I apologise to members for the typographical error in regard to the date. We put the document together over a couple of nights this week.
On behalf of the HSE we welcome the opportunity to come before the joint committee and report on progress made since our last appearance on 8 November 2001. The review group was set up in April 2006. Our terms of reference which are set out in the paper are clearly linked to the recommendations made in the committee's own reports.
The membership of the review group included representatives from the consultant orthodontists, local health managers, both dental schools and the Department of Health and Children. The group met on five occasions, the last meeting being on 17 November 2006. The recommendations that appear in the document were accepted on Monday night last by the HSE corporate national management team.
Part of the reason for the time it took to produce the report is that it was a complex area and many issues had to be resolved. In overall terms, we benefited greatly from the time spent on it in that we were able to reach a large level of agreement on some of these complex issues.
We examined the recommendations from the Oireachtas joint committee reports under four principal headings: guidelines, training, manpower planning and service provision. The recommendations which did not fall under those headings were also considered by the group.
Public orthodontic services are located in all former health board areas. The budget assigned to the orthodontic service nationally is just less than €17 million per annum. I have set out in a table the latest statistics on staffing numbers. The committee will see the improvement, especially in the area of specialists from 18 whole-time equivalents, WTE, in 2001 to 37.7 WTE in 2006. We were able to gather further information in respect of the number of dentists working in orthodontic units, which is 11.17 WTE, 6.4 WTE dental hygienists, 82.56 WTE dental nurses, 4.2 WTE radiographers and 26 WTE administrative staff to support the delivery of the service.
The next table sets out the activity during the period 2001 to September 2006, the latest period for which statistics are available. In 2001 the assessment waiting list was 20,877 but as of 30 September 2006 the number had reduced substantially to 6,523. The number in treatment has grown from 17,000 in 2001 to 24,744 at the end of September. There was a big increase in the number in treatment in 2004 when the specialists who had completed their training under our sponsorship started to join the services.
Much discussion has taken place on patient eligibility, a matter on which the committee made recommendations. Eligibility for a public orthodontic treatment place is determined against the Department of Health and Children 1985 guidelines. Those guidelines present difficulties in that there are varying interpretations in operation throughout the country and some high need cases are not included in the 1985 guidelines. In the context of a HSE one uniform system, that kind of variation is no longer acceptable.
The review group recommended the replacement of the 1985 guidelines with a new assessment criteria based on the index of orthodontic treatment need. That national implementation of the proposed guidelines will ensure equity of access to treatment for all patients deemed eligible. The index of orthodontic treatment need is an internationally recognised valid, reliable and reproducible assessment tool which measures the variation from the norm. A copy of the proposed new HSE guidelines is appended to this document. An example of the type of case excluded by the Department of Health and Children guidelines can be seen in this document. This case will be eligible under the proposed new guidelines.
The report which will be published next week contains many photographs in order that people can see clearly the type of work involved. A photograph paints a picture that 1,000 words could not do. The report gives a clear indication of what we are doing.
We looked at the advantages and disadvantages, if any, in adopting new guidelines. The major advantage is equity of access. At present, many crowded cases are not eligible for a public orthodontic treatment place and parents borrow funds from the credit union to fund treatment for their children. Many of these parents are not entitled to a tax refund as they are below the income threshold. A single uniform eligibility tool which will have national application and is recognised internationally is a great advantage. Another advantage is a reduction in subjective bias which results from clinical opinion alone. The disadvantages include an increase in the number of patients eligible for public treatment and a decrease in the number of eligible patients in one region. In the national context we want to get a balance and ensure eligibility for many patients who currently are not eligible.
The review group examined the existing postgraduate orthodontic training courses in North America, Europe, the United Kingdom and Ireland which permit successful students to have their names included in the register of specialist orthodontists maintained by the Dental Council of Ireland. The group recognised the need for ongoing training for both specialist and consultant orthodontists. This training needs to be of the highest standard and must conform to the regulatory requirements in Ireland and in the EU. All training models should consider the manpower requirements of the HSE public orthodontic service. We were cognisant of that as was the joint committee in its own deliberations.
