I remind members of the long-standing parliamentary practice that they should not criticise or make charges against any person outside the House, or an official either by name or in such a way as to make him or her identifiable.
I welcome the witnesses and invite them to begin their presentation.
Thank you for having us back again. This is our second time here and we have been here on different occasions in the past. I have a short presentation on which there are two misspellings for which I apologise - I did not see them until last night.
My presentation is on behalf of the Mid-Western Health Board. The health board made a submission to this committee on 7 November 2001. It outlined the significant progress in building up the service in the mid-west, which, in 1985, was the first to be established. Thousands of children were treated over a 14 year period. The presentation includes the background and context to the current difficulties and a number of proposals to restore the service using the Moran report as its basis.
The specific proposals put forward included that appropriately qualified staff be appointed in the dental schools in Dublin and Cork; the implementation of a training programme which would take account of academic and practical requirements both during training and post registration; staff recruitment and incentives to retain staff in the public sector; meaningful representation from health board management on the Dental Council; and the reintroduction on an interim basis of the training scheme which has been in abeyance in 1999.
The report of the joint committee which followed was most welcome and provides a further basis for developing the service. It is imperative that the recommendations of the Moran report of 1996 and the report of the Joint Oireachtas Committee on Health and Children of 2002 are implemented fully in a planned and systematic way with the co-operation and involvement of all stakeholders.
The following proposals are now put forward to develop orthodontic services, based on the recommendations of the joint committee. The first is that a forum to resolve past difficulties as recommended should be put in place without any further delay. This forum should recognise that relationships were damaged and work to address grievances that have arisen during the past five years. It is imperative that there is an open and frank acknowledgement on this issue to enable the key personnel in organisations to engage in a positive and proactive manner.
In regard to the orthodontic service strategy, it is imperative that all stakeholders are fully consulted and involved in the preparation of a national service strategy and action plan. Regarding guidelines for prioritising service, the 1985 guidelines should be updated without further delay to ensure uniformity and assist clinical practice in a standardised national approach to service delivery. This matter also requires the involvement of all stakeholders.
The recent appointment of a chair to the dental school in Cork and the forthcoming appointment to the dental school in Dublin provides an opportunity to fully review the current training scheme, including current numbers and future capacity and to investigate standardised salary arrangements during training and the balance between clinical placement and academic practice during training. There should also be an agreement on the criteria for inspection of regional units.
A national recruitment campaign should commence with a view to increasing the staffing levels. The arrangements in regard to the recruitment of NCHDs might provide a basis for such a campaign. In regard to staff retention, while the recent recognition of special staff is welcome, it is imperative that contractual arrangements are put in place to ensure that those in training are obliged to work in the public sector for a period equivalent to the number of years sponsorship. Contractual arrangements should reflect this. Consideration should also be given to ensure that every incentive is provided to retain staff in the public sector.
The recommendations under the heading of delivery of orthodontic service should be implemented as a matter of urgency as they are critical to supporting service delivery arrangements and provide appropriate and relevant advice on national policy. Every consideration should be given to integrating the delivery of those recommendations with the new health care structures, including the Health Service Executive and the health information and quality authority.
The national orthodontic service is in crisis - a crisis created by the incompetence and dishonesty of the Department of Health and Children and the greed of the dental schools of Cork and Dublin.
In February 2002, this committee produced a report on orthodontic services in Ireland. I have gone through different recommendations and will not labour them by repeating them. If members skip to page four, I will summarise the recommendations.
The report should be welcomed. I am pleased that a professor of orthodontics has been appointed to Cork and question why there is no professor of orthodontics in the Dublin dental school. The school in Cork is to receive a grant of €4 million from the Department of Health and Children, yet it will not give a commitment to training people from the Southern Health Board on its training programmes. The professor has refused to accept patients from the board's waiting list for treatment.
The Department should be congratulated on it programme of training dentists to become orthodontists. However, one has to be realistic and realise that people on these training programmes are not dentists who have worked in the orthodontic services in this country but dentists who will revert to private practice following completion of their training programmes.
The anti-consultant approach of the Department of Health and Children is not conducive to attracting consultants to the public health service. It is disappointing that the Department continues to flaut recommendation 4 and to give some consultants a licence to lie to patients about eligibility for treatment in an effort to artificially reduce orthodontic waiting lists. The function of a public health service is to deliver treatment and care to eligible patients. It is not to deny treatment to eligible patients in an effort to hide the incompetence of a Department.
Never in the history of this country has so much money being squandered by one Department on orthodontics for so little benefit to patients. If the Minister continues to allow the Department to continue in the manner in which it has conducted itself, both prior to and subsequent to the report, I see little hope for the proper development of orthodontic services.
I welcome the delegates. It is difficult to know where to start addressing this issue. We had many quite emotive discussions prior to the report in 2002 and there were many personal differences between people at a high level in the Department.
There are thousands of children who could and should be treated if some sanity were brought to bear on the issue. It is very disappointing, two years after the publication of the report, that little movement has been made to sort out this difficulty. I have persistently asked the Minister to try to do something about it and he almost throws his hands in the air saying, "Will they not come together and agree something?" The proposal that an independent body try bring the people together to talk should be considered.
There are two systems, the first of which is the training system that was in place. Efforts have been made to impose the second system since 1999. However, the old system worked and children received the service they required. For some reason, there is a stand-off between the Department and those who want to provide the service that existed. If we reverted to the old system that obtained before 1999, how many more children would be treated and how many would come off the national waiting list?
People are now being treated through the treatment purchase scheme who would have been treated previously under what I call the old system of training. It is costing hundreds of thousands of euro extra to treat children who would otherwise be treated in an alternative way. Has any advance been made to try to come to an understanding and an acceptance on the part of the Department that the old system worked? It was evaluated externally and proven to treat children in a professional way. Now people are coming to us constantly saying they have no hope of treatment. We might as well tell those in group C that they will not be treated in this country. Under the old system, they would have been treated.
