JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 26 Jun 2003

Vol. 1 No. 12

Orthodontic Accreditation System and System of Training for Orthodontics: Presentations.

Chairman

On behalf of the committee, I welcome Mr. Brian Murray, chief executive, Dublin Dental Hospital, Trinity College; Professor June Nunn, professor of special care dentistry and head of the department of public and child dental health, Dublin Dental Hospital; Dr. PaulDowling, senior lecturer and consultant in orthodontics, Dublin Dental Hospital, and Professor Robert McConnell, head of the Dental Hospital of University College Cork. I ask Mr. Murray to begin the presentation on the Irish orthodontic accreditation system and the system of training for orthodontics currently being pursued, after which members may ask questions.

Before commencing the presentation, I draw attention to the fact that while members of the committee enjoy absolute privilege, the same does not apply to witnesses appearing before the committee. 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 House or an official by name in such a way as to make him or her identifiable.

Mr. Brian Murray

I thank the committee for its invitation to appear before it. First, I will introduce my colleagues. June Nunn is professor of special care dentistry and head of our department of public and child dental health which has responsibility for orthodontics. Dr. Paul Dowling is a senior lecturer and consultant in orthodontics. As Professor Nunn is involved in organising the healthy smiles programme for the Special Olympics, she will have to leave early. Dr. Dowling has interrupted his teaching of specialist orthodontics this morning to attend the meeting and will also have to leave before 11 a.m.

In relation to accreditation systems, it is important to state the accreditation system for the training of orthodontists is the responsibility of the Dental Council. Without accreditation we would be unable to attract applicants to our specialist courses. When we met the committee in December 2001, we set out the range of programmes we provide at undergraduate and postgraduate level, each of which requires accreditation. I have provided the committee with a table featuring the courses, their duration, number of students, qualifications and accreditation bodies. In addition, courses which carry with them a degree from the University of Dublin or Trinity College have in each year external examiners to assure their equality, equity and accountability.

Orthodontic accreditation is the responsibility of the Dental Council as the regulatory body with responsibility for the registration of specialists in orthodontics. The council appointed the Irish committee for specialist training in dentistry as the body in the State it recognises for the purposes of granting evidence of satisfactory completion of specialist training in accordance with EU directives and the guidelines of the EU advisory committee on the training of dental practitioners. The submission to this committee by the council last November set out the statutory position. I understand 71 people are currently registered on the specialist orthodontic register.

The process of accreditation as it impacts on the Dublin Dental School and Hospital is that the Irish committee for specialist training in dentistry must approve the training programme we deliver. The committee was appointed by the Dental Council in 1999 and carried out a review of our programme in May 2002. This was wide ranging and assessed not only the academic content of the programme but also our facilities, the level of clinical supervision, supports etc. It is a process with which we are familiar as it mirrors the arrangements in the United Kingdom for postgraduate training, on which we relied from 1989 when we first started training orthodontic specialists until the recent establishment of the Irish specialist register.

Most of our specialist and consultant training programmes are recognised by the specialist advisory committees of the United Kingdom. This is an important element in ensuring we attract good quality applicants and our courses are regarded as comparable with those in other countries. The Irish committee for specialist training in dentistry approved our training programme in 2002 and will revisit the hospital in 2004. Its approval permits us to train 12 specialists and up to two consultant trainees in orthodontics. We advertised a consultant training programme last year but failed to attract any suitable applicants. This reflects the difficulty in attracting people into orthodontic consultant training on these islands which will undoubtedly present difficulties for training at all levels.

When we last met the committee in December 2001, we had ten postgraduates in specialist training, four of whom graduated in July 2002, while the other six are due to graduate in July next year. With the approval of the Irish committee for specialist training in dentistry, we took on a further six postgraduate trainees in October 2002 who would be expected to graduate in July 2005. We have, therefore, 12 postgraduates in training. We are not planning an intake of trainees in 2003. The next intake is planned for 2004, subject to the approval of the Irish committee for specialist training in dentistry.

Given current constraints on supervision, space and support staff, we expect to graduate 28 people as specialists in orthodontics between now and 2010. We indicated when we last met the committee that we could increase the numbers in training to 18 at any one time with a further consultant appointment, additional facilitates and greater nursing, radiographic and administrative support. We have had discussions with the Department of Health and Children in this regard.

The Dental School and Hospital has only two consultant orthodontists, Dr. Paul Dowling and Dr. Therese Garvey. I publicly pay tribute to their hard work, commitment and dedication to public service. The committee will appreciate that specialist training in orthodontics is just one part of their consultant role. They also have teaching responsibilities for dental students, dental hygienists and dental nurses and a treatment load involving complex, multidisciplinary patient care. In addition, they must continue with their research interests.

Recently, the press has featured a considerable amount of comment about consultant contracts. It is important to draw to the committee's attention the difference between the dental academic consultant contract and the medical consultant contract. Our consultants work exclusively in the public service and are not permitted to accept VHI or private fee income. They may, however, opt to reduce their commitment to public service - 39 hours per week - to undertake a maximum of just three hours work in the private sector, for which their salaries must be reduced. Our staff are, therefore, fully committed to the hospital and delivery of service to the public. At present, students at undergraduate level in their fourth and fifth clinical years treat orthodontic patients on a weekly basis. This is a more extensive clinical training in orthodontics than is found in most dental schools and is in accordance with the Dental Council guidelines.

