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Senior dentists face many of the same challenges as medical consultants ensuring another demanding year ahead in these turbulent times writes Fintan Hourihan.
A quick glance shows that new regulatory legislation, challenges to the right to have professional representation, reduced state support for practitioners and their patients, rising consumerism and medical/dental tourism are among the many common challenges facing medical and dental professionals.
Notwithstanding the current economic difficulties, the Irish Dental Association (IDA) makes no apologies for insisting that dentistry in Ireland should be led by 'best-practice' and 'evidence based' principles and these principles must not be compromised by economic pressures. As the HSE seeks savings of almost E1bn, Association is demanding that an explicit commitment be given to prioritising the employment of front-line clinical staff such as dentists and doctors and for the immediate filling of all current vacancies.
We are also calling for the immediate appointment of a senior dentist within the Directorate of Clinical Care and Quality announced by the HSE in July 2008 in order that dental services can be managed and planned in a patient-focussed and systematic manner.
Furthermore, we believe that a full patient impact assessment must be published ahead of any changes proposed in the delivery of dental services by the HSE and that discussions take place with dentists prior to any changes being introduced.
However, given the latest reform plan for Integrated Care published by the HSE, it should be noted that engagement with the dental profession on long overdue reforms of publicly funded dental services have been stalled because of a belief that such discussions would contravene the Competition Act, 2002. In this regard, the Irish Dental Association faces the same assault on its right to represent its members as the representative bodies for doctors and pharmacists.
Significantly, the Government recently decided to "pursue appropriate amendments to Section 4 of the Competition Act 2002 to enable the representative body of medical general practitioners, the IMO, to represent its members in negotiations with the HSE and the Department of Health and Children in respect of the services provided to the public health service" (Government statement of October 21st). The Government also stated that it was "satisfied that the scope of the engagement by General Practitioners in the delivery of primary healthcare, and the significance of primary healthcare for the overall efficacy of the public health system, makes a more direct form of engagement with the representatives of General Practitioners both necessary and desirable. Accordingly, it is the intention of the Government to pursue appropriate amendments to Section 4 of the Competition Act 2002 to enable the representative body of GP's, the IMO, to represent it's members in negotiations with the HSE and the Department of Health and Children in respect of the services provided to the public health service in a manner consistent with the public interest. This will not affect in any way the status of the IMO or other representative organisations in respect of medical services other than those delivered by agreement with the public health service. The legal provision to be made will be subject to consistency with EU competition rules."
The Irish Dental Association believes that the same principle of partnership ought to apply to enable direct engagement with the Association, as the representative of general practitioners in dentistry, which the Government sees as "both necessary and desirable" in improving primary care "for the overall efficacy of the public health system." We believe that the IDA should have its role recognised in the same way when amendments to the Competition Act are considered.
Despite the crucial role of the dental profession to the health of the population, there is a shortage of dentists in the Public Dental Service and at secondary and tertiary care level, most notably in the areas of oral surgery and orthodontic services. Also, the number of training places for dentists has remained static and there are no plans to increase them. The limit on training places in Irish universities could lead to a serious shortage of dentists in the future and put further upward pressure on prices. Therefore the IDA is calling for the development and implementation of a comprehensive manpower policy relating to training, career structure, and service delivery.
Investment in dental practice facilities derives solely from funds generated by dentists and with no state funding being made available. Dentists and doctors in private practice are similar in this regard, i.e., in no other area of the health service are practitioners expected to develop and enhance practice facilities without any state funding or assistance. The availability of tax reliefs for patients attending for medical and dental treatment (as prescribed and detailed in the Revenue Commissioners' Med 1 and Med 2 forms) is essential to maintaining and promoting better health for the population as well as enabling practitioners to develop and enhance the facilities and the range of services they can offer.
The government's decision to restrict tax relief on dental work in this year's Budget is short-sighted and will result in poorer levels of oral health.
Until the latest Budget, tax relief could be claimed at the standard, 20 per cent, or higher, 41 per cent, rates of tax depending on a person's earnings. However, from January 2009 tax relief on all medical expenses is to be capped at 20 per cent. This will deter and unfairly penalise patients who require dental work. For example, in the case of children falling outside the HSE guidelines and requiring privately delivered orthodontic treatments (whose average costs could amount to E5,000 for a two year course of treatment), this change could mean the relief available being reduced from E2,050 to E1,000.
It had its critics as a means of ensuring support for patients in meeting the costs of treatment but the fact remains that the Med 2 scheme is the only state support offered to patients and practitioners seen in a private setting and we feel this area will need to be revisited quickly in order to arrest the inevitable decline in the oral health of the population.
In the same vein, immediate steps need to be taken to enable a comprehensive review, involving the HSE and the Irish Dental Association, of the DTSS (medical card) scheme. Meaningful confidence building measures need to be introduced to deal with the wholly unsatisfactory administration of claims / payments by the GMS Payments Board to participating dentists.