I thank the delegates for their presentations. There is certainly a lot of information to be absorbed. There is a complexity of issues, which is very unfortunate when one considers the size of waiting lists for orthodontic treatment. There is obviously a very strong message that there needs to be some unity of purpose across the service. The idea of having a service strategy seems to be of high priority. How realistic is it that there can be agreement across the various stakeholders?
A point was made in both presentations about the incentive to artificially reduce waiting lists. If the guidelines were updated, as referred to in the first presentation, would this prevent it from occurring? I know it happens in the provision of hospital care. Hospitals are sometimes rewarded for not caring for patients because it makes the figures look better, not because it is intentional so much but because the system of measure is not terribly effective.
Dr. McNamara mentioned contractual requirements on orthodontists to serve for specific periods in the public sector. If this is done, is it all we can do? Will it always be the case that the private sector will be so much more lucrative and attractive and that people will constantly leave the public sector? Is there another way of better integrating the two sectors?
We hope to have the Health Service Executive before the committee - we are obviously in the early days. How do the delegates feel the orthodontic and dental service will adjust to the changes that have been introduced by the Minister for Health and Children in terms of the management of the service?
I thank the delegates for their presentations. Looking at Dr. O'Dowling's presentation, I am absolutely flabbergasted that one consultant will tell patients they are eligible and another that they are not. If this is what obtains, very clear action must be taken. It is a scandal given that there are young people waiting for orthodontic treatment.
I am absolutely amazed to hear that a professor of orthodontics has been appointed to Cork with a grant of €4 million but has refused to accept patients from the board's waiting list for treatment. What about poor old Seán and Mary Taxpayer? What happened the great VFM everybody talks about? What service are the people getting for paying €4 million of their hard-earned money by way of a grant?
I am delighted Dr. O'Dowling acknowledged that the Department needs to be congratulated on the training of dentists to become orthodontists. This has happened in the Midland Health Board and has resulted in considerable benefits - as the Chairman will be aware as a former member of the board - to such an extent that the waiting list in four counties, certainly in three, has been all but eliminated. This is a success story, so it is not all bad news nationally.
I am absolutely gobsmacked by the problem to which I have referred and it is clear that something must be done about it. It is a scandal and a disgrace.
I am glad the delegation has had the opportunity to come before the committee again. This is an ongoing saga and while I was not a member of the previous committee which investigated orthodontic treatment, it is clearly a problem. We are aware of what is causing the problem but the difficulty is in getting the Department to make an adequate response.
The strongest sentence in both presentations is, "Never in the history of this country has so much money been squandered by one department on orthodontics for so little benefit to patients." We need to look again at that sentence. From previous presentations we were aware that the Mid Western Health Board had a very high level of achievement and was successfully dealing with the numbers on the waiting lists. As Senator Glynn stated, we want to provide a service of the highest standard while getting value for the money invested. It would appear that is not the case.
Having once had a good system, why can we not go back to it? That question is not being answered. I find the Department in dereliction of its duty in not responding adequately to it. The way lists are drawn up gives rise to anxiety. The patient is put in category A, B or C, and category C patients are ignored completely, giving a false number on the waiting list. Orthodontics is about the delivery of a service, not statistics. If the Department is interested in statistics only, I suggest that is a false notion of what the job should be.
In paragraph C, Dr. O'Dowling states:
We know the Minister for Health and Children is aware of this, [that patients in category C are not being treated] yet has introduced no sanction or censure on these Health Boards
That is damning. We need to reflect on it and what the Department is prepared to do about it.
Like Senator Glynn, I was quite surprised that the dental school in Cork will not give a commitment to training people from the Southern Health Board. How can it do that? We are getting a bad service and extremely bad value for money. Will it be clarified whether the service is working well in other health board areas? Is the problem confined to the Mid Western Health Board?
Deputy McManus may have a possible solution an asking to what extent the health service executive can offer light at the end of the tunnel. The problem is about relationships. I understood that at a point relationships had improved and progress was being made. It would appear now that is not the case. May we have an update on the position? Before Christmas it looked more hopeful and that a resolution would be reached.
As the duty of members of the committee is to focus on what is happening to public services and how treatment is being delivered, this is an absolute scandal and one of which I have been aware since I became a member of the committee. We need to resolve the issue. People are exasperated because a great deal of time was spent by a previous committee on this issue. When making recommendations we need as a committee to insist that the Department should make progress in this area.
I thank the panel for the presentation. This is a very difficult situation. Everything does not sit quite right and everybody, the members of the committee, the public and the profession, is concerned. There seems to be a void and the children who are waiting for treatment are the losers. I know I speak for everybody when I state that I have many inquiries about orthodontonics. In the Western Health Board area, after waiting for a long time, children who have been the subject of ridicule at school are called to the orthodontontic clinic. Having gone in droves to the unit in Galway, they are assessed and sent home again. They then seem to be off the list.
There is something not quite right about all this. I wonder what is driving it. Dr. O'Dowling states what he thinks is driving it but it would appear there are guidelines. Are the guidelines satisfactory or is the interpretation of the guidelines causing the problem? There are three categories, but is the devil in the interpretation of the guidelines? A great deal of time is spent measuring the overbite before a child is sent for an orthodontic assessment, then more time is spent reassessing them to get them off the list. If the overbite must be 10 mm, it seems ridiculous that a child with an overbite of the range 9.8 mm to 9.5 mm is sent home when the difference is only a fraction of a millimetre. How arbitrary can one get? What is the rationale behind assessing children, then reassessing them to try to get them off the list again? The child has to go back to school, having waited so long in the expectation of having treatment. The parents are then driven to seek treatment in private practice. Millions are spent on this service, yet the people on the ground are not getting a service.
