Dáil debates

Thursday, 19 January 2023

Public Dental Services: Motion [Private Members]

 

4:55 pm

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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I move:

That Dáil Éireann:

acknowledges that:

— most oral health conditions are largely preventable and can be treated in their early stages;

— oral diseases share common risk factors with chronic disease, such as heart disease, obesity and diabetes;

— oral diseases are caused by a range of modifiable risk factors common to many noncommunicable diseases (NCDs), including sugar consumption, tobacco use, alcohol use, poor hygiene, and underlying social factors;

— oral diseases disproportionally affect the economically and socially disadvantaged members of our society;

— out-of-pocket costs for oral health care can be major barriers to accessing care;

— an integrated approach for the prevention and treatment of oral and general healthcare is required;

— children and adults with disabilities may have an increased need to have dental surgery carried out under general anaesthetic; and

— access to dental care for all is essential;

recognises that:

— all medical card holders are entitled to the following specific dental treatments, dental examination, two fillings in each calendar year and extractions as necessary;

— a significant number of contracted dentists across the country have withdrawn from the Dental Treatment Service Scheme (DTSS);

— most community healthcare dentists are at full capacity and unable to take on new patients;

— primary school children should have check-ups in second, fourth and sixth class, however some children are not receiving their first dental check until secondary school, therefore, missing check-ups at essential dental development milestones;

— the lack of primary school and early dental check-ups causes delays in referrals for orthodontic treatments and early interventions such as fissure sealant treatments;

— over 13,000 children are awaiting orthodontic treatment for Grade 4 and Grade 5 on the Health Service Executive eligibility criteria;

— children and adults with disabilities are facing delays in accessing dental surgery under general anaesthetic;

— medical card holders are finding it difficult to source a dentist;

— the number of people treated under the DTSS is decreasing year on year;

— there are staff shortages across the sector including dentists, associates, hygienists and nurses;

— staffing shortages are having an impact on patient access to dental care; and

— there is a requirement for specific workforce planning for oral health to the development of a dental workforce plan; and

calls on the Government to:

— improve access to dental care in an equitable and sustainable manner for all, across all income groups;

— reform the dental tax relief scheme (Med 2) to increase the tax relief to a minimum of 30 per cent, expanding access to treatments and reliefs available;

— provide supports towards the cost of private dental care for children;

— include dentures in the scheme to reduce the burden of costs on all patients;

— provide additional training to allow paediatric dental services to operate where a lack of paediatric nursing staff is currently preventing dental surgery under general aesthetic;

— provide additional undergraduate places for dental graduates in Irish universities;

— provide extra training places for auxiliary workers and a renewed vocational training scheme;

— improve career paths for auxiliary dental staff;

— reform the work permit scheme for dentists and dental nurses;

— immediately address the uncertainty over the public dental service; and

— review, reform and implement a renewed DTSS with the engagement of all stakeholders.

I am delighted to be able to present this motion today and I thank my colleagues in the Regional Group and Cáit Nic Amhlaoibh, in particular, for all her hard work.

It seems not a day goes by when our attention is not drawn to some area of the health service which is in crisis. Today it is the turn of the dental services. It is not just to highlight the problems but to try to encourage and persuade the Government to bring about action that will move to solve the problems. In June 2021, I brought forward and presented a Topical Issue matter related to the dental treatment services scheme, otherwise known as DTSS. This was brought about on foot of many constituent patients and dentists coming to me and highlighting the issues they were facing with the scheme. For the benefit of those who are not aware, the DTSS means that medical card holders are entitled to a free dental examination in each calendar year, as well as any extraction required along with a number of other limited services. In November 2020, it was reported that the number of private dentists participating in this scheme had dropped by 16%, from 16,054 to 13,093, in the ten months between January and October 2020. It was estimated at the time that approximately 200,000 medical card holders were facing delays for treatment as a result. To give an example of the practical implications of this, at the time I put forward that Topical Issue, the number of dentists in the scheme from Wexford and New Ross districts had reduced from 14 to four. I also questioned the Minister, Deputy Stephen Donnelly, on the dental treatment scheme on 12 July 2022, and highlighted a constituent named Sean Hayes who resorted to pulling his own teeth due to a failure to be seen by the dentist; he had tried seven. In response, the Minister stated:

I have allocated a very significant amount of extra money. The forecast spend for this year would have been about €40 million for this scheme. We have increased that from €40 million to €66 million.

Unfortunately, thanks to an email I received from the dentist, I later was to discover that in 2009 or 14 years ago, the spend on adult medical card dental services was €86.8 million. That is some €20 million more than the increased budget for 2022. I wish the Minister had mentioned that in his response. The dentist also remarked that the costs in dentistry have increased exponentially since Covid-19 and this increase, will not even cover that. The dentist went on to tell me that they had resigned their DTSS contract in 2020 and was fully booked for the rest of this year and noted this story was similar with many of their colleagues. The dentist noted the DTSS is outdated in its scope and so burdened with bureaucracy that most dentists like my correspondent will never accept another DTSS contract, regardless of what increases in fees are offered.

This motion calls on the Government to review, reform and implement a renewed DTSS, to increase tax incentives for private patients receiving treatment and much more, as well as the engagement of all stakeholders. Dentists first and foremost need to be consulted about why so many are leaving the scheme. Those people have a greater level of knowledge as to what is happening on the ground than do the Department's administrators. Once those issues have been identified, we can go some way towards developing a realistic scheme that is attractive to dentists and will improve outcomes for patients.

We also recognise in the Regional Group, as stated in the motion, that the lack of primary school and early dental check-ups leads to problems further down the line. Some children are not receiving their first check-ups until secondary school age, which, coming after many essential developmental milestones such as the arrival of adult teeth, causes problems that are unnecessary and could have been prevented. We are all familiar with the phrase, "a stitch in time saves nine". Unfortunately, when it comes to dental services there are not enough stitches being sewn.

Looking at the HSE orthodontic services in County Wexford, we currently have only one of two consultant orthodontists in place, while HSE figures show that 524 children are awaiting orthodontic treatment while 93 over-18s, who were identified as needing treatment before the age of 18, are waiting for treatment. During a speech on dental services in April 2021, I referenced a letter from a parent which stated their child was assessed by a HSE orthodontist in Enniscorthy on 8 June 2018. The parent was informed the child would definitely qualify for dental treatment through the HSE as he is an extreme case but there was a four-year waiting list. The parent was extremely shocked by this but was reassured by the orthodontist as she explained this would be the optimal time for the child. The parent rang the orthodontist's department during the first lockdown but the phone was not answered and no one responded to the parent's voicemail. The parent finally managed to get through in April 2021 and was told by the secretary that the child would have to wait for another three years. That meant the waiting list had gone from four years to six years. A couple of weeks prior to that speech of April 2021, I wrote to the Minister's Department and received confirmation that the waiting list was approximately 72 months in duration. This is the reality for many parents and patients.

Oral health care is extremely important and fundamental to our overall health and well-being. Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected and sharing risk factors with chronic disease such as heart disease, obesity and diabetes. Our dental services are in disarray and need to be tackled head-on with sustained and meaningful action to bring about better and swifter results. This must include a top-to-bottom review and a long-term strategy for improvement, including providing additional training to allow paediatric dental services to operate where a lack of paediatric nursing staff is currently preventing dental surgery under general anaesthetic; providing additional undergraduate places for dental graduates in Irish universities; providing extra training places for auxiliary workers and a renewed vocational training scheme; improving career paths for auxiliary dental staff; reforming the work permit scheme for dentists and dental nurses; and immediately addressing the uncertainty over the public dental service. These are all necessary actions to bring about improvements.

I hope that Deputies from all parties and none will support the motion.

5:05 pm

Photo of Michael LowryMichael Lowry (Tipperary, Independent)
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As the Minister is aware, good dental health is paramount to good overall health. The connection between periodontal disease and a myriad of serious health conditions has long been medically proven. Without proper preventative dental care, people can become more susceptible to cardiovascular disease, kidney disease, cancer, respiratory infections and even dementia due to the circulation of various bacteria in the body. Yet, despite this knowledge and the constant emphasis on preventative healthcare, we continue to risk the health of 37% of people in Ireland. We risk their health because they receive their dental care through the medical card system. We threaten their health because of the dismal level of dental care that a medical card allows them to receive. Medical cardholders are entitled to one free dental examination in each calendar year. They can have as many extractions as they require, but only two dental fillings are free in a 12-month period. Just one first-stage root canal treatment is available annually for teeth, but only if that is at the front of the mouth. As medical cardholders, people are entitled to an upper and lower denture every five years. In fact, in some cases, dentures will not be approved by the HSE if it deems there is no clinical necessity.

