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Dáil Éireann debate -
Tuesday, 25 Apr 1978

Vol. 305 No. 9

Private Members' Business. - Dental Health Services: Motion.

I move:

That Dáil Éireann, noting the present inadequacy of our dental health services, calls on the Minister for Health and Social Welfare to introduce, as a matter of urgency, a new improved service that will (a) provide immediate free dental care for all school children (b) eliminate the present abnormally long waiting lists for treatment (c) introduce a choice of dentist scheme for medical card holders; and for this purpose to undertake a massive recruitment drive of dental surgeons, as well as initiating a programme for the training and utilisation of dental auxiliaries in a national dental service.

I know that the Minister has an important engagement tonight and I appreciate the courtesy he extended to me by informing me about it and by saying that he would pay particular attention to the points I am raising on this issue. The motion I tabled says:

That Dáil Éireann, noting the present inadequacy of our dental health services calls on the Minister for Health and Social Welfare to introduce, as a matter of urgency, a new improved service that will (a) provide immediate free dental care for all school children (b) eliminate the present abnormally long waiting lists for treatment (c) introduce a choice of dentist scheme for medical card holders; and for this purpose to undertake a massive recruitment drive of dental surgeons, as well as initiating a programme for the training and utilisation of dental auxiliaries in a national dental service.

The Minister in his wisdom thought fit to amend this for reasons which I find it difficult to understand or to accept and he asks that all words after "Dáil Éireann" be deleted and he substitutes the following:

"accepts that it is the intention of the Minister for Health to undertake a comprehensive review of the public dental services and to embark on a programme to remedy such deficiencies as that review may bring to light, and is satisfied that the Minister will implement necessary improvements as soon as circumstances permit".

I should like to explain briefly my reasons for bringing this motion before the House and what I hope to accomplish in the three hours we have at our disposal for it. I brought the motion before the House because of the abysmal state of dental health in Ireland and the failure of successive Governments to make proper dental care a priority in our health services. The result has been a history of neglect which has left this nation with a collection of the worst teeth in Europe and a standard of dental care which, in the words of the chief radiologist of the Dublin Dental Hospital, is comparable to that prevailing in Europe in the middle of the 19th century. So, we have a nation full of dead teeth and a dental service that in the opinion of experts is 125 years behind the times. My purpose in putting down the motion is to highlight in detail the facts and the statistics which will give us all a clear picture of the dimensions of our failure in this area and hopefully lift the lid off the complacency in Government and among the general public that has allowed dental disease to assume epidemic proportions in our community. We have tolerated a dental epidemic over the years.

In many ways I view this debate in a much wider context than a merely political debate confined to this House; I view it as a means of awakening the general public to the high incidence of dental disease and the low standards of care which they have tolerated for so long. I believe those in the dental profession and those in this House demanding a massively improved dental service cannot succeed unless public opinion is rallied in support, unless the public recognise the size of the problem and demand action. I believe we will be unable to bring the dental service into the 20th century in terms of quality without public clamour and outcry and active public support for change in it. We know that public interest in it does not exist at the moment; we can see that in the massive figures for those who never go near dentists and have little appreciation of the importance of dental health.

I should like to make clear that I do not intend to make this a party political issue in the narrow, petty sense of the word. I recognise that the history of neglected dental care is not the sole responsibility of any one Minister past or present. The present Minister inherits a tremendous problem and so faces a tremendous task. I hope these two nights of debate will make his task easier, not more difficult, by highlighting for the public the scope of the problem and by putting forward concrete, constructive proposals for action. I hope the Minister will approach the problem in the same light.

Too often the precedent invoked in Private Members' Time is that the Government introduce their own amendment and oppose a motion merely because it emanates from the Opposition. I think this implies that the Minister and the Department have a monopoly of wisdom. I hope that in time we may change that attitude on this matter and I regret that the Minister's amendment is perhaps rather negative in not seeing the purpose of the motion and the intention on my part to have the matter debated so that we might realise the immensity of the problem and see how we can tackle it.

I have placed a positive and constructive motion here and I had hoped the Minister would accept all that is embodied in it, most of which he should accept and some of which he must accept. However, he has responded with a curious and in some ways paradoxical amendment which states that he intends to undertake a review. I wonder about that. It seems to imply that the problems and deficiencies are not apparent, that they are not there or certainly are not obvious but rather must be sought out and discovered. The amendment says that the Minister will embark on a programme to remedy such deficiencies as that review may bring to light. That phrasing suggests the strength of the interpretation that these deficiencies are lurking somewhere in the dark and must be brought to light for us to see. The amendment goes on to say in a confusing and paradoxical way that the Minister will implement necessary improvements as soon as circumstances permit. That seems to acknowledge that deficiencies already exist and are apparent but that time is needed to put them right in which case I and many others may ask: Why do we need such a comprehensive review of the problem? Why do we need a review of a health epidemic that has been staring us in the face for the past 30 years? With due respect to the Minister—I do not think this was his own phrasing—the amendment is confused if not self-contradictory.

If the Minister's main contribution to the debate is to propose this comprehensive review I hope he will be specific about it, say what the terms of reference will be, who will undertake it and if there will be consumer representatives. Will there be a latest date by which they will report? If we can be specific about all this we may achieve something by this debate. There is an ignoble tradition in the Department of Health of sweeping difficult problems and decisions under the carpet of "a comprehensive review". We have work groups and task forces and so on and this has almost reached an absurd stage. I do not mean to be critical of the Minister but I want to caution him against needless delay in tackling these problems because in my honest opinion I do not think this review is necessary. In fact, I intend to give the Minister a comprehensive review this evening, the facts and figures of the neglect of dental care in Ireland, and to propose remedies. It is not such a subtle, complicated problem; it is as blatant as any other health epidemic. What will be required after this debate is not a comprehensive review but actual specific decisions by the Minister which he will have to implement and policies which we shall discuss and on which I think we can agree.

