I propose, Acting Chairman, with your permission, to allocate some 15 minutes of my time to Deputy Nuala Fennell.
Private Members' Business. - National Dental Service.
Is that agreed? Agreed.
I move:
That Dáil Éireann condemns the failure of the Government to provide an adequate dental service to medical card holders, with particular reference to the lack of provision of dental maintenance and dentures for adults and the extremely long waiting lists for orthodontic treatment; and calls on the Government to meet its obligations under the Health Act, 1970, to urgently provide a proper national dental service.
It is regrettable, given that a large part of the time of the last Dáil was taken up discussing health issues, that we resume once again discussing more health issues simple because no progress was made on most of those issues. It is interesting to note that during the period since this Dáil last sat an extra £15 million has been spent on the health services but every penny of this went to the general hospital programme and none to other areas such as the dental service.
In my view, the public dental service has virtually collapsed. There are 1.6 million people who are eligible under section 67 of the 1970 Health Act to free dental care. The breakdown of that figure is as follows: medical card holders and their dependants, 966,000; pre-school children, 344,000; primary schoolchildren, 564,000 and adolescent dependants, 90,000. If these people require dental treatment, dentures, fillings, or orthodontic treatment they have to seek treatment at their local dental clinic. They are told quite bluntly — this varies from one part of the country to another and I will go into this very shortly — that there is only one service available, that is emergency treatment, relating to levels of pain, for extractions only. In my own constituency, and this is mirrored across the eight health board areas, if an old age pensioner wants dentures they are told "I am sorry but you may go and get them privately fitted at a cost of up to £300. If you need dentures repaired, this cannot be done as there is no money available". It is undeniably true that the pressures on the emergency service and the local dental clinic are such that they are providing a reduced service for children through primary schools. People who are unable to afford private dental care have to suffer the pain and anguish of not being able to obtain treatment.
If we look at each health board we will see what the position is. This is a snapshot of what the position was in 1988; it is worse this year. In the North Eastern Health Board area, the Minister's own health board, no adult service has been provided since 1985. There is no priority for adolescents and a restricted service for children. In the Mid-Western Health Board area no adult service has been provided since 1986, there is no priority for adolescents and only 40 per cent cover for children. In the Eastern Health Board area, which has all the facilities of the Dublin Dental Hospital at hand, there is a very limited adult service, a waiting list of 16,000, no priority for adolescents and only 50 per cent cover for children. In the Midland Health Board area no adult service has been provided since 1987, there is no priority for adolescents and only 85 per cent cover for children. In the Western Health Board area no adult service has been provided since 1985, there is no priority for adolescents and only 40 per cent cover for children. In the North Western Health Board area no adult service has been provided since 1986, there is no priority for adolescents and 80 per cent cover for children. In the South Eastern Health Board area, which covers my area and Deputy Howlin's, no adult service has been provided since 1986, there is no priority for adolescents and only 58 per cent cover for children in two areas. In the Southern Health Board area no adult service has been provided since 1985, there is no priority for adolescents and an average of only 30 per cent cover for children throughout that region.
Therefore, in practical terms, the dental service has collapsed for the people who depend on the public dental service, the poorest 40 per cent of our population who rely on their medical cards to ensure service. As usual, the Minister decided there was a solution to these problems and that was to commission a report. A report of a working party of the Department of Health — I have a copy in front of me — was never published——
Why?
——but was ably leaked by all and sundry. It has been regurgitated many times. They reported in June 1988, which is now well over a year ago. It was an excellent report. That working party was chaired by the then Minister of State and comprised the chief dental officer, the deputy chief dental officer, representtatives of the dental hospitals and the dental section of the Department of Health. They clearly stated that the Minister and the health boards were failing to meet their statutory obligations under section 67 of the 1970 Health Act. Despite this, nothing has been done to resolve the problem. I will go into detail on some of those excellent recommendations in a few moments but what point is there in commissioning reports if we are not going to take any action on them?
The Minister commissioned another report from a working party on services for the elderly, who concluded in chapter 7, under the heading "Care In The Community", of the report "A Policy for the Elderly" and I quote:
In the interests of providing dentures to elderly people on low incomes the Dental Council should introduce a scheme to permit dental technicians to fit dentures. Section 67 of the 1970 Health Act should be amended to allow health boards to make charges for up to half the cost of fitting and supplying dentures. All elderly people should be entitled to an annual dental check-up free of charge. Elderly people with medical cards should be offered treatment without charge for necessary dental care identified at the annual check up.
Nothing whatsoever has been done about this. If we go even further back and read the report of the Commission on Social Welfare, in particular the section on treatment benefits where the results of an analysis of the PRSI dental scheme are provided, one can see that it clearly concludes from a submission from the Department of Health on 22 August 1984 that the takeover by this Department of the administration of the social welfare treatment benefit scheme is part of the long-term policy of both Departments. Nothing has been done on this. In their conclusion to the report, the commission state that since there appears to be acceptance in principle that treatment benefits should be administered by the Department of Health they recommend that the transfer of functions should be effected. However nothing has been done.
This is an appalling litany of neglect and inaction. Waiting lists were so long that they were suspended. It was futile putting one's name on a waiting list because one had no hope of obtaining treatment. There is still a waiting list for orthodontic treatment; at present there are 24,000 children awaiting such treatment. Because some of these will have to wait so long for treatment their eligibility will be lost. In some cases the children concerned will have left post-primary school before they are called when they will no longer be eligible. What will their options be then? Because there are only 25 orthodontists in the country and because demand greatly exceeds supply, in manpower terms, we have to pay roughtly double the fees charged for the same treatment in Northern Ireland. For major treatment families are asked to pay between £1,200 to £1,400. Such charges are exorbitant and beyond their reach.
What is even more depressing is that international experience shows that the one crucial investment in relation to dental care is in the area of prevention. As we have learned from the experience of the Scandinavian countries, if we have an effective programme of water flouridation, and where this does not exist a mouth rinsing programme, coupled with a proper programme of fissure sealants for the first and sixth classes of primary schools appropriately timed to catch the molars, we can almost ensure that dental decay is 100 per cent preventable. For a very small investment of 37p per head on water fluoridation we can cut down on the need for treatment. Yet we see that the health boards have huge debts and huge arrears in relation to water flouridation plants, that plants are being allowed decay and our coverage of water flouridation is decreasing instead of increasing with no capital provision being made. There is not adequate staff to carry out mouth rinsing programmes in the 33 per cent of the population not covered by flouridation, such as in rural areas. There is no comprehensive programme for fissure sealants. In fact, there is no movement worth talking about in relation to setting up a proper dental auxiliary of dental hygienists to carry out this work at low cost. The latest information I have in relation to the dental council and the development of dental hygienists and looking at the numbers that are going to come out is that the dental hygienists will be exclusively available for private practice. That will mean there will be no prevention programme coming forward.
