A complex case

Reform of Ireland’s oral healthcare system is under way, but challenges remain

Words: Will Peakin

The new year brought a renewed focus on the challenges facing public dental services in Ireland. The Irish Parliament’s debate in mid-January was not just a lively exchange of opinions; it was a sobering discourse on the complex challenges and anxieties surrounding oral healthcare in the nation.

The debate painted a stark picture of access disparities within the Irish dental system.

Deputy Mattie McGrath, highlighting the plight of medical card holders, described a system rife with lengthy waiting lists and limited treatment options.

He brought to life the human cost of these shortcomings through the case of Francis, a constituent suffering from severe dental issues due to inadequate access. This personal story resonated with other members, amplifying the call for a more equitable system.

Deputy Cathal Berry echoed McGrath’s concerns, adding the dimension of geographic disparity. He pointed out the lack of dentists in rural areas, further isolating vulnerable populations from essential care.

This highlighted the need for a holistic approach that addresses both financial and geographic barriers to access.

While access was a cornerstone of the debate, the discussion transcended mere availability. Deputy David Cullinane challenged the outdated Dental Treatment Services Scheme (DTSS), calling for a comprehensive overhaul.

He championed a preventative approach, advocating for investment in oral health education and early intervention programs.

This shift towards prevention was a recurring theme, highlighting the potential for cost savings and long-term improvements in oral health outcomes.

Deputy Gino Kenny delved deeper into the system’s inner workings, questioning the rationale behind certain DTSS limitations and advocating for greater transparency and accountability within the Dental Council.

His emphasis on resource distribution resonated with concerns about rural areas and
the need to ensure equitable access across the country.

Deputy Stephen Donnelly, the Minister for Health, said that in the previous year more than €200m had been allocated to oral healthcare.

“Everyone needs to have timely access to healthcare for diagnostics and treatment, but there are challenges,” he said.

“It is a priority for the Government to address this in the short term, and we are taking action through much-needed reform.

“The call for a significant overhaul of the DTSS has been heard”

Stephen Donnelly

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.

The scheme also provides a targeted programme that includes screening and necessary treatment for children at important stages of development – from six to eight years, between 11 and 16 and, subject to capacity, those aged between nine and 11 years.

Emergency care is also provided to children up to the age of 16 and those with complex and additional needs.

“As we are all aware, coming out of the pandemic, there are backlogs in the targeted screening programme in particular,” said Donnelly.

“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 health, and many other parts of healthcare.”

What is the Government doing about this? In the budget for this it has allocated €15 million, “an unprecedented allocation,” said Donnelly,  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. More than 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.

The Government has allocated €4m 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,” said Donnelly.

“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.” To address contractor concerns regarding the DTSS, interim measures came into effect from 1 May last year. Fees paid to dentists for most treatments were increased by between 40 per cent and 60 per cent.

But Connelly claimed: “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 to adult medical card holders. It was taken out of the scheme some years ago, but we put it back in. I allocated €10m to the budget for last year and 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 as a result. 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. Fees to dentists have gone up by almost 50 per cent in one year.

“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 [Irish Dental Association (IDA)], and we need to see how we can bring a lot more dentists back into the scheme.

A sum of €5m 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. [Deputies] have raised issues affecting their constituents in this regard. We need reform,” he added.

“The national oral healthcare policy, 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 extra money to oral healthcare and then in the budget for this year more again – 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 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 €15m 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.

“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.”

However, not everyone was convinced. Deputy McGrath expressed scepticism about relying solely on the IDA, suggesting a potential conflict of interest and the need for independent oversight and regulation.

This point of contention highlights the complex dynamics within the dental sector and the need for a balanced approach that ensures both collaboration and accountability.

The debate concluded with a renewed call for action and reform. Deputies from across the political spectrum expressed a shared concern about the state of public dental services and a willingness to work together towards solutions.

While the path forward remains unclear, the debate served as a catalyst for further discussion and potential policy adjustments.

Key points from the debate

  • Deep concerns about access and affordability: The debate exposed the stark reality of unequal access to dental care, particularly for vulnerable populations.
  • A push for preventative approaches: The emphasis on oral health education and early intervention programme’s signalled a shift towards
    long-term solutions.
  • Calls for systemic reform: The outdated DTSS and the need for transparency within the Dental Council were identified as areas requiring attention.
  • Collaboration and accountability: The debate highlighted the importance of both working with the IDA and ensuring independent oversight.

Potential policy directions

This report offers a springboard for further discussion and potential policy changes. Here are some key areas for consideration:

  • Increased funding and resource allocation: Expanding capacity, particularly in rural areas, and investing in preventative programs could significantly improve accessibility.
  • Review and revision of the DTSS: Modernising the scheme to address limitations, improve efficiency, and promote preventative measures is crucial.
  • Enhanced transparency and accountability: Mechanisms for independent oversight within the dental sector would foster trust and ensure equitable resource allocation.
  • Exploring alternative funding models: Investigating public-private partnerships or innovative financing mechanisms could provide additional resources for the public dental system.

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Published: 11 March, 2024 at 05:56