Dáil Éireann debate -
Wednesday, 22 May 2024

Vol. 1054 No. 5

Dentistry Services: Motion [Private Members]

Deputy Róisín Shortall

I move:

That Dáil Éireann:

acknowledges that access to dental care is in crisis and that urgent action is required by Government to address the many aspects of this crisis;

notes that:

— there are an estimated 104,000 children on a waiting list for the school screening dental service, out of an eligible 208,000 children;

— in the past five years there has been a 31 per cent reduction in children seen by Health Service Executive (HSE) dentists;

— the number of HSE dentists declined by 23 per cent between 2006 and 2022;

— the number of medical card patients seen under the Dental Treatment Service Scheme (DTSS) is down 35 per cent in the past ten years;

— the number of dentists participating in the DTSS has reduced by almost 50 per cent, from 1,600 to 810 in the past ten years;

— of the 810 dentists currently signed up to the DTSS only 600 are active;

— the Minister for Health announced in May 2021 that he would instruct his officials to begin talks on a new scheme as a matter of urgency, but the Irish Dental Association are still waiting for formal talks to begin;

— there is a need to address the overreliance of existing dental schools on non European Economic Area students in order to generate income;

— last year 50 per cent of the 300 students enrolled in our dental schools in Cork and Dublin were from overseas;

— plans to create a new dental school and hospital have been paused by University College Cork due to funding constraints; and

— access to operating theatres for patients who require general anaesthesia has been severely limited since the closure of the general anaesthesia clinic in St. James's Hospital in 2014;

further notes that:

— the National Oral Health Policy, Smile agus Sláinte, was published in 2019;

— one of the key actions in this policy was to bring forward a new Dentists Bill, as the existing legislation is almost 40 years old, however the heads of the Bill have yet to be developed;

— since 2008, the Dental Council has made five submissions to the Department of Health calling for the Dentists Act, 1985 to be replaced;

— recent reporting by RTÉ Investigates uncovered serious patient safety concerns which have eroded public confidence in dentistry;

— this includes 37 dentists who have worked in Ireland despite having been sanctioned in other jurisdictions, and a case of an individual convicted of sexual assault; and

— the Dental Council does not have the appropriate enforcement powers to take action against people practising dentistry while unregistered or to enter or inspect a dental practice; and

calls on the Government to:

— guarantee that all primary school children will receive their three school-based appointments at the appropriate age by 2027;

— urgently strengthen and expand the capacity of public dental services for children and special care patients;

— commit to providing the required funding in Budget 2025 to put the medical card scheme on a sustainable footing;

— immediately begin engagement with the sector to reform the DTSS;

— commit to publishing the heads of the long-promised Dentists Bill by September 2024 to ensure patient safety, the maintenance of professional competence, and to improve the regulatory framework; and

— address funding and capacity issues in dental educational provision in the coming academic year and prioritise comprehensive workforce planning to recruit and retain staff.

It is regrettable that the Minister for Health, Deputy Donnelly, has not turned up in the Dáil to listen to this debate. We have tabled this motion because access to dental care in this country is now in crisis. The current model of care for public dentistry is no longer fit for purpose. It is outdated and impoverished, and it is failing patients. For decades, it has been a Cinderella service, with successive Governments utterly neglecting it. While the current Minister for Health seems marginally more interested in reform than his predecessors, at least in terms of rhetoric, the bar was not high. Even he could hardly defend a record that includes over 100,000 children, or half of the eligible cohort, being denied school screening appointments last year alone.

Data shows that in respect of treatment under the medical card scheme, 150,000 fewer medical card patients received treatment last year than a decade ago. The medical card scheme is haemorrhaging dentists, with over 800 exiting the scheme since 2016. The Dentists Act remains largely unchanged since its enactment almost 40 years ago. By any measure, that is not a record to be proud of. The Minister, like his predecessors, has allowed almost every aspect of the service to spiral into crisis. In 1988, a Department of Health report found that the State's public dental service was failing in its statutory duty. That should give the Minister a moment of pause because 36 years later those words continue to ring true.

Following that damning 1988 report, and growing awareness of oral health inequalities, the dental health action plan was published in 1994. This was the first clear statement of the State’s aims and objectives in respect of dental care. Little did we know that it would be a quarter of a century before a Government would publish another national oral health policy. That came in 2019. In the intervening years, there were undoubtedly improvements in public dental services. For example, in 1994 the dental treatment service scheme, DTSS, for medical card holders was established. However, progress soon stalled. Even by 2002, a report commissioned by the Department described elements of the school scheme as a disgrace. In 2007, the then Minister for Health, Mary Harney, announced the development of a new oral health policy. That was followed by a two-year development process which led to the presentation of a draft plan to the Minister in 2009, but that plan never saw the light of day. It became a casualty of the economic crash and remains unpublished.

Due to this, oral health did not feature in any national health policy documents between 2001 and 2017, other than one mention of community water fluoridation. That was the extent of the interest in dental care. It would be 16 years before it received any further acknowledgment in national policy. That would come in 2017 with the Sláintecare report, which made two recommendations in respect of dental services, namely, to re-instate the pre-crash budget to the DTSS and to develop a universal package of dental care.

However, the following year the Sláintecare implementation strategy only made one passing reference to dentistry in the context of community-based care, and none of the subsequent Sláintecare action plans even mentioned oral healthcare. In 2019, however, the then Minister for Health, Deputy Simon Harris, finally published a new national oral health policy, Smile agus Sláinte. While many of its aspirations were broadly welcome, this document did not set out any roadmap for the practical delivery of its vision. This lack of focus on delivery is deeply concerning, and has led to endless talk about reform without any real reform.

It is also concerning and, quite frankly, bizarre that so little consultation with dentists and their representative body was carried out during the development of this policy. In a position paper published by the Irish Dental Association last month, its president, Dr. Eamon Croke, said that the Government launched its oral health policy "from behind a veil of secrecy, a residency it continues to inhabit". Despite numerous requests from the Irish Dental Association, the Minister and his officials have yet to explain to it how their vision is be enacted. In my view, there is one reason for that - they simply do not have a vision.

Successive Ministers have allowed every aspect of the public dental service to teeter on the edge of collapse, and it seems that the current Minister’s only solution is to outsource the problem. Instead of committing to building the capacity of public dental services, the Minister has suggested outsourcing children’s dental care to the private sector. That is not a solution. Even dentists in private practice do not think it is a good idea. They simply do not have the capacity.

Last month, a survey of Irish Dental Association members found that nine out of ten private dentists believe that the State should prioritise building the HSE dental service over a new scheme. The Minister already has a viable scheme in the existing school screening service; he just needs to prioritise staffing it. The school scheme needs at least 75 more dentists to bring it back to adequate staffing levels. It is also very disingenuous that the Minister consistently lumps dentists and doctors into the same category when citing rising recruitment figures. When we dig into the figures, we find that there are fewer dentists employed by the HSE now than in 2020.

