Vol. 357 No. 3
asked the Minister for Health if he is aware of a report prepared for the Eastern Health Board by Dr. Brendan Pigott, the board's chief dental officer, which showed that in the Dublin area the ratio of dentists in the public service to people entitled to public care was 1:2,900, whereas the desired ratio was 1:1,500; the measures he is taking to provide additional dentists in the Dublin area; and if he will make a statement on the matter.
2.
asked the Minister for Health if, in view of the serious shortage of dentists in the public health service in the Eastern Health Board area, the Government will exclude dentists from the embargo on recruitment to the public service.
3.
asked the Minister for Health if he intends to establish more dental positions with the Eastern Health Board, with particular reference to the Dublin area.
I propose to take Questions Nos. 1, 2 and 3 together. I am aware of Dr. Pigott's report.
On the basis of figures available to me the Dublin area and the Eastern Health Board area generally have a very favourable ratio of public dental officers to eligible children when compared with other health board areas. The desired ratio of one dentist to every 1,500 eligible children quoted in the report would represent an ideal situation in which there were no restraints on spending or recruitment. No additional posts can be created in the health services area at present due to the general embargo on the creation of additional posts in the public sector. I do not consider that the dentist/patient ratio in the Eastern Health Board area justifies an approach by me to my colleagues in Government to exclude dentists from the embargo on recruitment to the public services.
As the Minister is aware of the Pigott report he will be aware that, as it states, the waiting time is four months in some parts of the Eastern Health Board area for routine dental care and that in excess of 7,000, possibly 8,000, people between the elderly and students are on a waiting list for routine dental care. Does he not consider that this calls for a re-examination of the embargo on the appointment of dentists in the EHB area?
In the Dublin area alone there are 144,000 eligible school children in the EHB area. Taking in the other counties there are 180,000 in all. In Dublin there are 66 public dental officers. That is a ratio of 1:2,180 and it is the second best ratio in the country. The Southern Health Board have 2,128. There is a waiting list, but, as I indicated to the Deputy previously, the waiting time in May 1983 was between two weeks and three months in the EHB area.
The Pigott report indicates that in a greater emphasis on a preventive programme a ratio of 1:1,200 eligible persons would suffice. Have the Department of Health or the Minister embarked on any kind of increased preventive programme or is the Minister disposed to pursue such a programme?
One factor which adds to the relatively favourable position in Dublin is that while the ad hoc scheme under which adults are treated by private practitioners has been curtailed in some health board areas, it has not been so to any great extent in the EHB area. As a result, where the scheme has been curtailed adults are depending on public dental officers for treatment, but the situation in the EHB is not too bad. Undoubtedly I would like to see it improved, but one must remember that there are 66 public dental officers in Dublin and 75 in the EHB in all. That compares with ten for the midlands. In the north-western area there are only 11 public dental officers, that is one for every 3,000 people and in Dublin it is one for every 2,000 people.
Is the Minister satisfied that the Eastern Health Board are fulfilling their statutory obligation to provide a proper and adequate dental service?
They are doing their utmost within the limitation of the number of public dental officers available to the board. Ideally one would wish to see one dental officer for every 1,500 people but that would entail an enormous increase in general expenditure.
Does the Minister accept that it is now time for the embargo, which has been in operation for almost four years, to be reviewed and to have dental officers excluded from it?
I have always held the view that in this area the operation of the embargo is a rather crude and blunt instrument. My colleagues in Government are aware of my views in the matter but that is the way the embargo was brought in originally.
I asked if a preventive programme was being pursued by the Department. Is the Minister aware that the report indicated that, due to shortage of staff, it was not possible to carry out school examinations in all areas? Does the Minister agree that this is an important part of any preventive programme and that it indicates the need for the appointment of more dentists, especially in the Eastern Health Board area?
When resources become available, or if current resources become available they should go into such a programme for school children and young adolescents. Undoubtedly that is the area of greatest need. The working party report on dental care and services strongly recommended that and I am in favour of it. However, until such time as we get more resources we will have to make do with the position as it is but I agree that prevention is worth a lot more than subsequent cure.
