Deputy Boland is in possession. The Deputy may speak for six minutes.
Private Members' Business. - Dental Health Services: Motion (Resumed).
The following motion was moved by Deputy O'Connell on Tuesday, 25 April 1978:
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.
Debate resumed on 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".
—(Minister of State at the Department of Education.)
Last night I was talking about the need to have dental auxiliaries introduced into the entire dental field. Apart from the other purposes for which auxiliaries could be used as outlined by Deputy O'Connell, they could also be used in a massive programme of education in the areas of oral hygiene, diet control and other preventive measures in the schools. The national school dental system and the entire system of dealing with the dental health of young people could be improved by the introduction of an educational programme and by the use of trained auxiliaries to implement such a programme.
The situation in regard to staffing structures and career possibilities for dentists in the public service is very poor. These are virtually non-existent in some circumstances. There are only two positions in the health boards, those of senior dental surgeon and dental surgeon. Consequently, young dentists are not attracted to the public service. Since 1973 there has been no position in the Department of Health of senior dental adviser. Although interviews have been held in regard to this appointment I am disappointed that there has been no announcement so far. Hopefully, the Minister will be able to tell us this evening that the position has been filled at last.
In contrast to the career structure which consists merely of a senior dental surgeon and a local dental surgeon, the dentists' association recommended some time ago that there be set up a structure whereby there would be a chief dental surgeon with consultant status, a deputy chief dental surgeon, a senior dental surgeon, a deputy senior dental surgeon, a district dental surgeon and a deputy district dental surgeon. In other words the association suggested that there be six levels and six promotional grades, thereby allowing for a proper grading structure and an adequate number of staff. There has been no indication from the Minister of any change in the immediate future in that regard.
There is much disquiet, too, at the situation whereby the job specification of the senior dental surgeons has not been outlined or specified. That is a poor situation considering the health boards have been in existence since 1970. I understand that in Dublin and Cork there are two positions of chief dental surgeon but that this situation does not apply to the rest of the country. The fear is that it is the intention of the Department to phase out those two positions on the retirement of the occupants. I should have thought that rather than phasing out, there should be talk of introducing the other four grades that the association have asked for.
In a submission made to me the complaint was that the recommendations of the profession are almost always ignored by the Department, and the suggestion was that the consistent failure and resistance of the Department concerning advice in relation to recruitment, to the provision of dental auxiliaries, to specialist and consultant services in orthodontic and oral surgery and to a proper staffing and administrative structure for a national dental service has left the dental profession disillusioned and angry. That is fair comment. I do not think anybody could blame the profession for that.
There is a need on our part to accept that dentistry is a specialist medical field, that it is not a para-medical field, which is how it has been treated up to now by the Department and the health boards. One of my suggestions is that a dentist be appointed to the Health Education Bureau. I suggest also that there be a dental representative on Comhairle na nOspidéal who would be involved directly in ensuring that there was adequate staffing in the county hospitals.
To sum up, then, there is a need for a radical shake-up in the national school field, a need to include children attending post-primary schools, a need to introduce a scheme on a fee-per-item basis similar to the social welfare scheme for medical card holders, a need to extend the social welfare scheme to include dependants, a need to replace the 1928 Act, a need for planning at this stage to provide for the physical training and the provision of sufficient staff for the training of auxilaries, a need to revise the career structure in the public service, a need to clear up the confusion on whether to meet the statutory requirements that are not being met now and a need to clear up the confusion on whether there is to be a new dental hospital in the St. James's complex and whether it is to serve the dual purpose of teaching and training. There is a need, too, to emphasise preventive medicine and to appoint a dental representative both to the Health Education Bureau and to Comhairle na nOspidéal.
What there is not need for is a review body such as is referred to in the Minister's amendment, because if Deputy O'Connell and I and perhaps others can come here and outline clearly and simply the needs in the dentistry field, needs that are recognised widely, the last thing that is required is a review body.
There is no review body.
The Minister will tell us that the situation is not of his making, but I do not want him to blame his predecessor or any of his predecessors.
The Deputy would not want that.
He is not to blame Mr. Flanagan or the late Mr. Childers or even Deputy Corish. I am asking him to say what action he intends taking, but what we must not have is another investigative body, because it looks as if the corridors of the Department will have to be widened in order to allow all the working parties there pass each other by.
I should like to begin by acknowledging that there are many aspects of our public dental services which do not achieve the level of provision that we would all desire. The service is still at a growth and development stage. It does not provide, nor has it ever provided, on a readily available basis the full range of treatment procedures required by eligible persons.
All previous administrations have accepted that fact. However, compared with the position as it was ten years ago, the service today provides a much greater range of treatment and examination per year both in relation to children and adults and it places a much greater emphasis on fillings and other conservation procedures. The proportion of fillings to extractions is increasing. This is a good indication of improving standards in the service. It might be no harm to remind the House that in 1965 there were 88 whole-time dentists in the public dental service while in February this year, the number was 194. If we take into account the additional sessions worked by these officers and also the service provided by private practitioners, the service is now operating on what is estimated to be a whole-time equivalent of 222 dentists. That figure was mentioned by Deputy O'Connell.
