Public Orthodontic Service: Discussion with Department of Health and Children and HSE.

I welcome to the meeting Mr. Chris Fitzgerald of the Department of Health and Children; Mr. Hugh Kane, local health manager in Wicklow and chair of the orthodontic review group; Mr. Pat Healy, assistant national director services management, south; Mr. Seamus McNulty, assistant national director services management, west; and Ms Mary Fitzpatrick, manager orthodontic services, Dublin and mid-Leinster.

Before asking the witnesses to make their presentation, I draw their attention to the fact that members of the committee have absolute privilege but the same privilege does not apply to witnesses appearing before the committee. Members are reminded 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 by name or in such a way as to make him or her identifiable.

On a point of order, I note in the report that these recommendations were accepted by the HSE management at its meeting on 29 January last year. It is now February 2007 and we are all waiting for this report to be published. Is it appropriate to ask for an explanation at the outset as to why this report has not yet been published or given to the committee? It seems inappropriate to be discussing a report that was agreed more than a year ago without having had sight of it.

The report was agreed on 29 January this year.

That is two days ago.

If I may push this slightly, I note in the terms of reference setting up the review group that it was to submit its report to Professor Drumm by June 2006. In the interest of saving time, can we have an explanation why it is not yet published?

I thank the Deputy. I appreciate her concern for time.

I thank the Chairman for the opportunity to update the committee on developments in the public orthodontic service. I also thank the Chairman and the committee for their forbearance. We were asked to appear before the committee in November. I communicated with the Chairman at the time to say that the work of the committee reviewing this issue was well advanced and we felt it would be wise to defer our appearance until the report was produced and we were in a position to speak on something that was complete rather than still in gestation. I am grateful to the committee for acceding to our request and agreeing on a joint presentation between the Department of Health and Children and the Health Service Executive.

My colleagues are Mr. Hugh Kane, who chaired the review group, Ms Mary Fitzpatrick, Mr. Seamus McNulty and Mr. Pat Healy, who have responsibility for the south and west areas, respectively, from a delivery point of view.

The report is complete. As we debate the report it will be clear this is a complex area. The committee that was asked to look at this issue was a broadly representative multidisciplinary group. Having been a member of the group I can comment at first hand. It took a long time to go through some complex and difficult issues. I accept the plan was to produce the report earlier. I assure the committee it was not owing to a lack of effort that that did not happen. There were many difficult and complex issues that had to be waded through. In the interests of producing a more comprehensive report, time was taken to complete it. As I understand it, the report was finally cleared through the chief executive officer and senior management of the Health Service Executive on Monday night last and is with the printers. Given its complex nature and that it contains many pictorial graphics, the printing will take some time. The report will be finally printed in about a week or ten days' time and will be available to the committee at that stage. I assure the Deputy it was approved by the chief executive officer of the Health Service Executive on Monday night last. It is not a case that it has been around for some time.

When the committee has an opportunity to look at the report it will see that the level of detail, in respect of many of the issues it had to address, required that time be taken to get it right. We think the report deals with all the issues the committee raised in its fourth report and that it represents a platform on which we can begin to move forward on the important areas: the eligibility criteria, training needs, manpower planning and the delivery mechanism. I hope that at the end of this meeting the committee will be equally convinced that this report provides a platform to move forward and meet the points raised by the committee. I invite Mr. Hugh Kane to introduce the report.

Mr. Hugh Kane

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.

Before we take questions from members, I seek the permission of the committee to allow Deputy Fiona O'Malley take the Chair temporarily as I must speak in the House in a few minutes. Is that agreed? Agreed.

I must speak in the House after the Vice Chairman but we will return to the meeting afterwards.

I welcome the delegation. I am not too sure we can say there has been significant progress. Looking at the figures, six years ago, there were nine consultants but five years later, that figure has not changed. Six years ago, there were 11,000 people on the waiting lists but there are now more than 10,000 on them.

In Carlow, no orthodontist has been available for the past couple of months and it is unlikely that somebody will become available in the future. I understand the person concerned went on sick leave and is not coming back. We have been told it is next to impossible to recruit a replacement. Meanwhile, patients are being pushed to the bottom of the list. I appreciate that severe cases — category A cases — are being treated but anyone not in that category is not being treated.

What impact are staff vacancies having in the orthodontics area? Why are positions vacant as a result of extended sick leave and maternity leave not being filled? I received a letter from Martin McDonald of the HSE this morning in which he said it was up to the local health officers. Perhaps Mr. Kane can expand on that. Is the HSE constrained by budget deficits, or a lack of budget, from recruiting people to fill vacancies when it is clear somebody is going to be out on extended sick or maternity leave? Is it constrained by the ceiling mentioned in that the public sector is not allowed to recruit over a certain number? What is holding the HSE back and why are those vacancies not being filled more quickly?

I understand the guidelines have not been changed since 1985 — they are over 20 years old. I take it the new guidelines are on page 8. Are they radically different from the current ones? Am I correct in assuming that if those guidelines are accepted, it will put further pressure on our waiting lists because more people will become eligible for orthodontic treatment? I presume there have been advances in orthodontic treatment in the past 20 years.

It is worth noting that people are being told they might be waiting months, if not years, for public orthodontic treatment. They are also being told there is no difficulty going down the private route and that they will get immediate appointments.

Tax relief is an issue at which we must look, although it is not necessarily in the delegation's remit. It is a big problem, especially for parents who may be quite elderly, in receipt of a pension and perhaps have a teenage son or daughter. Unfortunately, they do not earn an income and, therefore, cannot offset the cost of the treatment against their tax. There is some discrimination, although I am not sure it is in our remit. It is more appropriately a tax issue but it is worth raising it. It also applies to those on low incomes who do not earn enough to pay tax and, therefore, cannot claim tax back.

Some €16 million was spent last year on orthodontic treatment. That is a tiny amount. I am not being political but when one compares it with the amount spent on PPARS, which was almost €200 million, it puts it in context. By how much would one need to increase that budget to bring about real change and eliminate the waiting lists? If the new guidelines are accepted, how many more people are expected to go on the waiting lists or what is the expected impact on them?

Mr. Kane

In terms of real improvement, the number of consultants has remained the same but the real improvement has been in the number of specialists. As one can see, the number has increased from 18 to 37.7. That is a very significant improvement.

What is the difference between an orthodontist consultant and a specialist?