When the spin is removed, it is clear that we are going backwards, not forwards. We now have some children receiving their first dental check-up in fourth year of secondary school, when they should have been seen on three occasions in their primary school years, during second, fourth and sixth classes.

For treatments requiring general anaesthetic, the waiting list is two years. These are serious treatments where a child needs a general anaesthetic and they have to wait two years. The delay in access to general anaesthetic treatment has been a major issue for children and special care patients since the closure of the clinic in St. James's in 2014. A new facility was earmarked for Connolly Hospital Blanchardstown but those plans have not progressed, leaving patients with complex needs languishing on waiting lists.

A complete overhaul of the medical card scheme is required. The Irish Dental Association has called for modernisation, not mere modification. Given what we know about the importance of prevention and retaining as many natural teeth as possible, it is perverse that the medical card scheme places restrictions on preventative treatments such as fillings when there is no restriction on the number of extractions . I could list countless other problems with the current model. Simply put, however, it is a relic of the 1990s and is no longer fit for purpose. The Minister, Deputy Donnelly, admitted that the State has had a blind spot when it comes to oral health. Why has he not done anything to change that? It is time for him to show urgency and act.

Deputy Holly Cairns

Dental services have been collapsing for years. There is no excuse for the complete neglect of the sector when it has been crying out for reform and regulation for decades. Dental services are out of reach for many people. Preventative care, regular check-ups and minor dental services are only available to people who can afford to pay.

There are many failures in the current system but one of the most glaring is the abandonment of the school screening programme. Every child in the State should have a free check-up with a dentist in second, fourth and sixth class. That is not a recommendation; it is a statutory requirement. I received those services in primary school, as did everyone I grew up with, but the scheme has been allowed to crumble to pieces. The number of HSE dentists has dropped by nearly a quarter since 2006. Is it any wonder waiting lists are out of control and children are not receiving the care they need? Only half of all eligible children were seen by a school dentist last year. In some rural areas, the figure was much lower. Almost 80% of school children in Laois-Offaly were denied a school screening last year. Some parts of the country have a backlog of up to ten years, and children are not receiving their first screening until they are in transition year. We need to acknowledge the consequences of these failures. Children who needed preventative care and simple check-ups are living in agony. Some of them cannot even get a public appointment to have a tooth extracted. The wait time for surgery in Cork university dental school and hospital is two years and six months.

There is a particular type of pain that comes with dental issues. We have all experienced it at some point. The idea there are children and adults around the country living with that pain for months and years because they cannot get basic dental care should be a source of shame for the Government. I cannot understand the sheer lack of interest the Minister and Department of Health seem to have in improving dental services. The Minister has not even turned up for this debate.

What little has been done is nothing short of insulting. Some €5 million was allocated in the budget to address the backlog in school screening. However, this money cannot be used to hire more public dentists. How exactly does the Government intend to fix the backlog without hiring more dentists? Is it by further outsourcing to the private sector? That is not working too well for medical card patients under the dental treatment services scheme. There are currently only around 600 private dentists working under the public scheme and some counties do not have a single one.

To make the situation even worse, for 40 years successive Governments have decided not to bother regulating the dental profession. The Dental Council has been pleading with Ministers for years for powers to regulate the conduct and activities of dentists, inspect practices and mandate continual professional development. "RTÉ Investigates" reports have shown how dangerous that lack of regulation is. Thirty-seven dentists who have been sanctioned by regulators abroad are practising in Ireland, one of whom has been convicted of sexual assault and is the subject of another criminal investigation. Serious infection control issues were raised, including a dentist working from a Portakabin, unsterilised instruments and reports of dentists leaving bloodied extracted teeth on a radiator. There have been repeated instances of people who seem to be pretending to be dentists causing damage to people's health and forging the signatures of registered dentists on forms. The clinics these people were based on are apparently still operating because no one has the power to stop them.

The Department of Health has been dragging its feet for too long and it is time the Minister committed to reforming the dental profession. We need basic regulation to ensure patient safety because people have been left completely vulnerable to fraud and malpractice. We need many more public dentists, which means more college places and reform of the dental treatment services scheme. We need to ensure that every child in this State, no matter where they live, receives the dental care they are entitled to.

I asked the Taoiseach yesterday if he would be supporting the Social Democrats' motion today. He said the Government would but I think it is pretty disingenuous to support it and then do absolutely nothing about it. Will the Minister of State outline the short-, medium- and long-term measures that will be taken to address this issue? That would be very helpful.

Deputy Jennifer Whitmore

The Ombudsman for Children has issued a report this week to highlight the many ways in which children are being failed in this country. The report states that children are competing for attention at a time of crisis in many areas. Dental health is one of those areas where children are being forgotten so I want to focus on children in this contribution.

We have 104,000 children on a waiting list for the school screening dental service. There are 4,342 children and special care patients on the public dental surgery lists, hundreds of them in CHOs 6 and 7, which cover my constituency of Wicklow. The impact of this on those tens of thousands of children is enormous, both on their physical and mental health. A further 13,294 patients are on the orthodontics waiting list, 11,000 of whom have been waiting for more than a year. This is extremely worrying when we know one third of children will need orthodontic treatment. The stated cost of private care is €3,500 and, even with the tax rebates, I do not know many families that could cover that, particularly at such an expensive time in families' lives, when they are paying mortgages, back-to-school costs, childcare and the day-to-day expenses that come with having children.

Maintaining good dental health is a huge component of creating a positive self-image for a child. It is not just about that; it is also about their ability to speak and smile, which is fundamental to a child's well-being, as well as being able to chew and swallow efficiently. It is important we get it right in the early days. As with much to do with children, it is all about early intervention. Yet again, we are seeing a failure to deal with that by the Government. Dr. Anne O'Connell, a consultant at Tallaght Hospital, has stated the early loss of primary teeth can have far-reaching implications for the child and necessitate future complex and expensive dental treatment. Even from a cost perspective, it makes sense to see these children earlier rather than allowing problems become deeper and more complex.

The HSE recognises and has given clear recommendations on its website that children should visit the dentist regularly. It states there should be a free dental appointment for all children in certain classes in primary school and for children with special needs.

A follow-up appointment for preventative care or treatment should be available at a child's local HSE clinic. Even children outside of these classes are supposed to be seen by their HSE dental clinic for emergency treatment. The HSE places a large emphasis, looking at its website, on dental health for children but it is not the lived reality for many. Some of the children’s experiences in Wicklow that I have been told about are far removed from the standard set out by the HSE. One parent told me that their daughter will be going into second year in September. She has never been called for a dental appointment. Another told me that they did not even realise there was a public dental health service despite having two children in primary school. One mother told me she had to find the money to get an extraction done through a private system because she was not even able to get that done on a public service. Many children are being failed and the more complex the case the longer the waiting time. Children are being left behind. It is happening on this Government’s watch and it is unacceptable.