The Dental School and Hospital understand the concerns of the committee in respect of orthodontics and welcomes the report from the committee. We are conscious of the public demand for more extensive services and we are endeavouring to facilitate that demand through our training programmes in orthodontics. We are training more orthodontic specialists than most European dental schools and we are doing so with fewer orthodontic consultants than other schools.

It is, however, incumbent on a dental school to look at orthodontics in the context of oral and dental health and not as an isolated area. As a school and hospital we have a responsibility to train 300 students at undergraduate level in dental science, dental hygiene, dental technology and dental nursing. We have nearly 100 postgraduates in training for diploma, membership, specialist or consultant training programmes. We are providing a further 300 dentists and dental nurses with continuing education lectures and courses.

In terms of our delivery of clinical care to patients, we provide some 14,000 treatment episodes in orthodontics each year out of a total of 100,000. Orthodontics is not a dental disease. Most of the care we deliver is to address disease rather than malocclusion. The demand for orthodontic treatment includes a significant amount of perceived need for treatment which is not a health need. In particular, we are concerned to ensure that care is delivered to those areas of dentistry which have not had the same degree of attention as orthodontics but which encompass patients who have disabilities and who are seriously medically compromised. We find it difficult to get access to operating theatres to treat persons with intellectual and physical disability. We are struggling to deliver pre-operative care to oral cancer patients. We are only now able to address the needs of hundreds of patients with missing and defective teeth as a result of genetic defects. We have one consultant in each of these areas of real need where dental disease contributes to their disadvantage.

We welcome the joint committee's interest and concern to expand orthodontic services. We would also welcome the opportunity at a future time to present to the committee our deeper concerns about the inadequate provisions made for the more vulnerable sections of our community.

Professor Robert McConnell

I thank the Chairman and members of the committee for the invitation to speak on the subject of orthodontics this morning. I will limit my presentation today to updating the committee on the developments since my initial presentation in December 2001. In that presentation I outlined the position of the Cork Dental School and Hospital under the following headings: the status and function of the Cork Dental School and Hospital; the undergraduate training programme; specialist services currently delivered; specialist training, and facilities, funding and plans for 2002. Those deliberations are a matter of record of this committee and I do not feel it necessary to cover all the same ground again, although I will be happy to respond to any questions members of the committee might have, or to provide any clarification that may be required.

In December 2001 I stated to this committee that the Cork Dental School and Hospital understood and accepted its remit to provide specialist training. I said that the Dental School would welcome the opportunity of working closely with the local health board in the development of specialist training in orthodontics. I also said that the Dental School was then unable to provide appropriate training in orthodontics because it did not have a second orthodontic consultant post.

I indicated that our plans for the year 2002 included: the employment of a specialist orthodontist; the appointment of a professor of orthodontics, and the commencement of a specialist training programme for two to four orthodontic trainees. With the co-operation of regional consultants, and with the approval of the Irish committee for specialist training in dentistry, it was hoped that the number of trainees could increase to perhaps six to eight per annum commencing in 2003.

In January 2002 the Dental School and Hospital appointed a registered orthodontic specialist. This person is currently engaged in the delivery of the undergraduate dental curriculum in orthodontics and in the delivery of orthodontic treatments to patients.

The chair in orthodontics in UCC was advertised in September 2000 with the retirement of the then incumbent. There were three applicants and one was short listed for interview in March 2001. The interview board did not consider this applicant suitable for the appointment. The post was again advertised in national and international press and journals in 2002 and in addition extensive searches were conducted. On this occasion two viable applications were received and in May 2002 these candidates were interviewed for the post of professor of orthodontics. The interview board was chaired by the president of University College Cork and included representation from the Southern Health Board, SHB, and two external assessors, one from the UK and the other from Europe. The interview board recommended one of the candidates for the post and it was duly offered to this candidate. An exchange of correspondence occurred over the next few months between the successful candidate and the head of the school, the school manager, the manager of the SHB, and the president of UCC in an effort to meet requirements requested by the candidate. These requirements included a considerable extension of the existing clinical facilities, the development of laboratories, and teaching areas, the provision of research facilities and the recruitment of staff.

The Dental School invited the successful candidate to visit Cork on 30 November 2002 to meet with staff of the Southern Health Board and UCC. He met with Deputy Batt O'Keeffe, chairman of the SHB; Mr. Tony McNamara, general manager of the SHB; Mr Gerry O'Dwyer, deputy general manager, Cork University Hospital; Mr. Ian O'Dowling, orthodontic consultant, SHB; Mr. Michael Kelleher, secretary and bursar, UCC; Professor Aidan Moran, vice president and registrar, UCC; myself and Ms Kathryn Neville, manager of the Dental School and Hospital. Detailed discussions regarding staffing, funding, delivery of patient treatment and the training of specialists were undertaken. There was a further extensive exchange of correspondence over a number of months culminating in another visit to the Dental School and Hospital on 26 April 2003. On this visit details of facilities and other matters were discussed with Mr. Tony McNamara, manager of SHB; myself and Kathryn Neville of the Dental School.

