Dáil Éireann díospóireacht -
Wednesday, 13 Apr 1994

Vol. 441 No. 2

Health (Amendment) Bill, 1993: Second Stage.

Minister for Health (Mr. Howlin)

I move: "That the Bill be now read a Second Time."

It gives me great pleasure to introduce the Health (Amendment) Bill. It is part of the legislative programme under the Programme for a Partnership Government and is an integral component of a comprehensive plan to develop the dental services in this country. While progress has been made in recent years in improving the services, this has taken place in a piecemeal fashion and regrettably, deficiencies still exist in the services. These relate both to individual components of the dental services and to specific areas around the country. For example, in some areas the children's services are being provided in an unsystematic way; secondary care orthodontic services still do not meet the needs of local populations despite significant investment; oral surgery services are limited and in many areas there is effectively only an emergency dental service available for eligible adults. I am determined to address these factors. These shortcomings and deficiencies have been of concern to Deputies on all sides of the House and have been raised through parliamentary questions and Adjournment debates on a regular basis.

I am particularly concerned that dental services are provided throughout the country on an equitable, efficient and consistent basis and have undertaken a comprehensive evaluation of the situation towards developing and implementing a co-ordinated and integrated dental plan in the medium-term. As a result of this evaluation, the Government has agreed to proposals submitted by me as the basis for this plan which will be implemented in coming years.

I propose to elaborate on the details of the dental plan in the national health strategy due to be published next week but it is intended that enhanced dental service will be provided under the following headings: primary prevention, including fluoridation and health education; primary care for children; services for the handicapped and persons in institutions; secondary care orthodontics; oral surgery services and a structured approach to dental health care for adult medical card holders and their adult dependants, including an accident and emergency scheme for the eligible adult population.

This area of health care requires investment to enable it to respond to the dental needs of the population and towards that end I propose to allocate an additional £4.4 million to the services this year. It is clear that this further impetus is necessary so that the progress to date can be accelerated in a way that the dental services throughout the country are provided in an equitable, efficient and consistent manner and that variations between health boards which can adversely affect access to and the quality of the services locally are removed.

This is particularly relevant in the case of adults who are eligible for dental services under the Health Act, 1970. There are about 915,000 adult persons eligible for dental services under the Act but, regrettably, the services available for such persons have declined in recent years to the point where, in many health board areas only an accident and emergency dental service is being provided through the health board dental personnel.

My Department is having discussions with the Irish Dental Association about the introduction on a phased basis of a new dental treatment scheme for eligible adults. It is envisaged that this scheme will involve both dentists in private practice and health board dentists, the latter working in the scheme under new, restructured arrangements. The services to be provided will include routine items of treatment, an accident and emergency service and the provision of dentures for the elderly and those in need.

Against the background of the current limited and unsatisfactory dental service arrangements for eligible adults, a dental scheme along the lines of that being discussed with the Irish Dental Association would be a major public health benefit to this group of the population. A satisfactory adults dental scheme is central to the successful provision of dental services to other groups and the services to those groups are delivered by dental personnel designated to individual areas. In this regard, the overlap between the children's and adults' services have restricted the development of both areas. Considerable progress has been made to date in the discussions with the association which have been constructive and positive. There are, however, a number of issues yet to be resolved and I am hopeful that these will be finalised shortly.

The expansion of the dental services in the coming years will require inputs of dental personnel and capital. My Department is addressing the detailed resource requirements for implementing the plan in conjunction with the health boards and is having discussions with the Irish Dental Association about the adult dental treatment services.

While I acknowledge that there are many deficiencies in the dental services, especially in the adult services, there have been major improvements in the levels of oral health in the population. This is especially true for children. These improvements have been achieved mainly as a result of a decision to implement community water fluoridation as a public health measure 30 years ago. One of the fundamental objectives of the dental plan is to facilitate further improvements in the oral health of children and to sustain these improvements into adulthood.

I now propose to outline the intent and the provisions of the Health (Amendment) Bill. The purpose of the Bill is to amend the Health Act, 1970, to enable health boards to make dental services available without charge to children who have attended national or certain other schools.

The Bill is a short one. Section 1 contains the necessary provision to enable the health boards to provide the services. It also contains a provision to enable the Minister for Health to specify the nature of the service to be made available and the age of the children to be provided with the service. This will enable me to extend services to children up to age 16 on a phased basis in accordance with the provisions contained in the Programme for Government.

The extension of entitlement to dental services to children up to age 16 will be a significant development in the primary care dental services for children. When the provisions of this Bill are fully implemented, persons will be eligible for dental services under the Bill from pre-school level to adulthood. This will involve a reorganisation of the health board dental services which has also been discussed with the Irish Dental Asociation.

The Health Act, 1970, provides that health boards shall provide a dental examination and treatment service for pupils attending national school or certain other schools as may be specified by order under the Act. The purpose of this extension is to achieve continuity of dental care by bridging the gap between national school primary care dental services and the provision of adult services. Accordingly, emphasis will be placed on those adolescents who have had a previous involvement in the national school dental services.

For many years health boards have been progressively adopting a planned targeted approach to the delivery of dental services to national school children and phasing out a demand led system. This is to ensure the optimum use of dental resources and equal access for all national school children to the same level of dental care.

The school based approach puts an important emphasis on dental health education and prevention. Dental health education programmes are now available to all national schools. Children in specific classes, usually second, fourth and sixth classes, are targeted for preventive measures under the school based approach. The children in these clases are screened and referred for treatment as necessary. The provision of fissure sealants for vulnerable teeth is an important element of the preventive programme. The programme has been specifically designed to ensure that children are dentally fit before they leave national school.

The small number of children who require more frequent attention are identified and the required level of advice, check-ups, treatment, etc. is provided as necessary. An emergency service for the relief of pain and infection is available on demand.

Under existing programmes about 275,000 children are screened annually for the provision of dental treatment. About 260,000 children receive dental treatment annually. Eligibility for free dental care to children after they leave national school is limited to the dependants of medical card holders. This means that two-thirds of all adolescents lose their eligibity for free dental services before the full eruption of their permanent teeth. However, the children of non-medical card holders remain eligible for any unprovided secondary care, e.g. orthodontics in respect of defects which were diagnosed while they were still at national school.

