Oireachtas Joint and Select Committees
Thursday, 8 October 2015
Joint Oireachtas Committee on Health and Children
Dental Regulation: Dental Council of Ireland
I remind members and witnesses their mobile telephones should be switched off. The joint committee's first meeting is with the Dental Council to discuss issues regarding dental regulation in Ireland. I welcome to the meeting from the Dental Council Dr. Eamon Croke, president, Dr. Barney Murphy, vice president, Mr. David O'Flynn, registrar, Professor June Nunn, chair of the auxiliary dental workers committee, Dr. Terry Farrelly, chair of the fitness to practice committee and Dr. Marielle Blake, chair of the education and training committee. They all are welcome and I thank them for their attendance. I also thank Dr. Croke for changing his diary around; he should not worry as we will have him out by 11 a.m. or 11.15 a.m.
In the past, the joint committee has raised a number of issues of concern with regard to dental regulation in Ireland and this meeting is an important opportunity for members of the joint committee to engage with the Dental Council and to identify areas in which further regulation may be needed or where actions may need to be or already have been taken. I again thank the witnesses for their attendance. In respect of witness privilege, I advise witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence in respect of a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him or her 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 by name or in such a way as to make him or her identifiable.
I call on Dr. Croke to make his opening remarks.
Dr. Eamon Croke:
I wish the Chairman and members of the committee a good morning. I thank the committee for the invitation to appear before it to discuss dental regulation. The Dental Council of Ireland has been in correspondence with the joint committee following a letter of 16 October 2014 from Mr. Paul Kelly, principal clerk. This letter resulted from the meeting of this committee with representatives of the Clinical Dental Technicians Association Ireland, CDTAI, on 1 October 2014 and I will return to the matter of that letter in the course of our submission.
First, I will outline the role of the Dental Council of Ireland. The council was established by the Dentists Act 1985. The primary function of the Dental Council of Ireland is to protect the public. It does so by promoting high standards of education, as well as professional, ethical behaviour for all its registrants. The council is composed of 19 members. There are three main committees of the council, namely, education and training, fitness to practice and auxiliary dental workers.
The council's term of office is five years. There is mandatory registration for dentists and specialists, of which there are two recognised specialties - orthodontics and oral surgery. Mandatory registration is in place also for dental hygienists, clinical dental technicians and orthodontic therapists. The council has a voluntary register for dental nurses and is working very closely with dental technicians to establish a voluntary register.
The Dental Council of Ireland awaits a new dental Act. The council has been consistent in seeking new legislation that would permit effective, flexible regulation which is evidence-based, equitable and proportionate. The council acknowledges the progress made by the Department of Health in the lifetime of this Dáil but regrets the continuing delay in the enactment of new legislation. The council met with the representatives of the professional regulation unit of the Department of Health recently to discuss its summary of policy issues for inclusion in the new dental Bill, of which members have a copy.
I will introduce the major topics which arise from the summary of policy issues. Key policy issue No. 1 is fitness to practise. The council urges in the strongest terms that the wording in Part V of the Dentists Act 1985 on fitness to practise be retained and amended rather than introducing the very prescriptive provisions of both the Medical Practitioners Act 2007 and Nurses and Midwives Bill 2010. The council's experience of operating the provisions of Part V of the current Dentists Act is that the procedures work well for managing fitness to practise matters. The Dental Council of Ireland broadly supports the main provisions of both the Medical Practitioners Act 2007 and the Nurses and Midwives Bill 2010 in providing for a preliminary proceedings committee which is separate from the fitness to practise committee, the establishment of a health committee and for a wider range of sanctions. In the Dental Council of Ireland’s view, the same range of sanctions that apply to practitioners should apply to all registrants and to the entity registering dental premises including, in the case of the latter, the power to temporarily or permanently close dental premises and to attach conditions to the ongoing registration of dental premises.
Key policy issue No. 5 is the regulation of the allied dental health professions. The Dental Council of Ireland strongly disagrees with the provision in the summary of policy issues that only those allied dental health professions who work independently will be registered. The Dental Council of Ireland believes this proposal to be regressive and potentially harmful to patient safety and the development of the dental team. To ensure it has the capacity to fulfil valid regulatory function, to enhance patient-centred safer, better health care, the Dental Council of Ireland requires the new dental Act to provide mandatory registration for all members of the dental team, including dental technicians.