It should be noted that the chair in orthodontics in Cork is only one of a number of similar posts vacant in Ireland and the United Kingdom. There are not enough qualified persons available to fill these posts and candidates are in a very strong negotiating position. A further visit to Cork by the candidate took place on 22 May 2003 when he met with the president of UCC, Professor Gerry Wrixon. At this meeting outstanding issues were discussed and it was confirmed to the candidate that the following commitments had been received and would be made available following his acceptance of the post: funding from the Department of Health and Children for the development of a new orthodontic clinic and related teaching areas; funding from UCC for clinic, staffing and research areas; funding from the Southern Health Board for staffing for the new facility. The candidate has now requested that these commitments be confirmed in writing and the president will do so forthwith.

Members of the committee should appreciate from the foregoing the difficulties in filling the chair in orthodontics in UCC and the necessity in the prevailing climate to hasten slowly. While I can give no guarantee at this juncture I know that the candidate is seriously interested in coming to Cork and I am quietly confident that he will be in post at the end of this year or early 2004.

Assuming the appointment of a professor in orthodontics, following a short lead-in period, the Cork Dental School and Hospital should be in a position to offer a specialist training programme in orthodontics.

I thank you for your attention and I will be happy to answer any questions from the Chairman or any members of the committee.

Deputy O. Mitchell

I have been a member of this committee for one year, during which I have managed to assimilate a great deal of information about the health service. The dental service, however, completely eludes my comprehension. It is tantalising in that just when you think you have got to the nub of the problem it turns out to be something else. From what we have heard this morning, particularly in regard to orthodontics which often seems to be the focus of the problem, there seems to be a difficulty in filling the chair of orthodontics at UCC. It seems to be impossible to get orthodontists and equally difficult to get trainees to become orthodontists. Why is this the case? Either they are not being paid enough and it must be increased or their contracts need to be completely changed. This issue is of great interest in the context of the Brennan report. The Minister for Health and Children should take note, as this will face him in the entire health service if he moves to exclusively public work for consultants, given what is happening in orthodontics. The nub of the problem is that no one sees orthodontics as a rewarding career. I am reluctant to ask my next question. On foot ofthe letter which we have before us from Dr.McNamara and the letters we have received from Dr. Dowling in recent months, what on earth is the problem? Can anyone synopsise what the problem is in this profession which causes such dissension?

Deputy F. O’Malley

May I pose questions and have them answered rather than going backwards?

Chairman

As long as we move along at speed.

Deputy F. O’Malley

Can Professor McConnell confirm that there is a professor of orthodontics?

Professor McConnell

I cannot do so until he signs a contract.

Deputy F. O’Malley

Does ProfessorMcConnell have any idea of when that might happen?

Professor McConnell

As I said in my presentation, I would hope very shortly. However, having been down that road before——

Deputy F. O’Malley

Is there a professor of orthodontics in Dublin?

Mr. Murray

No. We have two senior lecturer consultants. We have the committee and the report recommended the appointment of one and we have had a conversation with the Department of Health and Children.

Deputy F. O’Malley

To date, none has been appointed.

I recognise that much of what happened predates the appointment of those before the committee. Like Deputy Olivia Mitchell, I have been on this committee for only a year. However, I am concerned at what is happening in orthodontics. If we are all motivated by the delivery of public service, there is an easy solution to the problem. In 1999, changes happened and, effectively, a collapse of the service occurred. Can the witnesses comment on the transitional arrangement? I recognise that they were not in their present positions. However, they must be responsible for the consequences of what happened. Some 12,000 children were in treatment. What transitional arrangements were put in place to treat those children?

Mr. Murray

We are a training body. That is not a question I can answer.

Deputy F. O’Malley

The body decided that the training that three orthodontists were giving was not of a sufficiently high standard. However, in pulling back that treatment, the training body must have realised the consequences. It effectively created a monopoly situation, where one training body was to decide on standards. It is fine for the training body to do this if it is entitled, but the representatives are not prepared to comment on the consequences of disallowing the alternative method of training.

Mr. Murray

There may be some confusion. I am not privy to the correspondence the Deputy has had from consultants. We are a training body which abides by the guidelines laid down by the Dental Council in terms of the training which we must provide. Those guidelines apply to everyone - Cork or anywhere else. We do not set those standards. We have nothing to do with any of the——

Deputy F. O’ Malley

Who are the members of the Dental Council?

Mr. Murray

The Dental Council is a statutory body.

Deputy F. O’Malley

Who are its members?

Mr. Murray

Half the membership is elected by the dental profession. There are two representatives from each of the two universities involved in training and two representatives from the Medical Council. One of the members of the committee, Senator Feeney, is a member of the Dental Council. A number is also appointed by the Ministers for Education and Science and Health and Children. It is the body that is responsible for what the Deputy refers to. I am not in a position to answer questions of that nature.

Deputy F. O’Malley

Alternative trainingwas available up to 1999, if I was in Readingor Cumbria, but how would I get that level of training?

Mr. Murray

I can only say what we, as an institution, were doing.

Deputy F. O’Malley

I am asking Mr. Murray to look a little bit beyond in terms of his European colleagues. Is the standard any different in the rest of Europe?

Mr. Murray

The standards laid down here are the European standards and we abide by them. We have been providing training in orthodontics since 1989 to the European directive standard, according to the guidelines of the European training body and with the co-operation of specialist advisory committees in the UK. The only change in that respect was in 1999 when the Dental Council took responsibility for the accreditation here because it established, with the consent of the Minister for Health and Children, a specialist register.