Children often experience an increase in dental decay after they leave national school. The presence of untreated decay in the teeth of these children very often causes further complications and problems extending into adulthood and can make necessary treatment in adulthood more difficult and more expensive.

It is proposed to phase in eligibility for children up to age 16 — i.e. up to the 16th birthday — during the course of the Programme for a Partnership Government. The extension of eligibility up to age 16 — i.e. up to the 16th birthday — will give entitlement to an additional 190,000 children.

The strategic approach adopted for delivering care to national school children will be continued when extending eligibility. The extension of existing preventive programmes including health education and fissure sealing where necessary to those up to age 16 will further reduce disease levels.

Each health board will evaluate the situation in its area to determine how best to implement the screening and treatment programmes for those to whom eligibility is being extended. As over 95 per cent of these children will be living in the catchment area of their national school, it is envisaged that most health boards will do so by a follow-up on the existing national school programmes.

Section 2 of the Bill provides for title, citation and construction.

The Bill is a short but important one. It is part of a major expansion of the dental services and its implementation is being backed up by the provision of the necessary resources as are the other elements of the dental plan, which I have outlined.

I commend the Bill to the House.

Mr. Durkan

I welcome the Bill. I am always prepared to offer encouragement to the Government when they propose to implement some of the promises incorporated in numerous documents. A Minister who comes into the House to deliver on one of those promises should be welcomed and it is incumbent on me to do so.

The principles in the Bill are excellent. The proposals set out are necessary, as we have all recognised for a long time. The theory is all very well but in practice we are a long way short of target and, in his heart of hearts, the Minister must know what the real situation is, particularly in relation to orthodontic treatment.

I do not like to disillusion the Minister, but if he thinks the £4.4 million will be enough to make the improvements that are necessary, he is mistaken. It is not enough by a long shot. The Minister says that the health boards will implement his proposals. However, as a member of a health board I know what they are capable of doing and why they are incapable of doing the things they want to do. The financial constraints on the health boards limit their ability to deliver in this important area.

Let me dwell for a moment on what is happening. Like many Acts of the Oireachtas, the 1970 Act is limited by the extent of the funding provided. The Minister cannot provide money for everything, but lest there be any doubt, if there is one subject on which public representatives have received much correspondence, it is the subject of dental care and orthodontics in particular.

I agree with the principle of preventive medicine in this area because prevention is always better than cure, but let use examine the involved process of screening that takes place to identify people in need of treatment. There are category 1, category 2 and category 3 patients. If the parent of the category 1 patient are prepared to allow their son or daughter to suffer pain for some time, he or she will be attended to within reason. Unless there is extreme pain or discomfort, the category 2 patient is not likely to be attended to for 18 months to two years, by which time that patient may be outside the school system. At that stage the parents may have given up hope, have taken out a loan of approximately £2,500 from a credit union, and gone to a private orthodontist to have emergency work carried out. Under the present system, category 3 patients have no chance whatever. They might as well not be on a list because the reality is that they will never get treatment. The Minister's proposals are welcome but they will not help those people except, perhaps, through prevention or earlier identification of problems. That remains to be seen. The £4.4 million will not turn around a problem that has existed for a long time and which is getting worse.

Most alarming is that, despite improvements introduced by the Minister in the last year and previously, the problem has got worse. One of the problems is that the health boards are not in a position to pay orthodontists a remunerative rate that is attractive enough to draw people to work within the system. Why should they work within the system if the conditions and the rates of pay are not comparable to what is available in the market place? That shortsighted policy causes serious problems further down the line.

Let us look at some of the things that happen. A classical case, which I referred to the Minister about a year ago, is that of a patient identified as being in need of treatment five years ago and put on a list. After three or four years the patients got worried because by then the child was approaching 21 years of age and nothing had been done other than that she was checked once or twice and, on the second occasion, deemed not to be in immediate danger and put on a further waiting list. I then took the initiative of asking the parents to refer the child to a private orthodontist for a second opinion and not to mention that the child had already been screened and identified as in need of treatment. The private orthodontist was of the opinion that the child was in need of urgent treatment if irreparable damage was to be avoided. The system did not respond favourably on receiving this information. Much shuffling about took place before the patient was eventually seen again. After much hassle, including representations, and accusations that the patient was attempting to jump the queue, attention was received. That patient was identified by a private orthodontist as being in urgent need of treatment and had that private orthodontist not seen that patient she would not have got treatment under the present system.

What happens where the parents are medical card holders or do not have an income that would bring them within reach of a private orthodontist? Absolutely nothing. I know of another case where a young girl who was sitting her leaving certificate examination was in severe pain during the examination and was offered no medication. This girl was a category 1 patient and had been put on a waiting list but her case was not reached for one reason or another. That unfortunate child had to sit the leaving certificate examination suffering from that pain and agony with no more than a prescribed mouthwash to alleviate the immediate infection problems. Those are two examples of the hundreds of cases I have come across over the years and I am sure the same applies to most Deputies, whether members of the medical profession or not. Those of us who are not members of that profession frequently have faster remedies than those who are.

Unless a fundamental overhaul of the entire orthodontic system is undertaken under the provisions of this Bill, it will be a failure. The additional funds provided will be a case of throwing good money after bad and will not solve the problem. It will only create further anomalies in the system. To clear the waiting lists, would it not be possible to refer to private orthodontists many more patients deemed in need of urgent treatment, for example, category one patients? Otherwise, we will have an ongoing waiting list of up to 4,000 people in each health board area. That is not feasible. Though they cannot afford to, many parents are borrowing money from moneylenders and legitimate institutions to provide treatment for their children. Even medical cardholders are borrowing money for this treatment because they cannot gain access to the service. In theory, the service is provided, but that is not the case in reality. It is only when one of us is in that position that we will fully recognise the frustrations which parents have to put up with. It is pointless the Minister saying to parents he has provided a categorised system and that in time all patients will be dealt with. Parents are well aware that only a minority will be dealt with.