The issue of registration and regulation is at the core of illegal practice, which the Clinical Dental Technicians Association Ireland, CDTAI, brought to this committee's attention. In that meeting the representatives alleged "that there are significant numbers of people illegally practising as dental technicians in Ireland" and further alleged "there has been a complete failure on the part of the Dental Council of Ireland to regulate the profession". The registrar of the Dental Council of Ireland repudiated the false allegations made against the council in his letter to Mr. Kelly of 23 October 2014. The Dental Council of Ireland, under the Dentists Act 1985, has no power to inspect or close illegal practice. The limitations imposed on the Dental Council of Ireland by the present Act to deal with alleged illegal practice are widely recognised and were noted in the Competition Authority's report on dentistry in 2007. The inability of the Dental Council of Ireland to directly intervene in illegal practice is known to the CDTAI, as clinical dental technicians have representation on the council's auxiliary dental workers committee. Many hours have been given to the CDTAI representatives, within Dental Council of Ireland and in informal meetings, to explore their concerns. They are fully aware of the limitations of the Dental Council of Ireland's power and the CDTAI has misrepresented the council's powers to the committee.
The issue of illegal denturist practice highlights a quintessential issue to any discussion on dental regulation. Without registration, can regulation be effective, transparent or consistent? How is accountability enforced? It is the stated desire of all organisations representing those who work legally within dentistry that mandatory registration should be provided by the new dental Act for all dental health care professionals.
Key policy issue No. 7 is the board. The proposal that a new dental Act would limit the council size to a maximum of 12 members will irrefutably change the successful operational traits of the Dental Council of Ireland. While the council appreciates that one of the main aims of having a non-dental majority is to minimise the perception of professionals protecting professionals when considering fitness to practise cases, it is important to understand that most of the work the council undertakes relates to dental education and general practice. To operate effectively, it is vitally important that the voice of dental educators and specialists, as well as members of the general practice dental team, are represented at council. The Dental Council of Ireland advises that regulatory impact analysis specifically assesses the necessity and effectiveness of the proposed changes in light of the council's day-to-day workload and international best practice.
Key policy issue No. 9 is the regulation and inspection of dental practices. The Dental Council of Ireland welcomes the provision made in the summary of policy issues that new legislation will provide for the regulation and inspection of dental practices and premises and that it will also provide that regulation and inspection powers will be held by the Dental Council of Ireland. The Dental Council of Ireland believes it is best positioned to oversee the registration and inspection process because of the expertise it has developed over years of regulating dental practitioners. Legally and administratively, it makes sense for one body to regulate both dental practitioners and dental practices and for that body to have an inspectorate. Most important, it is probable that serious breaches of regulations concerning dental premises will also uncover matters which may form the grounds of a complaint against one or more dental health care professionals. In order to deal with such matters expeditiously it is necessary to have both regulatory functions under the direction of one organisation.
The Dental Council of Ireland would wish to see the new dental Act contain provisions giving it the power to enter and inspect a place where it is reasonably suspected that dentistry is being practised. That power is essential to the ability of an inspectorate to investigate reports of illegal practice and would address the issues highlighted to this committee of illegal work undertaken by some dental technicians. The Dental Council of Ireland is of the view that registered dental premises need not be owned or controlled by dentists but must be regulated. The council proposes that the entity registering a dental premises must be accountable to the Dental Council of Ireland for ensuring compliance with the new Dental Act. The framework set out in the Pharmacy Act 2007 allows the Pharmaceutical Society of Ireland to register and inspect pharmacies as well as to regulate retail pharmacy businesses and could be adopted for inclusion in the new dental Act.
Key policy issue No. 10 relates to the principal dentist and registered owner representatives in dental practices. The Dental Council of Ireland welcomes the provision made in the summary of policy issues that new legislation will provide for the appointment of principal dentists and registered owner representatives in dental practices and that this provision will also apply to any independent allied dental health practice established. The council recommends that the proposed new dental Act allow the council to take criminal prosecutions in a manner similar to the provisions under the Pharmacy Act 2007 and the Food Safety Authority of Ireland Act 1998.