Mr. Kane

If one looks at the document, I set out the route of training. Someone begins by training for five years as a dentist. After that, a dentist must spend a period of time building up experience and he or she must do an entrance examination. Following that, there is a three year postgraduate course which trains somebody to become a specialist in orthodontics. A specialist is really a highly trained person who can deal with most cases with support from a consultant from time to time. A consultant receives further training in addition to the specialist training. One is talking about a training path of ten to 11 years from starting training as a dentist to becoming a consultant. Internationally — certainly in Europe — specialists do most of the orthodontic work. That is critical. In the context of moving on, they will generate the real outputs for us over time.

I have not experienced any difficulties having vacancies filled or receiving approval, either in regard to the budget or the ceiling. If a specialist orthodontist goes on sick leave, maternity leave or is not available, the number of people available to fill the vacancy on a locum basis is quite restrictive. That certainly presents a problem. If a person's leave is planned, we try to manage by giving colleagues the most critical parts of his or her cases. However, this grade is not as freely available when somebody goes on sick leave. The constraint is really the availability of these people.

One will see in the report that we have made specific recommendations in respect of training which will bring many people into the system over time. We have already trained many people. The salary is reasonably attractive to people and training conditions are good. We have been trying to make it much more attractive to people. The budget or the ceiling have had no impact on placements.

I refer to the question of whether the guidelines are radically different. Our estimate is that approximately 7% more children will become eligible with the new guidelines. We said we would make the change, then attempt to measure the impact and top up the resource we have to deal with that further impact. The impact is quite varied because in some places, the changed guidelines will have minimal impact compared to others. Where people use the 1985 guidelines, our estimate is that 7% more children will be eligible. There is an increase.

Senator Browne spoke about the historic waiting lists and what we might do. We are looking at targeting them in a specific way by using the National Treatment Purchase Fund and getting the historic backlog, where it exists, out of the way, while at the same time, continuing to build our capacity on an ongoing basis so that we are able to meet the continuing need and new cases. Having used the guidelines for a certain period of time with the new data set, we will be in a much better position to be able to measure precisely the impact. I do not know about the specifics of the case in Carlow.

Deputy Fiona O'Malley took the Chair.

When somebody leaves on sick leave or decides to take up another appointment, it can cause some difficulty but there is a national recruitment campaign going on. It is taking place this week and it is our intention to fill two posts in the south. I also hope we will be able to backfill that post on a temporary basis.

The Carlow-Kilkenny post.

Yes. Hopefully, that will resolve the issue.

People leave jobs all the time and, normally, one gives one's employer notice. Depending on the arrangements, if somebody is able to fill one's job, one can leave sooner than planned. Generally, one cannot walk out of a job without someone being in situ. In the past has the HSE delayed someone leaving or refused extended absence or extended maternity leave due to lack of cover for the person concerned? I get the impression that patients are pushed down the line of priorities, that those who want to pursue their profession elsewhere seem to be allowed do so irrespective of whether it means there is no coverage for patients for six months. It is not acceptable.

Mr. Kane

That is quite a difficult issue for us. Certainly, we would not countenance pushing patients aside. We would always focus on the patients' needs and how we best meet them. People get sick and one is not able to plan for that.

I appreciate that.

Mr. Kane

We are aware in advance of maternity leave. As soon as we would hear that someone is due to take maternity leave in a number of months time, for instance, we would immediately begin a process of assessing whether it is possible to put a locum in place. Many colleagues would know of persons, who are finishing training and perhaps working outside of the State, who might be interested in working on a sessional basis. We use a mix of replacements where we can get them, bringing persons in on a sessional basis to provide cover and getting existing staff to take on additional work on extended timeframes.

Such staff are a scarce resource. As I stated, we have focused on trying to increase that pool. We want to expand the existing training methods and work on the distance learning model described to build up that particular pool over time.

With this particular grade, especially at specialist level, it will be difficult on an ongoing basis. We try to reduce the impact on patients when somebody is sick or on leave. If somebody wants to resign, he or she has a contract which sets out clearly the length of notice necessary. Generally, that is quite a short notice. Even if it was extended to three or six months, for instance, that may or may not be a timeframe—

What is the timeframe currently?

Mr. Kane

Generally, one month because people are employed on monthly contracts.

I do not know what would be gained by telling a person who wants to resign that he or she cannot do so for three months or six months, given the productivity one would get from a person who is switched off. I will ask my human resource colleagues if there is anything we can do in that regard.

In fairness, due to manpower planning and working with our staff we would have a good sense of where people see their future, and in planning their career progression we would engage actively on that issue. For example, a consultant would be speaking to his or her specialist. The managers would be speaking to them. We would know in the long term where people's interests lay.

We in the public service have been trying to make our service increasingly more attractive by improving the environment and being flexible with the working hours, the days of work, the training provided and the collegiate element. A person in private practice works alone and is isolated. The financial benefits may be better, but we offer a good financial package, including good training, a good collegiate and support. There is a balance which people must consider. Our family-friendly employment policy would also assist with it.

A month is a short notice period. The corresponding period for primary school teachers is three months. If someone announces he or she is leaving Mr. Kane's workforce, it seems an unrealistic amount of time in which to arrange interviews, recruit and free up an appointee from previous work, and, unfortunately, the patient suffers.

The budget is €16 million. What budget is really needed?

Mr. Kane

At present, we are finalising an action plan and working on the numbers. If we were to use the national treatment purchase fund option, we would see a number of millions of euro involved. We are still working out the precise figures to assess the quantities required in which parts of the country. A focused couple of million euros this year would begin address that.

We are working on a proposal to increase capacity, in providing additional specialists and consultants. In overall terms, I think it will not be a significant bill. My guesstimate, in the absence of receiving the final detail, is €4 million or €5 million.

I am not a member of the committee but I appreciate the opportunity to speak. I apologise for not being here for the initial presentation but I have had an opportunity to study the presentation document.

I have been following this issue, particularly in my area, for many years. I cannot understand how enormous progress has been made by the HSE on the waiting lists in a range of areas and yet orthodontics — despite resources not being an issue in any sector of the health services — still seems the Cinderella of the HSE and the health service in general.

We, as public representatives, come across this on a daily basis. We meet the families. We actually meet the children. We go into their homes and see their terrible conditions, and hear that they will not get treatment for 18 months' or two years' time. Following on the previous questioning, the key issue is the length of time between assessment and treatment, and everything else is subsidiary. That is the question we are being asked on a daily basis. We would like to know, today if possible or as soon as the report is published, how long the waiting time will be across the country from initial assessment to treatment. We were told that this report was meant to be available in the middle of last year. Mr. Kane might explain this. Perhaps he has done so already.

We have not received a confirmed date for when it will be published, but we will press for that.