This is the full extent of the entitlements of medical cardholders. It is the barest of minimums. If a dentist determines that a medical cardholder needs further fillings to save his or her teeth, the medical cardholder is prevented from having this work unless he or she can fund it independently. Dental care is expensive. Therefore, many, if not all, choose to have their teeth extracted when fillings would be appropriate, as they cannot afford costly dental work. They choose that option because extractions are free.

We threaten the health of people even further because up to 80% of those who have a medical card have enormous difficulties when trying to access dental care. There are currently fewer than 650 dentists remaining in the medical card scheme in Ireland to serve 37% of the population. The number has hit a ten-year low. These figures show that the current situation is untenable, and it becomes more untenable with every passing year. Countrywide, private dental practices that were contracted to provide services have turned their backs on the dental treatment services scheme. This is not because they do not want to treat medical cardholders. The reality is that it is not viable for them as business people to do so.

Modern dental practices employ nurses, hygienists and office staff and have substantial overhead costs. They must be fairly reimbursed for their work. They must protect their businesses. In almost all cases, community healthcare dentists are at full capacity. They are simply unable to take on new patients and have no choice but to turn people away. In my constituency of Tipperary, hundreds of patients, young and old, are denied access to dental treatment. It goes against the ethos of medical practitioners to deny people with a medical card, including children, disabled people and elderly patients the proper care they need, yet this is what is happening every day in Tipperary and across the country.

As is the case with almost all health professionals in this country, there is a serious shortage of dentists at the present time. Those who are practising cannot run and staff a business by working for the reduced rate of pay they receive for treating people in the medical card scheme. Despite their best efforts, community dentists are overwhelmed. The availability of licensed dentists per capitain this country has not increased since 2005. The number of new Irish-trained dentists entering the Dental Council of Ireland has not changed in 25 years. Therefore, Ireland has become reliant on overseas-trained dentists with almost half of our current dentists receiving their training in other countries.

Ironically, dentistry remains among the top choices on CAO applications every year. However, because there is such a limited number of training places available, even those who achieved the highest possible number of points in their leaving certificate fail to secure admission. The Irish Dental Association has been calling for significant investment in the UCC and TCD dental schools to enable Ireland to train more dentists, dental nurses and dental hygienists. The call goes unheard, despite the dental crisis we have been witnessing in recent years. A dental school at UCC was due to commence development in 2019 but, as yet, nothing has happened. Many students who wished to study dentistry left Ireland to study abroad and have not returned once qualified. Emigration of our healthcare workers and, indeed, our potential medical professionals is a significant part of the crisis in our health system. Unless constructive action is taken, the slippery slope will continue to get steeper. The dental service is falling apart. Thousands of patients are neglected. The system is broken. We need radical action to rescue dental services.

Photo of Peter FitzpatrickPeter Fitzpatrick (Louth, Independent)
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I welcome the opportunity to contribute to this debate. I thank my colleagues in the Regional Group for tabling the motion before the House. In recent years, I have lost count of the number of times I have heard of people going up to the North to Newry, or even abroad, for dental treatment due to the cost and availability of dental services in my constituency of Louth and East Meath.

In tabling this motion, we in the Regional Group want to highlight the problem while also offering real solutions to the Government. The bottom line is that dental services should be affordable and available. Unfortunately, it is neither. We must improve access to dental care in an equitable and sustainable manner for all, across all income groups. With an almost 25% fall in the number of dentists claiming reimbursement through the dental treatment services scheme since December 2020, the Minister for Health approved new measures to provide expanded dental healthcare for medical cardholders in the DTSS in April 2022. However, according to the Irish Dental Association, many dentists have withdrawn from the scheme, as it is not fit for purpose, which means that assess to dental care, despite having a medical card, is scarce. The number of dentists providing treatment to medical cardholders has more than halved. For this reason, the motion calls for the provision of additional undergraduate places for dental graduates in Irish universities, as well as extra training places for auxiliary workers and a renewed vocational training scheme.

The lack of dental services is having a knock-on effect on children, whereby some children who should have been seen by the HSE dental service three times before the age of 12 are only seeing a dentist for the first time when they are well into secondary school. To put this in context, children are between 15 and 16 years old before they receive the first of their three dental checks. There is a backlog of almost ten years in parts of the country to access the HSE school dental screening service. For this reason, we wish to push for reform of the dental tax relief scheme, the Med 2 form, to increase the tax relief to a minimum of 30%, and to expand access to treatments and the reliefs available. We are also calling on the Government to provide additional training to allow paediatric dental services to operate where a lack of paediatric nursing staff is currently preventing dental surgery under general aesthetic.

I have recently been contacted by numerous concerned constituents who have been refused dental care at their regular practice due to their medical card status. Additionally, constituents who are on the adult oral surgery list or who have a child on the paediatric special care waiting list for patients have also come to my clinics having been waiting an extraordinary amount of time for essential medical treatment.

In tabling this motion, we in the Regional Group want to highlight the potential dangers that can result from delayed dental care. Due to the effective collapse of the dental treatment services scheme, oral diseases are becoming more common and share common risk factors with chronic disease, such as heart disease, obesity and diabetes. Modifiable risk factors, such as the overconsumption of sugar, tobacco use, alcohol use, poor hygiene, and underlying social factors are often the primary cause of oral disease.

This should indicate that oral health conditions are largely preventable and can be treated in their early stages. However, the Government must step in. Out-of-pocket costs for oral healthcare can be major barriers to accessing care. Therefore, an integrated approach for the prevention and treatment of oral and general healthcare is required. When the oral health of the nation suffers, the people who suffer most are usually the people who have the greatest oral health needs and the least amount of income to afford dental care. That is what dentists report to us all the time.

In 2021, Dr. Joseph Green warned that unless the provision of basic dental services for adult medical card holders is addressed urgently at the highest level, the HSE Louth and Meath dental service may be forced to confine dental services to emergency treatment only, to the detriment of the oral health of children and adults and, in particular, those with special care needs.

I am shocked that, two years later, the scale of the problem in terms of waiting times for dental treatment and the impact of withdrawal of care for medical card patients have not been addressed. This flies in the face of the Government's promises under the national oral health policy to develop a model of care that will improve access and enable preventative approaches. The Minister for Health and the HSE urgently need to engage with providers and the representative body and put an effective plan and resourcing in place to ensure the people of Louth and east Meath have timely and full access to essential dental treatment.

Our motion highlights the urgent requirement of reform of the current DTSS contract model, in particular as it applies to medical card holders and children who urgently require dental care or orthodontic treatment. We call for the reform of the working permit scheme for dentists and dental nurses, a commitment to the training and recruitment of dentists and the immediate addressing of the uncertainty the public dental service has caused. My colleagues in the Regional Group and I are looking for cross-party support for this motion. I look forward to working with everyone to find a solution. We feel the review, reform and implementation of the DTSS, through the engagement of all stakeholders, is required immediately.

I meet a lot of children who come in with their parents and the condition of their teeth is dreadful. A child who is 15 or 16 years of age has been waiting nearly ten years to get their teeth seen. As Deputy Murphy said, 20 years ago the budget was perhaps €20 million more than it is today. That is wrong. I am a firm believer that prevention is the best cure. Older people in my constituency give up when they sit in a dentist's chair and tell the dentist to pull all of their teeth out because they cannot afford to come back again. We cannot afford that in this day and age.

Children who are six, seven or eight years of age come to my clinic with their parents and their teeth are all over the place. Having an examination or a brace could help them. They sit beside children in school and children say there is a smell off someone's breath. It is wrong. All organisations need to get together. Communication is the best way forward. Everybody wants the best for children, families and everyone else. I ask the Minister to renegotiate the contract and get the system up and running again.

5:15 pm

Photo of Stephen DonnellyStephen Donnelly (Wicklow, Fianna Fail)
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I thank the Deputies for tabling this constructive motion. I have taken on board the points that have been made. I acknowledge that many Deputies in the House have raised this issue. It is one of which I am very aware and one on which were taking a lot of action. We all want to see more happen as quickly as possible. I want to lay out some of the actions we are taking.

I acknowledge that for too many people this has become very urgent. We know many dentists have left the treatment scheme. I will cover the various aspects of oral healthcare covered by the HSE. A lot of money and services are provided and many adults and children are helped every year. However, there are some significant pinch points, and for those adult and child patients, this is an urgent issue. I will come back to the DTSS in a moment.

I would like to lay out for colleagues the level of increase in investment and some of the things that are happening. We are discussing what else needs to be done. Last year, post Covid, the allocation to oral health care was more than €200 million, a sizeable investment in oral health care from Government. It shows a commitment to the best possible oral healthcare. We want this and know we are not there yet, but we are committed to improving the service year-on-year.

