dentists who do not want to be identified have said to me that the waiting lists in some parts of the country are far longer.
Dr. Andrew Bolas:
There is certainly a lot of media interest in it at the moment. One must really look at the scientific evidence available. The level at which we fluoridate our water supply is perfectly safe. None of the studies identify any of the diseases many of the campaigners identify as being the reality. Why is it so good? As a dentist, I would say the difference it makes to the prevention of cavities in teeth is huge. I qualified in Belfast and worked in the hospital for sick children there. It is a non-fluoridated area and routinely, we would have had 26 children on a theatre list to get teeth out. That was on a weekly basis. In Sligo, where I now work - a fluoridated area - we see six children per week to get teeth out. The benefits from the point of view of dental health are marked. A recent study showed that 15 year olds in County Donegal had 70% fewer cavities than 15 year olds in County Derry, just across the Border.
Dr. Andrew Bolas:
Donegal is a fluoridated area but Derry is not. The sample was chosen to try to equalise social class and so on. It is a very cost-effective method of preventing treatment. I dread to think what the state of our children's teeth would be like if we did not have it. Areas in the UK where one can match social class, economics and so on show marked increases in dental decay. As a consequence of that, one may need to use general anaesthetics to remove teeth from children, and there is no such thing as a safe anaesthetic. One is putting the child at risk to solve a problem that could have been prevented.
I thank the witnesses for their interesting and informative presentation. I support the referral of pages 19 and 20 to the Department, as well as the question of the chief dental officer. Perhaps we should include the dental area in the joint committee's work programme in the future, because it is an area that tends to be forgotten.
Is it agreed that we send the proposed solutions as part of the document to the Department and that we write to it about the vacant position? We will put this on the work programme after Easter in the context of getting a response from the Department to today's presentation.
I thank the witnesses and Ms Elaine Hughes, the assistant chief executive, who is in the Visitors' Gallery, for coming in. I also thank them for their ongoing communication and for raising the issues with us. It has been a valuable learning exercise. We appreciate the work they do in their practices around the country. Some members raised questions about hours of operation. I know quite a number of dentists in my area in Cork and they are very much patient-focused. They have emergency numbers on their answering machines and I had to use one last weekend. To be fair, the dentist was available if I needed him. Dentists place their patients at the heart of what they do. Again, I thank the witnesses for coming in.
I remind Deputy Healy that the select committee will meet at 5 p.m. on Tuesday, 23 April 2013 to deal with the Health Service Executive (Governance) Bill 2012. We will discuss organ donation at our next meeting. I wish everyone a happy Easter and ask members not to cause too much harm to their teeth by indulging in too many chocolate Easter eggs.