Dáil Éireann debate -
Wednesday, 25 Oct 1989

Vol. 392 No. 2

Private Members' Business. - National Dental Service: Motion (Resumed).

The following motion was moved by Deputy Yates on Tuesday, 24 October 1989:

That Dáil Éireann condemns the failure of the Government to provide an adequate dental service to medical card holders, with particular reference to the lack of provision of dental maintenance and dentures for adults and the extremely long waiting lists for orthodontic treatment; and calls on the Government to meet its obligations under the Health Act, 1970 to urgently provide a proper national dental service.

Debate resumed on amendment No. 1:

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

"notes the recent announcement by the Minister for Health of the distribution of £300,000 in the current year to commence the treatment of 500 priority orthodontic cases and commends the resolve of the Minister for Health to concentrate further resources on improving the dental services generally in 1990 and subsequent years".

—(Minister for Health).

Mr. Howlin

Last night I said a few things in relation to the fact that we had started off the new Dáil session with yet another Private Members' motion devoted to the health services. The fact that that is the case is an indication that the crisis in the health services that I and my party have underlined for three years still exists despite the very clear message given by the electorate in the June election. Despite the shock given to the Fianna Fáil Government and the belated awareness of the Taoiseach that a crisis exists in the delivery of the health services, precious little has been done in the intervening few months to put a halt to the crisis or to redirect significant or relevant funding to the areas of need in the health services. Once again we will face into a Dáil session where week after week it will be necessary for us on the Opposition benches to point out to the Minister the responsibility which he has so obviously neglected.

Last night I listed a number of cases to give a vivid example of the crisis that exists in the delivery of dental services. The evidence I cited related to one narrow aspect, orthodontics for children. I listed children who are in dire need with no hope of treatment, whose parents are in despair and I read letters from health workers who are unable to provide the service and who are forced to write to parents in the terms I described last night. Because of time allowed tonight I will not reiterate those cases, but children of 11, 12 and 14 who urgently need dental care simply have not that facility available to them.

Despite the Minister agreeing last night that the dental care system was inadequate and despite further agreeing that additional funding must be found, what funds has the Minister found and what money has he provided? The Minister has provided £300,000 to cater for 500 priority cases in orthodontics, when in my area alone there are 700 on the waiting list. One can realise the waiting list throughout the country. Every health board is forced to implement a draconian system whereby priorities are arrived at and two out of every three children presenting themselves are denied a service because they are not judged to be severe enough or acute enough in their needs. An additional £200,000 is to be provided for water fluoridation. That is the Minister's total response. It is not good enough to address the problem which the Minister is surely aware of by now.

Last night I was beginning to look at the report on health funding in so far as it dealt with dental services. Basically, the commission recognise that the scheme is in crisis and acknowledge that the health boards are failing in their statutory obligation under section 67 of the Health Act, 1970 to provide dental treatment for eligible adults. The report was a disappointing one but some of the statistics that were published in the report are most revealing. The total cost of the schemes has risen from almost £9 million in 1979 to over £25 million in 1987, but the number of people treated by health board dentists has risen in the same period from 213,000 to 380,000 and the number of claims under PRSI dental benefit has risen from 150,000 to 308,000.

It is clear that the scheme at least provides value for money for the State. There is no other service where so many people can be treated for so little money. That is the good news. The bad news, confirmed by the commission report, is that most adults now treated under the schemes can only get emergency treatment as a result of the growing size of the waiting lists. In the four years covered from 1983 to 1987 the number of cases where treatment was confined to emergencies only goes from one-third of all cases to precisely two-thirds of all cases. The commission in response recommended the abolition of the PRSI scheme and the transfer of funds to the health boards, the employment of more dental auxiliaries and the introduction of charges. Then, of course, the whole system could be taken over by the new administrative structures proposed by the commission. This response is typical of a commission that is committed to the notion that we can run a health service without a single extra penny being spent on it. It is a ludicrous approach in the face of the major crisis that is clear to everybody in the State.

I wholeheartedly support many of the recommendations in the Commission report. I support the notion recommended in the report at page 228, chapter 14.3.6 which recommends the appointment of dental hygienists for health education, hygiene instruction, the application of fluoride solutions and fissure sealants and cleaning and polishing of teeth. The Minister has pointed out that since the enactment of the Dentists Act, 1985, that is possible and I know he is taking some steps to bring dental hygienists into the system.

An Ceann Comhairle

I hesitate to interrupt the Deputy but he might now bring his remarks to a close.

Mr. Howlin

In conclusion, I support the introduction of dental hygienists recommended by the dental therapists and the denturists. I support the fluoridation of water, fissure sealants and all the positive recommendations but the bottom line has to be that the service demands and deserves more funding. We have already pointed out that the system has saved more than £6 million because of the dental dispute and this should be put back into the system.

An Ceann Comhairle

I must now call another speaker.

Mr. Howlin

We are not prepared to allow the dental service to collapse further. The Labour Party will wholeheartedly and unreservedly support the motion tonight.

Minister of State at the Department of Health (Mr. N. Treacy)

Tá áthas orm bheith páirteach anocht sa díospóireacht tábhachtach seo faoi sheirbhísí fiaclóireachta ár dtíre. I am very pleased to come in here tonight to participate in this important debate. I have listened with great interest to the Opposition speakers last night and again tonight. Listening to them you would think there was no dental service at all as they have painted a very black picture indeed. We are well aware that there are problems. Indeed why else would the Minister have established the working group to review the delivery of dental services last year. There are nevertheless many positive aspects to the health board dental services at present.

There are about a third of a million attendances by children at the health board dental clinics every year. Until recently the different health boards had different methods for selecting children for treatment. Some boards used a school-based system, where they visited the schools on a rotational basis and screened all the children before setting up a course of treatment for those who had caries or other problems. Other health boards target specific classes and screen all the children in those classes.

One health board has relied on selfreferral by patients. This last approach has been less than satisfactory, because it is widely believed that some children never visit the dentist because the parents may not put dental treatment high on the priority list for whatever reason — lack of knowledge of its importance, bad family circumstances or otherwise. It was in the light of this problem that the working group recommended a standardised approach, based on the targeting of specific classes. The working group recommended that first and sixth classes should be the target classes but on reflection it became obvious that in most instances second class would be more appropriate because at that age the first molars would have grown. As a result of this recommendation, the health boards have now adopted this approach to the delivery of dental services for children. The Eastern Health Board which had the self-referral method is piloting the new approach in three community care areas.

In this health board area it will of course be necessary to re-educate the parents to come to accept that this new approach is more advantageous to the population at large and that their children will be examined and treated at the appropriate times rather than on demand.

Some health boards have already introduced fissure sealant programmes. The application of fissure sealants to the molars reduces the incidence of dental decay in those teeth and as these are the teeth most prone to decay the application of the sealants can help to keep the mouth decay free. We are hopeful that more health boards will introduce fissure sealant programmes to the routine treatment programme of the second class children.

In targeting the sixth class group, the health board dental service can ensure that each child is made dentally fit before he leaves the care of the public dental service.

I cannot talk about children's dental services without referring to the tremendous improvement in the dental health of our children which was noted in the national survey of children's dental health. The survey found that there was a significant decrease in the incidence of dental caries in all our children. However, that decrease was most significant in the children who had been lifetime residents of fluoridated areas.

That brings me to another great success story of the health board dental service — the water fluoridation programme which celebrates its silver anniversary this year — 25 years which have seen this country as a European pioneer of the addition of fluorides to the public piped water supplies.

This major contribution to oral health was not introduced without a considerable amount of opposition, which some Deputies may remember. But it is clear that those who were far-sighted enough and determined enough to push ahead with its introduction have been fully vindicated.