Some €200 million is allocated to HSE public dental services, HSE orthodontic services, the DTSS, which colleagues have discussed, and the dental treatment benefit scheme for insured, self-employed and retired workers, that is, those who have the necessary PRSI contributions. Last year, more than half a million people benefited from those services. While we in politics focus on the parts that are not working, which is where we spend the vast majority of our attention, it is important to acknowledge the work done by healthcare workers. More than half a million men, women and children received world-class dental care and oral healthcare last year, provided through Government funding and largely implemented through the HSE.

Everyone needs to have timely access to healthcare for appointments to see healthcare professionals for diagnostics and treatment, but there are challenges. It is a priority for the Government to address this in the short term, and we are taking short-term actions, as Deputies have referenced, through much-needed reform to oral healthcare in Ireland. Important structural changes are required and are being implemented.

I want to talk about the HSE public dental service. The salaried public dental service last year provided care to 143,000 adults and children. Those with additional needs who cannot receive care in a general dental practice may receive special services provided by HSE public dental services. These patients are given oral health examinations, where necessary, and treatment is provided using additional supports. The scheme also provides a targeted programme that includes screening and necessary treatment for children at important stages of development, that is, children aged six to eight years of age, those aged between 11 and 16 years and, subject to capacity, those aged between nine and 11 years. They are the three development stages addressed. Emergency care is also provided to children up the age of 16 and those with complex and additional needs.

The service provides care to many children and adults who would not otherwise have access to oral health care services. As we are all aware, coming out of the pandemic, there are backlogs in the targeted screening programme in particular. This is leading to delays in children receiving their first appointment. It is something none of us want. We know early intervention is essential in oral and many other parts of healthcare.

What are we doing about this? In the budget for this year, the Government has allocated €15 million, an unprecedented allocation, for a range of measures to protect access to services through once-off funding. A total of €5 million is being invested on a once-off basis to support the provision of care to eligible children and adults, including addressing the backlogs in targeted primary school class programmes.

On orthodontic services, the public oral healthcare service provided by the State includes orthodontic treatment. It is provided by HSE orthodontists to patients referred before their 16th birthday who have a significant need. In excess of 10,000 people are currently in active orthodontic treatment funded by the State. Given the nature of treatment, it takes several years to complete. More than 2,000 of these patients are receiving treatment with a private provider through a procurement initiative. We have allocated €4 million in additional funding for that programme for this year. It will allow us to target those who have been waiting the longest to make sure they get access to treatment and, in some cases, more complex surgical care.

Last year, through the DTSS, which is the subject of a lot of debate in the Chamber, the State provided care to more than 360,000 medical card holders. I fully acknowledge that more needs to be done and dentists have been leaving the scheme for a variety of reasons. Nonetheless, 360,000 men, women and children received oral healthcare through the scheme last year. It is important we acknowledge the work that was done to that effect.

The scheme provides basic and more complex care such as dentures and a broad range of treatments for patients with additional needs. To address contractor concerns regarding the DTSS, interim measures came into effect from 1 May last year. We also increased the fees paid to dentists for most treatments by 40% to 60%. Dentists have said they want more and are clearly making more money from private than public patients. They are choosing to spend their time treating private patients over public patients. Deputies have raised concerns around the administrative burden faced by dentists, something which has to be looked at.

One of the things we are not good at is having streamlined processes and easy access for providers. That is something I will take on board and bring back to the Department.

On the DTSS payments, we looked at November of last year, which is the most recent month for which we have information, versus the previous year. What we found is that the level of activity on the scheme is increasing, which is positive. We found that 3,000 more patients received care, year on year, and over 15,000 additional scale and polish treatments were done. That treatment is now available, as colleagues will be aware, to adult medical card holders. It was taken out of the scheme some years ago but we put it back in. I allocated €10 million to the budget for last year to put that back in, which was important. It brought medical card holders in line with people who have PRSI eligibility and it is good to know that 15,000 extra scale and polish procedures were done on foot of that. Nearly 2,000 more oral health examinations were also carried out.

I fully acknowledge there are difficulties in some parts of the country where many dentists have left the scheme. That is a real concern for me and for everyone else in this House. That said, it is positive that a lot more money is being allocated. It is important that the fees to dentists have gone up by almost 50% in one year, which is a very big increase. It is also positive that the volume of care being provided and the number of patients being seen has gone up but there is more that we need to do. We are engaging with the representative body and we need to see how we can bring a lot more dentists back into the scheme.

A sum of €5 million has been allocated on a one-off basis to support the HSE's safety net service for adult medical card holders. These are people who need emergency care but who cannot get it through the DTSS. I have allocated €5 million for a safety net fund specifically for those patients. Deputy Verona Murphy and others have raised issues affecting their constituents in this regard previously.

We need reform. The national oral healthcare policy, called Smile agus Sláinte, was approved in 2019 but it is fair to say that due to Covid-19, it was not implemented between 2019 and 2022 at anything like the level needed. One of the things that was needed was a significant increase in funding. Through last year's budget I allocated a lot of extra money to oral healthcare and then in the budget for this year, I allocated a lot more again, in order to increase services, engage with the representative bodies and reform the DTSS. We are also going to start hiring some senior clinical leadership roles into the HSE. The feedback I got from the chief dentist who works in my Department is that while the national strategy is excellent and the money that was put in place last year and this year to apply the necessary reforms is welcome, we need to have serious senior clinicians within the HSE driving the reform. On that basis, I funded those posts through the budget as well. There is a provision of an additional €15 million this year to progress implementation of the policy.

I thank Deputies for continuing to raise this issue with me. It is a priority. There has been a big backlog and we know there are challenges. I have allocated a lot of additional funding and we are now getting on with implementing the national strategy, Smile agus Sláinte. The call for a significant overhaul of the DTSS has been heard and that is something we are undertaking now. I acknowledge that this is urgent and needs to be progressed quickly.

5:25 pm

Photo of Cathal BerryCathal Berry (Kildare South, Independent)
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I thank the Minister for his opening statement. I am very grateful for the opportunity to contribute to this debate. I thank Deputy Naughten and Ms Cáit Nic Amhlaoibh, our group administrator, who have done most of the legwork in preparing this motion. I would also like to acknowledge two dental colleagues in the Public Gallery, who are very welcome to this debate. I very much like the motion because, like any good motion, it is simple and straightforward. I endorse and support every single word in it.

I support the motion for a number of reasons. First, we all acknowledge that dentistry is generally regarded as the poor relation from a healthcare point of view. It does not have the same status as other medical professions. A lot of the public discourse around health is dominated by the acute hospitals and GPs, and for good reason, but dentistry is also super-important. This motion will go some way towards providing a more level playing field and parity of esteem for the dental profession. Second, we know that dental disease disproportionately affects the poor, the disadvantaged, the people on the margins and these are precisely the people that this Parliament should be reaching out to and assisting. We know that most healthcare problems affect the middle-aged and the elderly, but dental issues primarily affect the youth, the future of the country, and we should be targeting them for that reason. We know that good dental practice can reduce the risk of obesity, cancer, heart disease, and diabetes so it is worth investing in it. Third, and most importantly, as my colleagues have already mentioned, prevention is better than cure. I do not think there is any profession for which that phrase is more appropriate than the dental profession. From the point of view of a bang for our buck, dentistry is where it is at from an investment perspective.

The word "crisis" is thrown around a lot. Every place seems to be in crisis these days but dentistry genuinely is, and we know what the problems are. The first is access and the second is staffing. On access, the main problem is cost. We know that it is really expensive to get private dental care. We also know that medical card holders are finding it hard to get access to a dentist. They are the two big issues from a cost perspective. On staffing, every sector is screaming for staff at the moment but the dental sector is different because we actually control the levers. The State has a monopoly on the amount of dentists in the country because we decide how many people we train. Undergraduate training is an area that we must focus on.

As the Minister is aware, the Regional Group comprises very solution-focused people. We know what the problems are and we try to offer, in good faith, constructive solutions. The solutions we would see from an access perspective are all about cost. The costs of private dental care are astronomical but there is a solution. People can get a tax rebate on dental care of about 20% and we would be of the view that this should be increased to 30%. The next budget is less than nine months away and we would be supportive of any proposal that would increase the tax rebate for dental care to 30%. People are still willing to pay 70% of the cost so it would be a very good investment from the State's perspective.

On the DTSS, I acknowledge what the Minister said with regard to the additional supports that have been provided, but the bottom line is that our colleagues in the dental profession are not being reimbursed sufficiently for extractions and fillings. It is unfair to expect private dentists to be out of pocket for providing a service that the State should be providing directly. If additional resources were made available to dentists, that would be hugely appreciated.

