JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 29 May 2003

Vol. 1 No. 9

Orthodontic Service Report: Presentation.

Chairman

I welcome Mr. Gerard Gavin, chief dental officer; Mr. Tom Mooney, assistant secretary; Mr. David Maloney, principal officer; and Mr. Liam McCormack, assistant principal officer, Department of Health and Children. In your presentation the committee would like to hear of the progress made in implementing the recommendations contained in the report on orthodontic services and particularly the joint committee health and children report, following which members will ask questions.

I draw attention to the fact that while members of the committee have absolute privilege, the same privilege does not apply to witnesses appearing before the committee. I remind members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House, or an official, either by name or in such a way as to make him or her identifiable. I invite Mr. Mooney to make his presentation.

Mr. Tom Mooney

I am grateful to the Chairman and members of the committee for inviting us back here today to review progress on the development and delivery of orthodontic services. The committee's report on orthodontics covered a very wide range of issues and made over 30 recommendations. With your permission, Chairman, I will briefly outline the progress on some of the key issues for service delivery identified in the report.

The Department and the health boards have worked hard to get more children into orthodontic treatment. When I reported to the committee in November 2001, there were approximately 16,100 children in treatment. I am pleased to say that since then, the health boards have taken on 200 new children for treatment every month and as a result 20,200 children are now receiving orthodontic treatment.

When I last appeared before the committee I emphasised that the provision of orthodontic services was severely restricted due to the limited availability of trained specialist clinical staff to assess and treat patients. The committee acknowledged the importance of this issue in its report and made a number of recommendations in relation to training. I am pleased to report a number of important developments in this area.

When we were here on the last occasion there were nine dentists in specialist training for orthodontics. This year we sponsored an additional 13 dentists for training. Six of these dentists are training at the Dublin Dental School and Hospital. We acknowledge the co-operation of the Dublin Dental School and Hospital, the consultant orthodontists in the regional units and the Irish Committee for Specialist Training in Dentistry, whose close involvement has enabled this programme to take place. We have agreed programmes for and funded a further five dentists from the health boards to train in Cardiff and Leeds. The boards are sponsoring a further two dentists to train in London.

The Department provided almost €1 million for this tranche of training, in addition to funding of over €500,000 for existing training programmes. With the recent qualification of two orthodontists who have already started work with the Western Health Board, there are now 20 dentists in orthodontic training for the health boards. All these dentists will have been trained to an internationally accepted standard and will be recognised as specialists once they qualify.

The Department recognises the importance of recruiting a professor at Cork Dental School. We have recently approved in principle a proposal from Cork University to further substantially improve the training facilities there for orthodontics and so enable the recruitment of a suitable candidate. This project should see the construction of a large orthodontic unit and support facilities. It will ultimately support an enhanced teaching and treatment service to the wider region under the leadership of a professor of orthodontics. A proposal to expand facilities at the Dublin Dental School for postgraduate training in orthodontics is also under active consideration.

We know we need to keep our best people in the health boards - orthodontists are specialist people who are difficult to recruit. The creation of a specialist in orthodontics post in the health boards will attract orthodontists to work in the health service on a long-term basis. The committee recognised this when it recommended that the qualifications for the grade of specialist orthodontist be directed by the Minister as a matter of urgency. I am pleased to say that this has been done and the first competitions have been held by the Local Appointments Commission.

The Department has also promoted the development of an assistant grade which will allow the orthodontist to achieve a greater caseload and so increase the number of children in treatment. The Dental Council has called this grade orthodontic therapist. The Department and the council have completed the work required to create the orthodontic therapist post and we are now bringing together the various staff associations at the Health Service Employers Agency to discuss the terms of the post in the health boards.

Following publication of the committee's report, the Department requested the chief executive officers of the health boards to consider the report and its implementation. The chief executive officers agreed to establish a review group to consider the report in tandem with assessing progress in implementing the 1998 Moran report on orthodontics and in that context preparing an action plan for orthodontics within the framework of the national health strategy. The group was made up of senior managers and orthodontists from the health boards. It has now presented a report to the Health Boards Executive which in turn has formally adopted the report subject to a small number of clarifications and reservations. The Health Boards Executive has recently sent this report to the Department where its findings are being considered.

Our aim is to develop the treatment capacity of the orthodontic service in a sustainable way over the longer term. Given the potential level of demand for orthodontic services, the provision of those services will continue to be based on prioritisation of cases based on treatment need, as happens under the existing guidelines.

The Health Boards Executive report refers, as did the Moran report, to the index of treatment need which is an alternative means of assessing children's need for orthodontic treatment. Its report recognises that the shortage of trained orthodontists currently restricts the use of this index by health boards.

I noted at my last appearance before this committee that a national survey of children's dental health was under way. The information from this survey should provide us with better information to identify accurately the number of children that would benefit from orthodontic treatment and the resources, particularly manpower, which would be needed to provide the corresponding level of care. The preliminary findings of this report are to be launched in the very near future.

We are also required to develop areas of dentistry, including those directly affected by the high level of orthodontic work now being done by health boards. We know from our previous experience that there is a strong demand for a range of health board dental services. We need to plan for all areas of dentistry on a balanced and proportionate basis.

The Department has implemented a range of measures to boost the number of children being treated in the short-term using both public and private treatment providers. For example, €5 million was provided for health boards from the treatment purchase fund. The Department directed each health board to use its allocation to treat children who were waiting longest and who most urgently needed treatment. This allocation has enabled health boards to provide additional sessions from existing staff and purchase treatment from private orthodontists. The committee has indicated in its report its support for such a public-private mix of treating children.

Orthodontics is unique in that the treatment period for a child is between 18 and 24 months and each year thousands of children, with varying degrees of need, are placed on assessment waiting lists. This undoubtedly presents challenges for service delivery and will continue to do so. However, we have made significant progress. Currently, twice as many children get orthodontic treatment as there are children waiting to be treated and almost 3,000 extra children have been getting treatment from health boards since the committee's hearings took place. Our aim is to continue to make progress and to develop a high quality, reliable and sustainable service for children and their parents.