To listen to the Opposition here last night, you would get the impression that the water fluoridation programme was a shambles. Nothing could be further from the truth. About 65 per cent of the population are served by water supplies which are fluoridated. I must emphasise that it is not possible to fluoridate every water supply and, as I speak, every water supply which is suitable for fluoridation has had a fluoridation plant installed. Some supplies are too small. We consider it viable to fluoridate supplies which serve a population of over 1,000 persons. Some supplies have a number of water sources, which make the installation of fluoridation plant impossible. However as every small supply or group of water supplies is replaced by a new regional water scheme, the water fluoridation plant is installed, bringing the benefits of fluoridation to an increasing number of people.

As the Minister pointed out yesterday, we have made an additional £200,000 available this year to the health boards for projects in connection with the water fluoridation programme. The health boards were asked for their own proposals in this regard. In some cases they wanted to fund new schemes, in other cases they found it necessary to purchase stand-by plant — new pumps to serve in the event of pump failure. At this moment the health boards are engaged in the purchase and installation of this new equipment. In drawing up their plans for the present year, they were also asked for their needs for the coming few years and thus we have been able to draw together the material to enable us to put together a strategic plan for the further development of the water fluoridation programme in the future.

In talking about the water fluoridation programme, I feel compelled to refer to the improvements in the results returned by the health boards in recent years. In 1988, over 80 per cent of tests taken showed fluoride levels of at least 0.7 parts per million. Four years previously only 67 per cent of tests reached this broadly acceptable fluoride level.

In many areas where the water supplies are unsuitable for fluoridation for the reasons I have already instanced, the health boards have introduced and maintain fluoride mouth-rinsing programmes. These target in on school children and are usually administered in the classroom setting. When the new grade of dental hygienist is introduced to the health board dental service there will be scope for a further extension of the mouth-rinsing programmes, which must be administered under close supervision.

Much has been said here about the orthondontic service. The Opposition have put forward a figure of 24,000 awaiting treatment. The most recent figure is that there are 12,250 children awaiting orthodontic treatment. Of course, the fact that such a number of children are still on the waiting lists is far from satisfactory. Many of these children are awaiting the most expensive fixed appliance therapy. Again there is an on-going orthodontic programme in all health boards.

All dentists can fit the basic removable orthodontic appliances, which can be used to treat the more basic orthodontic conditions.

It is when we come to the more complicated treatments using the fixed appliance that the services of a consultant orthodontist are required to advise on, oversee and on some occasions actually carry out the treatment. The House is well aware of the difficulties which have been experienced in attracting consultant orthodontists to the health board dental service. The high rewards available in private practice are well known. Because of these problems we have decided to reexamine the conditions attached to the post before we re-advertise them.

You will also be aware that the one consultant orthodontist in the health board service is involved in the provision of a training programme for a number of health board dentists who will reach specialist level. There are two trainee consultant orthodontists in the Dublin dental school and it is known that there are eight Irish trainees in higher training pathways in orthodontics in the United Kingdom at present. It is understood that many of these are interested in returning to Ireland in the future. Thus the long-term availability of highly qualified orthodontists looks very promising. Rather than the gloomy picture painted by the Opposition spokespersons, I want to emphasise that the problems are recognised, the solutions — the long-term solutions — have been determined and we are now taking decisive action.

The Minister has already told the House that the Government have made £300,000 available to the health boards to enable the treatment of 500 top priority cases to begin immediately. These cases will supplement the cases already underway in the health boards. Indeed it may well be that the Opposition are unaware that about 5,000 children conclude courses of orthodontic treatment provided by the health boards each year. A full course of treatment can take as much as two years and thus there are many thousands of children under treatment at any one time. This fact, too, I want to emphasise.

The Minister and I are, of course, confident that, in the future, as recruitment problems are solved there will be a great improvement in the level of the orthodontic service, which the health boards can provide. In the meantime, we are confident that the health boards will continue to use the guidelines, issued by the Department of Health to ensure that priority in the provision of treatment is granted to those children, who have the most serious handicapping conditions.

We are aware that there have in recent times been some problems in relation to the highly sophisticated orthodontic treatment required by children who have been born with a cleft lip and palate and we are actively reviewing this service at present.

The dental hospitals also make a major contribution to the health board dental services. The two hospitals, in Dublin and Cork, provide routine treatment for adults and children as part of the training programme for undergraduate dentists. Specialist services are provided for particularly difficult cases. Each year about 28,000 patient visits are made to Cork Dental Hospital and about 75,000 patient visits are made to the Dublin Dental Hospital.

Therefore, in excess of 100,000 people are treated at these two dental hospitals each year in the public sector. At this point I wish to pay special tribute to the directors and staff of these two dental hospitals. I saw at first hand recently the tremendous work being done in the Dublin Dental Hospital, in the public sector, with regard to education, research and science and AIDS patients. We can be proud of the tremendous cadre of professional staff who work in these two hospitals.

In addition, the senior lecturer consultants in Dublin are involved in the training of health board dentists in orthodontics. Special arrangements are also provided for the treatment of AIDS patients, haemophiliacs, and other special categories. The Cork Dental Hospital provides a special clinic for the treatment of the handicapped who require special conditions for their dental treatment.

Following the enactment of the Dentists Act, 1985, the dental council was introduced to replace the dental board. The council has more far-reaching powers than the old board. It also has a wider membership. The council regulates the dental profession. It also has powers to create classes of dental auxiliary and to specify the training required by persons seeking registration.

The council began its deliberations on the creation of grades of auxiliary dental workers by looking at the grade of dental hygienist. A hygienist can carry out a number of procedures such as the scaling and polishing of teeth, the provision of education in dental hygiene, the application of fissure sealants, the administration of fluoride mouth rinsing programmes and other services. In some countries the hygienist can also administer fillings.

It will be a matter for the dental council under the Act to specify the tasks which is considers appropriate for the dental hygienists to fulfil in Ireland. The Opposition last night asserted that the newly registered dental hygienists would be confined to the private dental sector. This is not our policy.

Mr. Roche

Hear, hear.

Mr. Yates

There are no training schemes.

Mr. N. Treacy

The matter is being considered by the dental council at present.

Mr. Yates

They have to go to Britain for training.

Mr. N. Treacy

I presume the Deputy has listened to what I have said. They will decide on the jobs and tasks to be carried out by dental hygienists. It will then be up to the Department of Health to respond and put in place a training programme of the highest quality, be it in Ireland, if it can be done here, or elsewhere.

Mr. Howlin

Will money be provided?

Mr. N. Treacy

We welcome this innovative step forward and are very anxious that this grade be created in the public sector as quickly as possible to assist the dental programme and the school programme so as to ensure that children will not have to wait.

Mr. Howlin

Will funds be provided?

Mr. N. Treacy

This is progress. Perhaps the Deputy does not like it but these are the facts, and they stand up. Of course we will provide the money as it becomes available and as priorities are decided.

Mr. Howlin

Will the Minister of State confirm that he is providing money for it?

Mr. N. Treacy

I will answer that——

An Ceann Comhairle

I hardly need to remind the House that a very strict time limit applies to this debate and interruptions are particularly unwelcome.

Mr. N. Treacy

There is an important role for hygienists in the health boards, not merely providing dental hygiene instruction but also in the administration of many of the preventive dental programmes such as fluoride mouth rinsing and the application of fissure sealants.

Reference was made last night to the fact that the working party on the elderly made a recommendation in relation to the establishment of a class of denturist who would supply dentures directly to the public. If, of course, the dental council were to create a class of denturist then the position would change. Under the provisions of the Dentists Act, 1985, it would be possible for the dental council, with the Minister's approval, to establish such a class of dental auxiliary. As I said earlier, the dental council has been given the Minister's approval to proceed with the establishment of dental hygienists. However, the position with regard to other classes of auxiliary dental workers, including denturists, has yet to be clarified by the council.