I can conclude only that this Government have failed abysmally to meet their legal and statutory obligations under the Health Act. Knowing the situation, they have failed to act, and that is an unacceptable situation. There are remedies and we need to bring them forward now.
The first thing we need to do is ensure that there is one national dental scheme. There is no good reason for having two schemes. At present there is the inequity whereby the ratio of dentists to those who are eligible under the 1970 Health Act works out at one dentist for every 7,967 eligible persons. When one takes into account that some people who are medical card holders are also eligible under the PRSI scheme that figure is revised down to 6,344; but the full 8,000 all have medical cards and have to depend on one public dentist. In the PRSI scheme we have the iniquitous situation whereby there are 700 dentists providing dental treatment for 1.3 million people, some of whom are very well off — company directors and so on — giving a ratio of 1:2,000. That means that the poor people of this country have a four times inferior service.
The commission on social welfare brought clearly into focus the inequity of this situation. In the interests of running an efficient sevice there is no reason the Department could not run one national dental service. The PRSI fund should pay a credit of whatever the annual cost is to the Department of Health to administer that scheme and the officials of the Department of Social Welfare should be moved over.
We will have to provide an extra £3 million or £4 million a year to ensure that in conjunction with one national scheme people can have access to private dental surgeons on a referral basis through their local clinics. I am referring to the ad hoc scheme that was there from 1979 to the mid-eighties and which has been abandoned in all the health board areas. Under that scheme one went along to one's local dental clinic who approved the need for the treatment, and one was referred on to the local dental surgeon of their choice, who was paid on a fee per time basis. That scheme worked successfully and should be reintroduced. Under such a scheme the Minister could negotiate a much fairer scheme for the dentists, through the Irish Dental Association, and for the taxpayer by ensuring a single national fee, re-writing the eligibility circumstances and ensuring that people would have access to care. That is the first step that needs to be taken. It is clearly recommended by all who are directly concerned with this problem. It would allow the resources needed for people to get treatment.
The second thing we need to do to reduce dental costs is to introduce dental manpower changes. We need to have an extensive coverage of dental hygienists who will carry out all of the work of fissure sealants, mouth rinsing programmes and so on. Under the Fine Gael proposals for a revised national dental service the health board would have the exclusive responsibility for all preventative dental work and the referral work would be carried out by private dentists.
The advantages of introducing auxiliaries are twofold. First, less skilled work would be carried out at a cheaper rate and dental surgeons could get on with the more complex dental treatment. Also in relation to auxiliaries, I would favour the upgrading of dental surgery assistants to assist dentists in less intricate work. In relation to dental laboratory work, we can either upgrade the position of dental technician or introduce the new grade of denturist — I am not talking about allowing in any cowboy but something that would be effectively operated by the medical council whereby there would be a proper education and training programme to ensure that dentures were available at reasonable cost. There are provisions under the Dental Act of 1985 for the Minister to take initiatives in all of these areas. These areas have not been pushed as hard as they might have been. We now move to the manpower situation in orthodontics. The problem is that it is so lucrative to be in private practice that an orthodontic consultant would be out of his mind to be employed as an orthodontist in the public service. It is no use for the Minister to throw his hands in the air and say that five posts were advertised that could not be filled. It is obvious they could not be filled because the orthodontists are on to such a good thing with fee per item arrangements through the health boards and with the private fees they can charge that there is no incentive for them to work for the health board. We need to change the grade from orthodontic consultant with seven years' post-graduate training to orthodontic specialist with four years' post graduate training who could do the basic amount of work. We would employ some orthodontists who would train senior public health board dental personnel to do this work. We must remember that orthodontics is not covered under the PRSI scheme so that very many in the country are crying out for an orthodontic service.
The Minister has put forward a token amendment — and I will be as charitable as I can about it. It makes a meal out of the fact that £300,000 is being allocated for 500 priority orthodontic cases. Leaving aside the fact that the word on the grapevine is that these 500 cases seem to be taken in some kind of chronological order and not on the basis of priority — and there is some dissent about that — £300,000 for orthodontic services is a drop in the ocean, and it is a wrong drop in the ocean because, in my view, very basic dental treatment is not being provided for. The Minister of State was at a recent conference in Wexford in relation to the public dentists who are members of the IDA who had a seminar. I have to tell the Minister of State that they were very concerned to see that the total response to all these reports was a measly £300,000 for orthodontists when legal obligations were not being met for a basic adult service. Someone somewhere has completely misunderstood the extent of the problem. I really cannot take that too seriously although I welcome it for what it is worth.
It then goes on to say that it commends the resolve of the Minister for Health to concentrate further on improving the dental services generally in 1990. I have seen very little evidence of this resolve. All I can say is I wish the Minister well in his resolve but I hope it extends to his colleagues in the Department of Finance, as they seem equally resolved to thwart any effort he has made to date in this area, because all efforts have come to nothing.
It is important that we look at the dental career structures, introduce dental hygienists in the public health service, upgrade dental surgery assistants and introduce a new grade for dental laboratory work in the provision and repair of dentures by either upgrading the role of dental technicians or introducing a new grade of denturists, all of which would allow the backlog of work to be dealt with at lower costs. Quite frankly, anything less will not meet the present basic requirements.
I also note in relation to the publication of the health commission report that even before it was published the dental element was sabotaged by the Minister for Social Welfare, who went out of his way to say that the contents of the report vis-à-vis the PRSI dental benefit treatment scheme, were not on so far as he was concerned. With regard to the Minister's resolve to try to sort out these problems, the first thing he might do is talk to the Minister for Social Welfare and ask him to show some common sense and reason in his discussions with the Irish Dental Association and furthermore to come to his senses and realise that one comprehensive national scheme is the only solution to the problem.