My welcome for the Bill must be weighed against the problems that exist and the possibility that the Minister or officials of his Department may believe this cosmetic measure will solve the problem. It will not. Mention of cosmetics brings to mind the fact that when a health board comes under pressure to provide services it frequently responds by saying that much of the work is cosmetic and unnecessary. If that is the case those patients should not be placed in any of the categories. The first thing is to remove those who should not be on the waiting list. However, that creates a problem between private and public orthodontists. In order to shorten waiting lists public orthodontists will be encouraged to eliminate where possible, but of course private orthodontists will not operate under similar restrictions. I hope we do not have a repetition of the claim that most of the work required by parents for their children is of a cosmetic nature and should not be cluttering up the system. The treatment is either necessary or not and if it is deemed by a consultant to be necessary it should be carried out. Those on the waiting list whose treatment is deemed unnecessary should be removed from it.

I welcome the provisions for primary prevention, including fluoridation and health education, which will not require large scale financing. I also welcome the provisions in respect of primary care for children. I hope the Minister is sincere in his proposals for the handicapped as there should be no question of the handicapped having to wait for services. They have enough difficulties without placing them on waiting lists.

The Minister stated, "There are about 915,000 adult persons eligible for dental services under the Act but, regrettably, the services available for such persons have declined in recent years to the point where, in many health board areas, only an accident and emergency dental service is being provided...." I would go further and say there is no service at all. Even in urgent cases it is almost impossible to get a desirable response.

Many other countries place a great deal more emphasis on dental care. We are supposed to be a sophisticated developed country and part of the European Union, but compared with other countries we fare badly in respect of dental care. This is evident when people from foreign countries are interviewed on television. When they smile it is immediately obvious whether their country provides a good dental care service. The same is true here, especially in rural Ireland, although I am not advocating that people should cease to smile.

I wish the Minister well with his proposal, but I do not know to what extent the services can be extended on the basis of the moneys available. Giving the impression that all will be well is one thing but carrying it out is another. If we have a repetition of more of the same, the Minister will probably be back here in six months' time or less to answer questions.

The public has been concerned about this issue for some time and whatever is done now should be done in a progressive fashion which will achieve something in the next 12 to 18 months. If that is not the case the public will give their verdict and it will not be positive. They will call for extraction and I would not like that to happen to any Minister, but if the anaesthetic is applied in sufficient time and quantity it might give some assistance.

I wish the scheme well. If it fails it will not be for want of keeping the Minister on his toes or for want of bringing matters to his attention through the health boards. That good will exist because members of health boards and Members of this House, who meet their constituents on a regular basis must keep in mind the problems in this area and try to ensure that if they do not achieve the ultimate goal they will discover some light at the end of the tunnel.

The Explanatory Memorandum states:

Section 1 provides that a health board shall make available without charge a dental service for children who have attended a national or certain other schools and that the Minister for Health may specify, by regulations, the nature of the service to be made available and the age of the children to be provided with the service.

I presume the proposed regulations will be in accordance with the Minister's speech and will not be restrictive so that what may appear to be a useful though short Bill becomes a retrograde step. We would not support the Minister in such a measure. I am sure that is not his intention and he would know that it would not suffice to come up with a measure like that which would give rise to cynicism.

I welcome what the Bill purports to do. In the past 12 to 13 years many Bills incorporating great ideals, ideology and theory have passed through this House but they failed in practice. I hope this is not one of them. If it is, there will be many red faces in this House and maybe one or two extractions without an anaesthetic.

Ms Keogh

I too welcome the Bill. I am not loath to criticise when necessary, but where praise is due it should be given. The Bill has been aptly introduced a little earlier than I anticipated on a day when details of the Irish Heart Foundation's national survey on health behaviour are published. One newspaper's headline stated that we are lazy, toothless and smoke too much. Whatever about being lazy and smoking too much, I thought the position in respect of teeth was somewhat better than it is.

Mr. Browne

(Carlow-Kilkenny): The Deputy can afford to smile.

Ms Keogh

I know I can. I have cared for my teeth over the years. There is an angle to this survey with regard to women who have problems with teeth. The old adage that a woman lost a tooth for every pregnancy is significant in the area of preventative medicine, oral hygiene awareness and issues addressed in the Bill. The survey in referring to oral health states that 45 per cent of people visited their dentists in the year preceding the survey, 19 per cent had dental treatment one to three years earlier and 36 per cent had not visited their dentists for three or more years. From a preventative medicine viewpoint, I am pleased that women and men were equally likely to have visited their dentists in the previous year. Younger men and women were more likely to have had recent dental treatment, perhaps because older people were more likely to have dentures. I am concerned that the age gradient and the social class differential for treatment was greater for women than men. More than half of those surveyed had most of their own teeth and no dentures, nearly a quarter had some dentures and a quarter had mostly dentures. Women were more likely to have dentures than men probably resulting from childbirth as much as anything else. It is sad that 57 per cent of older women had mostly dentures. It is obviously too late for some people to avail of the preventative services proposed in the Bill.

I am glad the Minister has reached agreement with the Irish Dental Association on a great number of issues and agrees that a dental scheme along the lines of that currently under discussion with the association would greatly benefit public health. He also said that a number of issues have yet to be resolved and hopes they will be finalised shortly. I would like to tease out those matters.

Obviously the Minister in implementing the Bill will start at the beginning. We all agree that schoolchildren should be annually screened and treated and should receive necessary preventative and restorative care. I know there are difficulties and while I receive many complaints from constituents about available treatment, including orthodontic services, I am aware that colleagues receive many more complaints. The gaps in dental care are distressing for parents and urgent attention is necessary. Screening should be available for pre-school children from the age of 3 — it would minimise children's fear of dentists and later pain and discomfort. Adequate dental care and treatment should be available to all children up to the age of 16 and school based programmes are welcome. As with education, early identification of a problem facilitates treatment. The service should also be available to dependants of medical card holders who are entitled to it but sadly do not receive treatment. I am pleased the Minister introduced the Bill and will provide moneys to address problems in this area. It is difficult to bridge the gap between primary school dental treatment and adult services.

There are issues to be teased out, particularly those which the Minister discussed with the Irish Dental Association.

The Irish Heart Foundation includes oral health as an important part of its health survey. Standards have dropped and this should be addressed as a matter of urgency. It is very distressing to see so many Irish people wearing dentures at a young age. Many suffer needlessly because preventative measures were not taken in time. I hope that we see the results of this Bill soon. I welcome the Minister's statement that more than £4 million will be provided in this area and I hope this money will be spent wisely.