A comprehensive review of our dental services was undertaken by Professor Kaim-Caudle in 1969 on behalf of the National Economic and Social Council. The situation he outlined still exists today, a dreadful population-dentist ratio, advanced dental disease in the population, particularly and most ominously among children, insufficient dental preventive measures, gross regional inequalities in dental services available and restrictive laws inhibiting the use of dental auxiliaries as well as a crying need for a new Dental Act. He also emphasised the overall low priority in terms of Government expenditure accorded to dental health. At the time of the report he said that judging from surveys in the late sixties the situation had not improved from the fifties and it only remains for us to update his study with recent figures. This I have done through parliamentary questions and other means in the past few months. The facts that emerge show that the situation has not improved since the late sixties when he issued this report with the exception of fluoridation of the water. His comprehensive review and his recommendations are as relevant as they were when he issued them in the sixties.

Let us look at these statistics of failure in dental health and services. Over 50 per cent of our population have gum disease and this insidious process attacks the tissues of the gum surrounding the teeth and makes future loss of teeth inevitable. It results in significant costs for our dental services. As well as that, 127,000 of our people suffer from trench mouth. An even more appalling figure is that two-thirds of our people over the age of 40 have no teeth of their own and a high proportion of the remainder are heading in that direction. What better witness have we of the history of neglect of dental health?

There are 1.4 million people eligible for free dental care and there are only 222 full-time dentists providing that care. The ratio is one dentist per 6,300 eligible patients in the public dental service. What does that mean? It is over three times the ratio recommended by the WHO. They recommend one dentist per 2,000 of the population. This is a terrible indictment of our service. In the public sector alone there is a serious shortfall of nearly 400 dentists. With 888 dentists currently registered the shortfall in the country at large is at least 700.

The situation is as bad when one looks at the delivery of dental care to those eligible. Only 10 per cent of the adults and 40 per cent of the children entitled to free dental care actually receive it. I will admit that this is in great measure due to public apathy about dental health, but the fact that the service is so inadequate is a serious disincentive to public dental health. For those who are seeking it, the waiting lists are appallingly long.

According to figures from the Department of Health in reply to a parliamentary question, on 1 August last year there were over 24,000 children covered by medical cards awaiting dental treatment and the average waiting period for these children, who are entitled by law to this treatment, was 9.9 months. The situation for adults is not any better. Over 27,000 adults covered by the medical card were waiting an average of 10.9 months for treatment. These appalling waiting lists are adding to the tremendous cost. The whole policy and rationale of preventive treatment is such that early attention is essential. These long waiting lists are inexcusable. If the answer is that we have not the money, then it is false economics. Costs in later years will be enormous and these costs could be avoided now, or drastically reduced, through preventive care. We are not solving the problem by extending the waiting lists; we are adding to future costs.

There is also the matter of the paper entitlements, paper social rights which, in my capacity as Labour spokesman, I am constantly talking about. Actual rights and rights on paper are completely different. It is fine to say that the medical card entitles one to free dental treatment but it is hypocrisy to make such a statement without providing adequate funds to provide that care.

In 1977 we provided a miserly 1.2 per cent of total health expenditure for the dental services, £3.9 million out of a total of £350 million. The Minister this year raised that sum to £4.2 million and one could claim that this is an increase of 12 per cent. Percentages can be extremely misleading. As a percentage of total health expenditure, the percentage devoted to dental care this year has actually dropped. Last year it was 1.2 per cent and this year it is 1.1 per cent. That is significant. It means that dental care has assumed less priority this year than last year.

The attitude of the Department of Health to a proper dental service must be highlighted. Let us consider, for example, the school health examination programme in child welfare clinics. According to the Health Act free dental treatment is available to children for defects noted at these sessions. The Minister replied to a question of mine regarding the frequency of school health examinations in primary schools. He said that it is the policy of his Department to provide a full, comprehensive medical examination for each child towards the end of his first year at primary school and selective examinations for older school-going children. He went on to say that it is considered desirable that schools with over 50 pupils should be visited each year and smaller schools should be visited at least every two years. The phrase "considered desirable" is a bureaucratic euphemism used by the Department to say that this is their policy but they should not be expected to fulfil it.

When I asked a question requesting information on the proportion of all primary school children who have received examinations and treatment under the scheme and how often these examinations have taken place for each child. I was told that the information could not be extracted by the Department from the health boards. The Department are not doing their job at all. How do we know the scheme is working if we cannot get the figures? How do we know that all our primary school children are receiving examinations and treatments at least once a year? How do we know that we have even a semblance of a preventive dental scheme, the minimum requirement of which is at least one examination per year?

I did not receive any details about the number of children examined in the child welfare clinics and the frequency of these examinations. As far as I can judge, they were feeble and ineffective efforts. The only information I was able to extract from these stingy mandarins in the Department was that out of a total of 600,000 pre-school and national school children only 46 per cent received a dental examination under these programmes in 1976. There are 320,000 eligible school children who did not receive any dental examination at all in 1976. This is irrefutable evidence that the Department's policy of a visit to every school on an annual basis is not being fulfilled. It is pie in the sky to say otherwise. The other problem is the examination of children at secondary school level. This is virtually non-existent. This is a crucially important period when attitudes are being formed towards dental hygiene and regular check-ups are still of major importance. I have received many complaints about this total neglect of dental care at secondary school level.