My understanding is that a child is first assessed by the dentist in his dental service area, that a card is filled out and if the dentist thinks it necessary he or she sends a recommendation that the child be assessed by the orthodontic service. This child is then assessed, but I now understand that children already assessed have to be reassessed. Usually the health boards have a so-called validation system, where they send out a letter every year asking if people on the list are still alive, but in this case it is a young population, so it seems that they are now changing the ground rules and are now looking for X-rays and clinical records. It is obvious to a blind man that all that is needed is a letter from a professional stating that the child needs to be assessed. What is happening does not make sense. Let it be clarified.
Will the panel respond to that bank of questions?
I will start with the first question from Deputy Neville who asked how many patients would we have treated by now. We remain very optimistic that the orthodontic service can be brought back to normal. Dr. Ian O'Dowling has carried the entire Southern Health Board orthodontic service for the past 13 years. He works tremendously hard and has developed services in Kerry as well as in Cork, setting up satellite clinics there. He treats about 80 patients daily as well as supervising his staff. We have all done thousands of sessions; I personally have delivered over 24,000 patient assessments. Dr. T. G. McNamara has provided treatment for thousands of children, he has trained most of the consultant orthodontists in the country and has trained specialists and dentists in private practice and in community service.
As stated in my first submission, I started out in Galway and then returned to the east and that is where I met Dr. Antonia Hewson. When I was in Galway I had over 3,000 children getting fixed appliance treatment and it was an extremely happy time with wonderful staff. Most of the staff I have ever worked with have stayed with me. One of them actually came with me to Dublin afterwards.
I want to explain our position. Dr. Hewson is as committed as we are. Our reasons for being here is that we know we can treat thousands of children, we care about public patients and we know we can provide value for money. When I came back to Dublin Dr. Hewson helped us keep the system going. It was a very happy time with tremendous unity among the regional consultants. While I was starting up in Dublin they helped in the west until my successor arrived.
I set up a lot of satellite clinics in Dublin, as I had done in the west and as Dr. T. G. McNamara and Dr. Ian O' Dowling had done in Athy, Kildare, Wicklow town and elsewhere. As the trainees got experience they were able to provide treatment in the clinics and they also involved the community dentists who wanted to do a small amount. The whole operation worked really well. I would say conservatively that we saved the State at least €50 million in our working careers if the committee checked our track records. Dr. T. G. McNamara was the first in the mid-1980s, services improved year on year and waiting lists diminished in an honest way. People were getting treated, not being artificially eliminated.
We had a very happy relationship with the Department of Health and Children until 1999 and this famous SAC inspection. In fairness to the Department, there are problems within the Royal College and within the dental profession that probably overwhelmed it. There was not an understanding of SACs within the Department. All we needed in 1999 was a fair inspection and we could have continued.
In answer to Deputy Neville's question, if we had succeeded in 1999 not only would we have completed 9,000 treatments to children, but the three of us would have been capable of carrying out another 18,000 treatments by today. That level of service has been lost.
We did everything in our powers to stop that irregular inspection from going through. Once it went through we could not go with the Department on it because it meant abandoning our patients and it meant that our services would be destroyed and our children damaged. We could not stop it, as there are only three of us, and we could not prevent the damage that occurred. That is where we are coming from. Children need never have been damaged in the first place and our services could be so much stronger now.
The Department of Health and Children realised as long ago as 1985 that one could not provide treatment for everybody and that is when they introduced the guidelines. There are three categories: A, B and C. I apply those in order that patients who are in each category get treatment through the Southern Health Board. It is quite clear that there are other health boards where they do not provide treatment for patients in category C. That is completely contrary to the recommendations of this committee in 2002 and also to what the Department set out to do in 1985. They selected certain conditions which they felt needed treatment and care and which therefore should be provided through the public health orthodontic service. Simply for fiddling the figures, cooking the books, whatever phrase you may wish to use, the decision has been made in certain health boards that category C patients are not to be offered treatment. It is very frustrating for me because I offer treatment to a greater number of patients as the Southern Health Board is the second largest health board in the country and I have longer waiting lists than others. I therefore get abuse from the Department and I am accused of having long waiting lists and creating further problems for patients by putting them on those lists.
I have another problem as I am the only orthodontist in the SHB. I have dentists with me who work very hard treating patients to a high standard but they are unable to become orthodontists. They cannot train to work as orthodontists in this country.
When the SAC came to visit my department in Saint Finbarr's hospital in 1999 to inquire if it could be used for training dentists in the public service to become orthodontists, I was refused that recognition and I was directed that my staff had to go to the dental school in Cork to receive that training. Both the visitors and I knew that the school in Cork was not recognised for training. I describe it as wanting to see the latest Harry Potter film and being told to go the local cinema, but the local cinema is not showing it and being told to stay there as it is the only place allowed to show it. That is the stupidity of what happened in 1999 where decisions were made to bolster the dental schools in Dublin and Cork and the Department just ignored the fact that we had patients who needed treatment and we had dentists who wanted to be trained and qualified as orthodontists. That was completely irrelevant. All that was relevant was that the status quo should remain.
The fifth page of my statement outlines the last three years of the SHB service, bearing in mind that I am the consultant and there are eight dentists none of whom is trained in orthodontics. It contains the number of new patients, the treatments completed and the total number of appointments that are seen. We are trying to run a service and we are getting abuse because our waiting lists are long as I will not refuse treatment to patients who are legally entitled to it.