When will the report be published and available to the Oireachtas? Will there be an opportunity to bring the officials back before the committee to discuss the report in detail, specifically on the waiting time issue?

We hear anecdotally from numerous sources that this entire area is riven by internecine politics between different and competing interests and we hear definite stories that the public orthodontic system has been sabotaged by private interests. In the course of their work, have the officials received any evidence, submissions or credible information to the effect that this is true?

The 1985 guidelines are 20 years old and I understand the new report will contain new guidelines. Even with the new guidelines in place, surely it is a question of having the personnel to deliver the treatment in accordance with those eligibility criteria and the guidelines for treatment, and can we be assured that the personnel and resources will be in place to ensure that a person meeting those criteria will be treated in an appropriate and reasonable period of time in the same way that people in other sectors of the health services are now being treated?

When I came in I heard that work is being done on an action plan. I would have thought that the report should have been the action plan. The committee prepared a well-received report and I would have thought that the document that we are about to receive would state exactly how this issue will be addressed.

I will take some of those points and my colleagues will address some of the others. For Deputy Power's information, earlier we discussed the question of the timing of this matter. The point was made that the target was to complete this work by the middle of last year. It is worth stressing that the group which looked at this was broadly representative of the profession and those involved in service delivery. As we worked our way through issues, it was not possible to do a thorough job within that timeframe. I commend the chairman of the group for taking the time to work through some extremely complex issues and get us to the point where we were able to produce a report, to the entirety of which, with the exception of one particular issue, everyone was able to subscribe. That is the explanation for its taking somewhat longer than envisaged. I understand that the report will be printed and available within a week or ten days. The Department will have received a copy at that stage. We, and I am sure the representatives of the HSE, would be more than happy to return at that point to discuss the report in further detail with members.

How closely does the document presented today relate to the report?

It is a very good précis of the report. Obviously, the actual report is slightly longer.

On the point raised about eligibility criteria, etc., the 1985 guidelines were in place and, inevitably, these were interpreted differently in different jurisdictions. This led to some subjective views being taken in respect of children who may or may not have been eligible. There will from now on be uniform eligibility criteria so such different interpretations will be eliminated.

The report is structured in such a way as to begin with the eligibility criteria and then deals with training and manpower planning. I hope this will address the Deputy's second point in that if we are to consider delivering a service with a uniform set of criteria, we must ensure that the right training is provided and that there will be a proper manpower planning link thereto. The report goes through those points sequentially.

On a point of clarification, are the eligibility criteria in line with international standards.

Yes, they are based on the index of orthodontic treatment need, IOTN.

They are being benchmarked in that context.

Mr. Kane

On assessments and treatment times, one of the issues for us is that having long waiting lists for assessments is not appropriate. We have targeted this matter very clearly in some areas and we are proposing to take further action. On some level, what we have are people queuing to join a queue, which is not acceptable in a modern service. The new guidelines will be clearer and those referring people will have clear criteria in that regard. When people come to be assessed, their assessments will be dealt with quickly and in a targeted way. Parents will at least be in a position to know whether their children will be included. If they are included, some indication of the treatment timeframe will be provided.

What timeframe is envisaged?

Mr. Kane

We are trying to set targets. People should not be on waiting lists. The target we need to set in respect of assessments should be no more than six months. That would be an initial target. Thereafter, and based on need, which involves a clinical judgment, those with serious problems should be able to undergo treatment without delay. Category B patients — these will be category 4 under the new IOTN model — should also be seen on a needs basis as quickly as possible and this will be clinically driven

I wish to pursue this point because it is the essential aspect of the issue. Everything else is padding. People will want to know what will be the longest period after they are first assessed that they will be obliged to wait before being treated.

Mr. Kane

Currently, it is up to four years in some areas.

I am aware of the current position. People are sometimes left waiting even longer. What does the report say about the length of time it will take to be treated under the new system?

Mr. Kane

The report did not make a specific recommendation around that particular timeframe.

Will Mr. Kane indicate why that was the case?

Mr. Kane

Part of the issue for us — I mentioned this in my previous report — was that when we were trying to draw conclusions from the data we compiled, we did not obtain a uniform answer in that regard. That is why we decided to opt for a new data set that would be collected in a uniform way. It was also decided to review the new data in six months, which would, at that point, put us in a position to deal, in a concrete and clear way, with the peaks.

It is not, therefore, possible, even in light of all the work that has been done and the extra time provided, to include in the report a target in respect of a timeframe for children who have waited many years to be treated. In other words, people will still not know when they will receive treatment. That will be a source of much disappointment.

Mr. Kane

We have taken a two-pronged approach to this matter. I stated that what we will do, as part of our actions in respect of this matter, is to target, in a focused way, the areas in which major waiting times obtain in respect of assessment and treatment. We also intend to use mechanisms such as the National Treatment Purchase Fund to allow us to work quickly to reduce waiting times. We will be extremely precise in terms of what we do in this regard. When the report is published, it will contain details of the numbers of people involved and how quickly they will enter treatment. We will also target the longer assessment lists to discover precisely what we are dealing with.

It was just not possible for us to be precise and prescriptive at that point. We all have views on what we wish the new system should be but in terms of being able to predict precise timeframes, we just could not do so at that point. Our targeted approach will quickly deal with the blackspots. Large numbers of children will be removed from lists and will enter active treatment, which is something we all desire. We will also carry out a national calibration or training exercise so that everyone involved in assessments will be trained in the context of the new guidelines in order that uniformity will be achieved.

I did not receive any submissions regarding the politics of this matter or the different interests involved. However, it is fair to say that people have some strongly held and different views. This was one of the aspects within the group—

It is well known that, as Deputy Peter Power stated, there is a major issue regarding the politics of the situation and one of our recommendations relates to it.

Mr. Kane

The major areas of conflict and difference — there is a great deal of energy being expended in this regard — revolve around the guidelines and training. Within the group, we dealt comprehensively with those major areas of conflict and difference of opinion. We arrived at a recommendation with which everybody can deal.

It would not be appropriate for a review group to deal with the personal issues people may harbour. However, we made a clear recommendation that, under our dignity at work policy, people would be invited to submit their complaints in writing and that we would, in a process agreed with them, establish a review to examine the issues they wish to raise.

That is the reason Dr. O'Dowling dissented from the report. It could not, therefore, be ignored.

