National Oral Health Policy: Discussion

This morning the committee will meet representatives from the Irish Dental Association and the faculty of dentistry at the Royal College of Surgeons in Ireland, RCSI, to hear their views on our national oral health policy. On behalf of the committee, I would like to welcome the president of the Irish Dental Association, Professor Leo Stassen, and its chief executive, Mr. Fintan Hourihan, as well as the dean of the faculty of dentistry at RCSI, Dr. John Marley, and Professor Chris Lynch, vice dean.

I wish to draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I also wish to advise witnesses that any opening statements they have made to the committee may be published on the committee's website after the meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I ask Mr. Hourihan to make his opening statement.

Mr. Fintan Hourihan

I thank the Chairman.

I am the chief executive of the Irish Dental Association and I am joined by Professor Leo Stassen, a consultant oral maxillo-facial surgeon and president of the Irish Dental Association. We are pleased to present the views of the association on the new oral health policy generally and specifically in regard to two matters highlighted in the committee's invitation. The association represents 2,000 dentists, which constitutes the overwhelming majority of dentists in practice across all branches of the profession in Ireland.

The association was not invited to participate in, nor was it consulted in any meaningful way on, the preparation of this new oral health policy. We saw its contents for the first time on the date of its publication last month. We are currently awaiting a meeting with the Minister for Health and his team at the Department of Health to be briefed on the policy and how the Department intends to proceed. Our board of directors met to consider the policy document along with our key committees for dentists in general practice and working in the HSE public service. Last weekend we had a briefing and consultation meeting attended by 200 members of our association where dentists were briefed on the basis of our understanding of the oral health policy document and where we fielded questions and comments from our members. Before commenting on the policy further, it is fair to say that the most common first reaction among our members is disbelief and anger at how few dentists in practice, whether in general practice, specialist practice or within the HSE, were consulted in the preparation of this new policy, even though they are the ones it is hoped will deliver 90% of dental care in future. Therefore, we respectfully submit that this is not the last word on oral health in Ireland. We regard this as a starting point for a badly needed discussion on oral health.

To give a broad overview of oral health in Ireland today, dental care is primarily provided on a private basis by dentists who work independently of the State, and without any of the levels of resources provided to doctors in general practice. These dentists can be contracted to provide care for large cohorts of eligible holders of medical card or PRSI benefits, although the dental treatments funded by the State are extremely limited. Public service dentists employed by the HSE play a critical, complementary role in providing expert care, primarily for children and special care children and adults. In addition, we have two dental hospitals and a small number of acute, tertiary facilities. Private out-of-pocket payments account for 83% of all money spent on dental care, with State-provided or State-funded services accounting for just 14%. The latest CSO survey on income and living conditions published just before Christmas shows that almost a third of households with children where at least one person in the household had either a dental examination or treatment, or both in the last 12 months reported that the associated costs were a financial burden. This clearly shows the consequences of the decision by the State to take away an estimated €100 million per annum in State supports for patients after 2009 with cuts to the two State schemes, namely, the medical card and PRSI scheme. That is equivalent to nearly €900 million over nine years before there was some restitution as regards the PRSI. While oral health in Ireland is improving, most of the gains are being recorded by higher income groups in the main, and the resulting chasm in oral health status according to income is widening as a direct result of the massive cuts in State support. In passing, we should say that the oral health policy fails to explain that the reported level of dental decay is seriously under-reported by the exclusion of as many as 21% of children from the so-called Fluoride and Caring for Children's Teeth, FACCT, study on which it relies.

It is notable and very welcome, therefore, that the Minister for Health has identified reducing oral health inequalities as one of his two goals for the new oral health plan. Regrettably, based on our members’ initial analysis of the plan, it seems certain that oral health inequalities will increase rather than reduce with the plan’s proposals in regard to the provision of dental care and treatment. We see this as the inevitable consequence of moving from a targeted approach, where HSE public dental surgeons directly target children at key age ranges of their development for dental services, including but not limited to prevention, restorative care and referral to secondary services where eligible. This approach enables those who do not attend to be identified and followed up with. The policy’s proposal is to redirect this service into general practice where identifying risk will be dependent on attendance by the very groups who are both least likely to attend but also have the worst oral health and the greatest treatment need.

There are some notable positives but also some obvious flaws in this policy. It is a positive development that we finally have an oral health policy to consider. It stimulates discussion about oral health and that can only be a good thing. The focus on prevention and screening, the policy’s provisions in regard to building links between oral and general health through a common risk factor approach, its proposals in regard to the dental workforce and professional development as well as research and evaluation, are all positive developments. However, the policy’s focus on prevention needs to be counter-balanced by the fact that prevention going forward cannot fix the significant amount of untreated oral diseases that are already present today. Our wish to replace the unfit for purpose medical card scheme and contract has been stymied by the declaration of the Department over many years that this could not happen until the publication of a new oral health policy. This has also been used as an excuse also for the delayed publication of new legislation to amend the 1985 Act. We see the publication of this policy as clearing the pitch and allowing all parties to engage without delay in long overdue discussions on the State contracts and also the need for new legislation.

The most glaring weakness in this policy is the section dealing with the provision of dental care and treatment. The headline proposal, at least according to the initial media coverage, is the proposal to extend limited free dental care to children under the age of six and eventually to under-16s. However, the plan offers no evidence to justify taking care and treatment of children from the HSE public dental service. It might seem easy to suggest taking work from the HSE public dental service when it has been hollowed out and left to crumble over the past decade. As the number of eligible patients increased by 20%, the number of dentists and other key support grades in the HSE fell by 20% with inevitable reductions in key targeted developmental exams and preventive dental work and with the service largely reduced to an emergency dental service. The consequences for patients were inevitable and have unfortunately resulted as we predicted. It is therefore incomprehensible to our members in both the HSE public service and private practice that key aspects of the public dental service are now to be privatised.

Our members are concerned that to move from a targeted, risk-based model to a demand-led model would be catastrophic for patients in lower socio-economic areas with high treatment needs. All dentists are upset at the risks posed by the new proposals to continuity of care and the provision of emergency care for children and the possibility that the expert skills and experience of dentists in the HSE's public dental service will be lost. They fear that the public service will ultimately prove to be a dumping ground when the unworkable model proposed, which our members believe is based on a failed and discredited NHS experiment, inevitably collapses.

No mention is made in the policy of how the current crisis in arranging dental care for children who require to be treated under general anaesthetic, which we fear is anywhere up to 10,000 per annum, is to be addressed. Equally, raising unrealistic expectations as to what general practice can deliver or wishes to deliver in regard to treatment of children is also dangerous and suggests that the authors are seriously out of touch with the realities of general dental practice in Ireland. The provisions in regard to the care and treatment of adults represent little more than repackaging of the existing suite of treatments which was savagely cut in 2009, a decision which every right-thinking person described as shameful at the time. In some cases, adult medical card patients could actually be left with even fewer treatments than they can currently access. More fundamentally, the policy offers nothing to the 60% of adults who do not have access to free or subsidised dental care other than very limited PRSI dental benefits. We ask why there is no support or funding towards the cost of dental treatment provided to those adults and why no change is being made in the tax relief being made available to adults. In summary, our members believe that the provisions in the policy for the care and treatment of children and adults are seriously flawed, economically unviable and operationally unworkable.

A policy that is good for patients will be good for dentists but our members feel this policy fails patients. Any oral health policy has an obligation to use the resources of the state to the benefit of all its citizens but to ensure the most vulnerable are first served by those resources. This is the ethical principle of justice and it is a cornerstone of medical service delivery. This policy, as it has been presented, stands to fail this essential principle. Despite not being consulted on the new policy, the Irish Dental Association produced its own document, Towards a Vision for Oral Health in Ireland, which we wish to see incorporated in a new oral health policy. We have sent copies to the Minister for Health, Deputy Harris, and the main political parties and we have circulated a copy to the committee. Over the past year, the association has decided as a matter of policy to prioritise independent practice and to reduce the reliance of general dental practitioners and their patients on dental schemes funded by third parties, such as the State, for reasons which are obvious. Independent dental practice needs to be complemented by a stronger not weaker public dental service. This will not preclude the association and its members from engaging with the Department of Health and its representatives following publication of its new oral health policy. What is clear, however, is that any prospect of a successful realisation of the objectives contained within the new oral health policy will require a fundamental shift in the attitude of the State towards the profession in tandem with a new approach towards promoting oral health into the future. The Irish Dental Association has many positive proposals to share with the Department of Health for enhancing oral health for all but only time will tell if the Department is interested in or capable of engaging with the profession.

We were asked two specific questions by the committee which we are happy to address. The association supports the registration and regulation of all dental technicians. The association believes that dental technicians should not see patients directly unless they have completed training to clinical dental technician, or CDT, level. All persons providing direct dental care must have a clear scope of practice and they must be regulated fully. Clinical dental technicians are regulated but dental technicians are not. The association believes that it would be dangerous and unethical to allow dental technicians or any member of the dental team to provide direct access to the public without formal compulsory regulation and a clearly defined scope of practice. Unfortunately, the public and patients do not understand the difference between clinical dental technicians, dental technicians and denturists. Regarding school based interventions, we are extremely concerned at what we understand to be a move away from a targeted approach to provision of dental care and prevention by HSE public service dentists in favour of a demand led approach to the provision of dental care in general practice. We are happy to address any comments or questions the committee wishes to present.

I thank Mr. Hourihan for his opening statement and call Dr. John Marley to make his.

Dr. John Marley

I am the current dean of the Faculty of Dentistry at the Royal College of Surgeons in Ireland. Attending with me today is our vice dean, Professor Chris Lynch. I thank the committee for inviting us this morning to present on oral health policy in Ireland. I will first set out why were are here today and we will then be very happy to address questions the committee has.