The funding we receive has not altered in the past three years. The funding for the orthodontic service in the SHB, the second largest health board in the country, is €1.5 million. The funding for the Western Health Board is €2.4 million. Because we are sticking to the guidelines and refusing to deny treatment to patients we are being penalised financially. It is frustrating. We are trying to run a service, trying to treat patients, and its becoming increasingly difficult because the problem is literally within the Department of Health and Children.
There are three sets of criteria. There is an index called the index of treatment need. All orthodontists are in agreement that this IOTN would be an acceptable index, but the problem is the Department does not see it that way and therefore it has not been introduced. If it were introduced then the problems with category C patients could not occur. There is an option but the Department is unwilling to take that option because it knows it means the number of patients on waiting lists will increase, despite all the funding that is being invested.
Would Dr. O'Dowling explain the meaning of IOTN?
It is indicative orthodontic treatment need.
The word which upsets me, although I know that was not intended, is "complex", because this matter is not at all complex. We had a good service. Similar to other members of the delegation, I spent ten years in postgraduate training at the top British hospital, the Eastman Dental Hospital, of which I am very proud. I have no problem telling the committee that, as I am the only Irish person who ever got that post in England. During the time of the Troubles, it was difficult for an Irish person in England to get such a post.
I returned to Ireland where I tried to introduce the same high standards I had been used to at that hospital, and I succeeded. Suddenly, in 1999, everything stopped and we were told there was an old system and a new system. However, that was not the case. In 1999 we carried out our normal procedures and applied for an inspection, as we had for years - I had been involved in the system for close on 20 years - but that inspection was hijacked. In any other country where inspections took place, the department responsible for health would have stated that the inspection should be stopped in order to have a proper one. That did not happen and since then we have been in this mess.
If there had been a proper inspection, as in all the regional units throughout the United Kingdom such as at Carlisle, Basingstoke or elsewhere, we would not be attending this committee but would be treating patients and working properly. Those involved came over and were met by our colleagues from the private sector and, I would have to admit, the dental schools. The committee will remember that the last time a presentation was made to it on behalf of the private orthodontists, it was by somebody from the Dublin dental school. The schools and the private orthodontists work together.
There have been very few people working in the regions over the years, just three of us, but I believe we were doing the right thing. We were properly qualified, providing good services and following the correct criteria for inspections but were blown away by those who were not orthodontists. Most of these treated no public patients whatsoever and were in private practice. However, as there were only three or four of us, we had no hope.
Why is it that some consultants will tell patients they are eligible and others will tell them they are not? Why is it that the Cork school of orthodontics will not accept patients for treatment? Perhaps I am asking the wrong people.
To be fair to the professor in Cork, he was only appointed some four months ago. I am based in Limerick, fairly close to him, but we have not had an opportunity to discuss this issue although I phoned him at Christmas to welcome him to the job. However, I am not willing to condemn the new man. He is a good person whom I have known for years. I do not know why, on that line——
I would like to know why, as I am sure would my colleagues.
I would like to give him a chance.
If €4 million is being spent, those concerned should be brought before this committee to answer our questions.
I was a member of the committee which drew up the last report in this regard. The greatest scandal to emerge this morning is that 18,000 extra children could have been treated if the existing scheme had been in place before vested interests won the day. At my clinic on Monday last, I met a 51 year old widow who has five children, one of whom was assessed and told she was to have orthodontic treatment. All of a sudden, there was a change in the regulations and, after being brought to Galway, the child was told she did not qualify under the new guidelines and sent home. The widow also told me that the new regulations mean that a child must undergo X-rays and moulds, and that the whole manner of treating children has changed.
This woman had to bring her child to the private sector despite being on widow's pension. She could not take an appointment this week because it would cost €50 and it would cost €2,000 to have her child treated. She is currently paying €50 per month to the private sector to have her child treated and is also paying for her husband's funeral out of her widow's pension.
Is this the kind of society we now have? A child needs treatment and is entitled to have it covered by the State, and would have got the treatment if the old scheme had been in place. The situation in regard to this service is outrageous. The Minister can no longer sit back and take the side of the vested interests. We must return to the old system, with which I was quite happy, in which children and others were referred and treated. They were very satisfied with the service and treatment they received from the members of the delegation attending the committee today.
However, vested interests came in and the private sector is now the real winner. Many parents must borrow money for treatment, as Deputy Cowley said, and I could easily bring 100 such people with their children to show them to the committee, the Minister for Health and Children and the country. While I am not an orthodontist or dentist, I know when a child needs treatment and I have experience of this from having children's mouths shown to me at my clinics. Children are often brought to Galway from north Mayo, 75 miles away, and five or six parents together with their children travelled there last week. However, they were then told that they did not qualify under the new guidelines and that their children were not in need. Such parents are upset that they must raise money and go to the private sector. The private sector is winning the battle, which is wrong.
A service was in place in the west and I compliment those involved in it, including those present at the committee today. Although they were committed to the public sector service, did not have private practices and worked hard for the health board and the State, they never got the recognition they deserved. The private sector won the battle. The Minister should come to the committee to hear that we want him to take action in this regard. Some 18,000 children who could have been treated were not.
Is it possible for the consultant orthodontists to work with the new guidelines? I was told recently in regard to the new referrals system that it was necessary to include X-rays and moulds, which will hold up the entire system. Children will have their teeth X-rayed when there is no need. The situation is outrageous and the Minister must take control, take a political decision and put children's interests ahead of those of private consultants, who seem to control the actions of the Department of Health and Children.
I am appalled at the situation and that parents are forced to tell me their children are in need of treatment and suffering at school. In a recent case, a child could not even pronounce words at school and was being laughed at by other children. That child was told by the Western Health Board that he did not qualify for orthodontic treatment. I knew he qualified when the parent of that child went to the private sector and was told that the child need immediate orthodontic treatment which could not wait. We cannot hold back such children who need treatment. It is wrong that they are not being treated and something must be done.