On staffing, we are not just talking about dentists but dental hygienists, dental nurses and all of the auxiliary staff. As I said, we do have capacity in our universities to push more people through those training pathways. The CAO points for dentistry are massive, as Deputy Lowry said, which proves that the demand is there, but we need to increase the capacity.

My final point relates to a public awareness campaign. I have not heard or seen advertisements on traditional or social media reminding people of the importance of dental hygiene in a long time. Many people put off looking after their dental hygiene because of Covid-19. We should keep the public informed of its importance and remind them that it is something they need to keep an eye on, for themselves and their children. As Deputy Verona Murphy said earlier, a stitch in time does save nine.

I am hugely supportive of the motion. It makes perfect sense. In the past we could not invest in our dental services because we did not have the money but we had a €5.2 billion surplus last year. Obviously, we should not spend everything and should bank some of that for a rainy day but we do have the means now to invest in our dental services. The only question that remains is whether we have the political will to do so.

Photo of Matt ShanahanMatt Shanahan (Waterford, Independent)
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My colleague referenced the word "crisis". Every time we have a debate on healthcare, the word "crisis" crops up. Normally a crisis is seen as something that is short term and refers to some impending or looming danger. The word should not be used to describe a situation that has been in evidence for a number of years. What we are suffering in dentistry is not, in fact, a crisis but a failure to address known and increasing deficits and problems.

When it comes to dental care in Ireland, we have two streams - similar to our national healthcare -namely, public and private. We do not worry about people in the private stream because we assume that they have the financial resources to pay for services. However, we do not take account of the people in the public system who are waiting so long that they are forced into the private system and must pay for services that they find very difficult to afford. Beyond that, the Minister mentioned three schemes. The DTSS is supposed to provide dental treatment to adult medical card holders. The treatment benefit scheme, previously known as the PRSI scheme, covers adults who have sufficient PRSI contributions.

Finally, there is the public dental health service, which is largely community-based, as well as being based in some hospitals. It is supposed to treat children and adults requiring specialised and complex care. It is also supposed to support children in national schools by giving them their first access to a dentist and a dental assessment, often resulting in the diagnosis of a need for fissure seals, which are a great way of preventing future tooth decay. In addition, the HSE has a statutory requirement to provide emergency treatment, and even free orthodontic treatment, for children who have the most severe orthodontic problems. As the Minister will be aware, the waiting lists for that service are extending to ridiculous lengths. It is not even feasible for some people to consider orthodontic treatments three or four years away.

Despite the lofty ambitions of those three schemes, the departmental information and published data show a significant decline in the number of treatments being provided under the scheme. The Minister provided updated figures in his statement but, between 2019 and 2021, there was a decline of 280,000 in the number of overall treatments in the public system and a decline of 110,000 in the number of patients treated. We have seen the difficulties coming down the line.

The Minister has engaged with dentists in the private sector to try to understand the problems. The problems largely relate to adequate compensation for the work dentists are doing. As Deputy Berry stated, the stakeholders have been telling the Minister that the payment they are receiving does not make economic sense in the context of the work they are doing, and that is why they are leaving the scheme. It is not difficult to understand. The Government, in its wisdom, decided to reduce the PRSI scheme to a scale and polish. What good is that to a person who is in pain or requires an extraction? Who should pay for that?

Medical card holders are finding it difficult to access dentists in their towns and regions who are participating in the public payment schemes. These include patients with other significant health issues, as the Minister will be aware, which is all adding to the overall care burden. I will highlight an anomaly that needs to be addressed, which is the issue of autistic children in mainstream schools who do not get the same access to dental services as children in disabled schools. That needs to be addressed. We cannot have a situation like that. The parents of these kids are already facing the challenges of trying to access other disability services, such as speech and language therapy or occupational therapy, and now they have to try to figure out their route to oral supports as well.

As the Minister will be aware, oral diseases are becoming more common and they share risk factors relating to obesity, diabetes and heart disease. Our motion calls for a number of things but, in essence, we need to address the fact that more than 13,000 children are currently awaiting orthodontic treatment, we need to get dental checks done earlier and we need more adults, especially those with disabilities, who are facing delays to be able to access services, particularly under GI.

Beyond that, we need to up the numbers in the service. I am sure the Minister has heard that from the professionals. They have been telling him that more nurses and hygienists are needed and more access to work permits. They need more people in the system and they need to know what is the policy for the future. As has been stated, the private sector is largely carrying the public dental quota at the moment. That is a fact. One cannot expect professionals to go in and support the public component at their own cost. The Minister recently stated in the House that he is committed to finding a resolution. We recently received a briefing from members of the Irish Dental Association. I am not sure they share his position at the moment. I hope we will hear there has been some kind of re-grounding to all that.

5:35 pm

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I commend the Regional Group on bringing forward the motion. I have been raising similar issues with the Minister for some time, as have many other Deputies in the House, which he acknowledged. The starting point is the waiting lists, which paint their own picture. There are 13,000 children and adults on waiting lists for dental and oral surgery in the public system and a further 13,000 on orthodontic waiting lists. Of those, more than 1,000 special care patients and 3,000 children are on waiting lists for dental surgery under general anaesthetic. We know the waiting lists are chronic. Children with special needs, other children and adults, many of whom are in pain, are waiting long numbers of years for access to basic dental treatment. We also have what can be described as a perfect storm in oral and dental health.

On top of that, the dental treatment scheme has collapsed, with the vast majority of dentists having left it. I have engaged with the Irish Dental Association on its role in encouraging dentists to be part of the scheme. At my first meeting with the association, its representatives told me they had been dealing with this issue for years, not just with this Minister for Health, but also with several of his predecessors, and they had lost trust. Their members have lost trust. The Minister stated that he has allocated more money to this issue but that has not worked and is not attracting more dentists back into the scheme. There is need for negotiation on a new contract. If that is what he wants to do, there must be genuine negotiation with the association. Its representatives told me that they want more money for screening and to provide more preventative care. Some of that was done in the most recent budget in providing for additional services, but more needs to be done. If we are going to get dentists back into the scheme, more will have to be done and the Minister will have to engage with them.

In parallel with that, more dentists need to be hired to work directly in the public system. There simply are not enough of them. The same is true in the context of general practice. We need to start looking at directly hired GPs to do public work as well. That is all part of what needs to be done.

This all comes back to the core issue that is preventing us doing lots of things in healthcare, namely, workforce planning. We need to train more dentists in the first instance. We need to have more graduates coming through and we need to encourage more of those newly qualified dentists to be part of the DTSS. We also need to put in place opportunities for more of those people to work directly for the State within the public system. That is what needs to be done. I acknowledge what the Minister has done in this area. Some of it has been of benefit. He needs to genuinely commit to finding a resolution to the DTSS, however, because it is not tolerable. It is not just that people are not able to pay for treatment; even if they can pay, they are finding it difficult to access a dentist who will take them. As the Minister said, it is an urgent issue and it needs an urgent response. A direct intervention from him with the Irish Dental Association is the only way this will be moved on.

Photo of Rose Conway-WalshRose Conway-Walsh (Mayo, Sinn Fein)
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I thank my colleagues for allowing me time to speak and the Regional Group for bringing forward the motion. I am supposed to be in Mayo at the moment but I stayed on because this issue is such a problem in the county. No dentists are taking on new clients. This is not just coming to the fore now; it has been going on for months and it must be addressed. I wish to follow on from the point made by Deputy Cullinane that it takes direct intervention with the dentists to get this sorted. I am aware of teenagers who are suffering mental health and physical health difficulties because they cannot get something as basic as their teeth done. The integrity of any essential health service that precludes dentists from providing vital treatment must be questioned. Such an approach cannot be condoned. Forcing people to have their teeth extracted in 2023 is inhumane. It is the wrong thing to do. Even just saying it sounds wrong. I appreciate that money has been allocated but I read the Minister's statement and there are references to millions of euro here, there and everywhere. Why, then, can people in Mayo not access the basic dental services they need?

With regard to training, there are students doing their leaving certificate this year who will get maximum points but will not be able to get a place to study dentistry. That is wrong. The issue is not only that there are not enough places on dentistry courses - the current number needs to be doubled - it also relates to the chronic underfunding of the third level sector. There is a need for joined-up thinking in this regard. The Minister knows that a college will get €9,630 to train an Irish person to become a dentist but it will get up to €46,000 to provide the same training to a wealthy international student.

That also has to be examined in terms of the overall funding of our higher education institutions. They cannot be forced to do these things, which are impacting women, children and elderly people in Mayo.

5:45 pm

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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The dental waiting lists are chronic. Constituents of mine, from Balbriggan to Swords, cannot get a dentist. There actually is not a dentist in my constituency who will take a medical card at present. We have tried and tried. The result is that we have an unusually high level of extractions. That is really not good. It is a major sign of a failure within the system and of Government policy. Those affected are not just figures on a page; they are real men, women and children.