In association with that considerable increase in the number of dentists employed in the public dental service, funds have been made available to improve the standard of clinical facilities available to health board dentists. This improvement has received a ready acknowledgment among the profession, and any proposal for further improvement is considered sympathetically by me in the Department.
Although the improvement is significant it is not enough to provide 100 per cent cover for all eligible persons. In this situation we must operate on a system of priorities, and that, too, has been accepted by all previous administrations. Indeed, it has been accepted also by the practising profession.
Broadly speaking the current system gives priority to children, to expectant mothers, to persons suffering from TB and to certain handicapped persons. The system allows scarce resources to be allocated to those areas of greatest need and in which the greatest benefit can accrue. Regrettably, though, it entails an element of sacrifice on the part of some older age groups, but at least there is consolation in the fact that children and the most needy benefit.
The case for developing the dental services is obvious and is accepted by all. This Government have clearly indicated already their intention to divert resources towards the improvement of the service. However, that is not an objective that can be achieved in large measure overnight. I want to make it clear to the House that there are many problems involved. It would be superficial to dismiss these problems. It is important that the House and the public know what the problems are. Only then will there be full appreciation of what is being done and what can be done reasonably quickly to improve the situation.
I wish to pay a well-deserved tribute to our public dental officers, that very dedicated group of men and women who are working against considerable odds but despite which, down through the years, they have provided consistently a first-class service. The current demand for improved dental services is the greatest tribute that can be paid to them. That demand comes largely from people who as youngsters obtained a good standard of treatment from these public dental officers and who learned to appreciate the need for good dental hygiene both for themselves and for their children.
The curious thing is that most dental diseases are a product of our civilised way of life, a direct result of our dietary patterns. In short we eat too much sugar and the price we pay for this self-indulgence is dental disease, a painful and debilitating condition as we all know all too well. It gives rise to much misery and suffering. Any health service worthy of the name must regard it as a major health problem. I would emphasise that it is this Government's intention, and my intention to treat it as such.
Conservation measures alone will not eliminate dental disease. All the authorities agree on that. There must be a very strong emphasis on preventive techniques to reduce the treatment case load. This is a point I wish to stress very strongly. It is fundamental to any organised assault upon dental disease on a national basis. The treatment case load must be reduced by positive preventive measures.
The two main branches of dental disease are dental caries, which attack the teeth proper, and periodontal disease which attacks the supporting tissues. Happily the two branches are responsive to some extent to preventive measures. Fluoridation of piped water supplies is the most effective agent yet discovered for reducing the incidence of dental caries. We are fortunate in Ireland that fluoridation of piped water supplies commenced in 1964. At present supplies serving about 57 per cent of our population are equipped for the process. There were some problems with the service in recent years largely arising from the fact that home produced supplies of fluoride virtually dried up. Supplies are available again on a regular basis and every effort is being made to have all plants, even the smallest, restored to full operational efficiency. In Dublin, for instance, the incidence of caries among four year olds has been shown to be 65 per cent less than it was prior to the introduction of fluoridation.
I might mention that in this field also we keep a constant watch on the possibilities of other preventive procedures emerging. The most promising of these in recent times is xylitol, a form of sugar substitute which is claimed to be caries inhibiting. While xylitol appears to have some promise, I am advised it is not certain that it will eventually emerge as a viable public health measure. Nevertheless, we will keep in touch with the developments on this and other procedures to ensure that every advantage is taken as soon as possible of any new preventive procedures emerging.
The other main preventive field lies in the control of plaque and this is largely a question of correct and constant personal hygiene. What is needed is effective instruction in personal dental hygiene aided by regular treatment. The public dental service does a great deal of work in this field and is anxious to extend the range of its activities by using auxiliaries. We must also acknowledge the contribution of the Irish Dental Association and the Health Education Bureau in awakening public awareness of the need for good dental hygiene. Deputies are aware that the budget of the Health Education Bureau has been very considerably increased this year to enable it to extend all its activities, including education in dental hygiene and preventive techniques.
However, no matter how well we deploy our preventive resources we will still have to cope with a very large treatment requirement. It is in the deployment of manpower resources to meet this treatment requirement that our real problems arise. I want to suggest that neither of the two main Opposition speakers has adverted sufficiently to this aspect. I do not think I would be unfair if I accused them of ignoring it, but it is the key to the central problem.
We must maintain a balance between the treatment requirements of the private sector and the treatment requirements of the public sector. The World Health Organisation have suggested an overall provision of one dentist for every 2,000 population. I do not altogether accept that approach. For our circumstances and our population structure I could be more inclined to accept a ratio of one dentist for every 1,500 children and one dentist for every 2,500 adults. This suggest a national requirement of 1,550 dentists which, as it happens, gives on a national basis a figure very close to that recommended by the World Health Organisation, that is, 1,560. However, whichever approach is used the figure which emerges is far higher than the total of dentists currently registered to practise dentistry in this country—that figure stood at 898 on 31 March 1978 as against 1,560 which is the required number.