Essentially we have no strategic plan for our dental services. We had the ad hoc scheme and the cutbacks in the allocations by the health boards. Some of those health boards decided that the dental service was not a statutory service and that relative to other needs, such as the general and special hospital programmes, they could afford to abandon dental care. I believe that decision was not based on sound legal judgment but the people we are dealing with are so poor they are not in a position to go to the High Court to fight for their theoretical rights under the 1970 Health Act. That is the way this problem has evolved and quite frankly it has got worse. All of us in this House have people coming to us saying they have to go to hospital in three weeks' time to have a number of teeth extracted. They ask if they can get dentures and are horrified to hear they cannot.
With regard to the children's service in schools, there is a new recommendation that there be one check-up for children to be co-ordinated in primary schools. I believe that recommendation in the health commission report can be tied in very effectively with the other recommendation so that hygienists can carry out the work of fissure sealants. Effectively this is new technology we are talking about — painting a plastic gel on children's back teeth to ensure that they do not get caveties. Why is it that we cannot make a small investment in this new technology and fluoridation which would ensure that large, longer term saving can be made? I understand that in the Scandinavian countries dental hospitals which train dental surgeons are being closed down simply because there is no requirement for them any more. As a result of an adequate prevention programme dental and tooth decay is a thing of the past there.
I should like to see the following: a reorganisation of our dental services so that they would all be under the Department of Health; what is being done by the Department of Social Welfare to be continued but administered by the Department of Health, and paid for by the PRSI credit fund as is the case already; the health boards given an exclusive role for prevention work and the 246 dentists to get on with that work; the appointment of new hygienists who can do some emergency work; the introduction of a referral scheme so that public patients can go to their local dental clinic and be referred, as was the case under the ad hoc scheme, to get that work done; orthodontic services to be reorganised and public provision made through the health boards where there would be a national orthodontic service. There will always be waiting lists for orthodontic treatment and I am advised that some elements of orthodontic treatment is perhaps cosmetic and is not as urgent as other dental work. Maybe out of the 24,000 cases there are 10,000 very urgent cases but at present the urgent cases are not being seen at all. Once there is a new grade of specialist — I understand that is totally in conformity with the 1992 position — we will be able to attract back on reasonable terms specialists for that programme. We should be able to put in place a proper capital programme for fluoridation work and auxillaries for a very small amount of money. Out of a total State health expenditure of something in the order of £1,300 million, I am talking about £3 million or £4 million, which could be saved on drugs in a week. It is a very simple equation. We could introduce modest charges for orthodontic treatment.
What we have had from this Government and the previous Government is a litany of neglect and failure. Unless there is a radical departure, this problem will fester and worsen and the next generation will have as many dental problems as the present adult population because preventative work was not done. This situation is worsening. I hope this motion will bring a new focus to this area and that the Government provide adequate money in the Estimates next week. We will be putting this motion to a vote tomorrow night and will be asking for the support of other parties for this reasonable motion. I hope the House reaches a consensus that this is an area which cannot be neglected any longer.
Deputy Nuala Fennell has 15 minutes.
I can assure the Acting Chairman that I will not take all that time because I want to share it with my colleagues.
Acting Chairman
Is it agreed that Deputy Fennell can share her time with the other two Deputies? Agreed.
I commend my colleague Deputy Yates on his very comprehensive contribution. I believe he has covered the major areas of need in this prevailing crisis in health care. I shall not go into the same detail in my contribution, but I support his approach and the things he said.
As part of this Dáil's aim to deal with the crisis in the health service, I hope serious consideration will be given to providing adequate and fair dental programmes for all who need them. We have to see dental care as an intrinsic part of the total health care for all our people. It seems that for years successive Governments have had struggles with the dental profession — sometimes disagreements and rows broke out in public, but not always, and the relationship was perpetually on the brink of collapse. It seems that representatives on each side have done little more than snarl at each other over the years. I was particularly aware of the bad relationship some years ago during efforts to bring in that category of spouses, the wives of insured workers, who had sought for so long to be brought in under the social welfare scheme. None of this conflict is conducive to the operation of a satisfactory service. Of course, the victims of this disagreement are those who can least well help themselves — those who have entitlements under the 1970 Health Act, people who are medical card holders.
There is a great deal wrong with our dental service and I believe the main fault is that it is unavailable for thousands throughout the country. Dental care is a very basic need and I hoped it would have gone beyond the status it had 30 years ago. When I was a child dental care was seen as a luxury, it was something the rich availed of. Poor people never went to the dentist and consequently huge numbers of our population, those over 50, lost all or most of their teeth because of a lack of care and treatment. Even though the fluoridation scheme has significantly reduced decay, if preventive measures in dental care are not put in place now, further generations will be condemned to using dentures at too early an age and will suffer great pain because of neglect and inadequate local service.
The waiting lists are appalling and unacceptable. Again and again during the recent general election, most of us heard at first hand details of the problems people are having with the health service but the main problems I heard about dealt with dental care — parents felt frustrated trying to get dental care for their children. In my constituency two mothers brought their children out to the door to meet me. One was 13 years of age and the other 15 years and they are waiting for orthodontic treatment. They have been on a waiting list for two years and one was 550th and the other something like 420th on the waiting list. It is absolutely horrendous to think of the time it will take for these two young boys to get treatment. Neither of these young people needed this care for cosmetic or trendy reasons — I believe it is often alleged that that is what orthodontic treatment is all about. These young people need treatment for the proper spacing of their teeth and they are suffering psychologically because they look so disfigured. I and the mothers I spoke to have little hope of early treatment for these boys and they certainly will not be able to afford the kind of fees being charged privately. I recently was at the dentist and was charged £100 for one filling. It took about 45 minutes and it was an expert job, beautifully done but I question how anybody can justify charging £100 for a filling. On the basis of an eight-hour day one can earn £800 or £4,000 for a five-day week. Can we ever hope to have a scale of fees which would give some idea of what it would be reasonable to pay for different types of dental care?
We must question why we have such a dearth of dentists to deal with this crisis. Why can we not give jobs to our graduates? Are we simply educating them to supply the National Health Service in the United Kingdom? When I inquired I was told that there are about 70 dental graduates per year, of whom 80 per cent go in the first instance to Britain where they are absorbed into the system under which everyone is entitled to dental care. Most are lost forever to this country but a few come back, usually the female dental graduates. How can we allow this to happen? They go because they cannot afford the £30,000 or £40,000 it would cost for the equipment to set up in private practice. The State scheme is not able to embrace them.