I want to share with the Minister some examples from my office. I have changed people's names. Bronagh is a medical card holder. She recently needed to have a tooth extracted. She tried for weeks to secure a dentist who would accept her medical card but was unable to do so. As a result, she had to attend a dentist privately. It cost her €196 to have the tooth removed. This is a 71-year-old pensioner. She had to fork out the money in the run-up to Christmas, money she has not got for a procedure she should not have had to pay for but absolutely needed. As with all of us, she did not go to the dentist because she wanted to but because she was in chronic pain. She had to find the money.

Abigail lives in Mosney. I say "lives" but "exists" would probably be closer to it. She had a fractured tooth and could not get a dentist. Her tooth was injured in intensive care after the birth of her child. She had to be put under for a placenta removal. She cracked her tooth. She found herself back in Mosney with two children – a two-year-old and a newborn baby – in a tiny, cramped space. Her tooth was cracked but she could not get a dentist to take a medical card.

The Minister said he is spending a lot of money on this, and I have no doubt it is being spent, but if it is not reaching the people who need dental services, there should be a rethink. I echo the calls made by my colleague Teachta Cullinane on the Minister's personal intervention in this matter. His direct intervention is required.

Photo of Réada CroninRéada Cronin (Kildare North, Sinn Fein)
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There are so many people in north Kildare in agony with their teeth. Anyone depending on the medical card scheme is back to Dickensian times. For a supposedly modern state to leave somebody in this situation is degrading and perverse. With dental health affecting heart and brain health, we are storing up problems for the future for our young schoolchildren and others who are facing delays in the dental health crisis. It is impossible for anybody with a medical card to find a dentist in north Kildare. It is worse than ever with so many dentists retiring.

I had a constituent in north Kildare last year who had the points to do dentistry but who could not get a place. I would like the Minister to consider what my colleague Deputy Conway-Walsh said because we have a growing population and need more Irish dentists trained. Therefore, we support the broad thrust of the motion. I thank the Regional Group for raising this important matter. In the broader context of the motion and the effective collapse of the dental treatment service scheme, I want to raise with the Minister the circumstances of a vulnerable group of people, namely the men and women who cannot communicate verbally or who have cognitive impairment. It chills me to the bone that there are men and women who are not being examined regularly by dentists in nursing homes. They could be in agony with their teeth but unable to tell anybody, by speech or otherwise.

Last year, I asked the Minister to give me a list of all the dental examinations carried out in State-run nursing homes in each of the preceding five years, well before Covid. The reply from the HSE was that it does not keep the data. The service provided by the dental treatment service scheme collapsed. I also asked whether antibiotics were being relied on and repeated as opposed to giving dental care per se, with all the implications for antibiotic resistance. The reply was that there was a lack of dentists and that dentists were having difficulties accessing nursing homes during Covid. We know that. It was also stated that oral and dental infections need to be managed by accessing a dentist to have the required procedure undertaken. What dentist? It was stated the repeated use of antibiotics without accessing appropriate dental treatment contributes to antimicrobial resistance and is not the optimum management. This is something we all know. Beyond the broader context of this motion and its concerns, we need to examine what is happening, or not happening, as seems to be case, with dental care in our nursing homes. I ask the Minister to consider this urgently.

Photo of Johnny MythenJohnny Mythen (Wexford, Sinn Fein)
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Without stating the obvious, we have a major problem in dental services nationwide. Along with others, I have raised this issue many times through parliamentary questions, the Minister's Department and local media since 2021. On the ground, dentists are not taking on any new clients, particularly those in the medical card scheme. In 2017, there were 1,700 dentists registered with the dental treatment service scheme. In 2022, there were only 650 left. In Wexford in 2020, 70 dentists were operating under the scheme. In 2021, there were only 29, and this number was declining.

The majority of students who graduate as general dental practitioners leave as soon as they qualify. Approximately 200 dentists, a minute number, register every year and come from two dental schools. In my constituency, Wexford, there are children with special needs and disabilities who need immediate dental treatment, particularly under general anaesthetic. They have to wait months for an appointment. Some have to wait a year, and some even more. We have a well-documented case concerning an old-age pensioner from New Ross who had to resort to pulling out his own teeth. Is this the level of care we have reached in the country? This is one of the wealthiest countries in the OECD. In fact, a top representative of the Irish Dental Association, from south-west Wexford, described the impact of dental shortages as "unacceptable for a first-world country".

There are only two practising dentists in the dental treatment scheme in New Ross, causing people to travel up to 30 km or more to try to obtain a dentist who will take them on. Each town across my county has the same tale to tell. We need to reform the dental treatment service scheme. Dental contracts need to be reviewed and related to best practice based on international standards. The national oral healthcare plan needs a proactive workforce plan, as was covered in Sinn Féin's alternative budget. We need to provide additional undergraduate places for dental undergraduates in Irish universities immediately. We need to expand training places and examine vocational training schemes. The work permit scheme must be addressed immediately because it could be one of the instruments that could help in addressing the current crisis or current failures in our dental healthcare. This needs to be prioritised and acted upon. Over 11,000 people have been left in pain for months on end waiting for orthodontic treatment. No longer should this be tolerated or accepted. Over 5,000 are waiting for more than three years. I support this motion and thank the Regional Group for introducing it. I hope the Minister will act upon this very serious situation.

Photo of Patricia RyanPatricia Ryan (Kildare South, Sinn Fein)
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Ireland's dental service is in crisis and the Government is burying its head in the sand. I have previously spoken about the fact that there is just one dentist and one dental technician accepting medical cards in County Laois. I asked a question on this recently and the answer, which I received this morning, was that only one dentist and no technician accepts medical cards in Laois. I called the surgery only to be told it is not taking on new patients. There is no medical card dentist in the whole county, with its population of 90,000. I do not know how this Government sleeps at night. The Minister referred in his presentation to a town with no dentist but I am talking about a whole county.

I asked a parliamentary question recently to receive a list of dentists accepting medical cards in Kildare. The list looked hopeful but when we started calling to see whether the practices were accepting new patients, we found 95% were not. People in extreme pain are popping pills waiting for appointments in other counties. There are children missing the chance to have dental problems discovered and dealt with because the schools programme is in disarray. Early intervention is key to dental health, and the public is being failed by a broken system.

I had a man in my office recently who could not get an appointment locally. He ended up in hospital with sepsis, which was life-threatening. I spoke to a lady last month who had not done food shopping because she was saving up to have a sore tooth dealt with. She is yet another medical card holder who cannot find a dentist. She had been surviving on cereal and tinned food that she got from a local food bank, in which, ironically, the local Fine Gael counsellor is involved. Talk about rubbing salt in somebody's wounds.

The best time to start dealing with this crisis was ten years ago. The second-best time is today. In Sinn Féin's alternative budget for 2023, it proposed an expansion of public dentistry, starting with school screening and an oral health scheme for children, and the negotiation of a fix to the dental treatment service scheme.

In any other country this scandal would be a resigning issue. Shame on you.

5:55 pm

Photo of Ruairi Ó MurchúRuairi Ó Murchú (Louth, Sinn Fein)
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I thank the Regional Group for tabling this motion. Nearly every Deputy in this Chamber, including Deputy Munster and me, have raised the DTSS and received many answers over a long period. We all know that the inability of people on medical cards to get dental care is having a major impact. We all know people are putting off dental care and we know the long-term impact this has. The Minister must actively address this issue as quickly as possible. The situation is not getting any better.

Since 2017, dentists have been leaving the scheme and there are now 1,000 fewer dentists operating it. In 2016-17, there were 35 dentists in Louth operating the scheme. At the end of 2022 there were only 13. On the basis of those figures, the Minister can work out what the impact has been.

I will read out a message that was sent to me by a constituent. This will get across the impact, especially of one pressure point within the health system and how it impacts others.

My son was in a bad way with a dental issue two or three months ago. His dentist would not take his medical card, so he went, as suggested, to the doctor on call. The doctor on call said that if he could not get a dentist within 24 hours to go to A and E. [People can see where this is going]. We had to borrow money to get him an emergency dentist in Dublin. Two weeks before Christmas I had a dental issue. I had registered with a new dentist in Dundalk as mine also had stopped taking medical cards. When I went to the new dentist, even though I was in agony and I had the €40 deposit they required, they told me that as I was a new client I was not a priority, which I do understand. They advised that I go to a GP and if I could not get an appointment [wait for it] to go to A and E. I did go to my original dentists, who were excellent. It cost me €35 for the appointment and €95 for an extraction or filling. If you are on social welfare while looking for work, it is devastating. It meant no heat in the house over the past week. I am happy and grateful to have home and food and electricity but the Government need to fix the issues with the dentists also. So, the GPs are out the door, the dentists won't take the medical card and everyone is suggesting to us A and E.