Key policy issue No. 12 relates to staggered term of office board appointments. It is the strong view of the Dental Council of Ireland that corporate memory primarily rests with the staff of the Dental Council of Ireland who have acquired an understanding of the day-to-day functions of any council and the relevant legislation. The Dental Council of Ireland is unaware of any evidence to indicate that staggering the terms of council members will improve the effectiveness or consistency of the council's functions.
Key policy issues Nos. 18 and 19 relate to continued professional development for dentists and allied dental health professionals. The Dental Council of Ireland welcomes the provision in the summary of policy issues that will require dentists and allied dental health professionals to maintain their own professional competence and that the Dental Council of Ireland can require them to demonstrate competence to its satisfaction in accordance with a professional competence scheme. However, it questions how it is possible to do this when the proposals will effectively deregulate most allied dental health professionals. If one has no register, how can one enforce a mandatory code of continuing professional development?
It is the council's intention that all registered allied dental health professionals will be accountable to the council with regard to continuing competence. The Act should allow the council to refer issues concerning non-compliance to the preliminary proceedings committee under the fitness to practise provisions of the new Act.
The council has made previous submissions to the Department at its request.
There are two outstanding matters related to standards in patients safety which the summary of policy issues has not addressed.
The Dental Council of Ireland is very disappointed that foundation training is absent from the summary of policy issues. The council aspires to the introduction of a mandatory foundation training scheme as it considers it not only an elemental part of continuing professional development but also an essential part of the development of any young dental professional. Foundation training is a period of training following initial qualification and registration that builds on the achievements in the undergraduate curriculum and aims to produce a competent, caring, reflective practitioner. This is generally achieved through treating patients under supervision and in taking part in structured and unstructured clinical review and learning. The Dental Council of Ireland acknowledges that the current economic climate might make the introduction of a scheme challenging in the short term. The council seeks a provision in the proposed dental Bill that would allow for the introduction of such a scheme by way of statutory rule.
Finally, the Dental Council of Ireland is concerned that professional indemnity is not addressed in the summary of policy issues. Professional indemnity is an indispensable element of patient protection. The Dental Council of Ireland is of the view that any registered member of the allied dental health professionals team who can perform intra-oral procedures for his or her patients must have appropriate professional indemnity cover. The proposed Bill should allow the council make regulations in relation to indemnity.
I thank the committee for taking the time to consider this oral submission. My colleagues and I would welcome the discussion of these and any other matters that the committee may wish us to address under dental regulation.
I thought Deputy Kelleher would be getting the first slot. I join the Chairman in welcoming the representatives from the Dental Council of Ireland and I thank Dr. Croke for his comprehensive address to the committee. I am encouraged by much of what Dr. Croke stated in terms of the importance of registration across the entire dental or dental-related team. That is vital.
I will not go down the cul-de-sac of previous engagements that this committee has had with other voices from within the dental profession. There is no benefit to that. Dr. Croke will have his view and others will have theirs and our role here as legislators is to inform the Minister and inform the elected representatives of the people of the importance of given measures in the public interest, and it is on the public interest that we are primarily focused.
I have a number of issues. The proposed dental Bill is long awaited. There is a frustration in this that no doubt is shared among us all. I note the position heretofore, as Dr. Croke's stated in his opening remarks that the primary function of the Dental Council of Ireland is to protect the public and ensure ethical behaviour for all its registrants. That is the critical point here, that the behaviour of those who are not registrants but who are presenting themselves as duly approved practitioners creates a situation where, apparently, the Dental Council of Ireland does not have a role in terms of enforcement. How do we address the situation where persons are not entitled to advertise the services that they offer and are neither properly qualified nor legally entitled to direct their services to the public? There are examples of this, some of which are high profile. Some have names with which we have become familiar in terms of an individual practising dentistry who is not registered with the Dental Council of Ireland and thereby is not an approved practitioner in this jurisdiction and, I understand certainly in one or more cases, not entitled to practice in any jurisdiction. It is a matter of how we bridge all of these issues in the intervening period.
Has the Dental Council of Ireland confidence that the proposed legislation will properly provide and does it see, as I read from what Dr. Croke stated here this morning, that the council should have enhanced powers of enforcement, oversight, etc., and that it would cover the critical areas, including dentists, orthodontists, hygienists, dental nurses, clinical dental technicians and dental technicians? It is critically important that all of these are properly registered. Registration is the key issue. Initially, one is talking in terms of dental technicians, of voluntary registration which would lead on the enactment of the proposed legislation to mandatory registration. That would be a pathway to overcome some of the existing dichotomies.