Deputy F. O’Malley

Does Mr. Murray agree that this has lead to a collapse in the service? The Dental Council is a self-serving body. Does Mr. Murray agree that the service collapsed because it was being too efficient? Since 1999, the waiting lists have increased no end. I find it hard to justify the changes that took place, particularly in light of the standard that was being provided. There was no question about the level of standards. I ask Mr. Murray to go back and examine what happened pre-1999.

Deputy Neville

My question was similar to that of Deputy O'Malley's. However, I do not think Mr. Murray has a role in this. The Dental Council is the body we should be talking to. Is Mr. Murray happy with the training programmes from the SAC, the British-based orthodontic inspection group which was involved here until the late 1990s? I am not saying that he or the training body has no role and should not comment on it.

Mr. Murray

We have a role since that issue is directly concerned with training. On page 2 of my document, I set out a schedule of all the programmes we offer and which accreditation body is responsible. The specialist advisory committees in the UK are still responsible for the recognition of most of our specialist programmes because there are only two specialties approved by the Minister which are oral surgery and orthodontics. We provide training in a full range of specialties and they are also set out. This happens in medicine too. It is not unusual.

Deputy Neville

I am from the mid-west. Is Mr. Murray saying the training service which was supervising that training is still continuing with the present training of orthodontists?

Mr. Murray

The training requirements that the Irish committee have - which are similar to those of the SAC in the UK - require the substantial part of training to take place in a dental school. At the moment Dr. Dowling would be better able to describe the division between working in a dental school and commitment in the regional service.

Dr. Paul Dowling

The regional units throughout the country participate fully in the training programme which we co-ordinate. Our students spend a certain amount of time each week in these units, supervised by consultants who work in the units. In regard to the collapse of the service - and the term "collapse" is emotive - Deputy O'Malley asked if the waiting lists are now longer. It is not the role of the school to know or identify whether there are waiting lists. That is the role of the serviceproviders such as the units in the health boards and that question would be better directed at them.

Deputy Devins

It takes five years to complete the bachelor of dentistry degree. A specialist with a medial background is synonymous with the term "consultant". However, there seem to be two groups: one can be a specialist for three years and then move on to be a consultant. What is the role of each? Are they interchangeable?

In Dublin about 40 dentists graduate every year. How many of those go on to practice orthodontics, either to specialist or consultant level? Why, in 2003, are there no postgraduate entries at all?

Mr. Murray

To take the last question first, I mentioned in my presentation——

Deputy O. Mitchell

Am I to get anyanswers?

Chairman

This is the last round of questions, so we will take the rest and then allow Mr.Murray to answer.

Mr. Murray

I will wait until the questions are finished.

Deputy O. Mitchell

I realise it is more satisfactory to receive an answer as one asks the questions.

Chairman

No, that is not what I mean.

Deputy O. Mitchell

We can finish withDeputy Devins's questions and then return to mine.

Mr. Murray

We are obliged to follow the directive given to us by the Irish Committee for Specialist Training in Dentistry, which allows us to train 12 people. We currently have 12 in training and we will have 12 until 2004, so we cannot take in any more as we are not allowed to train more than 12.

Deputy Devins

It is not 12 every year?

Mr. Murray

No, it is 12 in total. The accreditation body tells us the number of trainees we are permitted to take on given our staffing, facilities, support staff, supervision and so on. We are obliged to follow that.

Deputy F. O’Malley

Who is the accreditation body? The Dental Council?

Mr. Murray

The Irish Dental Council has appointed the Irish Committee for Specialist Training in Dentistry to act on its behalf.

Deputy Devins

Does that mean that every three years, 12 trainees enter the programme?

Mr. Murray

We roll it over. We have two intakes of six trainees in order to try to get as many people out as quickly as possible. This means, however, that there must be a gap year, and 2003 is the gap year.

Deputy O. Mitchell

I may have been asking the wrong questions, from what I am hearing now.

Dr. Dowling

The Deputy asked about the difficulty in recruiting people and the lack of attractiveness of the post. That certainly contributes to people not pursuing an academic or consultant post. The rewards in the private sector are far greater. That is the only one contributing factor, however. Some people would not be interested given the nature of the post, which involves teaching, research and administration; they would be more interested in the hands-on clinical treatment of patients.

Deputy O. Mitchell

We may be talking about different things. How does one become a private consultant orthodontist?

Dr. Dowling

To answer another question at the same time, one goes through a five-year dental course followed by a three-year specialist programme, although it is some time before one can gain access to that. After completing that programme one is entitled to go into either the public or the private sector as a specialist. If one wants to pursue a career as a consultant one must do some further training, which is two to three more years.

Deputy O. Mitchell

What about the difficulty in attracting trainees?

Dr. Dowling

There is no difficulty in attracting trainees to become specialists. When we advertise a course leading to the qualification of specialist we receive far too many applications. There is a difficulty with attracting people to become consultants. When we advertised the higher training programmes last year we failed to fill the course.

Deputy O. Mitchell

Is that because once it is over they must do only public work? No.

Dr. Dowling

There are different contracts. The academic contract in a hospital does not permit any private work; the health board contracts permit a limited amount of private work. One is limiting one's options, or making a very clear decision at that stage that one will mainly concentrate on public sector work.

Deputy O. Mitchell

Very few of them are making that decision.

Deputy Devins

I still do not understand. Is a specialist the equivalent of a senior registrar?