Chairman

We heard on the last occasion that 55,000 people were awaiting treatment. You said in your statement that the numbers treated have increased from 16,000 to 20,000, but where stands the waiting list at this time?

Mr. Mooney

The total number awaiting assessment in March 2003 was 11,846 and the total number awaiting treatment at that time was 9,362.

Chairman

One of the major problems highlighted on the last occasion was that some health board areas were operating to the 1985 guidelines. Other health board areas were far more stringent in terms of the people they deemed qualified for orthodontic treatment. There was a major difference between the waiting list in certain health board areas as against others. For instance, the guidelines in the Western Health Board area differ very much from those operating in the Southern Health Board. If I recall correctly, letters emanated from Mr. Gavin suggesting we move away from the 1985 guidelines, but the Minister does not appear to have issued an instruction in that regard. We indicated in the report that we found that situation to be unsatisfactory, yet I understand that it still persists. Perhaps you will comment on that.

Mr. Mooney

As I said in my statement, the health boards' proposal, and our intention, is to move to the internationally accepted index of treatment need, but frankly our service in terms of trained specialists would not be able to sustain that level of service currently. Technically, as far as the Minster and the Department are concerned, the current guidelines are those published in 1985. It was mentioned that in some areas they are somewhat restricted, but they are the guidelines. As I understand it - perhaps Mr. Gavin may have other information - until recently some boards had a skeleton level of service and they had to restrict the guidelines to keep the numbers being treated within manageable proportions. However, we have indicated to boards that where the resources are at their disposal, they are free to go beyond the guidelines. I understand a number of boards have done that.

The position is somewhat flexible, depending on the resources at the disposal of the boards, but we hope that when the increased numbers in training, which I have outlined - 20 are in training at present - come on stream we will be able to move towards implementation of the IOTN in all areas. This is an internationally recognised index and we are conscious that we drew attention to it in the previous report and made some recommendations as to procedures which should be put in place before we would change the guidelines. The most obvious thing to do is to try to move to this internationally accepted position when there will be no dispute between us and the committee or between us and the service providers or whatever. It would be an internationally designed and accepted set of criteria which would be applied to the assessment of need.

Mr. Gerard Gavin

What Mr. Mooney has said is essentially correct. I am happy to have circulated for discussion a copy of the letter I wrote on request to a manager of one of the boards. It did not indicate moving on from the 1985 guidelines, but it interpreted our understanding of how they should operate from their inception, in other words, that they operate on a prioritised basis and that the most severe cases should be seen first.

Where resources are not available - we had a long discussion about this - we consider it to be inappropriate to put children on a waiting list when there is no prospect whatsoever of them receiving treatment. I explained that in the letter. As I understand it, that is currently the case with regard to the board you mentioned, Chairman. It leaves children and their parents in a very difficult position when they find themselves in that situation.

Chairman

Perhaps we will pursue this further.

Deputy O. Mitchell

My question is similar and perhaps we can pursue the matter further. I thank the delegation for the presentation. I was not a member of the previous committee when the report was made, but I was struck by the fact that when they made their last report, nine people were in training, whereas today there are 13 orthodontists. I realise that more are abroad and the total number is 20. The demand is very much greater than can be met, but unlike any other area of the health service, the problem has never been lack of funding but the absence of orthodontists. Those of us who are members of health boards have seen what a cynic might call a manipulation of lists to make them look as though not as many require treatment. I understand it is inappropriate to have people on a list when there is no prospect of them getting treatment, but they have an entitlement to it and some qualified person considered them to be in need of it. Are there enough people in training to provide for future needs?

A positive aspect to which Mr. Mooney referred is an awareness of the need for a career structure and promotional opportunities, which will help bring people into the industry. However, we do not seem to be training enough people. Increasingly, parents are borrowing to send their children to private orthodontist, but the cost of a private orthodontists is again related to the numbers in the system. I am sure members of the delegation are aware that hundreds of families from Dublin and probably other parts of the country travel to Belfast to avail of dental services there at between one third and one half of the price of the treatment available in the South. This must be related to the number of orthodontists in the system. Are we doing enough and is it fast enough?

Deputy McManus

The improvement in the service is welcome. From my experience of the East Coast Area Health Board, there has been a significant improvement, although more needs to be done. However, the improvements have occurred in an area where there was great dissatisfaction, with children being left for endless periods of time on waiting lists. While children are still waiting for treatment, the improvements must be acknowledged.

On the question of training more doctors, is there a requirement or safeguard in terms of keeping these people in the public sector? I am fearful that while the increased numbers are in training, we may not be able to hold them in the service. What safeguards are in place to secure these people into the future?

Why has it taken so long to fill the vacancy in the professorship of the Cork Dental School? Why has it not been resolved? When Mr. Mooney says the point of appointing orthotherapists and specialists in orthodontics has been reached, does he mean appointments will be made by each health board or by a private scheme? The health board review group has issued its report. Are there costings in terms of the response to the report and is the Department committed to meeting them?

It is alarming to note the reduction in children's health in terms of obesity, which is related to diet. While there have been great improvements in children's health, there are issues of diet which presumably will have implications for dental health. Will the witnesses comment on this aspect? What promotion is being done to encourage good dental hygiene?

If the health boards are to be abolished, what will be the implications for the orthodontic service? The Taoiseach made great play about the lack of competitiveness among the professions. Are real measures being taken to address the very high cost of private dental practice?

Deputy F. O’Malley

I thank the members of the delegation for presenting this report. I am alarmed at comments made by Mr. Gavin that, where there is no prospect of a child receiving service, it has been decided to remove him or her from the list. That is not appropriate. If a qualified individual has determined that treatment is necessary, it should be provided, even if it takes longer.