I also want to draw attention to another element of our motion, namely the public service for medical card holders. Only this week, I received a letter from an 82-year-old man in my constituency. He was turned away from his local dentist because they said they do not take medical card patients any more. He has been unable to find a dentist that will take him. Surely the most basic interventions should be available for people who need them and who have medical cards. I want the Minister of State to think about what it must be like for that man who has gone seeking help for a basic dental treatment to be told that it is not available to him simply because he is living on a State pension and cannot afford to go private to do it.

There is a decided lack of dignity in how we treat people in this system and particularly for public patients who are meant to be looked after by the HSE. It is probably one of the most blatant and acceptable instances in healthcare where people are told that they are just not wealthy enough and they are not priority for this care. It is rotten and should not be the way – not for our children and not for our retirees. Due to the constant failure of this Government to deliver much-needed public services, we in the Social Democrats continue to need to bring forward motions such as this to try to get people the basics.

Minister of State at the Department of Health (Deputy Colm Burke)

I thank the Deputies for tabling the motion and giving us the opportunity to discuss oral healthcare services, to provide some updates on developments in the sector and to outline the Government’s priorities to fundamentally reform these services over the coming years. I am taking this debate on behalf of the Minister.

To be clear, this Government allocates over €200 million to the provision of oral healthcare every year. This shows our commitment to delivering real change in important areas. Improvements in access to care and in reducing waiting lists over recent years have been supported by significant additional investment since 2020, including an additional €15 million in core funding to support progression of the national oral health policy, Smile agus Sláinte, and a further €17 million in one-off funding to improve access and respond to waiting lists. This investment demonstrates the increased focus placed on improving oral healthcare services. I know that the Minister for Health wants to do much more to improve oral healthcare services and to address the access issues that are still there, through implementation of the national oral health policy.

The salaried HSE public dental service, PDS, provided care to several groups of patients. Last year it provided care to over 155,000 adults and children. Those with additional needs, who cannot receive care in a general dental practice, may need special care services provided by the HSE. The PDS provides these patients with oral health examinations. Where necessary, their treatment is provided using additional supports. This service provides care to many children and adults who would not otherwise have access to oral healthcare services. The HSE public dental service also provides oral examination and treatment identified as necessary for children at three intervals, at ages six to eight years, 11 to 16 years and, subject to capacity, nine to 11 years. These ages align with second, sixth and fourth classes. Emergency care is also provided for children up to 16 years of age and for those with complex and additional needs. The Minister is aware that there are backlogs in the examination programme in particular and that these are leading to delays in children receiving their first appointment. Notwithstanding that, in the first quarter of 2024, the HSE offered oral examination appointments to 13% more sixth class children and 9% more second class children relative to the same period in 2023, and the backlog in sixth class appointments has now been cleared in most areas. However, ultimately children need access to prevention-focused oral healthcare from birth, which points not just to improved access to healthcare services, but the need to align with new evidence which requires changing the service we provide to children and their families across the public and private dental services. This needs to be addressed through implementation of the national oral health policy, which I will speak to shortly.

On orthodontic services, the public oral healthcare services provided by the State includes orthodontic treatment. Increased investment, including an additional €10 million in one-off funding in 2023, has reduced orthodontic waiting lists by 8,700 patients, or 44%, between end-March 2019 and end-December 2023. Last year, more than 2,000 patients were transferred to private care through this funding. A further €3.35 million is being invested this year on a one-off basis to support the continuation of measures to reduce orthodontics waiting lists.

Last year, through the dental treatment services scheme, DTSS, the State provided care to over 283,000 medical card holders over the age of 16. In order to address contractor concerns regarding the DTSS, a range of measures came into effect in May 2022 to introduce and reintroduce elements of preventative care. The Minister for Health also increased the fees paid to contractors for most treatment items by between 40% and 60%. Fees paid to dentists for DTSS care are now aligned with other European countries which provide comparable public dental care, noting that many European countries, especially in the southern and eastern regions, do not have any scheme in place for adults, which is free at point of access. These measures are having an impact, with access to care increasing in 2023 and increasing further again into 2024.

Comparing the claims made by DTSS contractors nationally, in 2023, 154,864 additional treatments were provided under the DTSS, with over 26,700 extra patients treated in comparison with 2022. Activity has continued to increase further into this year. Preliminary data indicates an additional 12,104 patients treated and 43,158 extra treatments provided to compared to 2023.

These are all important measures making a real difference for patients today. In tandem we are also driving fundamental reform of our healthcare services for the future. In 2019 the national oral health policy, Smile agus Sláinte, was published. This Government policy aims to radically transform our current oral healthcare service, recognising that we need an entirely new approach to oral healthcare to meet the needs of our population into the future. The policy was informed by considerable evidence inputs, including support by an oral health policy academic reference group, consultations with key stakeholders, considerable feedback from a number of consultations with front-line workers including dentists and auxiliary dental workers, and a comprehensive qualitative research project.

The policy provides a framework to comprehensively reform oral healthcare services, supported by accompanying reforms to legislation, strategic workforce planning and education and training. Collectively, these reforms will examine the scope of oral healthcare in Ireland, to ensure a focus on basic and essential oral healthcare, provided in a reoriented community-based model of care to ensure our most vulnerable can access the care they need. The State has a responsibility to do this.

This is in line with the WHO's global oral healthcare action plan. For children, the HSE is developing comprehensive prevention-focused oral healthcare packages, starting with the group aged zero to two years. The aim is to support children to attend a local dentist from birth. This represents a significant expansion of care compared with the current model, which centres on three examination appointments starting at the age of seven. This will ensure a greater emphasis on prevention and early intervention for children when required. For adult medical card holders, the HSE is committed to the design and development of packages of expanded preventative care and will consult with the profession this year on the draft design as the first phase of reform of the DTSS.

As we systematically work through the implementation of the policy, we will walk through a public conversation on what oral healthcare is needed in Ireland within the framework set out within the policy, which is, in turn, based on international evidence. This requires a substantial change in dental training and education and an enhanced role for a wider range of dental professionals on the dental team, including nurses and hygienists, in the provision of oral healthcare.

Having been impacted by the pandemic, among other things, progress on the reform envisaged in the policy has been slower than the Minister would like. However, to support a focused and structured implementation of the policy, the Department of Health and the HSE are currently developing a three-year implementation plan for the first phase to guide an acceleration of reforms. This plan will be published in the third quarter of this year, following consultation with the sector.

On legislative reform, the Minister for Health is committed to reviewing the legislation underpinning the regulation of oral healthcare professionals, the Dentists Act 1985. A priority for 2024 is to consider the development of a small number of interim enhancements to the Dentists Act in areas identified as a priority by the Dental Council and to proceed with these where appropriate. This will include provisions enabling the Dental Council to develop a statutory scheme for CPD and competence assurance for registered dentists in line with those provided for other regulated health professionals. These interim measures will progress in tandem with a wider and fundamental reform of the 1985 Act, which must align with the reform envisaged in the oral health policy.

I assure the Deputies that the Minister for Health will continue the ongoing work being delivered by his Department to fundamentally reform the oral healthcare sector through the implementation of the national oral health policy to ensure that patients can access care. The continuing investments made will mean that, through the reforms being enacted, Ireland will have a modernised oral healthcare sector designed to provide the care that patients need when and where they need it.