There have been instances of dental technicians dealing with the public. How, in the absence of the legislation, do we deal with the fact that there is evidence even of advertising by dental technicians who have no entitlement to so advertise their work? Their engagement and their direct line management is through properly qualified dental practitioners. They have no entitlement to engage with or service directly the public. How does the Dental Council of Ireland see that weakness being dealt with in the absence of legislation? Has it confidence that the proposed legislation will see that matter put to bed once and for all?
As matters stand in terms of the Dental Council of Ireland's powers, apparently over those only who are registered with it, how does it see the matter of those not registered with the council opening their doors and offering their so-called "skills" to the public? I refer to persons who, in other jurisdictions within the European Union and perhaps elsewhere, have been de-registered in their respective countries of origin where they have so-called "qualified". In this regard, we have heard members of the Irish public on the national radio. Although I am not a regular listener as it clashes with Dáil business, I am sure Joe Duffy has attended to it at some point in time. How do we collectively address the fact that there have been - I cannot say that there are but there have been - persons who were not properly entitled to present themselves as they did within the dental profession?
On the question of registration, I have concerns in regard to the proposed legislation that not all elements of the team of dental practitioners that I have mentioned earlier will be compelled to register. Can Dr. Croke tell me what he knows or, if there any fears in regard to the areas of dental practitioners, dentists, orthodontists and hygienists?
It is my understanding that there is some fear that it might be delisted, for want of a better word; I am speaking as a layperson here. That would be absolutely outrageous.
I have named some of the key areas and the witnesses could probably add to them. Are we on the one page that all the areas I have mentioned already and any others should have their respective registration lists and should all come under the council's oversight and control, as I would want it to be? I would appreciate any assurances or advices the witnesses could offer on how we might work together collectively to ensure the legislation is fit for purpose across the board.
I welcome the witnesses. Based on their statement we have major challenges in ensuring we have integrity in a process to oversee all dental practice in the country. There are varying views from other organisations and individuals. The bottom line is that we must consider this from the point of view of the patient or client. We need to ensure there is proper oversight and regulation in place along with disciplinary procedures, if necessary, when in breach of that.
By any stretch of the imagination, it is quite loose in the areas of dental hygiene, orthodontics, cosmetic surgery and the definition of a technician. We are consistently inclined to regulate those who are already regulated and not regulate those who should be regulated when introducing legislation regulating entities and it seems to be our difficulty in this case. We have met other individuals and groups. We have also seen the difficulty and damage done to people by those who are not fit to practice and should not be practising.
We have a variety of legislation underpinning regulation, including the Medical Practitioners Act and the Nurses and Midwives Act. I always thought the difficulty we had in regulating dentistry was in defining dental technicians, cosmetic surgery and cosmetic dental interventions. Those grey areas will be very challenging in the years ahead. As we have seen in other countries almost anybody can put a plaque on the wall and claim to do cosmetic surgery and cosmetic dentistry. Much of it is very invasive and potentially damaging to people.
That highlights all the obvious stuff but within that, how can we ensure that the legislation governing enforcement of fitness to practice, medical misadventure, etc. can encompass all those who are practising? We need to ensure they come into the system and are regulated. If they are not regulated, they are no longer in the system at all. The Dental Council of Ireland has almost no enforcement. It has no ability to inspect. What can it do to give me confidence that the plaque at the front door means a dentist at the top of the stairs? That is what people want to know. The legislation seems unclear in defining that and the Dental Council of Ireland is quite powerless in enforcing that.
Do the witnesses believe the new proposals will give Dental Council of Ireland more powers and - I am trying to avoid the term - more teeth. The bottom line is more teeth in all its facets to ensure people have confidence. I have come across cases of people who were given hope that their teeth could be resolved by special therapies, cleaning agents and all the rest of it, and it has worked out tragically. They then need to head back to dental hospitals in Cork to try to rectify all these issues.
Most people believe when they see a doctor's surgery that there is a good chance there is a doctor behind it. However, there are question marks when it comes to dentistry and that issue needs to be addressed once and for all. We have one chance to do it now. I ask the witnesses to highlight the key facets they have in their presentation and to give confidence to the public that we have integrity in the profession in all its aspects. I do not doubt the Dental Council of Ireland but it needs to ensure it is enforced.