This debacle means the DTSS is putting further pressure on the accident and emergency department in Our Lady of Lourdes Hospital in Drogheda. We also have the possible impending closure of the Navan accident and emergency department, which would lump even more pressure onto this particular problem. We can see that all of these crises are coming together. It is an absolute necessity, even if it is all we do, for the Minister to engage with the Irish Dental Association and bring this one part of the problem to a closure. We would then have dealt with at least one of the many issues that exist in the health service.

There are 1,000 special care patients and 3,000 children on waiting lists for dental surgery under general anaesthetic. There are 13,000 children and adults on waiting lists for dental and oral surgery in the public system and a further 13,000 on orthodontic waiting lists. As was said previously, we need more dentists and better workforce planning, we need work permits dealt with and we need to consider the possibility of directly employing dentists to deal with the issue we have. This is an ongoing disaster and we need delivery, not positive words from the Minister.

Photo of Carol NolanCarol Nolan (Laois-Offaly, Independent)
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I am delighted to speak on this important motion and I thank the Regional Group for bringing it forward. I held a very good briefing with the Irish Dental Association before Christmas attended by Deputies Verona Murphy and Matt Shanahan from the Regional Group. It was great to have so many people from different groupings and parties present.

It is no shock to any of us that the dental services are in crisis. They are in deep crisis as we speak. My constituency of Laois-Offaly is one of the worst affected in the State. A couple of weeks ago, I was contacted by the parent of a ten-year-old boy. The parent pleaded with me for help to access dental treatment for the child who would end up having an operation on his jaw if he did not have urgent treatment. That shows the seriousness of the issue. The Government, the Department of Health and the HSE do not treat this issue with sufficient urgency.

I thank the Irish Dental Association and welcome its representatives to the Chamber. The association has been highlighting the challenges dentists are facing with a medical card scheme that is not fit for purpose. The scheme does not focus on prevention strategies. It does not do anything to deliver for people in the long term. Urgent intervention by the Minister for Health is required. This cannot continue and should not be allowed to continue any longer.

I understand there have been some calls for meetings with the Department and the HSE. There needs to be meaningful and constructive engagement and the Minister for Health should be central to that process. It is my understanding that the Irish Dental Association has written twice to the Minister for Health and has yet to receive a response. I believe the association wrote on 10 January 2023 and before that on 6 December 2022. I again ask for the Minister for Health to intervene on this issue. He is central to making things happen. With constructive engagement, we can certainly progress this issue and bring in the necessary and meaningful reforms to a medical card scheme that is currently not fit for purpose.

I urge the Minister to take on board what I am saying. I have raised this issue in the Dáil a number of times. I have asked parliamentary questions. In November 2021, during Leaders' Questions, I expressed concern that my constituency was becoming one of the worst affected constituencies in this regard. I specifically asked the Taoiseach if the Department of Health would respond positively in the near future to the Irish Dental Association's request for the appointment of an independent chair and to confirm a framework for negotiations, equivalent to that agreed with the Irish Medical Organisation seven years ago. That is not a big ask. It is very constructive and it could certainly bring a resolution to this issue if the political will was there. I will end on that note. Again, I ask for urgent intervention.

Photo of Richard O'DonoghueRichard O'Donoghue (Limerick County, Independent)
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This did not happen today or yesterday. In the period from 2002 to 2005, the Oireachtas Joint Committee on Health and Children expressed its total dissatisfaction with the delivery of orthodontic services. It considered the position adopted by the Dental Council of Ireland on the issue of training in orthodontics to be unsustainable. In 2002, concerns were raised that quality orthodontic care was not available through the Irish system. The Dental Council of Ireland controlled the dental schools and these were in competition with the regional services. Therein lies the problem. One was in competition with the other when they should have been working together and having the same funding to sort out the problem. The committee agreed that a very good service was being offered by the regional service in the mid-west region and commended it on its excellence. The Joint Committee on Health was on board to support the regional service. It made recommendations, which were sent to the health board at the time. Subsequently, the HSE set up a review body, ignoring the recommendations made by the health board.

Needless to say, they went nowhere and the follow-up died a death. Hundreds of children have been damaged, there are restrictions of education by the Dental Council of Ireland, there is restricted training. Again this goes back to funding whereby both systems could have worked together. The recommendations went nowhere. The aim was to stop regional services. The bottom line is that children being hidden behind improper systems for 21 years. There is no consultant professor overseeing what is required within the dental schools. There is no academic consultant professor in the dental schools. We are talking about 21 years; we are not talking about yesterday or a week ago. This has been going on for 21 years as a result of politics. The services on both sides could have been invested in rather than setting one against the other and causing the problem that we have 21 years later. Why did the Dental Council of Ireland stop qualified orthodontists coming in from the UK? Public orthodontic services are now even worse than they were when the health committee expressed its concerns in respect of the period from 2002 to 2005.

A report compiled by Bearn and Richmond in 2015 was never published despite several calls on the Minister, who left the House two minutes ago, to publish it. The then Minister, Deputy Harris, got the report and has it. The Taoiseach, Deputy Varadkar, and the Tánaiste, Deputy Micheál Martin, all have this report. Why was it never published? It would have highlighted the problems that the Government created. Who is going to suffer for this? Children and adults have suffered for 21 years because of bad policymaking and funding. The Government could have funded both services and there would be no backlog. If it is serious about fixing this problem, the first thing it needs to do is accept the blame for its part in what has happened. The Minister should publish the report, if he is not scared to do so, and show the people what actually happened, rather than pitting the regional service against the Dental Council of Ireland, with one blaming the other. That is not the problem; the problem lies with Government.

6:05 pm

Photo of Joan CollinsJoan Collins (Dublin South Central, Independents 4 Change)
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I support the motion from the Regional Group. I thank the Deputies involved for putting it forward. The debate is badly needed in this Chamber. There is quite rightly deep anger at the moment over the trolley crisis in the HSE. However, the health crisis extends much further than what is taking place in our accident and emergency departments. The DTSS for people on medical cards is in a total state of collapse. The Irish Dental Association has called it unfit for purpose. Dentists are leaving the scheme in their droves. The Government slashed funding for the DTSS after the recession hit in 2008. The Irish Dental Association called these cuts savage. The Government has continued to cut funding since then. It cut funding by 36% between 2017 and 2020 alone. All of this has left many of those who need help the most with a severe lack of access to dental care. Many people simply cannot find a dentist who accepts medical cards. The Minister has acknowledged that the scheme is not fit for purpose, but he still failed to meet his own deadline for a review last year. The Irish Dental Association states the scheme has remained largely unchanged since it was implemented in 1994 at the same time as privatisation of dental care for medical card holders. We have seen the number of dentists enrolled in the scheme fall from 1,600 in 2019 to just 600 last year. That leaves more than 2,500 medical card holders for every dentist in the scheme. The Government has failed to lift a finger while a vital service for some of the most vulnerable people in this country has completely fallen apart.

As was said by previous speakers, we know that gum disease increases the risk of heart attack, stroke and other cardiovascular events by two to three times the average. In the middle of a cost-of-living and inflation crisis, retired, low-paid and unemployed people cannot always afford a healthy diet. They cannot afford the cost of private dental care and they certainly cannot afford the time and money it takes to actually find a dentist who accepts medical cards. To make things worse, in June last year I received a letter from a constituent whose son has a disability and who had been that told they could no longer attend the public clinic at Old County Road because it would only be serving those who could not physically attend a community dentist, sit to wait for the appointment or sit still in school. That was the reply I received. This was confirmed to me as being in line with HSE policy by the Minister when I raised the matter by means of a parliamentary question. This is a massive change for many with disabilities who have been attending public dental clinics their whole lives. It pushes more and more people into a rapidly shrinking system that cannot provide for them. The failure of the scheme leaves people who are largely struggling in serious physical pain. It puts the burden of dental care on those who can least afford it and the burden of a lack of preventative care on a health service that is already bursting at the seams.

Another matter was raised with me by families of autistic children. They were told that only autistic children who are in special needs schools or classes can access the special care programme. Children in mainstream schools who have autism are not entitled to access the special care programme. This is a failure for those people in our communities. It is yet another result of failing to implement the recommendations laid out in the Sláintecare report. Sláintecare lays out the need to return to pre-austerity levels of funding and highlighted the shocking situation where we have seen massive reductions in access to regular dental care and massive increases in emergency extractions. This situation is just not good enough. We need to look after people on medical cards. We need an emergency return to pre-recession funding for the DTSS. We need investment in and expansion of our dental schools. We need to implement the reforms of Sláintecare that were promised five years ago. We need to end the privatisation of the 1990s and ensure proper, public dental care for everyone in this country.