Without doubt, the creation of grades of auxiliary dental worker is cost effective in that it releases the dentist to carry out the highly skilled tasks and permits the auxiliary to concentrate on carrying out the often time consuming but less specialised tasks appropriate to the grade.

The Minister informed the House last night that he has the question of allocating funds, specifically for the provision of a routine dental service for adults, under review at the moment. We are all aware that that adult dental service has been fraught with problems for years. Indeed it was on account of the adult dental service, or lack of it, that the present Taoiseach established a working party back in 1977, to review the delivery of dental services. That working party recommended the use of dentists in private practice to treat eligible adults. The acceptance of the recommendation led to the establishment of an ad hoc dental scheme whereby eligible adults were referred by the health boards to the dentist of their choice, from among those who had agreed to provide services for the health boards.

Mr. Howlin

The scheme was stopped.

Mr. N. Treacy

At its peak, about 32,000 persons received treatment annually under the ad hoc scheme. However the health boards found that the scheme was very expensive to operate and that it was eroding funds required to maintain the other health board dental services, notably the services for children. The main problem stemmed from the age treatment need of the medical card population. A particularly high percentage of applicants required dentures. Indeed the cost of providing a full course of dental treatment under the ad hoc scheme was considerably higher than the cost of an average course of treatment under the Department of Social Welfare's dental benefit scheme, because although the fee scale under the two schemes is identical, the treatment need of the medical card population is much greater and in particular the need for dentures is very great and, therefore, the scheme was very expensive to operate.

As the Minister pointed out last evening, the health boards have now almost entirely curtailed their use of dentists in private practice to treat eligible adults. In order to maintain the services for children they find themselves unable to provide routine dental treatment on demand for adults. Indeed, in most areas they can only provide emergency treatment for the alleviation of pain. Where the health board dental surgeons have spare work capacity, they provide limited routine treatment for persons in high priority groups such as the elderly and pregnant and nursing women. We are aware that this situation is inadequate — but it is not a new problem. It is a problem that has been growing through successive Governments. However, this Minister and I are committed to seeking a solution to the problem and will continue to give the fullest consideration to the conclusions and recommendations contained in the report of the working group chaired by our Government colleague, Deputy Terry Leyden. As with the orthodontic problem, we cannot hope to have an instant success but we are committed to the goal of a steady improvement in our dental services.

To sum up, I do not think there is cause for the depressing picture which the Opposition paint of the dental services. We continue to provide a good service for children. We have in place a number of preventative measures, including our highly successful and much praised water fluoridation service. We have put in place the first measures to tackle the problems of the large numbers awaiting highly sophisticated fixed appliance orthodontic therapy. We are aware that there is a need to provide additional funds and we accept that.

I have listened with great interest to the Opposition speakers. I have seen their attitude while we were in Government in the last two and a half years and since we came back into Government a few months ago. Deputy Howlin and his party said we need £245 million more for this service.

Mr. Howlin

Not for this service, for the health service.

Mr. N. Treacy

I would point out to Deputies Howlin and Yates that they cannot have it both ways. They cannot be in the streets shouting for lower taxation and at the same time be in the Dáil looking for better services.

Mr. Yates

The Deputy did it for long enough.

Mr. N. Treacy

We must have sufficient resources——

(Interruptions.)

Mr. N. Treacy

The Minister for Health has allocated one fifth of the State's budget to health services. The priorities are decided. The resources are allocated and the money is available.

Mr. Howlin

But the Minister of State says there is not enough.

Mr. N. Treacy

We appreciate that and we intend to work to get more resources. We inherited a situation from the Deputy's Government——

Mr. Howlin

That was three years ago.

Mr. N. Treacy

We inherited a disastrous health situation. Not alone had we to remedy the general structure but we had to get the public finances right; otherwise we would have no public service. Taking all that into account, the Minister and I are fully aware of and are totally committed to providing additional funds and routine dental care for eligible adults. Taking into account the available Exchequer resources and the many priority health areas, we shall do our utmost to deliver the best possible dental service quam celerrime.

Mr. Sherlock

The admission by the Minister for Health in this debate last night that our public dental service was not providing the full range of treatment procedures which eligible people need is a shameful indictment of the appalling record of successive Governments in this vital health area. It is important to emphasise that dental health is not a minor health issue or a cosmetic exercise. Apart from causing considerable pain and discomfort, poor dental health can damage the overall health of an individual through digestive problems and leave people prone to infection. Dental health and dental care should form an essential part of an overall health system particularly for our children. Instead, our dental services have been very much the poor relation of the overall health service.

The public dental service has never been allowed to develop properly because it was starved of adequate cash and resources and the development of the service for insured workers and their dependants has been blocked by the vested interests of the dental profession. When speaking last night the Minister said that it is doubtful if such a level of service could ever be obtained given the need to prioritise the essential services in the context of our resources. He said that in that context it was never intended that the service provided for under the Act would be provided for in full.

What does that Act say? Section 67 of the Health Act, 1970, says that a health board shall make dental, ophthalmic and aural treatment and dental, ophthalmic and aural appliances available for persons with full eligibility and persons with limited eligibility. Subsection (2) of section 67 says that a health board shall make available without charge a health examination and treatment service for pupils attending a national school or a school to which this section had been applied under the subsection. In this State at present children who have been assessed and deemed in need of dental treatment are kept on that waiting list until they leave the national school and consequently they do not get the dental treatment that they are entitled to under that Act. That is happening in the community care area I represent. That is not an exaggeration of the facts.

The Minister referred to the working group. What did the working group established by him in 1988 say? The working group strongly recommended the adoption of a national strategy for the delivery of dental services to ensure that an equal standard of service is available to all persons. Can we say that that is the case at the moment? On page 13 of that document it says that the working group believe it is desirable to initiate a more structured approach to the health board dental service and that at present there are wide variations between health boards and even within health boards in their approach to the delivery of dental services. The working group strongly recommended the adoption of a national strategy for the delivery of dental services to ensure that an equal standard of service would be available to all eligible persons.

The last report we got in the community care area in which I reside was at the end of 1987. Referring to national school children it said that the interval between school inspections is far too long and this delay gives rise to demands for emergency treatment for children in such schools still waiting to be seen and this provision of emergency treatment means there is less time for the school programme. The result is that the numbers needing treatment get larger. That is the situation we have at present.

It states in the same report, and this was referred to by the Minister, that for many years the service operated by default on a priority basis and the service to adults has never achieved a high rating. In 1981 an ad hoc dental scheme was introduced whereby the treatment of adults was referred to private dentists on a fee per item basis similar to the Department of Social Welfare scheme and the ad hoc scheme was suspended in the board's area in 1984 for financial reasons. If that was the case, is the Minister carrying out the obligation that he has under the Health Act, 1970, to provide dental treatment for people with full or limited eligibility? The present situation is that a person who may be badly in need of dental treatment must first go to a general practitioner. The general practitioner has to state that for the person's health it is urgent and necessary that the service be provided by the board. That is not good enough and that type of dental service is not acceptable. The Department of Health guidelines on orthodontic treatment should be scrapped. When young people are recommended for orthodontic treatment it is invariably stated that it is merely cosmetic and thus does not come within the guidelines. This creates great problems for parents and young people. The Minister's representatives on the board of the health board area which I represent have been very vocal on this matter and I am surprised that they have not brought it to his attention long ago. I suggest that such guidelines should be withdrawn and a more realistic approach to orthodontic treatment for children should be adopted.