I welcome the witnesses and acknowledge the broad statement they made earlier. I have read the executive summary. Dr. Barney Murphy and I spent some time together in the South Western Area Health Board. He gave me an outline of what maxillofacial surgery was about. I had to ask him on many occasions what we were talking about. I welcome him; it is nice to see him again.
As a citizen of this country, when there is a sign over a door that indicates a GP or dental clinic and one goes through the door, one leaves one's health in the hands of the people behind that door. When I go in I want to see a welcoming place, a clean place. I want the people behind the desk and those doing the surgery to be professional and to know what they are doing. That starts from the time one walks into any surgery and how one is treated by the receptionist.
In my experience, in some of the places I have attended over many years that has not been the case. When I had young children, they were sent to the local health centre for examination of their teeth through the school. I always found them very welcoming people, if not welcoming places. Certainly I had no difficulty with the professionalism of the people involved in polishing teeth, etc., but the state of the premises left a lot to be desired. Thankfully, things are changing in that regard with new primary care centres locally, which have helped.
There is nothing in the summary with which I disagree. However, I suppose the witnesses are here because they believe the legislation, as proposed, will not cover some of these things. That is something for the committee to identify and address.
On a daily basis, we hear advertisements on radio and television promoting other forms of dentistry abroad. People on these advertisements outline their great successes but I, and other public representatives, hear of the damage that can be done to people when they travel abroad not very far from our own shores. I have a fear about people not being professional, whether in this country or elsewhere.
I do not have much to add. I am not a dentist, thank God, or a medical professional. However, I believe that someone going into a clinic should be able to put their confidence in the medical team. Everything should be above board and professional. Some people are being seriously damaged, not only through malpractice but through people claiming to be professionals when they are far from professional. The Government and this committee need to seriously look at how to identify these people and take them out of the system, as Deputy Kelleher said earlier.
I thank the Dental Council of Ireland for its presentation and for taking time out to come here this morning.
Dr. Eamon Croke:
Before I answer individual questions, there is a common theme which is close to the heart of the Dental Council of Ireland. The committee members have all talked about the protection of the public, which is absolutely what we are about.
To address Deputy Ó Caoláin’s points about those entitled to advertise or perform the treatment they offer, in the policy issue statements from the professional regulation unit, which the Deputy has a summary of, there is a break down in thought - on the one hand, it has accepted that regulation, licensing and inspection of practices have to take place and, on the other, it will quite severely limit the number of people registered. That brings us back to the problem we have at present and back further than that. We will go back 30 years because people such as dental hygienists - whom the members highlighted - may or may not be on the register now but they would not have been on it then. The problem will get bigger unless registration is combined with the licensing process for premises and the inspection of premises. It requires that joined-up thinking. In our view, there is no other way of doing it.
We are aware of the cases to which the Deputy alluded. As the Deputy will appreciate, prima facie evidence must be established before a case can be taken against anybody. Where the Dental Council of Ireland has uncovered evidence, however, it has informed the Garda which has the power to go into places where we believe illegal practices are being carried out. The Garda brought a successful case against an individual who was practising illegally in the midlands some years ago. Around last April there was a case of someone practising illegally. Initially, this person was in charge of the practice. We believe it is possible to have a non-dentist in charge, provided the practice is regulated and someone can inspect it to ensure that proper procedures are being carried out. The person to whom I refer suddenly started to practice. By the time that became obvious, the Garda was informed but the individual was gone.
We share the Deputy’s concern and frustration. For a lay person, the Deputy does himself down to an extent. He is very well informed and I thank him because he has presented a very good reason for bringing the new legislation forward quickly. The existing Act is 30 years old, is grossly out of date and does not protect the public. In our written and oral submissions, and in the submissions to the Department, we have consistently looked for those powers. We believe we are well positioned. When an inspector goes into these places, he or she will find problems not only with regard to the regulation of premises but also in respect of the behaviour to which Deputy Catherine Byrne alluded. It is important that those who carry out inspections possess the skillset to examine all aspects.