Obviously there is a servere manpower shortage—something in the order of 600 to 700 dentists for our population as a whole. This shortage is by no means confined to Ireland. Many other countries are faced with a similar problem. Our nearest neighbour, the United Kingdom, estimates that it will be the year 2000 before sufficient dentists are available to meet their requirements, and this despite the fact that operating auxiliaries, who are not fully qualified dentists, are employed there.
We have two dental schools capable of qualifying about 75 dentists every year. That should yield sufficient dentists to meet our requirements. Unfortunately, a substantial proportion of our graduates elect to emigrate. This is not a situation which can be easily rectified and certainly not where there is virtually a worldwide shortage of dentists. Furthermore, the Treaty of Rome provides for the free movement of dentists from Ireland to other member states within the European Community. That is an existing right and directives which are intended to facilitate dentists wishing to exercise that right are at present being finalised in Brussels. In this context one must remember also that the United Kingdom, which traditionally has taken the bulk of our emigrating graduates, is also a member state of the European Community. There we have our first major problem. How are we to deal with this manpower shortage? Is the answer to increase our output of graduates and accept that a proportion of them will emigrate? We must remember also that it takes five years to train a dentist.
It is sometimes suggested that adults should be catered for by the private sector—something on the lines of the choice of dentist scheme as mentioned in the motion. At first sight that might seem attractive, but if you examine it carefully you will find that it raises some very serious problems. Children form the main priority group for dental care. Everybody agrees on that. If, however, we ask the private sector to provide dental care for eligible adults, say on a choice of dentist basis, then inevitably the earning capacity in the private sector will increase. Consequently, dentists will be drawn away from the public sector. No matter how you look at it this simply means that more eligible children will be denied dental care.
No matter what arrangement we may make with private general practitioners, we would still be faced with the problem that sufficient manpower is not available. Here we must remember that an important objective of the public dental service is to seek out those children most in need of dental care. Manpower shortage has prevented this objective being achieved to date but we must look forward to the day when it will be possible to achieve it. However it is an objective that can only be achieved through a public dental service. This is simply because the services of private practitioners would be availed of only by children whose parents were sufficiently interested to seek out the service for their children. Those children whose parents were not concerned about dental care —or in some cases who were not fully aware of the need for it—would simply not be brought forward for treatment. Either approach would mean that in a manpower shortage situation our main priority group, our children, would undoubtedly suffer.
In this type of situation there are other options which must be taken into account as has already been adverted to in the course of this debate. First, there is the question of the hygienist. The hygienist undertakes some of the more routine dental procedures such as scaling and polishing of teeth and instruction in dental hygiene techniques. This grade would be welcome by the dental profession. It is intended to make provision for this grade in an amending Dentists Bill which is now under active consideration. While hygienists would be a boon to the public dental service I fear that experience in the United Kingdom and other countries indicates that thehygienists themselves prefer to work in the private sector. However, irrespective of whether their preference is for public or private sector work, they would help to decrease the workload which now has to be undertaken by too few dentists.
There is another very important option which must be fully examined and that is the New Zealand type dental nurse. This nurse is an operating auxiliary who works only in the public sector and who provides what to this day is accepted as a first class dental care service for children. These nurses undertake a two year training course and care for about 500 children each. They tend to be based at local level, functioning within the school system. My information is that they provide a very effective service for children and their role is fully approved by the dental profession in New Zealand.
The United Kingdom considered the introduction of this grade in the 1950s and finally opted for a modified version, called colloquially, the new cross auxiliary.
The basic difference between the systems in New Zealand and the United Kingdom is that in New Zealand the auxiliary works virtually on her own responsibility whereas in the United Kingdom she works under the direct supervision of a dentist. Faced with our current and likely future shortage of dentists, we have no option but to examine fully the potential of these grades of dental auxiliary in our public dental services. A factor that would tend to influence me in this context is that emigration outlets for these grades would be limited. Consequently, we could plan for the future with more assurance. Again, on the basis of New Zealand staffing levels we are talking in terms of about 1,000 jobs, a not unimportant consideration in the context of our national economy at present.
Another problem that is assuming increasing importance is the question of specialist and consultant level services. There is a growing demand for specialist dental services, particularly in the orthodontic area. Again, this is a reflection of the higher standards of dental care now being enjoyed by increasing numbers of children but it poses a problem in a situation where scarce resources have to be rationed on a priority basis. To what extent should we expand our specialist services where basic services for the main priority group—children—are not met? Should we encourage the development of a consultant status service at this stage? If so, should we model our post-graduate programme on the European mainland approach of three years' intensive training, or upon the United Kingdom system of an eight-year training period? Which specialities should we recognise and what role will the public dental services play in all of this? It is obvious that the answers to these problems will require considerable negotiations and discussions and here I must seriously take issue with Deputy Boland when he suggests there is no need for any review, examination or discussion in this area, that the only thing required is to get on with it.
There are many other important issues that must also be considered. Should the public dental services be extended to cover adolescents? Indeed, should these services be extended to the limited eligibility group as a whole? The legal requirement for this was included in the 1970 Health Act and, in fact, was in health legislation as far back as 1953. Pressure on public funds for other needs has prevented this legal provision being implemented to date. Quite clearly, the time has now come to decide upon the pathways along which the public dental services will develop in the coming years. There are two ways of approaching this. We can take a piecemeal approach and try to solve existing problem situations by attempting to recruit additional officers or by involving private dentists to a greater extent. Bearing in mind that the private sector also has its needs, by solving a problem in one area—such as by offering special inducements to dentists to settle in neglected areas—we must not create problems in other areas.