A great deal is wrong and we must look seriously at the lack of availability of dental services throughout the country. The Minister's backbenchers will tell him of the appalling conditions in some health board areas. I support the appeal by Deputy Yates and ask for a programme for the training and appointment of the necessary dentists to make a proper attack on the waiting lists. We must also train and appoint dental auxiliaries to operate as they do in other countries. They can play a most important role in the promotion of dental health in schools. This is an area of serious neglect and radical measures such as outlined in this motion are necessary to redress the position.
(Carlow-Kilkenny): This is becoming a question of theory as against practice, ministerial theory against dental practice. Everything can appear to be fine by saying that we have a very good dental service. I cannot but recall the phrase that there is nothing either good nor bad but thinking makes it so.
I have been a member of a health board for a number of years. We are told there is a service but we know that in practice there is not. Positive thinking is a help unless one happens to be a person waiting for treatment. People in receipt of medical cards are entitled to get a service but they cannot get it. This is leading to problems for health board clinics dealing with emergencies consisting of extractions. They cannot deal with fillings or the provision of dentures. As a result of people crowding in for emergency services the staff are over-worked trying to catch up on children's cases. I have seen dentists visiting schools on a regular basis and deciding what has to be done but then we find there is a queue and a waiting list.
There is a national problem in regard to orthodontics. The queue is very long. Treatment is expensive and many people entitled to free treatment have to get it privately. There is a limit on the amount of money that can be made available by the State but we have to measure the scarcity of money against the problems being caused. We are either providing a service or we are not. I have been told of a woman in her thirties whose teeth have been extracted and who cannot get dentures. She describes herself as a nervous wreck, being embarrassed to appear in public. In theory she could have had her teeth filled and is entitled to dentures but in practice neither option has been available.
Deputy Yates mentioned the grading of consultants. I proposed at the health board that we should face the truth that we will not be able to attract consultant orthodontists into the health service. Three appointments were made in the South Eastern Health Board. One person asked for six months to wind up his private practice and the other two also wanted time. Finally none of the three entered the public service. We cannot ask people to give up what is readily theirs and to accept a much lower salary. It is not fair to ask dentists to treat public health patients for a much lower fee than they can get from private patients. The Department might not be able to pay the same amount as private patients but they must pay some figure approaching it, otherwise dentists will have no particular interest in helping. They have the same overheads and the same expenses and they will be working twice as hard to make as much money. All these people must come together and we must devise a service which will give the best value for the money available.
My sympathy goes out to those who have no money to pay for dental treatment. Some who are entitled to a free service can get relief if they opt to pay for it but for many others there is no way out. They either get treatment through the dental service or they suffer. Many people are suffering. If teeth are not filled when necessary these teeth will eventually have to be extracted in an emergency operation. It is criminal that anyone should need to have teeth extracted when they could have been kept in good condition for years. It is also criminal that people who need dentures have to suffer the shrinking of their gums and the digestive problems which are caused by the inability to chew food properly.
The service we have in theory is not matched by the service in practice. If our children are being left aside simply because we are treating medical card holders in public health clinics and the children cannot get the treatment to which they are entitled, it is time we examined our conscience and did something about it. It would be a pity if, to use an analogy, like Nero, the Minister fiddled while teeth decayed.
I move amendment No. 1:
To delete all words after "Dáil Éireann" and to insert the following:
"notes the recent announcement by the Minister for Health of the distribution of £300,000 in the current year to commence the treatment of 500 priority orthodontic cases and commends the resolve of the Minister for Health to concentrate further resources on improving the dental services generally in 1990 and subsequent years".
I listened to the contributions of the three Deputies opposite. Deputy Fennell suggested that I should ask my backbenchers about the dental service while Deputy Browne gave the impression that I had said we had a good dental service and that everything was fine. Deputies will agree that I have never defended the dental service as being a fine service. In fact, in my 25 years in general practice. and my 16 years as a member of a health board, I was only too well aware of the deficiencies in the dental service. It is important to point out that the deficiencies are not new. I should like to pay tribute to Deputy Yates for his frankness in pointing out that six of the eight health boards did not have an adult dental service for a number of years. The North Eastern Health Board and the Western Health Board had no adult dental service from 1985. The North Western Health Board and the South Eastern Health Board had no adult dental service from 1986. There was no adult dental service in the Southern Health Board region from 1985. It is important to point out that the Coalition were in office during those years. It was when they were in office that the dental service deteriorated.
I should like to inform the House of the number of adults who were on the waiting list when the Coalition Government were in office. At the beginning of 1983 there were 2,744 adults awaiting treatment in the South Eastern Health Board area and by the end of 1986 that number had increased to 8,717. That is an indication of the problem that existed before we came into Government. I accept that we have not made any great improvement in the dental service but Deputies will be aware that in recent weeks we provided extra money to commence a programme which I am satisfied will improve the service. That programme will bring the service up to a standard that we will all be proud of.
There are some aspects of the public dental service which do not achieve the level of provision which we would all like to see. The public dental service does not provide, nor indeed has it ever provided, on a readily available basis the full range of treatment procedures which eligible persons may demand. It is doubtful if such a level of service could ever be attained given the need to prioritise essential services in the context of finite resources.
It was in recognition of the fact that there were problems with the public dental service that early last year I commissioned Deputy Leyden, Minister of State, to chair a small working group to look into all aspects of the dental services for eligible persons and, where appropriate, to make recommendations for improving them.
The working group produced a report which gave a full and frank account of the existing dental services and highlighted those areas where improvements were required. The report covered the four major areas of public dental services as follows: (i) children's dental services; (ii) orthodontics; (iii) adult dental services and (iv) water fluoridation and prevention.
The dental service for children is povided almost exclusively by the salaried dentists employed by the health boards. Over the past ten years there has been an increase of about 25 per cent in the numbers of dentists employed by the health boards. A notable feature of the dental service for children is that the health boards have managed to maintain dental staff numbers up to strength despite the cutbacks of recent years. I understand that there are about 240 dentists working in the public dental service at present.
Some years ago there was great difficulty in recruiting dentists into the health board service but the situation has now changed dramatically. Every competition for dentist posts in the health board service is now keenly contested. Many of the young dentists entering the health board dental service are doing so with a genuine enthusiasm for the task in hand. In association with the increase in health board dentist numbers over the years there has been a continuing improvement in the quality of the clinical facilities available to them. In this regard it should be noted that in 1983 the number of children treated was more than 296,000 while in 1987 the figure was just under 319,000. That represents a sizeable increase in the number of children treated under the public health dental service in the last six years.