I was not a member of the previous committee which deliberated in producing the report, but I am familiar with problems that have arisen in the area, especially with regard to training. I too am alarmed that a professor has not been appointed in Cork. That is extraordinary and I would like a direct answer as to why it has not happened. Previously when three people who were involved in the original report were providing a good service and clearing waiting lists at a rapid rate, there was an irregular review by the SAC, on which I am open to correction, which determined that the level of service they were providing was not of a high enough standard. Yet the dental hospital does not have a professor, which the delegation might indicate was preferable and that could be questioned.

I am concerned about the cost of a fee per item. Why was this adopted? I have heard of many instances where people who were working in the public sector and earning a wage brought many cases, whereas now that the Department, and probably the dental hospital, have chosen to opt for fee per item, there is a much lower rate of return for the public money. I would argue that this does not deliver good value, which is what we are here to insist on. I have heard of an orthodontist in Cork who is receiving €1.7 million from the Department for treatment and another individual, who has 26 times the case load, is receiving a great deal less money.

Something must be done about this, although we will probably lose people from the service, as Deputy McManus indicated. How can we guarantee that we will retain these people in the public service when the Department has made it so much more attractive to go into private practice where the indications are that one may earn much more money? I am concerned about that.

It seemed that we had a service that worked - the delegation will know what I am talking about. The figures in the Limerick area were very much reduced and a large caseload went through quickly, but something happened to stop that. I would like the delegation to comment on that because training is the problem.

Chairman

That was fairly well discussed in the course of the last report but the problem still persists.

Deputy F. O’Malley

It persists in the cost, and that is what I would like to address.

Deputy Neville

I was a member of the previous committee and our first recommendation was to get over the difficulty with regard to the differences within the system. Orthodontic consultants were clearly at odds with the Department. We as a committee deliberated long and hard on that, and our first recommendation was entitled Relationships. Has there been an improvement in that area? As the previous committee pointed out, we wanted that problem overcome so that everybody would work in tandem.

What Deputy O'Malley has said is correct, and as the Chairman said, we dealt with that, but we are still concerned that this situation persists and that an opportunity, which was there to treat hundreds of patients under the old system, was removed. As a result, relationships have deteriorated. We saw unusually emotive scenes here during the course of our previous discussion. What is the position in that regard? That is my first question, and I will not pre-empt the delegation's answer.

My second question is about waiting times. Whereas waiting lists are an issue, what are waiting times? I understand that at present there is a four or five year waiting time in my health board, the Mid-Western Health Board. There is insecurity, both for parents and children, when they do not know when the child will be treated. Perhaps the delegation will give the committee information on waiting times.

Chairman

I ask the delegation to address that issue because that was vital to us the last time the report was issued. Relationships was the number one item. There were three consultants within the system who were obviously divorced from the practices in other areas. They obviously felt very much aggrieved. The first recommendation we made was to set up an expert panel with representatives and you would also have representatives. Somebody would adjudicate the result, which would be binding. However, nothing has happened in that area. The letters are still coming to all the members of the committee telling them that the situation has been exacerbated rather than improved. You are before us this morning and, two years later, the same situation pertains. It is not satisfactory.

Mr. Mooney

It is not satisfactory and that has been the case for a number of years. I certainly could not even begin to suggest to you that it might be any different in the next few years. We discussed this in considerable detail when the issue was first addressed here by the committee. The committee made a recommendation that an expert panel be set up. We were somewhat taken by surprise by that because perhaps we had not explained the situation or perhaps the matter had not arisen specifically. We had, just prior to that, made a number of attempts to deal with the matter. Indeed the chief officer and myself approached a very senior person in the medical profession involved with specialist training to try to sort out the issue. He brought together all the various interests involved but, by his own admission, he failed miserably to make inroads in terms of a meeting of minds on that issue.

When the committee sent us the report one of our first actions was to ask the health board chief executive officers, who, after all, deliver the service, to look at the detailed recommendations in the report and to come up with a plan or a report based on that. They invited one of the individuals to whom the Chairman referred to attend and, as I understand it, this individual was to represent the three of people involved as part of the consideration of the committee's report. The chief executive officers, in the report, pointed out that he attended the first meeting of the group but did not attend afterwards.

Deputy Neville

Did he say why he was not attending?

Mr. Mooney

No. I do not know why he did not attend beyond the first meeting. Deputy Neville spoke about the difficulties in the system and said that these people were at odds with the Department or the Department was at odds with them, which is not correct. There are times when we have had our differences in meetings and all the orthodontists have come to my office on a number of occasions to try to resolve the matter. It is not necessarily that the Department laid down rules or guidelines, or that problems were created for them. The issue revolved around training.

Deputy McManus and Deputy Mitchell spoke about the training of these specialists and retaining them in the health board service. I mentioned that these 20 specialists are being trained to a professional level agreed by the training bodies which have statutory responsibility for training. It is not the Department's responsibility, although we have a role and we are involved. As I see it, there is a great deal of history to this issue. The kernel of the problem was training. We had to ensure that training was in line with what was required by the universities, professional training bodies and EU directives. That is the training system we have in place now.

We have had great difficulty in finding the places to train people. Orthodontic specialists are scarce throughout the world which largely explains the fact that we have had difficulty in recruiting additional consultants for whom we have advertised in the Southern Health Board and Eastern Regional Health Authority areas.

We have had difficulty in getting a professor in Cork and there has been a long running issue there between the prospective candidate and the university in relation to whatever arrangements take place in the university with the appointment of a professor. I am given to understand now that they are very hopeful a professor will be in place for the next academic year.

They are things that are outside our direct control. We can influence them and try to help and work them along. In getting the 20 places, it will be seen that not alone have we used up every bit of capacity we have, we have also trawled anything we could find in the United Kingdom and now have people training in London, Leeds and Cardiff.

It is difficult enough to find places because these people are scarce internationally so in getting people into the schools in Britain we had to compete or try to be facilitated against the internal competition there.

Perhaps I have answered some of the questions. If the committee wishes to come back in more detail on any aspect, I am happy to oblige.

Chairman

There were some other questions from Deputies McManus and Olivia Mitchell.