The HSE needs to continue to access training, wherever that is available, in the two dental schools in Ireland, in the United Kingdom as long as the option remains viable and through the use of outreach models such as the distance learning model. Within our working group we had much discussion on this particular way of training. I had discussions with the dental council, the higher committee for specialist training in dentistry and a university. All those organisations were happy to support that type of training regime in principle. In accepting this recommendation, the HSE proposes to put the proposals together and process them through the regulatory system to ensure we get it through. It will give us access to another avenue for training people.
There were a number of specific reviews. We recommended the appointment of additional senior lecturer-consultant posts for the Dublin Dental Hospital to get training reintroduced in 2007. Funding for the programme in the Cork Dental School needed to be confirmed and put in place.
At present, four postgraduate students are pursuing funded training posts in the United Kingdom, which they began in 2005. We recommended that funding for those training posts should continue and that when they are finished we would transfer that funding to support training in Ireland when the current cohort of students qualifies. Four students commenced in Cork in October 2006.
On training, we made another recommendation that we would have a uniform sponsorship agreement in one system. When people are training over a period of three years the sponsorship includes salary for three years as fees. It is quite an expensive training programme so, nationally, we are asking that people who are sponsored in this way would commit to working in the public orthodontic service for a minimum of four years. As regards some in-house issues, we recommended that responsibility for funding and sponsorship agreements for training would fall under the assistant national director, who is responsible for professional education and development.
On the issue of manpower planning, at present there are 9.25 whole-time equivalent consultants working in the public orthodontic service. In HSE west there are three, which accounts for 2.5; HSE south has two; Dublin mid-Leinster has 3.6; and the north east has one full-time consultant, but it comes up to 1.15. We recommended that each area would examine its existing consultant staffing levels and act on that review based on its local knowledge.
The introduction of the specialist grade occurred in 2002 and staffing levels are stabilising. Thirteen specialist orthodontists joined the public service in October 2005. Given the variety and complexity of cases and the increase in productivity which occurs with experience, it is difficult to predict specialist manpower requirements, especially when the revised guidelines are considered.
By way of information, the HSE advertised nationally for a competition to recruit specialists into the HSE on a permanent basis. That competition is being run this week by the Public Appointments Commission. That will hopefully allow for some people who came through the sponsorship arrangements to become permanent officers, if that is what they choose. It will also allow for other people, who are interested in returning, to be recruited on a permanent basis into the HSE.
In the absence of agreed measurement indicators it was not possible for the review group to make more definitive recommendations on the number of specialists required so the group recommended that the number of specialist orthodontists employed in the HSE should be reviewed on a regular basis, every two years.
At present, the dental schools are developing a training course for the grade of orthodontic therapist, which would be a specialised support grade for orthodontic services. The review group recommended that the terms and conditions of this grade should be negotiated by the HSE employers' agency. This would give us an increased capacity to treat patients and allow for an improved skill mix.
In terms of physical infrastructure, we sought information from all orthodontic departments nationally and noted that some locations are operating at full capacity. A review of infrastructure, which includes both physical and staffing resources, should be undertaken in each administrative region with a view to maximising existing resources. We need to ensure that whatever plant and staff we have are "maxed out" before we add on new pieces. Therefore, we are talking about trying to extend the day, which we did successfully in some parts of the country, even to working on Saturdays. We recommended that the review should be finished by mid-year, which would allow it to feed into the normal service planning process.
In terms of service provision, the group noted that the orthodontic service does not operate in isolation. The primary dental care services act as gatekeepers and support orthodontic services by providing dental care, including extractions, restorations and oral hygiene instruction. The service also requires inter-disciplinary support from oral surgeons, oral and maxillo-facial surgeons and advanced restorative specialists.