I recently received a letter from Oughterard in County Galway stating that from Cleggan to Galway, a distance of 56 miles, there is not a single dentist. If a child gets a toothache in Oughterard he goes on a waiting list for a busy Galway dentist. This is our country and there are people in Cleggan and Oughterard. It is important that we pay attention to their needs. The letter states that delays of up to three weeks are not unusual and pain must be endured because there is no dentist within 56 miles. The child has to endure the pain and then, on the appropriate day, having waited for a private dentist, the child is taken to Galway and misses school. It may require several such appointments. Transport is an additional expense. The situation is archaic and incredible in 1978. These people count themselves fortunate because they do not live as far away as Cleggan. Surely it is not unreasonable to demand at least a part-time dental service in this huge area. It is not being provided.

All school children should be eligible and receive free and regular dental care. This is the first proposal in my motion. The school examination programme fails to reach 54 per cent of pre-school and national school children presently eligible, and merely extending it to secondary school level will mean extending an almost negligible service to the point of exhaustion. The service must be completely rehabilitated. There must be a significant influx of staff. I shall deal with staff later. The only point I wish to make here is the failure of the preventive dental care programme which fails to reach the majority of those children most at risk. Even if a dental health officer visits the national school the onus is on the parents to follow up a recommendation to visit the dental clinic. In too many cases this visit never takes place. I do not say it is wholly the State's responsibility to care for the nation's teeth. The parents also have an obligation and in many cases they are not living up to their responsibility. The long waiting list is a disincentive to them.

With regard to the facilities for dental education the President of the Irish Dental Association has gone on record as saying that a serious shortage of dental teachers is inevitable in view of the present unsatisfactory dental hospital facilities. The staff of the Dental Hospital went on strike fighting for a feasible career structure. About 60 dentists qualify each year but, because of the total lack of post-graduate training facilities and consultancy training, emigration amongst dentists since 1969 has been as high as 60 per cent. Six out of every ten who qualify go abroad. The Minister must realise that this is a very serious situation. We train these people and other countries reap the benefits of that training.

The Dental Hospital in Dublin, the major training ground, is incredibly outdated. I will not accept that this hospital should be the responsibility of the Minister for Education. It should be the responsibility of the Minister for Health and there should be close liaison between the two where dental health is concerned. The Dental Hospital was built in the last century to accommodate 15 students. It now caters for five times that number. It has a permanent staff of 11. Compare that with the veterinary college. It has half the number of students and over 100 permanent staff. Bearing those statistics in mind I would not be too bold in asking what our priorities are. It is absolutely wrong to allow that situation to continue. The chief consultant in the Dental Hospital in Dublin said the Dental Hospital in Cork was outmoded even in the 1950s. He also said that top priority for a dental service must be providing proper dental hospitals. There must be consultants within reach of the people, and dental hospitals without consultants are useless.

We can provide these facilities. A new teaching hospital has been in the planning stage for 20 years. We had this division of ministerial responsibility, and the Minister for Education finally decided that the new facility would be on the James's Hospital site. Planning for this is proceeding at a snail's pace. Unless space and staff are provided there is no good in our talking about dental auxiliaries. It takes two years to train them. The EEC directives provide for 18 months after the finalisation in autumn for a new dental Act and, therefore, any new dental Act will not come at the initiative of the Minister. That new Act must be passed by order of the EEC within 18 months after next autumn and, if we are to fulfil our obligations under the EEC directive to provide auxiliaries, we should be starting now making elaborate plans for their training. This is where the Minister for Health should be stepping in with plans to provide the space and staff in the new dental hospital for the training of these auxiliaries. I ask him to look at this aspect urgently.

The Dublin Dental Hospital does not provide any care for the mentally and physically handicapped. This is a scandalous situation. It is another indication of the utter contempt in which these citizens are held by the State, the least advantaged in our society, who need expert care and for whom no attempt of any kind is made to provide that care. It is relegated. It is not the responsibility of the Department and so the Department do nothing about it. I raised this on previous occasions.

In regard to emergency dental care, I asked a question about the emergency service available on a 24-hour basis all the year round in the Dublin Dental Hospital. The Minister said the emergency service was available from 9.00 to 5.00 on weekdays and 9.00 to 12.30 on Saturdays. No one could call that an emergency service. There were loads of complaints from people over the Christmas. These people could not afford the services of private dentists but they needed emergency dental care. There is no such thing as emergency dental services, and if one is unlucky enough to need emergency dental treatment after hours or over a holiday period then it is just one's tough luck.

There are gross regional inequalities. Within a 56-mile radius of Galway there is no dentist. The ratio of prospective patients to dentist in Donegal is 11,000 : 1. There are three times as many dentists in Dublin as there are in Connacht and the three northern counties. We must provide some incentives so that dental surgeons will work in these isolated areas where the rate of patient population to dentist is excessively high.