All of these developments augur well for the future of the health board dental service. In regard to the working group report, what emerged in relation to children's dental services was not so much a criticism of the service itself as of the different approaches and procedures that have developed in different health boards. It is clearly unacceptable that there should be wide fluctuations in the availability of dental services for school children between one geographic location and another, given that all the children have the same eligibility and the same entitlement to treatment. The question of standardising the approach and procedures and of achieving a greater productivity in all the health boards is being pursued with the boards by my Department.
Deputy Yates referred to dental hygienists. I should like to tell him that one proposed development that will have a significant effect on the public dental service is the introduction of dental hygienists. Prior to the enactment of the 1985 dentists' Act this would not have been possible because under the old dentists' Act it was illegal for anybody other than a registered dentist or a registered medical practitioner to practice dentistry. The 1985 Act contains provisions which permit the Dental Council, with my approval, to make schemes for the establishment and registration of classes of auxiliary dental workers. Schemes made by the council under the Act can determine the nature of the dental work an auxiliary worker may undertake and the circumstances under which it may be undertaken.
I am pleased to be in a position to say that progress is being made by the Dental Council, in consultation with my Department, on the formal establishment of the grade of dental hygienist. It is our intention that, when established, dental hygienists will be recruited into the health board dental service where they will be particularly useful. Deputy Yates said he had information to indicate that those dental hygienists would only be available to the private sector but that is not the case. I have taken a personal interest in this matter and have spoken about it on a number of occasions to the President of the Dental Council.
When dental hygienists are available they will be recruited into the public dental service and will be available to health boards. At present health board dental surgeons may find themselves spending valuable time on oral hygiene and instruction. That is something that can obviously be adequately done by a less qualified person such as a dental hygienist. The use of dental hygienists therefore will free the dentist to devote his time to the more specialised work for which he is trained. The economic sense of this arrangement is obvious. In addition, dental hygienists will be able to take part in the provision of fissure sealants — a preventive measure which has been proven to be quite effective in reducing the risk of dental caries. I would see the introduction of dental hygienists in the health boards as supplementing the existing service rather than replacing any element of it. There would certainly be no question of the new grade being used to replace dentists.
The question of providing orthodontic treatment for eligible persons has been a source of much aggravation for the health boards over the years. The main difficulties have been the scarcity of persons qualified to carry out orthodontic treatments, particularly the more complicated ones, and the relatively high cost of treatment by orthodontists in private practice. Indeed, Deputy Yates was correct when he said an effort was made to recruit five orthodontists and only one of the posts was filled from that competition, but it is an indication, first of all, that orthodontists are in scarce supply, even in the private sector. There is a scarcity of orthodontists in the country. The creation of a number of posts of consultant orthodontist in the health boards seemed to offer a solution to the problem but with one exception it was not possible to fill these posts, as I said, and to a great extent the health boards must rely on the services of private practitioners to provide orthodontic treatment. However, the prospects for the future look distinctly brighter.
In view of the difficulties being experienced by health boards in filling posts of consultant orthodontists, my Department are currently examining a number of proposals which have been made for amending the conditions of employment for consultant orthodontists under the health boards. We have looked at a number of possibilities, including the possibility of orthodontists being able to divide their time to make a commitment to the health board and perhaps do some private practice themselves. We are particularly anxious to make the posts attractive so that we will be in a position to recruit orthodontists to the health boards within the next year. My Department will be having discussions with the health boards concerning this matter; in fact, we are in discussions with the health boards about this issue.
An active training pathway in orthodontics has been established with the co-operation of the health boards and it is expected that the orthodontic manpower problem will be greatly relieved in the coming years. For example, the Eastern Health Board in the absence of their own consultant orthodontists have reached an arrangement with the Dublin Dental Hospital whereby the senior lecturer consultants in orthodontics assess and treat eligible children on a sessional basis. The Eastern Health Board are also funding a registrar post in orthondontics in the Dublin Dental Hospital while the senior lecturer consultants are also providing training in orthodontics for a number of health boards. The Department recently approved the sending of one of the dentists from the North-Eastern Health Board to the dental hospital to train in orthodontics.
One problem in relation to orthodontics that has been tackled successfully is that of identifying those children whose condition merits treatment by the health boards. There have always been problems arising from the difficulty in deciding about the priority needs in orthodontic treatment, cosmetic, for example, the functional reasons for, the various aspects of, orthodontic treatment. The guidelines on orthodontic treatment needs were issued by the Department of Health in 1985 and have given the health boards a yardstick against which the merits of different cases can be measured. The criteria to be applied in assessing degrees of priority for orthodontic treatment, listed in decreasing order of priority, are as follows: (a) patients with cleft palate and/or cleft lip, or with oral pathology, or with an orthognathic survey requirement (b) patients with extreme handicapping malocclusions (c) patients with non-handicapping malocclusions associated with a definite treatment need.
Let me say a word on the special allocation for the 500 priority cases. The training and recruitment of sufficient qualified orthodontists into the health board dental service will undoubtedly provide the solution in the long term. Meanwhile the problem of those who require orthodontic treatment now or in the near future has to be addressed. I am very pleased to say that the Government have recently made available an additional £300,000 this year to help reduce waiting lists for orthodontic treatment. This will enable the health boards to initiate programmes of treatment for 500 priority cases. It is expected that treatment of all these cases will have commenced within the next few weeks. This is merely the beginning and from now on it is my intention to see some significant and steady movement in the waiting lists for priority orthodontic treatment. The money has been provided, and we will be taking up the capacity available from now to the end of the year with private orthodontists mainly to ensure that the 500 children who need orthodontic treatment will have their treatment commenced within the next few weeks.
Over one million adults and adolescents have eligibility for dental services provided by the health board. Of that number between 300,000 and 400,000 would also have entitlement to the dental treatment benefit scheme administered by the Department of Social Welfare. I am interested in Deputy's Yates's comments about having a single dental service between the Department of Health and the Department of Social Welfare. I have always had an open mind on that issue, but what surprises me is that from 1973 until 1986, for at least two-thirds of which time a Coalition Minister was in power, the Department of Health and the Department of Social Welfare were under the same Minister. If there was such a commitment from the Coalition partners I am surprised that when one Minister was in charge of both Departments that issue was not addressed. Between 600,000 and 700,000 adults and adolescents are relying exclusively on the health boards for dental treatment.