It is not as if successive Ministers for Health have been unaware of the problems in the dental service. The Workers' Party have repeatedly raised the issue and in Parliamentary Questions have drawn attention to the appalling extent of waiting lists. For example on 6 December 1988 the Minister gave Deputy De Rossa details on the number of children awaiting treatment at health centres in the Eastern Health Board area. In some clinics, Blessington for instance, the waiting period was 20 months and in Blanchardstown, Dublin, there were no fewer than 3,000 children awaiting treatment and in the Roselawn clinic in Naas there were 1,600 on the waiting list. It is not only under Fianna Fáil that these difficulties have arisen because in 1985 when Fine Gael and Labour were in Coalition the then Minister for Health disclosed that there were more than 12,000 children awaiting dental treatment for up to two years in the South-Eastern Health Board area and that in the Western Health Board area 11,000 children were waiting between 12 and 18 months for treatment, and in the community care area that I represent, which is just one section of County Cork, there are 3,000 on waiting lists this very day. These people are entitled to the service under sections 66 and 67 of the Health Act, 1970.

Workers who pay significant sums in PRSI are statutorily entitled to a certain level of dental service. There is an obligation on the Government to ensure that this service is provided. The members of the Irish Dental Association are clearly far more interested in protecting their economic interests than in promoting the dental health of the public. Their blackmail must be resisted.

The cost of dental treatment needs to be addressed urgently. Fees charged for private treatment can vary enormously. In many cases the waiting time for public treatment is so long that people have no alternative but to seek private treatment. The Irish Dental Association does not have a recommended standard rate of fees. The cost of dental care in the Republic is believed to be about twice that charged in Northern Ireland. It was suggested that dental practice is so lucrative that dentists from Northern Ireland were coming down to set up practice here. I understand that a dentist in Britain could expect to receive £30 sterling for extracting 32 teeth while a dentist here would be likely to receive £170. A single filling costs the Department of Social Welfare approximately £8.50, while in Britain the DHSS would pay only £4.80 sterling. There is similarly a huge gap in the cost of other dental services.

The Workers' Party want an extension and improvement of public dental care together with controls and safeguards in private care. We favour a totally free dental service for all in the long term with payments to dentists on a capitation system. We also support the demand for a new dental hospital and for the immediate improvement in the staffing levels, equipment and facilities in the health board clinics. We also favour the introduction of more trained graduates, who should be required to spend at least one intern year working in the free dental scheme.

We want to see more emphasis on preventive dental care which would involve routine checks and monitoring of the entire population. However, this can only be successful within a fully comprehensive system where dental services are freely available to all. In the short term we believe that the Government should establish a representative commission on dental services whose main remit would be to investigate and report on the fees and charges, the question of coverage and access to adequate services for all citizens; the desirability of price control and the need to adjust the allocation of resources and State subsidies as between public and private provision of such services.

A Leas-Cheann Comhairle I should have reminded you that I wish to share my time with Deputy Pat Rabbitte.

An Leas-Cheann Comhairle

The formal agreement of the House is required in respect of your intentions, but I am sure we can anticipate that. Does the House agree to that request? Agreed.

Mr. Sherlock

I will conclude very shortly. A report produced by the Eastern Health Board painted a dreadful picture of the collapse of the dental service in their area with 35 people, aged 16 or over, in the high priority group waiting up to ten months for treatment, 8,868 adults waiting up to two years for routine treatment and only 84,000 children from a case load of 250,000 receiving treatment in 1988. There is up to a two-year waiting period for elective surgery such as on impacted teeth and more than 500 cases are awaiting assessment at the Dublin Dental Hospital. These figures apply to the Eastern Health Board area but a similar service can be found in almost every health board area. While in theory we have a free dental service for those with medical cards, in practice there is only an extraction service with no preventive care.

There are many on low incomes who do not have a medical card and are dependent on the dental service for which they have paid through the PRSI. The Irish Dental Association have been trying to suggest that they are concerned about the plight of those on low incomes and that they object to having to provide free services for well-off people. In fact only 2 per cent of PRSI claimants earn more than £20,000 and this shows quite clearly that ordinary middle and low income workers are dependent on these services.

An Leas-Cheann Comhairle

Deputy Rabbitte has 12 minutes.

Mr. Rabbitte

A Leas-Cheann Comhairle, you successfully frustrated me earlier in contributing to the NESC report, and I thought for one terrible moment that you, Sir were going to repeat it. I am delighted that the approval of the House was forthcoming.

An Leas-Cheann Comhairle

I know the Deputy is being a bit flippant. I do not make the rules, I only respond to the rules and the Order of the House.

Mr. Rabbitte

I think there are occasions, a Leas-Cheann Comhairle, when they can be more pliant than others and certainly I was a victim of that after a long wait today. I think it is an unacceptable way to order the business of the House.

Mr. N. Treacy

They also serve who only stand and wait.

Mr. Rabbitte

I think it must be some yardstick of the state of collapse of the public dental service when the Minister is prepared to come into the House as he did last night and concede that the service is in a shambles.

Minister for Health (Dr. O'Hanlon)

I did not say that.

Mr. Rabbitte

It is not very long ago, immediately prior to the summer recess, that the Minister and the Minister of State tried to defend the state of the health service which we all know, and which the people proved in the General Election, was in a terrible state. Nonetheless the Minister tried to defend the indefensible. It is some indictment of the State of the dental service — and every Deputy in this House agrees with the Minister — that it is in a state of collapse. Every single one of us has horror stories of children and women waiting for care.

Mr. N. Treacy

There are wonderful people working in the service.

Mr. Rabbitte

There are wonderful people, but too few of them. Too many are attracted into lucrative private practice and are not working in the public health service and I intend to deal with that point. I think all Deputies in the House know the state the dental services are in. In every clinic around the country citizens cannot get access to orthodontic care because dentists do not have access to the specialisation necessary. I understand that in Deputy Roche's constituency or nearby there is a litigation pending by a citizen who is attempting to assert her constitutional right to care under the Health Act. In my constituency for example, it is estimated, from the latest figures available, that about 400 people are taken off the waiting list every year but some 700 people are added.

There is no necessity at this stage in the debate to refute the argument that orthodontic care is merely elective or cosmetic; it can be a very serious matter for a great number of people. We now have the situation where the "new poor", if I may call them that, cannot afford this treatment while those who are eligible can no longer get access to the service.

Why is there this crisis in the orthodontic service? It is simply because orthodontic specialists will not be attracted into the public health service while there is such a lucrative private practice. Private practice increases the access to cash payments. It is one of the notorious areas of tax evasion. It is not subject to retention tax and the more money which is available to these people in the private sector the less attractive the public sector will be.

I must say I agree with my colleague, Deputy Sherlock, that the dental lobby and the Irish Dental Association in particular, are not in the least interested in the public sector, as the lockout of patients by 75 per cent of their membership proves. Depriving PRSI workers of tooth extractions unless they pay for them and depriving their spouses entirely of any kind of dental care is scarcely the action of any trade union. Indeed, an entire generation of women have been neglected as a result of the disgraceful state of our dental services. It is the utmost in hypocrisy for the dental profession to couch their action in terms of positive discrimination in favour of the poor. I am in agreement with the Minister on this point. I regret very much that the commission on funding in the health services seem to have bought the bogus argument that transferring many citizens with PRSI cover eligibility at the moment into the private sector is going to release moneys which can then be better targeted to social welfare recipients and the poorer sections of the community generally. The only reason the dental association are putting forward that bogus argument is that it will release 1.3 million people into the private pool, thereby enhancing their practice, etc. and further running down the public dental service.