Mr. Mooney

Deputy Mitchell asked if we are doing enough quickly enough. We are doing it as quickly as we can. I do not know whether we are doing enough. We have the maximum number of people we could find, which is 20 in training at present. We are also creating the auxiliary post of orthodontist therapist which we hope will enable orthodontic teams to increase their throughput. Additional consultants have been appointed and that is reflected in what Deputy McManus said, especially in the south Dublin and Wicklow areas. That has greatly improved the service there.

Deputy O. Mitchell

If the 20 trainee orthodontists stay in the service, and we do not even know they will, does that increase our capacity to train in future? Is there any long-term gain?

Mr. Mooney

There is but we would like to get them in. As I understand it, all the people in training are linked to a service provision. They are not students with no attachment. They are part of the system and are assigned to a health board. It is not as if there are 20 students whom we hope will apply for jobs. They are employed in the system and are training. We have tried to create the career structure within the health board system which will give them a career pathway and, it is hoped, greater career satisfaction.

I cannot for a myriad of reasons give the Deputy a guarantee that we will keep all 20 of them, but we are doing what we can to ensure that they have a secure and fulfilling career within health boards. I made that point previously. It is crucial for us and we see it as something that is very important, namely, to retain these people. It is very expensive to train them. It cost us about €100,000 per trainee this year. It is very expensive and we would be looking to use every device at our disposal to ensure we retain them when we have them trained.

Deputy O. Mitchell

Will the fact that we will have 20 orthodontists increase our capacity to train in future and will they be used to train more orthodontists? Mr. Mooney said there was a worldwide shortage.

Mr. Mooney

Of itself, it does not increase our capacity. We still need places in the dental schools to train them.

Deputy O. Mitchell

Do they not have a training role themselves?

Mr. Mooney

They would have a training role, but not in the academic end of things which is the real problem we have.

Deputy O. Mitchell

Does this mean the real problem is not the training but the academic capacity?

Mr. Mooney

That is part of the training. People could be trained to do orthodontic work as they could be trained to do dental work. They would be trained as technicians but not as professionals who can deal with patients in their own right and have clinical responsibility for the patient and all the other things that go along with it.

Deputy Cowley

Regarding the committee in question, would there not be an obligation on regional orthodontic units to do the best they could? Is it not true that because of the lack of a postgraduate training system, the consultants leading departments trained people and made great inroads into the work involved and that since that system was dismantled in 1999, there has been a reduction in the number of eligible children and the numbers treated and that it has cost much more?

Will the witnesses explain why the number of children receiving orthodontic treatment in the Western Health Board area is more than 1,500, whereas the figure I have for 1996 is 3,600. In the same year, there was one consultant orthodontist and no specialist. In 2003, there is one consultant orthodontist and three specialists. In other words, there are half as many children being treated and three times as many specialists. In 1996 the budget for the regional orthodontic department in the Western Health Board was €500,000 and was €2.4 million in 2002. Can the witnesses explain that?

Will they also explain why only 5% of the 12 year old population should qualify for orthodontic treatment when the report states that 33% should qualify? The existing 1985 guidelines estimate that 23% of children should come within the eligibility criteria. In that regard, would the witnesses not think that the old saying, "If it's not broken, don't fix it" applies, given what happened? What was the rationale for this?

I wonder about the bias that exists because I understand the committee in question was composed of academics and specialists, mostly from the private sector. Is there an agenda to wind down the public service in favour of the private sector? Is it still true that the children must wait a year to get on the list and four years after that to be seen? What type of system is that?

Deputy Devins

The purpose of the meeting is to review the improvement or otherwise since the report issued in 2002. When the witnesses state that 16,000 children are in treatment, what do they mean by "treatment"? Do they mean they have been assessed and are undergoing treatment or have been assessed and are on the waiting list for treatment?

Mr. Mooney

They are in treatment.

Deputy Devins

What about all the children who have been assessed and have been put on waiting lists for treatment? What are the figures for those?

Mr. Mooney

I gave that figure earlier. It is 9,362.

Deputy Devins

Have these been assessed and are they awaiting treatment?

Mr. Mooney

Yes.

Deputy Devins

Is this across all levels?

Mr. Mooney

Yes.

Deputy Devins

My impression is that if a child does not fit into the top three grades of urgent treatment, he or she will not be within the appropriate window of opportunity for treatment.

Mr. Mooney

He or she would not be on the treatment waiting list.

Deputy Devins

No, what I am saying is that they are assessed at different levels and then they go for treatment. As a result of the difficulty in providing treatment, only the top two or three levels receive it. If one is assessed at level 4, 5, 6 or 7, one is on the treatment list but one has no realistic hope of ever getting treatment during the window of opportunity in which treatment is needed.

Mr. Mooney

That was the point the chief dental officer and I were making. People will only be put on the treatment waiting list if they come within the guidelines. Even within that, as we discussed earlier, in some boards resources were insufficient up to now to cope with that level, so there may have been restrictions; of course, there were boards with resources to go beyond the guidelines and they did so. The 20,000 people referred to are those getting work done on their dental problems at present.

Deputy Devins

How many are being referred for assessment and are progressing a stage further on the lists as a result?

Mr. Mooney

At the moment, some 11,846 children are on the waiting list for assessment.

Deputy Devins

Not for assessment. These are children who have been assessed and have been put on a treatment list.

Mr. Mooney

That is——

Deputy Devins

I mean those who go on a treatment list. Unfortunately, as I well know - and as I presume Mr. Mooney will know - many of them never get treatment. They reach 14 or 15 years of age and have still not been seen for treatment. They have been assessed but not treated.

Mr. Mooney

That may have been the case previously but these 9,362 people are on a treatment waiting list with a very realistic prospect of treatment. I have some figures on waiting times for treatment. It depends on the category people are in, as waiting times for treatment vary according to category: Category A patients are generally treated almost as necessary. The waiting times vary from around 12 months to three years, depending on health board area.

Deputy Devins

I know that. The figures are massaged.