I compliment those who provided the service in the public sector in recent years, such as Dr. McNamara who worked in my area. While they did an excellent job, they have been told by the Minister and the health boards that they were not carrying out their duties in the right way. That is wrong. The orthodontists were doing well and people were quite satisfied with the service. They treated thousands of children who would not have been treated under the guidelines currently in place.
I want to return to the old system until enough orthodontists are trained to enable change to happen. Vested interests are winning out and it is wrong that parents and children should suffer because of that. I hope the committee and the Minister make a proper decision promptly to get rid of the vested interests which control the health service.
I welcome the delegation and thank its members for the tremendous work carried out in the health services over the years. In regard to the mid-west region, I know that Dr. McNamara has provided a fine service and trained personnel who have won top prizes throughout the country.
I fully support the questions that are being asked in the submission and the summary. These questions need to be asked. At a time when we are hearing of public private partnerships and value for money, the door should have been opened in the 1980s and the 1990s, but instead obstacles were put in the way of the provision of this service to ordinary people waiting for it in the regions.
I thank them for the service provided for all these years. I hope common sense will prevail. The past is the past, but we can work together to find solutions to the provision of this service. A figure of €18 million has been mentioned for the purchase of schemes. However, tremendous value for money has been given by these people. If this were to be reproduced in the future we would have quite a service in our region.
I welcome the delegation. I am shocked to find that health boards which remove patients from category C will gain financially from the Department of Health and Children. I do not want to labour the point as a lot of issues have been covered. In my county we have children with special needs and we have not a senior orthodontist. For some reason, senior orthodontists do not even want to come to Roscommon. Each county seems to guard its patch very jealously.
In the year of special needs there are parents of such children who must bring their child to Dublin or perhaps the hour and a half journey to Galway and must pull in at the side of the road if something goes wrong. This is unacceptable. The parents are frustrated about this. I have asked questions in the Seanad, to which I have received no satisfactory answer. I have applied to the North Western Health Board to have the service located 20 miles down the road in Sligo. If the reply is satisfactory I will hear within a week. If the reply is not satisfactory I will be told it is being dealt with or the letter has been lost. What must I do as a public representative? What must the parents and the children do? This is one area which has not been mentioned. It is a disgrace which I, as a public representative, am unable to remedy. Can the witness tell me what I or the parents of the children can do about this?
I welcome the group here this morning. It is nice to put faces to the correspondents.
This is all very alarming. I am shaking my head and wondering if this is all really happening. We have had an excellent presentation from the witness, with whom we are very familiar as we have been discussing this for the last few months. However, prior to talking to him we took evidence from the Department of Health and Children, who painted a rosier scenario than we are hearing today. We went through all the different categories with them. They talked about the waiting list of which they were very proud. Then the witnesses' communication reached us. I remember receiving from Dr. McNamara the most horrifying and graphic pictures of children's mouths. This is probably not the right terminology, but they were so badly deformed I had to put the pictures away. It was very unpleasant to look at them. I wondered how this could be happening when the Department was giving us one version of events with the witness now giving us another.
Dr. O'Dowling is the only orthodontist in the Southern Health Board, yet the Department did not give him an accreditation to act as a trainer. They have a trainer or trainers in the dental schools who are not adequately qualified to be trainers. Did I understand that correctly?
What role does the Dental Council play in all this? Is part of its remit to inspect the dental schools? Where does the witness fit in with the Dental Council? Is it the regulatory body and what is its opinion on the way the witness is being treated by the Department?
According to Dr. O'Dowling's paper, we are spending €500,000 every year in the training of dentists in different centres in the UK, none of whom, he feels, will return to work in the public service. It seems ridiculous to pluck people out of private practice to send them on very expensive training courses in the UK, from which they come back to feather their own nests instead of going into health board practice which would allow the taxpayers to derive some benefit.
As other speakers have said, the losers and victims in this are the children of the State, which is the most horrifying part of it. We are all familiar with physical and sexual abuse of children, but this is also a type of abuse, if what we hear from the witness is really going on. I have no reason to doubt what he is saying.
How do we break this logjam and move it on? Has the witnesses' relationship with the Department completely broken down or can we salvage something from this and move on?
The witness has mentioned categories A, B and C, and said that in most other health board areas C category patients are not treated. Is that an official decision in those health boards? We are all horrified by what has happened.
We have spent some time on this but we would be derelict in our duty if we did not attempt to question the Department of Health and Children about this. We need to make a recommendation of the committee that the Minister for Health and Children appear before us to answer the charges that have been brought. For 18,000 children to lose the right to treatment is outrageous. As a committee, we could not claim to have carried out proper scrutiny if we did not ask the Minister to appear and did not try to obtain redress in this issue. As the witness states, there is a relatively simple remedy to this. I propose that the committee ask the Minister to appear before us.
I thank the Chairman for allowing me the opportunity to speak at this committee as I am not a member. I welcome Dr. McNamara and his colleagues. I have been familiar with this matter for a long time as I am a Deputy from the mid-west region. I share the concerns of my colleagues.
What are the qualifications of the inspectors from the Department and who are they? I would also be grateful for a brief breakdown of the situation in the mid-western health board area currently. What was the situation prior to 1999 and what is it now?
Like Deputy O'Malley, I too feel that we should have another discussion here. I second her proposal to invite the Minister to attend.
Would the group please develop their recommendation as it is an important one? A forum to resolve past difficulties, as recommended, should be put in place without any further delay. We should reiterate that proposal as a priority of this committee and press that the forum be immediately established. Would the group flesh it out, please? I will obviously not ask for names, but what type of person would be acceptable to both parties in this? I almost said "sides" involved in this, as there are three sides involved, the most important of which, the children, are not here. We should strongly state that this forum should be established. We as a committee should, in future meetings, ask for a progress report on the setting up of that forum, and also for a response from the Minister to Deputy O'Malley's proposal, which I second.