Mr. Kane

Dr. O'Dowling dissented on one specific recommendation regarding relationships. He supported the remainder of the document and members will see that when the report is published. If people wish to have particular issues about which they are concerned examined, a clear way is set out in the document to allow them to have such issues addressed in a way that makes sense. From a service point of view, that is what the view focused upon. The major areas of difference, difficulty and tension surfaced in respect of the guidance and training routes. We have arrived at a way to resolve those differences, to which we have all signed up and on which we are agreed. That is a positive development and it will progress matters.

The report, when it is published a week from next Monday, will contain an action plan that will outline the number of children involved, the relevant costs and precisely what we intend to do. The report sets out a number of actions but this plan will put meat on the bones and outline in detail the action that will be taken. It was not possible to do that at the particular point in question.

Mr. Seamus McNulty

Deputy Peter Power referred to the west. When the action plan is agreed and finalised, the intention is to have some significant impacts on the waiting lists for assessment and treatment. We can discuss that matter with the Deputy later.

We have a slight problem. Deputy Cooper-Flynn wishes to speak but she is in the Dáil to make a contribution on Private Members' business, the proceedings relating to which have not yet commenced. I wonder if it would, therefore, be appropriate to suspend the meeting. I accept, however, that Deputy O'Connor wishes to put a question.

I am due to contribute after Deputy Cooper-Flynn but I will do so now, if that is acceptable, because I am also due to speak in the Dáil. I will not repeat what has been stated.

I welcome the delegation. Mr. Kane and I served together on the health board. Many of us associated with the health board in the Dublin region were upset by the passing of Martin Gallagher during the week. He was my programme manager on the drugs group and he worked with many committees. It is very sad.

I share the concerns of colleagues. Mr. Kane knows that our problem is the public does not believe the HSE. People want their children looked after and they attend dentists privately and obtain a view, but then they go through the public system and are given a completely different view. This is a political issue at the end of the day and reference has been made to progress in the health service. As Deputy Peter Power said, there is a Cinderella view of the orthodontic service. Deputy Fiona O'Malley chaired the sub-committee established by this committee to examine this service and I contributed to that based on my experience in my constituency.

Tallaght is the third largest population centre in the State and many things that happen there are reflected around the country. The public relations battle has been lost but, hopefully, progress will be made so that people who genuinely feel they are entitled to orthodontic treatment can avail of the service in an effective and timely manner. I hope progress will be made following the report because the public needs action.

Orthodontics is a branch of the dental profession where function and aesthetics clash and what a parent thinks of a child's orthodontic needs may not be agreed. Parents look at this in the context of aesthetics and the development of a child's self-esteem while dentists and orthodontists do not always agree. The guidelines are functional, acceptable and practical, but the trick is to get people moving through the system. The sooner children are dealt with when they are aged between nine and 11, the better the results.

Reference was made in the submission to relationships. The committee has been bedevilled by personality clashes within the profession every time it has dealt with orthodontics. We spent hours listening to detailed analysis, which was not always presented well or clothed aesthetically. The review group recommended that under the HSE's dignity at work policy an independent skilled and experienced person, acceptable to all parties, be appointed by the CEO to investigate complaints. That is a logical, straightforward and honourable initiative because it is open, accountable and transparent. However, one of the panel dissented. Why?

Mr. Kane

The group had a long discussion on this issue. One of the dissenters felt what we needed to do was broaden the investigation required and my view, as chair, and that of the group was to go further was not warranted as it was outside our terms of reference. The judgment I made was based on how long the review would last and what were the key issues.

The key issues of dissent and difference related to guidance and training and we reached a resolution on them. Once the service operates, whether we get on with each other is a separate issue. We all work together from day to day and sometimes we will have a pint with one fellow but not with another, and it was not appropriate for the group to get into that. However, if colleagues in the HSE feel the way they were treated as employees has impacted on them and they have issues that need to be raised and dealt with, the clear vehicle for doing so is the dignity at work policy. Clear procedures are documented to do that.

Has Mr. Kane washed his hands of the issue? I do not agree it is beyond the terms of reference because they required the group to examine the recommendations—

Mr. Kane

How far does one go in trying to help colleagues get on better? It was not a function of my group to ensure all the clinicians working in the orthodontic service got on socially. I tried to focus on the issues impacting on service and the service differences. We targeted them and we came up with a reasonable way forward. If individuals have a grievance about how they were treated as employees of the HSE, the route to address that is through the policy. That will require them to make written submissions. We put the process in place and the chief executive officer has accepted the recommendation so that if people make complaints, he will appoint somebody to investigate and he will take whatever action is recommended.

Is this accepted by all the parties and personalities involved?

Mr. Kane

I do not know. One must stand back and ask what is a reasonable way forward and how long should the process go on. We made huge progress working together to resolve problems and that provided a reasonable way forward. If, as an employee, I had a concern, this is the route I would go. I applied the same rule to everybody else working in the system.

This is none of our business. We are interested in service delivery, which presents pressure points for us. Is this issue obstructing service delivery? Can a way be found around this to avoid interruption to service delivery?

Mr. Kane

The report addresses service delivery and key actions and gives us a way forward to which we have all signed up. That was the critical element of the work, time and energy we spent resolving issues. The recommendations on training and guidelines in the report will bring about an improvement in access for our clients by targeting the waiting lists and blackspots. The system will be allowed to develop training routes and options, of which everyone can avail. There comes a point when we must say this is what we need to do and move on it. That is how we dealt with the service issues in the report in a pragmatic way. If people still feel aggrieved, a process is in place which they must to go through to gain satisfaction. I can do no more than that.

What is the acceptable timeframe for treatment once a patient has been accepted for assessment?

Mr. Kane

We will initially target those who are no more than six months on a waiting list to be assessed. Following on from that, for level 5, there should be no delay. Such patients should receive treatment straight away because they are critical. Time is of the essence. In terms of category B, some of them have a higher need and a clinical judgment must be made in their regard. In terms of target times, we consider it would be appropriate to get treatment within 12 months. That should be set as a starting point or benchmark and we should start to work towards that.

How soon will that be up and running?

Mr. Kane

The report has gone to our executive and been accepted. We are in the process of finalising an action plan that sets out how we will target the blackspots. We will see clear progress on that once we commence.

We also spoke about changing the guidelines, about training, clinical issues and bringing in other teams. There will be a lead-in time in terms of recruitment for these changes. We see clear progress being made in terms of the wait for assessment and treatment, once we focus and target those areas this year.

I am not a member of the committee, but my colleague, Deputy McManus, who is a member, cannot attend as she is speaking in the Dáil. I wish to raise concerns I have had for some time and to point out that the original training programme we had in the mid-west worked very well. As public representatives we recognised that. The programme provided children with a service with a not undue waiting time, which is the bottom line in what we want to achieve. I know this committee has been involved in ongoing discussion on these issues.