The Faculty of Dentistry of the Royal College of Surgeons in Ireland was established in 1963. It is made up of dental specialists and consultants, senior academics and general dentists who provide education, accreditation of postgraduate educational programmes and assessments of qualified dentists both in Ireland and abroad. The faculty is Ireland’s leading centre for postgraduate dentistry examinations, with around 900 dentists from Ireland and abroad examined each year and more than 2,000 of its graduates working as dentists across Ireland and the world. Faculty representatives were invited to participate in a consultation day on the national oral health strategy which was held in Thomond Park in May 2015. This day consisted of general information sharing and discussion activity. I was formally invited to a meeting by Dr. Kavanagh, the chief dental officer, to meet her and the deans of the dental schools in Cork and Dublin on 7 November 2018. The group was informed that the publication of the oral health policy was imminent. At no time was the RCSI faculty invited to be represented on the scientific panel which was tasked with developing the policy.

As stakeholders with a significant interest in the delivery of quality oral and dental healthcare for the Irish population, the faculty has raised concerns on a number of issues. The first is the lack of a foundation year of dental training. Unlike our medical colleagues, where a pre-registration year, or intern year, is mandatory, newly qualified dentists are permitted to practice independently without the benefit of formal mentoring, clinical support, supervision and training in their first and pivotal year as a qualified dentist. Such a scheme exists in the UK for dentists who have trained in England, Scotland, Wales and Northern Ireland. We strongly support a mandatory year of foundation training for newly qualified dentists in Ireland. This would ensure that a dentist’s initial training requirements correspond to that of a medical graduate. As in the UK, it is envisaged that this training would take place in established practices. With regard to continuing professional development, we are concerned about the absence of legislation in Ireland to ensure and reassure the public that all dentists and their teams are subject to mandatory, lifelong learning and development through CPD. That would ensure that they continue to provide safe, effective and contemporary treatments for their patients throughout their working lives. There is a marked contrast to our medical and pharmacy colleagues in Ireland where CPD and lifelong learning are an expected and mandatory requirement. In the UK, the equivalent scheme for dentists includes mandatory training, including in radiation protection, infection control, oral cancer detection and complaints handling.

We are also concerned regarding the lack of access to dental speciality and consultant training in Ireland. Currently, there are just two dental specialties recognised by the Irish Dental Council in Ireland, namely, orthodontics and oral surgery. There are a further 11 recognised dental disciplines in the UK and other jurisdictions. There are a small number of specialist training programmes in Ireland but, unlike medical training, these are self-funded by the trainees. There is also no formal mechanism for training dental consultants in the Republic of Ireland. Currently, there is no national body or forum where consultant dental training issues, including funding, can be discussed and progressed. On foot of section 86 of the Medical Practitioners Act 2007, the Health Service Executive has a number of responsibilities in relation to the development and co-ordination of specialist dental education and training and the subsequent alignment of this activity with dental workforce planning. We propose that this training be expanded to include all dental specialties and consultant level training and that, as is the case with medicine, this be funded by the HSE and Department of Health instead of personally by the trainees.

I turn to the impacts of the policy.

Dental foundation, DF, training provides an important transition for the newly qualified dentists from the sheltered environment of the dental school to that of the rigours and demands of general dental practice. It follows that with the absence of a foundation year of training, with protected time for learning and self-reflection in a supportive environment, the newly qualified dentist is immediately deep-dived into a complex environment of independent practice without the safety net of the support and guidance that could be provided and is provided to their medical peers. DF training has been established, in a mandatory arrangement, in the UK setting since the early 1990s.

The next impact results from the lack of legislation to mandate dental CPD. The Dental Council's code of practice pertaining to professional behaviour and dental ethics states that "all dentists have an obligation to maintain and update their knowledge and skills through CPD and the Dental Council decided to introduce its voluntary scheme." As a voluntary scheme, it follows that in the absence of mandatory, audited CPD, there is an increased potential for patients not to receive as good-quality care as they should expect and deserve. As occurs in other European jurisdictions, without this significant governance pillar, there is no formal mechanism for dentists to demonstrate to their patients that they are keeping their skills and knowledge up to date. While we know that all members of the dental team are appropriately trained and qualified at graduation, there needs to be a formal mechanism to allow them to keep their skills up to date, continue to know their limits and continue to be able to recognise when to refer patients appropriately.

With regard to the lack of access to funded higher specialist-consultant training, there are many implications for the current state of, or lack of, postgraduate dental training in Ireland. Fees payable for a three-year university-based specialist programme can be in the region of €100,000 and this is frequently a barrier to entry to such training. Talented young dentists who want a career in the public sector or academic dentistry in Ireland have only limited access to training programmes, unlike their medical peers. These young dentists are likely to leave Ireland to access these programmes of training in the UK, Europe or the USA, benefitting the dental health of other countries at our expense.

As there is no formal pathway for dentists to undertake consultant training in Ireland, any consultant appointments in Ireland are being made by equivalence which is determined by individual institutions in collaboration with external assessors as part of the selection-appointment process. This poses significant problems with appointments when specialists claim equivalence as a result of additional training. There is no clear mechanism to evaluate equivalence, which has resulted in competitions for consultant posts being abandoned. There are also concerns surrounding the quality assurance of training for individuals being considered for appointment to such posts.

Most dental consultants in Ireland are in their mid to late 50s or the early 60s. Many are expected to retire in the next three to five years. With no formal training and the difficulties with assessing equivalence, there is an existential risk to the dental service in terms of expertise, experience and delivery of undergraduate dentistry courses. Such considerations raise concerns about the training of the next generation of dentists, dental hygienists and dental nurses in Ireland as well as the leadership of dentistry in the 21st century.

I will now discuss the position in Ireland versus other jurisdictions. Within the UK, dental foundation training is administered by the 12 postgraduate deaneries in England and one each in Scotland, Wales and Northern Ireland, and currently there are in excess of 1,000 dental foundation trainees across the UK. Key exemplars of mandatory CPD requirement in Ireland are in medicine and pharmacy. In the UK, dental CPD is also mandatory and is overseen by the UK General Dental Council. Higher specialist and consultant training in all dental disciplines is available in the UK, which recognises 13 specialist lists.

Regarding reform proposals, for the foundation training year, the FoDRCSI supports a compulsory year of foundation training for newly qualified dentists. This would ensure that their immediate post-qualification training requirements correspond to that of a medical graduate. These posts should be salaried and would complement the oral health policy objective of equitable access to dental care for all. The FoDRCSI recommends the implementation of mandatory CPD through new legislation as a matter of urgency. There are several possible models including that of the General Dental Council of the UK. This will require new legislation. However, we feel that this development would be a significant external reassurance and oversight of the commitment of Irish dental team members to the safe delivery of quality oral health care for patients in Ireland.

In regard to specialist and consultant training, the FoDRCSI recommends an expansion of the current list of recognised specialties through new legislation as a matter of urgency. The FoDRCSI also recommends the creation a specific dental body which has, as its responsibility, the setting and quality assurance of consultant training programmes in all the dental specialties. The FoDRCSI would be happy to input to this body given its expertise in this field. This body would require ring-fenced funding so that both dental specialist and dental consultant training regains equivalency with medical consultant training.

The Faculty of Dentistry, RCSI, has laid out its concerns and recommendations for change. At the core of these issues is the need to maintain the quality of care and services provided to our patients. Professor Lynch and I are happy to respond to any further queries on the issues as outlined.

Some members have to leave at 10.30 a.m.because there are questions in the Dáil to the Minister for Health and they are obliged to participate. Some will return if the time is available. We had invited representatives from the Department of Health but, through circumstances outside their control, they are unable to attend. We will, however, return to hear their views at a later date.

I thank the witnesses for their detailed statements. They make for some stark reading and I imagine that many members of the public listening to the submissions will be worried about what was said regarding the new national oral health strategy and the issues with training, recognition, continuous professional development, etc. The two opening statements were stark, even within the parameters of what this committee hears on a weekly basis. It is incumbent upon us to take them seriously and I thank the witnesses for the work they put into them.

I will start with the oral health strategy. I was exasperated but not surprised to hear that yet another healthcare strategy was being developed, rolled out, printed, launched and tweeted without anybody talking to the medics themselves about what might be a good idea. The witnesses did not pull their punches on this and I do not blame them. It is professionally disrespectful but, much more serious than that, one cannot get a decent healthcare strategy without talking to the medics in the field, in this case oral health. What has been the level of exclusion in respect of consulting dentists from the oral health strategy? It seems quite extraordinary. Do the witnesses have a sense of why they were excluded from inputting into a strategy that their members will have to implement? Did they ask if they could input into it? They said they were still looking for a meeting with the Minister and his officials. How long have they been looking for that meeting?

Mr. Fintan Hourihan

We wrote to look for a meeting with the Minister following the publication of the policy. That was just over a month ago. There were a number of occasions when meetings were arranged but, for genuine reasons, they did not proceed because the Minister was caught up in controversies here at the time. I have detailed a list of all the submissions we have made in the past few years.

We made regular pre-budget submissions from 2014 to 2018, as well as submissions to the Sláintecare project. We also made submissions to this committee in 2013 on issues regarding the draft medical contract for general practitioners as well as countless other submissions. We have published a number of documents regarding our efforts in the area of oral health. Dr. Marley mentioned an event which happened in Limerick in 2015. We were present at it, but I draw a distinction between what I call "tick-box consultation" and meaningful consultation.