Mr. Mooney

The figures are not massaged. These are the figures presented to us by the consultant orthodontists who do the work.

Chairman

What Deputy Devins is getting at is the number of people who come to the local dental clinic for assessment and are then referred to the orthodontist to see whether they qualify for the list. It is up to the orthodontist in many areas. If he or she sticks by the 1985 guidelines then more and more appear on the list. If one has an arbitrary system, where a west of Ireland orthodontist decides not to abide by those guidelines, then the figures coming through for treatment there will be far lower than those in the Southern Health Board area, where there is rigid adherence to the guidelines.

It is very unsatisfactory that we have allowed a situation to develop where orthodontists can make arbitrary decisions and guidelines are not being adhered to. Would parents have a legal case if guidelines are set which are to be followed, yet individuals decide children do not go on the list as qualifying applicants?

Mr. Mooney

I said earlier that we intend as soon as possible to go to the internationally accepted IOTN index of treatment guidelines. These guidelines are just guidelines; we must leave some level of discretion to professionals dealing with this. They are always pointing out, for example, that one may have a child who does not fit technically in the guidelines but whose orthodontic problem, biting or whatever it is, is causing real difficulties. Clearly in that sort of situation one must leave discretion to the professionals.

These guidelines were set in 1985 when there were no internationally accepted guidelines available. However, such guidelines are available now and we hope to move to those as soon as our resources allow us. By "resources" I mean trained people to provide a service; that is what we are seeking to do with our training programme.

Senator Feeney

Mr. Mooney said there was a difficulty with recruitment and a scarcity of specialists all over the world. Why does a similar situation not obtain elsewhere in the world if there is such a shortage? I agree with him that training bodies have responsibility for the training of a dentist or specialist. How long does it take to train an orthodontic specialist? Also, Mr. Mooney spoke about orthodontic therapists. Are they trained dentists?

Some 20 people are being trained at present and those numbers seem too small given the demand. Is there a problem with the number of places in the dental hospitals - the numbers we are training with a primary degree in dentistry?

Going back to a question from Deputy Mitchell, what kind of contracts and incentives are to be offered to the 20 people being trained? It is expensive to train them and one hopes they are retained in the public service. What kind of contracts and other incentives will be offered to them? Also, is it practical to use those 20 trainees as trainers for other new recruits? I know Mr. Mooney said it is down to places in schools but half of the training must be practical. Can they be used as trainers?

Deputy Cooper-Flynn

It is great to be back here reviewing the progress of a report we produced last year. I thank the Department for its submission and for outlining what it has done. Clearly there has been some progress.

While the committee would agree with Mr. Mooney on the key issues, they are not necessarily the same priorities we identified as being important in producing our report. The Chairman was correct in identifying the importance of relationships. It appears that Mr. Mooney does not agree with our first recommendation that the relationship issue be referred to an expert panel. I recognise that he has made some moves to resolve this but not in the manner we outlined and recommended in the report. Does he not agree with the report in that regard? It is important to know this.

This report was discussed at some length - for months - and the most controversial matters were the 1985 guidelines and the list. I felt strongly then, and still do, about what the list tells us about the number of children who have needs. It appears to me that the waiting lists are manicured lists of what is manageable, which is entirely different to the true picture of children's needs. I have had cases in my area where children have been assessed as ineligible for treatment. However, they have been seen by others in the health board who assess them as meeting the 1985 guidelines. As Mr. Mooney said, resources in the health board are obviously scarce so rather than giving parents false hope that their children will get treatment, those children are not put on the list; that is the easier of the two options. Why raise a family's hopes when the children will never get treatment? They will only be torturing me in my clinics for the next four or five years.

That may be a convenient picture for the health boards to paint, but it is not a true reflection of the situation. Whether the resources are available or are different in different health board areas, there must be uniformity in waiting lists. This is important regardless of whether it is done under the 1985 guidelines or the IOTN guidelines.

The report makes specific reference to the Western Health Board where two orthodontists have started work. I contacted the orthodontic department in the board a month ago and was informed that they had started work and their caseloads are full. There are 900 children on the waiting lists and the waiting time remains at four years. This is unacceptable. Children must wait for a considerable time to be assessed and if by some chance they get onto the waiting list they will have to wait a further four years for treatment. Deputy Devins mentioned children that are still waiting for treatment at the age of 14 of 15. I have met children that have gone into third level education and, despite being on a treatment waiting list, have not yet received orthodontic treatment. There is a suggestion that despite the passing of time, the treatment will not be any less successful when it eventually comes. However, it is not easy to convince a 14 or 15 year old of this. This delay can also cause psychological damage to young people.

The report referred to the number of people being treated by each orthodontist. Has anything been done regarding the auditing of individual orthodontists and the number of cases they deal with each year? While I accept every case is different, there should be some similarity in the caseload of each orthodontist.

While it is clear the Department has developed links with Britain, one of our recommendations was to develop links with Northern Ireland. Have we had any success in having orthodontists trained in Northern Ireland or was the Leeds-Cardiff option deemed to be the most acceptable? The most important issue is the reduction of the waiting time. The correct assessment of need must be put in place in order that children entitled to treatment can be put on a list. If we can solve this, we will have made a lot of progress.

Mr. Mooney

Many questions have been asked. I will try to answer them as best I can and will ask Mr. Gavin to deal with some of the specific questions relating to training duration etc. Retaining orthodontists with the health boards is obviously a concern. I cannot give a guarantee that all 20 being trained will stay in the public health service. It is important that we retain them and they all have contracts of employment with the health boards.

Senator Feeney

Will they be permanent or temporary?

Mr. Mooney

They are permanent dentists working with health boards and we have arranged for specialist orthodontist training.

Senator Feeney

Will they be employed on a permanent contract when they qualify as orthodontists?

Mr. Mooney

My understanding is that they are on permanent contracts.

Senator Feeney

We all know that it is not attractive for an individual who has undertaken training to be offered a temporary contract when he or she returns to work. This is how we lose good consultants.