I agree that the Minister, or somebody from the Department, should come in and explain matters to us. This committee has spent more time on orthodontics than any other subject since I joined it.
We are the meat in the sandwich and are the victims of orthodontic politics. This is the forum where heads should be banged together and people made to provide a good service. Our remit, as a Health and Children committee, is to see that services are delivered.
I wish to address two points to Dr. O'Dowling whose presentation impressed me. There is an old saying in politics to the effect that honey is better than vinegar. The opening paragraph of the witness's statement would get up anybody's back, even that of a disinterested person. A little revision would be suggested there. The witness also made the point that a professor has been appointed to the Southern Health Board, or to the Cork dental hospital. Does that professor of orthodontics not have a service remit to the Southern Health Board which is purely teaching and research?
It is an academic appointment to NUI Cork and that is all. It is frustrating. I have seen various politicians state that Cork will get a new €4 million state of the art orthodontic unit and this will sort out all of the problems. It will not sort out the problems. The unit is going into a university - it is like putting it into Trinity College - and it is not going to treat patients.
I am still working away with €1.5 million a year trying to run a service for the whole of the Southern Health Board and that is frustrating. Money is going to areas which are not delivering on service.
We want to work with people. Historically, there were no regional consultants, therefore we are not on any committees. The committees exist all around us in Cork, Dublin and Belfast. In 1985, I was the first and the oldest consultant appointed in the country and Dr. O'Dowling came a few years later.
We have never been accepted into the dental profession. We are a nuisance and we interfere with the committees, which tend to be controlled largely by people in private practice in Dublin. They are not orthodontists but dentists in general practice. In order to get on the committees in Dublin, one almost has to be invited to join and there have to be enough of them to vote for someone to get them in - it is a bit like a golf club. If there are not enough people around, one can be co-opted, one can bring one's friends on to the committee. It seems to us that we are very excluded from things. Some of our colleagues go along with that and it is tempting for them.
I am not sure whether it is appropriate to mention this but the Department of Health and Children has made no secret of the fact that it has organised a fairly strong bullying campaign against us. I need to be careful given what the Chairman said earlier on, but if the Chairman could help us——
We need to be aware of that.
We would appreciate it if the Chairman could help us. We are paralysed in our lives. I have been in bad health and people attribute that to the stresses imposed upon us by what has happened. It is political bullying. If somebody could organise that to be taken off us——
If I go down that road, it might cause problems. Perhaps the advice of Deputy Fitzpatrick, to use a little honey at this point, could be taken.
The first recommendation of the delegation is on the issue of the group to the forum that the delegation suggest. Could the witnesses develop that a little and how they feel about it?
There needs to be a discussion. We must get back talking together. That gives us an opportunity to speak. I am not totally familiar with the new structures. Some people are on an interim board of the new health executive. That could be helpful as an overseer.
There are many people on the Dental Council and when it makes a decision, we all go crazy with the vinegar. Many on the Dental Council support us, we get on well with them and we play golf with them. This applies to some of the other committees as well.
I spoke this morning to the president of the Dental Council, Mr. Gary Heavey, who is someone I respect. He has been a member of all of the committees that I have attacked but I respect him fully. He might be able to help.
Please try to be careful about naming people, as I said earlier.
How many are in the group of witnesses? Is it just the four of you, or are there others?
The problem started before the other consultants were appointed. They all received lots of honey. Things were offered to the other people.
How many orthodontic surgeons are in the country?
About ten.
Are there six others out there who work with the Department of Health and Children?
Yes.
Chairman, this is a democracy, not a dictatorship. These people have a right to express a view and if it is the truth, they are entitled to do so. I agree with Dr. McNamara. He says that the health board is reacting because the witnesses come in to the committee and state what they believe are the facts and are doing what is right.
The chief executives from all the health boards have been here. If some of those people were working for me, they would not be long employed. They should not be intimidated, but should be protected.
We are trying to go the right road on this.
At the same time——
The Deputy should not say that. That is not the issue.
They have to be protected too.
We are doing all we can.
They have a right to express a view.
There is no point in making headline statements without leaving the room. Just give us a chance to conduct——
No, no. They are the facts.
That is how we do our business here and we do it without grabbing headlines.
Chairman, that is a fact. They have a right to say what they have to say.
We are dealing with the accusation of bullying. We are trying to take on the advice of Deputies Fiona O'Malley and Fitzpatrick.
This country is turning into a dictatorship. People have a right to say what they want to say.
We were very pleased and privileged to be brought here the last day. It was the first time since 1999 that anybody had spoken to us. There is tremendous hurt within this group because we have given our heart and soul to public patients.
Deputy Ring will know that we were not the only group to be victimised. Our trainees, who had worked extremely hard for us, were blocked. Dr. O'Dowling has talked about his staff. I had very fine staff in Galway. A woman who had worked, day in and day out, treating hundreds of patients, was forced to go to the UK to give treatment. Another person I had in Dublin was forced to go the UK. The committee's recommendations stated that they were to have been given priority. We do not have a system of service delivery. We talk about new and old but there is nothing at the moment.
We are baffled that the Department of Health and Children has ignored the committee's recommendations. What became obvious to us in 1999 was that we needed somebody who understood postgraduate training and service delivery. We did not have that. The implementation of the committee's recommendation number 29 would have been the beginning of turning things around. There was another recommendation on page 21, section 3.7, of the recommendations - the appointment of somebody with appropriate post-graduate training and education - which, if implemented, could also have given us a chance to turn things around.
