That Dáil Éireann, noting the present inadequacy of our dental health services, calls on the Minister for Health and Social Welfare to introduce, as a matter of urgency, a new improved service that will (a) provide immediate free dental care for all school children (b) eliminate the present abnormally long waiting lists for treatment (c) introduce a choice of dentist scheme for medical card holders; and for this purpose to undertake a massive recruitment drive of dental surgeons, as well as initiating a programme for the training and utilisation of dental auxiliaries in a national dental service.
I know that the Minister has an important engagement tonight and I appreciate the courtesy he extended to me by informing me about it and by saying that he would pay particular attention to the points I am raising on this issue. The motion I tabled says:
That Dáil Éireann, noting the present inadequacy of our dental health services calls on the Minister for Health and Social Welfare to introduce, as a matter of urgency, a new improved service that will (a) provide immediate free dental care for all school children (b) eliminate the present abnormally long waiting lists for treatment (c) introduce a choice of dentist scheme for medical card holders; and for this purpose to undertake a massive recruitment drive of dental surgeons, as well as initiating a programme for the training and utilisation of dental auxiliaries in a national dental service.
The Minister in his wisdom thought fit to amend this for reasons which I find it difficult to understand or to accept and he asks that all words after "Dáil Éireann" be deleted and he substitutes the following:
"accepts that it is the intention of the Minister for Health to undertake a comprehensive review of the public dental services and to embark on a programme to remedy such deficiencies as that review may bring to light, and is satisfied that the Minister will implement necessary improvements as soon as circumstances permit".
I should like to explain briefly my reasons for bringing this motion before the House and what I hope to accomplish in the three hours we have at our disposal for it. I brought the motion before the House because of the abysmal state of dental health in Ireland and the failure of successive Governments to make proper dental care a priority in our health services. The result has been a history of neglect which has left this nation with a collection of the worst teeth in Europe and a standard of dental care which, in the words of the chief radiologist of the Dublin Dental Hospital, is comparable to that prevailing in Europe in the middle of the 19th century. So, we have a nation full of dead teeth and a dental service that in the opinion of experts is 125 years behind the times. My purpose in putting down the motion is to highlight in detail the facts and the statistics which will give us all a clear picture of the dimensions of our failure in this area and hopefully lift the lid off the complacency in Government and among the general public that has allowed dental disease to assume epidemic proportions in our community. We have tolerated a dental epidemic over the years.
In many ways I view this debate in a much wider context than a merely political debate confined to this House; I view it as a means of awakening the general public to the high incidence of dental disease and the low standards of care which they have tolerated for so long. I believe those in the dental profession and those in this House demanding a massively improved dental service cannot succeed unless public opinion is rallied in support, unless the public recognise the size of the problem and demand action. I believe we will be unable to bring the dental service into the 20th century in terms of quality without public clamour and outcry and active public support for change in it. We know that public interest in it does not exist at the moment; we can see that in the massive figures for those who never go near dentists and have little appreciation of the importance of dental health.
I should like to make clear that I do not intend to make this a party political issue in the narrow, petty sense of the word. I recognise that the history of neglected dental care is not the sole responsibility of any one Minister past or present. The present Minister inherits a tremendous problem and so faces a tremendous task. I hope these two nights of debate will make his task easier, not more difficult, by highlighting for the public the scope of the problem and by putting forward concrete, constructive proposals for action. I hope the Minister will approach the problem in the same light.
Too often the precedent invoked in Private Members' Time is that the Government introduce their own amendment and oppose a motion merely because it emanates from the Opposition. I think this implies that the Minister and the Department have a monopoly of wisdom. I hope that in time we may change that attitude on this matter and I regret that the Minister's amendment is perhaps rather negative in not seeing the purpose of the motion and the intention on my part to have the matter debated so that we might realise the immensity of the problem and see how we can tackle it.