The 1988 Department of Health report stated that health boards were failing in their statutory obligation to provide dental treatment for eligible adults and that the curtailment of routine services for adults and the consequent large increase in demand for emergency services was hampering the development and, in some areas, maintenance of dental services for children. I hope that as a result of this Bill that trend will be reversed. There is a high level of professionalism in this area and the Minister, in his dealings with the Irish Dental Association, should seek the use of that professionalism to the best effect for our children and adults who are in need of dental treatment.

I welcome the Bill and thank the Minister for introducing it. I am glad it will have a speedy passage through the House.

Ms McManus

On behalf of Democratic Left I welcome the Bill and wish the Minister well. I do so in the full realisation that to bring in a Bill to deal with this matter is not sufficient. The history of dental care provision is littered with regulations that give people entitlements, but when they try to avail of them the facilities are not there.

If this Bill is to have any meaning a capital injection must be made into the dental service. I welcome the Minister's announcement of the allocation of £4.4 million for this purpose. I doubt if that amount will be sufficient but it is an indication of the Minister's seriousness of intent to provide a proper dental service. There are thousands of children on waiting lists for orthodontic treatment — some have been waiting for up to four years without satisfaction.

I have considerable experience of trying, often in vain, to help parents who are distressed that their children who are not top priority will not receive treatment. In the past the dental service has been inadequate and facilities have been very poor, out of date and unsuitable. However, improvements have been made in general dental care. There are more than 20,000 people on the Eastern Health Board waiting list. The idea of breaking down lists into categories is a good one which will enable health boards to clearly assess priority cases. We should get away from the nonsense that people who are down the line will be treated because the reality is they will not receive treatment. It is poor comfort to a person in category 5 to know that only those in categories 1 to 4, if they are lucky, will be treated.

For a very long time the dental profession has been driven by financial considerations. This has led to the provision of a service at a cost well beyond our means and has meant that those who most need treatment are unable to avail of it. The concentration has been on treatment rather than prevention. The widening of the scheme to include more children is welcome, but we must recognise that this is an uneasy compromise between the demands of the dental profession and the political will to provide a good service for our people.

The cost of orthodontic treatment in the private sector is prohibitive. The irony is that the taxpayer subvents these exorbitant costs as full tax relief is granted to people who avail of such treatment. This has increased the cost of treatment and constitutes bad value for money. Under the present system pressure is put on parents to provide orthodontic treatment for their children, treatment which sometimes is not necessary. To put too much emphasis on aesthetics will make money for dentists but it may not make the slightest difference to the dental health of a patient. This distorts the system because it creates a demand led service. Those who are better at demanding will avail of the service while those who are poorer or who may not be aware of the necessity of seeking treatment will not avail of it. Often those most in need do not get the attention they require.

It is time to put the dental patient at the centre of the service. For too long the service has been driven by the dental profession, its requirements and agenda rather than by the needs of patients. There is clear evidence that the poor and unemployed do not avail of treatment to the same extent as do the better off.

The system of school check-ups which is availed of by many children should be extended, not just for examinations but also in the provision of primary care. There are many dental hygienists who are not employed within the system. Yet it is such auxiliary staffing that offers the best opportunity for value for money. If we promote primary care, whether in fissure sealing, advice on health care or whatever, and target attention to those most in need we will improve the general level of dental care. This has been the subject of debate and consideration in the past, but sadly the rhetoric is better than the practice.

What we need is a dental service that is based on need rather than on demand. We do not need a dental service that is based on the demands of the profession. The current service is dependent primarily on intervention rather than prevention. As a result those who experience social disadvantage and live on low incomes lose out.

Although it is not directly related to the dental plan, I wish to pay tribute to the Dublin Dental Hospital which continues to provide a very valuable service in training and the provision of care. It was originally proposed to relocate the Dental Hospital in the St. James's Hospital complex, but I understand it is now intended to build an extension to the existing facility. I welcome the £8 million allocated for this purpose. It is a better idea to leave the Dental Hospital where it is. The present tendency to move medical facilities to the suburbs will lead to a loss of neccesary facilities in the city centre. It is important that the Dental Hospital maintains its independence and retains its facility in the city centre from which it can provide its services. It is also important that this hospital continues to contribute to the debate on dental services. Sometimes its views have not always been popular, but they have been helpful in defining the real needs in the service. I think the call for an extension to the Dental Hospital began 30 years ago. I welcome the funding provided for the extension to the hospital and look forward to seeing the improvements carried out.

On the question of extended primary care, dental hygientists have a greater role to play in this area. We are inclined to think that dental work can be carried out only by dentists, in the same way as we think doctors are the only ones who can provide medical care. We have to move away from this traditional way of thinking. There is no reason prevention work cannot be carried out by hygienists or denturists who have a particular role to play in the provision of dental treatment for people who are terminally ill, patients in oncology units and those infected with the HIV virus. Auxiliaries can deal with these people in a sensitive way and devote more time to them.

We do not have a great record in terms of dental health but there has been a steady improvement in recent years. The survey carried out by the Oral Health Services Research Centre in UCC shows that there has been a noticeable improvement in the level of oral health among Irish adults. However, as in so many other areas of health, the survey found evidence of a lower level of oral health among medical card holders and women. It is vital that we concentrate our efforts and resources on targeting those groups who do not enjoy improved standards of health.

One obvious way of improving dental health is through the fluoridation of the water supply. The use of fluoride in toothpaste has been another weapon in the fight against tooth decay. However, it should be remembered that less than two-thirds of our water supply is fluoridated and it is the urban rather than the rural dweller who benefits. I am very interested in hearing the Minister's plans for additional fluoridation of our water supply. One could not argue that there should be no extension of fluoridation. I accept the argument that the fluoridation of water and the use of fluoride in toothpaste benefit people. However, the reality is that people in certain areas have more protection than others. In my county a man contested elections on the platform of "no fluoridated water". I would be concerned if the philosophical argument about private liberty versus public good exacerbated the problem and became a live issue. The arguments against the use of fluoride in water do not stand up when one looks at the benefits of fluoridation.