Mr. Mooney

It is not a question of these people coming back into the health service. They have never left other than having time off for training. It is not as if they are students, they actually work in the health service and have a certain amount of time off for training.

Mr. Gavin

The training period is three years. Those trained agree to be bound by a contract to provide service for three years following the training. In addition, the Local Appointments Commission has advertised permanent specialist posts, the first of which has been filled in the past week. Such specialists are given permanent contracts like those given to other permanent staff in the health boards. While the salary level is not that of consultants, it is quite close. Some of these staff may be able to treat patients under the treatment purchase fund. I do not think it can be said that the conditions are unattractive. We will have to make our judgments and assessments over a period of time.

One dentist is undergoing specialist training in Northern Ireland. I understand three to be the maximum number of dentists undergoing training in Belfast at any one time. The number of places for training throughout dental schools is quite limited. There are up to nine other areas of specialist training and these have also to be catered for. That is the danger when people look at the dental service through the microscope of orthodontics. Some of the other areas relate to the care of people who are having orthodontic treatment. Some people are on the waiting list due to the lack of specialist services in other areas of dentistry. This is why the service must be developed in a balanced way. We must try to bring orthodontics as far forward as we can with the capacity available to us in Ireland and internationally, while also developing these other areas of dentistry.

Deputy Cowley

Not all my questions were answered.

Mr. Mooney

I am sorry. The Deputy threw up a lot of detail and I could not absorb it all.

Deputy Cowley

The Western Health Board will have one consultant orthodontist and three specialists in 2003. In 1996, there was one consultant orthodontist and no specialist. The number of children currently receiving orthodontic treatment in the Western Health Board is just over 1,500, while 3,000 children received treatment in 1996. The cost of the service was €500,000 in 1996, when twice the number of children were being treated, and it cost €2.4 million in 2002. How can this be explained?

Why do only 5% of 12 year olds qualify for orthodontic treatment? The orthodontic report recommends that 33% should qualify and the existing 1985 guidelines estimate that 23% should be eligible. Why was a system that was operating so well ended? It was doing twice the work for a fraction of the cost.

Mr. David Maloney

The chief executive officer of the Western Health Board informs us that 3,000 patients commenced treatment in the area in 1994-96. During that time, 800 of those completed their treatment. In the intervening period the board experienced some staffing shortages resulting in reduced levels of activity and an increase in waiting time for assessment and treatment. Some 300 cases commenced between 1996 and 1997. The board has made some progress since 1991 in recruiting an orthodontic specialist. Furthermore, another two specialists commenced duty with the board on completion of their specialist training last year. The chief executive officer has advised us that the number of cases awaiting assessment or treatment was 1,633 as of 31 March. The corresponding figure in 1996 was 2,392, 3,642 in 1997 and 4,003 in 1998. Those are the figures we have received from the chief executive officer and they show some improvement, albeit that there were difficulties in the Western Health Board as a result of staffing shortages in that intervening period.

Deputy Cooper-Flynn

Does Mr. Maloney have a figure for the number that have been assessed and are on the list?

Mr. Maloney

Some 818 are awaiting assessment.

Deputy Cooper-Flynn

I was told the figure was 900. What is the waiting time for the Western Health Board? Mr. Maloney mentioned a three year period.

Chairman

We would like a written report on the waiting times in the various health boards.

Deputy Cooper-Flynn

I have been to health board meetings and we are told the waiting time is three years. However, when one calls, one is told the waiting time is four years. There are children waiting four years. Reports will only be worthwhile if we get accurate figures.

Chairman

At least we will get a figure on paper and we can then look at comparisons with the different health boards and see if the figures stack up.

Deputy Cowley

How can they say just 5% of the general population of 12 years olds qualify for orthodontic treatment, when the report itself recommends 33% and the 1985 guidelines estimate 23%? That is based on the number of children put on the assessment list last year as a percentage of the total number of 12 year olds in the three Western Health Board counties.

Mr. Gavin

Can we get back to the beginning? What was the Deputy's first point?

Deputy Cowley

Why do only 5% of the general population of 12 year olds qualify for orthodontic treatment?

Mr. Gavin

I will take that point first. The IOTN category, to which the Deputy referred, refers to 33%, as is mentioned in the report. We have readily acknowledged that we will not be in a position to reach that level of treatment until we have significantly more specialists in our health system.

Deputy Cowley

The point I make is that there are three types of specialists compared with 1996, when the figure was 5%, whereas the 1985 guidelines said it should have been at 23%.

Mr. Gavin

According to the 1985 guidelines, when one puts a random population through them, the figure comes out at about 23%. However, when one does a realistic treatment need study of that group, the figure comes down to about 15%. When one prioritises it further and looks at A and B cases, the highest priority cases, one is looking at 5% to 6%. From what the Deputy has said, it seems that what he is seeing reflected in his board is that, with the level of resources the consultant has available to him, he is able to do the category A and B cases.

We would hope that with the additional specialists who are in training, the number of specialists in the service will be increased and expanded out of the secondary care area. Hopefully the Western Health Board will be successful and the consultant therein will stay with the board and be supported by all those involved with it, including politicians.

Chairman

I must suspend the committee for 15 minutes as a vote has been called in the Dáil.

Sitting suspended at 10.55 a.m. and resumed at 11.20 a.m.

Mr. Mooney

Mr. Gavin dealt with most of Deputy Cooper-Flynn's questions on the Northern Ireland issue, the waiting lists and so on. On the relationship issue, I have already outlined in some detail our efforts and we hope that the coming on stream of the additional consultants, specialists and the professor in Cork will go some way towards dealing with that. The training programmes are now on a firm footing within the parameters set down by the training body so that the people coming out of these courses will be officially recognised as specialists in orthodontics, and their training and qualifications will be recognised within the context of the EU directives.

Deputy Cooper-Flynn

The recommendation about setting up an expert panel because there may be a dispute in the future is not just a reaction to what happened in the past; the Department does not agree with that recommendation.

