A waiting game

A dentist checks a child's teeth from above.

With the medical card scheme for dental treatments ‘close to collapse’, Ireland is anxiously awaiting the roll-out of its new oral health policy

The medical card scheme for dental treatments in Ireland is close to collapse, according to figures released last month. There are 252 fewer dentists signed up to the Dental Treatment Service Scheme (DTSS) compared with last year. There are also major disparities in the number of participating dentists depending on the county in which people live.

This is resulting in “a completely unacceptable postcode lottery for those in need of treatment,” according to opposition parties. Social Democrats health spokesperson Róisín Shortall said: “The scheme is haemorrhaging dentists and requires immediate attention. Alarmingly, the number of dentists in the DTSS has dropped by almost 50% in the past 10 years.

“The existing scheme is a relic of the past and flies in the face of best practice. Inexplicably, the DTSS restricts the number of preventative treatments allowed to save a tooth, such as fillings, but permits an unlimited number of extractions. Reform of dental services in Ireland has moved at a snail’s pace. It is now five years since the national oral health policy, ‘Smile agus Sláinte’, was launched and we are still waiting on an implementation plan. The Social Democrats brought forward a Dáil motion [in May] calling on the Government to deal with the deepening crisis in public dentistry. We are seeking a commitment to provide funding in Budget 2025 to put the medical card scheme on a sustainable footing and for the Minister for Health to immediately begin engagement with the sector to reform the DTSS.”

Shortall added: “Reform of the Dentists Act – which is almost 40 years old and hopelessly out of date – must also be prioritised. It is way beyond time that the Minister showed some urgency and ended decades of State neglect of oral health.”

“There are an estimated 104,000 children on a waiting list for the school screening dental service”

Ossian Smyth, Minister of State at the Department of Public Expenditure, National Development Plan Delivery and Reform, said that an additional €15 million in core funding since 2019 and a further additional €17 million in one-off funding has been supporting the ongoing work to reduce waiting lists and to address access to services through policy implementation.

The Government is easing current access issues through a range of interim measures, he added. These include a 40% to 60% increase in payment for treatments under the dental treatment services scheme and substantial investment in orthodontic waiting list initiatives.

“Ultimately, implementation of the national oral health policy will achieve the substantive service reforms required to ensure that patients can access the care they require as set out in the best international evidence and practice,” said Smyth. “In turn, we recognise that the oral health care sector must be enabled and supported to provide this evidenced-based care through an appropriate framework of professional regulation, education and training and strategic workforce planning, as well as modernised contractual arrangements.“

Smile agus Sláinte sets out the vision for the future of oral health care services in Ireland. It is described by the Government as a body of wide-ranging and transformative reforms and the implementation plan for the 2024-26 phase is in development to set out the key milestones and outcomes.

“The lengthy phase of policy development between 2014 and 2019 was fully cognisant of two policies in particular that have provided the framework for the vision of transformative change that the Smile agus Sláinte policy sets out,” said Smyth.

“Smile agus Sláinte is based on technical concepts that the World Health Organisation has endorsed for several decades and which embed oral healthcare in a primary care setting rather than in an acute setting, that emphasise the integration of oral health into general health through the recognition of common disease risk factors such as diet, alcohol consumption and tobacco usage and that endorse the use of comprehensive oral healthcare packages that are prevention-focused.”

Accordingly, he said, Smile agus Sláinte reflects the ethos, practices and intentions of the WHO’s global oral health resolution strategy and action plan. Smile agus Sláinte also applies the Sláintecare vision of enabling patients to access the right care in the right place at the right time in respect of oral healthcare based on the best international evidence and practice in oral healthcare.

“This means that the care the State is enabling the sector to provide will emphasise prevention and will aim to keep patients out of an acute setting as much as possible. The design and development of oral health care packages for adults and children underway in the HSE represents a significant expansion of preventive care,” said Smyth.

Care in the right place, as it applies to oral healthcare, means that people of all ages should be able to access care at local dental practices of their choosing, thereby establishing a dental home for continuity of care and allowing dental practices to build enduring relationships with their patients, he added.

The public dental service will continue to play a core role in oral healthcare provision. The changes envisaged will increase the capacity of the HSE service to reorient and develop oral health promotion programmes. There will also be greater capacity to provide care to those more vulnerable groups in the community, including adults and children with additional needs and adults living in residential settings.
The Sláintecare approach also means that people should have sufficient access to care from birth and across the full life course to prevent problems before they arise. “This is why starting with our zero to two-year-olds, who can currently only access emergency care, is a priority,” said Smyth. “This is a considerable change. It is based on the evidence identified. The Government will work with the sector to support these developments but the sector must also recognise the shift towards a primary care-based preventative model across the life course.

A key enabler of this transition towards a Sláintecare ethos is ensuring that there is a sufficient number of appropriately trained oral healthcare professionals.

In particular, the country needs to leverage and maximise the contribution of hygienists, dental nurses and other auxiliaries to provide the modernised, prevention-focused care that we are developing to the maximum extent possible.

“This requires changes to our educational and legislative frameworks, which are comprehended in the policy implementation plan in development,” he said. “We need to consider educational models that will enable students to experience providing care in a community setting within our most vulnerable communities.

Smyth argued that there are currently more dentists on the Dental Council’s register “than ever before. We had 3,661 as of 20 May, but many more are needed. There is also a need to increase the number of dental nurses and other auxiliary grades. 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,” said Smyth. “This workforce plan will consider how other dental professionals, such as an expanded role for dental hygienists, can best support the new model of oral healthcare services and how they in turn can be supported with career pathways that support staff retention.”

To support this work, the department is finalising the design of the first oral healthcare workforce census skills assessment. This workforce census will gather information including the proportion of registered oral healthcare professionals who are practising in their registered profession, the services they provide and the skills they have.

The census data will provide information to support the development of the sector and to support workforce planning by identifying the skills that oral healthcare professionals need to provide the new model of service set out in the policy. The department is also examining a mid-level professional grade for oral healthcare.

By reviewing the dental teams, including the auxiliary dental workers’ scope of practice, it is hoped this will create more capacity in the workforce by enabling direct access to the public where appropriate. “Such an approach will ensure that professionals are working to the top of their licences,” said Smyth, “enhance the potential of these roles and expand our workforce capacity and our ability to meet the population’s primary care dental needs. Aligned with Sláintecare’s workforce reforms, introducing a mid-level professional grade is a key priority for the policy.”

The Department of Health is collaborating with the Department of Further and Higher Education, Research, Innovation and Science and the Higher Education Authority and is currently working through a process to identify opportunities to build capacity in the higher education system for dentistry and to support more oral healthcare graduates.

The process is designed to respond swiftly to national skills needs. Expressions of interest were sought from institutions with the capability to expand existing courses or create new ones. This expansion is being considered by the Department of Further and Higher Education, Research, Innovation and Science in the context of the budgetary process. Potential new innovative models of dental education are also being considered, with a focus on primary care.

“[We] will continue the ongoing work to address the access issues affecting current healthcare services and also to progress work on the implementation of the national oral health policy that sets out a body of transformational reforms,” said Smyth.

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Published: 8 July, 2024 at 07:56
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