I was interested to read the survey on health behaviour in Ireland which produced important documentary evidence in this area. The Irish Heart Foundation's report highlighted the continuing prevalence of smoking and alcohol drinking and the low level of physical activity among adults. However, one fundamental question was not addressed in this survey but should be addressed if health care, dental of otherwise, is to meet the needs of the population. The Irish Heart Foundation in this survey pinpointed factors such as diet, smoking, drink and a lack of exercise as the causes of coronary artery disease. However, the reality is that an unemployed middle aged male is twice as likely to suffer a heart attack as an employed middle aged male.

Any survey on health behaviour must take into account the class nature of our society, the fact that almost one-third of our children live in poverty and our endemic unemployment problem. These issues must be tackled and addressed if we are to improve the general health care of the nation. The promotion of healthy but expensive diets to reduce cardiovascular disease does not address the problem for those who cannot afford the diets. Yet these are the very people whose needs must be addressed if overall improvements are to be obtained. The dietary habits of our population have an impact on our dental health. There is a general recognition that sugar is a cheap source of energy but it is also a cause of tooth decay. Our level of sugar consumption is very high — I think it is double the level of some developed countries. Evidence is available to show that poorer children are more at risk because of the amount of cheaper foodstuffs they consume. The question of diet is dealt with in this major national survey but the implications of poverty are not. While there has been an improvement in terms of the amount of fruit, vegetables and fish consumed, the reality is that the biggest restriction on diet is poverty, an issue which has to be addressed.

It is interesting to note that only one out of three of those surveyed had not visited their dentists in three or more years. Reference is made in the report to the early age at which people have dentures fitted. I have no doubt that the number of women who have dentures fitted has more to do with their background than whether they have had children. It is not so much childbirth as the class into which one is born which causes this phenomenon. When talking about dental or any other form of health we must take the class factors into account and research the matter fully. Not enough research has been carried out into how unemployment and poverty affect health, both dental and otherwise.

I am very interested in seeking the Minister's national health strategy. I welcome the dental plan outlined by him. This element has to form part of any health strategy. However, the strategy must be tailored towards those individuals and groups among whom the greatest improvement can be expected. As in the case of all major diseases, dental or otherwise, this means directing prevention treatment towards those living in poverty. This point has to be repeatedly made because this is the context in which we are talking when we refer to any health measure or improvement in the health status of the nation. If we concentrate on those groups who suffer most from disease and are most in need of dental treatment we will have a better chance of raising the general level of the nation's health.

This comes back to my original point about the dental service — it is time to put the needs of patients at the centre of the service. There has been this domination of the interests of the dental profession. I would support the Minister if he put the patient at the centre of the service in a way that will improve the standards that exist at present. That will require resourcing. The professional contractual issues necessary will have to be tackled and there will have to be a shift. That is necessary and I hope with the allocation of money there will be a greater concentration on the needs of those most at risk and also a concentration on primary care, on prevention rather than treatment, because that is the key.

I welcome the Bill. In my experience in County Wicklow, in my local health centre dentists operate in dilapidated prefabricated buildings. There are specific accommodation needs of which the Minister is well aware. I accept he made a statement on health centres, including the welcome one that the health centre in Bray is to go ahead, and he is due to open the Roundwood health centre next week. The Minister will be very welcome to County Wicklow and I ask him to keep up the good work.

I wish to underline the point, however, that there are good people working in the service at present but the facilities with which they are provided are totally inadequate to meet their needs. We have to use whatever resources that are made available to service patients in the most effective way possible and to target those most in need, the poor, families who suffer as a result of high unemployment and need to be encouraged into the system. They should have an equal opportunity to care for their teeth.

Dr. Moffatt

I compliment the Minister on introducing this timely Bill. I am glad its provisions will be implemented on a phased basis and will result in a full national dental programme for all our people in due course. I hope this will not be done on an ad hoc basis and that improvements will be made to it in time.

The increase in the age limit from 14 to 16 years is to be welcomed because many of the dental problems diagnosed while children are at national school, particularly orthodontic problems, are not fully dealt with before they leave national school. This welcome measure will obviate many of the present problems.

I hope parents will have an opportunity to choose their own dentist. If there is an inadequate response from dentists in the private sector the Minister might consider employing dentists on a contract basis as is the case with regard to orthodontists. I have no doubt that if the Minister deals with the dentists in a fair manner those operating in the private sector will support him.

We do not have adequate orthodontic services in the west of Ireland and there is only one orthodontist for Galway and Mayo. While this represents an improvement as no service existed previously, it is not sufficient. I ask the Minister to consider engaging dentists to undertake much of the preliminary orthodontic work in conjunction with the orthodontists in the different health board areas. Approximately 60 to 70 per cent of orthodontic work could be carried out by regular dentists and the special cases could be referred to the orthodontist.

I wish to refer to the matter of young children requiring anaesthetics. We have a major problem in the west, particularly in Ballina, in that parents are sometimes required to travel 70 miles or more with young children fasting to have dental extractions and other dental work carried out under anaesthetic. I hope the Minister will introduce a programme using district or county hospitals for anaesthetic services, thereby eliminating the need for people to travel long distances.

This Bill represents a welcome start to a new programme. I look forward to the implementation of its provisions, but not on an ad hoc basis. I hope it will lead to a full programme being introduced.

Mr. Browne

(Carlow-Kilkenny): Cuirim fáilte roimh an Bille seo agus cuirim fáilte roimh an dearcadh atá ag an Aire. Tá súil agam go mbeidh go leor airgid, fiaclóirí agus orthodontists ar fáil chun go mbeidh maitheas sa Bhille.

It is difficult not to welcome this Bill because it sets out to do what we would all like to see happen. Without wishing to sound like a doubting Thomas, the theory of a Bill is one thing but the implementation of its provisions is another. In theory, up to now school children at primary level were entitled to a free dental service but, unfortunately, the service was simply not available. Many of their parents, if they could afford it, paid for private treatment. I hope that the £4 million to which the Minister referred, in addition to the negotiations the Minister is involved in, will result in the provisions of the Bill being implemented in practice.