The HSE has a good document on managing change. It states there are three principles, namely, discuss, design and deliver. That is a very good model. We have not been involved in the discussions regarding this new strategy but we want to be involved in the design and we certainly want to be involved in the delivery. That is because the dentists we represent are the people who will be expected to carry out that delivery. I cannot speculate on the motivation of the Department of Health, but I am sure it will explain its approach. Two documents were published, however, including one containing more than 50 pages, which is being circulated widely, and another 160-page document detailing in an appendix all of the groups and individuals who helped in respect of the strategy. It is notable that only one dental general practitioner is mentioned.

I will point out that we did make submissions and we published a document as recently as last September. That has not been acknowledged or referenced. We also developed a document as far back as 2013, in conjunction with the college faculty and the two dental schools. I do not believe that has been acknowledged either. I cannot speculate on why the Department did not engage with us fully. In response to the question posed, we are interested and we want to be involved from this point on.

I thank Mr. Hourihan. He laid out many different things in his opening statement. People will be very concerned about two of the aspects he mentioned. One is the assertion that oral health will get worse for some or even many people. The other is the clear concern about growing inequality in healthcare. Would it be fair to state that it is Mr. Hourihan's considered view that the new oral health strategy, as it stands, could make oral health and oral health inequality worse?

Mr. Fintan Hourihan

That is undoubtedly the case because oral health is one of the areas of health where there is already a very clear divide between those in more deprived backgrounds and those who are better off. What is proposed in this plan will unwittingly make the situation worse. That will be the case particularly for children, and there will be resultant consequences throughout the entirety of their lives. The approach at the moment is a targeted one where children are all seen. They are brought into the HSE clinics and there is a follow-up if someone is missing on the day of the check-up.

In theory, children should be seen at three different age categories while in primary school, but that has not been happening because the number of dentists is insufficient. The ideal, therefore, is that children should be seen and there should be follow-up care and treatment. Education and information on the prevention of oral health problems should be provided on the spot. We understand that what is being provided now would be replaced by a model based on there being encouragement to visit a dentist in general practice. All of the evidence, unfortunately, is that those most in need, those who have the worse oral health to start with, are also the ones least likely to attend, even if such visits are free.

Will Mr. Hourihan give us an example of a child who should and would be seen through a properly resourced public intervention system? We have such a system today but it is not properly resourced. Let us assume the proper resources are provided and the system functions as it should. In the context of these new proposals, will Mr. Hourihan outline what will happen to children who will no longer benefit from intervention because their parents, for whatever reason, may not bring them to the dentist?

Mr. Fintan Hourihan

I am happy to do that. We have three different patient scenarios. I did not include them in our submission but I am happy to send that information to the committee. One of the scenarios addressed the exact question posed by Deputy Donnelly. These scenarios are based on real experiences but I am using different names. Let us take the example of four year old Millie and her eight year old brother. They live at home with their father who works full time in financial services. He drops them to the crèche at 8 a.m. The staff there bring Millie and her brother to school and both of the children are collected by their dad from the crèche at 6.30 p.m. They go home, have dinner and then go to bed. Millie's mother no longer resides in the family home as the parents separated due to her mother's mental health issues. Millie's dad manages to organise the day-to-day schedule during school term by cooking and supervising. He states that tooth brushing does not always happen. The children sometimes stay with their mother or at the home of their grandmother.

Millie mentions to her dad that she has a sore tooth, but it is not until her face is slightly swollen and the crèche staff remind him that her dad organises a dental appointment. As things stand, he takes time from school to bring Millie to the emergency dentist at the HSE. It is noticed there that Millie has a reasonably high rate of decay in her baby teeth and has an abscess in one of her molars. In that situation, the HSE staff would refer Millie to a general anaesthetic extraction service, having managed the symptoms with an antibiotic. Her social circumstances are noted on the dental records and she is registered as having a reasonably high risk of future decay. The HSE staff record that Millie and her brother will need to have a good reminder system in place. The children are placed on recall to enable support to be given to them and Millie and her brother will be targeted at intervals throughout their school years. They will also have continuous access to emergency care. The HSE staff will arrange with the children's dad to liaise with the crèche staff to bring Millie for dental appointments to enable her to continue her dental care.

As outlined in this new policy, in a future version of this same scenario, while Millie will have access to care bundles, it is uncertain how support will be given to her dad to remind him of the importance of the child's dental health. It is unclear if the children can be registered as being at risk due to the mother's mental health issues. It is also unclear how any symptoms can be managed while Millie waits for her general anaesthetic extraction appointment. In this new scenario, after Millie has her tooth taken out, her dad may wait until she has another toothache before bringing her to the dentist again. Millie relies on her dad to recognise the early signs of dental decay, and it is uncertain if there is any safety net for children within the new proposed structures. It is also uncertain how the new arrangements will interact with Tusla, the child and family agency.

The system in place identifies, manages and arranges treatment and referral where necessary. It also allows what presents to be recorded and a plan to be set out for the future. That is how the public service is set up. The difficulty is that the public service has been run down, with an insufficient number of dentists in place. With the best will in the world, those resources are not available in general practice and those systems of recording information, arranging care and treatment and referrals and follow up are not in place. We have no confidence that what is outlined in this strategy document suggests that is something that can be provided in the near future.

I thank Mr. Hourihan. We have time constraints and I want to pose a question to the team from the Royal College of Surgeons in Ireland, RCSI. I thank them for their submission. It makes very stark reading. It essentially states that there is no supervised year of training, so a college graduate can go straight into private practice. I did engineering as my undergraduate degree. I am pretty sure nobody would have left me unsupervised to design, build and roll out anything. This lack of a supervised year of training is worrying. The lack of continuing professional development is deeply worrying as well.

I have two questions. Presuming all of this information has been submitted on numerous occasions to the HSE, the Department of Health and the office of the Minister, it is safe to state this is not the first airing for these concerns and policy recommendations. The concerns being raised seem to be reasonable and urgent. What has been State's response to date? If the recommendations of the RCSI dental faculty are not implemented and we proceed with the status quo, what are the implications for the oral health of patients?

Dr. John Marley

I will take the first question. I am the dean of the Faculty of Dentistry. I will comment on my time in this post. I have raised these issues with the chief dental officer, whom I view as an extension of the HSE, whenever there has been an opportunity. As I have probably intimated, I have not had any formal response regarding the concerns I expressed at those meetings.

I can find out about the historic interactions for the Deputy and forward that information. With regard to the second comment, one of the pillars of this proposed healthcare-----

Before Mr. Marley continues, to summarise what he said, am I correct that he has raised these concerns previously at the appropriate level and has had no response from the relevant people within the State?

Dr. John Marley

They were raised in my discussions with the chief dental officer.

Has Dr. Marley had no response to these issues, verbally or in writing?

Dr. John Marley

No.

I thank Dr. Marley.

Dr. John Marley

We had written to the chief dental officer after the meeting to request access to the document for public consultation in advance in order that we could have a more detailed response in advance and have that to inform the decision process of the policy but that was not replied to.

The second question was on implications for patients.

Dr. John Marley

One of the key pillars of this proposal is to have a stratified system of healthcare delivery, the final one of which is the so-called specialist centres, which are referred to as dental schools and hospitals, and others. It remains to be seen how they will manifest themselves. Specialists are clearly needed for those specialist centres. If, as Mr. Hourihan noted, there is inevitable swamping of the services as they now stand, there will inevitably be upward referral to those specialist services, going by bitter experience in the UK. They have to balance it. If there are not specialists and consultants to manage that, there will not be a system.

What does that mean for patients? How will it play out for patient oral health?

Dr. John Marley

Any system worth its salt will have provision in place at various levels so that the right patient gets the right practitioner at the right time. Prevention is the way ahead but it has to be adequately resourced. If that does not work out, there will have to be a safety net to deal with the inevitable problems that patients have because people are people. Prevention is the answer for future but one still has to manage those with current difficulties, including those with significant comorbidity, and the elderly population. We are all getting older, especially me. We have to have a 21st century healthcare delivery system that allows that to be addressed. That can only be addressed through appropriately trained, adequate numbers of experts, both at specialist and consultant level. They will also be the leaders for the future of dentistry and without the leaders, there will not be dental provision.

I welcome the witnesses. I thank Professor Stassen, in particular, for coming in, since he operated on my daughter. This is the first time I have seen him since the very successful operation in St. James's Hospital, for which I thank him. I read the submissions, which are quite scary. As Deputy Donnelly said, it is rare that we would get submissions in which the language is so stark. The issue is quite serious. I am concerned about the exclusion of the relevant health professionals and representative bodies from the consultation process. Does either group have a view on why they were excluded and why it would be in the interests of the Department? I am sure the Department has a good reason for not being here but I am disappointed about it, because that would round out our discussions. I fully appreciate that officials have sent their apologies but it would have been better if we had been able to speak to them at the same time or as part of a separate session on the same day. Do the witnesses have a good working relationship with the Department? Mr. Hourihan and I would have previously interacted monthly, although it felt like it was daily, with the HSE in formal meetings where issues of concern were raised. Is there a similar set-up in dentistry? Is there anything like that at all? The witnesses might offer a view as to why they feel they were excluded.

Mr. Fintan Hourihan

It is important to distinguish between the HSE and the Department of Health. This is a Department of Health policy. As the Deputy alluded to, we have plenty of experience engaging with the HSE. For all that it can be difficult at times, there is a structure and basis to it. I am not directing any of this comment to the HSE but to the Department because it is the Department's document. We have not been shy about highlighting the effect of the cuts introduced in 2009. Perhaps people did not want us to continue to point out the difficulties for patients. We have commissioned countless articles and research, which is published in our journal. Perhaps it was simply the fact that we are not shy about highlighting the difficulties. Oral health has traditionally been the Cinderella within the broader health system. I previously worked for the Irish Medical Organisation. I commend it on its efforts.