The joint working party on dental services who reported in 1979 recommended that where health boards are unable to provide an adequate primary care service for all eligible persons, any spare capacity in the private practice area should be availed of in order to improve the level of service for public patients. As a result the health boards introduced the new ad hoc arrangements in 1980, when the present Taoiseach was Minister for Health, to provide dental services for medical card holders and their adult and adolescent dependants. Under the scheme dentists in private practice provided routine dental treatment for eligible adults referred to them by the health boards at the same rate of charges as applied under the social welfare dental benefit scheme. At its peak in 1982 and 1983 about 32,000 adults received treatment annually under the ad hoc scheme at a cost of about £2 million. The scheme is quite expensive to operate, possibly due to the high average age structure of the medical card population, which increased the demand for dentures, and to the volume of dental treatment need that has accumulated over the years. However, available resources at the time could not sustain this level of expenditure, and as far back as 1984, which Deputies will appreciate was the second year of the Fine Gael-Labour Coalition, one by one the health boards either suspended or curtailed their use of the private dental practitioners.
At present large numbers of persons are awaiting routine dental treatment to which they have statutory entitlement. The health boards continue to make emergency treatment for the relief of pain available to eligible adults. Emergency care is provided almost exclusively by the dental staffs of the health boards. It was mainly in the context of the growing waiting lists for adult dental services that I asked my colleague, Deputy Terry Leyden, Minister of State, to chair the working group to whom I have already referred. It is clear from the working group's report that part of the solution to the problem with the adult service lies in additional funding.
It is evident that, to enable the further developments in the dental services which we all desire, additional funding must be found. I need not remind this House of the radical steps which, of necessity, had to be taken to reverse the downward slide of the economy and the effects these measures had on public spending but I would remind Deputies that the problem experienced in the health services did not occur only in the past two years.
On taking office, I was faced with the task of re-orientating a service which on the one hand was expending more and more resources and on the other required a major assessment of the priorities and how they were managed. This I have been attempting to do within the overall constraints on resource availability. Unpalatable but vital decisions had to be taken to ensure that the basic fabric of the services were preserved, on which we could build for the future.
I accept that there are a number of areas within the dental services which now need attention. I have already referred to the additional £300,000 made available this year to help reduce waiting lists for orthodontic treatment. Also, the services for eligible adults need to be improved. This I intend to do as part of the strategy for 1990.
However, I do not accept that the solution to the problems as regards the dental services is simply and only the provision of moneys. How those moneys are expended and the effectiveness of the services as a result must also be evaluated. This, too, is being addressed.
In regard to dental health generally, we here in Ireland have reason to be thankful to those who, in the face of considerable opposition, had the courage to introduce fluoridation of water supplies nearly 30 years ago. That the fluoridation programme has been a success is without doubt. Several surveys, most notably the national survey of children's dental health carried out a few years ago, have proved conclusively that fluoridation does work in reducing the incidence of dental disease in the population.
Of course the fluoridation process has not been without its problems. Over the years there have been difficulties in maintaining the correct dosage rate in certain water supplies and there have at times been interruptions to the supply of hydrofluosilicic acid. It is well know that fluoridation is most effective when administered to water supplies at the recommended dosage rate of 0.8 to one part per million. There had been a proliferation of bad results from the water supplies over the years but I am pleased to say that there has been a marked improvement in recent times.
Having regard to the enormous benefits of fluoridation and its cost effectiveness as a preventive measure it is essential that the ongoing programme of fluoridating new supplies and updating and improving existing installations be maintained. In view of this I have allocated a sum of £200,000 to fluoridation projects in the current year and I will continue to support these projects. This will alleviate to a significant extent the problem in relation to new and replacement fluoridation equipment.
I was surprised at Deputy Yates when he contrasted what is happening now with a few years ago because a few years ago funding was allocated on an ad hoc basis by the previous Coalition Government when equipment broke down.
It was working.
When Fianna Fáil came into office we decided because of the importance of ensuring that the flouridation programme was effective to allocate £200,000 to the flouridation projects and have promised to continue to finance the flouridation projects to ensure a proper and adequate flouridation of the water supplies.
Just as in all aspects of health care, it is now accepted that a structured preventive programme is an essential element in service provision. It is all the more so in relation to dental care. I have already mentioned the flouridation as one of the main preventive measures, but it is necessary to look further and wider than that. I am at present examining ways and means of strengthening the existing oral health promotion approaches. This will have to be done at a number of levels.
The Health Promotion Unit within my Department will be concentrating in particular on drawing up appropriate programmes with the health boards and the Dental Health Foundation, but, as with all aspects of health promotion, effective campaigns in oral health must totally involve every level of administration and service. The involvement of individual dental surgeons and other professionals who have a day-to-day contact with the population must be at the forefront of this approach. I am very pleased, from my own contacts with the dental profession, to note the wholehearted enthusiasm to co-operate in this direction.
To summarise, the health board dental service for children is in pretty good order and has not been affected to any great extent by the cutbacks of recent years. This is because the health boards have managed to maintain their dental staff numbers at full strength.
On the question of achieving uniformity of the level of service for children in the different health boards we are pursuing this with the boards. We believe that it would be appropriate to target two classes in the national schools in the first instance and believe that second and sixth classes are the most appropriate. These classes have been selected because in most children in second class it could be expected that the first permanent molars would have erupted while we would like to target sixth class to ensure that children are dentally fit when they leave the national school.
Demand for orthodontic services is far in excess of what the health boards can provide. Nevertheless progress is being made. Present arrangements for the training of orthodontists should ensure that in a few years time the health boards will have a number of full time consultant orthodontists on their staff. The £300,000 which the Government have recently allocated to the boards will permit 500 of the top priority cases to commence their treatment within the coming weeks.
The £200,000 per annum which is being allocated to flouridation will safeguard the flouridation programme for the next few years. In regard to other preventative measures, mouth rinsing programmes and the provision of fissure sealants are being carried out in certain areas. The problem is lack of manpower. However, the introduction of dental hygienists will have a considerable impact on these services.
The question of allocating more funds specifically for routine dental work for adults is one I am addressing at present.