Mr. Mooney

No. It was not a panel. The chief dental officer and I brought the problem to an eminent person in the medical field here, who is involved in training. He had agreed to act as a facilitator to bring the various interests together. I do not know in detail how he operated but he met the various people, including some from the SAC and from Belfast but eventually he admitted defeat. In his view it was impossible to reconcile the conflicting views within the context of the officially recognised training parameters that had to be applied. That was just before the committee issued its report. We had nowhere to go. What could we do, get somebody else? The word was out and I do not know that anybody else would have taken on the job.

We discussed the matter with the chief executive officers and they agreed to set up a review group to take on board the committee's report and to see how this could be implemented at local level. We felt that one way of doing that would be to involve all of the people from both sides in drawing up this report. The person attended the first meeting but did not attend subsequently. We sourced an international body that tries to deal with conflict situations but the problem we were dealing with was too small for it.

Deputy Cooper-Flynn

I hear what Mr. Mooney is saying and I do not want to belittle his efforts but the committee tried to help him to resolve the problem because we knew it was going on for years. We gave him a formula whereby the two disputing sides nominated their representatives and there was an independent chairman. The independent chairman would have listened to both sides and issued his findings and they would have been binding on both sides, so the basis of a resolution was there.

Mr. Mooney

That could not work because that group would come up, for example, with a proposal that training programmes should be different from the officially recognised training programmes.

Deputy Cooper-Flynn

The Department was afraid that the independent chairman might have come up with a finding by which it could not be bound.

Mr. Mooney

Presuming the chairman would be in the same situation as the person we brought in earlier, there are certain givens to consider. One could train people but they would not be trained to an officially recognised standard and that would probably expose the health service to serious problems if people who were not fully accredited and trained were working with patients. The Department of Health and Children is not a certifying body. There are training bodies out there. We can only employ people who are trained to the level approved by the accredited bodies.

Deputy Cooper-Flynn

I am not disputing anything the Department officials are saying but if the Department nominated its experts to convey that point of view and if that was convincing to an independent chairman, why was it not confident enough that the independent chairman might come down on its side? It seems the Department decided that it would be better not to set up the expert group in the first place because the independent chairman might produce a finding by which it could not be bound.

Mr. Mooney

The chairman could not come down on that, no more than he could come down and say the health service should employ doctors who are not approved by the Medical Council. There would be no choice there.

Deputy Cooper-Flynn

Then why did the Department do that?

Mr. Mooney

There was no choice there. We had a very eminent person involved and there was nobody around of any greater stature. Given the knowledge in the system of what had happened, I do not know that anybody would have taken it on. We had the proposal that we would bring them on board as part of the review at the health board level but there are certain givens here and the issue revolves around training. It spills over into the service delivery side as well but that is also linked to the training and particularly to the amount of time specialists have to spend on academic training, as opposed to working under the direction of the consultant. We spoke about the link between the on-the-job aspect of the training and the academic side earlier. If we want to have fully trained and accredited specialist orthodontists working in our service, that is how they must be trained. We have tried to resolve this on a number of occasions.

Chairman

Our problem is that this issue has been burning for years and will reach a crisis point. Somebody somewhere will have to sit down and resolve it one way or another because there are three independent republics operating within the orthodontic system in the health service, all of which are absolutely convinced of their positions and what they are trying to achieve.

The Department has certainly stood back from this for the past five years. Nobody is taking the issue by the scruff of the neck and acknowledging that there is perhaps some right here on the part of these three individuals. The committee gave a route out for them and the Department of Health and Children when we suggested a link programme with one of the UK universities. The university would be willing to meet all the criteria required in training. In the report, one of the recommendations was that we would look at that as an option in terms of training in the short-term, due to the manpower shortage. That does not appear to have been examined as a possibility. All members of the committee are receiving letters from the three consultant orthodontists on a weekly basis stating that nothing has changed. This is unsatisfactory.

Mr. Mooney

I would dispute the claim that nothing has changed. I have met not just the three people concerned but all of the consultant orthodontists, separately and collectively, on a number of occasions about this issue. We have moved forward in putting in place the training programmes, which is what the whole issue boiled down to - we have put the training programmes in place and we have people on them. We have made arrangements that the boards involved in the dispute will get students from these training courses and will not be in any way disadvantaged because of this ongoing controversy.

Deputy Fitzpatrick

Is Mr. Mooney telling us that if the health boards or the Department of Health and Children employ orthodontists who have not followed this accreditation process, and there is a failure in a treatment plan, we would then be left open to legal action?

Mr. Mooney

Yes.

Deputy Fitzpatrick

And we do not have a leg to stand on?

Mr. Mooney

That would be a distinct possibility.

Deputy Fitzpatrick

Does Mr. Mooney envisage any time in the short to medium future that the health boards will be able to employ sufficient orthodontists to deal with the backlog of people awaiting treatment?

Mr. Mooney

We have approved additional consultant posts but we have not been successful in filling those posts in that we have only recruited some consultants. We have now sought out training places in a number of areas and have been successful in that we now have 20 specialists in training. For example, I understand there are only three training places in Belfast and we have managed to get one. At least they have been good enough to give us one of them. We have also sought out places in Cardiff, Leeds and London. We have people training there and at Trinity College, Dublin.

At the moment we have the maximum number of people in training for whom we have been able to find places. I doubt that will be enough, but at least it is the most we can do at the moment. By comparison from where we set out, tremendous progress will have been made as these people come off training courses. From here, hopefully, we can build on this and get a better handle on what is required to meet all reasonable needs. We will never be able to meet demand in this area, but need and demand are two different things. Deputy Cooper-Flynn made that distinction earlier on.

Deputy Fitzpatrick

When these people are trained, is there anything to prevent them from not working in the public service?

Deputy F. O’Malley

My direct question on the fee per item was not addressed. On the training system issue, it is unsatisfactory that the service has worsened, the cost has risen and it appears there is an "interest" in keeping a closed shop. It is as if people regrouped to protect practices.