What we must do is to have a very full examination of the whole pattern of present and future services. This would have to take into account all the options open to us. In particular, it would involve a decision as to whether we should rely totally on dentists in the future or whether we should promote the development of auxiliary grades. I should not like to take decisions on issues as fundamental as these without the fullest consultations with the various interested agencies including in particular, the health boards and the dental profession. Indeed I am fully satisfied that the practising dental profession would welcome and, in fact, anticipates this consultation process.
Here I come to something of considerable importance and it is by way of reply to criticism which Deputy Boland, in particular, has levelled at me, namely, that I am too anxious to review and examine matters and to engage in consultations. His suggestion was that I should plunge into immediate action. Since I took up office, and long before that, consultations between the Department and the profession in regard to the many problems that had to be faced had been inhibited by the absence of a full-time dental adviser in the Department. I am glad to be able to announce now that a new chief dental officer has been selected and shortly he will take up duty. The full laborious procedure of the Civil Service Commission selection machinery has been gone through, a man has been selected and it is only a matter of some further details before he takes up his post.
I could not really get down to the kind of examination that I want to make of the dental services and all the problems and to project policy even for the immediate future until I had such a man beside me to advise me in regard to these difficult, complicated professional matters. The appointment in this case will make available to me a professional input of a high level that I am certain will be of great benefit in the resolution of the many problems that have to be faced and particularly in the continuing consultation with the dental profession that is fundamental to this matter.
What is required is a comprehensive development programme worked out in consultation with the interested agencies and taking all possible options into account in the consultation process. Only in that way can we produce a worth-while programme. That programme will have to maintain a balance between the legitimate needs of the eligible patients, the legitimate interests of the dental profession and of the general body of taxpayers. It is no easy task and there is no simple solution.
This consultation process inevitably will produce a number of new approaches. There is no doubt in my mind that an overall comprehensive programme will cost a great deal of money but I am glad to be able to say that we have more money at our disposal this year. The Government and the Minister for Finance have recognised that an improvement is necessary in this area and money has been made available for suitable development. There will also be very heavy demands on available manpower. I believe we will have to proceed on the basis of priorities that we will have to sort out. The Government have recognised the problem and have indicated that resources must be directed to improvement of the dental services. I want to get on with the consultation process as quickly as I can and try to hammer out the lines on which we will proceed.
I should like to deal with some of the arguments put forward in the course of the debate. Deputy O'Connell asked for details of the format and the terms of reference of the review of the dental services that I am proposing. Deputy Boland went further and seemed to interpret from the amendment that I was going to set up a review body. There is nothing of the kind intended. I agree that a review body is not necessary. I intend to carry out a review as expeditiously as possible with my advisers and with the chief dental officer when he is appointed. There is no need for any other kind of review. A review in depth with expert advice available to me in the form of the chief dental officer is necessary and I think Deputy Boland was wrong in brushing it aside as unnecessary. Perhaps he was indulging in a legitimate political tactic in suggesting it is something I am using only to delay action but I want to assure him it is not. It is necessary and important. I hope I have given some indication of the problems we have to resolve and the decisions we have to take. I repeat again that the basis of the problem is the question of manpower.
Deputy O'Connell and Deputy Boland made the point that a new dentists Act will be required by the EEC directive regarding dentists which is nearing finalisation. There is need for a new dental Bill. That is under way and I hope it will not be delayed much longer.
I readily acknowledge that this motion and the putting down of it have served a purpose in focusing attention on the problems in the dental service. I assure the House clearly that the proposals and ideas put forward by the Fine Gael and Labour Deputies will be considered carefully. I hope I have given some idea first of all of the sort of problems that confront me, the issues that have to be faced, and the fact that I am concerned and anxious to get on with the review whose aim is the formulating of policies in this field. I have indicated a number of problems which confront us.
In the short term context of this year, money is not one of them. We have some additional finances both in the preventive and the other side and I would hope that improvements will be made in the course of the year. However, I want to make it clear that there are real difficulties which prevent simple straightforward solutions to the serious problems confronting us in the dental field.
The Minister has agreed there was justification for the leading contributions made by spokesmen like Deputy O'Connell on the issue of dental care. In his contribution the Minister acknowledged that there is a great need, after the reviews he has promised, for remedial action at official level. I interpret from the Minister's contribution that this, like any other area of health care, is a question of choice of priorities.
My only reason for intervening is that I want to make a few brief comments on certain complaints I and other Deputies have received from parents of schoolchildren who, on the figures available to us, do not receive adequate dental care. It is true that public education comes into this, but there remains for the Minister for Health of the day the problem of credibility, of explaining how it happens that the present Minister is anxious to improve the situation at a time when the percentage of total health expenditure devoted to dental care has dropped. Of the total expenditure in the Health Estimate in 1977, 1.2 per cent, or £3.9 million, has been devoted to the dental service. The total Health Estimate was £350 million. The size of that indicates the enormous burden on the Exchequer.