We are in a dilemma. We should not be here today. Ideally, we would like to talk to the Department of Health and Children, but the Department says that waiting lists are not massaged, that we are getting value for money and that children are not damaged. Everything is denied. A mistake was made in the Department in 1999. I do not think it was intentional, people were doing their best, but we cannot seem to get over it.
We have a proposal from Deputy Fiona O'Malley, seconded by Deputy Fitzpatrick and agreed by all members.
It is easy to say that Dr. Ian O'Dowling is vinegar or the term used today. He, like all of us, has been very isolated and I will give an example of the off the wall behaviour of officials in the Department of Health and Children. Dr. Ian O'Dowling's budget is curtailed but when the treatment purchase fund was brought in, a very fine colleague was offered €1.8 million to treat a fraction of the number of patients that Dr. O'Dowling is treating. Moreover, as money had to be spent before Christmas this colleague was given €800,000 to treat 240 children. With the same amount of money Dr. O'Dowling could have treated 3,000 children. Things are not right.
We will invite the Minister for Health and Children to come before the committee to put those exact points to him.
I add my support to the suggestion to bring the Minister before the committee and trying to find a middle ground. We are all agreed that the panel are most sincere in what they say and do not have a vested in that they are not in private practice. They are a very valuable resource and are acting as advocates regarding a system that in their experience is not equitable or correct. They say that 18,000 children could have been treated. We know that is true because their parents tell us of the injustice that is meted out to them as a result of not getting treatment.
Clearly there has to be bridge building and I think we have to find the middle ground. The hatchet should be buried. We have to get both sides to put their heads together. The panel are a valuable resource and are willing to give. I hope the Minister will make it very clear to the committee where he stands on this issue.
When I used the words "vinegar and honey" I was not being pejorative or personal. I accept the bona fides of the panel and I have the height of respect for them. What struck me was that neither Dr. McNamara nor Dr. O'Dowling had seven dentists in training.
I have seven dentists, but they are not in training. They are treating patients.
When these people have spent so many years in assisting Dr. O'Dowling, a consultant orthodontist, they have learnt a great deal and there is no reason that they should not set up as orthodontists themselves.
They would be prohibited from setting up as orthodontists. To be recognised as an orthodontist, one has to have certain qualifications. Because they cannot be trained they cannot get access to sit the examination. While they may be very competent at orthodontics, they are not eligible to sit the existing examination. Therefore they cannot get on the specialist register and be recognised as orthodontists.
A point was made by Deputy Fitzpatrick the big problem was that the dental school in Cork which lost its recognition for training in 1996. In an effort to try to protect that dental school, two consultants from the school in Cork and two consultants from the school in Dublin entered into an arrangement in 1998 that people from Cork would not be accepted on to training programmes in Dublin and that has remained to this day. Nobody from Cork and nobody from my unit can be trained in orthodontics in this country.
As I was a practising dentist myself for many years, I know something of the background. I take what Dr. O'Dowling is saying. However, there is nothing stopping these people who worked with Dr. O'Dowling for years going out to general dental practice and developing an orthodontic practice. When I started it was extractions and dentures. There was only one orthodontist in Dublin when I was training. When I finished, it was different, due to fluoridation mainly, and there a great many orthodontists now.
I agree with Deputy Ring that Dr. O'Dowling was taking on the vested interests. There is serious money involved. It was diluting the pool of people who can deliver an orthodontic service. Would the panel agree with that?
Why was the decision made not to take on people from Cork on the training programme?
Basically to protect the dental school in Cork. That is why they are getting €4 million from the Department of Health and Children.
The very people who turned down the application for the recognition of the unit in St. Finbarr's for training purposes are now in the process of giving it to schools in Qatar, United Arab Emirates and Khartoum. If I had a sunny climate down in Cork, I would be grand but unfortunately it is not the case.
In relation to people who are trained by the State, the State pays for their training, yet they have no commitment to entering the public sector and may go into the private sector.
Is the Deputy referring to people in training at present?
Yes.
They are meant to spend some time with the various health boards. However, what has been found in the past is that they have been able to buy out those contracts. In the Western Health Board area, they had somebody training in Liverpool and when he came back he did not want to work with the Western Health Board and went into private practice and he returned the money it gave him.
I will give the Deputy an idea how simple that can be. If a person decided to open up an orthodontic practice and not work with the health board that funded him for three years at €50,000 per annum, a total of €150,0000, he would only need to treat 50 patients under the treatment purchase scheme free of charge for the health board to have bought out his responsibility to that health board.
I first asked that question and the reason is that I had tabled the very same question to the Department five months ago. I hear what Dr. O'Dowling is saying. Would that be a rare rather than a normal occurrence?
That is normal.
It is alarming if that is normal.
The people selected on the training programme in Leeds, Cardiff and London were Irish people who would be training in Leeds, Cardiff and London anyway. They were subsequently approached and funding was provided for them. They had not been interviewed and selected for training. What we wanted was that the people working in the health board service, the eight people working with me in the Southern Health Board, would get an opportunity to train as orthodontists. That has not happened and that is the problem.
Clearly, the Minister has a major case to answer. Public funds are being used in this way and that is directly responsible for the mess we are in. I thank Dr. O'Dowling for bringing that to our notice because it is a very important fact as to how the State is investing major money in training. If this were to happen in business, it would not last a day. This is unprofessional and unbusinesslike and the Minister has to say why he is standing over it.
Is it funded or part funded by the Department?
They get €50,000 a year.
How much is that?
They would have to pay fees, accommodation and so on.
Would they be matching that funding or would that funding completely cover them?
Roughly they save €300,000 in going through the training programme by having the Department pay for it. What is happening locally is that immediately after completing the training they are setting up in private practice and are taking more treatment fees. For another 100 patients, that is €300,000.
If they are getting €50,000 from the Department, does that cover the entire cost of orthodontic training in the UK?