4.
asked the Minister for Health when an orthodontist will be appointed to the Western Health Board; and if he will outline the reasons for the long delay in this appointment.
5.
asked the Minister for Health when funding for the post of orthodontist will be provided for the Western Health Board.
I propose to take Questions Nos. 4 and 5 together.
The post of orthodontist with the Western Health Board was recently advertised by the Local Appointments Commissioners. Interviews will be held soon and it is hoped the commissioners will be able to recommend a person for appointment.
Interviews for the post were previously held by the commission in January 1984 and a person recommended for appointment in April 1984. Subsequently, this person declined the offer of appointment. The cost of this post must be met by the Western Health Board from within their existing approved allocation.
In view of the fact that the post is not filled in spite of previous advertising will the Minister recommend to the health board that, while waiting for the post to be filled, emergency cases be farmed out to orthodontists in private practice with the burden of cost being carried by the Western Health Board?
No. The best thing to do is to have the post filled as soon as possible. It was advertised on 24 January and I am very anxious that it be filled. I regret that last year the successful candidate did not accept the post when it was offered to him. However, to make interim arrangements at this stage would leave us with the problem of dismantling them subsequently.
Until the post is filled, will the Minister recommend to the health board that emergency cases be farmed out to private practice?
I would have to have a look at that. I find it difficult to believe that we will not be successful in getting an orthodontist to take up the appointment.
The Minister must be aware of the difficulty of getting orthodontists and other qualified personnel to go to the west and north-west. Does he agree that increased incentives must be provided to encourage people to go to these areas?
That is more relevant to the next question.
Does the Minister agree that incentives will be necessary?
It is a Local Appointments Commission appointment and the salary scales and other associated incentives are known. I see no good reason why somebody should not find it an attractive position.
The Minister has been trying to fill it for two years. What are people supposed to do? Deputy Coogan made a reasonable request which should be acceded to.
6.
asked the Minister for Health if he has any proposals to make terms of appointment of dentists more attractive in areas finding it difficult to attract dentists such as some areas in the North-Eastern Health Board region.
A special salary increase was approved for all dentists employed by health boards in late 1984. There are no further proposals on hand to make the terms of appointment of these dentists more attractive.
Is the Minister aware that we have been pursuing this matter for years? There is a backlog of children awaiting treatment. As regards the ad hoc scheme, out of the 42 dentists operating it, 39 are in Counties Louth and Meath and three are in County Monaghan. There are not any in County Cavan. Does the Minister agree that there is a serious imbalance?
The salary scales are clear-cut and were revised following an arbitration report last year. An increase of 19 per cent is recommended for dental surgeons. This is being phased in as follows: 4.75 per cent was approved last October and was backdated to 1 October 1983; 2.25 per cent on 1 December 1984 and in November-December 1987 there will be a further 12 per cent increase. That is in addition to the ordinary public service pay awards and is in an effort to make the posts more attractive. I have no doubt that with the increasing number of persons available for appointment these posts will be taken up.
Would the Minister agree that these pay scales are not adequate to attract dentists into these areas? We can see the proof of that. In parts of Cavan an adult will not receive treatment unless it is an emergency case. Does the Minister agree that it will be more costly for adults in future as a medical card is of no use to an adult in County Cavan because there are no dentists to carry out the necessary treatment under the ad hoc scheme?
The salary for a grade 1 clinical dental surgeon is £12,600 and will go up by another 6 per cent this year. For a clinical dental surgeon grade 2 the salary scale ranges from £13,000 to £17,000. For a senior clinical dental surgeon it is £16,500 to £18,800. A principal dental surgeon has a salary range from £18,000 to £19,600 and a chief dental surgeon gets £21,200. I do not maintain that the salaries are princely but, in the context of payment for work done and the other opportunities, the scale has been considerably improved.
While the salary scale may be attractive in Rathgar or Greystones, it is very hard to attract these people to Killeshandra or Belturbet. The ad hoc scheme creates a more serious problem. We have not sufficient private dentists to operate the scheme and to give the necessary treatment to people with medical cards who are in need of treatment.