The Minister claims that the amount allocated this year represents an increase of 12 per cent, but the percentage devoted to dental care is only 1.2 of the total sum. I do not know the priorities which guided the Minister.
Job creation is the main thing. We shoved expenditure into job creation.
I agree with that priority. The Minister will agree that the cases made here yesterday by Deputy O'Connell and Deputy Boland were alarming. I doubt if the Minister will challenge their accuracy. These figures certainly do not explain why that small percentage for the dental service was agreed. Perhaps the Minister is laying a foundation for a more significant advance in the future, but that reduction in respect of the dental service has not been explained, and therefore the Opposition were right to draw attention to the need for more investment in this area.
The Minister has said that there is a manpower shortage. That is true. Speaking of the general manpower shortage the Minister referred to the emigration of dental graduates, which is very difficult to stop because of the greater attractions, remuneration included, in other countries. In the context of that general exodus is the problem of the public service itself and its attractiveness for dentists. We say that the remuneration in the public service is not sufficiently attractive to keep adequate personnel in that area, and that must be tackled in whatever review structure the Minister considers necessary. I accept the common sense of having an adviser for the Minister in this matter. Prima facie, there is a case for the argument that remuneration for public service dentists is not sufficient either to attract fresh graduates or to retain staff. Dentists remain in the public service only for a short time. I have not got figures to substantiate that, but from the two cases of which I have knowledge, I know that the job of public service dentists is regarded as a temporary state before the personnel take up private practice. Because there is this manpower shortage the conclusion is inescapable that only by altering the remuneration structure available will we get the incentive for dentists to remain in the public service—only in that way will the public service have the necessary attraction for people to come in and stay in.
The Minister was right when he said that it is the children who are the principal victims of the inadequacy of the present system. We have, theoretically, a dental service for schools but the figures are quite alarming. We have some information on the frequency of school health examinations in primary schools. It is considered desirable for schools that have more than 50 pupils to be visited each year and that smaller schools be visited at least every two years.
Questions that have been asked here about the frequency of those visits suggest that the examinations are very infrequent, presumably because of the shortage of manpower. It means that a great number of the children simply receive emergency treatment. There can be little question of preventive treatment where the personnel are so thin on the ground and where the examinations take place so infrequently. If children do not benefit from an adequate dental service at an early age, whatever importance may be given to the question of public education in relation to dental care, if the majority of children in the country do not as of right get adequate dental care and preventive treatment in their school years we are obviously creating a future of dental trouble for those children.
I understand that there are 320,000 eligible schoolchildren who did not receive any dental examination at all in 1976. I suppose the figures for 1977 and this year will be an increase on that figure. All the TV ads in the world on the necessity for proper dental care will not get away from the weakness the whole system suffers from and which those figures expose. Only 46 per cent of our children received any dental examination under the programme in 1976.
The Minister may justifiably say that the problems he is facing are not of his creation, that they have been there for some considerable time. We would not deny that. I am not sure the Minister is right in saying that the choice of dentists suggested by the previous Minister would not be of any assistance. This should be looked at more carefully in his review of the whole service. The previous Minister, from what I can gather, appeared to think there might be some benefit even in the present situation in adopting that choice system.
I do not want to leave the Minister with the impression that we are saying that this is a new problem. It has obviously gone on for a long time, but now he is the responsible Minister. Crudely, what it requires, for improvement in the short term and in the long term, is a large infusion of extra cash. I do not think it requires much examination of the options before us to realise that the glaring need is for more personnel and a bigger investment. Admittedly the whole health area needs larger investment, but this cries out for an urgent injection of capital in order to get an adequate dental service for our children. If we are concerned about the public education aspect of this problem, we must give priority to our children in seeing that a decent dental service is provided.
Additional money is required to solve such problems as remuneration of the personnel in the public service, to make it more attractive for them. If this new dental Bill comes before us in the near future money will be required for the new auxiliary people the Minister referred to. The dental profession would have to be consulted on this and they appear to welcome this proposed auxiliary service. I saw from a recent interview with the President of the Dental Union that he appeared to welcome the provision of that type of extra help in the service.
We cannot escape responsibility for initiating very early action to improve the position in the country. International statistics on the subject suggest that there is a truly alarming position here. The preventive side of dental care is not, obviously, accorded very high priority. How could it be accorded high priority when one considers the few personnel operating in this area? There is need for improvement in the service to the schools. People on medical cards can obviously receive only emergency dental treatment. There is a long queue for appointments. I believe that the average is about nine months' waiting time for children and ten months' for adults. Very early action is required in that area and there is need for a greater number of personnel.
We must have the highest extraction rate of all EEC countries because of the make-up of our dental service, its undermanned state. We certainly must have the highest rate of dental caries in the Community. We need more dentists in the public service as well as in the country at large. I ask the Minister, in his consideration of this matter with his advisers, to look into the case of people who receive their dental treatment by means of the insurance stamp. I believe consideration should be given to the actual payment to dentists for examination. I have heard that the amount paid for examination to dentists is less than——
They are not paid for examination.