I will quote from a letter in which I was informed "health board services were becoming too efficient, thus posing a threat to their private practices or institutions." I cannot help believing that something happened in 1999 to change practices. There were people who were able to provide good service and a clear throughput, but for some reason a shadow and doubt was cast upon the training standard. One of those providing training trained somebody who went on to get a gold medal in the area. How can one cast aspersions on the training of somebody who produces such high qualifications?

The three people in question have demonstrated an ability to push through others in different training practices. I cannot accept that their training is substandard. I do not know if this is being inferred, but that is the message I got from some of the comments here. These people were providing a service that was delivering better value for public money. We should invite those three individuals to the committee to hear the other side of the story.

I accept that I was at the previous meeting, but it is our function to get better value for money and we must ensure this. Training is the critical issue here and these three individuals had no problem. They went on for five years training people, while they were practitioners. It seems we were getting a better service before and it should be returned to us.

Mr. Mooney

The way the Deputy makes the argument infers that this is a case of the Department versus these three individuals. That is not the case. It is not right to say we do not have a function as we do not have a direct statutory role in training or accreditation, but it does behove us to ensure that the people we employ in the health service are properly trained and accredited. That is down to the training bodies.

Once or twice I can recall in the media, that some doctors were found not to be properly accredited by the Medical Council. There was an enormous furore about it. I cannot say that an individual doctor is any less or more efficient than the others who had gone through the process. Nonetheless, these bodies are there for a particular reason, which is to promote high standards and protect the public.

I see little point in the Deputy's suggestion to bring the three individuals before the committee. It is them versus the training bodies; that is the issue. Part of the reason that the throughput dropped when the training programme had to be changed was that the training bodies required that these people spent more time on the academic rather than the service portion of their training. That is running through the whole training system at the moment. It is also part of the controversy relating to NCHDs in hospitals. In the medical area, people are also moving away from this arrangement. The Department of Health and Children and the health services face severe criticism for the amount of service delivery for which we depend on NCHDs. We have been asked to move away from that arrangement by the Medical Council. The parallels are not exact but they are there.

Deputy Cowley

It appears there is a pool of people with this expertise and a certain amount of training that is not up to what the Department expects. Can the Department play some role as an honest broker in all of this? A number of people badly need this service but are not getting it. In the Western Health Board area, some people must wait four years for treatment while others must wait a year to be assessed. That is terrible. Surely there is room for some common ground.

In a situation where a consultant is supervising trainee dentists, and a specialist then steps in, following from the consultant's initial assessment, there is surely some way in which the consultant could continue to supervise those people who are trained to a certain level. Discussions could be held with the accrediting bodies in order to come to some arrangement which would at least ensure there would be a chance of getting a service at a more reasonable cost. That is possible, because there are personnel there who would be in a position to deliver a greater throughput of numbers.

Mr. Mooney

There may well be. We have tried mightily over the years, but we have not been able to persuade the training bodies to accept an accreditation level which they would see as below the standard over which they are prepared to stand. Perhaps Deputy Cowley or the committee might be able to persuade them, but we have not been able to do so. We have managed to source and fill to the maximum the number of places available both in Ireland and the UK. Indeed, we have had to almost call in favours from people to make room for our students on these courses, because the number of places in these colleges is very limited, and the demand from the UK health services for orthodontists is almost as great as it is in Ireland. Even if we were to change all that tomorrow, there would not be one further place available, as far as we can ascertain. Even if we had twice as much money for training, there would be no other place to be obtained anywhere. We would love to get places if we could.

Mr. Gavin

Deputy Cowley has a point regarding the people with non-specialist training. Perhaps when we get the extra specialists on board we may have a resumption of supervision of dentists at primary care level doing a certain amount of orthodontics. I do not think it is a desirable situation at present, where we have work ongoing at secondary care level in the regional units. In order to have a comprehensive service, it needs to be further developed. If we were to get sufficient services or staff, for example in Castlebar or Ballina, one might have a specialist there doing a certain amount of work, but also supervising other primary care dentists. That can happen, but at the present time it is a bit difficult.

Deputy F. O’Malley

The fee per item question was not answered.

Mr. Mooney

I apologise to the Deputy. I was not too clear on the points she was making. Up until last year, the entire orthodontic service was, in effect, provided through the health board services. Following recommendations from this committee, and Government decisions regarding the involvement of the private sector and the public-private mix, we were allotted some money for orthodontics last year from the treatment purchase fund. That money was used to buy some level of service from the private sector.

Deputy F. O’Malley

That is not really what I was talking about. In the past, an orthodontist was retained on a wage but he or she is now paid on a fee per item basis resulting in a much greater cost to the State.

Mr. Mooney

All orthodontists in the health board service are on a salary.

Deputy F. O’Malley

They are paid an additional fee per item.

Mr. Mooney

Last year, we tried to get optimum use of the treatment purchase fund and used it for a number of purposes. One purpose was to buy services from private orthodontists. Another was to enable a health board orthodontist to do some work out of hours. It was a quasi-private-public thing, if you like, but it was work done outside of the orthodontist's normal hours. It was basically a once-off arrangement in response to both the recommendations of this committee and to the Government making available money through the treatment purchase fund.

Chairman

I thank Mr. Mooney and the officials for attending today and outlining the progress made. We acknowledge that significant progress has been made. There are many other issues out there to be tackled. The great news for us in Cork is that it would appear that the professor has indicated he will take up the post sometime towards the end of the summer. That will give us another training college which will be up and running and will ensure that we will have a sufficient number of orthodontists trained in time.

Deputy F. O’Malley

Before we finish, I would like to make one recommendation. The whole training issue is very precarious, as has been demonstrated by what has been said here. Training happens on a wing and a prayer. We need to get the accreditation boards before the committee.

Chairman

I cannot take motions at this stage of the meeting; the Deputy might table a motion to that effect for 12 June.

Deputy Cowley

I would second that motion, because I too feel we need to look further at the training issue.

The joint committee adjourned at 11.50 a.m.