I have placed a positive and constructive motion here and I had hoped the Minister would accept all that is embodied in it, most of which he should accept and some of which he must accept. However, he has responded with a curious and in some ways paradoxical amendment which states that he intends to undertake a review. I wonder about that. It seems to imply that the problems and deficiencies are not apparent, that they are not there or certainly are not obvious but rather must be sought out and discovered. The amendment says that the Minister will embark on a programme to remedy such deficiencies as that review may bring to light. That phrasing suggests the strength of the interpretation that these deficiencies are lurking somewhere in the dark and must be brought to light for us to see. The amendment goes on to say in a confusing and paradoxical way that the Minister will implement necessary improvements as soon as circumstances permit. That seems to acknowledge that deficiencies already exist and are apparent but that time is needed to put them right in which case I and many others may ask: Why do we need such a comprehensive review of the problem? Why do we need a review of a health epidemic that has been staring us in the face for the past 30 years? With due respect to the Minister—I do not think this was his own phrasing—the amendment is confused if not self-contradictory.
If the Minister's main contribution to the debate is to propose this comprehensive review I hope he will be specific about it, say what the terms of reference will be, who will undertake it and if there will be consumer representatives. Will there be a latest date by which they will report? If we can be specific about all this we may achieve something by this debate. There is an ignoble tradition in the Department of Health of sweeping difficult problems and decisions under the carpet of "a comprehensive review". We have work groups and task forces and so on and this has almost reached an absurd stage. I do not mean to be critical of the Minister but I want to caution him against needless delay in tackling these problems because in my honest opinion I do not think this review is necessary. In fact, I intend to give the Minister a comprehensive review this evening, the facts and figures of the neglect of dental care in Ireland, and to propose remedies. It is not such a subtle, complicated problem; it is as blatant as any other health epidemic. What will be required after this debate is not a comprehensive review but actual specific decisions by the Minister which he will have to implement and policies which we shall discuss and on which I think we can agree.
A comprehensive review of our dental services was undertaken by Professor Kaim-Caudle in 1969 on behalf of the National Economic and Social Council. The situation he outlined still exists today, a dreadful population-dentist ratio, advanced dental disease in the population, particularly and most ominously among children, insufficient dental preventive measures, gross regional inequalities in dental services available and restrictive laws inhibiting the use of dental auxiliaries as well as a crying need for a new Dental Act. He also emphasised the overall low priority in terms of Government expenditure accorded to dental health. At the time of the report he said that judging from surveys in the late sixties the situation had not improved from the fifties and it only remains for us to update his study with recent figures. This I have done through parliamentary questions and other means in the past few months. The facts that emerge show that the situation has not improved since the late sixties when he issued this report with the exception of fluoridation of the water. His comprehensive review and his recommendations are as relevant as they were when he issued them in the sixties.
Let us look at these statistics of failure in dental health and services. Over 50 per cent of our population have gum disease and this insidious process attacks the tissues of the gum surrounding the teeth and makes future loss of teeth inevitable. It results in significant costs for our dental services. As well as that, 127,000 of our people suffer from trench mouth. An even more appalling figure is that two-thirds of our people over the age of 40 have no teeth of their own and a high proportion of the remainder are heading in that direction. What better witness have we of the history of neglect of dental health?
There are 1.4 million people eligible for free dental care and there are only 222 full-time dentists providing that care. The ratio is one dentist per 6,300 eligible patients in the public dental service. What does that mean? It is over three times the ratio recommended by the WHO. They recommend one dentist per 2,000 of the population. This is a terrible indictment of our service. In the public sector alone there is a serious shortfall of nearly 400 dentists. With 888 dentists currently registered the shortfall in the country at large is at least 700.
The situation is as bad when one looks at the delivery of dental care to those eligible. Only 10 per cent of the adults and 40 per cent of the children entitled to free dental care actually receive it. I will admit that this is in great measure due to public apathy about dental health, but the fact that the service is so inadequate is a serious disincentive to public dental health. For those who are seeking it, the waiting lists are appallingly long.