Equally congratulations should be offered to the minority of dentists who refused to join in this selfish and misdirected action, the dentists who continued to work the system with all its imperfections and dentists who, it seems to me, are badly paid in the public dental service area, and certainly badly paid by comparison with their colleagues in private practice. Perhaps this point should be addressed directly rather than by way of the Minister's statement last night when he said he was addressing the question of the difficulty of filling posts in the orthodontic area by bringing in amendments to the contracts under which consultant orthodontists are employed by the health boards. It seems that introducing the common contract system operable for consultants generally throughout the health service is not the way to address this problem. We will merely have the situation where the element of private practice will predominate and the two tier dental service we have at present will be exacerbated. I do not think that is the way the Minister should approach this problem. Dentists should be paid commensurate with whatever it takes to attract the best young dentists into the public health service.

The Government should address the question of those in the private sector who are using the strike weapon to direct into the private sector PRSI workers, who have been paying insurance all their lives in order to have cover, thereby enhancing the earnings of those dentists operating in that sector. While earnings in the private sector remain at the level they are at the public sector will always be the poor relation. The only way to address this problem is through the taxation mechanism where there is wholesale tax evasion. The professional area is generally acknowledged as one of tax evasion and it is very specifically the case in regard to this particular area.

Of course, the dental association have always done this. The Minister should have a discussion on this matter with the Taoiseach who, when he was Minister for Health in 1979, introduced a very worthwhile reform which allowed medical card holders into the social welfare scheme. That was a very worthwhile reform at the time but it was fought tooth and nail by the dental association and the representatives of the dental lobby. If the Minister was to take a leaf out of that book there might be some relief from the difficulty we are now in. How long can this go on? How much longer can we allow the queues which my colleague, Deputy Sherlock, and others in this House have spoken about to continue? How much agony do young children have to endure before the Minister breaks this log-jam? Are we going to continue the neglect of an entire generation of women right into the future? It is a disgraceful situation and unless the Minister tackles the power of the dentists' lobby there will be no improvement in this situation.

In conclusion, I want to underline the point about tax evasion and to repeat the policy commitment made by my colleague that the public dental service is under resourced, that more resources will simply have to be made available if the crisis we are in now is going to be successfully addressed.

Mr. Wyse

I thank the Deputy for giving me five minutes——

An Leas-Cheann Comhairle

To keep things in order, I understand you are giving ten minutes of your 15 minutes to Deputy Roche.

Mr. Wyse

Yes.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Mr. Wyse

The Progressive Democrats have no illusions about the severity and extent of the problems in all aspects of our health services. The dental services have suffered a great deal and there are now enormous waiting lists and queues for treatment for both adults and children. The agreed programme for Government between the Progressive Democrats and Fianna Fáil, and a special allocation of £15 million this year for the health service, reflect the anxiety of the Progressive Democrats on this issue. The programme specifically commits the new Government to taking urgent action which will tackle problems in the area of acute hospital services, with special reference to waiting lists.

In that context I am glad to see that the Minister and his Department recognise the extreme problems facing the dental service. I welcome their action on two fronts, the allocation of an additional £300,000 this year to begin to tackle the waiting lists for orthodontic treatment and the additional money for the extension of the fluoridation of our water system, which I hope will improve oral hygiene. This service is an excellent one and is paying dividends among children especially since they are most receptive to this kind of oral hygiene.

Welcome as these measures are, much more is needed in terms of extra financing and improved management if serious progress is to be made in tackling these problems. It is vitally important to ensure the employment of more professional orthodontists by the health boards. Only one such persons is employed at present in the health service and this is totally inadequate. I urge the Minister as a matter of urgency to employ more people or at least to ensure that such services are provided through the private sector for the 750,000 people who rely solely on the health boards for dental treatment.

The Progressive Democrats are determined during the coming months to try in Government to ensure improvements in the dental service and in the health services generally. I understand that one million of our people are under the age of 16 years. It is assumed that at least one-third of them need orthodontic treatment. This is statistical information from an excellent hospital, the Cork Dental Hospital. I would pay a very special tribute to Professor Hegarty and the tremendous work he is doing there.

I would ask the Minister to give serious consideration to the schools inspection service. It is vital that dental diagnosis should be made at an early stage but the service is practically non-existent in our health board area. At least school inspection would detect problems at the very beginning.

Excellent statistical information in the field of dentistry is now available and I would hope for more time on another occasion to engage in a fuller contribution.

Mr. Roche

There is no doubt that the dental services leave a great deal to be desired. The private service costs are ruinous, as any family person knows. The public dental service is, as always, the victim of a voracious lobby. I agree with many of the points I have heard this evening. The position in regard to orthodontic treatment is extremely disquieting and the news that the Minister is injecting an additional £300,000 for the balance of this year — effectively it has only a few weeks to run — to help move some of the more urgent cases from the orthodontic waiting lists is very welcome. Equally welcome is the news that the Minister intends concentrating further resources on improving the dental services generally in 1990 and subsequent years.

Whatever the motivation for the original motion, this debate is welcome in that it affords us a chance to consider what is wrong with the dental service. Fatuous analysis is not sufficient in this regard. One obvious answer which has been suggested several time tonight is to push endless amounts of additional resources into the services. Clearly putting more resources into the services is one answer and the Government have given an indication that they are putting in more resources, but in the real world where resources are finite this is a limited answer. There is a limit beyond which the taxpayer will not go. For this reason I found much of Deputy Rabbitte's analysis compelling and very interesting. I do not find myself in disagreement with many of the points he made. The problems which exist call, however, for a more intelligent and a broader response than politicians simply calling for more money while at the same time pressing for lower taxes.

A first step must be the prioritisation of the services we provide. If there is a limit we should say honestly what services we intend to deal with as a priority. We are spreading a very small cake over a very large area and we are not achieving the level of service or penetration, particularly in the public service, that one would desire. We all know that funds are in short supply and it is untruthful for any of us to suggest that they are not or that they can readily be conjured up from somewhere. If funds are in short supply they should be concentrated on those areas where they can be used to most effect. They should be spent to yield £1 in value for every £1 spent.

Several Deputies present are members of health boards. Deputy Sherlock referred to the situation in his area and Deputy Rabbitte referred to an issue I have raised in the health board. Many of us who are members of health boards have a great concern as to the value we are getting from the dental service. A clear area of focus is the children's dental service. The Minister has noted that there has been a maintenance of dental staff numbers in the health boards. The Minister also pointed out that there is now keener competition for positions within the public dental service. That is very welcome.

While we hope those welcome trends will continue, it poses the question as to how the health boards utilise the staff resources which they have. There is no doubt that a comparison in the throughput of private and public dental health clinics would reach the inescapable conclusion that the throughput from private clinics would be far greater than the throughput from the latter. The reality is that the throughput from some of our public dental health clinics is lamentably low. While the waiting lists grow the output has tended over the years to diminish. I am suggesting that tighter management of staff resources within the health boards would help to provide a marginal improvement but nonetheless a very worthwhile improvement.

More flexibility in how clinics draw their patients is another aspect. I will illustrate this point by reference to the position in County Wicklow. As Deputy Sherlock mentioned, the waiting lists at some clincis in Wicklow are absolutely unacceptable. There is a waiting list of something like 20 months in Blessington and even greater in Bray. When one examines the statistics right across the health boards one finds vast differences in the length of waiting lists and, therefore, differences in the level of services being provided. The reduction of the longest lists is within the scope of the existing services if we had more flexibility and better management of resources. For example, in population centres in County Wicklow such as Bray and Greystones there have grown over the years unacceptable waiting lists and it is not for the want of investment. I recognise that not only the last Government but preceding Governments invested a great deal of money in a new clinic in the Greystones area but the problem is that there is an inflexibility in the staffing arrangements which means that that clinic is not fully utilised. At a time when we have waiting lists growing as they are that is not acceptable.