I have only briefly glanced through the report, which was completed on 29 January. I am concerned about some aspects, in particular, whether it has the capacity to respond to the existing need. It has been suggested that because of the changes in guidelines, there will be an increase in the number of people waiting for treatment. I will not detain the committee long on this because I accept the issue has been raised by others.

I want to focus on the fact that there is such a small number of orthodontic consultants in this country. It will take some time to achieve the number recommended in the report. Realistically, will the service be able to address the current waiting lists in a reasonable timeframe in the context of the recommendations? While there are many good recommendations in the report, it will take time to implement them. My main concern is whether the capacity exists to address the issues in the immediate future. I regret the system that was in place in the region I represent was terminated.

Mr. Kane

In terms of the regulatory framework, the old system was not approved as an ongoing process and the special advisory committee at the time recommended the discontinuance of that programme.

I would like to know why. I support the point made by Deputy O'Sullivan. We had a wonderful service run by highly qualified people. The numbers are on the record and prove the system worked.

Mr. Kane

I do not want to go into the history because we have a way forward in this report. However, in 1999, the special advisory committee mentioned the sort of issues involved. It stated that at present, there was evidence that those dentists with the least training were treating the most severe cases, often without direct supervision. There was little or no evidence of formal didactic teaching, no research element to the training, and no audit of treatment being undertaken.

That would not have been the case in our region. We had the most highly qualified people, not just in Ireland but including the United Kingdom, conducting the orthodontic service successfully in the mid-west.

I support that and that was also the case in the western region. This is evidenced by the recommendations and references provided when some consultants moved from the western region because waiting lists there were virtually nil. The service at the time was second to none.

Mr. Kane has quoted from one report. However, many other reports conducted around the same time spoke highly about the level of service. The selective quoting being done is slightly inaccurate. We have come to the nub of the problem and must deal with it. Our recommendation in the second Oireachtas report, mentioned by Deputy Fitzpatrick, relates to the delivery of service and good value for money. We had it, but we have lost it.

Mr. Kane

Let me deal with it in two ways. I will talk about my experience in the eastern region. We started using the new training model in 2002 and have delivered on it in terms of productivity, training, quality and numbers. We have the statistics to prove it. However, rather than staying with the historic model, I pointed out there had been a training group that had appeared to work very well. I suggested we should explore how or in what sort of framework we might be able to reintroduce similar training to fit with the regulatory programme. As I said earlier, when looking at this particular way of training, we put together an outline paper on how a 2007 version of that outreach or distance learning model of training would work. I submitted that and had discussions on it with the Dental Council of Ireland and the special committee for training in dentistry. Both said that in principle they had no difficulty engaging with us in redeveloping that particular model. I also spoke to some academic institutions to see whether, if we used that kind of model, we could get academic and research input. Again, that was clearly available to us.

Our report states that we recommend the introduction of a distance learning model. That model must meet the criteria just as every other training programme does. The HSE would take the model, work it up into a document and-----

To clarify, one is not exactly reinventing the wheel. Is it not the case that we are talking about a service and a method of training that are available in other places in Europe?

Mr. Kane

There are various ways through which people are trained generally, for example through the route of dental schools. What is important is that we have accepted there is a way to use the distance learning model.

I am going to push Mr. Kane on that point because I want him to spell it out that it is a system that is also available as a training mechanism in other parts of Europe and elsewhere in the world.

Mr. Kane

Yes, and what we have to do to reintroduce-----

Was that a "Yes"? Does Mr. Kane admit to that?

Mr. Kane

Yes, absolutely. The group agreed there was validity in it and that it was something with which we could work. What we must do now is to take what we have, write it up in a formal proposal and drive it through the regulatory process, thereby providing another route whereby we can train people to the appropriate level and treat people at the same time. The report is specific on that. We have taken the recommendation and agreed this is a way forward and that we will work on it and push it through the process.

To clarify, is Mr. Kane saying the method of training available in the former mid-west region is something he will look at now?

Mr. Kane

We are actually saying more than that.

Is it likely to be re-introduced?

Mr. Kane

What we have said is that we will use a distance learning model, which is what the Limerick model was.

The training model to be used will be very similar to the training model that was employed in the mid-west region.

Mr. Kane

Yes. We will work into a formal document a proposal based on what existed there and put it through the regulatory process so that we can reintroduce that training model.

Can we clarify some points with regard to the previous system? I have been on this committee for ten years and I saw the introduction of both of the committee's reports into orthodontic services. Therefore, I am familiar with the history of this case. I am also familiar with the sub-group, chaired by Deputy O'Malley, that brought the most recent report to the committee.

With regard to the consultants operating the training service which seems to have caused us all the difficulty, is the allegation accepted or denied that children were damaged within the public health orthodontic service? Does Mr. Kane accept the service provided in the past was good and did not damage children or does that allegation still stand?

It is important to establish that for the record.

Yes. We need to clear the air on this issue. These allegations were made and should be cleared up and resolved before we can move forward.

Mr. Kane

I have said clearly that if someone has evidence that children's teeth were damaged, the complaint should go to the regulatory body dealing with such matters, namely, the Dental Council of Ireland. In my experience, I am aware of children whose care was less than optimum, whose treatment was interrupted and who had appliances leftin situ for longer than they should have been. When such issues arose in my area, we addressed the issues. We brought children—

I am sorry to interrupt as I know it is unfair. Is it not the case that the children's treatment was interrupted because of the suspension of services? It has nothing to do with the care that the orthodontist in question was giving them but more because the services were suspended and therefore they were left.

Mr. Fitzgerald seemed to nod in agreement when I made the point. I ask the delegation to clarify whether there were any complaints. It seems there were no complaints and these allegations that have been left to float around that there was poor and substandard treatment, are false.

There is no clinical evidence of permanent damage to children's teeth. If there is evidence then the appropriate place to bring that evidence is to the Dental Council which is the statutory regulatory body. I have checked with the Dental Council of Ireland and it has received no complaints. I am certain no complaints have been made either to the Minister or to the HSE. No formal complaints were made.

Is Mr. Fitzgerald certain of that?

I am absolutely sure, yes.

Is there no difficulty with the service that had been provided historically?

Mr. Kane

I am conscious that I do not enjoy parliamentary privilege so I will be careful about what I say. When I took on the management of the orthodontic service in the eastern region, I noted numerous ongoing problems. It was clear that some of the care was not optimal and some of the treatment was interrupted. We took particular steps with the cases which had been interrupted to have that treatment restored and resolved and progressed. Despite the publicity surrounding this matter, I have not received in recent years any communications from any parent about their child's treatment. When issues arose in particular cases we as managers addressed them by using other clinicians to resume the treatment and bring it back up to par. This is as much as I can say on this issue.