I would like to say, a Leas-Cheann Comhairle, that I recognise there are deficiencies in the health service. We have already shown in a number of areas that we are dealing with some of those problems and I can assure the House that we will continue to deal with them and we will not be satisfied until we have in place a first-class dental service for the needs of our people.
As I rise I cannot help but get a feeling of déjà vu— the same people sitting in the same seats and playing the same tunes. It is almost as if we had not gone through the past four or five months, that we have not had a general election and that the voice of the people of the country had not been heard on the issue of the health services when the cant which we have listened to again from the Minister can be regurgitated again as if it was new.
The timing of this debate is particularly appropriate and, indeed, I commend Deputy Yates for putting this down as the first motion in Private Members' Business this session. It comes on a day when one of our national newspapers publishes a report, prepared in the Department of Health, which clearly recognises that the dental scheme in all its aspects has collapsed. Although the Minister has had this report for more than a year and there has been selective leaks of it in the past he has as yet decided not to publish it. Presumably, once everybody has read all the newspaper articles about it he will eventually decide that it is safe to let the public have the total copy of the Leyden Committee. At least we may be able to draw some comfort from what is happening now. The comfort I refer to is that at least tonight the Minister for Health, in dealing with this particular motion, will not be able to fall back on the hoary old excuse he has used for two and a half years in this House in response to any crisis in the health area that he will establish yet another commission, yet another committee to look into the problems. In this case he has his committee, his commission and his report and what is required is his solutions. From the script we have just listened to it is clear that solutions will be very slow in coming. There is a realisation of the degree of crisis, especially in the dental service, by independent bodies.
Apart from the appropriateness of the motion, it was also appropriate to commence the session with one put down by the Fine Gael Party. I said that little has changed since we last met. Perhaps one thing has changed, the willingness of Fine Gael at last to face up to the crisis which has beset the health services in recent years. This is indeed a welcome — if belated — change. Members on these benches who have been trying to force a debate on the inadequacy of our health services have been frustrated all too often by the willingness of the largest of the Opposition parties in this House to swallow any medicine prescribed by the Minister for Health. It is refreshing, even if it is nearly three years overdue, to see a Private Members' Motion from Fine Gael that is not hedged with a mass of qualifications about the public purse, public finances and acting within the constraints of published figures.
For three years, three budgets and three sets of Estimates the Labour Party sought to bring home the extent of the depth of the crisis to the previous Fianna Fáil Government and all the other parties who were part of the consensus that maintained that Government in office for two and a half years. It was not until the Dáil was dissolved and Members began to knock on peoples' doors that they began to realise that what we had been saying for two and a half years was the reality although it had been glibly dismissed, week in, week out, by the Minister for Health and his Government colleagues in the previous administration. The hardships which people were enduring were not fabrications of the Labour Party but the reality for the majority of people.
It is all the more remarkable, given the Taoiseach's extraordinary admission during the course of the last election campaign, that the response of this new Government to the crisis has been so pathetic. It can only be described as pathetic in the light of the publication of the document Lets Look Again by the Joint Health Commission of the Catholic Church. That document unequivocally described health care as a basic human right, so basic a right that there is an explicit obligation on the community to discriminate positively in favour of the poor in relation to health care. The last Government discriminated positively against the poor making it increasingly difficult for people on low incomes to secure any access — let alone equality of access — to health care. The sum of £15 million which the new Government have allocated as an extra increment in health spending will not reverse that trend. It is a sop to the cry from the heart that the people made during the course of the last election campaign. At very best the £15 million will stave off some of the worst consequences of the cutbacks in a narrowly defined area, geographically and medically, for a short period.
We will never have equality of access and, therefore, we will never be able to describe health care as a basic human right until we face up to the need for a proper level of resources. No final decision can be made on how much we should spend on the health services until we decide collectively whether health care is a basic human right. If we decide it is then we must make the necessary decision to give effect to that fundamental principle.
In a document published during the last election campaign the Labour Party committed themselves to some short and medium term measures based on a total acceptance of the principle that health care is indeed a basic human right. While our ultimate aim is the development of a comprehensive, unified national health service, we recognise that in the interim action must be taken to ensure that the service provided is capable of meeting the needs of the community. To that end the Health Estimate for 1989 must be increased by £48 million as the sum of £15 million in the Government's programme is totally inadequate.
We said that we would seek in this Dáil in the context of the 1990 Estimates and next year's budget additional health spending on top of the present allocation of £70 million. We will take similar action in respect of the Estimates for 1991 and 1992. This objective would mean that £245 million more will be spent on the health services by the end of 1992. Health spending, with its additional allocation, would then be restored to the equivalent of 7.2 per cent of GNP.
We also spelt out very clearly the immediate needs of the health service in current and capital terms. A sum of £20 million is needed immediately for the reopening of public beds functioning during holiday periods and a substantial proportion of the 7,000 staff currently employed on a temporary basis should be made permanent. There should be more community care in the following areas: additional public health nursing staff, additional social work staff in the child care area and a reinstatement of transport service for the elderly. At least 300 long stay beds in health board areas should be reopened, there should be additional staff in the provision of services to the adult mentally handicapped and all the health charges introduced in the last Dáil by Fianna Fáil should be abolished.
We spelt out all these and costed them in detail in various documents published in the last number of months. In relation to the dental scheme which is the subject of the motion tonight——
The Deputy is not sticking to the motion.
I have to put things into context and we could put down a dozen motions in the area of health because the whole structure is collapsing. We are now focusing on one aspect of a crumbling health service.
The Deputy will appreciate that he is confined to the motion before the House.
I intend to focus sharply on this scheme. In relation to the dental scheme, which is the subject of the motion, the Labour Party have pointed out several times that the sum of £6 million saved in the social welfare budget arising from the dental dispute must be reallocated. We advocated that this money should be used to hire additional public health dentists and orthodontists to deal quickly with the enormous waiting list for dental services. The crisis in the dental service is real and acute. Some of the parameters of the crisis were outlined by Deputy Yates in his initial comments. Almost two million people are eligible for services under the medical care scheme, category 1 eligibility. The fact that it is simply not available to the vast majority of people is recognised, not only by the Leyden report but, more recently, by the report of the Commission on Health Funding. The Minister has a statutory responsibility under section 67 of the Health Act, 1970, to make dental, opthalmic and aural treatment and appliances available without charge to category 1 patients and their dependants and also to pre-school and national school children referred from child health examination. These services are provided by 250 salaried dentists employed by the health boards.