There could be patients going to see a doctor in general practice and a dentist in general practice. I know the Chairman is a doctor in general practice. There is substantial funding for it. Prior to the most recent negotiations, the Department of Finance estimated that grants, allowances and supports to doctors in general practice are approximately €135 million a year, while there is nothing for dentistry. Dentists have had a sanguine view of the interest of successive Governments in oral health. We do not shy away from highlighting the impact on patients of not supporting oral health. It is perhaps because we are as vocal as we are that we were not brought into the fold. In our defence, we have a track record of innovation. Ironically, when the current Taoiseach was the Minister for Social Protection, we negotiated, to our mutual satisfaction, changes to the dental benefit scheme. We have been involved in innovation such as the establishment of a dental complaints resolution service, which is recognised as a model of its type. We have been involved in advocacy with the annual mouth cancer awareness initiative, without support from the State or the HSE. We have a track record of innovation and speaking out for oral health. If that is why we are being punished, that is the only explanation I can offer.

That is regrettable for the witnesses.

Dr. John Marley

That is a question one would have to ask the Government. To bring up what Mr. Hourihan said earlier about meaningful engagement, if I was developing a healthcare policy, I would want to engage the main stakeholders proactively. I would want to listen to what they have to say. I would want to return commentary on that as a show of respect. I would want to make a contemporaneous return on that and then, through action, show that that input was valued. I do not see evidence of that within this document, from the perspective of the Faculty of Dentistry and our concerns about postgraduate training.

It is regrettable that the very people who are going to be on the front line of implementing any strategy are being excluded. I have my own view on why that would happen. We all share the same sentiment that it is regrettable that we are talking about a discussion document into which the witnesses had no input.

On the number of vacant consultant posts, they gave information on the age range and confessed to ageing themselves. I have to confess to the same. We are all going in the same direction. Are we facing an age-related cliff with regard to consultant posts, the number of vacancies, the number of retirements and the lack of consultants coming through or those who are leaving and not coming back? Do the witnesses think that if we had a more formalised system of continuing professional development and training, we would be able to resolve that issue and head it off at the pass?

Dr. John Marley

It is a good question. Replacing specialists and consultants at that level is about successional management.

Part of successional management is planning ahead, from the undergraduate through to the postgraduate continuum. If the system is not doing this, it cannot be a surprise that it is not generating the people who are needed at the top end of the pyramid to deliver the leadership and expertise required to treat the very sick patients with comorbidities, the elderly and those with special care dentistry needs. I shall defer to Professor Lynch who is a consultant and professor within one of the dental schools in Ireland who can perhaps comment on that issue also.

Professor Chris Lynch

I thank Dr. Marley. I thank the joint committee for meeting us and members for their interesting questions. It is quite engaging sitting on this side of the table. One can sense how members feel about the subject from the level of the questions they are asking us, for which I very much thank them.

I agree with much of what Mr. Hourihan and Dr. Marley said. We are facing a people and power crisis in successional planning within the leadership and services in the dentistry profession in Ireland. It relates to a number of issues surrounding the specialist training aspect, including the lack of a framework for training individuals who wish to train, the lack of funded opportunities and the failure to recognise the relevant specialist list, which is a big problem. We operate under the Dentists Act 1985. It was published and passed when I was in fourth class in primary school. There are two recognised dental specialties in Ireland. I have recently returned to Cork having worked for 11 years as a senior consultant in the United Kingdom where there are 13 dental specialties. I was based in the main dental hospital in Cardiff in Wales. We had a network of individuals around us such that the management of very complex and needy patients was quite straightforward because of the range of services to which there was access.

My specialty is restorative dentistry. It is not recognised as a specialty in Ireland, but it is in the United Kingdom. I was involved in the management of patients with, for example, head and neck cancer. They would have had areas of their mouth removed owing to the nature of their disease. My job was to put things back and rehabilitate patients, either with implants or plates. I am also involved in treating patients who have a condition called hypodontia. They were born with certain teeth absent.

The network in the United Kingdom was much more established. I work with very gifted people in Ireland and there is a similar service in Cork, but, again, if the network was established around us, it would make life a lot easier for us as professionals in delivering an enhanced service for patients. We need to look in a very serious way at the framework for training consultants and specialists and also at the recognition of dental specialties.

I thank Professor Lynch. I have one more question. I do not disbelieve the figures that show there is an unusually high level of extractions in Ireland, especially among young children or younger people. Notwithstanding the fact that the people who are material to the new strategy were left out of any meaningful discussion on it, do the delegate believe it will be possible to implement the new strategy with current staffing levels? In attempting to implement the strategy with current staffing levels will it make any meaningful difference to the high level of extractions? As a lay person, my reading is that the high level of extractions, particularly among children, is an indication that they are not undergoing their three dental checks in primary school. I can hold my hand up in that regard. Although it is a good while since I had any interaction with a primary school, it definitely did not happen three times. Given the strategy and current staffing levels, is there any hope we will see a meaningful reduction in the level of extractions? That is assuming I am correct in saying difficulties and missed appointments are flagged.

Professor Leo Stassen

When the Government introduced the change and reduced the level of dental treatment available to patients, we saw a significant increase in the number of children who presented for dental extractions in the hospital and the HSE extraction centres. It is frightening when one sees the damage it does to a child and their future. It frightens them away from prevention and everything else in that regard. The new oral health policy refers to prevention, which is excellent and which we support completely, but the problem is that it takes time for prevention measures to work. We believe the current structure of packages will actually detract from the ability to look after children, in particular those children with special needs. We honestly believe there will be an increased need for extractions, not only in children but also adults, because of the way the policy has been put in place. I hope that answers the Deputy's question.

The Deputy also asked if there were enough staff to undertake the treatment in the public dental service and the hospitals. I say "No". The waiting lists in both areas are very significant. If the strategy was to be implemented - that is the important element - it would send patients to general dental practitioners who in many ways would not be able to cope with what the Government was asking of them. There was no discussion on the policy, which was very unfortunate. We believe it will increase inequality in providing dental care for all patients - young and old - and think that is very serious. We want to work with the Department of Health. We certainly would welcome a national oral health policy, but there are many flaws in what has been produced. It is akin to a computer programmer producing a computer programme without discussing it with the people who will need to introduce it.

I thank Professor Stassen. I apologise because I must leave to deal with questions in the Dáil Chamber. When they are finished, I will come back to the committee if it is still sitting.

I thank the delegates for their presentations. There seems to be a concern about the structure in place for trainees and newly qualified dentists. Perhaps the committee might receive clarification on the matter. What is the number of trainees who come out each year having completed degree courses in the two dental colleges? What numbers are we talking about? I understand dental training forms part of the degree course. Will the delegates outline the training provided?

Reference was made to UK graduates having to perform an intern role for 12 months. What is the procedure in Ireland when a person gains a degree and qualifies in dentistry and travels to the United Kingdom in the first 12 months after qualifying? Is that graduate able to take an intern position there? Perhaps the delegates might clarify the matter. Normally in the first 12 months after qualifying people in the medical field work as an intern in hospitals. We do not appear to have the same provision in the area of dentistry in Ireland. Will the delegates outline what the process is in Ireland and the numbers involved?

Dr. John Marley

I will ask Professor Lynch to address the issue of numbers for the dental schools in the Republic of Ireland. I will then give some figures for expected costs on top of what Professor Lynch will discuss about the pathway.

Professor Chris Lynch

I thank Senator Colm Burke. There are two dental schools in Ireland, one of which is based in Dublin and the other in Cork, where I work. Approximately 50 students graduate in each per year. There is an emerging dental workforce in the region of 100 individuals each year.

Dr. John Marley

If we include the North, there are another 60 graduates. Would it be useful to the committee if I were to use the foundation training programme in the North of Ireland as a reference point?

Dr. John Marley

There are approximately 32 places which, with those in Wales, England and Scotland, are advertised at national level. There has been national recruitment in the past three to four years, if memory serves me correctly.

The individuals who have approximately six months to go to graduation will undergo national recruitment interviews and be placed, based on rank, in the various regions in the United Kingdom. The cost per trainee in Northern Ireland is in the region of £60,000. That includes various sundries such as travel expenses, etc. It is an approximate cost for foundation training.

On the question of access for graduates from the Republic, they will find it very difficult to get into UK-based foundation training programmes, if they can do so at all.

What are graduates in Ireland doing? Obviously, they graduate with a degree, but what is the process thereafter? I presume a person who has just qualified would not get insurance to open his or her own practice and would probably have to move into an existing practice.

Dr. John Marley

I will defer to Mr. Hourihan on that issue, but, based on the evidence I have accrued from the academic reference group which helped to inform this health policy and the publication in 2016, there are slightly more than 2,000 dentists undertaking private work for a population of approximately 600,000 paying patients. I presume the graduates enter that marketplace. As of 2016, there were only 350 health board salaried dentists. Mr. Hourihan may be able to comment further.

Mr. Fintan Hourihan

It would be most unusual for a dentist to set up his or her own practice on graduation. It is theoretically possible. It would be possible to get professional indemnity insurance, but it tends not to be what dentists choose to pursue. Traditionally, the route was for dentists to travel to the United Kingdom where they were able to access training scheme places. As a result of administrative changes, that is no longer viable. There was a vocational training scheme here, but it never had more than approximately 12 to 20 places. It was abolished in 2010. Currently, some graduates travel abroad to countries such as Canada, the United Kingdom or further afield. Others apply for work in the public service, but such opportunities are few and far between. Others seek to be taken on as an associate, a fully independent practitioner, seeing patients within a practice where a senior dentist is present. Members may be familiar with the medical model in general practice or hospital specialties and the general practitioner training programme. There is no equivalent for dental graduates. There is no clear pathway.