According to figures from the Department of Health in reply to a parliamentary question, on 1 August last year there were over 24,000 children covered by medical cards awaiting dental treatment and the average waiting period for these children, who are entitled by law to this treatment, was 9.9 months. The situation for adults is not any better. Over 27,000 adults covered by the medical card were waiting an average of 10.9 months for treatment. These appalling waiting lists are adding to the tremendous cost. The whole policy and rationale of preventive treatment is such that early attention is essential. These long waiting lists are inexcusable. If the answer is that we have not the money, then it is false economics. Costs in later years will be enormous and these costs could be avoided now, or drastically reduced, through preventive care. We are not solving the problem by extending the waiting lists; we are adding to future costs.
There is also the matter of the paper entitlements, paper social rights which, in my capacity as Labour spokesman, I am constantly talking about. Actual rights and rights on paper are completely different. It is fine to say that the medical card entitles one to free dental treatment but it is hypocrisy to make such a statement without providing adequate funds to provide that care.
In 1977 we provided a miserly 1.2 per cent of total health expenditure for the dental services, £3.9 million out of a total of £350 million. The Minister this year raised that sum to £4.2 million and one could claim that this is an increase of 12 per cent. Percentages can be extremely misleading. As a percentage of total health expenditure, the percentage devoted to dental care this year has actually dropped. Last year it was 1.2 per cent and this year it is 1.1 per cent. That is significant. It means that dental care has assumed less priority this year than last year.
The attitude of the Department of Health to a proper dental service must be highlighted. Let us consider, for example, the school health examination programme in child welfare clinics. According to the Health Act free dental treatment is available to children for defects noted at these sessions. The Minister replied to a question of mine regarding the frequency of school health examinations in primary schools. He said that it is the policy of his Department to provide a full, comprehensive medical examination for each child towards the end of his first year at primary school and selective examinations for older school-going children. He went on to say that it is considered desirable that schools with over 50 pupils should be visited each year and smaller schools should be visited at least every two years. The phrase "considered desirable" is a bureaucratic euphemism used by the Department to say that this is their policy but they should not be expected to fulfil it.
When I asked a question requesting information on the proportion of all primary school children who have received examinations and treatment under the scheme and how often these examinations have taken place for each child. I was told that the information could not be extracted by the Department from the health boards. The Department are not doing their job at all. How do we know the scheme is working if we cannot get the figures? How do we know that all our primary school children are receiving examinations and treatments at least once a year? How do we know that we have even a semblance of a preventive dental scheme, the minimum requirement of which is at least one examination per year?
I did not receive any details about the number of children examined in the child welfare clinics and the frequency of these examinations. As far as I can judge, they were feeble and ineffective efforts. The only information I was able to extract from these stingy mandarins in the Department was that out of a total of 600,000 pre-school and national school children only 46 per cent received a dental examination under these programmes in 1976. There are 320,000 eligible school children who did not receive any dental examination at all in 1976. This is irrefutable evidence that the Department's policy of a visit to every school on an annual basis is not being fulfilled. It is pie in the sky to say otherwise. The other problem is the examination of children at secondary school level. This is virtually non-existent. This is a crucially important period when attitudes are being formed towards dental hygiene and regular check-ups are still of major importance. I have received many complaints about this total neglect of dental care at secondary school level.
I recently received a letter from Oughterard in County Galway stating that from Cleggan to Galway, a distance of 56 miles, there is not a single dentist. If a child gets a toothache in Oughterard he goes on a waiting list for a busy Galway dentist. This is our country and there are people in Cleggan and Oughterard. It is important that we pay attention to their needs. The letter states that delays of up to three weeks are not unusual and pain must be endured because there is no dentist within 56 miles. The child has to endure the pain and then, on the appropriate day, having waited for a private dentist, the child is taken to Galway and misses school. It may require several such appointments. Transport is an additional expense. The situation is archaic and incredible in 1978. These people count themselves fortunate because they do not live as far away as Cleggan. Surely it is not unreasonable to demand at least a part-time dental service in this huge area. It is not being provided.