The biggest area of failure is in the field of dental health education. With only 20 per cent of those entitled to free dental care availing of the service I do not think I exaggerate when I say the Government are getting things on the cheap. They are providing a poor service because the majority entitled to it are not claiming their rights. I am beginning to believe that there is a conspiracy in the Department to stop people knowing their rights. That is very obvious. The Department makes no effort to let the other 80 per cent know their entitlements, because that would cost too much. The entitlements are there but the Department keeps quiet about them. I believe there are those who will be annoyed at my highlighting this fact. It is typical, of course, of the inward approach of the Department. It will not let people know their entitlements. This is painfully obvious in all aspects of health. It is in the interests of the Department not to let people know because, if they know, demand will increase.

I am suspicious of the policy of the Department in the field of health education. The Minister talked about a comprehensive review to bring deficiencies to light. The deficiencies are glaring and we would want to be blind not to see them. A review is quite unnecessary. I would hope now for constructive, specific and concrete proposals designed to improve the service. Eligibility must be extended to all school children under 16 years of age. If we provide the care at an early age we will cause less hardship to people and less cost to the State. There is no other domain of health care where the benefits of preventive care, both personal and financial, are so obvious. The Minister is a great exponent of preventive medicine. This has been the underlying theme of his ministerial responsibility to date. That is why I put this proposal in my motion. I do not think it is asking for much. It is practical and realisable and I am asking that he consider it. I know there are financial constraints on him and that he cannot provide everything. I know the difficulties he has in establishing his priorities, that more money here means less money elsewhere. What I am asking for is an extension of eligibility to start with for all children to secondary school age. I think it is realistic and feasible and the benefits would definitely far outweigh the cost to the State.

The second feature of my motion relates to the need to eliminate this diabolical waiting list for medical card patients. With 50,000 people waiting a minimum of one year to receive the dental care to which they are entitled, we have an emergency situation which must be rectified immediately if our system of health entitlements is to hold any credibility. I am asking for a choice of dentist scheme for medical card holders. I believe this would be a rational and progressive reform in the service. It is a disgrace that thousands upon thousands wait a year, in many cases longer, because a filling that is delayed for a year becomes an extraction, which is more costly and of greater distress to the people concerned. At the same time private dentists are crying out for work. As the choice of doctor scheme has proved to be adequate and is working efficiently, there is an obligation on the State to provide a similar scheme for medical card holders. If the State provided such a scheme the waiting list would be eliminated almost overnight.

The main proposal in my motion, the one upon which all the others depend, is to call for a massive recruitment of dental surgeons and the training and utilisation of auxiliaries in the national dental service. The shortage of dental surgeons in the public health service is almost 400, yet we have only recruited 40 dentists in the last four years. If we are to continue at that pace we will be waiting 40 years to bring the number of dentists up to the required figure. What we must seriously consider is the question of dental auxiliaries. They not only could clear the waiting list for treatment but would also reduce the number of dental surgeons necessary to bring the public dental service up to acceptable minimum standards.

There is much confusion over the terminology of what constitutes a dental auxiliary, but there is no need to go into the details of it. The main point is that it involves a two-year course and it is embodied in legislation in other countries. Call them what you like, dental hygienists, school nurses and so on, these people could provide fundamental dental care under the supervision of qualified dental surgeons. This is a recommendation of Professor Kaim-Caudle and it is one that we should seriously consider at present. The only way we can conquer the problem is to recruit and train people who could undertake work after a two-year course and thus relieve dentists of normal routine work.

The Deputy has five minutes left.

If we could recruit these people and commence the course immediately we would have a number of dental auxiliaries to provide the necessary care and thus relieve the waiting list immediately.

Another important aspect of the matter, which is not included in my motion, is that so many of those who qualify each year go abroad. It is our entitlement as a State to ask new dental surgeons to contribute one year's service to the State. After all, dental education is as highly subsidised by the State as medical education, and we should ask them to provide a compulsory year in the public dental service. In this way we would have an extra 60 dental surgeons each year, which would immediately relieve this tremendous problem.

The Director of the Experimental Dental Care Project at the London Hospital Medical College, Professor Harry Alfred, conducted exhaustive and complex studies into the efficacy and efficiency of different methods of providing dental care. He concluded that the least expensive and most productive dental care schemes were those which included operating dental auxiliaries to carry out the drilling and filling of teeth in addition to other duties. We should pay particular attention to him and forget about undertaking a review. The information is all there and I think we should do it.

Forty-five countries have already embodied in their legislation the question of allowing dental auxiliaries to work and I am positive that the dental profession would not object to it. There is only one dental Act, the 1928 Act, and it is time we had a new one. The profession is demanding it. If the Minister is willing to enter into full consultation with the profession on these problems, I am sure arrangements can be made to solve the problem. Consultation there must be, and it should be done without fail and immediately.

Another matter which should be considered is the fees being paid to dental surgeons in the social welfare scheme. There are no fees being paid to dental surgeons for dental examinations. A full examination is necessary. If we are going to have proper primary dental preventive care we should provide fees for examinations. The lack of dental examinations is responsible for spreading gum disease, so I think there should be regular examinations and that they should be paid for.

Doctor Mageen, Director of Dental Caries and Fluoride Studies at UCC, said that the EEC subsidy on milk should be used for fluoridation programmes and that milk is the most economic vehicle for providing fluoride for those children who do not have access to piped fluoridated water. We should seriously consider this matter and aim at providing milk for them. We know that the EEC could provide half the cost of such a scheme.

Another area is dental care for pregnant women. It is a crucial priority for the dental health of ourselves as well as that of our children. All pregnant women should be eligible for free dental care which should continue for a full year after the birth of the child. There should be communication between the medical and dental professions in regard to these things.