The language used by Mr. Kane, the phrase "bringing it back up to par", seems to suggest that treatment was below par and there was a problem.

Mr. Kane

It was below par in so far as treatment had commenced and was not completed for some children. Treatment should be completed within an optimal timeframe. There was sub-optimal treatment in that the time deadlines were missed. The HSE had to identify where this had happened and take specific steps to put those children back into treatment and to complete their treatment.

I refer to a time when a service operated in the Western Health Board area with virtually no waiting lists. A particular consultant left the service with high commendations and references from everybody at the highest level of the health board. It is now the case that waiting lists are three or four years long. Mr. Kane refers to interruption of treatment and timescales; what about the children who received no treatment at all? A previous admission at this committee means there is no credibility to the chart detailing waiting lists and waiting times which the delegation has presented here. The Department of Health and Children freely admitted that people were not put on waiting lists because there was no point in putting a qualified child on a waiting list when they were never going to be seen anyway. This policy was admitted to at a meeting of this committee.

Mr. Kane referred in his presentation to the 85 guidelines and the difficulties presented in that there were varying interpretations in operation throughout the country. What does this chart mean? How can it have any validity in terms of waiting times?

Mr. Kane

We introduced new standardised national guidelines so that we will apply the same counting criteria everywhere. We made a recommendation about gathering similar information in the same format on a national basis which would provide us with data set against an agreed set of calibrated guidelines. There will be a unified system and this will be a significant improvement even in terms of data. At least we will know the guidelines being used and people will be assessed against them and the data being gathered is collected in the same way throughout the country. This will provide consistency so that when we produce—

That is to be welcomed.

Mr. Kane

—information in future to bring to the committee, we will be able to explain the basis on which people were assessed which is the agreed national basis. The form of counting will be uniform throughout the country.

I wish to press Mr. Kane on that point. With reference to the report and the waiting list times, I agree with Deputy Cooper-Flynn's point. It seems sort of meaningless. Previously, A, B and C were the categories counted but I note that the HSE is now only counting categories A and B. I refer to a form of the maxim, "Treatment delayed is treatment denied". This is of concern to the committee. I regard it as extraordinary that Mr. Kane is not aware of any instance of a person making a complaint because I have received plenty of complaints and I am sure other public representatives can refer to many instances where parents complain about treatment and delays in treatment. I ask Mr. Kane to address this point.

This committee is concerned about public moneys being used to develop a service. The service used to be an excellent service but it has collapsed.

I refer to the review group which reviewed our reports among other things and to its make-up. When the group was set up I e-mailed the HSE to find out who were the members of the group, who appointed them and whether the group was representative of the profession in general. How were the members of the review group selected and did it represent everybody? I find it difficult to discuss a report that has not yet been published in full and I am aware of a dissenting view. The committee cannot be given an opportunity to go through the details. How many people made up the review group to begin with? Is one dissenting voice a total of 20% or 10% of the group? I wish to hear an overview of the situation.

Mr. Kane

The nominations to the review group were made by the CEO and by the assistant national directors for the service in the regions. I chaired the review group. HSE south was represented by my colleague and local health manager, Anne Kennelly and by Dr. Ian O'Dowling, consultant orthodontist; HSE Dublin mid-Leinster was represented by Dr. Marielle Blake, consultant orthodontist and Dr. David Hegarty, consultant orthodontist; HSE north was represented by my colleague, Bernadette Kiberd, local health manager and by Dr. Pat McSharry, consultant orthodontist; HSE west was represented by my colleague, John Hennessy, local health manager and by Dr. Niall McGuinness, consultant orthodontist. Dr. Berga Healy, a specialist orthodontist was also a member of the group. The dental schools were represented by Catherine Neville from Cork and Brian Murray from Dublin. The Department of Health and Children was represented by Mr. Fitzgerald. This is the total membership of the group.

Is that 12 members?

Mr. Kane


Did the CEOs in the various regions appoint their people?

Mr. Kane

Yes. For instance, in my region my assistant national director appointed the two consultants and my colleagues in other regions nominated people from their regions in the same way.

I will play devil's advocate with this question. If it was wished to maintain thestatus quo, would each region not appoint the people that were running the service in that region? I want to see behind the issues that started this investigation by the committee in the first place. If a certain result is desired then the nominees will be those who have been operating the service in a particular way.

I refer to the south region as an example. Dr. Ian O'Dowling had fairly strong views about how services should be progressed and we appointed him to the group. This was a representative group where all the interests and stakeholders were fully represented. In the context of what has been presented to the committee today by Mr. Kane as chairman of the group it is fair to say that everybody -----

I take Mr. Healy's point.

We are concerned that Mr. Kane as chairman was the one dissenting voice.

That was in regard to one particular aspect of -----

Of course Mr. Healy has the benefit of knowing what was in the published report more than the committee has.

The chairman of the group referred to that, in fairness. The guidelines and training were two of the very contentious issues. It is important that the committee recognises that there was agreement and consensus on that. However, there was dissent regarding one aspect about relationships and the chairman has outlined the difficulties. We are not downplaying those difficulties.

I commend the HSE south region on making the right decision in nominating Ian O'Dowling who held a particular point of view. I reiterate the point made by the Acting Chairman. It stands out all the more that his is the one dissenting voice. If each of the old health board areas had done the same, it might have been more representative of what was going on in the profession. I make the point to try to be fair to everybody. The central issue for us during the years related to the provision of service and the training mechanism which seem to represent the one crisis point, according to the report.

While I am probably restating the point Mr. Kane has made, it is important to make it. I was a member of the group and from that perspective I can say there was a robust exchange in the group throughout. I was coming to it relatively new, as I did not have much background knowledge. I got no feeling that this was in some sense a packed group to achieve a particular result. Throughout the report the areas of contention all along centred on the assessment criteria and training. There was unanimity in the group, including Dr. O'Dowling, on these issues. There was one issue at the end of the process to which Dr. O'Dowling felt he could not subscribe. As the members will see when the report is made available to them — they will have got a sense of it from Mr. Kane's presentation — on the issues on which there were professional differences and disagreement in the past regarding the selection criteria, training and manpower planning, there was unanimity in the group.