All school children should be eligible and receive free and regular dental care. This is the first proposal in my motion. The school examination programme fails to reach 54 per cent of pre-school and national school children presently eligible, and merely extending it to secondary school level will mean extending an almost negligible service to the point of exhaustion. The service must be completely rehabilitated. There must be a significant influx of staff. I shall deal with staff later. The only point I wish to make here is the failure of the preventive dental care programme which fails to reach the majority of those children most at risk. Even if a dental health officer visits the national school the onus is on the parents to follow up a recommendation to visit the dental clinic. In too many cases this visit never takes place. I do not say it is wholly the State's responsibility to care for the nation's teeth. The parents also have an obligation and in many cases they are not living up to their responsibility. The long waiting list is a disincentive to them.
With regard to the facilities for dental education the President of the Irish Dental Association has gone on record as saying that a serious shortage of dental teachers is inevitable in view of the present unsatisfactory dental hospital facilities. The staff of the Dental Hospital went on strike fighting for a feasible career structure. About 60 dentists qualify each year but, because of the total lack of post-graduate training facilities and consultancy training, emigration amongst dentists since 1969 has been as high as 60 per cent. Six out of every ten who qualify go abroad. The Minister must realise that this is a very serious situation. We train these people and other countries reap the benefits of that training.
The Dental Hospital in Dublin, the major training ground, is incredibly outdated. I will not accept that this hospital should be the responsibility of the Minister for Education. It should be the responsibility of the Minister for Health and there should be close liaison between the two where dental health is concerned. The Dental Hospital was built in the last century to accommodate 15 students. It now caters for five times that number. It has a permanent staff of 11. Compare that with the veterinary college. It has half the number of students and over 100 permanent staff. Bearing those statistics in mind I would not be too bold in asking what our priorities are. It is absolutely wrong to allow that situation to continue. The chief consultant in the Dental Hospital in Dublin said the Dental Hospital in Cork was outmoded even in the 1950s. He also said that top priority for a dental service must be providing proper dental hospitals. There must be consultants within reach of the people, and dental hospitals without consultants are useless.
We can provide these facilities. A new teaching hospital has been in the planning stage for 20 years. We had this division of ministerial responsibility, and the Minister for Education finally decided that the new facility would be on the James's Hospital site. Planning for this is proceeding at a snail's pace. Unless space and staff are provided there is no good in our talking about dental auxiliaries. It takes two years to train them. The EEC directives provide for 18 months after the finalisation in autumn for a new dental Act and, therefore, any new dental Act will not come at the initiative of the Minister. That new Act must be passed by order of the EEC within 18 months after next autumn and, if we are to fulfil our obligations under the EEC directive to provide auxiliaries, we should be starting now making elaborate plans for their training. This is where the Minister for Health should be stepping in with plans to provide the space and staff in the new dental hospital for the training of these auxiliaries. I ask him to look at this aspect urgently.
The Dublin Dental Hospital does not provide any care for the mentally and physically handicapped. This is a scandalous situation. It is another indication of the utter contempt in which these citizens are held by the State, the least advantaged in our society, who need expert care and for whom no attempt of any kind is made to provide that care. It is relegated. It is not the responsibility of the Department and so the Department do nothing about it. I raised this on previous occasions.
In regard to emergency dental care, I asked a question about the emergency service available on a 24-hour basis all the year round in the Dublin Dental Hospital. The Minister said the emergency service was available from 9.00 to 5.00 on weekdays and 9.00 to 12.30 on Saturdays. No one could call that an emergency service. There were loads of complaints from people over the Christmas. These people could not afford the services of private dentists but they needed emergency dental care. There is no such thing as emergency dental services, and if one is unlucky enough to need emergency dental treatment after hours or over a holiday period then it is just one's tough luck.