I might quote from the Report of the Commission on Health Funding, page 281, paragraph 14.12 under the heading "Evaluation" where it says:
Two major areas of concern are apparent in the provision of these services. The first is the wholly inadequate level of service available in the health board system.
In the next paragraph 14.13, under the heading (i) Provision it says:
Health board services cater for a relatively small proportion of those statutorily entitled to them. Certain categories, including pre-school and national school children, expectant and nursing mothers and the handicapped, are accorded priority; the great majority of persons with Category I eligibility are effectively without public dental care other than for emergencies.
That is an indictment of the Minister and his responsibilities. He has a statutory responsibility in law for the 1970 Act. How can he justify his inaction in this regard? The Minister has now been in office for nearly three years. When will he assume the responsibilities of his ministry? When will he stop blaming somebody else? When will he decide that he is responsible, that he must answer to this House for the state of the health services? Will he do so when he has been five years in office?
Deputy Desmond has gone to Brussels.
I have a thick file on health care problems, a huge proportion of which relates to the narrow area of orthodontic care for children. All of them are heart-rending and constitute indictments of the Minister's inaction in this regard. I will quote some of these letters for the benefit of the House. One is a letter dated 16 October 1989 from a principal dental surgeon in the South Eastern Health Board area in relation to a case I had referred to them, and which says:
I have received your letter concerning a patient. His recent examination — last month — was for the purpose of assessing his eligibility for treatment under the Department of Health guidelines which we are now obliged to implement. Approximately two-thirds of patients called from the waiting list for assessment have conditions which are not of a severity to warrant treatment under these guidelines.
I might add that these are the new guidelines issued by the Department of Health. The letter continues to say:
Great as our sympathy is for these patients — almost 700 on the current waiting list ——
—— and 700 on the waiting list in the one area puts the Minister's recent allocation in some degree of perspective. To continue the letter:
or for their disappointed parents, there is nothing which can be done in the present situation. This waiting list was initiated and maintained in the expectation that (1) a regional health board consultant orthodontist would be appointed and (2) an orthodontic specialist would visit the area on one day per month. Neither has materialised and it is now no longer acceptable to delude patients and parents with the illusion offered by a place on the waiting list. I enclose a copy of a letter which I have now sent to parents of children who are being called for reassessment.
I might quote from the letter referred to being sent to each parent which reads:
Dear Parent,
Your child is presently on the waiting list for orthodontic treatment. Demand for such treatment has greatly increased in recent years. At the same time the capacity of the dental service to provide basic treatment has become so restricted that the only service now available to eligible adults and post-primary school children is an emergency one to provide relief from pain. Any improvement in this situation is extremely unlikely in the foreseeable future.
As it has become clear that there is no reasonable prospect of affording treatment to all those on the waiting list we are now obliged to implement recommendations issued by the Department of Health which restrict treatment to children with very severe defects. Patients on the orthodontic waiting list will be called for reassessment in the near future with a view to making a priority listing of those in greatest need. It is a matter of regret that a substantial number of children will, of necessity, be excluded from treatment, but in the present circumstances it has become inevitable.
That is a letter dated 16 October 1989. I will not read all of these letters but each constitutes a litany of misery for individual families.
There is a letter to one constituent of mine, referred for orthodontic treatment when in fourth class, who was put on a waiting list, who has now awaited treatment for four years. I have another letter about a boy, aged 12, who was seen by an orthodontist last month after a four year wait. Apparently the result of that visit was that a brace was prescribed but his mother was informed that a brace will not be provided for him. There is no possibility of private treatment in this case as the father has deserted the family. Another child in my constituency was informed by the orthodontist who assessed her condition that, although she needed a brace, she would have to wait for it until she was working and could buy it herself. Yet another child has been informed by a nurse that there are now two books full of names of people awaiting orthodontic treatment in the South Eastern Health Board area. I could continue to cite this litany of despair. I am sure all of those people would take cold comfort from the statement the Minister made in the House this evening that virtually all is well, that the health board dental service for children is in pretty good order and has not been affected to any great extent by the health cutbacks of recent years. That is cold comfort indeed for all those people awaiting basic treatment from the Minister, his Department and the health service he is statutorily obliged to maintain and oversee.
The crisis is only one of a number. The overall crisis in our health services continues unabated. It has not been abated by the General Election, nor by the £15 million the new Government allocated on assuming office. Neither was it helped by the publication of the Report of the Commission on Health Funding. When that report was published I said it was particularly disappointing. Any rational analysis of the crisis in our health services must lead to the conclusion that the main cause of the crisis is lack of adequate funding. I am relieved to note this evening that that realisation is beginning to dawn on the Minister also when he says that additional funding must be found, whereas his only response to the publication of the document was to regurgitate the £300,000 for the 500 emergency cases. I have said that there are 700 in my health board area alone. Welcome and all as is the £200,000 allocated for a flouridation programme, it hardly constitutes a response to the scale of the crisis obtaining. The Minister must now be aware of that fact.
It is possible to construct a universal health service in this country, efficiently run, managed and free, at the point of need, to every citizen. We regard that as a right of every citizen: this level of care must be provided. It is gratifying to note that the Commission on Health Funding agree with that belief. The Commission, having accepted that health care is a right, then go on to argue that the quantity and quality of health care can be determined only by what the Exchequer can afford. This type of argument undermines the whole approach of the commission. It effectively places them in the position of arguing that people have a right only to whatever the Government decide to give them. I indicated, when published, that that section of the report had all the marks of having been published, indeed written, by the Department of Finance. The commission then go on to compound that fatal flaw by advocating, in what they describe as the kernel of their report, a new administrative structure which, in practice, will vary from the present structure only by adding yet another layer of bureaucracy.
There are good things contained in their report. However, they can be seen as pious aspirations only for as long as they are fatally undermined by the evidence of what must be secret writing instructions which clearly controlled the deliberations of the commission. In overall terms the implementation of this report would not improve the quality of our health services or its efficiency. It would condemn us to the maintenance of a health service provided on the cheap and add confusion to the delivery of care.
It is instructive to look at what the Commission have to say about the dental services. Basically, the Commission recognise that the scheme is in crisis, that the health boards are failing in their statutory obligation to provide dental treatment for eligible adults.
Debate adjourned.