There was certainly robust discussion. The delay in completion was to try to accommodate that level of discussion and ensure all members of the group had an opportunity to say their piece. That said, ultimately there was one issue, the relationship issue, which caused a difficulty for Dr. O'Dowling. The route recommended in the report should be tried. If he still has a difficulty, it will be open to consider other areas. The HSE has a process for its entire staff. What has been proposed to deal with that issue is logical and sensible. It has been tried and tested. The CEO is prepared to trigger that mechanism very quickly. It behoves everybody to explore all the options to deal with the remaining personality issues, given that there is consensus on all the technical issues. If that principle is accepted, we will have a platform to begin to address some of the issues about which members of the committee have been concerned, as are we.

Given the way the service developed over a period of time with eight and then ten health boards using old criteria, we must recognise that there were differences in interpretation. Obviously, eligibility caused problems but it has been addressed. There were issues concerning training. The report suggests having three parallel levels for training — the UK model, Cork and Dublin, and distance learning. That issue has been addressed. Many of the practical issues over making this happen will be addressed also. One can accept that people might be disappointed that we may have not produced a silver bullet. However, there is a platform on which the service can begin to be planned. The report outlines clear timelines for reviewing progress on a number of issues. It will be in the public domain and the HSE and the Department will be under scrutiny as to how well we deal with it.

It would be a pity if the one dissenting voice on one aspect of a very detailed report was taken as indicating there is not unanimity within the profession. Members will have seen the list of those who were represented. There is unanimity in the profession on the important issues dealt with in the report.

I accept that there is significant common ground, which we welcome. We certainly welcome what has been decided on the guidelines. When will they be implemented? Mr. Fitzgerald asked why the new mechanism should not be tried. We were discussing an historical dispute. I understand there is now peace and harmony all around. How will the new mechanism deal with this? There are issues regarding the good name and integrity of the people involved. These are significant issues for professionals who have operated in the utmost good faith in the service. These matters cannot be swept under the carpet. We cannot move on and pretend it never happened.

There are legal issues for the HSE regarding children who qualified for orthodontic treatment under the guidelines but were never placed on a waiting list because it was known they would never be reached. What are the implications for us? Can we just forget about this or do bigger issues arise from the past? I wonder whether the mechanism suggested, to appoint three consultant orthodontists and an independent chairman, is the best way forward. Given the level of agreement among the 12 people involved, was it not a pity they could not have accommodated his views and resolved the issue to publish a unanimous report? This was the number one recommendation of this committee, which is why we are harping on about it. The delegates have said there was dissension on the issue. However, given that it was our top priority, it is a significant matter for the committee. It is disappointing that all those involved in the group could not have been accommodated in order that it could have come back to us and shown a united front. We could all have moved forward in harmony and with satisfaction.

Mr. Kane

I worked very hard to try to get agreement. In fairness to all my colleagues, including Dr. O'Dowling, their contribution to this work was enormous. Huge energy was exerted at meetings which were very difficult because people were being upfront and honest, and worked to solve problems. Everybody contributed very well and there was coherence within the group. However, it was just not possible to reach agreement. We worked over the issue. We had side meetings. We used different formulae. We reached an understanding at our penultimate meeting and thought the matter was resolved. However, when we returned for our final meeting, the understanding we had reached at the previous meeting was unpicked again.

We made efforts in a number of ways to try to resolve the matter. I was under pressure to complete the work. I spent much time trying to resolve the issue. At the last meeting in November, as chairman, I needed to make a call as to whether we should spend another six months on the issue or accept the majority of 11 out of 12 who recommended that the point we had reached represented a reasonable way forward. I made that judgment call which was supported by the majority of the committee. It is not always possible to reach consensus. However, on the serious issues we needed to address on moving the service forward, there was a fantastic level of engagement and agreement. I was very disappointed not to reach unanimity — I was just not able to achieve it. I have developed considerable skills in chairing groups and reaching conclusions. However, it was just not possible on this issue, despite our best efforts. It is important to acknowledge that even Dr. O'Dowling worked with us to try to resolve the issue. He contributed to the group as much as everybody else. Ultimately, it was just not possible to resolve the issue, unfortunately.

Does Mr. Kane envisage that the historical issues in dispute will be dealt with through this new mechanism or does he anticipate that the new mechanism will only be used in dealing with issues which arise in the future?

Mr. Kane

The recommendation I have proposed is to deal with the historical issues. If the three colleagues felt there were particular issues in their work with the HSE, the matter would be addressed at this forum.

When the report is published, will we have the opportunity to meet the full review group? While I accept what Mr. Kane has said, I am still not contented. Will we have an opportunity to revisit the matter with all 12 members appearing before the committee?

Given the place it had on the agenda, both at this meeting and at our previous meeting, it would be a good suggestion.

When will the new guidelines be introduced?

Mr. Kane

I have approval from my CEO since last Monday night for the new guidelines to be introduced. I now need to establish a training or calibration exercise. I have organised for Professor Stephen Richmond from the United Kingdom to come to carry out the calibration training, initially with consultants. They will then carry out the training with specialists and those making referrals. Approximately six weeks after that training process has been completed, we will be in a position to work on the new guidelines.

Mr. Kane

I was targeting May, but I lost some time because I was trying to book space in Professor Richmond's diary so that he could come to Ireland. I lost the initial slots I had booked because the report was not approved until last Monday. Our very clear plan involves Professor Richmond coming to Ireland to do the training and calibration exercise with all the consultants, who will then roll it out to their own staff. When that process has been completed, it will take us about six weeks to move to the new system. I intend to do that by the summer.

Does that mean the HSE feels it will be able to address the issues of capacity and waiting times?

Mr. Kane

In respect of capacity, we will use something like the National Treatment Purchase Fund to target the historic problems we have had. That is one strategy for getting people into treatment immediately. The second strategy involves recruiting additional staff to start to roll out the system. We have set a new date, as I have said, and new guidelines have been put in place. We will measure the impact of the new guidelines in a more concrete way at the end of the year. As someone said to me earlier, the new criteria we have agreed will help us to find out who is and is not being treated. We went around the country to examine the various guidelines which were being used.

When the new guidelines are in place, everyone will be using the same thing. We will know exactly what we are talking about. We will have accurate data because we have agreed a data set to gather information. When we sit down at the end of this year with six months of information, we will be in a much better position to say precisely what we can do. We will concentrate on services which are not based between 9 a.m. and 5 p.m. when we target the historic blocks in a focused way.

Has the HSE reached agreement on the budget for that plan?

Mr. Kane

We are finalising that agreement. I do not foresee any difficulty with it. When we publish our report the week after next, people will be able to see clearly the precise numbers we will be targeting.