Was there a clear pathway? I am familiar with the GP training programme which takes three or four years to complete after qualification. Other training programmes in hospitals run from five to almost 12 years. The latter period is to reach consultant level. Was a detailed proposal made?

Mr. Fintan Hourihan

Yes.

Would it be possible for the committee to be given a copy of that detailed proposal? When such a proposal is made, associations usually engage with Departments or the various universities, hospitals and so on. What level of engagement has occurred? Obviously, if there were 100 per annum, it would not be a huge number. It would be quite easy to calculate the cost of a year's training on the basis of the stated figure paid in Northern Ireland. The homework seems to be done. The question now is how it can be translated into a positive policy. Has there been engagement with the Department or the HSE on this planned approach to training?

Mr. Fintan Hourihan

A detailed proposal akin to the medical GP training scheme which involves rotations in the public service and general practice sessions was prepared in 2013 and formally presented to the Department of Health in the names of the Irish Dental Association, the Royal College of Surgeons in Ireland faculty of dentistry, the dental schools and, interestingly, the Dental Council. We were told that it would be considered in the context of the oral health policy, but it was not. The policy contains passing reference to training, but there is no comment on the proposal that was submitted with a probably unprecedented number of signatories, which is very disappointing. We can supply copies to the committee.

That would be helpful because we would, at least, know from where we were starting. Yesterday the Cabinet signed off on something that I initially proposed in 2014. Hence, I am not surprised when a matter is not progressed in a five-year timeframe. If the committee sets a target of securing change in this area in the next 12 months, it will be quite an achievement to reach it. It would be helpful for us to receive the documentation such that we could set it out as a goal to try to secure that change. When was the most recent engagement with the Department on this matter?

Mr. Fintan Hourihan

I will have to check. It is a recurring issue that has been highlighted in countless presentations and submissions. I am unsure whether there was a meeting specifically to consider that proposal alone. It is well known within the dental community that the proposal was presented to the Department in the names of a large number of organisations. It is referenced in several documents. Recently the focus of the Department has been on the oral health policy document. We were waiting to see what it contained. I cannot say when the most recent engagement on the issue was per se.

On CPD, I am a qualified solicitor and must complete 21 or 22 hours of CPD training per annum or my practising certificate will not be renewed. It is not a case of legislation. Mr. Hourihan referred to legislating for CPD. Obviously, dentists must renew their insurance each year. I presume there is a structure whereby they must have membership of and pay fees to a professional body each year. Would it be possible to require evidence of CPD to be shown before one was issued with a certificate to practise each year?

Mr. Fintan Hourihan

The Dental Council is the regulatory body for the profession. Every dentist must be registered with it in order to practise. Registration is renewed annually. The Dental Council makes it clear in its ethical guide that there is an obligation on dentists to engage in CPD. There is documentation which details what is required, akin to what Senator Colm Burke has said is used to as a solicitor and similar to the situation for doctors. However, it is an obligation, rather than a mandatory requirement.

Could the Dental Council make it a mandatory requirement if there is concern that CPD training is not being completed?

Mr. Fintan Hourihan

The Dental Council which is a separate organisation from the Irish Dental Association and the Royal College of Surgeons in Ireland states it needs legislation to change in order to issue that type of directive. It goes back to the point made by Dr. Marley which we support that the legislation is badly in need of renewal. My organisation would support mandatory CPD, but the Dental Council is of the view that it cannot implement it until the dental legislation is changed and updated.

I am open to correction, but I do not think there is legislation in place governing CPD for solicitors. The Law Society of Ireland brought forward the requirement and stated a practising certificate would not be issued unless the CPD requirement was fulfilled. I presume the Dental Council would have the same power without requiring legislation to be changed.

Professor Leo Stassen

I thank the Senator for his questions. CPD is not mandatory, although it should be. The Dentists Act 1985 does not allow us to make it mandatory. All of the relevant organisations, including the Royal College of Surgeons in Ireland, the Irish Dental Association and the Dental Council have pressed for it to be mandatory. Currently, all one must do to register is show one has a qualification in dentistry from Ireland or elsewhere. That is a serious issue.

On the issue of somebody having qualified as a dentist, all of us support what we call vocational training, the foundation training and general professional training. Once a person qualifies as a dentist, he or she can, if that person likes, go into the high street and set up his or her own specialist practice or dental practice and, as a dentist, do all aspects of dentistry. Our problem is trying to reassure and safeguard the public. To do that, we have always advocated for the introduction of what happens in the medical world - an intern year, a professional training or a foundation year which is, basically, a mentorship and supervisory experience. At present, a person who qualifies as a dentist can become an associate. He or she works for somebody but still remains an independent practitioner and the person for whom that person works cannot tell him or her what to do. It is a poor situation we are in.

Dr. John Marley

Senator Colm Burke has probably seen the document I hold.

Dr. John Marley

I refer the Senator to pages 40 to 42, inclusive. He will see there are priorities and action points in that. The Department talks about nine priorities over three years that it would wish to see actioned, but within those there are 16 action points. One of the nine priorities is action 28, which is when we first hear about updating the Dentists Act. In terms of an evidential base of the priority placed on that, it speaks for itself, yet we are somewhat confused as to why that would not be in place to begin with before we introduce what is being proposed in terms of the oral health policy. Professor Lynch has a comment to make in terms of continuing professional development, CPD, as well.

Professor Chris Lynch

Senator Burke's points on the CPD are very well made. The Senator is speaking from his own experience within the legal profession. We would like to have mandatory CPD within dentistry. All the organisations in dentistry in Ireland feel that way. It allows our practitioners to reassure patients that the dentists themselves are engaging in updating their knowledge and providing contemporary high-quality care. It is about creating a framework which will allow our practitioners and dentists in Ireland to reassure the public that they are updating their knowledge and maintaining high-quality care for their patients.

In another way, it links back to the questions about foundation training and the year of supervised and mentored care. I am a graduate from the Republic of Ireland. I am a graduate from Cork. My first job was as an associate in the UK 20 years ago where I worked in somebody's practice without the availability of a suitable mentoring arrangement. The introduction of such a scheme in Ireland would be of great benefit to our graduates and to our patients.

In the UK, there is considerable research. Educational research has been carried out on graduating dentists moving into this year of sheltered training and moving onwards into independent care. It shows that there is a significant increase in the confidence of practitioners, but also in their ability to deliver high-quality care to their patients.

Within dental schools, we have directives and guidelines as to what we teach and train our students. Our students are trained quite significantly in terms of the clinical skills they are expected to deliver, but there is an overall process where graduating students can move or transition from dental school into independent practice, and the year of mentored training and foundation training has been shown to have a significant positive effect in that regard.

I have a final question. I refer to the issue of people going abroad for dental treatment. I have come across a number of problem cases where people have gone abroad for dental treatment because they thought it would be far cheaper and, a year, two years or three years later, are running into major problems. It is not clear that we have a sufficient warning system on this issue that just because it is cheaper does not mean it is value for money. I have someone now, for instance, who is going through a process which will cost €25,000 to rectify the problem that the person had dealt with abroad. How can that message be got out that there is no question about the competence of practitioners here in Ireland but that there are dangers in going abroad, and just because the treatment is cheaper does not mean a person will get value for money?

Mr. Fintan Hourihan

There is an excellent document, which the Dental Council has published and which is available to view on its website, which offers advice to patients in choosing a dentist, be it here in Ireland or abroad. It sets out good questions, particularly if one is considering going aboard. It is perfectly legitimate for people to choose where they are treated, but especially if they are going outside the country, there are some specific questions they need to ask. The Dental Council has put together an excellent document. The pity is that it is not widely known to the public.

As an association, part of our role is to advocate. We convey that from time to time. Sometimes people will criticise us because they will suggest we have an ulterior motive. We do not because our members, as the Senator indicates, are the ones to whom the patients come back presenting and asking to be provided with remedial treatment. As the Senator states, often it can be a multiple of what it cost and what they thought they were saving in the first place.

We would like to see greater awareness. The Dental Council has a remit to care for patients and to look after the welfare and interests of patients. We would like to see greater awareness of the excellent guide that it has published, that is available to view on its website but, unfortunately, is not as widely known as it ought to be.

I apologise I have to race over to the House for questions as well. I will be as quick as possible. I thank our guests for coming before us this morning and making their presentation.

Orthodontics in particular has been an issue that I have pursued over many years, and I am sad to say that the service has not improved over the years. It did not arise in 2009, by the way. It has been there for many years. In comparison with other jurisdictions, the level and quality of service available through the schools and thereafter, with particular reference to young women, is appalling, is recognised as such, and has been commented on repeatedly in international journals. How often do our guests interact with the HSE or, previously, with the Department of Health, the health boards or whatever? Do they do so annually, as I believe they need to do, or at particular times? Do they have ongoing dialogue with the responsible officials in the HSE with a view to advancing the cause to which they have alluded? My colleague raised questions about those seeking service outside the jurisdiction, which practice, incidentally, I do not agree with. People will say, for instance, that access to dental services is less costly in Northern Ireland. I do not support moving outside of the jurisdiction. They might give us some idea.

The year 2009 was a watershed in the sense that cuts took place everywhere, and implicit in what we say from time to time is a suggestion that we should go back to 2009 levels everywhere. If we go back to 2009 everywhere, we will be broke again. That is the short and simple answer to that. I would caution everybody that if we proceed to go down that road, there will be a higher price to pay.

The dental health of women throughout their lives does not receive the kind of attention in this country that it receives in other countries. My colleague will deal with this subject in greater detail. I deal with it in my clinics. Every week, I have young women coming in who have serious fundamental dental problems for which they must wait. If they cannot afford it, they wait forever. This is not a new development. This was the modus operandi 30 years ago. The health boards and the Department of Health at the time changed the categories under which a child could get treatment. There were categories A, B and C. In A, a person might be lucky if he or she got treatment in a couple of years. In B, that person almost hardly ever did. In C, he or she never did.