I thought some payment was made for examination, but I now learn from Deputy O'Connell that no payment is made, which makes the matter even worse. If there is no payment for examination and only a fee-per-item for treatment there seems to be a bias there on what should comprise dental care. I would like the Minister to have a look at that matter. This suggests that the whole system, with all its inadequacies, is geared only to the treatment side of dental care and is not geared to the preventive, which is the more important area. I have not an adequate answer to this but I imagine that the Minister is back to the old problem again in respect of how he primes up the treatment side. He will be back to the question of additional moneys being made available again.
There is a plan for a new dental hospital in Cork and a plan for one on the site of St. James's Hospital in Dublin. Obviously, that will improve the situation. The Minister indicated that we appear to turn out sufficient graduates if they remain in the country but there is no easy way of ensuring that they will remain here. It would help if the conditions were made attractive. There have been calls for improved conditions in the public dental services run by the health boards and better promotion and career structures for dentists. Apart from the question of remuneration those matters should be given early attention.
It is a good thing that we will shortly have a new Bill dealing with dental services that appears to have as its main feature the appointment of auxiliaries. I accept the Minister's point that more public education is needed on this matter. We cannot blame the Minister for the incidence of dental caries or the state of the teeth of the people of the nation but we can criticise him if he does not prove to the House annually that he is at Cabinet level securing sufficient cash for the improvement of the service. If he sees his role as one of discussing the options, as one of a public educator-in-chief on the necessity for correct dental care he will be making the same mistake and subject to the same criticism as the wife of the Lord Lieutenant at the start of the century who, looking at malnutrition, put the cause of it down to the faulty diet of the unfortunates concerned. The Minister's sincerity in this area will be called in question if he cannot tell the House that he has secured from the Cabinet the right priority. As far as a Minister for Health is concerned the right priority—I accept that the Minister approaches his task in a serious fashion—is to carry his sincerity and seriousness into force at Cabinet level to secure sufficient investment in this area. If he does not do that he will have failed as Minister for Health and, instead of being, as I understand is his ambition, the best Minister for Health in the history of the State——
No, just a good one.
The figures suggest that he has not succeeded this year in getting the right cash allocation to correct some of the weaknesses in this service. In his role as public educator in this matter I would like him to consider the situation in relation to toothpaste. It has been brought to my attention that toothpaste is regarded as a cosmetic and as such is liable to VAT. Toothpaste appears to be some help as a preventive treatment and it seems wrong to regard it as a cosmetic. I understand that one brand of toothpaste is manufactured here. Toothpaste should be considered to have some medical property and relieved of the VAT imposition. The Minister should talk to his colleague, the Minister for Finance, about this matter and I am sure he will secure the utmost co-operation from him. It would not do the Minister any harm to ensure that VAT was removed from toothpaste.
The dental profession do not consider that they are being taken as seriously as the medical profession in the Department of Health. I do not know the attitude of the Minister in this matter but I presume he believes that all medical personnel should be treated equally. This view is corroborated by many dentists when they see that within the health boards they operate under the jurisdiction of medical doctors. I hope the Minister will have a look at that aspect in any discussions he will be having with his chief adviser.
The status of the new chief dental officer will resolve that.
I welcome that development. The Minister appears to agree with the opinion I have heard expressed that dentists are not taken as seriously as medical doctors. Dentists have been fighting for a long time for professional recognition. Considering the problems we have in that regard we should resolve any feelings we have of that character that may still exist. I was anxious to air the complaints I have received about the dental service over the years. Parents have complained about the inadequacy of the service, especially at school level where children receive only emergency treatment. If we are anxious to develop the preventive side of dental care this is a poor foundation for the future. As well as introducing this new Bill dealing with dental services the Minister should, by supplementary budget or otherwise, prove his goodwill by arranging the provision of extra funds to be devoted to the dental care side of his Department.
I was disappointed that the Minister did not accept this motion. It would have been a gesture of his goodwill and his intention to tackle this serious problem. His amendment seems to indicate that he is putting the matter on the long finger. I am not accusing the Minister of being responsible for dental care here in the past. But he is here now and he has the responsibility for it. It is a very big responsibility. Talking about preventive health care seems to be the order of the day. Teeth play a vital role in health, particularly in the health of young people. Teeth are the gateway to the body and defects in the mouth can have serious repercussions. The ill-health that bad teeth can cause cannot be quantified. We cannot point the finger at a death and say that it was the result of bad teeth, but over the years neglect in this area can cause a serious decline in health of large numbers of people, and that is easily recognised when we hear of people having teeth removed for health reasons.
The personnel problem is a large one. A number of our dentists leave the country. Perhaps they do so because they feel that the training they get in our dental hospitals might not be up to standard. Since I came into this House there has been a number of problems in the dental hospital in Dublin, and these can have only a detrimental effect on the training of dentists. Only months ago there was a protracted dispute concerning an extension of six months in the training period for dentists before they would qualify, and this would mean a further cutback in dental care. Dental care is the Cinderella of the whole health spectrum. The affluent in our society can afford to go to a dentist and pay. The less well-off have to wait many months before they can receive treatment, and consequently severe damage to their general health occurs while waiting.