It does.
Do they have to put their hands in their own pockets?
Not at all. It costs €50,000 per annum for the three years of the training programme.
Under the pre-1999 system initiated by Dr T. G. McNamara, the trainees worked for the health board. They had significant case loads and it took them five years to receive that training. The health boards had a service, they could not lose out. Now, as was just stated, they may or may not decide to give any service back.
Senator Feeney mentioned the reduction in waiting lists. This is an interesting issue related to validation, which Deputy Cowley raised. Part of the reduction in those waiting lists in my own health board, the Western Health Board, is as a result of validation. I would like the Department of Health and Children to address that because I believe validation has occurred in other health boards and I would like to know the protocol for it. In the Western Health Board over 1,000 children have been removed from the treatment list since the year 2000. The significance is that these children had already been assessed and been put on the treatment list but they have since been removed as a result of validation. The Minister might like to address that.
We were here in November 2001 and all the health boards made a submission. I have a lot of friends in management in the midlands as it is very close to the mid-west. The Midland Health Board in those days had the best service. The funny thing was that it took 33 years to recruit a consultant orthodontist; it was the second last health board in the country to do so. That consultant had only been appointed two or three months before this submission was made. Therefore, the Midlands Health Board took years to set its service and when its representatives appeared here, everyone was congratulating it on having the best service. It made me feel inadequate that a service with no consultant could be so much better than mine. This shows that there are effective ways of reducing waiting lists without treating anybody.
There is one more thing we want to talk about but I am not sure if it is appropriate. There are many children out there that have been damaged and it seems there has been an effort to hide that. Is there any way they could be called in and the damage rectified? We have hundreds of photographs.
I am not clear in my mind how the deal between the professors in the Cork dental hospital and the Dublin dental hospital protected the Cork dental hospital. How is that the case? And are full-time orthodontists in the public health service precluded in their contract from private practice?
We feel that the Dental Council is probably the meeting point. At the time Cork had one consultant orthodontist; for a number of years it had no consultant orthodontist. Eventually one junior consultant was appointed and he was someone that I had trained in Limerick. The Dental Council has a lot of influence from the two dental schools. The schools were upset, they used the word "compete". When Dr. Triona McNamara reduced the waiting list in Dublin from 18,000 to 6,000 in two years that upset the dental hospital in Dublin as we see it. Of course we might be totally wrong ourselves.
The Dental Council brought in this new regulation where we would have to use Dublin or Cork. There was one academic day a week and in the past one could be sent to Glasgow or Belfast for four days a month. That was stamped out so we had to use the Dublin or Cork dental schools. We would have had to go to Dublin or Cork ourselves to give the lectures so it was making our lives more difficult, but it was the only way to get approval. The Dental Council claim it has nothing to do with it.
We would have preferred to use places like Bristol that were properly staffed and units that were not trying to stop us treating patients. We felt the dental schools were trying to stop us treating patients as they were competing for the same funds. The registrar of the Dental Council officially said the dental hospital has nothing to do with it. We have been told that several people on the Dental Council lobbied the inspectors to put this forward and since then a very senior member of the Dental Council at that time told me that the Dental Council was wrong for doing what it did. If that is acknowledged maybe we can all get back talking to one another.
That is the most important thing.
What was the situation in the Mid-Western Health Board in 1999 and what is the current situation?
Before 1999 we trained people. Some seem to think of training as sticking an orthodontist in here and getting hundreds of patients treated. It tends not to work like that because some orthodontists will complete 50 patients a year and others will complete 250 patients, depending on where they have trained.
The training is important but it became particularly useful for me in a health board situation because it would generate a very strong work ethic. We used education to bring that about, for example we had tutorials which generated enthusiasm. Removing that from us diminished the situation. We have two qualified orthodontists in the Mid-Western Health Board, one of whom got a gold medal, a feat which has never occurred before in Ireland as we were competing with all the British schools.
The treatment purchase fund which covered the Deputy's home town of Nenagh was an amazing story. We had an excellent orthodontist working one day a week in Nenagh who would have been earning around €18,000 per annum for this work, treating roughly 100 patients. The treatment purchase fund was brought into the Mid-Western Health Board and we had €350,000 to €400,000 to spend. The private orthodontists mostly did not want it but the chap in Nenagh took patients from us and he would have got multiples of €18,000 per annum for treating the same number of patients in his practice. We were then left with the patients in Nenagh whom I had to send to my existing staff, some of whom were treating 500 patients each. They are not stupid people. They realised they could make €1.5 million treating 500 patients under the treatment purchase fund, yet they only receive €18,000 for one day a week. This is very demoralising and has stopped the work ethic. I am afraid to ask them to work harder. Anybody who works on the health board is made to look stupid, everyone of us.
We have heard all the presentations and the members responses as well. Obviously people and members feel annoyed to say the least and the proposal of Deputy Fiona O'Malley is to invite the Minister here. Before I do that I want the agreement of the committee that we should send a copy of the presentations and the transcript to the Minister, give him time to read up on what happened this morning and then invite the Minister to meet the committee.
And to indicate that we want very specific responses to what we have heard today.
We might come together before the next meeting and put together our questions to the Minister in advance of that. We will arrange to meet 30 minutes before the next meeting.
Will the Minister attend that meeting?
No. We will need some time and maybe put the questions to the Minister in advance.
We could meet some afternoon for those who are interested in this. There is a lot of work on the agenda.
We will ask the clerk to arrange a meeting for an afternoon and will put together the most important of the questions which have arisen this morning. I thank the delegation for its presentation, which will not fall on deaf ears. What we heard was alarming to say the least. We will set in train the pattern of how we deal with the issues by inviting the Minister, knowing in advance what we are to do, and we will hold that meeting as quickly as possible. Thank you very much.