Dr. Dowling

The higher training is the equivalent of a senior registrar, leading to consultant. It is not an exact copy of the medical model. A specialist is the equivalent, for example, of somebody who has done three or four years of general surgery in Europe establishing themselves as a specialist surgeon.

Deputy Devins

A specialist orthodontist is entitled to work on his or her own, treating orthodontic problems?

Dr. Dowling

Yes.

Deputy Devins

What is a consultant then? What does he or she do?

Dr. Dowling

A consultant is involved in education, organisation of services and carrying out research. It is a broader remit.

Deputy Devins

Are consultants located only in dental schools then?

Dr. Dowling

No, in the health boards their concerns would be more to do with the organisation and planning of services.

Professor June Nunn

The clinical role of the consultant includes the management of much more complex cases, including children with cleft palates and patients who need oral and maxillofacial surgery in combination with orthodontics. The clinical case load is different from that of a specialist.

Deputy O. Mitchell

Does the specialist and consultant training course have a limited intake?

Mr. Murray

We are limited to 12 specialist trainees and two consultant trainees.

Deputy O. Mitchell

No wonder we have a problem.

Deputy Cooper-Flynn

I welcome the two groups present. Unlike the other members, I was on the previous committee so I am very familiar with this debate. Over recent years we have all formed our opinions. The motivation of the committee in having this debate was to see how orthodontic treatment could be obtained for as many people as possible. That was the reason for our concern - it is not that we wanted to invite the representatives in time and time again to question them on what was going on. What happened in the west and the mid-west in orthodontics formed part of our initial discussion. Unlike Deputy Olivia Mitchell, I do not think there is any problem whatsoever in getting people into this profession. Dr. Dowling has answered that question. It is a very rewarding profession, but the difficulty is in getting into it.

How exactly is the selection for the training courses made? In my health board area I met a person who had spent seven years in an orthodontic department with an element of training, yet was unable to obtain a place on a course in Ireland. The person subsequently went to the UK to be trained, with funding from the health board. I also know people who have been selected although they had no experience whatsoever. I would like to know the criteria for being selected.

Once a person is selected and training is carried out, given that many people are trained at the expense of the health board, how many years must these people give back to the public health system under their contracts? People who have been trained at the public's expense can leave and go into private practice. In the past ten years there have been ten graduates from the Dental School. Some detail is provided in the report, but how can we fulfil the requirement to provide a decent service, meeting the 1985 guidelines? How can we realistically expect to train enough people to fulfil the need we have? If we cannot do that, with the system as it is currently set up, we are looking at a problem that will get worse as the years pass.

The representatives have explained the make-up of the Dental Council, which appointed the ICSTD, which then approved the training. It seems to me that the same people are involved in everything. Everybody seems to be approving what the other is doing, which is a very cosy arrangement. Who set up the regional orthodontic departments in the first place? Because there were not enough people in training, these departments started off doing the training themselves, particularly in the mid-west and the west, which was the issue discussed at our last meeting with these three consultants.

In 1999 that was found to be unsatisfactory, and we know why the Dental School thinks that and why the consultants think differently. Were those departments set up initially by the Dental School? Is it not the case that the rules were changed in 1999 rendering that situation unsatisfactory and that there is now a different training programme that fits in with the Dental Council and the Dental School which are happy now but unfortunately fewer children are being treated? That is the difficulty, and we will always ask questions about this training because at the time, in my health board region, there was a short waiting list for orthodontic treatment and now it is a four-year waiting list. As long as that exists we are going to ask those questions.

Senator Henry

Have you much leakage to the UK of the people trained here and have you any suggestions as to how we could retain people in the public service here?

Dr. Dowling

Most of the people whom we have trained in recent years operate within the public service. There has been no leakage to the UK or to any other country. Some specialists divide their weeks between public service and private practice. Some paid for their education independently and have ended up working in the public service. Most of their contracts say they are expected to work for the health board for three years after qualification so it is a three-year training programme and a three-year pay back.

Deputy Cooper-Flynn

When did that contract come into effect?

Dr. Dowling

That is the current contract. It applies to the 12 people now in training.

Deputy Cooper-Flynn

Prior to that?

Dr. Dowling

Prior to that it was mixed, some had two years, for others it was ambiguous, whether it was one, two or three.

Deputy Cooper-Flynn

Do they all have a minimum of one year?

Dr. Dowling

I could not swear to that but as far as I am aware anyone who was previously funded by the health board had one, two or three years in his or her contract.

Deputy Cooper-Flynn

Are they receiving a salary while they are in training?

Dr. Dowling

They are.

Deputy Cooper-Flynn

So the training is paid for and the students get a salary for the work that they do as part of their training which presumably is minimal, is it?

Dr. Dowling

They have a case load of about 120 patients each so it is significant. It is not as big as one would expect a specialist to have but it is about one-third of what a trained specialist should carry.

Deputy Cooper-Flynn

They are receiving a salary and in some cases their training is provided for as well and presumably if one is in the western health board region one gets expenses to travel to the Dental School in Dublin.

Dr. Dowling

That is being debated with the Department of Health and Children. They are supposed to be entitled to expenses.

Deputy Cooper-Flynn

In some cases they might have had only one year to give back to the public service, which is totally unacceptable, although I appreciate that the new contract says three years.

Could Dr. Dowling outline the selection process?