I am glad that the Minister stated that there will be a new dental hospital. This is long overdue and should get priority as early as possible. When one walks through some areas of the dental hospital here one would seem to be in a museum, a memento of something that was a dental hospital 50 or 60 years ago and now is there to show what was done in the past. It is crude, and how people trained there I cannot understand. The whole dental hospital is a disgrace, and the dental board who control it had serious reservations as to whether they would qualify people trained there. Stop-gap arrangements were made there to carry on. The hospital epitomises the attitude of successive Governments to dental care as something that could be put off, that we did not have to spend money on because there was no urgency about it. Many young people, particularly girls, need orthodontic treatment. The very long delays often mean that when they do get the treatment it may be too late. They cannot get it done privately because of the prohibitive cost which their parents would have to meet. These children—again with special emphasis on the girls because they want to be glamorous and look well— are the sufferers and they carry this stigma, as it may be called, right through their lives. We have tolerated this over the years without doing anything to remedy it.
The amendment put down is a further recipe for doing nothing. The Minister should have been courageous and accepted this motion. We would not have expected him to operate it overnight. It will take a number of years to get some progress on it, but we would at least have a clear indication from the Minister that he was going to do something. The only indication we have is that the Government will merely undertake a comprehensive review. That is what we have been hearing from the Government since they came into office. In every Department we are having a look at this, we are going to review that, we are examining the other thing. That is all right and will get them by for a while, but they must face up to reality. It is not the solution to this very serious problem. I am surprised at the Minister adopting this stance in this case because there is no doubt in anybody's mind about the dental problems in this country. Let us cut out the codology of reviews and face reality. If children have to wait nine months for treatment that is scandalous. Adults have to wait longer than that and people needing specialised treatment may have to wait three or four years. It is time that this was remedied. The sooner we get down to doing something about it the better.
I am disappointed at the Minister's approach to this very serious problem. From the point of view of political gain there may be nothing in this, so it is put on the long finger. There is no real pressure and no real outcry for a change in the system and therefore it is not a matter of urgency and we can defer it until another day. That is the only conclusion I can reach.
We cannot defer the problem until another day because of the decline in young people's health as a result of grave dental problems they have due to the type of food they eat. Because of easy access to sugared items and soft drinks the situation is much worse than it was years ago. This is all the more reason why we should tackle this problem urgently. I ask the Minister to accept this motion as a gesture of his concern for the problem. In other areas of health the Minister has shown concern but in this area he has not grasped the nettle. Perhaps he has been advised by the people in the Department that this has been deferred for a long time and that we can procrastinate a little longer on it and nothing will happen. It is bad.
In the short term we should consider some form of mobile dental treatment. There are mobile services in other areas. There is no reason for not being able to attract people to the service. It is said that our young dentists are emigrating but they are emigrating because the stakes elsewhere are high. Let us make the stakes here high for them. If the people across the water can pay them we should be able to pay them also. We need them to work in the built-up areas and in the schools where comprehensive and regular checks are important. If the service were satisfactory there would be a gradual cutting down in the need for dental attention because defects would be diagnosed in time. Another important aspect is that of education in relation to dental health. There is very little such education, apart from the odd word of warning that may be included in some of the slick advertisements on television for the various kinds of toothpaste—the ring of confidence or whatever—but that is not education. It is aimed only at selling the various products.
The Deputy should not mention any of them.
I have not mentioned any of them. Can the Chair name one that I have referred to?
The "ring of confidence" may mean something.
It is the Minister's ring of confidence that is a cause for concern; it is becoming shaky.
Education in this sphere is of the utmost importance and the right place to begin is in the schools. We need personnel to visit the schools and lecture children in oral hygiene and so on. It should be possible, too, to put in train some mobile dental units provided we can keep adequate staff here.
Generally our people prefer to work at home but they may emigrate if the terms elsewhere are much more attractive. England provides a large market for dentists because of the comprehensive service that is available there, whereas the young dentist here may have to struggle for a number of years after qualifying. We must do everything possible to make conditions attractive for them. The situation for most of them is that on leaving the dental hospital they drift around for a while and then emigrate unless they find it possible to set up a private practice but that takes time to develop.
While the Minister is waiting for his comprehensive review he can at least improve the standard by utilising those dentists that are available but he must increase substantially their rate of remuneration. Money spent in the area of preventive care is money spent wisely. It is an investment for the future. I ask the Minister to accept the motion in the name of Deputy O'Connell. In this way the Minister will be showing his concern for the people, particularly for those who cannot afford private dental treatment.
The motion has achieved some purpose in highlighting the deplorable state of our dental services. In addition it has brought from the Minister an acknowledgment that the situation is far from satisfactory.
I regret that it was found necessary to bring in the amendment. I do not consider the proposal in the motion in my name to be extraordinary especially since the Minister of State at the Department of Education called for greater steps. He called for a further extension of our dental services and said that those middle-class people who are not insured need dental care for themselves and their dependants. The Minister of State said that the wives of such people were depriving themselves of essential dental service in order to allow their children to have attention. I pay tribute to Deputy Tunney in going a step further than I have gone. All I was attempting here was to have provided an interim kind of service that would be an improvement. I was not advocating any sort of socialist solution to the problem. If I were to do that I would be calling for a full national dental service. I am humble in what I have called for compared with what Deputy Tunney has called for.