One of the telephone calls that I do not like receiving from my constituents is from a parent whose child left primary school last year and is now in secondary school, and is in need of orthodontic treatment before it is to late. Many Members have had similar representations, depending, of course, on what area they represent. Some areas appear to have a good orthodontic service. The Minister represents my health board region and Carlow and Kilkenny are two of the counties that did not have an orthodontist. I realise strenuous efforts are being made to train people by way of special weekend training sessions — that is to be lauded — but it is no consolation to the parents who telephone me with this problem.

I have been a member of a health board and I had a special interest in the appointment of orthodontists. During my term of office we appointed three orthodontists, none of whom took up the positions because they could earn more money in private practice. At that time I suggested an increase in the rate of payment to encourage orthodontists to take up these positions because we cannot expect them to leave a private practice that is providing them with a large income to join the public service which is suffering from cutbacks etc. This has been a difficult problem over the years.

I am glad free dental care will be made available to the children of those with medical cards. It would have been unfair to have excluded them but, unfortunately, there is inequality in all walks of life. I am referring to those whose income is just above the medical card limit. I feel very sorry for those people because they cannot afford to obtain these services privately. Deputy McManus referred to five lists — I am only familiar with "A" and "B" and if a person's name is not on the "A" list he or she is excluded. Certainly if one's name is not on the "A" list with which I am familiar, one could do without because, on the "B" list, one is regarded as a cosmetic case. Very often the people whose treatment is regarded as cosmetic have crooked teeth, or teeth growing out of the side of their gums but still are not eligible for inclusion in the "A" list due to pressure on the system. I hope the Minister, in his forward-looking fashion, will contact the health boards and endeavour to ensure that orthodontic treatment is available to people in need of it, especially children who have been told in primary school that they need such treatment who, if they do not receive it, correctly feel they are deprived of something they need.

I listened to the Minister and other Members talk about this treatment being made available for children up to 16 years of age but I find that it is applicable up to the 16th birthday, so that it is really children up to and including 15-year-olds who are covered. However, it sounds much better to say up to 16 and I suppose technically it is correct. It is a good stroke; well done to whoever thought of it.

Mr. Allen

I am becoming worried about myself politically, because I have found myself agreeing with many of the Minister's recent decisions.

Mr. Howlin

Very discerning.

Mr. Allen

Like his initiative on the orthopaedic services which I defended in my home base in the Southern Health Board area and, again last week against some of the misleading statements by the President of the Irish Hospitals Consultants Association, here again the Minister is dealing with an issue involving a certain level of vested interest.

This Bill is being introduced against a background of services for one million insured adults having virtually collapsed. I welcome any attempt by the Minister to deal with this. I can speak from my experience only in the Cork/Kerry region where, unless one is in deep pain and trauma as a result of dental problems, one will not be treated; it is an emergency service only. We have a two-tier system in that, if one is a public patient, one must wait but, if one can afford to pay, one receives immediate treatment. I hope the Minister's discussions with the Irish Dental Association will result in some solution for that problem.

Referring to the Minister's discussions with the Irish Dental Association, I am somewhat worried about the provision of denturists. Some years ago I thought one of the Minister's predecessors had almost completed an agreement with the Irish Dental Association regarding the status of denturists here. Indeed it would greatly relieve consumers' finances if there was direct access to denturists. I am not convinced by some of the arguments put forward by the Irish Dental Association on recognition of denturists. Will the Minister, in conjunction with his colleague, the Minister for Social Welfare, reach an agreement at some future date on the provision of dentures for insured persons by allowing insured persons direct access to denturists, when there would be a substantial saving for the consumer and Exchequer alike.

A very serious position obtains for orthodontists. In the Southern Health Board area approximately 2,000 persons wait orthodontic treatment with approximately 800 being treated annually. The parameters for eligibility for orthodontic treatment were changed some years ago resulting in the exclusion of many of the children on the waiting list, which meant there was an effective reduction in the waiting list. However, that did not change the public's overall perception of a very expensive service where if one has the requisite moneys, treatment is available on demand whereas, if one does not one has to wait. We should remember that children between the ages of 12 and 14 are very sensitive about this problem and orthodontic treatment cannot be classified as a cosmetic exercise.

At some stage, perhaps not this evening, will the Minister address the position in the Southern Health Board area where six orthodontic units at St. Finbarr's Hospital are set up and ready to go but the health board do not have the requisite finances or resources to staff those units? While the provisions of this Bill are laudable, unless adequate resources are made available for the delivery of the service, it will be so much pie in the sky only.

Additional funds were provided by the Department in 1992 for the capital development of orthodontic services in the Southern Health Board area, which allowed for the provision of an orthodontic unit comprised of six dental surgery units. In a letter dated 23 June, 1993 the Department provided £55,000 funding for those orthodontic services and indicated that under no circumstances should the health board commit itself to expenditure above that sum unless approved. If the Southern Health Board in consultation with its consultant orthodontic surgeon, takes five dentists from the rooting services, must it provide resources to fill the five vacant units in order to deliver an orthodontic service? Within the context of this Bill — since £4 million is being made available — will the Minister say whether part of that funding will be set aside for the appointment of the five dentists required to fill the five vacant positions there? There are six units to be manned; we have a consultant orthodontic surgeon and we need five more orthodontic surgeons. Will the Minister release funds from the £4 million to fill those five vacancies to allow us continue to deliver the primary services to the people of the Cork and Kerry area? This additional funding is required to staff the orthodontic unit with five dental surgeons and six dental surgery assistants, who would be trained under the consultant orthodontist and who would serve each community care area.

The statistics available are quite frightening. Certainly in national schools in Cork city, rather than two examinations being made, one early in a child's national school career and another just prior to leaving national school, there is only one examination now, normally in the fifth or sixth year of primary school, and the children will have moved on to secondary school before receiving any treatment. In many cases treatment is not delivered at all. To say that the service is in a "shambles" is perhaps overstating the position but certainly it is very disturbing and upsetting for parents, in that some schoolchildren are being treated and others ignored because of the pressures and inadequate resources.

I welcome any improvement in the services. One must set aside political differences and support this Bill. Will the Minister, not alone in relation to dental services but in the delivery of medical services generally at some future date address the issue of professional fees?