There is a picture on page 4 which gives some indication of the kinds of cases we are dealing with. On the next page there is a picture of a young man. We have permission from children's parents to use their photographs. The children were quite excited about it. Members of the committee can see that the jaw is way out of line, while the other photograph shows a patient with 14 teeth missing. That requires complex treatment, including implants and orthodontic treatment.
The other thing we noted — members of the committee will see that in the report's case studies — was that the number of visits required for a treatment is high and the time-scale is quite lengthy, up to three years in some cases with between 30 and 40 visits. It is therefore quite complex.
In terms of information technology, at present five units nationally use ortho-tracking, a computerised patient management system which includes clinical records. We recommended that we would ask our ICT service colleagues to review the efficacy of the ortho-track and make recommendations on a uniform system for use throughout the national public orthodontic system. That would then be rolled into place in order to do so.
In terms of performance measures, one of the issues was that the existing data set was presenting difficulties. We were not able to count in a uniform way what was actually going on. I have set out information by former regions concerning the waiting times for assessments and treatment times for categories A and B. We can see that there is no waiting time for some of the more serious category A cases.
We have recommended a standard set of performance measures, which I have included in the report. In some areas, we will collect the data manually. We will review the consistency of the data after six months. After a 12-month period we will be able to review it so that it makes sense and is counted in the same way.
The committee looked at the area of relationships and made a number of recommendations that I have included in the document. As chair of the review group, I spoke to my colleagues on this issue. Through our work we were able to see that we had made significant progress within the group in reaching agreement on areas upon which, up to now, there had not been agreement. Within the group, we reached agreement on a way forward for the issue of guideline usage and training. That showed that when people are working together with different views they are able to bring their expertise together and come up with a result that gives us standardisation.
The outstanding piece around the relationship concerned what I would describe as personal or individual issues raised by a number of consultants. The HSE has a policy of dignity at work, which covers matters concerning employees. Under that policy, we recommended that the CEO should appoint an independent, skilled and experienced person who would be acceptable to all the parties, to investigate complaints by these people, once they are received in writing. That person would then make a written report. That particular recommendation did not have unanimous support. One member of our group, Dr. O'Dowling, dissented from the recommendation.
Recommendation 3 refers to the proposed legislation for an independent health information and quality authority. We noted that an interim HIQA body is now in place.
Recommendation 6 was that the primary dental degree course in Dublin and Cork be upgraded-amended to cover primary level orthodontics. We noted that was a matter for the Dental Council of Ireland and the dental schools in Dublin and Cork, not for the review group.
Recommendation 14 concerned the Dentists Act. We noted that that was a matter for the Department of Health and Children.
Recommendation 16 was that qualifications for the grade of specialist orthodontist be directed by the Minister. We noted that that grade is now in place.
Recommendation 26 referred to a grant-in-aid option. We recommended that the possibility of a grant-in-aid scheme should be investigated by the Department of Health and Children. We will refer that recommendation to the Department's eligibility review group.
As regards recommendation 27, the group noted that the dental schools in Dublin and Cork currently provide a large element of treatment for Health Service Executive patients.
As regards the appointment of the chief dental officer — recommendation 29 — we noted that that was a matter for the Department of Health and Children.
We have been examining what we might need to do to implement the report. We are finalising an action plan to implement the report, make changes and target the existing problem areas. We are in discussions with our colleagues in the Department of Health and Children. By the time the report is published, I expect we will have a clear action plan that sets out precisely how we will target the issues it contains and deal with them.
For the information of members of the committee, I have included the proposed guidelines on eligibility. Members can see that this group of children has the most crowded teeth. We have agreed to include the most needy of those cases and have included some pictures there. That is what we are proposing in terms of guidelines.
The next page sets out the pathway to becoming a dentist, a specialist and then a consultant. The last number of pages set out the recommendations the review group made.