I support the motion. We need immediate intervention by the Government to implement the plan to help those on medical cards.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank the Regional Group for putting forward this motion. It is an important motion that highlights the necessity for greater investment in dental services, particularly for greater investment in human resources and training of people to work in that area. It is neither today nor yesterday, but in the early 1980s, a time of great austerity in Ireland, when I was in primary school and I and all my schoolmates had two dental check-ups. I still remember them. Notwithstanding the difficulties the State was in at the time, we were able to provide dental care to children. Maybe it was not anything like the same level of care as is provided now in the event of somebody having a serious difficulty, but, nevertheless, relative to the times that were in it, it was quite a level of dental care. Unfortunately that is no longer the case to the same extent. In theory children are entitled to two dental check-ups, but those are not possible because of lack of resources.

I asked a parliamentary question of the Minister for Health last year and received a reply from the HSE in respect of the number of whole-time equivalent, WTE, posts in dental care in Clare. Those persons are employed to provide the dental check-ups to primary school children and also to persons with disabilities in Clare. In 2006 there were 10.2 WTE posts; five years later, in 2011, the number was down to 9.2; in 2016, notwithstanding the period of austerity, it was down to 8.2; and in 2021, when things were supposed to be picking up, it was down to 6.8. It had risen very slightly by October of last year to 7.4. We are still less than what we had in 2006. I appreciate that it is very difficult to recruit health professionals right across our healthcare system for a variety of reasons. They are in high demand not just in Ireland but across the world. Those who are educated in Ireland are in demand across the world and we have to compete with the rest of the world to hire them. It is a failing that needs to be addressed as a matter of some urgency.

On the matter of accident and emergency departments, County Clare is served by the HSE mid-west, which was in the news for unfortunate reasons over the past couple of months.

This is something that also needs to be addressed.

I am not suggesting for a moment that there are easy answers and nobody in the House is doing so. Nevertheless, there are answers and we need to move forward. Part of that is investment and part of it is training up hygienists and dental nurses so they can provide a greater level of service. It is also about investing more in our dental schools and training. Ultimately we must ensure that children get the early intervention they deserve and need. It is a truism but it is nevertheless true that a stitch in time saves nine and we want to avoid children having to have more traumatic interventions due to them not being seen at an early age. I support the motion.

6:15 pm

Photo of Dara CallearyDara Calleary (Mayo, Fianna Fail)
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Gabhaim buíochas le gach Teachta sa Teach a bhí páirteach sa díospóireacht seo. I thank every Deputy, on behalf of the team at the Department of Health. The Minister, Deputy Stephen Donnelly, was here until just a few minutes ago and I assure the House that the Minister appreciates the serious difficulties that are being outlined this evening. I thank the Regional Group for bringing this issue forward.

The Minister has noted that the Government is committed to addressing the issue by easing current access issues through a range of interim measures, which still include a 40% to 60% increase in payment for treatments under the dental treatment service scheme, DTSS, last year, but ultimately through substantive service reform. In saying that I also want to acknowledge the truth of many Deputies’ feedback, including my own, on the inaccuracy on HSE lists on those participating in the DTSS. That needs to be improved. An additional allocation of €15 million has been invested in budget 2023 to support the work.

The national oral health policy, Smile agus Sláinte, sets out the vision for the future of oral healthcare services in Ireland. This is a body of wide-ranging and transformative reforms. While it will take a number of years to bring to complete fruition, there will be an early and continued emphasis on addressing the issues described this evening. The policy will support the provision of all levels of care by appropriate healthcare professionals and in the most suitable settings. It will support patient choice and access across the life course. The fundamental aspiration is that all Irish people will have their own dental home where they will build a lifelong relationship with a local dental practice or with practices of their choosing, for continuity of care from birth to old age. It will replace the current service approach, which is based on the dental health action plan 1994, which was informed by data from the 1980s. The policy has two goals, the first of which is to provide the supports to enable every individual to achieve his or her personal best oral health; the second goal is to improve access to dental care in an equitable and sustainable manner, therefore enabling vulnerable groups to improve their oral health. The policy reflects the WHO approach, grounded in primary healthcare, which is being informed by and aligned with other relevant Government and health policies, including the primary healthcare approach, Sláintecare and Healthy Ireland.

We know that oral health is linked with general health. Alcohol, tobacco use and poor diet are common risk factors that not only lead to poor oral health but to heart disease, stroke, diabetes, cancer and other non-communicable diseases. We know from Healthy Ireland surveys that the population highly rates the advice they receive from their dentists and from other oral healthcare professionals regarding these risk factors. Oral health promotion, based on a holistic approach, that acknowledges lifestyle-based risk factors common to oral and non-oral diseases, will be made available to all age groups under the policy. The Government has already taken the first steps towards this preventative approach in the measures introduced to the DTSS last May, which included the requirement for dentists to provide advice on diet, tobacco, alcohol and other lifestyle impacts as part of the oral health exam, and the reintroduction of the scale and polish treatment for all adult medical card holders. More than 93,000 additional people received scale and polish treatments under the scheme in 2022, versus 2021.

For children, the best evidence shows they should have access to oral healthcare services as young as possible to establish their dental home with their local dentist or oral healthcare professional of their choice. This ensures they can access support before they have problems. The Government is committed to starting the process of developing these new and more comprehensive services for children this year, starting with the zero to two years old age group and then moving to seven years. This change will increase the capacity of the HSE public dental service to reorient and develop oral health promotion programmes. There will also be greater capacity to provide care to those more vulnerable groups in our community, including adults and children with additional needs and adults living in residential settings.

All of this requires a sufficient number of appropriately trained dentists and oral healthcare professionals, including dental nurses and other grades. The Minister has said many times that we need a radical approach to increase the number of healthcare professionals available. At the end of December there were 3,442 dentists on the dental counter register. As Deputy McNamara has referred to, we need many more. The Department of Health is collaborating with the Higher Education Authority, HEA, to identify opportunities to build capacity in the higher education system for dentistry and for more oral healthcare graduates. Potential new and innovative models of dental education are also being considered, with a focus on primary care. The HEA initiative is aligned with a Department commitment in the national oral health policy to improve access to care.

The Department of Health is committed to the development of an oral healthcare workforce plan, as set out in the national oral health policy. Dedicated resources have been set aside to advance this work. This work and workforce plan will consider how other dental professionals, such as expanded roles for dental hygienists, can express support for the new model of oral healthcare services, and how they in turn can be supported with career pathways that support staff retention and development. The Department has asked the Health Research Board to review the type of work placements used in dental undergraduate education in other EU countries. All of this should help to ensure our higher education system provides enough oral healthcare professionals with the relevant skills to meet our population’s needs.

I want to assure the House that the Minister will continue the ongoing work to address the access issues, which are affecting current healthcare services and which have been described throughout this debate. He will also progress work on the implementation of the national oral health policy, which sets out the body of transformational response. I thank the Deputies who participated again and I thank the Regional Group again for bringing forward this motion. I assure them of the Government’s complete commitment to improving our oral healthcare services and the access issues raised this evening.

Photo of Peadar TóibínPeadar Tóibín (Meath West, Aontú)
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I welcome the representatives of the dentists to the Gallery to listen to the debate. It is frustrating to hear the response of the Government to what has been put forward by the Opposition. For years the dental sector in this country has been on the brink of collapse. We know it is at breaking point across the country, which is staggering, given the importance of dental care to so many people.

The heart of this problem is administrative. The problem with the administration in so many sectors in this country is that it does not listen to the sector. The sector itself is the group of people who are best tooled to be able to come up with solutions and design the system going forward in the future. They are frustrated that they are not being listened to. I know the Minister of State is new in his role but if I could give him any advice it would be to allow those people a position to steer the direction of the sector in the future.

We need proper systems that wrap around communities, not narrow and restrictive schemes. Firing money at those narrow and restrictive schemes will not fix the problem. One of the difficulties I have with the Minister of State's speech is that much of it is in the future tense and if you take away the future tense there is very little left in it. Given the difficulties that have been created in recent years, we should have been able to point to actions that have been carried out and delivered upon.

It is clear that the lack of dental staff in the system is a difficulty. The emigration of so many healthcare workers is a problem that the Government is not grappling with. A key to grappling with that problem is to provide proper terms, conditions and pay. Anybody who is employing a person in any business anywhere in the world has to create a proper recruitment package to be competitive, and that simply is not the case for so many people at the moment. We need far more dentists in the system.

The public dental system is a particular gripe I have.

It is the poor relation of this Government in terms of the delivery of the service. It has massive outcomes for people right across the system. In my own county of Meath, our public dental clinic is being closed. It is going to reopen in Dunshaughlin, but the four dental clinic surgeries in Navan will not be replaced. Only two will be built in Dunshaughlin. Will the Minister look at this specific issue for us, if he can? That one of the fastest growing towns in the country does not have a dental clinic for children is a major problem.