Deputy Cian O'Callaghan

I thank my colleague Deputy Shortall for her work in bringing forward this motion. It is very disappointing that the Minister for Health is not here and that the second junior Minister who has just come to join this debate is not connected to the Department in any way. The response the Minister of State has just read out does not address many of the fundamental issues we have listed in the motion. It is simply a statement of what is being done now rather than what the Government is going to do to address the very serious issues we are raising. That shows the Government's complete lack of priority for this very important issue.

What is happening in the dental sector is symptomatic of this Government's hands-off approach. We see the same pattern time and again. The Government deregulates or fails to regulate, leaves it to the market, looks the other way and hopes nobody notices. We see it happening in housing, in our healthcare system and in infrastructure. We know the terrible impacts this approach has. Its impacts on the dental sector could not be starker. Some 104,000 children are on the waiting list for the school dental screening service. That is 104,000 children the Minister of State did not mention. There has been a 31% fall in the number of children being seen by public dentists over the course of five years and a 35% fall in the number of medical card patients being seen over the course of ten years. The number of dentists participating in the dental treatment scheme has fallen by 50% over the past ten years.

Much of the calamity in dentistry is a direct result of years of inadequate funding of our universities. Back in 2021, I received an email from a leaving certificate student who was desperate to study dentistry in UCC. She said that she was an extremely diligent student with very high aspirations for herself in the CAO courses she was going for. She wanted to study dentistry in UCC, which was 613 points the year prior, although she noted that, even if you got 613 points, you were not guaranteed a place, which she said was ludicrous. She went on to say that there were simply not enough places, especially given the vitalness of this career. She begged us to ensure there were adequate places in college that year for her sake and for her peers' sake. That worried leaving certificate student watched the points for dentistry rise to 625 that year. It has remained at 625 ever since. There is no space for as much as spelling mistake if you want to enter this essential field, which is in desperate need of dentists.

This example of the leaving certificate student from 2021 paints a picture of everything that is wrong with the Government's hands-off approach to dentistry. Universities are not adequately funded to provide the places we urgently need. This means they rely heavily on overseas students, who pay vast sums to study here in Ireland. These overseas students are much less likely to stay in Ireland after graduation, leaving an ever-growing hole in our workforce. In fact, 50% of the 300 student places in Cork and Dublin now go to overseas students. The same issue of underfunding caused UCC to recently announce a pause on the construction of its new dental school. In May 2022, the Irish Dental Association stated:

The pressure from dental patients will not and cannot be relieved until proper investment is made. We need the Government to intervene in the medical card scheme, public dentist recruitment and the training of dental graduates immediately before we reach crisis levels.

These urgent calls made in 2022 were ignored.

Will the Minister of State guarantee that all primary school children will receive their school-based appointments at the appropriate age by 2027? Will the Government strengthen and expand the capacity of public dental services for children and special care patients? Will it commit to providing the required funding in budget 2025 to put the medical card scheme on a sustainable footing? Will it commit to publishing the heads of the long-promised dentists Bill by September of this year? Will it address funding and capacity issues in dental education provision in the coming academic year? Will the Minister of State listen to the dentists who are working on the front line? Will he act on the issues we have raised in this motion?

Deputy Catherine Murphy

I will read back to the Minister of State one line that he read. He stated:

The HSE public dental service also provides oral examination and treatment identified as necessary for children at three intervals, at ages six to eight years, 11 to 16 years and subject to capacity, nine to 11 years.

Why are we hearing from parents and on the doors that children in certain locations have never seen a dentist at any point in primary school if the Minister of State is saying that service is offered? It is not being offered. To be perfectly honest, it is insulting to people who feel that this public failure is a private cost that he would stand up and say that line. A dad rang me to tell me that he had spent €200 to get his three children checked out. If he had to do that, they must not be on a list. He said his family is struggling to pay the mortgage. I met a woman on a doorstep in Maynooth who said that her child had never seen a dentist in their entire time in primary school. There is no dental service. What is happening with the dental service? It is beyond patchy.

The Government talks about prudence. Prudence is about spending money rather than just collecting it. It is about spending it appropriately to deliver public services. Many of our public services are poverty-stricken. In this service, there is a postcode lottery and long queues. The Minister of State knows that but it is not reflected in the response he has given us. If you can afford to pay, you can bring your child to a private dentist. However, many people cannot do that.

What happens to those children who are not given the opportunity to see a dentist right through their primary care and where preventative action is not taken?

The other thing the Government does with public services like the dental service is to outsource it. It will throw money at the private sector rather than building a comprehensive public dental health service that is available for people at the point of need. That point of needs includes statutory obligations to provide screening for children.

It is impossible for us to deal with constituents when they say there is no screening service for whole areas. That has been happening for years. It is quite obvious that failure has been going on for years and the public is now raising routinely and when we are knocking on the doors this issue of the kind of services that are absent in their areas.

We are a very wealthy country but why are we not capable of putting basic public services in place with that wealth? That is the kind of question which makes people think we are a wealthy country but in many ways it feels like a poor country when it comes to public services. This is one of those public services where that poverty is felt.

If people can pay privately for their children, they will do that because they will not see their children neglected, but there is an awful lot of people who are not in a position to do that. We are also seeing people with medical cards who are not getting routine services. I pick up the point made by my colleague Deputy Shortall, where we are paying for extractions but not for preventative care, which is madness.

The other issue about screening and routine care is that other things are picked up like mouth cancers. If these are not picked up or dealt with, they are much more difficult to deal with for the individual with a late diagnosis. They are also much more expensive for the healthcare system. There is no rationale for not putting together a proper system from very early ages right up and certainly for people who do not have the ability or the funding to deal with issues as they are presented and identified. I have no doubt there are people suffering in pain because of the inadequate provision in this service.

I must say to the Minister of State about his statement that, if I was him, I would go back and haul over the coals whoever gave him that because it is a load of nonsense when he starts saying there is provision when we can clearly say there is not provision. It has been repeatedly raised with us that there is not provision. That is an insult and the Minister of State should not allow that to go past.

Deputy David Cullinane

I thank Deputy Shortall and the Social Democrats for moving the motion in the first instance. I do not know if the authors of the motion received any prior notice that the senior Minister would not be here but it is not acceptable that the Minister is not. There may be a reason for it but I heard the Chair himself raise this issue this morning-----

An Cathaoirleach Gníomhach (Deputy Michael Ring)

It is not good enough.

Deputy David Cullinane

-----with regard to senior Ministers not coming in. Particularly when people are putting forward very substantial motions, the senior Minister should be here. That is what Opposition time is for. Time and again we are seeing it where a junior Minister is sent in and senior Ministers seem to think it is not their role, but it is. It is their job to be here and to answer the questions that are being put.