We all know that there is a problem with the professional association and this has been referred to by a number of speakers. I do not want to be verbal bashing the Dental Association because every organisation will look for a better deal for their members. While that is to be expected some flexibility should be forthcoming from that organisation. The second area where there is a screaming need for rationalisation is in the use of dental hygienists and dental auxiliaries. The Minister of State, and the Minister in his contribution last night, referred to that matter. Many basic services currently provided by trained dentists within the public dental system could be provided by dental hygienists. I am not sure what Deputy Yates had in mind when he referred to the capacity to train hygienists in Ireland but certainly the staff of the Dublin health clinic, and staff that I have discussed this matter with, are only too anxious and happy to get such a scheme underway but the profession, again, are dragging their heels on that. Seeking to lay blame at a Minister's door is what politicians do best but in doing that they are helping to confuse the issue and maintain something that is unacceptable. If in private practice here, and in practice in other developed countries, dental hygienists and auxiliaries can be used for treatment such as the fissure sealant treatment, a valuable treatment for young children which helps to prevent the incidence of dental cares, there is no reason on God's earth why it cannot be done in the public service in Ireland.

Many basic services can be provided by dental hygienists. We do not employ hygienists and auxiliaries here and I do not see us employing them to anything like the extent we should in the foreseeable future. Since the Dental Act went on the Statute Book in 1985 it has been possible to employ hygienists and auxiliaries in a wide number of areas but that has not happened. Talks on this have been allowed to drag on for far too long. The fact that they have dragged on is to the eternal disgrace of the profession which, after all, is supposed to be a caring profession. If they seek continuously and selfishly to consider their own interests then the entire population will suffer but ultimately the profession will suffer also.

I urge the Minister to press ahead with all the vigour he can muster. He has shown in this and other areas that he is capable of exercising considerable vigour and that when it comes to standing against vested interests there is no better man. The Minister should push this issue and I hope the association will be more accommodating than they have been.

The position in regard to orthodontic care is a public scandal and there is no point in mincing words about it. The simple unadorned fact is that while the Minister has given the green light to the health boards to recruit new staff that recruitment has failed in several health boards because the pickings are better elsewhere. I do not disagree with the point made by Deputy Rabbitte in this regard but I am not sure where his analysis led. He suggested that there should be an increase in salaries but the salaries I saw advertised in the last six months were not small by any means; they were very substantial indeed. What is Deputy Rabbitte suggesting? Is he suggesting that we should increase the salaries to £50,000 or £70,000?

Mr. Howlin

That the Government should tax the private sector.

Mr. Roche

I would not disagree with taxing the private sector and our Government, unlike the Government that included the Labour Party, have made real steps in regard to tax reform.

Mr. Howlin

By abolishing land tax?

Mr. Roche

We have gone after these issues with a vigour that was strangely lacking when the Labour Party were in Government.

Mr. Howlin

The Government are confining taxation to workers.

Mr. N. Treacy

That is not true.

Mr. Roche

That is an avoidance. The issue is being clouded when such statements are introduced. I do not disagree that everybody should pay their fair share of tax. I doubt that one of the 166 Members would disagree with that but that is not the issue now. The issue is that a group has been allowed to hold the public dental service to ransom. If we start squabbling with each other as to which side is more macho we will never solve this problem. What we need from all sides of the House, and those involved in the dental service, is a little bit of logic and concerted action. The Minister and his Department are trying to rectify this by amending the contracts with the consultant orthodontists. That would allow a degree of private and public health practice. I have some personal doubts about that and I hope that abuses which are obvious elsewhere are not allowed to crop up here.

It is true that the dental service is in some difficulties. The problems of the service will only be resolved by taking practical steps such as those announced by the Minister. They will only be resolved by goodwill from the dental profession which has been strangely lacking as we all know. They will only be resolved if Members, and politicians on health boards, show a little bit of common sense and common purpose on the issue.

Mr. Yates

With the permission of the House I should like to allocate some of my time to my colleagues, Deputy Deenihan and Deputy Owen.

An Leas-Cheann Comhairle

A division of the loaves and fishes; the 14 minutes remaining will be divided by three.

Mr. Deenihan

In the short time available to me I should like to highlight the inadequacy of the dental service in County Kerry and emphasise the importance of the promotion of an effective dental hygiene programme in primary and post-primary schools. There is no doubt that if young people take greater care of their teeth the financial burden on the State will be decreased considerably now and in later years. Th school dental service in Kerry is stretched to its limits. In most cases it is totally inadequate. For example, the three primary schools in Killarney town with a pupil population of 1,500, have been without a dental service since July 1987 when the private dental scheme which was part of the school dental programme had to be suspended because of cuts in funding. There are 565 pupils attending the two primary schools in Castleisland and they have been without a dental service since 1987. Those examples reflect the general level of the school dental service in Kerry.

The orthodontic service in the county is almost non-existent. There are more than 1,000 patients on the waiting list for orthodontic treatment and 400 of them are classified as having severe problems. Some young people between 17 and 18 years are still waiting for orthodontic treatment and it is doubtful if they will ever receive it. The £300,000 allocated by the Minister for treatment of the worst cases while welcome will have very little impact on the waiting list. I understand that the Southern Health Board will receive £30,000 of that figure and that that will go towards treating 50 severe cases. I hope that 25 of those cases will be from Kerry. When one considers that there are 400 severe cases in Kerry one realises that the Minister's proposal will do little to reduce the waiting list. The figure allocated is just a drop in the ocean.

Adult medical card holders in Kerry must wait between 18 months and two years for dentures. There are more than 400 people on the waiting list for dentures. There is also a long waiting list for extractions although I accept that emergency cases are dealt with, I am not exaggerating when I say that the public dental service in Kerry has almost collapsed because of the lack of adequate funding. I appeal to the Minister to provide increased funding in 1990 so that we can start to correct this unacceptable neglect.

Mrs. Owen

I should like to thank Deputy Yates for giving me some of his time and to commend him on the motion before the House. I am sorry the Minister is not present but I hope his colleagues will convery to him my view that he should not be reacting to a Private Members' motion which suggests that more money should be made available for our disastrous dental health service.

Mr. N. Treacy

That is not true. The motion is a reaction to the Minister's initiative.

Mr. Yates

That is a joke.

Mrs. Owen

The Minister's actions should be active as opposed to reactive. If one reads yesterday's edition of the Evening Press one will get the impression that the Minister was reacting to our motion. Why is it that he had to be prompted to take action? He, more than anybody else, is aware of the problems. An article in that paper states he is considering a scheme to make parents pay in future for the thousands of other children who need corrective dental treatment. All those who could in any way find the money to have the corrective dental treatment done have done so and the people remaining on the list needing that care just cannot stretch to the high costs of orthodontic work. Perhaps I am the most appropriate person to speak tonight on this because less than six hours ago I collected my 13 year old from orthodontic treatment on which we eventually decided. I know how much it costs, but we are among the lucky parents who can afford to pay for it. Despite what the Minister says, that he is taking the most urgent cases, many more cases have to be dealt with and many parents cannot afford to pay.

I understand from a number of dentists I have spoken to that a large number of the 24,000 on the orthodontic waiting list could be dealt with if the will was there to allow ordinary dentists to do so. One dentist told me that many children are assessed for orthodontic work. It can be done now with the specialised training with which dentists are coming out of college. Only special cases, of which there are a large number, need the full skill of an orthodontist. The Minister could clear that list tomorrow if he wanted to and would make the money available to allow that.

The Minister is neglecting and has neglected in the dental service a large range of women particularly during the years when they can be pregnant. It is well known, and he as a doctor will know, that during pregnancy women's teeth suffer and it seems shortsighted for him to say to women who are on medical cards and require dental service: "Sorry, you will have to wait two or three years". Two or three years is too long. They lose their teeth and eventually the cost is a great deal more than it would have been if they could have had their treatment immediately after pregnancy.