I read in a newspaper today that the Irish Hospital Consultants' Association and its President, Mr. Healy, are adopting a militant attitude, threatening to have their members withdraw from the VHI scheme. On professional fees, the bullet must be bitten at some stage and consumers interests must be protected. At present unreasonable, at times outrageous, fees can be demanded and if one does not pay one must do without the service. Indeed I know of people who have been forced to pay over and above the VHI limit before a medical service was delivered. That must be taken on board by the Minister. When a person is in poor health the last thing they want is a demand for moneys over and above what they expected to pay. I wish the Minister well in his dealings on this whole issue. A recent survey showed that the level of professional fees for dental services in Northern Ireland contrasted starkly with the fees charged in the Republic for similar services.

Minister for Health (Mr. Howlin)

I express my gratitude for the welcome the Bill has received from speakers on all sides of the House. Although it is a short Bill it deals with an area all practising politicians are aware of. One of my first ordeals as Minister for Health was to attend an open forum with the members of the Health Boards Association. That was a daunting prospect because it involved an open question time, without an agenda, for the real practitioners who know what is going on on the ground and are familiar with all the problems.

Mr. Allen

The Minister will be on home ground this year in Wexford.

Mr. Howlin

I said then I was aware that there are good parts and bad parts of health service delivery and the dental services came into the bad parts. I said I was not satisfied that the public dental services were all that they could be. They are deficient in a number of ways. They are deficient in the overall but they are also deficient on a regional basis.

Although the Bill does not deal specifically with orthodontics, virtually every Deputy who contributed referred to that issue. While welcoming the Bill, Deputy Durkan referred to the amount of money being made available this year. I am glad I have Government approval in 1994 for the expenditure of £4.4 million additional moneys. When we consider that the total spend on dental services is approximately £25 million in percentage terms it is a significant start. What I have embarked upon is a plan dramatically to improve dental services. I will not pretend that will be achieved in one year or that it will be achieved with £4 million additional moneys. It is a phased plan over three years. Before I leave office as Minister for Health I hope we will have a dental service of which we can all be proud and that as practitioners in public life we will not have the same number of calls at our clinics and our offices from people who are entitled, under the Act, to services which they are not receiving.

Prior to 1992 there was only one consultant orthodontist employed in the health board system. Now there are consultant orthodontists in the Southern, Western, South-Eastern, North-Western, Mid-Western and Eastern Health Board areas, as well as consultant orthodontists operating in the Dublin Dental Hospital and St. James's Hospital who are treating public patients. The two health boards who do not have consultant orthodontists have authorisations for them and have arrangements for cover. The North-Eastern Health Board is covered by Northern Ireland while the Midland Health Board is covered by the Mid-Western Health Board. I am not suggesting that that is adequate cover but we have made a dramatic improvement during the past two years.

The staff required to provide a proper orthodontic service will not be entirely consultant. We also require specialists and sub-specialists to deal with the different categories of orthodontic deformity, some of which will be relatively minor and can be dealt with by sub-specialists who have training in orthodontics. That is all programmed into the plan which will be underpinned by resources. When sitting on the Opposition benches nobody repeated more often than I that grandiose plans were useless without money.

Mr. Durkan

We will keep reminding the Minister of that.

Mr. Howlin

I have refused to bring plans to the floor of this House unless they are realistic and can be achieved. During the next four years we can bring orthodontic treatment levels up to the European-norm. No more than any other country, we will not be able to treat every person who presents for orthodontic treatment. A debate is taking place within orthodontics, as Deputy McManus stated, concerning the number of people seeking treatment. Not everybody can present themselves to a public health system and demand to have a nose straightened or some facial deformity cleared up.

Mr. Allen

Do not look at us when you say that.

Mr. Howlin

There is almost an expectation that if one has a crooked tooth it must be dealt with. We will not be able to deal with every single case. Nevertheless I am confident that the programme I am negotiating and resourcing will bring treatment levels in Ireland up to the European norm. That would be a desirable objective and one I would be proud to achieve.

Adult services, referred to by Deputy Durkan, are those which cause me the greatest worry. The dental teams focus on children, they carry out the assessments and provide the treatment. Throughout the country generally we have a good children's dental treatment service but not a good adult treatment service. That is the reason I have embarked on discussions with the Irish Dental Association with a mix of both private and public to provide adequately for adults who have an entitlement.

The main elements of the development plan are as follows: a phased extension of the new fluoridation plants and maintenance of the existing plants, some of which need further capital investment; the extension of eligibility to children up to 16 years for free dental and orthodontic services, as will be enabled by the legislation before us; the restructuring of the schools dental service to provide for the systematic screening of a minimum of two to three designated classes in each national school and follow up screening and treatment, up to the age of 16, on a phased basis; improvements in both primary and secondary orthodontic services; improvements in oral surgery and new structured arrangements for dealing with adults, which I have outlined.

Deputy Keogh who welcomed the Bill said it had arrived in the House earlier than expected, due to the expedition of the House in dealing with other legislation. I confess I would be happier had I finalised a deal with the Irish Dental Association before bringing the Bill to the House. My contribution would be even more up beat had that been the case. We are in the hands of the legislative process and we have to deal with the realities as they unfold. I hope within days, or at most within weeks, to have the agreement with the Irish Dental Association in place.

Deputy Keogh spoke at some length about the happy heart national health survey, carried out by the Irish Heart Foundation, which I launched yesterday. Some of the facts that emerged from the snapshot of our health statistics leave much to be desired, not only in the area of dental care. I am concerned that we have good data. It is important to know the system and then set about improving it. The measurement of the health vital signs and the development of a programme to substantially improve them is the framework which will guide the health strategy which I hope to publish next week. I hope we will have an opportunity in the House to debate it at some length. It will be an important framework for the evolution of the health services during the next four or five years and well into the next century. As a people we will have to make choices. Every health system in the world is under pressure for resources. We can spend an infinite amount of money and we have to make health choices about what is proper. We must make choices in a democratic way through discussion with all parties. Deputy Keogh sought further information on the discussions with the Irish Dental Association. Over the last six weeks positive, encouraging and amicable discussions have taken place between the Department and the Irish Dental Association. Both parties have the same broad objective to provide dental care to all eligible adults. The scheme will involve private dental practitioners and health board dentists, the latter working under new arrangements. Discussion so far has centred on a number of issues — treatments both routine and emergency, the provision of dentures, fees to be paid to dentists participating in the scheme, the role of health boards in the context of their statutory responsibilities under the health Acts to provide dental treatment and the contractual arrangements to be worked out for participating dentists in the new scheme. Hopefully the discussions will be concluded shortly. A broad consensus has been reached on a number of these issues. Another meeting will be held on Friday next. The Deputy will appreciate the Irish Dental Association will put whatever proposals emerge to a ballot of its members.