On advertising, the registrar has done work with The Golden Pagesto try to ensure that it is very obvious that clinical dental technicians, CDTs, are qualified and registered to carry out their work. One of the difficulties that has arisen is that we do not know how many there are. I commend the work of the Dental Technicians Association of Ireland, DTAI, which has spent a great deal of its own money in preparation for going onto the voluntary register and in trying to identify both those who are operating in this area and the individuals who are in possession of qualifications in any form. The association has been surprised by what it has discovered, even though its members are involved in the profession. The Dental Council of Ireland would be very concerned if legislation gave carte blancheto everybody who had acted illegally to join the voluntary register without any assessment of their ability or skills to qualify for inclusion on it.
This relates to the points raised by Deputies Kelleher and Catherine Byrne that people need to be confident that when they walk into a premises, the person there is ethical, skilled and professional in approach. In the voluntary understanding with the DTAI, the Dental Council of Ireland has agreed that a step would have to be taken to prove the practitioner had a level of skill and expertise and that an assessment would be carried out if the person did not have the required documentation from a dental hospital, City and Guilds or from FÁS or AnCO, the training council, which in years past ran courses. We would look for that. It is very important that committee members, as public representatives, are mindful that "grandfathering" individuals who have no training will not encourage the necessary confidence that Deputies Kelleher, Catherine Byrne and Ó Caoláin have sought.
In response to Deputy Kelleher, the Dental Council of Ireland has developed a scope of practice to identify those who should be in the register. We know the roles people can carry out. That is very clearly laid out, for example, a dental technician can do the fabrication and the supply of dental appliances but not the fitting, whereas a CDT can do the fitting, provided there is no interference with living tissue. The scope is relatively easy to work out if we know who are the individuals. That goes back to a general concern that the Deputies share about identifying who can do this and whether the person is qualified to do it.
Deputy Kelleher made several references to cosmetic procedures. The Dental Council of Ireland produced a code on non-surgical cosmetic procedures very early on and in the face of some opposition because wherever large interests are involved, as they are in the cosmetic industry, one faces considerable pressures. We have defined where a practitioner can use certain materials, such as Botox, off-licence because they have a function in health care. We have distinguished between the cosmetic and non-cosmetic sides. That also went through the National Adult Literacy Agency, NALA. We invite the public to look this up. For example, Deputy Byrne can look up the Dental Council of Ireland website and see in plain language what she can expect from her dental health care professional when she comes for treatment. We tried to bring in the public. We did that with our ethics and display of fees documents to let the customer see what to expect. We encourage the committee to do that.
In respect of to whom the committee and Department should listen, all voices carry some weight but on the basis that we are transparently in the business of protecting the public, a statement the lay members of the council would support - as they did to the Minister whom we met recently - perhaps, with respect, our voice should carry more weight. We have the experience and we stand up to scrutiny. We are, and are willing to be, accountable for the actions we take. I hope our submissions to the Department and to the committee today will be given some extra weight in that regard. We will only sort out where the grey areas are when we marry registration with inspection and licensing. That is the only way around it.
I agree with Deputy Catherine Byrne. Whenever I put trust in somebody else, I want to know that person has a standard and I want to be treated fairly and with respect.
The various codes of practice and ethics the Irish Dental Council has produced is very important to that.
The Irish Dental Council is a founder member of the International Society of Dental Regulators. Our registrar is chairman of the society, which suggests we are held in high standing abroad. It is very important to us that we show leadership in order that the public can have confidence in our remit under the current Dentists Act but also that they will understand we are trying to make matters better, and we hope to achieve that. We have shown leadership also in terms of the profession. It is to the credit of those in the profession that they have come with us without kicking and screaming because the proposals we have made in our codes are seen to be proportionate and effective, and they are welcome. The display of fees, which is an early item we brought in, has been very well received not only by the public but also by the Office of Fair Trading in the United Kingdom, which has held it up as an example of how professionals should interact with the public. I agree with the Deputy that it is about standards as well as skills. It is about being treated as a human being.
Dental tourism is a fact of life. Even with the National Health Service, which has an accessible, relatively cheap form of dentistry, dental tourism is still rife in the UK. The previous Irish Dental Council produced a document called Choosing a Dentist at Home or Abroad which sets out for the public what they should look out for, not just when going abroad for treatment but also in terms of dentists and all dental health care professionals registered here in terms of standards and that they will work with them to ensure they get the service they want and that they are treated as they would want to be treated. Those are the areas we will continue to develop with, I hope, the support of legislation, and I believe the skillset lies with the dental council. The goodwill of the dental council is very much to continue the work we are doing, but to do it better. We need a new dental Act to do that, and we need it quickly.