That situation continues to this day and has not changed. It needs to be addressed, however, and there are a number of ways in which it can be. As the professionals in the business, do our guests foresee being able to interact with the authorities, the Minister and the responsible persons in the Department of Health and the HSE with a view to bringing forward the kind of service required in modern times?

Our guests presumably make submissions annually. They needs to be submitted annually. There is not much sense in making a comment at some time and then letting it go away and not happen again. I return again to the old days of the health boards. The matter arose monthly throughout the country in the course of the debate in the various health boards. There was a recognition at the highest level that the issue was causing problems downstream and that something should be done about it. Something was not always done, but at least there was a focus on the issue and it was recognised as being of some urgency.

Mr. Hourihan suggested there had been little response from the Department of Health. How often has the Irish Dental Association corresponded with the relevant authorities?

I apologise that I will be unable to remain for our guests' answers because I must attend the Chamber, but I will read them carefully and relate them to my constituents at my clinics next week. It will help us know what we might expect in the near future.

I thank our guests for appearing before the committee. Back in my days spent working in Dublin City Council, I worked with a few of them in the context of fluoride being in the water supply. For the benefit of the public and the committee, will they speak briefly on the role of fluoride in the water supply and the risk that removing it would pose, with specific reference to oral health inequality and the difference in dental and oral health among socio-economic groups?

As a pharmacist, I have long been concerned with prophylactic antibiotic use in young children awaiting dental care, such as children with enamel hypoplasia and other conditions. The waiting list for the required treatment can be so long that, as our guests will be aware but I am trying to explain it for the public, children are often prescribed a continuing dose of antibiotics. I have seen cases of courses lasting more than a year, although perhaps our guests have seen worse cases than that. I raise the matter in order that we will know what we are dealing with, and have dealt with for years, in the case of children. This is how it has been managed. It is not the same as when one is waiting for a hip operation, takes a few painkillers and suffers for a few months. In the case of children, a significant portion of their young life can be spent on oral antibiotics which, if they had been treated earlier, they would not need. As professionals, our guests might explain the impact of such prescriptions on children and their long-term health, as well as the negative effects of long-term antibiotic use. If we had enough capacity, that type of treatment would not be used.

Thankfully, there has been much conversation in recent years about HPV vaccination. Whichever of our guests is an expert on it might speak briefly on the rise of head and neck cancers, especially among young men, and how it affects the role of dentists, as people who look into mouths, and the strain it has on their service, if it does. What is our guests' position on the roll-out of the HPV vaccine to young boys?

I return to the issue of fluoride and socio-economic groups, as well as the effect of junk food in children's diets, especially those which include dried fruit and similar foods which are bad for teeth. Have we done enough to educate young parents? I know that juice is the devil in the world of dentists, as are dried raisins. I myself have young children. There is a lack of information available for parents, young or old, given that one might expect giving freshly squeezed juice or dried fruit to one's children to be good. Is there work to be done with the public, perhaps at the point of delivery of a baby, to educate people about how to prevent children's dental decay and extraction?

Mr. Hourihan referred to the role of dental technicians and providing direct access to the public. Will he elaborate on that? I might ask some more questions. I know what a dental technician is but I am concerned about the clinical interface. Dentists are clinical specialists, regarded as doctors and permitted to use the title as such. Will Mr. Hourihan comment further on the move he mentioned? I did not understand what he meant. Did he mean that somebody can substitute for a dentist? Somebody might inform me better in that regard and I might ask more questions.

Dr. John Marley

I will deal with the theme common between Deputy Durkan's first two questions, namely, the idea of engagement. The idea of meaningful engagement was raised earlier but there is also the concept of engagement fatigue. That we are appearing before the committee should be an index of the fatigue and frustration we feel as bodies and it should speak volumes. I will hand over to Mr. Hourihan to address the other issues because I am not an expert on them.

Mr. Fintan Hourihan

I will ask Professor Stassen to address a number of clinical matters raised by Deputies Durkan and O'Connell because the professor is eminently qualified to deal with them. To supplement what Dr. Marley said, we have regular engagement, far more frequently than annually, with the HSE and the Department of Health. In recent years, the standard response has been that orthodontics is considered as part of the oral health policy. We now have the policy, which is a basis for discussion and we intend to approach it on those terms.

Deputy Durkan raised the matter of orthodontics. As he correctly indicated, there have been problems with waiting lists and the demand for orthodontic care and treatment that long predate 2009. A report into orthodontic services has been commissioned by the HSE. It has not been published, although we would like to be. We are aware there has been another recent controversy and that a report will be published imminently in that regard. We are keen for both reports to be published sooner rather than later and we will see what issues will arise. There is no getting away from the fact that there is insufficient capacity in the public service to offer the care required. The index of treatment need system is a way of dealing with that and rationing what can be provided with the available resources. It cannot be denied it is a resource related issue. As for the regularity of our submissions, we take the point that we must keep making representations on the matter.

Professor Stassen might speak about the issues of fluoridation, antibiotics, HPV and technicians.

Professor Leo Stassen

They are all good questions and I hope I can answer some of them. On the HPV vaccination, much has been written in the newspapers and discussed around the Government about cervical cancer and the problems it has created for women, in general, but also the serious problems it has created for how medicine and surgery deal with it. The HPV vaccination has been shown to be significantly protective. It has been shown to be useful and has been given to many girls for many years, but it should also be given to boys.

It is, without a doubt, one of the most lifesaving things that could be produced. If it had been introduced at such a level in the past, which it would not have been, we would not be where we are now with these court cases and the threats to cervical screening.

With regard to the input, I treat an awful lot of mouth cancers. I treat more than 100 cases of mouth cancers each year. There has been a significant increase in the amount of mouth cancer, in particular oropharyngeal, which is directly related to HPV. This is placing significant stress on our system of providing care for mouth cancer patients. How it reflects in dentistry is important because many cases of mouth cancer are picked up by dentists as well as by pharmacists and doctors and they often end up with us. Many of them require radiotherapy and they need screening by a dentist prior to having radiotherapy. We heard Professor Lynch speak about this. They need screening after their radiotherapy in the context of dental care. The HPV vaccine is an absolute no-brainer and I hope the committee will push it as strongly as it can for girls and boys.

We then come to enamel hypoplasia but we are really speaking about caries, infection and other problems in young children that require antibiotics. Antibiotics are not the treatment for caries. Prevention is how it should be managed, followed by early detection, protecting and saving the teeth. A tooth that develops an abscess and requires an extraction is a failure of a health system and of dentistry. I agree completely that antibiotics are not the treatment; the treatment is prevention. If a patient has an abscess, the treatment is probably root canal, if possible, in the older population and, for a child, extraction of the tooth but we cannot actually provide this. This needs to be addressed. Enamel hypoplasia is a very small part of the story. Caries is the big problem.

Fluoride was mentioned, as was sugar. What we do know is if we want to have in place a good programme to prevent tooth decay we require fluoride, decreased sugar by whatever means in the diet and tooth brushing. We can teach children through proper systems to brush their teeth. We are working on trying to decrease the amount of sugar people take. As president, I will be pushing for a lot of support for this. We need to inform people on how children get sugar because mothers and fathers do not know. People who train them for sport give them a sugar treat at the end of training, which is absolutely the wrong thing to do. They should get an apple or even a toothbrush but they should not get a sugar treat.

Fluoride has been shown by all of the research available at present, and research needs to continue, to be the most practical, cost-effective and safe way to help manage caries. Unfortunately, in the strategy put to us, it is seen as everything and it is not. Many places do not have fluoride. Children older than two need topical fluoride, fissure sealants and varnishes. They are not part of the national oral strategy. If we cannot prevent decay developing in younger people, we will have a serious problem. If fluoride is pushed, we will also push tooth-brushing and reduced sugar of any type. I guarantee that all of the research so far shows the application of fluoride to be safe at the levels recommended by Europe.

Dental technicians were mentioned. The problem is educating the public on what is a dental technician. People working on the high street as what we call denturists or dental technicians have no training in examining a mouth, head or neck, which a dentist does. They have no experience of what mouth cancer looks like and, as I have stated, I see more than 100 cases of this year. They are dangerous. Many of them who provide treatment to patients are assaulting those patients and it should be taken up by the Garda as assault.

If dental technicians who do not have the clinical training to look into somebody's mouth take it upon themselves to go outside their remit and start examining someone's mouth, essentially it is a form of assault.

Professor Leo Stassen

It is a form of assault. Clinical dental technicians are a different group of people. There is not a huge number of them but they work very closely with general dental practitioners, hospital specialists and consultants. They are trained to a very high level. They know their scope of practice and what they can and cannot do. In fairness, their role is well supported by the Irish Dental Association and hospital practice. The clinical dental technician is a completely different person to the dental technician or denturists who, in many cases, provide illegal dentistry to patients. Anybody who provides direct access must have a scope of practice and must be compulsorily regulated.

I believe I have answered most of the Deputies' questions but I will go back to Deputy Durkan. Orthodontics is a very sexy name and everybody likes to talk about it. Orthodontists do an extraordinarily good job and many of my very good friends are orthodontists. What are forgotten about are the other dentistry professionals who work very closely with orthodontists. I am speaking about restorative dentists, periodontists, endodontists, oral surgeons and maxillofacial surgeons. We all work very closely together. Part of the problem with orthodontics is when a mother and father are, quite correctly, worried about their child and bring the matter to all of the Deputies to highlight the issues with orthodontics. However, the rest of dentistry and the specialisations we have spoken about are sometimes forgotten. I have four children and I want them to have nice teeth, as does every parent, because it is very important. I am supportive of what has been achieved. I agree with Deputy Durkan that dental care is not just about orthodontics; it is about the whole of the dental team providing a service to patients in order to ensure that they have what the Minister, Deputy Harris, referred to, which is equitable and the highest quality of oral health. I do not know whether I have answered all of the Deputies' questions.