Deputy Keogh mentioned the disparity between dental services. I am aware of the differences in the dental service available to insured workers and that available to meet medical card holders. The social welfare scheme is a good one and I am determined medical card holders will not have a scheme which is less good than that available to insured workers. They are both entitled to the best possible service.

Deputy McManus welcomed the Bill. She spoke about legislation which is hopeful, positive and idealistic but fails to deliver. I am determined this legislation will not be passed and forgotten about. The framework for its implementation is well advanced. I agree with her comment regarding real need as opposed to perceived need. She said, in essence, that the meek do not inherit the earth because those who are meek do not get the best services. Those who are pushy and vocal often get a service not because they need it but because they have clout. We must address that. She spoke of the need for dental hygienists. Negotiations with the staff are well advanced and it is my intention to employ dental hygienists in the public dental system before the end of this year. I support her views on the role of dental auxiliaries in the provision of dental care.

She raised the issue of the dental hospital. There has been much debate about who should be responsible for it. I was determined to do something about it and my concern was shared by the Minister for Education. The Dublin Dental Hospital was covered by her capital vote. For many years it fell between two stools It was covered by the Education Vote but perceived to be a health facility. This year an interdepartmental group chaired by my Department and involving the Departments of Finance and Education was set up. There is agreement that the school should be rebuilt on its current site at Trinity. It provides a valuable service for inner city Dublin and it would cost a vast sum of money if it were located elsewhere. I concur with the views expressed by the Deputy that the training and treatments provided by the hospital form a vital component of the dental services. I am delighted that £8 million was approved by Government and that construction will commence, hopefully, this year and be completed within three years.

Mr. B. Allen

What is the throughput of students?

Mr. Howlin

Approximately 40 per year.

Mr. B. Allen

Will it affect the future of the other dental school?

Mr. Howlin

There is a state of the art dental school in Cork which will continue to provide a service in Cork. Students will be trained there. There is scope to recruit all the dentists into the public system, if we can pay them.

Deputy McManus raised the issue of fluoridation. It is 30 years ago since the scheme commenced and it is something we now take for granted. It has contributed to the huge improvement in the oral health status of people. Overall 74 per cent of the population is serviced by fluoridated water varying from 99 per cent in the Eastern Health Board to 50 per cent in the Western Health Board. It is difficult to extend it to individual water schemes. However, it has led to a dramatic reduction in dental disease and in the requirement for treatment. A significant amount of the plant is now 20 years old and needs to be upgraded. Part of the scheme will be the installation of new plant and the upgrading of existing plant. Where fluoridated water is not available the use of fluoride toothpaste and fluoridated mouth washes are recommended.

Mr. Browne

(Carlow-Kilkenny): The Minister better not name them as he might be on television.

Mr. Howlin

Deputy Moffatt welcomed both the proposals and the plan which he hoped would be a structured one. Rather than saying we have a sum of money for this year and working on that, we worked on having a system we could all be proud of which will be phased in over four years in a structured way. It will not impact to the degree we would like everywhere this year but in the next two or three years we will see a significant improvement in the dental services.

The Deputy spoke about the choice of dentist and that formed part of our discussions with the IDA. I hope to be more specific when the discussions have concluded. He said there was only one orthodontist in the west. He is very busy and is currently training three dentists. Hopefully there will be an improved service available in the west in the future.

Chuir an Teachta de Brún fáilte roimh an Bille chomh maith agus tá sé ag súil go mbeidh go leor airgid agam chun na haidhmeanna atá sa Bhille a chur i gcríoch. Tá ormsa rá go bhfuil an aidhm chéanna agamsa agus tá súil agam go mbeidh an t-airgead agam chun na haidhmeanna a chur i gcríoch.

Deputy Browne mentioned orthodontics. It will be the duty of the consultants who are appointed to train dentists in orthodontics and ensure there is an adequate service available. It is one area I am nervous about because the demand is so enormous. When staff are recruited a dramatic improvement will take place because a large number of cases will be taken off the list but the treatment lasts for a year and so there will not be another dramatic improvement for a long time.

Mr. Durkan

It is a long time since there was a dramatic improvement.

Mr. Allen

It will take a long time to straighten things out.

Mr. Howlin

It will take a long time to "bridge" the gaps that are evidently there but it is hoped that my work will crown the success.

Mr. Durkan

It is like a trip along the canal.

Mr. Howlin

There is a great deal to be done and many layers to the plan. To deal adequately with children we will recruit 110 additional dental teams in the next four years to add to the 300 in place across the country to deal primarily with children. We will have a screening process in place for all primary schools, we intend to have a better primary system of fluoridation and to have auxiliaries, including dental hygienists, employed in the system. We hope to have the new adult treatment scheme in place to deal on a phased basis with the different cohorts of eligible people. It is an ambitious plan but one that will bring dramatic improvements in the next four years.

Deputy Allen welcomed the Bill. He need not be concerned that he agrees with the development plan because I know that the minute I do something wrong he will be the first to point it out forcefully. I am sure it will not be too long before he will have ample cause to disagree with me.

Mr. Durkan

He will be the second because I will be ahead of him.

Mr. Howlin

I welcome his support for the plan as outlined. He referred to the provision of dentures in particular which is a key element of the adult dental scheme. Our objective is to ensure that dentures are provided in the most cost effective way and I hope the Deputy will understand my views on that. There is a number of options to achieve this, they are being discussed and I hope we will come to a solution that can be supported by the Deputy opposite.

Deputy Allen raised the specific needs of the Southern Health Board and I commend him for making an immediate bid for a slice of the £4.4 million. I am aware that two additional dental surgeons have been allocated to the Southern Health Board area and without giving a specific commitment further moneys will be provided in 1994 for the service and will continue to be provided in subsequent years.

I have dealt with the points raised by the Deputies and I thank those who contributed to this very positive and constructive debate. I commend the Bill to the House.

Question put and agreed to.