A few minutes ago the Minister expressed concern about the ratio of dentists to patients in the Eastern Health Board area where it is one to 2,900. Is he aware that in the Cavan-Monaghan community care area the ratio is one to 8,000 which is the worst ratio in the country? Does he not consider that this is a crisis? The North Eastern Health Board cannot carry out their statutory responsibility to these people. Will the Minister take some action and, if not, will he ask the health board to make a public announcement to the effect that they are not in a position to discharge their statutory obligations, and not have people waiting for a service and perhaps losing teeth which could otherwise be saved?
The position is not as bad as Deputies might fear. In Cavan-Monaghan the principal dentist surgeon's post is filled. The senior dental surgeon post is filled. Seven clinical dental surgeons, grade 2, have been approved and three of those posts are filled. The vacancies were re-advertised on 23 January 1985. In Meath the principal dental surgeon's post is filled. Seven posts were approved for clinical dental surgeons and five of them were filled. There is one temporary post and one post is covered by sessions. In Louth five posts for clinical dental surgeons were filled plus a temporary post for a senior dental surgeon.
Has the Minister the figures for the ad hoc scheme?
In the North Eastern Health Board area 48,000 children are eligible and there are 16 public dental officers. The ratio is one to 3,000. That is not as good as the figure of one to 2,900 in the Eastern Health Board area. The situation should be much better.
We cannot debate this all day.
Does the Minister accept that it is not much comfort to people to tell them that there are established posts? In the Cavan-Monaghan community care area fewer than half of the posts are filled. Surely this is a crisis for people who are waiting to avail of the dental service. It is not much comfort for them to be told there are established posts which have not been filled.
I am accused every day of the week of not providing money for the health services. These jobs are there for dental surgeons.
They will not take them.
The salaries are not princely but they are reasonable. They are going up by 12 per cent by 1987. They were the subject of a special arbitration award last year and 19 per cent was conceded, 6 per cent this year. Over the next few years these posts should be filled having regard to the numbers qualifying now and getting public service contracts with superannuation and other opportunities.
Could I ask the Minister——
We are having debate and argument.
I will not repeat the question I asked about incentives to attract qualified personnel to these areas. It is all very fine for the Minister to say these posts have been approved and he has provided the money.
Will the Deputy please form some question?
Is the Minister aware that that was done years ago and the posts have not been filled as yet? Therefore, it is time for him to have a new look at the problem from two angles. One is to provide incentives to attract qualified personnel to the more remote areas in the west, north-west and north-east. If he fails in that, will the Minister farm out the public work to the private dentists?
I am not prepared to farm out public work. The work is allocated on a public basis and it will stay public.
The Minister is prepared to let the people suffer.
I cannot do any more about the salaries of the staff concerned because of the enormous impact that would have on the other professions. The knock-on effect of a 1 per cent change is £70 million.
Not if the Minister gives incentives. He knows it can be done because it is being done in certain areas.
Ceist 7.
7.
asked the Minister for Health the plans he has for the development of the dental services.
8.
asked the Minister for Health if he is aware that many children in County Meath are waiting one year or more for urgently required dental treatment due to the lack of professional services in the North-Eastern Health Board; the action, if any, he intends taking to improve the situation; and the plans he has for the development of the national dental services.
I propose to take Questions Nos. 7 and 8 together.
The report of the Joint Working Party on Dental Services, which consisted of representatives of the Department of Health, the health boards and the Irish Dental Association, is the blueprint for the development of the dental services. Among recommendations of the working party which have already been implemented are the use of dentists in private practice to treat eligible health board patients and the re-structuring of the grading of dentists in the health board service, including the provision of additional promotion outlets for dental surgeons.
In line with the recommendations of the joint working party efforts are being made at present to recruit a number of full-time consultant orthodontists for the health boards and it is intended to proceed also with posts of oral surgeon when circumstances permit. Recommendations to increase substantially the numbers of dentists employed in the health boards cannot be proceeded with at present due to the general embargo on the creation of additional posts in the public service. Some other recommendations of the joint working party, involving the use of auxiliary dental workers in the health board service, cannot be proceeded with until the new Dentists Bill has been passed.
