Smiles all Round?
Oral Health Policy: Despite claim and counterclaim over the Irish Government’s engagement with dentists, the roll-out of the new oral health policy has begun
[ Will Peakin ]
From approval by the Government in March, through its public launch in April, implementation of Ireland’s new national oral health policy, Smile agus Sláinte, is underway. But in the immediate aftermath of its unveiling, the Irish Dental Association (IDA) was quick to cry foul; not only was the policy flawed, the association claimed that it had not been consulted during its development.
“The association represents 2,000 dentists – the overwhelming majority of dentists in practice across all branches of the profession,” said Fintan Hourihan, its chief executive. “The association was not invited to participate and nor was it consulted in a manner any way consistent with the terms of the agreed information and consultation agreement for the HSE [Health Service Executive] and its staff in preparation of the new oral health policy. We only saw its contents for the first time on the date of its publication.”
It is a view that has flummoxed Dr Dympna Kavanagh, Ireland’s Chief Dental Officer (CDO). “We had briefings and engagements with the association,” she said. “On the policy specifically, we met the association in 2018 and 2019, where we gave it a comprehensive briefing of the policy and an overview of the ethos. We then met it again before the policy was launched.”
Kavanagh said that IDA representatives had previously attended a stakeholder day and led some of the roundtable discussions. “We also carried out a year-long structured engagement for dentists and salaried services,” she added. “There were intensive, structured, interviews analysed by the University of Sheffield. Many of those
who participated were Irish Dental Association members.”
Professor Brian O’Connell, vice chair of the policy’s academic reference group, added: “Over the years the association and many other associations have produced much of their own documentation, policy suggestions and recommendations. We considered all of them and one will find a great deal of crossover between the consistent recommendations of bodies such as the Irish Dental Association and what is in the policy. I speak to dentists every day. Their concerns are largely about the implementation of the policy rather than the policy itself. They ask whether there will be enough funding for it, whether the entire policy will be implemented and so on.”
As detailed in News (P11), politicians are at a loss over how the IDA and the Department of Health could hold such diverging views of the consultation process. They have called on the organisations to “re-establish” their relationship. This may, perhaps, come about through the implementation period as outlined by the Chief Dental Officer. “The implementation period is needed to commit actively to engagement on significant and complex issues,” commented Kavanagh. First, she said, a framework is required “to support long-term sustainability” of the policy. A review of undergraduate and graduate education “is a priority”, said Kavanagh, along with the establishment of a system of career-long mentoring. There will also be a focus on “legislative issues”, specifically to update the Dentists Act 1985. “The Department has already begun to discuss the priorities with key agencies, and we are agreeing targets and timescales,” said the CDO.
“Implementation of a transformative policy such as Smile agus Sláinte will present challenges,” she added. “All change is challenging. However, those challenges will present opportunities for the staff in private practice and the public dental service. It is important that implementation is owned by the profession while listening to the voice of the public. To achieve these priorities, we need key leadership roles operationally and in dental schools. Primary care, special care, advanced or specialist care delivery and public health leaders must be in place so that implementation is sustainable and placed where it belongs in the services.”
The Government said its policy is wide-ranging and takes an “intersectoral approach” as well as being consistent with the primary care philosophy of prevention, treatment at the lowest level of complexity and recourse to specialist care where clinically appropriate. It is, a Department of Health official said, the “culmination of a comprehensive programme of research, analysis and consultation over a number of years and, over time, we will update models of care and service delivery that have been with us for 25 years or more”.
The policy is not only aligned with international models of good practice but with the ideals and approach in other healthcare policy areas, such as Sláintecare and Healthy Ireland, added the official. “It is important to say that it does not seek to change all aspects of service delivery overnight,” he cautioned, “but it puts in place the framework for real and substantive change on a phased basis. As with any area of public service provision, implementation will need to be planned and managed in consultation with all interested parties, particularly the dental profession, as well as all those who use and depend on the services.”
About Smile agus Sláinte
It is a comprehensive and evidence-based policy informed by extensive research and consultation, said CDO Kavanagh. Its aim is to better facilitate oral health for everyone and to support continued professional development. The programme is transformative, introducing and managing a series of changes over eight years, said Kavanagh.
“The policy is aligned with other Government policies, including Sláintecare, Healthy Ireland and First 5, which is a whole-of-Government strategy for babies, young children and families, as well as the national strategies on disability and mental health,” she added. “It conforms to the international policies of the WHO and the European Union. The policy embraces the ‘no child is left behind’ principle of First 5 and the education policies.”
Kavanagh continued: “This is the first major oral health policy statement in 25 years and much has changed in Ireland in that period, including the standard of general and oral health, the materials and technology used in dentistry, and the types of services we aim to provide. In developing the policy, we have ensured that it is supported by up-to-date information about the oral health of the population, as well as by appropriate international evidence. A broad range of stakeholders was consulted, including those who use the services and those providing the care.
“Our current oral health system is out of step with other Irish and international health services. There are gaps remaining in routine dental care for the very young and the vulnerable, including people in residential care, people with disabilities and older people.
“Smile agus Sláinte reorients how care is provided in line with Sláintecare so that most dental care is provided in people’s own communities, as close as possible to where they live.
“This is beneficial for service users and allows acute services to focus on more complex care. What is described in Smile agus Sláinte is not a demand-led service. Instead, it enables the Irish public to access services and forge a relationship with their chosen dental practice; we call this their ‘dental home’.”