Looking at all of the issues in this motion, and I have been raising some of these issues myself over recent weeks and months, it is all down to Government failure. The first one is the children who are deemed eligible for school dental screening - more than 200,000 children. Because of failure on the part of the Government to put the capacity into the public system to allow us to have the dentists working in the system to do the screening, half of those children are not getting access to that dental screening. We know that for all of those children who do not get screening, there is a higher risk of poor oral dental care. Their teeth and condition could deteriorate. Even for those who get the screening and it is captured in the public system, we know they are waiting far too long for access to orthodontic care and treatment. It is a clear failure on the part of the Government where 200,000 children are deemed eligible but only half of them are receiving the treatment. The Minister of State must take full responsibility for that because it is on him, it is on the senior Minister and it is on the Government.

On the dental treatment service scheme, and I will be very deliberate when I say this, the collapse of that scheme is an absolute disgrace. There have been countless Dáil motions on this from multiple different political parties in the Opposition time and again calling out the Government on this. If this was in any other area and if it was not for medical card patients, this would be sorted. I believe there is a real class element to this by just allowing people who have a medical card, who need access to dental services, to go without because it involves medical card patients. It is absolutely unacceptable. This has been a problem for far too long and the Minister has not addressed or fixed it. We had the Irish Dental Association appear before the Oireachtas Committee on Health last week and it spelt out again chapter and verse all of the problems that led to the collapse of that scheme. Of course, there is responsibility on dentists as well - of course there is - but there is a bigger responsibility on the Government and it has failed to deal with it. I have seen representatives from my party using Topical Issue Matters and promised legislation time to raise the fact that, in their constituencies, dentists are not signed up to the scheme, the scheme has collapsed, and medical card patients who are registered for the scheme have either to pay for the treatment or to wait longer to get access to very basic dental care. Again, this is a clear Government failure where the senior Minister is not here to answer all of the questions.

The third issue is regulation. How in God's name have we allowed a situation to develop but also to be sustained for so long when we have the regulators calling for more power in this area? I have met members of the Dental Council of Ireland several times and they actually drafted legislation. They did the work for the Minister and for the Government and yet the Government has not moved or delivered on this. We have very serious problems in the registration of dentistry. It has been highlighted time and again. I have seen "RTÉ Investigates" programmes on it, the media have raised it and everybody seems to want to deal with it except the people who can deal with it, the Department, the HSE, but, more importantly, the Government.

All of the failures in this motion today are Government failures, but there are solutions. The first thing you do is lift the recruitment embargo. When the HSE is responding to parliamentary questions from the Opposition saying it cannot recruit dentists other than consultants because of the recruitment embargo, there is nobody else for me to point the finger at than the Minister of State, sitting where he is because the senior Minister is not here. The Government needs to lift that embargo because it is dangerous, counterproductive and it is absolute madness that, at a time of crisis in healthcare, when children, in this instance, cannot get access to dental screening, the Government has a recruitment embargo in place which prevents, blocks and prohibits the HSE from recruiting the staff we need to deal with it. Wake up, do your job and I hope that, when we are putting forward Private Members' motions again on healthcare, the Minister for Health comes in and takes it because it is happening far too often that senior Ministers are not coming in. It is unacceptable.

Deputy Louise O'Reilly

I join my colleague, an Teachta Cullinane, in saying it is very disappointing the senior Minister is not here. This is an important matter, it is Opposition time and it is a time when the Opposition have, or should have, a chance to address senior Ministers directly. It is very disappointing he could not make himself available for this.

I listened with some interest to the Minister of State's speech. I am a fan of fiction so it was possibly not as painful for me as it was for some. However, he has to be living on a different planet to come in here and tell us there is any kind of dental plan at all. As was pointed out, there is a class element to this because if you have the money, you can trot off and purchase dental services, but for my constituents in north county Dublin who do not have the money and who are in need of dental services, if any of them looks up the HSE website, it will say please be advised there are no walk-in dental emergency clinics operating at this time and attendance is by appointment only. The Minister of State knows well that because of the manner in which the Government has systematically decimated the dental services within this State, that preventative care does not happen. It does not happen in our schools or in our communities. Therefore, people get left in a situation whereby every issue turns into an emergency. If you have an emergency and you think of contacting the dental hospital which perhaps might be able to help you, you will see on its website that any patient who requires emergency treatment should in the first instance contact his or her own dentist or, if eligible, the local health board clinic.

People are going from Billy to Jack literally over and over again without getting anyone to treat them. For many people the choice then is a credit union loan and a trip to a private dentist if they can get one. Others must wait until the situation deteriorates to the point where an extraction is required. This is what we hear in my offices in Balbriggan and in Swords. That is what we hear when we are out on the campaign trail. Time and again people tell us that because there is no intervention and no preventative care, people are ending up having to get extractions. The Minister has acknowledged this himself on a number of occasions. Our extraction rates are very high and they should not be. Minister of State, it is not enough just to accept the motion; you should act on the motion.

Deputy Imelda Munster

Public dental services have almost collapsed under this Government's watch. There are two main issues here. Primary school children are not getting vital checks in second, fourth and sixth class. Nearly half of children are not getting their checks. This was around 100,000 children last year and 100,000 children the year before that. Up to one year ago, more than 12,000 children had been waiting for up to three years for dental assessment and treatment in counties Louth and Meath. Such basic preventative healthcare is so important for children. When a child is denied dental screening, they run the risk of not having oral diseases diagnosed and treated or of missing serious orthodontic interventions.

The other main issue is dental care for medical card holders. There are 600 practising dentists under the dental treatment services scheme. This is to cover a population of more than 1 million medical card holders. In 2016, there were 1,600 dentists in the scheme, but for several years now there have been no dentists in Drogheda offering services under the scheme. Do you hear that, Minister of State? There is no dentist in Drogheda, the largest town in Ireland, offering services under the scheme. Constituents are coming to me with serious medical conditions like oral cancer and diabetes who cannot access a dentist. I have been raising this issue for a long time and in that time nothing has improved. There is a shortage of 1,000 dentists in the public scheme in comparison with the 2016 figures.

The HSE has no plans to recruit staff to deal with the problem. The recruitment embargo means it cannot appoint any dental staff other than those at consultant level. The Government has just given up and is not even trying to fix it. Maybe it does not care because many of those affected by this are from low-income households. The Government does not care if people are neglected, left in pain or are struggling to make ends meet to pay for private dentists. Dentists and patients have been getting nothing but lip service since 2021 when the Minister, Deputy Donnelly, started talking about solving the problem. When is the Minister going to get the dental treatment service scheme back up and running and fit for purpose? We need a commitment on this. It is a total farce.