With regard to how the organisation has been affected by FEMPI, people used to get two examinations a year through PRSI. This was cut and now has been restored. Is this correct?

Mr. Fintan Hourihan

A number of changes were introduced through FEMPI. What the Deputy is referring to is the PRSI dental scheme. It provided examinations twice a year. It is now once a year.

Did it go to zero?

Mr. Fintan Hourihan

No, it went to one. It was the only treatment available. There were free and subsidised treatments above and beyond the examination under the PRSI benefit scheme. The fees to the dentist under the medical card scheme were cut.

FEMPI is separate.

Mr. Fintan Hourihan

Yes. That was the PRSI scheme. Changes were also made to the medical card scheme and there were two aspects to this. These were the cut in fees to dentists and the severe restrictions on the range of treatments provided to the patient. In fact, in terms of the consequences, the restriction on the range of treatments was far greater. Obviously, dentists are unhappy that their fees were cut. From the point of view of patients, however, the severe restrictions were greater. Previously, it was an open-ended scheme with certain treatments explicitly provided for. Two changes were made. It moved to a capped or budget-led scheme. It was a demand-led scheme and it is now a budget-led scheme. Changes were also made whereby some treatments that were previously covered automatically are no longer covered, or some are still available but dentists must seek approval or permission, which is sometimes given and sometimes not. The FEMPI consequences for the two schemes were many and varied but the consequences for patients, as was said earlier, mean an increased number of presentations with far more advanced difficulties.

Prior to the FEMPI changes to these open-ended schemes, if Mr. Hourihan, as a treating dentist, saw a person with a medical card, he knew he could plan a pathway of treatment without getting approval from whoever pays him. Now, he must get approval for a treatment plan before he can proceed. Is it true to say that perhaps this is hindering the progression of a treatment pathway?

Mr. Fintan Hourihan

Yes, it is definitely hindering it. As medical card patients were not given access to all dental treatments, implants, crowns and so on were never part of the scheme. In simple terms, the scheme provided the essentials or routine treatments. After 2009, there was a scaling back or reduction in the number of routine treatments that were covered automatically. There were some treatments that could be approved on application to the HSE. To give a short answer to the Deputy's question, the dentist sees the patient and draws up a treatment plan, which will encompass some treatments that are covered automatically by the medical card, some which can be applied for and others that will never be covered. The great difficulty is that the HSE has not recognised that a treatment plan will include prescribed treatments that are not available automatically, if at all, and has made no provision for that. While I accept the point made by Deputy Durkan that we cannot return to the position that pertained in 2009, we can go some way towards it or, failing that, we could introduce a completely new system because the medical card system is completely unfit for purpose.

Even in terms of the drugs that are allowed, the scheme is very limited.

Mr. Fintan Hourihan

It is very limited in terms of medication.

As a pharmacist, I find it ridiculously limited. It is not as if a dentist will prescribe a medication for rheumatoid arthritis.

Mr. Fintan Hourihan

No.

Dentists will prescribe drugs that are needed. The scheme is very restrictive.

The costs of some components of the treatment pathway are paid for and the dentist may decide that the patient also needs other treatments. Let us say a dentist wants to give a child or an adult with a medical card a certain type of treatment. How long does it take to obtain approval? Is approval given in weeks?

Mr. Fintan Hourihan

Yes.

Who decides? Is it a dentist or someone else?

Mr. Fintan Hourihan

The decision is made by dentists known as principal dental surgeons who work in the public service. There are 17 of them around the country and they are practising dentists. Their decision is largely informed by what presents and what budget is available. Treatment was not previously restricted for budgetary reasons but it is now.

Does anyone have figures on this? Perhaps the committee could get them. Has there been a saving? Are there comparative figures?

Mr. Fintan Hourihan

We commissioned research by a health economist before the cuts took effect. The research showed that the cost of the cuts would be three times higher than the cost of keeping the existing benefits. The savings achieved by keeping them would be three times higher than the savings achieved by abolishing them and the converse follows. One would need a health economist to consider the number of cases. However, a public survey has shown that there has been a 40% increase in the number of acute hospital admissions.

Has that increase occurred since the cuts were introduced?

Mr. Fintan Hourihan

Yes, it is directly linked to the cut in the benefits available to prevent problems or treat them at primary source.

Does an acute hospital admission in dentistry mean someone turning up with astronomical pain, probably heading towards sepsis?

Mr. Fintan Hourihan

Yes.

Professor Leo Stassen

People are turning up not only in absolute pain but with life-threatening infections-----

Professor Leo Stassen

-----and abscesses, requiring them to be admitted, usually necessitating a general aesthetic and often drains. They often have to be in hospital for-----

Intravenous antibiotics, the lot.

Professor Leo Stassen

-----intravenous antibiotics and painkillers. They are often in hospital for a period.

With regard to mouth cancer and HPV, which was just mentioned, when I worked in the dental school we would have to apply to the principal dental surgeon to reconstruct the mouths of these patients with implants and-or rehabilitation. Professor Lynch may comment on this matter as well. It would probably be more than a year or sometimes two years before we received a response. Frequently, if the principal dental surgeon could afford it with the budget available, we might be able to reconstruct the mouths of these patients so that they could eat, drink and have a life. When I excised the cancers of these patients, it often involved excising all of their teeth or their jaw. When they have no teeth they cannot eat, speak or drink. I do not know whether Professor Lynch wants to comment. It is very hard to get funding for such treatment. While I admit that is at a higher level, it should be automatic.

Professor Chris Lynch

I work in the Cork Dental School and treat the same sort of patients that Professor Stassen treats. He is a surgeon and removes tumours. My role, as a restorative dentist, is to reconstruct and put back missing teeth. There is funding available from the HSE. Our institution has a service level agreement but it is ring-fenced and a certain amount of money goes with that every year. These are primarily the sorts of patients we should be treating in our hospitals. Treatment for these patients should be free at the point of delivery because they find themselves in a very unfortunate and distressing situation.

Is there a gap between the extraction and removal of cancer by Professor Stassen and reconstruction?

Professor Chris Lynch

Yes.

The argument being made is that there should be a seamless transition from treatment to reconstruction to allow patients to get on with their lives.

Professor Chris Lynch

In my experience in our institution, part of that relationship already exists but we need more of a team. This goes back to the point Dr. Marley made about the need to develop consultants and specialists in the associated specialties that do not exist in Ireland. Professor Stassen is speaking about his own arrangement in Dublin where there seems to be an issue with funding.

Dr. John Marley

As an addendum, it would be important to note that if the concerns expressed by our colleagues in the Irish Dental Association come to fruition and the default, in terms of managing patients, is referral to tertiary centres, there will not be much time to deal with the head and-or neck cancer patients and other patients who should be treated in tertiary and quaternary centres because there will be a tsunami of referrals coming in. Without that succession of management and training of specialists to deal with that, we will have a big problem down the line.

I thank all of the witnesses for their comments.

To return to policy issues, how does the new oral health strategy fit into the Sláintecare strategy? Sláintecare was mentioned earlier. Will the oral health strategy complement Sláintecare? Are there overlapping elements? One of the fundamental principles of Sláintecare is to provide care on the basis of need, not on the ability to pay. Obviously, Sláintecare also encompasses dental care. How can Sláintecare be implemented within the oral health strategy?

Mr. Fintan Hourihan

Yesterday, I attended a meeting at which Ms Laura Magahy made a presentation on progress with Sláintecare. She specifically mentioned the publication of the oral health policy, which was welcome. As such, the policy fits in with Sláintecare and our document notes that it is consistent with Sláintecare. We agree that if one of the essential principles of Sláintecare is meeting need, that should apply certainly to the same degree to oral health. We are very keen to make sure that approach is taken.

Can the dental community provide access, in the context of the Sláintecare proposals, at little or no cost to the State? Would provision for a number of free dental visits for children specifically, but also for adults, be incorporated in the contractual arrangements for dentists? What contractual arrangements do dentists have with the HSE?

Mr. Fintan Hourihan

Currently, eight or nine of ten adults are entitled to a free dental examination because they are covered by the medical card scheme or the PRSI scheme. The profession currently provides examinations to practically everyone. Likewise, when children are seen in the public service there is no charge. There is, therefore, no charge for the overwhelming majority of adults and for children under 16 years of age. The question is whether sufficient resources are in place to allow that to happen. Obviously, not everyone will avail of the option.

Dentistry is all about prevention and dentists would like to see far more focus on prevention. To be fair, this has been recognised in the oral health policy but making it happen requires supports. As a medical doctor, the Chairman will be aware that a significant level of free care is available to patients when they see their doctors and the cost is met by the State. Far less free care is available to patients when they see their dentists but that is the nature of the existing contract. The problem is that the treatments and the limitations on treatments render that less than ideal. Clearly, more people are coming into the country all the time and more expenditure is needed to allow them to avail of treatments.

Children are currently seen in the public service. Every child is seen, which is a great facility. If they are not seen as regularly as they should be, it is because there are not enough dentists in the public service. That is why it is astonishing to us that there is a proposal to take the service away and to instead have a completely different model that relies on people showing up, instead of bringing them all into the public service clinic. The problem with the service. as currently structured, is that there are not enough dentists. This means children are not seen as frequently as they would otherwise be.