Dr. Dowling

It is a highly competitive process. We are oversubscribed every time we advertise so we have a structured selection process whereby we rank a number of categories: academic record, general and dental experience, research experience, publications. We should have brought this today but we score a range of things on a set system.

Deputy Cooper-Flynn

I would appreciate if you could forward the selection criteria to me. It is hard to pick one case that I might be aware of out of the air but it seems unusual that someone who had several years of experience - I do not know about the academic record - can be deemed suitable to train in England at health board expense but cannot get into the Irish Dental School. I am unhappy about that.

On the question of the school's ability to train enough people over the next few years to meet the demand, and the comparison with the system that existed previously, is the school satisfied that with the present system it will be able to train enough people to meet the demand?

Mr. Murray

The committee set a target of 50 specialists being required.

Deputy Cooper-Flynn

Over what time scale?

Deputy Devins

For the country at large?

Mr. Murray

There are 18 there now so there is a gap of 32 to be filled and four graduated last year leaving a gap of 20 or more.

Deputy Cooper-Flynn

So there are about six coming out every year.

Mr. Murray

Yes and over the next eight years we will train 28 more. If the Cork school comes on stream it will train four to six a year from 2004. We indicated to the committee when we last met that we could increase our intake to a total of 18 trainees but we would require additional resources and we are discussing that with the Department. I am optimistic that we will get the two things we require, additional physical facilities and a professor of orthodontics because we cannot do any more with only two consultants. The Department supports our proposal to extend our physical facilities and we have to have further discussion about a professor.

Deputy Cooper-Flynn

So it will take eight years in Dublin for the school to give us what we require and if Cork comes on stream that may be reduced?

Mr. Murray

It will reduce that time. If we can train a team instead of 12 that would reduce it even further.

Deputy Cooper-Flynn

Meanwhile the problem is getting bigger.

Dr. Dowling

In July 2005, 19 people will graduate who are committed to public service for three years. Six will graduate in July 2004 and the balance a year later. Seven of these are training in the UK and 12 with us.

Deputy Cooper-Flynn

We have no control after the three-year period so when that expires people will leave and go into the private sector and the problem will continue. Who was responsible for setting up the training in the regional orthodontic departments?

Mr. Murray

The health boards, I presume.

Deputy Cooper-Flynn

Who set up the training within those departments?

Dr. Dowling

There were very few specialists available to provide services so the people in the original regional orthodontic units took in dentists and supervised their treatment of patients. Only at that stage was an attempt made to retrospectively accredit that as training. It was not established initially as a training pathway. It had no accreditation from any other body and an application was made to have it retrospectively accredited but it did not get accreditation in 1999. We would provide only training that meets internationally acceptable standards of education. The SAC had a difficulty because there was no association between those regional units and the dental schools. That clearly created a problem for the SAC in recognising them.

Deputy F. O’Malley

Was that dental schools in Ireland as opposed to abroad?

Mr. Murray

Any dental school, if linked with another dental school.

Deputy F. O’Malley

I understood that they were linked with Edinburgh.

Mr. Murray

One would have to ask about their agreements.

Deputy F. O’Malley

I think that they were.

Mr. Murray

I do not know. However, it is not a matter for us to say whether the training is good or bad, for we are not the accreditation body. Up to 1999, that was the SAC, and we had to go through that process with it. We were visited in 1999, and during the 1990s because we ran a programme. We first started doing formal programmes in 1989. We were only able to graduate ten specialists and perhaps five consultants between 1989 and 1999. I explained to the committee on the last occasion when I was before it why we were not able to do that. I can understand why the regional consultants would have been impatient to have more people in training. We were not able to deliver training, and there were good reasons which I mentioned during my last visit. We were in a building condemned by the Dublin fire authorities as dangerous. It was only in 1998 that we got a new building. Since the opening of our new building, we have massively increased the number of people in specialist and postgraduate training. We now have nearly 100 people on postgraduate programmes. I could count on one hand the number of people we had in 1999 engaged in such training. There has therefore been a complete shift in the provision of facilities.

Deputy F. O’Malley

It is not of service to patients, which is most important.

Mr. Murray

With respect, our role is to provide the country with the manpower to deliver the service. We were constrained in what we could do because we did not have an adequate dental hospital until 1998. Since then I can assure the Deputy that we have the maximum number of trainees permitted by the accreditation bodies. We are the only place in the country providing training and are "maxed out" on what we can do. With more facilities and additional staff, we can squeeze more out of the system. We are being asked now in addition to start a new training programme for orthodontic therapists. We are happy to do so, for we have always responded to the needs presented to us and the requirements of the State for training. However, we need the staffing and facilities to do so. The committee's last report was very positive in its support, and that allowed us to go to the Department of Health and say what we could do in addition if it gave us extra resources. The report was very helpful.

Chairman

So it comes down to facilities and resources.

Deputy O. Mitchell

That may be the answer to my question. I am trying to establish the basis for the restriction on the numbers of specialists that you are permitted to train by the accreditation body. Is it to do with physical facilities? Is it operating a closed shop? Is it similar to the restrictions that the royal colleges are imposing on the hospitals now, saying that certain hospitals do not have a sufficient throughput of patients? What excuse are they giving for this? The reason for the restriction in the numbers of specialists who may be trained is not coming across to me - unless it is a closed shop.