Deputy Rose Conway-Walsh

I thank the Social Democrats for bringing forward this very important motion. As was said, and the Cathaoirleach Gníomhach knows this, for the past number of years we have been highlighting and giving examples of the collapse of the dental care system for medical card holders in Mayo. I am currently dealing with an 80-year-old woman. Two years ago her dentist told her they were no longer taking medical card patients. She had to go somewhere else. For two years she has been trying to find a dentist to take her. The HSE recently confirmed to me there are no dentists taking new patients on medical cards. The best the HSE could do anywhere in Mayo is a waiting list. The 80-year-old woman is from Achill Island. She has been left waiting and hoping for a cancellation. She asks me what is happening. What do I tell her? Now I have to go back and tell her there is an embargo by the Minister on recruitment of staff by the HSE. You could not make it up. I do not know what to tell her. The truth is that Fianna Fáil and Fine Gael have facilitated the collapse of our dental service system for elderly people, for 100,000 children, and for the least well-off in our county and in our country. It is devastating. I am absolutely sick and tired of bringing this issue to the floor of the Dáil and nothing being done about it. I have another case of a 72-year-old.

We are in a situation where we have a Taoiseach who has been Minister for Health and Minister for further and higher education and yet he does not get it with regard to what is happening in the constituencies. We have a surplus of €8.6 billion and we cannot provide a dental service for elderly people, for children and for people who are least well off. It is not good enough and something has to change. This is why people have lost faith in this Government and this is why we need a change of Government, because this Government will not do anything about it.

Deputy Martin Kenny

I thank the Social Democrats for bringing forward this motion. It is an issue in every constituency in the country and it is certainly an issue in my constituency in regard to the school dental service. Parents contact me regularly where their children have gone into sixth class and have never seen a dentist and go on to secondary school without seeing a dentist. This is happening throughout the country. The Minister of State gave a history lesson rather than the facts of the reality. It was the situation that children were seen in second class, fourth class and sixth class. This is no longer happening anywhere. They are very lucky if they are seen once in primary school. In a lot of cases even the provision of emergency services for children needing dental care is very difficult to access. It must be recognised there is a complete failure in this system. The orthodontic services for children who have difficulties that may require orthodontic treatment is also totally backlogged. The Minister of State must recognise that the system is broken. There needs to be an urgent recruitment of additional dentists into the school dentist service immediately.

The other issue is that people with medical cards cannot get a dentist anywhere. I recently had an elderly couple in with me who said they were trying to get a medical card service. We rang around dentists and we looked online. The nearest dentist they could get would mean them having to travel 77 miles, and that would also require a wait. I am sure the Minister of State, like most of us at some stage in our lives, has had a toothache. To suggest you would have to wait maybe a week with that toothache before you would be able to see a dentist is totally outrageous. I have come across people who have a medical card who have had to go to the credit union to borrow money to try to get their teeth situation sorted out. This should not be happening in a so-called developed, modern society and economy that is booming. It simply should not be happening.

We also have many more children in our schools now, including children who have come from Ukraine and other countries. They are also coming into the system. We need to recognise that the only way this will be solved is to lift the embargo, to recruit more dentists and to train more dentists. This situation is bad now but in another three years it is going to get worse.

On the suggestion that the Government will not oppose the motion, as Deputy Whitmore mentioned, the Government keeps doing this when the Opposition brings forward motions on serious issues. It says it will not oppose the motion but it will not do anything else either. That is the problem we have. It is simply unacceptable that the Government continues on this charade that everything is good. It is not. People out there are suffering and the Government needs to step up to the mark, recruit more dentists, and provide services for people across the country.

Deputy Pa Daly

I thank the Social Democrats and Deputy Shortall for bringing this motion. It typifies the lack of attention and lack of care of the Minister that he is not here to address this. If I thought he was away negotiating with the HSE or working on a dental Bill, that would be one thing, but we can be sure that he is not. The state of dental services, particularly for children and the elderly, is a disgrace, and especially in County Kerry with an older and more vulnerable population and a high degree of peripherality, proper services are essential.

I raised the case before of a man who returned from the Netherlands. He had a medical card and he had been many years abroad but he expected that he would receive treatment for some urgent dental care he needed. He could not find a single dentist in the whole of County Kerry to look after him. After spending a few years abroad and returning to his home place, the services were not the same as he would have expected to receive abroad.

Medical card patients have nowhere to turn in County Kerry. No dentist will take them on. One dentist in mid-Kerry who was still taking on medical card patients had to stop because there was an overwhelming demand for his services as he was the only one doing it. This situation requires negotiations with the Irish Dental Association but nothing is being done about it. Dentists are frustrated, families are frustrated and patients are frustrated.

The children's services are appalling for the 21st century. Primary school dental checkups are way behind schedule, and in County Kerry, a child is lucky to be seen by sixth class if at all. For orthodontic services, a child is lucky to be seen by the age of 16, and that is only in situations where the teeth are so bad that the child will be seen.

This problem typifies the lack of attention by the Government.

It starts in the dental colleges, where 50% of the students come from abroad. There are no plans to fund or to increase the number of students passing through the dental schools in Dublin and Cork. The exodus of dentists from the DTSS over the past ten years, amounting to a reduction of 50%, is quite simply due to the fact that reimbursement rates are so low and costs are so high. Dentists are not going to run their practices at a loss. It is not economically viable to do so and it is making a mockery of Smile and Sláinte, the national oral health policy, which is now five years old.

Deputy Patricia Ryan

I, too, am disappointed that the Minister is not here this morning. I thank the Social Democrats for tabling this motion.

An ounce of prevention is worth a tonne of cure, as the old saying goes, especially when it comes to children’s dental health. Even the current Government’s failures are stark. More than 200,000 children are entitled to school dental screening appointments with public dentists but only half got appointments. The numbers include children who missed essential milestone screenings that would identify early signs of disease or more serious orthodontic problems. When these issues are missed, they get worse and require more serious intervention, all for the lack of an ounce of prevention.

Services cannot be offered if there are no staff to provide them. The Government’s recruitment embargo strikes again. Confirmation from the HSE that no additional staff will be appointed while the embargo remains is absolutely unacceptable. All these reasons add up to a huge backlog in screenings and appointments, with the number remaining in the thousands. Even the medical card scheme is floundering. It has lost half its 1,600 dentists since 2016, meaning fewer dentists, fewer appointments and more pressure on patients and parents to pay for private treatment, the alternative to which is leaving their children or themselves in pain. Parents and families are already being crucified by high rents, mortgages and huge cost-of-living pressures. They do not have spare resources to pay for expensive dental scares.

The Government’s relentless drive to privatise basic dental services is punishing those who can least afford them. These people are ordinary families. I will give a real example. I recently submitted a parliamentary question for a constituent whose daughter, who needed urgent orthodontic treatment, was told there was a minimum waiting period of four years but that if her parents could pay for the treatment, they would have it in several months. That is disgraceful. It is a real case of having to put your money where your mouth is, if you have money. A waiting period of four years for a child is not good enough.

At least let us not forget the special needs children who get general anaesthesia for treatment. That service has been severely limited since Saint James’s closed its clinic ten years ago. What is the Government going to do for the affected children? It says it will accept solutions. Well, I am going to give it some: address funding issues, recruit more dentists, strengthen and expand children’s public dental services, engage properly with the sector to reform the DTSS, and, more important, have a change of Government and put in Sinn Féin.