I would like to add my voice to that of the Irish Dental Association in calling for Ireland to join the world teeth survey which is presently being undertaken by WHO in conjunction with the American public health service. Such a review should be in addition to our own plan of action. We know the problem. Fifty per cent of our population has gum disease; two-thirds have not their own teeth; only 20 per cent of those who are entitled to dental care actually avail of it; there is only one dentist to 6,300 eligible persons in our public health service; only 1 per cent of our total health expenditure goes towards the dental service; we have 50,000 people on the waiting list for treatment under the medical card. These are the starting facts, and I am asking the Minister to forget his reviews and to start talking about taking action. A genuine school visiting programme based on a dental health team, utilising dental auxiliaries, is necessary. A new dental Act is urgent and there should be a compulsory one-year service for newly qualified dentists. These are constructive and specific ways in which to overcome the backlog and bring our dental service up to the standards available elsewhere. This is the only way we can do it. There is no point in sweeping our problems under the carpet and having a review, which the Minister suggests. I hope the House will support me in what I call for.

I move the following amendment:

To delete all words after "Dáil Éireann" and substitute the following:

"accepts that it is the intention of the Minister for Health to undertake a comprehensive review of the public dental services and to embark on a programme to remedy such deficiencies as that review may bring to light, and is satisfied that the Minister will implement necessary improvements as soon as circumstances permit".

There are few Deputies who would take issue with Deputy O'Connell in the matters to which he has referred. For my own part, allowing for the characteristic mild exaggeration or hyperbole in which we indulge, I would accept that the case which he has made would be more or less in accordance with that which I find, and presently I shall be adding one or two categories to those which have been mentioned by him as areas that should qualify for early consideration in the review which the Minister has proposed.

No Deputy in the House is unaware of the many deficiencies in the public dental service. This is not of recent date. The service gives rise to a considerable volume of representations in virtually every constituency. I have no doubt the Minister receives an equally substantial volume of these complaints. The volume of complaints reflecting the inadequacies in the service varies greatly from region to region. This regional variation is easily explained and is related to the key problem of the provision of dental services. This is a topic to which I will return later.

The sense of dissatisfaction with the service is widespread. The Minister said in this House that he is not satisfied with the existing dental service and that he is anxious to proceed with the implementation of a comprehensive programme for dental health. Thanks to the development of clinical expertise, a wide variety of procedures is available to the modern dentist— to enable him to provide a better service for his patients. Conservative procedures, however, still play a predominant part in the public dental service here as elsewhere.

In practice, the objective of most public dental services is to achieve a state of dental fitness which enables a person first, to deal effectively with his usual diet and, secondly, to speak in comfort and articulately. Strategic planning of the service in Ireland must be based on these objectives. Under the Health Act, 1970, the regional health boards are obliged to provide dental treatment for those with full eligibility, that is, to medical card holders and their dependants, pupils in national schools, and all pre-school children under the child health services.

This service is provided by a dedicated number of public dental officers. Every effort is being made by the boards—and they are encouraged by the Minister to do so—to provide first class clinical facilities for their dental patients. However, as I mentioned earlier, the service is not without its difficulties and the unfortunate delays which occur in the provision of the service in no way reflect upon the ability and diligence of the staffs of the health boards.

Here I propose to treat with a category who are deserving of our immediate attention especially in connection with the review. In identifying this category I am mentioning those who, because of pressure of time, were overlooked by Deputy O'Connell. I refer to a number of young boys and girls in my constituency and in other constituencies who are in need of orthodontic treatment. It may be said that what is in question here is cosmetic. I do not entirely accept that having regard to my earlier premise referring to diet, ability to articulate and comfort in utterance.

We could add a third consideration especially in respect of young girls. It is one of the tragedies of our time that we see girls on Sunday at Mass or in other places where young children congregate, girls aged 14, 15, 16 or 17 years, whose teeth have not been attended to. If they had been attended to at the appropriate time, if they had not escaped the net, if they had been encompassed in the net, they could look forward to spending the rest of their days with an attractive set of teeth. Unfortunately, they now have teeth which are prominent or which do not function properly, and which are not as attractive as they might have been because they did not enjoy the service which is available in Ireland but not to the extent and not with the range which would cover all.

We should all be ready to accept that improvements have occurred. Of late—I will not say whether in the past nine months of the past year—there has been some improvement, but we cannot be happy that all children in need of the service will enjoy it. The fact that children leave primary school and go on to post-primary education does not mean they will be deprived of the service. But, unless they are detected at primary level, the service will be denied to them. That is not in accordance with justice and I hope that, in the review, the special position of those children will be noted and they will get priority treatment.

When discussing public dental services we must bear in mind that an extensive dental benefit scheme is available to insured persons who meet the contribution conditions laid down by the Department of Social Welfare. Over 800,000 people are entitled to this service. Many of them would be relying otherwise on the health boards for the provision of dental treatment.

I now propose to introduce my second category. I am sure Deputy O'Connell and Deputy Boland will accept that the category to whom I refer are in need of special consideration. I refer not to medical card holders and not to persons covered by insurance contributions, but to the person called the middle-class housewife, the lady who in her middle-forties finds herself with four, five, six, seven or eight young children, most of whom are in need of dental treatment, and some of whom will get it only if it can be paid for privately. The income in the house is such that surplus money is not available. The good mother finds herself now in the appalling position that she must in the matter of dental care decide between herself and her offspring. It is very poor acknowledgement of mothers. Their contribution invariably is lauded by all, and having regard to the special position of the family in our Constitution, mothers must make that decision. I hope that the review that will take place will have special regard to the position of those mothers and that we will not have that situation very much longer.