He is a man of great integrity.
I trust that the Minister will consider seriously what the Minister of State has called for. The Minister has emphasised the preventive aspect of dental care and said that I had not attempted to do this. In this context perhaps the Minister would take immediate steps to provide that the Department of Social Welfare will pay for dental examinations. Deputy O'Leary adverted to the situation in this regard. It is something the Minister should do as a first step.
There is an urgent need, too, for the initiation of a public education programme in order that the 80 per cent who are entitled to benefit would be so aware. Only 20 per cent of those people are availing of the service. The launching of such a programme would be an indication of the Minister's sincerity in this area and of his determination to provide a proper dental service.
Hopefully, too, the Minister will arrange that dental examinations in schools will be conducted more frequently so that defects will be discovered and attended to in time. Perhaps, too, steps would be taken to ensure that the 320,000 children whose teeth were not examined in 1976 would have them examined now. To take action on these matters would be a major step forward on the road to improved dental services.
Something else that the Minister might do is to talk with his colleagues about the EEC grant for the flouridation of milk—dental milk as it is known. If the Government are prepared to contribute 50 per cent of the cost involved, the EEC are prepared to pay the other 50 per cent. About 40 per cent of our population will never have a flouridated water supply.
The Minister adverted to the manpower shortage and said that of the 70 dental surgeons who qualify each year, the majority emigrate. Would the Minister take steps now to have incorporated in the dental Bill that is to come before us shortly a provision whereby a dental surgeon would have to complete a compulsory year's service on qualifying. This would not be without precedent. There has been such a provision since 1953 in regard to doctors. It would give us immediately an extra 70 dental surgeons per year in the public dental service.
This would immediately help to alleviate the manpower shortage in the public dental service. Is it too much to ask dental surgeons who have received State grants towards their education to give one year's service to the public dental service? This is the time to do it, before the dental Bill is introduced. In my view we are achieving something in discussing this motion. Although this is not mentioned in the motion, the Minister should give it serious consideration because it could be a step towards alleviating the manpower shortage in the public dental service. The Minister says the cash is there and that we do not have any money problems.
Not quite.
The Minister said that "money has been made available; there is more money now". Is there any reason why we cannot use that money to provide a free dental care service for all school children? This is one big area which demands immediate action. School children who go on to secondary school cannot have this service at the most important time of their lives. If they were given this service it would mean a vast saving to the State. To deprive them of this service as soon as they go to secondary school is false economy. We want them to go to secondary schools but we are not willing to provide that service. I am asking the Minister to provide the money for this one aspect of the service.
I am not blaming any Government for this. We have so-called free education but parents have to pay so much and this added burden for dental care for their children could be alleviated if the Minister took one bold step forward. As I pointed out last night, there has not been an increase in the proportion of the total health expenditure devoted to this service. It was 1.2 per cent and it is 1.1 per cent; it has been reduced this year. We should seriously look at this and not say that there has been a 12 per cent increase because in terms of the proportion of the total expenditure it has been a reduction.
Why not bring in a supplementary estimate and do the few things I asked? That would be a stop-gap measure but would do something to help. This Minister is decisive and this is one area where his efforts would win public acclaim. Would he look seriously at the payments made to dental surgeons in the public service in order to attract more people into that service? I know from experience that if he were to improve the conditions of service and the salary structure in the public service, many people would be attracted into that vital area. This would help to alleviate the chronic waiting list because there are on average 24,000 children waiting an average of 9.9 months—and they could be waiting up to two years—and 27,690 adults waiting an average of 10.9 months. We must not neglect the aged, the impoverished who need dentures and often have to wait two or three years for them. They suffer serious digestive disorders because they cannot chew their food. That is happening to many old age pensioners. The Minister would save a great deal of money on pills and medicines if these people were provided with dentures. If that is not false economy I do not know what is.
Perhaps that is an over-simplification.
I am speaking now as a doctor and I can tell the Minister that 80 per cent of the digestive disorders suffered by old people are due to the fact that they are not masticating their food properly and because they have no dentures.
I accept that.
Perhaps the Minister could look at that. It is a shame to have to write a prescription for antacids and other correctives for digestive disorders. If the Minister would look into this, his Department would save money.
To have a choice of dentist is not creating a precedent because it is already incorporated in the social welfare code. Would he consider doing this as an interim measure to relieve the waiting list? This would reduce the tremendous backlog that exists. He could discuss this with the Irish Dental Association and I am sure they would be very willing to discuss this subject seriously with him.
I accept that the Minister is serious and sincere about wanting a review and I have no doubt we will get action. Would he give some indication when it will take place or could he bring a report to the All-Party Health Committee of the Dáil? If he did that we would know where we stand. That report could tell us that we would have this scheme before us for consideration in two or three months' time. That would be a step in the right direction. I ask the Minister to consider the other suggestions I have made.
It would be wrong to call a vote on this because I think the Minister is sincere about it and I am prepared to accept his amendment.
Amendment agreed to.
Motion, as amended, agreed to.
The Dáil adjourned at 7 p.m. until 10.30 a.m. on Thursday, 27 April 1978.