To support this universal primary care approach, said Kavanagh, a safety net system will identify those who do not or cannot attend their local dentist. This safety net system is part of the surveillance system outlined in the policy and ensures that the most vulnerable children and adults, including those on lower incomes, will be supported and receive the same quality of service as the rest of the population.
The existing public dental service will be stronger, she said. A key service will be to identify, support and deliver care for vulnerable children and adults when it cannot be provided in the local dental practice. The measures set out in the policy will provide professional opportunities for staff in areas such as health promotion, special care services and public health.
Kavanagh identified some of the key policy strategies and proposals. “Water fluoridation is one key reason we have such good oral health in Ireland and will remain a cornerstone of oral health policy.
“Health promotion programmes will be put in place for the whole population and to target the most vulnerable. Most children and eligible adults will be treated in local dental practices and a package for children from birth until the age of 16 will, in a phased way, replace the existing schools programme.
“It is the first time that those under the age of six, teenagers and adults will have lifetime access to preventive treatment such as fissure sealants and fluoride varnishes, as well as access to dietary advice in dental practices.
“The expansion of primary care is proposed from birth until old age, across the whole life course.
“We have focused on improving access for vulnerable groups such as those on low incomes, rural dwellers and people with disabilities. Enabling them to get to local dental practices is key. As I mentioned, the safety net service is essential to ensure that their needs are addressed, and they get comprehensive care.
“We must not forget that we need advanced care and specialist care services, and that includes the concerns around general dental anaesthesia. Monitoring systems will have to be put in place to identify people who are not taking up the services, overall dental needs and the policy’s impact. There must be a full review of dental undergraduate education, in tandem with career-long professional mentoring for dentists.”
A spokesperson for the Dental Health Foundation Ireland said it was “delighted that such a positive step is being taken to improve the oral health of people in Ireland”. Their counterpart at the Dental Council added: “The policy presents a welcome number of opportunities to align the activities of stakeholders on a national basis to promote oral health and protect patients. The strong focus on primary care dentistry is appropriate, as is the focus on prevention and the emphasis on dental professionals working in a team structure.”
Despite the IDA’s issue with the extent of consultation undertaken by the Department of Health, its president, Professor Leo Stassen, commented: “[The policy] will hopefully stimulate constructive and full debate on oral health and that is a good thing. Indeed, the focus on prevention, on screening, the policy’s provisions for building links between oral and general health through a common risk factor approach, its proposals on dental workforce, professional development, on research and on critical evaluation, are all positive.”
But he added: “That very focus on prevention, which we welcome, will not address the significant amount of untreated oral disease that is already present. Patients with dental disease will progressively deteriorate, leading to vast resources being required to try to get them back to a status quo, and putting more pressure on already overstretched secondary care centres.”
Worst case scenario: Millie’s story
What, asks the IDA, will happen to children who elude intervention because their parents don’t bring them to the dentist?
Four-year-old Millie and her eight-year-old brother live with their father who works full time in financial services. He drops them to the crèche at 8 am. The staff there bring Millie and her brother to school and both of the children are collected by their dad from the crèche at 6.30pm. They go home, have dinner and then go to bed. Millie’s mother no longer resides in the family home as the parents separated due to her mother’s mental health issues. Millie’s dad manages to organise the day-to-day schedule during the school term by cooking and supervising. He states that tooth brushing does not always happen. The children sometimes stay with their mother or at the home of their grandmother.
Millie mentions to her dad that she has a sore tooth, but it is not until her face is slightly swollen and the crèche staff remind him that her dad organises a dental appointment.
As things stand, he takes time from school to bring Millie to the emergency dentist at the HSE. It is noticed there that Millie has a reasonably high rate of decay in her baby teeth and has an abscess in one of her molars.
In that situation, the HSE staff would refer Millie to a general anaesthetic extraction service, having managed the symptoms with an antibiotic. Her social circumstances are noted on the dental records and she is registered as having a reasonably high risk of future decay.
The HSE staff record that Millie and her brother will need to have a good reminder system in place. The children are placed on recall to enable support to be given to them and Millie and her brother will be targeted at intervals throughout their school years. They will also have continuous access to emergency care.
The HSE staff will arrange with the children’s dad to liaise with the crèche workers to bring in Millie for dental appointments to enable her to continue her dental care.
As outlined in this new policy, in a future version of this same scenario, while Millie will have access to care bundles, it is uncertain how support will be given to her dad to remind him of the importance of the child’s dental health. It is unclear if the children can be registered as being at risk due to the mother’s mental health issues. It is also unclear how any symptoms can be managed while Millie waits for her general anaesthetic extraction appointment.
In this new scenario, after Millie has her tooth taken out, her dad may wait until she has another toothache before bringing her to the dentist again. Millie relies on her dad to recognise the early signs of dental decay, and it is uncertain if there is any safety net for children within the new proposed structures. It is also uncertain how the new arrangements will interact with Tusla, the child and family agency.
The system in place identifies, manages and arranges treatment and referral where necessary. It also allows what presents to be recorded and a plan to be set out for the future. That is how the public service is set up. The difficulty is that the public service has been run down, with an insufficient number of dentists in place. With the best will in the world, those resources are not available in general practice and those systems of recording information, arranging care and treatment and referrals and follow-up are not in place.
We have no confidence that what is outlined in this strategy document suggests that is something that can be provided in the near future.
Real-world case; names have been changed.
Source: Irish Dental Association evidence to the Oireachtas Joint Committee on Health, 15 May 2019.