I do not have to remind the House that private dental treatment is not the cheapest available. When talking about mothers in the matter of payment of fees in question we cannot forget the fathers and husbands, but the special position of the lady has been overlooked. I know that having been reminded, if reminder is necessary, the Minister will give to them the consideration which he has demonstrated since the duties of this office have been entrusted to him.

The delays experienced by so many adults, including student medical card holders, before receiving treatment are the result of inability to supply public dental officers to match the demand from eligible persons for dental treatment. This shortage is due not only to lack of money on the part of the health boards but also to shortage of manpower. Bearing in mind the Minister's overall responsibility for the dental health of the community—not simply of eligible persons—I have no hesitation in saying that even if the Government were able to make an unlimited sum of money available to the public dental service tomorrow, the problem of promoting dental health would not go away. I am attracted to the proposition by Deputy O'Connell in respect of the dental students. I admit here to having a vested interest in so far as one of my family is pursuing those studies, but I have said in respect of other third level education that the beneficiary of the education does not pay for the service which he gets. He does pay a fee but that fee does not cover the cost of the service which is given to him or to her. The spirit of third level education, apart from the special course followed, should lead the student to an awareness of the obligation upon him to think of other people. I am disappointed that there would seem to be a reluctance on the part of many professions——

Hear, hear.

——to acknowledge the assistance which society has given to them in the satisfaction of their ambitions. It is not good enough to say "Now that I have been educated and have acquired my profession at the expense of the taxpayer"—to the extent to which we know it is provided—"I propose to offer myself in the market-place of the world to the best buyer". If that were so, ab initio we should be saying to all third level students “You must pay entirely for that which you are receiving and that which you propose to sell in the open market.” I have said that before in respect of other disciplines. I have been agitated to this thought by the proposition made by Deputy O'Connell. We cannot at any stage be accused of forcing any citizen to do anything.

We have done it with the medicals.

I was happy to hear the Deputy say that it operates in respect of certain surgeons.

All doctors who qualify must give a year in a hospital.

That is news to me, and I am happy to know it. It is a proposition that I hope can be put with advantage and result to the dental profession.

Hear, hear.

I hope that when my son reads the Official Report he will not be displeased with the case I have made which might affect his income in a few years' time. If he is displeased I will not be inclined to accept him as my true son.

I do not want to cover ground already covered by the proposer of the motion. My only other point is that I have more faith in the Minister than Deputy O'Connell seems to have. I am not saying that he indicated any lack of faith but he was somewhat dismissive of the review and he likened it to a sweeping under the carpet.

Not the Minister, the Department.

It is the Minister we must charge here all the time, not the officials.

I agree.

That is the rule. The Minister is the Department.

The history of the Minister in question will indicate that not at all times could he be——


——equated with the Department. I do not accept that the Department, this target for all our criticism is an inanimate as is sometimes thought. Today at a school-opening ceremony I was approached by several people who expressed criticism of the Department and who told me that six months ago the Department had said so and so. I wondered if at any time we attribute a sex to the Department or to Departments. Are they male or female?

Like a limited company the Department have neither a body nor a soul.

However I do not think that Departments are as inhuman as we are led to believe.

Would the Minister be inclined to attribute sex to the Department?

Departments are capable of benefiting from the direction of a good Minister.

A Department is as good as is the Minister concerned.

I am optimistic that when the opportunity arises we will see signs of improvements taking place. The area we are discussing is not one that is responsive to immediate result. There is the matter of preparing dentists. Such training cannot be carried out overnight. Rather, it involves a six- or a seven-year stint. There is also the question of accommodation and such other questions as the employment of lecturers and other staff. As in other areas improvements can be achieved only in time, but I trust that in this case the desired results will be achieved with all possible expedition.

I found both that profession of faith in the Minister for Health as enunciated by the Minister of State and the dissertation on whether the Department was of neuter gender to be rather interesting. Perhaps, though, it is not particularly relevant to the matter under discussion. Last week, too, we had a motion to the Minister for Social Welfare and I said then that the amendment to that motion tabled by the Minister was the worst amendment tabled since this Dáil was formed. However, this week the Minister has bettered that record by tabling an amendment to the effect that Dáil Éireann accept that the Minister intends undertaking a comprehensive review of the public dental service. This is in response to the relevant motion tabled by Deputy O'Connell.

As I said last week there are more surveys being undertaken by working bodies, review bodies, consultative councils and so on in respect of the Departments of Health and Social Welfare than there are problems in the Departments, and we know that those problems are numerous. The time for talking is over. The Minister has been in the Department long enough not to be able to point the finger at all his predecessors in office. The Minister has had nine months in which to improve the service. At least I can see no real improvement in the dental service in that time but in some areas I can see a disimprovement. We are asked to accept this comprehensive review and to accept also that as soon as circumstances permit the Minister will implement the necessary improvements. In other words, live horse and you will get grass. That amendment rivals only the amendment of last week in terms of inadequacy, inefficiency and an attempt to cover up the fact that no progress has been made either in the area of the motion we have tabled for this week or in the area of the motion that was discussed last week.

Let us consider the uneven nature of the dental service, and take an example that was put forward recently by the Minister of State when he referred to the situation of a middle-class housewife in her forties whose husband is likely to be insured and, therefore, entitled to dental benefit.

I was talking about the case in which the husband is not insured.

