Dr. Alison Dougall:

I am a special care dentist. I started work in general practice and moved to the equivalent of the public dental service, developing a special interest in the treatment of people with disabilities. I undertook considerable training and now provide care for people with complex disabilities. As well as perusing the evidence, we consulted extensively professionals working in the field and, along with our medical colleagues, people with disabilities. I draw the committee's attention to an excellent document published in 2005 that brought together the viewpoints of people working in the field, such as people from the HSE and the National Disability Authority, who were all in agreement that the key to managing the problem for people with disabilities was mainstreaming their oral health. There was wide agreement in that regard.

The availability of appropriate care is ad hoc. People with disabilities are grossly underserved, they experience high levels of unmet need, along with reduced treatment options even when they are able to access care, and their outcomes are poorer. A recent study from IDS-TILDA showed that people with intellectual disabilities who live into older age are twice as likely to have lost all their teeth. More importantly, they are 12 times more likely not to wear dentures, not to mention bridges or crowns, to replace their teeth, ensure their dignity and allow them to chew a healthy diet.

There is agreement among the profession that such inequality is unjust, unfair and unnecessary. Most people from vulnerable groups have needs that can be met with small, reasonable adjustments in primary care. As was noted in the consultation, we must be mindful that when the public service fails to meet such people's needs, the fact that they have been affected by social inequality and had less access to education or well-paid jobs means that their ability to pay for alternatives will be greatly reduced. From the literature, we know that only between 8% and 10% of people with disabilities require specialist care. Where that care is required, however, it needs to be produced by well trained staff with access to adjuncts such as general anaesthesia and sedation and who are well informed on consent, ethics and working with teams in social care. It is clear that people with disabilities want availability of care in mainstream services.

It is what they have asked for and there are great models to showcase this working very well. However, what is required by people with disabilities, long-term conditions and frail older people is well-signposted pathways to services in a timely fashion as for many of these people, the only way they can receive basic care is with general anesthesia, sedation or experts. The oral health policy and the consultation that we have gone through provides the structure and opportunity to address the frank inequalities that we see right from early intervention in childhood to frail older age. For the first time targeted, preventive packages in primary care and establishment of these community-based services is really important.

Evidence shows that educating the general dental workforce and exposing them to diversity in their training gives them the skills and knowledge to manage most people with disabilities. The training of the workforce, supported by specialists, is really important. We cannot expect our primary care providers to accept people with complexities into their workforce without a very well structured framework and pathways to support them, for the few patients for whom it is beyond their scope.