Members have referred to the historic situation, but the HSE considers that it is critical to focus on what it needs to do in the future if it is to deal with large waiting lists in certain areas. The HSE has focused on reaching consensus on the service development that is required. It has concentrated on issues like guidelines and training to ensure that each of the HSE local areas can look for the speediest possible resolution of the various problems. The HSE will continue to focus on tackling people's real problems.

I would like to ask one or two questions before we conclude. A chief dental officer has not yet been appointed.

What difficulties will arise if the Department cannot find a suitably qualified person to oversee all dental services?

I am glad the Chair added a second part to her question. The position of chief dental officer is vacant. The services of a dental adviser are available to the Department on a part-time basis. The ongoing vacancy is not having a significant bearing on the immediate issue that is under discussion. Our dental adviser was involved in the group. The absence of a chief dental officer will not prevent the implementation of the plan. The role the chief dental officer will have in developing and planning oral health services is a broader issue. The filling of the vacancy is under active consideration within the Department, which is considering the matter in the broader context of its changed role, following the establishment of the HSE, and the professional advice it has received from many sectors. I assure the committee that the filling of the position is under active consideration. The absence of a chief dental officer will not delay the acceptance of the report's recommendations.

I am glad to hear that the filling of the position is under active consideration because it has been vacant for a long time. It is important to find somebody suitably qualified to oversee national dental services.


I am concerned about the criteria for eligibility. Patients in categories A, B and C were being dealt with previously. As Deputy Cooper-Flynn pointed out, it is possible for the HSE to indicate that improvements are coming because it is no longer counting patients in category C for such purposes. Such children were previously eligible for services. They were looked after in the heyday of the Irish orthodontic service, when waiting lists were not really an issue.

Mr. Kane

When the HSE tried to gather information about patients in categories A, B and C, it was counting apples, oranges and bananas. It was not making sense because so many variables were coming into play.

The equivalent of categories A, B and C can now be considered, following the introduction of the standardised system. The HSE will now count pears alongside pears.

Mr. Kane

Absolutely. The guidelines we are proposing, which are very clear, will expand the eligibility criteria. The application of the guidelines will be consistent throughout the country. We are bringing Professor Richmond to do the training and calibration exercise so that the guidelines will be applied in a standard manner throughout the country. At the end of 2007, when the HSE starts to measure who is waiting for assessment or treatment, that measurement will be based on the same criteria in all areas.

Do I understand correctly that the new form of measurement will capture only those patients who were in the former categories A and B and not those who were in the former category C?

Mr. Kane

When we start to use the new guidelines, the full range of the former categories will be covered. When we start to count the patients, we will not make any reference to categories A, B and C. We will use a new categorisation that is based on the index of orthodontic treatment.

Does Mr. Kane see the point I am making? I do not know what category in the new index of orthodontic treatment is equivalent to the former category C.

Mr. Kane

I understand that the former category C is well covered within category 4 of the index of orthodontic treatment.

Will category 3 or category 5 be equivalent to the former category A?

Mr. Kane

Category 5 covers most of the former category A.

Category 5 will be like category A, category 4 will be like category B and category 3 will be like category C.

Mr. Kane

It will be like some of category C. As I am not a clinician, I will put it in layman's terms. If one has a condition that puts one in category C, one might also have a condition that puts one in category B. A patient in category A might also be in category C.

I am trying to find out about categories A, B and C, which were counted previously. There were no problems with waiting lists for people in such categories. I welcome the decision to adopt the international index. I would like to be sure that the entire cohort of people with certain dental problems will be captured under the new system.

Mr. Kane

Yes. The seven clinicians who were in the group drew up the guidelines and made recommendations to us about what we should use. Dr. O'Dowling was a key member of that group. The group's proposals were unanimously recommended by all the clinicians involved. They said that if we use the guidelines to standardise the categorisation of the children who are most in need of orthodontic treatment, they will get that treatment. While they had some concerns about capacity, they said it was important to adopt such a change, given that certain children had been excluded. They argued that we should start to deliver services to a wider group of children in a uniform way.

That is why we will move towards a European standard. An Irish child will get the same treatment as a child in similar circumstances in France or the Netherlands.

Mr. Kane

Absolutely. It is based on the same measurement in the index of orthodontic treatment.

Is it the case that what is available to children in other countries will be available to Irish children?

Mr. Kane

I am unable to answer that specific question. I would not like to mislead the committee. I do not know the answer to that question.

It is obvious that the adoption of the new approach will have huge resource implications for the Irish system. We are now covering more people than we ever covered before.

Mr. Kane

The evidence is not clear to me. There seems to be potential for an increase of 7% in the number of children aged 12 who will be eligible. The potential increase will be in that range.

There will be an increase of 7% on the number of children being treated at present.

Mr. Kane

Yes. Some of the 7% to whom I refer are already covered in different places and in different ways. It is not a net, or total, 7% because it varies — different people are doing different things. The overall increase will be approximately 7%. The children who are already being included in some places can be deducted from that figure. That will be the piece. We will put the data set alongside it so we will have very clear information on which to base future plans.

If the HSE implements this by May and then has to wait for assessments, etc, to be carried out, when will it have a true list of all those who are eligible?

Mr. Kane

We will target the assessment and treatment waiting lists off-line, using an approach like that used for the National Treatment Purchase Fund. That will help us to work straight away on validating what we currently have. As the new people come on stream and the operation of the system starts to build, we will be able to use the new guidelines to see clearly what are the numbers. If they increase, we will be in a position to see it.

The other advantage of using standardised guidelines is that it will clarify the position. Part of the difficulty with the old guidelines for a primary dental surgeon was that people were referred on when he or she was not sure about a case. With the training provided for the new guidelines, the referral path should be much clearer. Accordingly, dentists will have much more confidence when they see patients and will know whether they are eligible. This new approach will also speed up the process.

We have made progress here today. It was important to acknowledge the services previously offered in the mid-west region were not inferior. Mr. Kane indicated there would be a return to the level of service previously enjoyed and that waiting lists would become a thing of the past. Public representatives from around the country receive correspondence and representations on this issue. Accordingly, we look forward to seeing a reduction in the size of our mailbag.

I thank the witnesses for coming before the committee and for the work they have done. I appreciate the effort involved. The committee has done much work in this regard so we can empathise to some extent with them on this complicated issue. We look forward to the official publication of the report and the restoration of services in the coming year. It is good to have a timescale. I hope the objective will be met on time.

The joint committee adjourned at noon until 9.30 a.m. on Thursday, 8 February 2007.