Let us take the case of the man who is insured. His wife is not entitled to any dental benefit. Let us say that the couple have three children, the eldest of whom is 18 and attending a third-level education institute. Legally that child is entitled to a medical card and consequently to dental benefit, but in effect what he qualifies for is a pain-only or an emergency-only service. In that way the legal requirement is met. There is no provision in the Act for orthodontic or other service for him. If, say, the second child in the family is 14 and left primary school he has no entitlement to benefit although he is still attending school but at post-primary level. If the third child is attending a national school he will qualify for benefit but this will only be available in some areas. That is the situation of a typical Irish family in relation to dental services. It is very unsatisfactory.

There is an obligation to have dental inspections carried out in respect of all children attending national schools. However, figures published recently indicate that in County Kikenny last year only 19.5 per cent of all children attending national schools there were inspected. The indications are that the best inspection level is less than 50 per cent. Having regard to the sort of service being provided in a county like Kilkenny one can only speculate as to the nature of the service provided in the more remote areas. There must be many children attending national schools in those areas whose teeth are never inspected or, if they are inspected, the necessary treatment is not provided because of the delays involved.

Because of the length of time involved between inspections and the provision of the necessary treatment the problem has probably reached the stage where restorative treatment is not possible. There is very little preventive medicine. There is no instruction in such matters as oral hygiene, diet control or fluoride therapy. Such internationally recognised requirements are not met at school level. Another factor is that the service, hit-and-miss that it is, is available only to those children attending national schools. Children attending private primary schools are not included.

I am aware of that.

That situation is not satisfactory either. The Minister has suggested that children who leave primary school at 12 are not debarred from dental treatment in the national school scheme. I do not accept that to be the position. My information is that only those children who leave national school and go into a school with a secondary top qualify for the service. If a child moves from a national school to a secondary school that is not a secondary top he does not get treatment.

Only if the treatment has begun.

I seriously suggest that the Minister of State check up on that.

I was talking about the orthodontic service and I said what I know to be correct.

The Minister said that not enough attention was given to orthodontics. Let us look at the situation. Orthodontics are most needed during the adolescent years—between 12 and 16 years—when these children are inclined to have a high sugar intake. That is the very period when they are not covered by the State scheme. The main cost of orthodontics is borne by parents who have to send their children to private dentists for treatment.

Another unsatisfactory situation which needs to be changed is that the primary statutory responsibility for inspection rests with the chief medical officer of the health board, not the dental surgeon. It is through his grace and favour that the surveys and inspections are carried out. That is not as it should be. Wherever the scheme is operating satisfactorily at national level, any good effect that has had achieved is to a large extent negated because children are not eligible for treatment between the ages of 12 and 16. If they are still being educated at 16 they get a medical card but by the time they are eligible under the medical card scheme, a great deal of the work done during their formative years will have been negated because they have not had any treatment or care given during their adolescence.

I do not accept it as satisfactory that children over 16 years who are full-time students and can prove they have no income and get a medical card are regarded as a low priority. I accept the reason why this is so. There are insufficient resources and we must have a priority list. Therefore these children are listed as a low priority and are treated on a pain-only and emergency basis. That is not right. I do not accept the suggestion that the scheme is operating satisfactorily in so far as adult holders of medical cards are receiving a satisfactory service.

I especially reject the concept that there is an adequate public dental service operating in rural or remote areas for medical cards holders. Many of these people have to travel long distances to dental clinics to receive the free treatment to which they are entitled. Then they must be on a list for a very long period for an appointment. I do not accept that they are getting the service to which they are entitled.

There are approximately 200 dentists operating in the public service trying to provide a service for approximately 1½ million people. The figures do not add up. One does not divide into the other and leave enough days in the week for these men to do the necessary work to provide a public dental service for medical card holders.

I accept Deputy O'Connell's suggestion that a massive recruitment drive to, and a restructuring of, the public dental service is needed. It does not appear to be an attractive profession because there are 40 vacancies at present and for a very long time past there have been even more vacancies. It has been impossible to recruit people into this service. Why? Because there are only two grades—a senior dental surgeon and a dental surgeon. There are no promotional opportunities. There is no opportunity of getting involved in post-graduate work. The attractions of the boat and the payments under the national health service in Britain and abroad are so great that a young man has a struggle to decide that he has a social obligation to the State which helped to educate him as opposed to the large sums of money and experience he can earn abroad. After some years he can come home and set up in private practice. Until there is a complete change in the career structure and promotional opportunities in the public dental service, a sufficient number of people will not be attracted to the service.

I understand that in some rural areas, because of the lack of public dental clinics at accessible distances, dentists in private practice were asked to treat GMS card holders in return for payment by the health boards. I know one man who did that. He told me that he had washed his hands of it and would never do it again because he did not get any realistic payment for his work. A pilot scheme was set up in Donegal and Kerry under which private dentists would provide a service for medical card holders. All those dentists have pulled out of those schemes and refused to carry them out any further. Why? Because they were not paid adequately for their services.

I have been given to understand that private dentists would be prepared to operate a service for medical card holders on a fee per item basis. In other words, a choice of dentist could be provided or, if there were not a sufficient number of dentists in an area, the local dentist could provide a service for medical card holders on a fee per item basis based on the same scale of fees as is paid under the social welfare scheme. Admittedly, the IDA are trying to negotiate for an increase in that scheme but they have indicated that they would be prepared to offer such a service.