Significant expansion in resources and in dental Consultant staffing in our hospitals is also long overdue. The development of specialist care services in areas such as paediatric dentistry, special care dentistry, oral surgery and dental public health must be done on a nationwide level. This would lead to simpler journeys for patients as they would not need to leave the service for continued care. It would also improve the status and profile of the service and aid in the recruitment and retention of staff by providing career pathways in many areas of dentistry. The current burden on the dental schools would also be alleviated, and referral to dental schools could be reserved for the management of more complex cases requiring tertiary care.
Oral health should be part of every care plan for children and adults with special needs. Primary care services need to be expanded and secondary care services for these patients need to be developed across the country, to ensure equitable access to high-quality services.
Oral Health promotion activities need to move beyond the dental education model and to concentrate on tackling the main determinants of oral disease, which are largely socio-economic and cultural. The evaluation of oral health promotion interventions requires increased investment so that effective interventions can be identified and expanded.
Orthodontic care is also in need of significant extra investment. The HSE Orthodontic Review Group Report (ORGR), adopted two years ago, sets out a national framework and road map for the provision of HSE orthodontic care. Thus far, progress in implementing its recommendations has been painfully slow.
For example, the majority of orthodontic patients who are treated in the HSE units, require only orthodontic treatment, however about 33% of children on the highest priority waiting list (the most dentally challenged children) often require care from multidisciplinary teams, involving consultants and specialists in Oral and Maxillofacial Surgery and Restorative Dentistry. There is often a road-block to deliver a timely, first class service to this group of patients.
The organisation of multidisciplinary teams in general throughout the country is poorly resourced in terms of manpower and funding. There is insufficient integration between health organisations to facilitate optimal multidisciplinary team working and receives particular attention in the orthodontic review group report. As outlined in the ORGR, It is hoped on a HSE regional basis that specific appointments at consultant level will be made in the disciplines of restorative dentistry and oral and maxillofacial surgery. This would help facilitate multidisciplinary dental care to rehabilitate our most dentally challenged patients.
An area of great concern relates to accessing public surgical beds to allow orthognathic surgery to take place. There appears to be a shortage of surgical beds dedicated for oral and maxillofacial surgery in the country. The national treatment fund has been used on many occasions to ease this problem, however, while welcome; it also serves to mask the true funding and infrastructural deficit in the public oral and maxillofacial services. Currently the HSE orthodontic units cannot directly access the NTPF for their orthodontic patients. The outcome of this anomaly results in a doubling up of waiting time for patients. Firstly a wait on the orthodontic waiting list, then on a public surgical waiting list to access the NTPF. Direct access to the NTPF by the orthodontic units would eliminate the second wait and facilitate the patient care journey.
An issue which attracts media attention is the practice of commercial enterprises advertising to attract citizens to travel outside the state for dental treatment. The Association believes that not only is the assumption of cost savings open to serious challenge but more worryingly, we are concerned that increasing numbers of patients are presenting to Irish dentists having travelled abroad for treatment and had adverse outcomes or been over-treated.
We are concerned that from a patient safety perspective, there are not sufficiently resourced safeguards to ensure that those carrying out consultations in inappropriate settings in Ireland such as hotels prior to referral for treatment abroad (and such consultations are an integral part of dental practice) are registered with the Dental Council of Ireland and subject to its validation, oversight and disciplinary procedures. Equally, we believe that a properly resourced public education campaign is required, and the Association sees that it has an integral part to play in educating and informing the public, so that patients are fully informed about the risks as well as the perceived benefits of being treated outside the state.
For dentists, legislation embodying changes introduced in the Medical Practitioners Act, 2007 is also expected shortly. The IDA is gearing up to meet the competence assurance and continuing education needs of dentists in anticipation of the statutory requirement for competence assurance being extended to dentists in the same way as is required of doctors. The Association recognises the need to review regulation of the profession and is fully supportive of reforms which promote the highest standards of professional care and treatment and protecting the public. We stand ready to engage constructively with the Oireachtas in framing and developing such legislation to ensure that changes are appropriate, relevant and enjoy the confidence of society and the dental profession.
Recognising the need to enhance the strong support of the public for dental services and the profession in Ireland, the IDA is committed to developing a system of alternative dispute resolution to ensure that patient concerns are addressed in a timely, fair and comprehensive manner and also with a view to offering an alternative to costly and time consuming litigation.
Finally, as we await the imminent publication of a new Oral Health policy from the Department of Health and Children, the appointment of a Chief Dental Officer within the Department of Health embodies the Government's commitment to dentistry as an independent but integral component in public health policy. The ongoing vacancy has resulted in an unfortunate delay in the setting of oral health goals and the role needs to be filled as a matter of urgency.
ENDS
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