When we are discussing the proposed new dental Act and regulation, which we all believe is required, enforcement and so on goes with that. In terms of the perspective of members of the public, they want to have confidence in the profession but also value for money. They want reasonably priced dental services. When we regulate to the point where we are trying to protect the integrity of the profession, often it comes at a cost, but equally when we start to protect the profession or give it an advantage over anybody else who might want to compete, simply because they cannot register because they do not qualify means only one thing to many people, namely, dearer dentistry costs. Dental services in Ireland are quite expensive when compared with most OECD countries, particularly in the area of orthodontics. When we do regulate, if we cut out people currently providing services it will be argued that costs could become dearer for people. Does Dr. Croke see a potential loss of capacity in the system to deliver in the area of orthodontics if we regulate according to the way the council is proposing? Will there be a loss of capacity? If that is the case, the result will be increased prices.
Dr. Eamon Croke:
The provision of services is not a matter for the dental council. I accept that there is a cost to regulation but everybody in this room would accept that living in Ireland is expensive. That is an important starting point when we talk about costs.
In terms of costs of regulation, regulation is demanded by the public. The daily experience of the dental council is that the public demand we have highly skilled individuals to carry out the work and in whom members of the public can put their trust.
I do not believe that competitiveness will be served at all by bringing in unskilled people to carry out a job. All that happens in that case is that costs increase because indemnity costs will increase, and Ireland has very high indemnity costs. It goes back to issues such as the foundation training. It is a question of getting the skills level increased from the outset.
In terms of illegal practice on the denturist side, it is important to note that the dental council has put in place a clinical dental technicians register. The scope of practice and entry to it is well set out and it is reasonable. It protects members of the public when they are exposed and attends people who provide the service to them.
It is important for the committee to understand also that there is a training course in the Dublin Dental University Hospital. One can achieve the training levels one wants if one were intent on going from illegal practice to legal practice. That is the history there, and we have been encouraged by those who have taken the decision to go from illegal to legal practice, but there is a moral dilemma in grandfathering somebody who ignores the fact they are acting illegally and then telling them they can get on with it now. With regard to all the Deputy's concerns, that will serve the public very poorly if that were to happen in the future. There is a means by which to go legal, and I would encourage those in illegal practice to do it.
It is clear from Dr. Croke's contribution that while the council has a voluntary register for dental nurses, the voluntary register he proposes in regard to dental technicians has not yet been established.
Is that the case? The council is working very closely with dental technicians to establish a voluntary register. How well progressed is the council with that, and does Dr. Croke have confidence that it will be established in the short term? As I said, that is essential to get to the point of statutory registration in the event that the legislation will reflect the need.
My reading of what the drafters are thinking is in terms of independent practices as against those who are ancillary to them, that is, dentists, orthodontists - I presume - and clinical dental clinicians who are stand-alone in their respective roles and functions. The situation regarding dental nurses, hygienists and dental technicians is that these are not of themselves independent practitioners but are a part of a team working under any of the aforementioned. I do not know why that thinking has entered into this in regard to dentistry in the widest sense. Registration is an essential part of a range of other areas across the health sector and no such is distinction being made. Why does Dr. Croke believe such a distinction is being made between the referencing I have made to independent practices as against support staff? I am very much of the view, and I welcome the clarity of Dr. Croke's contribution, that it is an objective shared by this committee and the dental council.
As a Deputy, I have a degree of privilege which the delegates do not enjoy. I do not propose to name anybody, but there have been disturbing high profile cases in this area, including one which involved very objectionable behaviour on the part of a practitioner. This is a serious matter that I have no doubt gravely worries, annoys and vexes practitioners holding to the highest standards. How does the Dental Council of Ireland of Ireland react when such cases present, given that, as mentioned by Deputy Billy Kelleher, as things stand, it does not have the power to properly engage to uphold the highest standards across the profession? I would welcome some commentary in that regard, as we cannot ignore this issue. This is the first opportunity we have had to speak about it in this way. I do not want to leave this room regretting that I did not ask the relevant questions. I have put the question in the most appropriate way that will, I hope, allow for comfort in terms of our exchange.