When the health boards asked private dentists to operate on their behalf they were paying one-third less than the social welfare scheme would have paid. That is no attraction to a private dentist who is kept very busy with his private patients. It is very hard to blame an over-worked dentist for refusing to take on such a task for the very low sum paid by the health boards.

It is disgraceful that under the social welfare scheme dependants of insured people are not covered for dental, aural or ophthalmic benefits. This is an issue the Minister should consider. I was surprised during the last election at the number of people who made that kind of complaint. Wives complained that neither they nor their children were able to obtain any of those benefits although their husbands were insured. It is a silly state of affairs where a young man can go to a dentist for treatment after proving that he has six months' stamps but once he reaches 21 years of age he must have three years stamps. If he started work at 20 years and worked for six months he would be covered for all these services for the next six months, but once he reached 21 he would go out of benefit because he had only one year's stamps and he would not be in benefit until he reached the age of 23. That is not a comprehensive service, that is a cod.

Deputy O'Connell spoke about delays. What are the reasons for those delays? There are a myriad of reasons: there are no auxiliaries or back-up staff, there are over-crowded and in certain cases non-existent facilities in some of the clinics and public general hospitals throughout the country, there is no specialist service at regional level, and in many cases there is not sufficient staff to operate the facilities which have been provided because there is no promotional structure.

The Dublin Dental Hospital is primarily a teaching hospital. It is under the control of the Minister for Education—although he will not fully accept that—and I think the building itself is under the control of the Minister for Health. As the primary responsibility of the hospital is to teach the students, consequently there are long delays. The hospital was taken over in 1963. In 1964 there was an increase agreed in staff levels but 14 years later and with a larger population entitled to service the staff levels are the same, if not below the 1964 level. In that hospital there is also the physical problem of space, and this leads to delays and complaints of inadequate treatment. I am glad that the Minister of State at the Department of Education is present to hear this debate. There is a division in ministerial responsibility in the Dublin Dental Hospital and this does not allow the proper operation of the service. The Departments of Health and Education should get together to provide a better service for the city. I shall quote to the House the following comment from a letter:

It now appears certain that some very highly qualified personnel with international reputations in their field will leave the Dublin hospital because of the Minister's failure to accept the Dublin Dental Hospital as a treatment hospital.

The students also will seek the first boat out on qualification because the hospital is regarded solely as a teaching hospital. Its equivalent in Britain is much better equipped. The hospitals are much larger and they have dual staff for dual responsibility—one staff for teaching and another staff for treatment. That is the kind of approach that must be adopted here.

There is a divergence of opinion regarding the opening of a dental section in the new St. James's Hospital. Will it be a teaching section solely, a treatment section or will it have a dual function? In addition, will it have the capacity to train the auxiliaries whom Deputy O'Connell has urged should be introduced and whom I say will have to be introduced? At the moment there are EEC draft directives in the course of preparation dealing with dental matters. When they are finalised and published in autumn this year the Minister will be obliged to revise the 1928 Dentists Act. He will be obliged to implement the EEC directives within 18 months of their adoption and those directives will state clearly that there must be auxiliaries. It will take two or three years to train them but it will take much longer to provide the physical facilities and the teaching staff necessary to teach them. Unless that planning is taking place now in the Department we will fail to live up to the EEC directives and we will not be able to provide a much needed service. I hope that planning is taking place, but I suspect it is not.

I accept that the Department are giving an undertaking now that in the physical planning of new hospitals— and in so far as they can in some existing hospitals where they are doing renovations—facilities will be included for dental treatment. However, that does not operate in many of the public hospitals throughout the country. There is no emergency service in Dublin city after 5.30 p.m. each evening. It is perhaps the only capital city in Europe where there is no emergency dental service provided in hospitals——

That is no excuse for saying that it will still be the situation next year. I am not saying it is the fault of Fianna Fáil. I am saying it is wrong and needs to be rectified. The Government can stand on their own feet now. They have money to spend and they should spend it to improve this service. I am not saying other Ministers did better, but if the present Minister wants to be known as the best Minister for Health he should do something about the matter.

There is a suggestion that some dentists operating in the public service have not access to all eligible hospital patients. They are obliged to work only with the physically or mentally handicapped or disadvantaged patients. Dentists are denied access to many people in general hospitals because the dentist must work under the director of community care who is normally a medical man. Because of a strict interpretation of the report of the dreadful McKinsey people who ruined the health services and many other services of this country with all their reports, in some health board areas the director of community care does not allow the few dental surgeons he has to have access to some of the patients in specialised and geriatric hospitals. That allegation was made to me by people in the profession, and if it is true it is a shame.

I would remind the Minister that the Medical Protection Society in their report last year emphasised the fact that the State was not fulfilling its statutory responsibility in so far as emergency services and treatment services in some hospitals were concerned and they said the State was open to litigation. The concern of the society was that the dentists involved in the scheme could be open to litigation, and it advised them to take higher than normal cover. It it a damning indictment of our attempts to provide an emergency service that the insurance company covering the people working in the scheme are now concerned that they are open to litigation. It appears that emergency services will be provided eventually only because people will have recourse to the courts because of the failure of the State to provide treatment for themselves and their families. That is not the way the State should go about providing a dental service for citizens.

It is very important that we use auxiliaries in the dental profession. In most countries they extract baby teeth, they carry out fillings and they do scaling work, usually under the supervision of a dentist. They do worthwhile work in this area.

Debate adjourned.
The Dáil adjourned at 8.30 p.m. until 10.30 a.m. on Wednesday, 26 April, 1978.