There is a waste of money in the dental service. Picture if you will, Sir, a new building in the north city suburbs where there are four highly equipped dental surgeries with only two dentists working in them and two empty surgeries with thousands of pounds worth of equipment in them. Picture a town like Swords with 25,000 people and one dentist working from 9 a.m. to 3 p.m. five days a week to cover that population. There is waste of money. It would have been better if a better assessment of the needs of the north side suburb I have spoken about was made and the money had gone elsewhere to provide better facilities.

Finally, I have a question for the Minister. It is my information that a sneaky — that is all I can call it — little rule has slipped into the national school dental service. Up to now children at national school could be assessed for orthodontic or further treatment and once the need is recognised during their primary school time they can get it later if it is to take two or three years. I understand that a rule has come in — I want this confirmed or denied here tonight — that only children under 12, irrespective of whether they are still in the national school, are eligible now to be assessed for work to be done even after they leave. Many children stay in national schools after 12 years of age for many reasons and it would be disgraceful if they were being excluded from the dental service because they have reached 12 while still in sixth class. I would like the Minister to confirm or deny that and, if it is true, to change that rule.

Mr. N. Treacy

Not true.

An Leas-Cheann Comhairle

Deputy Yates has seven minutes.

Mr. Yates

I thank all Deputies who contributed to this debate. It has been very constructive and I thank the Opposition parties for their support for this motion. However, this debate has had some regrettable aspects. Obviously, Ministers do not put too much thought into the scripts handed to them five minutes before they come in here.

Mr. N. Treacy

Not true.

Mr. Yates

It is obvious that some people who are not too long in the Department have not taken the time to read all the lengthy documentation there is in the dental service. I would remind some of those who are a short time in the Department, of their own Department's documentation in relation to the dental service. Let me quote first from what the Minister of State said tonight:

To listen to the Opposition here last night you would get the impression that the water flouridation programme was a shambles. Nothing could be further from the truth.

Let us turn to page 19 of the Leyden report on the dental services and see what it says about water fluoridation:

The Working Group acknowledges that the water fluoridation programme does not always function at optimal levels due in the main to the age of the equipment, some of which is now in place for over twenty years; to the lack of stand by or short term replacement pumps which can be called into service during a pump failure and finally to the lack of adequate storage capacity for fluoride in some water supplies.

Mr. N. Treacy

And the Minister had——

Mr. Yates

That, in any man's language, is a shambles and they are set to spend £400,000 a year. The Minister is doing less than half that and only making a token response this year.

Mr. N. Treacy

You put nothing in.

Mr. Yates

I am coming to the Minister's speech shortly, let him not worry. The Minister of State tonight referred to the ad hoc scheme that operated from 1979 to the mid-eighties. This was a scheme whereby poor, unfortunate medical card holders who could not afford dental treatment would go to their county clinic and be referred under the ad hoc scheme to a private dental surgeon. The Minister said that at its peak 32,000 persons receive treatment annually. A particularly high percentage of applicants require dentures and, indeed, the cost of providing a full course of dental treatment under the ad hoc scheme was considerably higher than the cost of an average course of treatment under the Department of Social Welfare scheme. He said the need for dentures was very great and therefore the scheme was expensive to operate. The Minister of State blamed poor old age pensioners for the fact that they have no teeth.

Mr. N. Treacy

Not true. Do not take the thing out of context.

Mr. Yates

He was not able to find the money to maintain that scheme simply because so many pensioners require dentures, while only this afternoon——

Mr. N. Treacy

The Deputy told us last night.

Mr. Yates

——I received a phone call from a denturist who is prepared to go on hunger strike outside the gates of this building because this Minister will not direct the dental council to remove the restrictive practices of dental surgeons who charge £300, £400 and £500 for dentures which can be provided at between £50 and £120. If the Minister has any concern for the cost of dentures he will use the powers he has under the 1985 Dentists Act to do something about that.

The Minister last night said that the health board dental service for children is in pretty good order and has not been affected to any great extent. That is not at all what the Leyden report said. It said the pressures and the massive increase in demand for emergency treatment for eligible adults is hampering the development and in certain cases the maintenance of dental services for children.

We go to the most telling part of the report where it says the Minister is acting in defiance of the law. I quote from page 27:

The Working Group considers that the health boards are failing in their statutory duty to provide dental services for eligible adults. As the table below shows, fewer than 39,000 eligible adults received routine dental treatment in 1987. This represents only 6 per cent of the adult and adolescent population...

Since then the position has got worse, and if the Minister is going to take a different tack in this Dáil and say that in some way he is not prepared to carry the can and his Government colleagues are at fault, as he suggested last night and as this token amendment suggests when it "commends the resolve of the Minister for Health", implying that the Minister for Health has more resolve than the Minister for Finance and the Taoiseach, let me say this type of avoidance of collective responsibility is not acceptable.

Right across the country the type of health service you get depends on where you live. That is disgraceful. The Minister has presided over a patchwork quilt of health services where nothing is being done to provide a national strategy for the dental service to give guidelines to each health board to ensure a uniform level of service to which people can look forward and appreciate.

Much talk has been made about the role of hygienists. No provision whatsoever has been made to train Irish hygienists. There is some discussion and some improvement in relation to the dental council availability of hygienists. You have to go to Britain if you want to be a hygienist and you have to be a former dental surgery assistant. The Minister has taken no steps to bring hygienists into operation in this country. The Minister is evading his responsibilities. He is trying to blame the Government for what is his own neglect. He is trying to evade his responsibilities under the 1970 Act. This is unacceptable. In this debate we could have looked forward to some initiative. Instead, we are told we have to depend on his efforts around the Cabinet table. The £300,000 for orthodontic services is a joke in the context of what is required.

Mr. N. Treacy

That is an irresponsible statement.

Mr. Yates

I do not accept that the waiting list is 12,250 as opposed to the figure given by him by way of Dáil questions, that the waiting list for orthodontic services was 24,000. The only reason it is changed is that in some health board areas the service has been suspended and the waiting lists have been abandoned because it is futile trying to maintain them.

I appeal to the Minister of State at the Department of the Environment, Deputy Harney, and the Minister of State at the Department of Industry and Commerce, Deputy Leyden, who have shown a great interest in these areas in the past, to support this motion if Deputy Leyden's signing of this report is to mean anything. Again, I thank the Opposition Deputies and I hope the Government will not delay any further before providing a basic dental service for all our population.

Amendment put.

The Dáil divided: Tá, 76; Níl, 69.

Tá

• Ahern, Bertie.
• Ahern, Dermot.
• Ahern, Michael.
• Andrews, David.
• Aylward, Liam.
• Barrett, Michael.
• Brady, Gerard.
• Brady, Vincent.
• Brennan, Mattie.
• Brennan, Séamus.
• Briscoe, Ben.
• Browne, John (Wexford).
• Burke, Raphael P.
• Calleary, Seán.
• Callely, Ivor.
• Clohessy, Peadar.
• Connolly, Ger.
• Coughlan, Mary Theresa.
• Cullimore, Séamus.
• Daly, Brendan.
• Davern, Noel.
• Dempsey, Noel.
• Dennehy, John.
• de Valera, Síle.
• Ellis, John.
• Fahey, Frank.
• Fahey, Jackie.
• Fitzgerald, Liam Joseph.
• Fitzpatrick, Dermot.
• Flood, Chris.
• Flynn, Pádraig.
• Gallagher, Pat the Cope.
• Geoghegan-Quinn, Máire.
• Harney, Mary.
• Hillery, Brian.
• Hilliard, Colm.
• Jacob, Joe.
• Kelly, Laurence.
• Kenneally, Brendan.
• Kitt, Tom.
• Lawlor, Liam.
• Lenihan, Brian.
• Leonard, Jimmy.
• Leyden, Terry.
• Lyons, Denis.
• Martin, Micheál.
• McCreevy, Charlie.
• McDaid, Jim.
• McEllistrim, Tom.
• Molloy, Robert.
• Morley, P.J.
• Nolan, M. J.
• Noonan, Michael J. (Limerick West).
• O'Connell, John.
• O'Dea, Willie.
• O'Donoghue, John.
• O'Hanlon, Rory.
• O'Keeffe, Ned.
• O'Kennedy, Michael.
• O'Leary, John.
• O'Rourke, Mary.
• O'Toole, Martin Joe.
• Power, Seán.
• Quill, Máirín.
• Reynolds, Albert.
• Roche, Dick.
• Smith, Michael.
• Stafford, John.
• Treacy, Noel.
• Tunney, Jim.
• Wallace, Dan.
• Wallace, Mary.
• Walsh, Joe.
• Wilson, John P.
• Woods, Michael.
• Wyse, Pearse.