There are gross regional inequalities. Within a 56-mile radius of Galway there is no dentist. The ratio of prospective patients to dentist in Donegal is 11,000 : 1. There are three times as many dentists in Dublin as there are in Connacht and the three northern counties. We must provide some incentives so that dental surgeons will work in these isolated areas where the rate of patient population to dentist is excessively high.
The biggest area of failure is in the field of dental health education. With only 20 per cent of those entitled to free dental care availing of the service I do not think I exaggerate when I say the Government are getting things on the cheap. They are providing a poor service because the majority entitled to it are not claiming their rights. I am beginning to believe that there is a conspiracy in the Department to stop people knowing their rights. That is very obvious. The Department makes no effort to let the other 80 per cent know their entitlements, because that would cost too much. The entitlements are there but the Department keeps quiet about them. I believe there are those who will be annoyed at my highlighting this fact. It is typical, of course, of the inward approach of the Department. It will not let people know their entitlements. This is painfully obvious in all aspects of health. It is in the interests of the Department not to let people know because, if they know, demand will increase.
I am suspicious of the policy of the Department in the field of health education. The Minister talked about a comprehensive review to bring deficiencies to light. The deficiencies are glaring and we would want to be blind not to see them. A review is quite unnecessary. I would hope now for constructive, specific and concrete proposals designed to improve the service. Eligibility must be extended to all school children under 16 years of age. If we provide the care at an early age we will cause less hardship to people and less cost to the State. There is no other domain of health care where the benefits of preventive care, both personal and financial, are so obvious. The Minister is a great exponent of preventive medicine. This has been the underlying theme of his ministerial responsibility to date. That is why I put this proposal in my motion. I do not think it is asking for much. It is practical and realisable and I am asking that he consider it. I know there are financial constraints on him and that he cannot provide everything. I know the difficulties he has in establishing his priorities, that more money here means less money elsewhere. What I am asking for is an extension of eligibility to start with for all children to secondary school age. I think it is realistic and feasible and the benefits would definitely far outweigh the cost to the State.
The second feature of my motion relates to the need to eliminate this diabolical waiting list for medical card patients. With 50,000 people waiting a minimum of one year to receive the dental care to which they are entitled, we have an emergency situation which must be rectified immediately if our system of health entitlements is to hold any credibility. I am asking for a choice of dentist scheme for medical card holders. I believe this would be a rational and progressive reform in the service. It is a disgrace that thousands upon thousands wait a year, in many cases longer, because a filling that is delayed for a year becomes an extraction, which is more costly and of greater distress to the people concerned. At the same time private dentists are crying out for work. As the choice of doctor scheme has proved to be adequate and is working efficiently, there is an obligation on the State to provide a similar scheme for medical card holders. If the State provided such a scheme the waiting list would be eliminated almost overnight.
The main proposal in my motion, the one upon which all the others depend, is to call for a massive recruitment of dental surgeons and the training and utilisation of auxiliaries in the national dental service. The shortage of dental surgeons in the public health service is almost 400, yet we have only recruited 40 dentists in the last four years. If we are to continue at that pace we will be waiting 40 years to bring the number of dentists up to the required figure. What we must seriously consider is the question of dental auxiliaries. They not only could clear the waiting list for treatment but would also reduce the number of dental surgeons necessary to bring the public dental service up to acceptable minimum standards.
There is much confusion over the terminology of what constitutes a dental auxiliary, but there is no need to go into the details of it. The main point is that it involves a two-year course and it is embodied in legislation in other countries. Call them what you like, dental hygienists, school nurses and so on, these people could provide fundamental dental care under the supervision of qualified dental surgeons. This is a recommendation of Professor Kaim-Caudle and it is one that we should seriously consider at present. The only way we can conquer the problem is to recruit and train people who could undertake work after a two-year course and thus relieve dentists of normal routine work.