While the recommendations of the Joint Working Party on Dental Services represent the plans for future development of the dental services generally, the services are nevertheless the subject of an ongoing review by a group representing the Departments of Health and Social Welfare, the health boards and the Irish Dental Association.
In regard to the dental service for school children in County Meath, there are some children served by the Trim dental clinic who, on the basis of the numbers awaiting treatment and the staff available to attend to them, will have to wait more than a year before they are reached. However, many of those whose names are on the waiting list have not been clinically examined and it is thought that a high proportion of them may not require any dental treatment whatsoever. The health board intends to screen all those on the present waiting list and to draw up a new list of those genuinely requiring treatment. When this was done in other areas of County Meath the waiting lists for dental treatment were drastically reduced.
The Minister has told us about a number of recommendations which were made by the working party. He will have to accept that since he took office none of these recommendations has been implemented. The first one he gave us was the use of dentists in private practice to look after public patients. This was in operation when the Minister took office. In a number of health board areas it has been abolished as a result of the cutbacks. None of the other recommendations has been implemented. The Minister has already told us that he advertised for orthodontists but the posts have not been filled. He has said that at some time in the future an old surgeon will be appointed.
A question please, Deputy.
Is the Minister aware that in the official report of the working party it is stated that less than 10 per cent of eligible adults receive treatment and that the level of treatment provided for eight to nine year olds is only 40 per cent? The amount of money being allocated to the health boards for dental services has been reduced from 1 per cent to 9 per cent between 1983 and 1984. Surely the Minister must have some ideas of improving the services.
I would remind the Deputy that the recommendations to which he is referring are six years old. They were made in 1979.
But the use of private dentists had been in operation until the Minister came into office.
No Minister for Health since then has given more attention to this area than the present incumbent, whether it be in terms of——
Abolishing the services, certainly.
——of updating the legislation and conducting national surveys — particularly in relation to school children. All that work has been done. I have not cut back in any way on the allocations to health boards. I have given them sufficient money to run their programmes and they then decide how much money they are going to allocate to dental work. If they do not give it the kind of priority which I might believe they should and which members of health boards, such as the Deputy, might believe they should, that is the responsibility of the health boards.
Question 9.
They have sufficient money. If they want to spend it all on acute hospital care or other areas rather than on preventative work in dental care, which is far less spectacular but equally costly, they will have to accept responsibility for that.
Surely the Minister must accept that the health boards, with a reduced allocation, have no alternative but to reduce the services. He must accept that he is responsible for the fact that they have reduced allocations. Is he going to condemn the health boards for the manner in which they are using the allocations which they are receiving?
No. I would point out to the Deputy that the number of dentists employed in the health services in 1979 and the following years, including 1982 when I took over, has not been reduced. I have approved the employment by the health boards of five additional consultant orthodontists. The posts are being filled where they become vacant; there has been no reduction. We have not, however, increased overall the number of dentalologists. I would remind the House that the number of children being born dropped in the period 1979 to 1985 from 76,000 to 63,000. Therefore, in the years ahead those dentists dealing with schoolgoing children from the age of five upwards requiring treatment will have fewer cases to deal with. This is a valid point.
Would the Minister accept that the dental scheme has not been available in most health board areas since he came to office?
If they are not available, that is the responsibility of the health boards. I have issued no directive whatsoever on that.
9.
asked the Minister for Health if the dental examinations and treatment available to primary school pupils are adequate; and if an annual check-up should be provided for pupils.
The level of the dental service available to primary school children varies from health board to health board and indeed in some cases between different areas of the same health board. While the service may be adequate in some areas, it is less than adequate in others, due mainly to a shortage of dental staff in the health boards. The general embargo on the creation of additional posts in the public service prevents the health boards from employing additional dentists at present. The health boards do not have the dental manpower resources necessary to provide an annual check-up for all pupils of national schools. To attempt to provide such annual check-ups would only deflect very scarce dental staff from the delivery of dental treatment and cause a general disimprovement in the level of service available.