Níl

• Barnes, Monica.
• Barrett, Seán.
• Barry, Peter.
• Belton, Louis J.
• Browne, John (Carlow-Kilkenny).
• Bruton, John.
• Bruton, Richard.
• Byrne, Eric.
• Deasy, Austin.
• Deenihan, Jimmy.
• Doyle, Joe.
• Dukes, Alan.
• Durkan, Bernard.
• Enright, Thomas W.
• Farrelly, John V.
• Fennell, Nuala.
• Ferris, Michael.
• Finnucane, Michael.
• FitzGerald, Garret.
• Flaherty, Mary.
• Flanagan, Charles.
• Garland, Roger.
• Gilmore, Eamon.
• Gregory, Tony.
• Harte, Paddy.
• Higgins, Jim.
• Higgins, Michael D.
• Howlin, Brendan.
• Kavanagh, Liam.
• Kemmy, Jim.
• Kenny, Enda.
• Lee, Pat.
• Lowry, Michael.
• McCartan, Pat.
• McCormack, Pádraic.
• Carey, Donal.
• Connaughton, Paul.
• Cosgrave, Michael Joe.
• Cotter, Bill.
• Creed, Michael.
• Crowley, Frank.
• Currie, Austin.
• D'Arcy, Michael.
• McGahon, Brendan.
• McGinley, Dinny.
• Mac Giolla, Tomás.
• McGrath, Paul.
• Mitchell, Gay.
• Moynihan, Michael.
• Nealon, Ted.
• Noonan, Michael. (Limerick East).
• O'Brien, Fergus.
• O'Keeffe, Jim.
• O'Shea, Brian.
• O'Sullivan, Gerry.
• O'Sullivan, Toddy.
• Owen, Nora.
• Pattison, Séamus.
• Quinn, Ruairí.
• Rabbitte, Pat.
• Reynolds, Gerry.
• Ryan, Seán.
• Sheehan, Patrick J.
• Sherlock, Joe.
• Spring, Dick.
• Taylor, Mervyn.
• Taylor-Quinn, Madeleine
• Timmins, Godfrey.
• Yates, Ivan.

Tellers: Tá, Deputies V. Brady and Clohessy; Níl, Deputies J. Higgins and Flanagan.

Amendment declared carried.

Question put: "That the motion, as amended, be agreed to".

The Dáil divided: Tá, 75; Níl, 66.

Tá

• Ahern, Bertie.
• Ahern, Dermot.
• Ahern, Michael.
• Andrews, David.
• Aylward, Liam.
• Barrett, Michael.
• Brady, Gerard.
• Brady, Vincent.
• Brennan, Mattie.
• Brennan, Séamus.
• Briscoe, Ben.
• Browne, John (Wexford).
• Burke, Raphael P.
• Calleary, Seán.
• Callely, Ivor.
• Clohessy, Peadar.
• Connolly, Ger.
• Coughlan, Mary Theresa.
• Cullimore, Séamus.
• Daly, Brendan.
• Davern, Noel.
• Dempsey, Noel.
• Dennehy, John.
• de Valera, Síle.
• Ellis, John.
• Fahey, Frank.
• Fahey, Jackie.
• O'Connell, John.
• O'Dea, Willie.
• O'Donoghue, John.
• O'Hanlon, Rory.
• O'Keeffe, Ned.
• O'Leary, John.
• O'Rourke, Mary.
• O'Toole, Martin Joe.
• Power, Seán.
• Quill, Máirín.
• Reynolds, Albert.
• Fitzgerald, Liam Joseph.
• Fitzpatrick, Dermot.
• Flood, Chris.
• Flynn, Pádraig.
• Gallagher, Pat the Cope.
• Geoghegan-Quinn, Máire.
• Harney, Mary.
• Hillery, Brian.
• Hilliard, Colm.
• Jacob, Joe.
• Kelly, Laurence.
• Kenneally, Brendan.
• Kitt, Tom.
• Lawlor, Liam.
• Lenihan, Brian.
• Leonard, Jimmy.
• Leyden, Terry.
• Lyons, Denis.
• Martin, Micheál.
• McCreevy, Charlie.
• McDaid, Jim.
• McEllistrim, Tom.
• Molloy, Robert.
• Morley, P.J.
• Nolan, M.J.
• Noonan, Michael J. (Limerick West).
• Roche, Dick.
• Smith, Michael.
• Stafford, John.
• Treacy, Noel.
• Tunney, Jim.
• Wallace, Dan.
• Wallace, Mary.
• Walsh, Joe.
• Wilson, John P.
• Woods, Michael.
• Wyse, Pearse.

Níl

• Barnes, Monica.
• Barrett, Seán.
• Barry, Peter.
• Belton, Louis J.
• Browne, John (Carlow-Kilkenny).
• Bruton, John.
• Bruton, Richard.
• Byrne, Eric.
• Carey, Donal.
• Connaughton, Paul.
• Cosgrave, Michael Joe.
• Cotter, Bill.
• Creed, Michael.
• Crowley, Frank.
• Currie, Austin.
• D'Arcy, Michael.
• Deasy, Austin.
• Deenihan, Jimmy.
• Doyle, Joe.
• Dukes, Alan.
• Durkan, Bernard.
• Enright, Thomas W.
• Farrelly, John V.
• Fennell, Nuala.
• Ferris, Michael.
• Finnucane, Michael.
• FitzGerald, Garret.
• Flaherty, Mary.
• Flanagan, Charles.
• Garland, Roger.
• Gilmore, Eamon.
• Gregory, Tony.
• Harte, Paddy.
• Higgins, Jim.
• Higgins, Michael D.
• Howlin, Brendan.
• Kavanagh, Liam.
• Kemmy, Jim.
• Kenny, Enda.
• Lee, Pat.
• Lowry, Michael.
• McCartan, Pat.
• McCormack, Pádraic.
• McGahon, Brendan.
• McGinley, Dinny.
• Mac Giolla, Tomás.
• McGrath, Paul.
• Mitchell, Gay.
• Moynihan, Michael.
• Nealon, Ted.
• Noonan, Michael.
• O'Brien, Fergus.
• O'Keeffe, Jim.
• O'Shea, Brain.
• O'Sullivan, Gerry.
• O'Sullivan, Toddy.
• Owen, Nora.
• Pattison, Séamus.
• Rabbitte, Pat.
• Reynolds, Gerry.
• Sheehan, Patrick J.
• Sherlock, Joe.
• Spring, Dick.
• Taylor-Quinn, Madeleine.
• Timmins, Godfrey.
• Yates, Ivan.

Tellers: Tá, Deputies V. Brady and Clohessy; Níl, Deputies J. Higgins and Flanagan.

Question declared carried.