Professor McConnell

I have been very quiet up to now and glad to be able to field the questions to my colleagues on the right. With all the specialist training programmes, as Mr. Murray said, there is an accreditation body that visits facilities. It does so to see that the facilities are there for training, including the number of dental chairs, nurses to assist people in training and supervisors. The SAC in the UK and the Irish committee here lay that down for us as the training body very strictly. We have no choice. There are certain demarcations in the number of patients who may be treated by the trainees, and Dr. Dowling already mentioned that 125 patients can be treated at any one time. They do not allow our trainees to treat any more patients. Those regulations are laid down so that someone can end up with an accredited qualification, in this case that of a specialist. We have no input into that.

Professor Nunn

If we do not comply with that, we cannot attract candidates. Without accredited training places, we would not get candidates to enrol on specialist training programmes.

Deputy O. Mitchell

I understand that, but I do not understand what we are short of so that we cannot increase numbers.

Professor Nunn

The resources are consultants to train and other support services, including radiography, dental nursing and physical space. We also need a professor in orthodontics to provide the academic part and the research.

Deputy O. Mitchell

It is a vicious circle.

Deputy Devins

What is the situation in the UK? Is it training too many people? Does it have a surplus? I am trying to drive matters forward, for we will be short in the next three to five years. Can we get people over here from the UK in the interim?

Mr. Murray

The UK is training a total of 150 specialist orthodontists, 100 of whom are European Union citizens. The remaining 50 are non-EU and presumably are not going to stay in the system. The shortage is not in attracting people to be specialists but in attracting them afterwards to have further training to be consultants. One needs the consultants to manage the service and train people to be specialists.

Deputy Devins

If we advertised tomorrow, could we have enough specialists from the UK over here?

Mr. Murray

There are a number of specialists from overseas.

Chairman

The Dáil is just about to vote.

Deputy F. O’Malley

Can we reconvene? As Deputy Mitchell said, restriction is the bottom line, and we are worried about the future. Would you consider having a new, different, independent SAC?

Chairman

We will return in a few minutes.

Sitting suspended at 11.00 a.m. and resumed at 11.10 a.m.

Chairman

We will continue our business. We have got only 15 minutes. People have commitments after that. Is that agreed? Agreed.

Deputy F. O’Malley

As I was saying before we had to go to vote, what all of us here are somewhat concerned about is the fact that the training of orthodontists in Ireland is faced with tremendous restrictions. We are worried about this. It does not look as if the situation is going to get any better. I hear what Professor McConnell is saying in terms of his role and function as a trainer, but he does not appear to be concerned about the reality of curtailed treatment and increased waiting lists. That would seem to take second place in the scale of priorities. On this side of the House we are looking at the expenditure of public money for which we want patients to be treated. We want to find the best way to get as many people trained so that patients can be treated. The professor has nodded, so I imagine he would agree that this is the result we all want. I am concerned about the SAC which took place in 1999 and want to ask the professor if - in terms of strategic thinking and planning - he should once again look back to the alternative treatment that was on offer, given the current log-jams in the system. I understand it was and can be accredited. A similar service is available in England, for instance, and is accredited through the School of Dentistry in Edinburgh. I do not think it is good enough that a single SAC has led to a complete turnaround and diminution in the delivery of service to patients. I would ask if a further independent SAC comprising those three orthodontists is possible in the interests of widening the training remit.

Professor McConnell

First, I would not like the Deputy to feel we are not interested in patient care.

Deputy F. O’Malley

I was not implying that.

Professor McConnell

Second, as far as the group and I are concerned the way to increase patient care is to increase the number of people suitably qualified to deliver it - whether through the SAC, an Irish committee for specialist training or whatever. The specialist that we hired in the Dental School in Cork did her training in Manitoba, for instance. She came here, produced her accreditation and was registered as a specialist in Ireland. The issue is not that we are not interested in care. The issue is that we are interested in appropriate training, to the highest standard. The relationship to 1999 keeps coming up in your questioning. At that stage the way we did training, whether orthodontics, paediatric dentistry or whatever, was to invite the SAC from the UK to visit us to find out whether we had an appropriate training programme here that it could recognise. All of us went through this. After 1999, when the Dental Council was allowed to have two specialties, oral surgery and orthodontics, the training as was assessed to an appropriate standard by an Irish committee. We are an independent country.

There are two ways a person may become a specialist. He or she may participate in a programme approved by the Dental Council through the Irish committee for specialist training. People from outside the country may submit their qualifications to the Dental Council which will assess them and determine whether they are appropriately trained. Our only interest in this is to ensure that people who call themselves specialists - or who want to do specialist training with us - get the appropriate training. We do not have any hang-ups about pre or post-1999. The Deputy made a comment, linking the amount of treatment with 1999. They are two different issues. A specialist training programme is not about the numbers of patients treated. It is about training specialists so that in the end they can treat lots of patients. I would not like the Deputy to think those two things are linked. The training programme is not about treating 125 patients, as Mr. Dowling said earlier. After that you have a specialist who can treat - and I do not know the numbers - many more patients than that. That is really what we are here for. If I had a professor in Cork, we could set up programmes for training specialists so that they could go out and treat patients in the manner in which the Deputy says is appropriate.