First, fourth and sixth class children are not being called to dentists anymore in County Meath. It is incredible. These children are only receiving their first appointments in secondary school. That means far more damage being caused, far more invasive treatment being necessary and it being far more costly to the State in the long run. There is no logic there. There are 13,000 children awaiting orthodontic treatment for grade 4 and grade 5 eligibility criteria. There are 100,000 children on the waiting list for public dental appointments, and there is a six-year waiting list for orthodontic treatment. It is scandalous that we would allow that to happen. That people from lower socioeconomic backgrounds are more at risk in these terms is incredible. I was looking at the figures and the funding actually decreased from 2017 to 2020. Spending on dental care for medical card patients nationwide fell from €63 million in 2017 to €40 million in 2020. There is no excuse and no logic for that whatsoever. In some places the fall was recorded as being as high as 48%. As a result of the dental treatment services scheme haemorrhaging dentists, many cannot participate at the moment. There are 700 dentists State-wide participating in the scheme, and in counties like Meath there are now fewer than 20 dentists participating in it. It is almost creating what I would call a Victorian dystopia, where people from well-heeled leafy suburbs have good teeth and do not suffer pain, and people from working-class backgrounds have the opposite. Are we really talking about 2023 being reflective of what was happening in the 19th century? The Government needs to do far better.

6:25 pm

Photo of Joe McHughJoe McHugh (Donegal, Fine Gael)
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I thank Deputy Naughten, at the outset, for his generosity. I met him last night and he said I could speak for a couple of minutes. It is good to see the season of goodwill continuing right into the middle of January. A lot has been said here today and I think the tone of the debate has been very constructive. It is nice to see a motion being tabled where the Minister accepts the spirit in which the motion has been moved and many good suggestions have been made. That is very important. There are a number of points I wish to highlight. It is impossible to compare the situation with 2010. There were so many more services available through the medical card and the PRSI scheme before 2010. We cannot compare the situation with 2010 for many things in the economy and the country. It was a different period. However, I acknowledge that additional measures were introduced in the PRSI scheme and the medical card scheme last summer. It is interesting the Irish Dental Association has noted that 70% of people did not avail of the cleaning service available under the PRSI scheme last year. I will use this as an opportunity to appeal perhaps to men in particular. I know that on a gender front we are quite poor at presenting ourselves on health grounds. Maybe that includes dental care. I met one of our work colleagues outside the door and he told me he has not been to the dentist in a long time. There is a cleaning service included under the PRSI scheme for certain bands. I encourage people to take up that service. There is also an onus on the dentists as well. I have a very good relationship with my own dentist. He keeps the pressure on me to continue to present myself for treatment. That is important as well.

We all agree that preventative care and gum health is critical at an early stage to prevent further problems down the line. The Minister mentioned €200 million in funding. That is a lot of money, but he did acknowledge that structural change is needed. There are plenty of issues, including supply issues in the provision of orthodontic and dental services. A lot of structural change is needed. It is about getting to the root cause of where the issues are, if Members will pardon the pun. Orthodontic care is a massive issue in terms of affordability. It is also an issue in terms of orthodontic service provision. Indeed an orthodontic vacuum provides a very visible example of poverty, where people who cannot access and afford orthodontic care. It is a very visible reflection of poverty. That is something we need to continue to monitor.

My experience recently with dentists and dental hygienists through the HSE scheme in both Creeslough and Letterkenny has been nothing but positive, not just at a courtesy level but also at a professional level. It is essential that if there are any logjams within the primary school system, we continue to monitor them. The Minister may not be aware, but the children in the Finn Valley area have to travel to Letterkenny due to the closure of the dental service in St. Joseph's in Stranorlar. Perhaps the Minister would look at that to see if there is an opportunity to reopen that service. I was speaking earlier to my colleagues, Deputies Ring and Durkan. Deputy Durkan was keen to point out that the very issues we are raising here today were presenting themselves in a similar way back in 1981. Similarly, Deputy Ring referenced his own experience over the past number of decades in this profession. The issues continue to be the same.

I thank the Regional Group for raising the issue. I thank Deputy Naughten for affording me the time to speak on this important item. I certainly hope the spirit that has been taken on the part of the Minister for Health, and he did come across as being very sincere on this issue, means that whatever proposals coming from the Irish Dental Association are taken seriously and listened to.

Photo of Denis NaughtenDenis Naughten (Roscommon-Galway, Independent)
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I thank my colleagues in the Regional Group for tabling this motion and the newest member of the Regional Group, Deputy McHugh. He is very welcome on board. I also thank Cáit Nic Amhlaoibh for her assistance in this. I thank every Member in the House who spoke, both Government and Opposition, in support of this motion, and the fact it is being unanimously adopted by the House is a clear message. It is to be hoped we will see the proposals in this motion adopted.

I was contacted during the week by Mary. She has been trying to get an appointment with a dentist. She rang every dentist in County Roscommon, County Mayo and County Leitrim, and not one of them was taking medical card patients. Mary is a single parent with two adult children for whom she is the primary carer. She put it to me that it is not easy to survive on her welfare payments. She is someone who worked all her life. She was forced out of employment back in 2015. She paid all of her taxes like everyone else. She said she felt like she was begging to get the help she needed. For people like Mary, it is just not good enough. Under section 67 of the Health Act 1970, the HSE is obliged to provide dental treatment and dental appliances to persons under the medical card scheme. It is obliged to provide that. Instead of that, it has turned its back on those struggling to cope. The Minister spoke about engagement with the Irish Dental Association. It is my understanding the last engagement that took place with the Irish Dental Association was last March. That is the engagement that is taking place. Surely, for the sake of Mary and every other Mary in this country, we should resolve this issue and ensure people can get access to treatment.

In my area in counties Galway, Mayo and Roscommon, 36% of the dentists who were in the dental services scheme have left in the last two years. We are now down to just 36 dentists across our region, not one of whom is taking on additional patients.

Prevention with regard to our dental services is far better than cure. If we look at the oral health checks that have taken place over the last few years for children in first, second, fourth and sixth class and compare the figures for 2019 with the figures for the middle of this year, across counties Galway, Mayo and Roscommon in 2019, 11,632 children got access to that dental assessment. Up to the middle of this year, that figure was just 3,429. The bulk of those at 53% were in County Roscommon, 29% were in County Mayo and 11% were in County Galway. There has been an appalling fall-off in the number of dental assessments taking place for children within our primary school system and this is only storing up trouble for the future. With regard to our orthodontic services, again, in counties Galway, Mayo and Roscommon, we have 1,343 children waiting on orthodontic services in our region.

The final issue I wish to bring up with the Minister of State is with regard to people with a disability. As the Minister of State knows, people with a disability do have not the same ability to communicate. They do not have the same ability to express where the pain is exactly in their mouths or what is causing the pain and discomfort. Backs have been turned on those people in terms of the provision of dental services. I have one constituent named Francis who is an adult individual with an intellectual disability. He was added to the urgent inpatient waiting list on 11 November of last year. Francis ended up in University Hospital Galway accident and emergency department on 28 November of last year with swelling to his face, hallucinations and confusion. No-one wants to be going into that accident and emergency department any day of the year; not someone with an intellectual disability with swelling to his face, hallucinations and confusion. He spent seven hours along with 151 other people in that emergency department on that particular day. He is still waiting today for his emergency treatment.

This is not just in about adults. It is the same situation for children with a disability who are required to go under an anaesthetic. Children on the autism spectrum who need to go under an anaesthetic are being excluded from the provision of dental care today because of that. There are children who should be in the mainstream system. We have encouraged children with a disability and those on the autism spectrum with a disability to be in the mainstream education system. They are being shut out of access to these services today, however. It is not good enough that this is happening.

In fairness, the Minister of State, Deputy Rabbitte, contacted me before the debate today. She has committed to working with Deputies from the Regional Group to try to address the disability issues regarding this matter. However, we all know that if we actually neglect oral hygiene, it leads to emergency dental issues, advanced oral lesions, chronic ill health and sepsis that all add, like the case of Francis, to pressure on our emergency departments, which just cannot cope.

My one final ask is for the Minister of State to sit down with the Irish Dental Association to resolve these issues and provide a basic level of service to every single citizen, regardless of his or her income. Regardless of whether people have money in their pocket, they deserve access to a basic dental service.

Question put and agreed to.

Cuireadh an Dáil ar athló ar 7.36 p.m. go dtí 2 p.m., Dé Máirt, an 24 Eanáir 2023.

The Dáil adjourned at at 7.36 p.m. until 2 p.m. on Tuesday, 24 January 2023.