On the issues of registration and regulation, particularly voluntary regulation of dental technicians, the general experience across the board is that standards improve as a consequence of regulation. This is something that will unquestionably be shown in the case of dental technicians. Those who are qualified and committed to the future of their chosen career path surely should not hold back in the interests of some who are not prepared or willing to move forward. I would like to know why we do not as yet have voluntary registration. Are there people who are applying a brake out of selfish interests as against the collective importance of enhancing their particular role?
Dr. Eamon Croke:
On the voluntary register, the point had been reached where we had agreed to an assessment. The Dental Technicians Association of Ireland had identified hundreds of dental technicians who were willing to be involved in the scheme. The Dental Council of Ireland had identified, by way of an assessment carried out by the Auxiliary Dental Workers Committee, chaired by Professor Nunn, that approximately one in eight dental technicians had no proof or evidence of their educational qualifications or skills. We also worked with the Dental Technicians Association of Ireland on the issue. The summary policy was then issued by the Department and everything stopped. In fairness to the Department, that happened by accident rather than by design. In the past two weeks everybody stood back weeks waiting to see what would happen next. An early green light from the Department to progress the development of the register and encourage those without skills who want to become involved to register would be welcome. There are multiple reasons for putting the register in place, including the identification of technicians, raising standards and preparation for the future. It is important that people be given time to prepare to come on board to work to one set of codes in terms of standards. That would be a fair way of doing things. People expect inspections to be introduced. It is the one thing everybody across the profession has done, but, again, time is required to do it.
Another reason the Dental Council of Ireland was keen to do this was we knew that when mandatory registration was introduced, bringing all dental nurses and dental technicians together would involve a large body of work. Having a large number on board in the context of voluntary registration would be helpful. Also, they have representation at the Auxiliary Dental Workers Committee such that their voices are heard in the Dental Council of Ireland. That is hugely important. Unfortunately, the registration process has halted, despite the fact that we were close to agreeing a final set-up. However, as I said, that was not by design and it is hoped the situation can be adjusted quickly.
On the reason independent-only practice is to be taken on board in registration, it is an issue of perceived risk. In other words, the risk is perceived to be relatively low for other members of the dental team. The evidence suggests that in dentistry - working in the mouth - if a person is unskilled or not obliged to attain standards, the risk of injury or life-threatening or life-altering diseases is very real. Nobody here would agree that that risk was low or non-existent. The capacity for it increases dramatically when we get into the grey area of who is doing what because, as I mentioned to Deputy Billy Kelleher, the scope of practice is out the window, the attitude being that because a person is not registered, he or she can do the work and nobody will know. With registration comes the enforcability of standards. As stated, all members of the dental team and registered dental premises should be subject to the same sanctions and fitness to practise standards. That is important.
We are aware of the high profile cases. We feel inept, angry, frustrated and annoyed with the Department about the delay in the introduction of the dental Bill which will allow us to get on with the business we want to carry out. In cases in which evidence is available we provide it for An Garda Síochána. It would be a mistake to sit around and do nothing. That would be the worst possible position for a dental council to find itself in. We regularly notify the Garda about our concerns. However, doing something about an issue is very difficult because the Garda needs to have a reason to take action. It comes back, therefore, to the ability to go into a practice and knowing what one is looking for. A garda in walking through the door of a dental practice, bar catching an individual red-handed doing what he or she should not be doing, would not because of patient confidentiality and data protection issues be able to even look up a record. New laws are required to address these issues. In terms of how we feel, we are distressed, annoyed and angry and get it in the neck from the profession. We can also get it in the neck from members of the public who contact us to tell us what has happened to them and the distress it has caused. Our inability to help is hugely frustrating. It lets down what the Dental Council of Ireland is good at. We are good at what we do; we just need the powers required to support us in what we want to do. I appreciate the Deputy's comments in terms of the need for clarity. I hope the position is clear. To us, it is very clear. We have lived with this day in and day out. In terms of our functions, we know when something is not good enough and we also know what we should be doing. In all honesty, we would like to be able to do tomorrow what we know we need to do.
I thank the delegates for a very informative and thought-provoking presentation and question and answer session. This has been a very riveting meeting. I also thank Deputies Billy Kelleher and Caoimhghín Ó Caoláin for their engagement with the delegates.
I ask that the transcript of the meeting be furnished to the Minister and the Department, with a recommendation on the points highlighted, including the earliest possible publication of the new Bill.