Professor Leo Stassen

The other problem with dentistry is that it is not like medicine. An examination of a child takes a relatively long time. For the dentist, it is not just a matter of the examination because many of the children require treatment. That general dental practitioner is seriously restricted in the provision of that treatment under the current system. If the children require preventive treatment, tooth brushing and such measures can take a lot of time. Fissure sealings and fillings take a lot of time. Even if an extraction by a general dental practitioner is, unfortunately, required, it takes a lot of time. The examination is free, but the rest is not really. Is that not fair to say? Most of what we do in dentistry is preventive, with as little treatment as possible. We are slightly different from doctors who examine the patient to make sure there is nothing serious, as is right, and then manage to treat them. The doctor might see the patient again in a week to check that he or she is okay. In dentistry, it can be at least six weeks to two months before proper treatment is undertaken. Unlike doctors, everybody is afraid of the dentist. Therefore, it takes a lot of time for us to handle children.

Are the services currently available directed more towards extraction rather than conservation?

Professor Leo Stassen

The Chairman has hit the nail on the head. The services are encouraging extractions. I am not the expert because it is not what I deal with. If one has another disease, the condition cannot be treated. It is left and becomes an infection, requiring the extraction of the tooth. The number of teeth being extracted is significant. They do not need to be extracted. Mr. Hourihan will explain the details of the programme.

Mr. Fintan Hourihan

The unfortunate difficulty is the problem becomes more pronounced as children get older. If they are not seen at an early stage, the likelihood is extractions are more probable than otherwise would be the case. There are severe difficulties, but that is because of diet in the first instance and the need for greater health promotion and prevention messages. Children ought to be seen in second, fourth and sixth class. That is what the policy states. It is suggested in the oral health policy that it is happening, but it is not. In many parts of the country children are seen for the first time only in sixth class; therefore, they are ten, 11 or 12 years old, which is way too late. If one is only being seen at that stage, it is likely one will require far more extractions than would otherwise be the case. If children were seen earlier, privately or in the public service, much of this could be avoided.

On orthodontics, there was an issue in the mid-Leinster area. Going back to the period 1999 to 2002, there were issues with the suspension of orthodontic services. Children were not followed up properly following the suspension. This committee, in 2005 and later, dealt with the issue. There was a report commissioned in 2015 by two external dentists - from Wales, I believe - to examine this issue. It has not yet been published. Does Mr. Hourihan know what the position is on it?

Mr. Fintan Hourihan

No, the HSE is managing it. We know no more than what has appeared in the media.

I apologise as I had to slip out for a while.

I welcome the delegates. I really admire them for standing their ground and not accepting things. They did so in such a dignified manner. I say, "Well done," to them.

The name of the policy is Smile and Sláinte. As the delegates are not smiling, perhaps we should consider a name change. I am very disappointed that there is no representative from the Department of Health here. I spoke about this before. The delegates are speaking to the converted. If representatives from the Department of Health were here, they would, I hope, take on board what they are saying. It is like saying, "Dúirt bean liom go ndúirt bean léi." I acknowledge that the Department sent an apology, but surely somebody should be available.

We will invite them to come on another occasion. We will pursue them.

That is good. I am also amazed that there was no consultation. If there is a plan, the people directly affected should have their opinions taken on board. It beggars belief the delegates were not consulted. Professor Stassen said people were afraid of the dentist. It seems that the Minister definitely is. The delegates are awaiting a meeting with him which I hope will take place. They had made known their views on the lack of consultation. Has the Minister acknowledged them in any way? Has he picked up the telephone and spoken to anyone or reply to emails personally? Is he aware of the extent of the delegates’ horror at not being consulted?

Mr. Fintan Hourihan

I think he is aware of comments we have made that have been reported in the media. We have written to him and sought a meeting. At this stage, we have not received a reply. We wrote after the publication. I believe it was on 2 or 3 April, but we have not yet heard back from him. We hope to meet him sooner rather than later.

Professor Leo Stassen

It is very important to note that there is a little difference of opinion. Members have heard from the Royal College of Surgeons in Ireland and the Irish Dental Association that there has been no engagement. There has been a box ticking exercise. The Minister has been advised that there has been engagement and consultation. It is disappointing that representatives of the Department are not here because I would like to know what they consider engagement to be. In fairness to the Minister, the information he receives from his advisers is that there has been engagement, but members are hearing from very senior people in the Faculty of Dentistry and the Irish Dental Association that no meaningful engagement or consultation has occurred.

All of the delegates cannot be wrong. Mr. Hourihan has said the oral health policy fails to explain the reported level of dental decay and that it is seriously under-reported, involving as it does the exclusion of as many as 21% of children. Will the delegates expand on that matter? How could that happen?

Professor Leo Stassen

To be fair, it is acknowledged in the policy. The study examined children who were living continuously in areas where water was fluoridated. It did not, for a long period, take account of those in care settings or who arrived into the country. One of our members, a colleague, estimated that perhaps 20% of the population were excluded. Obviously, 80% were included, but the view of the experts we consult suggests it means that the level of decay is under-reported. If one examines the profile of those excluded, one notes that they present with greater levels of decay. What we are really saying is there is a significant number of caries or level of dental decay and that it is greater than the report suggests. Every survey works on certain assumptions. I am sure the one in question was appropriately designed and executed. However, the assumptions did exclude large numbers of people.

All told, this suggests the level of decay around us is greater than is suggested in the report.

What is the position on waiting lists in the dental hospital? The hospital provides complex care, in particular, for patients who might have intellectual disabilities, for whom getting access to the hospital for treatment can be difficult. What is the situation in regard to staffing and consultants in the hospital?

Professor Chris Lynch

The issue in the specific area to which the Chairman refers falls under the umbrella of special care dentistry, which, again, is one of the dental specialties that is not recognised by the Dental Council. In its own right, that poses certain difficulties. For my own institution, I cannot speak to it directly as it is not my area. We have a waiting list which is managed through the HSE and we deliver care in that context. In the Dublin dental hospital, at least two consultants are employed in special care dentistry. I am not sure what the situation is in regard to its waiting list.

Professor Leo Stassen

The dental school has three remits: one is to educate our new dentists, the second is to provide a treatment service and the third is research. In the provision of a service, the service has to reflect what the postgraduate and undergraduate training requires; therefore, a dental school is limited in the service it can provide in whatever area it be, whether special needs, extractions or periodontics. The waiting list in the Dublin dental school is closed for most services unless it can fit within the area of undergraduate and postgraduate education or research needs. The service commitment from a dental hospital or dental school is small and, therefore, it is not surprising that waiting lists are very long.

Is it only through the dental hospital that somebody with an intellectual disability or a substantial physical disability can access dental care?

Professor Leo Stassen

Some dentists work with special care patients. It is a particularly time-consuming type of treatment and it needs to be a particular person, which not everybody is. Some people like dealing with that type of person so one can get the provision of special care in general practice, but most dental practitioners are unable to provide that type of treatment. It is mainly in schools that it can be accessed rather than in hospital services.

I support the national oral health plan, which is to look at this issue, particularly in regard to the private people to see how they might be given dental care. Who is going to provide it is our question.

The capacity is not there within the dental hospitals.

Professor Leo Stassen

As I am no longer in the dental hospital, I am talking a little out of turn. I do not believe, based on the time I was there, that the ability to provide the type of care the Chairman is talking about is available in the hospital. Professor Lynch will talk about Cork, where I believe it is the same.

Professor Chris Lynch

It is the same. There is some provision within health board services for the management of special care patients through principal dental surgeons.

Professor Leo Stassen

That is in the public dental service, not in the hospitals.

Is that delivered in general dental hospitals?

Mr. Fintan Hourihan

No, it is in HSE clinics. Notwithstanding the fact there is no recognition of the specialist qualification, a number of dentists work for the HSE public dental service and they are managed by the principal dental surgeon. It is a regional service. There are dentists who see special care patients in the HSE as opposed to the dental hospitals.

Professor Leo Stassen

It is also important to note that when a public dental service dentist is providing treatment, it takes an inordinate time. I do not believe the national oral health strategy has looked at this. To provide treatment to a special needs patient, one could be talking about two or three sessions before they will even sit in a dental chair, and there is then the treatment. It can take an inordinate time. When one looks at the costing and the important resources that need to be put into this, it is not only people but it takes significant time, effort and cost to, quite correctly, provide treatment for special needs patients. That has not been accounted for. Everybody thinks that every dentist can provide this treatment. Although I am not a general dentist, if a person came to my practice and I had to see them four times, I have to consider I am paying for my premises and nurses, and I have no input from anybody else. That is a huge cost and it has not been addressed.

Does the oral health strategy address that issue?

Professor Leo Stassen

No.

Is it a substantial gap?

Professor Leo Stassen

I am not a general dental practitioner. I ask Mr. Hourihan to talk about it because he probably knows more about it than I do.

Mr. Fintan Hourihan

It is self-evident there is a serious deficiency and a gap. There is a demand for that level of care which cannot be discharged.

If no other members are offering, we will conclude. On behalf of the committee, I thank the witnesses for coming in. We will engage with officials from the Department of Health at a later session and we look forward to hearing their views.

Professor Leo Stassen

Will we come along when they come along to actually listen.

We will think about that.

Dr. John Marley

Given the limited time we have to extract and offer a lot of data, and the committee has had a lot of reading to do, is there potential for questions to be put in advance in order that we can provide a more structured reply, rather than sometimes being on the back foot? That would presumably help the committee to get more information and it would help us and arrest our cardiac stress. Perhaps everyone would get more out of it. That is just food for thought.

I thank Mr. Marley. We will suspend the sitting until approximately 12 noon, when we will hear from officials from the Department of Health on the heads of the Bill to establish a CervicalCheck tribunal.

Sitting suspended at 11.40 a.m. and resumed in private session at 12.10 p.m. The joint committee adjourned at 12.55 p.m. until 9 a.m. on Wednesday, 22 May 2019.