Deputy Duncan Smith

It is understandably disappointing that the Minister is not here. I understand he has a family bereavement and funeral this morning but I hope he gets an opportunity to look back at this debate. I sincerely thank Deputy Shortall and her party for tabling this motion. Not only does it relate to a contemporary, urgent health crisis – one of many – but it is also one to which I feel attached, given my history of dental treatment through the State. From the age of six, I needed emergency dental treatment. In fact, my first-ever trip to the dentist necessitated a raid of my own Communion money to afford it. Not long after, I got captured by the primary school screening system and was looked after by the State dental services from then on, be it in locations from Millmount Health Centre to St. James’s Hospital, where I was discharged a month before my leaving certificate examinations. I received the most comprehensive and, dare I say, socialist treatment. It was the most fantastic dental care for complex dental issues that you could get anywhere, and my family did not have to put their hands in their pockets. There was nothing exceptional about my circumstances except the fact that I had a need. The problem now is that children are not getting the treatment I got as a child more than 35 years ago.

This motion is not calling for something new or aspirational that we have not had before; it is calling for something we used to do quite well but that we have allowed to be run into the ground. It is at a point of such crisis that it feels we are a million miles away from ever getting it back on track. The Government has totally ignored dentistry services. It has ignored the calls not only of the Irish Dental Association but also of the Irish Dental Hygienists' Association, another body that has a good contribution to make in improving dental services in this country.

Some 104,000 children are on a waiting list for the school screening dental service out of an eligible 208,000. This failure is a searing indictment of the Government. Just under four weeks ago, the Minister for Agriculture, Food and the Marine, Deputy Charlie McConalogue, stated the requirement for dental services for young people was a key priority for the Government; however, as with many so-called key Government priorities, it has not been backed up with funding, resources and, most important, action. The reality is that the numbers are going in the wrong direction. In the past five years, we have seen a 31% reduction in the number of children seen by HSE dentists, and, indeed, the number of HSE dentists has declined by 23% between 2006 and 2022. The number of medical card patients seen under the DTSS has reduced by 35% in the past ten years. We are all dealing as best we can, through our advice clinics and constituency offices, with the crisis that is the collapsed DTSS. In the past ten years, the number of dentists participating in the scheme has dropped greatly, almost by 50% or from 1,600 to just over 800. Even more concerning is that of the 810, only 600 are active. How is the Government going to arrest this slide? How is it going to reverse these numbers? It has absolutely no plan to do so. It is long past time for action in this sector.

For a number of years, the Dental Council of Ireland has called for the Government to amend the Dentists Act 1985 to expand the council’s powers to enforce the regulatory code, a call the Irish Dental Association has supported. The 1985 Act is so far out of date and unfit for purpose that its amendment needs to be prioritised by the Government. However, it does not seem like we will see this in the lifetime of the current Government. We need the Government to prioritise increasing the number of dentists and dental hygienists, and that means taking key decisions and reversing the decision to pause new dental schools in Cork and Dublin due to funding concerns. The pausing of these schools equals an acceleration of need and pain for those who need dental care, particularly children. A screening service and the catching of complex and non-complex dental needs early not only save the State money in the long run but also save children a great deal of pain and sometimes stigmatisation and considerable difficulty in what are their formative years.

Since budget day, on 10 October 2023, we have heard story after story about the impact of the Government’s underfunding on our health service and, indeed, our dentistry service. The services are treated as separate. When the Government talks about health service Bills, it wants to talk about acute hospitals and accident and emergency services, and other parts of our health service are seen as ancillary or not even part of the health service at all. Our dentistry service is as integral to our health service as any other aspect, and this is a message the Government needs to take on board.

As with access to GPs, no one should be put off going to the dentist because of the cost. We are in circumstances in which the most vulnerable in society, those with the lowest amount of discretionary funding or zero discretionary funding, are forced into a position in which they must pay out of pocket for emergency dental procedures. That means difficult trips to the credit union or, indeed, family members or friends, if indeed any of the required facilities are available. Many cannot or will not get the money and many will have to live with the pain of toothaches and more complex dental conditions.

It is all well and good for the Government to say it will support this motion; however, as previous Deputies have said, that is just a facility to get the debate over and done with and into the history books so it can move on without taking any action whatsoever on the substantive issue dealt with in this motion or any other motion the Government decides to support in name but not in deed. What we want to know is simple.

Will the Government follow through and guarantee that all primary schoolchildren will receive their three school-based appointments at the appropriate age by the target of 2027? We need the Government urgently to strengthen and expand the capacity of public dental services for children and special care patients and to commit to providing the required funding in budget 2025 to put the medical card scheme on a sustainable footing. We also require the Government to immediately begin engagement with the sector to reform the DTSS and to commit to publishing the heads of the long-promised dentists Bill by September 2024 to ensure patient safety. There are actions the Government can take but I have no faith that it will. I am certainly not taking the Government's so-called support and acceptance of this motion as any kind of shift from the inertia and inaction it has taken towards our dental services.

Deputy Gino Kenny

I commend the Social Democrats on introducing a motion on this important issue. The Minister of State attended a briefing by the Dental Council and the Irish Dental Association at the Joint Committee on Health a number of weeks ago. The picture they portrayed was stark in respect of oral healthcare in Ireland. The reality is that 80% of oral and dental healthcare is privatised. That was not the case 30 years ago. In fact, the opposite was probably the case. We have seen this happen in other parts of our healthcare system.

We have an arbitrary system of routine checks in primary schools. At one stage, perhaps 30 or 40 years ago, school children got two, three or more checks when they were in primary school. Children are now lucky to get one check. That can have a knock-on effect on oral health. When children are not getting any sort of intervention in their primary years, it will have an effect on their oral health in their adult years.

The Irish Dental Association has stated that the medical card scheme is not fit for purpose. It is in a state of disarray. We see these issues throughout industrialised countries. If you are poor and working class, your oral health will be of a lesser standard than somebody who has access to more resources and so forth.

The Dental Council has stated that the legislation, which dates from 1985, is antiquated and needs to be reformed. Its representatives have met five consecutive Ministers for Health to say that the legislation, which was written 40 years ago, is out of date and needs to be completely reformed. That reform is required in respect of dental healthcare. We also need reform of the legislation around guidance and regulation. The Dental Council painted another stark picture of the regulation of dentists in Ireland. Some dentists should not be practising but are doing so because of the lack of regulation. It is important that the legislation from 1985 is reformed to make it fit for purpose for people who are seeking dental healthcare and for society as a whole.

Deputy Paul Murphy

I welcome the motion. The fact the Government is going to allow it to pass and do nothing about it will not change the fact that on the Dáil record, Fianna Fáil and Fine Gael will be named and shamed for their chronic underinvestment in public dentistry. The record will show, without opposition from Fine Gael and Fianna Fáil, that over decades when one party or the other was in power, public dentistry has been allowed to go to rot. It is part of their general neoliberal strategy of privatisation by stealth. They run down the public system so that those who can afford to are forced to pay privately and to hell with those who cannot afford to. We leave such people behind, suffering on waiting lists for years as their teeth rot in their heads and their orthodontic problems get worse. There is an incredible cruelty to this. Thousands of people are left to suffer from recurring toothaches. Teenagers are left with social anxiety because they need braces but cannot get them. It is also penny-wise and pound-foolish. Delayed care is more expensive. In dentistry, as in all other forms of healthcare, prevention is better than cure.