Deputy Cooper-Flynn

While I appreciate that from the viewpoint of specialist trainers the two are not linked, but in reality they are, because the numbers going through have a direct bearing on the numbers that are treated. It can be appreciated that from our viewpoint the two are closely linked. As a matter of interest, who is on the specialist advisory committee?

Mr. Murray

The Irish committee?

Deputy Cooper-Flynn

The Irish one, and also the one that did the infamous inspection in 1999.

Professor McConnell

That was a UK visit.

Deputy Cooper-Flynn

How is the committee constituted in the UK, and how is it constituted in Ireland?

Mr. Murray

I could not be certain how it is constituted in the UK, but it is generated by the consultant orthodontic group there.

Deputy Cooper-Flynn

Would these be people from the public or private sectors?

Mr. Murray

They would be from public service and academic backgrounds.

Deputy Cooper-Flynn

What about in Ireland?

Mr. Murray

The Irish Committee consists of representatives of the dental schools, representatives of the consultants, specialists, trainees.

Dr. Dowling

The trainee representatives, a representative from the SAC in the UK.

Deputy Cooper-Flynn

Again, would it be private or public specialists and consultants?

Dr. Dowling

Largely public, but there were some private ones. The two individuals who visited the Dental School in Dublin, and the facilities in the north-east, south-west, and east coast area in 2002, were Dr. Paul Cook from the United Kingdom, an external assessor, and Dr. John Lawlor, who is an orthodontist in private practice in Ireland.

Deputy Cooper-Flynn

What would the witnesses say to the suggestion that if I were a private consultant looking at a highly efficient operation in the public service, I would have a vested interest in its not continuing? I am just wondering if it is right for somebody who has a vested interest in training taking a certain direction, having a place on the SAC?

Dr. Dowling

It is a very small country and finding people without vested interests is quite difficult.

Deputy Cooper-Flynn

I know.

Deputy F. O’Malley

Is it not just independence of judgment?

Dr. Dowling

That is one of the reasons we looked to the UK in the past and still maintain a link, to ensure independent judgment.

Mr. Murray

For the visits to the Dublin Dental School, relating to orthodontics and oral surgery, there were two visitors. The Irish committee invited someone from the UK to be one of the visitors. In fact, generally speaking, the external assessor is usually the lead examiner.

Chairman

I remind the members of the long-standing practice that they should not comment on, or criticise, or make charges against, a person not before the House.

Deputy Cooper-Flynn

We are not. We are just posing possibilities and querying the independence.

I expect that there will be close links between the Irish dental schools and the UK dental schools. Would that be reasonable? If, for example, someone was coming to Ireland from the UK, would it not be a matter of picking up the phone and calling the Irish dental hospital to ask what is going on?

Mr. Murray

There are 14 dental schools in the UK. I have been in six of them. I attend a meeting of the managers of all the dental schools in the UK twice a year. That is as far as it goes. There is no conspiracy against anybody. We are generally working in an academic environment. Conspiracy is not an interest. We are all public servants here. We all have the interest of public patients at heart in the delivery of care. We are striving to do the best we can to deliver that. We have more people in training now than we had in 1999. We are doing the best we can, given the constraints.

Deputy Cooper-Flynn

I accept that. That is fair. It is interesting that Mr. Murray makes the point that we want the public interest to be at heart, but at the outset he was insistent that training was his area, end of story.

Mr. Murray

We are a dental school. We have three areas in which we have statutory engagement, those are teaching and training, delivery of care, and research. We have to balance our activities to cover those areas.

Our primary mission is to provide the State with qualified dental health care personnel, across the complete range of the State's needs, from dental nurses to specialists, to consultants. We provide care for patients across all disciplines as a referral centre, with dentists referring patients to us. We also carry out research. I mentioned that about 14% of our treatment load annually is in orthodontics, but we have to cover the full range. Our primary mission is not the delivery of patient care. The State has determined that that is the responsibility of the health boards. I apologise to the committee if it feels I was dismissive of patient care. I said that we welcomed the committee's interest and its concern to expand orthodontic services. I said that in my statement, and went on to say that we have interests in a range of other areas of much greater health need in dentistry that we would like the committee to examine as well, at some later stage.

Deputy F. O’Malley

Having listened to Mr. Murray outline his role it is remarkable to note that there is no professor of orthodontics in Ireland at the moment. Do the witnesses feel compromised by that absence?

Mr. Murray

I do not think it compromises us. We would wish to have a professor of orthodontics and a professor of oral surgery. We have just appointed a professor of oral and maxillo-facial surgery who will take up residence, but we have not had one for ten years. There has been great difficulty in attracting people of a high quality to posts in Dublin over the past ten years, as the committee is aware. It is hard to persuade people to live in such an expensive city. It has not compromised us as we have fully trained consultants. Dr. Dowling is a senior lecturer and a consultant. His standing, and that of Dr. Therese Garvey, is recognised by independent external accreditation bodies, which are satisfied as to the nature of their qualifications.

Deputy F. O’Malley

I am not querying anybody's status. The witness is from a training body that is at the top of the tree, without a professor of dentistry, and that is all I was saying. I was not casting aspersions on anybody's qualifications.

Professor McConnell

My understanding is that there are 17 vacant senior posts in orthodontics in the UK at present.

Chairman

That concludes the questions. I thank members of the delegation for attending at such short notice. They have given us a lot to think about. We will deliberate on what we have heard this morning.

The joint committee adjourned at 11.30 a.m. sine die.