What does it look like on the ground? In Tallaght, the impact of cuts to public dental care has been enormous. In the past, children in Tallaght were able to access public dental services in St. Dominic's but are now forced to travel across the city to Crumlin for every dental appointment. There are long delays in the system, with kids waiting years to be assessed for orthodontic treatment and then spending further years on orthodontic waiting lists. Parents in Tallaght are being forced to fork out up to €5,000 for braces so their children can access treatment in time for it to work. Families are being forced into debt to get their kids the dental care they need. The HSE's own website states that the best age for orthodontic work to begin is 12 to 13 years of age but children are routinely being left on waiting lists until they are in their late teens or 20s.

One Tallaght mother I know had to pay €4,7000 each for her two kids to get braces privately. A third child, now 17, has been on a waiting list for complex orthodontic treatment for more than four years. She was quoted €15,000 to get the treatment she needs done privately. This is utterly unacceptable. The Government must fund public dental services properly. It must recruit hundreds of new public dentists across the country. With €65 billion in Government surpluses expected over the next few years, there is no excuse for failing to provide the public dental services we need.

Deputy Mick Barry

I am glad there is a Minister of State from Cork in the Chamber because I would like to hear a response to the point I wish to make. Medical cardholders are finding it increasingly difficult to access the dental care to which the card entitles them. I know that is the case in Cork and suspect it is the case across the country. Some are being forced to wait a long time for appointments. Others are being told their dentist has left the DTSS and they can now be seen only as private patients. Most dentists who are still in the scheme are not taking any new patients. New medical cardholders are effectively being locked out.

In order to accept medical card patients directly under the DTSS, the participating dentist must have a DTSS panel number. At present, this is available only to an individual and is not available to an organisation. For this reason, the Cork University Dental School and Hospital cannot operate the scheme and accept medical cardholders directly for treatment. In order to provide treatment to a medical cardholder free of charge, the medical cardholder has to be referred to that hospital by the principal dental surgeon in the area. That is required under the service level agreement the hospital signed with the HSE and is primarily for patients who need specialist care, such as oral surgery and orthodontics. In contrast, the hospital is allowed to directly accept fee-paying patients. I believe that medical cardholders need to be able to attend that dental hospital in the same way as they would attend any dentist. The dental hospital should be allowed to operate the DTSS and be remunerated under it. This would very much have to include patients with toothaches and who need urgent primary care. If the Minister needs to intervene to arrange this, he should. I would like the Minister of State present to comment on this proposal. We cannot continue to allow a situation whereby medical cardholders are effectively locked out of the system and fail to receive dental care because they cannot afford to pay for it. This is Ireland in 2024. The Minister of State needs to comment.

Deputy Matt Shanahan

I welcome the motion, which is constructive and timely considering the present challenging trajectory of dental service provision in Ireland. Dental services are a subject that comes up repeatedly in constituency offices around the country. That is no surprise, given our increasing population and the declining investment in State-supported expenditure to dental schemes and care. The headline statistics show that the service is in crisis. Some 104,000 children, of the pool of more than 200,000 who can avail of them, are on a waiting list for school screening dental services. The number of medical card patients seen under the DTSS has declined by 35% in ten years. That is a horror statistic. At the same time, the number of dentists participating in the dental scheme has reduced by almost 50%, down to 810, in the past ten years.

The number of these who are actually practising is down to 600. As each year goes by more and more dentists are withdrawing from the DTSS. Surely this is evidence of a scheme that is not fit for purpose. Beyond all of this we have the issue of the number of dentists who graduate in this country each year. It is only 300 nationally and of these more than half are overseas students. This brings me to another interesting point, which is the issue of the South East Technological University. Dentistry is one of the programmes being bandied about as being possible for SETU. What is at play is lack of any will of Government to invest in providing increased dentistry services.

Among the main calls in the motion is to ensure by 2027 that all primary school children will receive their three school-based appointments at the appropriate age. This does not appear to be an objective that should be too difficult to achieve if the will was there to receive it. We used to be able to do this. The motion also calls for a review of the funding to expand the capacity of public dental services for children and special care patients, as well as for the medical card scheme to be resourced properly. The bones of the problem which the motion seeks to address is support for medical card patients and those who do not have medical cards trying to access private dental services. The motion also calls for the publication of a new dentists Bill by September 2024 to address the capacity issues in dental education and to prioritise comprehensive workforce planning. In other words, it calls for legislation to be published that will put out the roadmap to finally solve our problems with dental services in this country.

All of this assumes the Government has a comprehensive plan and that individual initiatives in the plan can address the limited access to services in a timely manner. Medical card holders are supposed to be able to access the DTSS and many Deputies have told the Minister of State there is ample evidence this is not happening. The treatment benefit scheme, another scheme in the service, is supposed to provide dental care for non-medical card holders if they have sufficient PRSI contributions. Anecdotal evidence suggests that dentists have also avoided providing services under this scheme and this is because of the long delays in getting reimbursed for their costs and their work.

The public dental service is also failing in its remit to provide early oral health assessment for primary schoolchildren and the primary care treatments that arise from this. Many of us are aware of parents whose children have gone into secondary school without being properly attended to under the scheme. It has already been said that many families are suffering significant additional costs in trying to access private care when they are already struggling with the cost-of-living crisis.

The situation for children with significant orthodontic requirements is even worse given the lack of access to qualified people to take on this work and the significant waiting lists. Again, as an elected representative I am constantly approached by people in this situation. It is heart rending to see people waiting years for children to have basic orthodontic treatment and to access the service.

Overall the summary is the business strategy is not working. The 2019 national oral health policy, Smile agus Sláinte, seeks to provide better care access at all levels but with a particular focus on reorienting the provision of public dental services for children away from the public dental clinics and towards the private dental sector. If we are going to do it, can we not get on with it? If we recognise that perhaps in the private sector it is possible to get value for money, then get about engaging with the dentists' representatives and reimburse them properly for their services. This policy would see treatments carried out by private dentists contracted by the HSE. The reason the policy is failing to get traction is that it has been the habitual failure of the Government to understand the costs of running a business. This is what a private dental practice is. It is a business. The logjam is in dealing with bureaucracy and delays in public procurement and reimbursement.

As I have said, there is a history of a lack of real engagement by the Government with national dentistry representatives. We have a capacity and funding issue with respect to national dentistry and orthodontic provision. We have to make steps to address both. It is the job of the Government to ensure these two objectives can be met while delivering value to the taxpayer and service to the citizen. The heads of the new dental Bill need to be published to show how the Government plans to address the continuing dysfunctional performance of our public health dental and orthodontic services.

Debate adjourned.