I am the newly appointed oral health lead. My own background is as a dentist and, more particularly a dental public health consultant. My remit in this post will be to develop a strategy for the effective and efficient delivery of HSE dental services, including the delivery of specialist services such as orthodontics.
The HSE is moving dental services towards an integrated care model. Appropriate care will be provided in appropriate settings with the simplest care provided in a local setting. The most complex and specialist care will be provided in a regional or, for very complex care, in a national service.
Several issues needed to be addressed in oral dental health services. A national system of governance and audit must be put in place to ensure appropriate and quality standards and outcomes. There must also be a skills-mix where appropriately trained dental professionals, matched to the complexity of cases in a variety of care settings, are made available to ensure ease of access, best value for money and quality of care in all settings. A more integrated approach to oral health care is also needed with joined-up care in which an overall and holistic approach to dental treatment is taken.
A substantial number of treatments have been provided and completed since 2007. I have already submitted to the committee figures relating to the increase in the numbers of people in receipt of dental services. A substantial budget is also available for these services.
I am recommending orthodontic services be provided across primary, community, secondary and tertiary care services and care should be provided at the lowest level of complexity nearest the patient. This should depend on the complexity of the case, the setting and resource including the skill of the providers. The assessment of waiting lists and treatment of those children, when growth is beneficial, so that an easier, less complex and shorter intervention is necessary will be a priority. In other words, the earlier we provide treatment to children with assessed need, the better the clinical and psychological outcomes for that child. There would also be a better chance of influencing growth patterns and of compliance with necessary treatment regimes.
The expanded index of orthodontic treatment need guidelines has been in place in the HSE since 2008. Persons in categories of 4 and 5, the most severe categories, are currently entitled to HSE care. These guidelines are now taught in dental schools as part of the undergraduate curriculum. Also, many primary care dental surgeons have had the opportunity to be up-skilled in the salaried services to enable appropriate referral.
While both these initiatives have been excellent, it is important we go to the next stage. I am proposing a reduction of the assessment waiting list, removing some parents' concern that their children may not be eligible for care despite waiting a long time for further assessment. A pilot implementation programme will allow us to learn lessons for full implementation and allow us phase out the waiting list in a controlled and managed way.
This initiative will also enable the prioritisation of children who will benefit most from early intervention. Those who would benefit more from later intervention will also be prioritised.
Other characteristics should also be taken into account such as a patient's medical history, social history, special needs including behavioural and phobic issues, benefit from early or later intervention and the complexity of treatment needed. Such holistic approaches have been piloted in Britain and elsewhere with considerable outcomes.
We have moved forward with our strategy of putting specialists and consultants in place. It is now timely to assess if we should put a further support in place for these specialists and consultants. By supporting a better primary care system and building on previous initiatives, we will not replace the strategy of specialists and consultants that is in place, but rather by putting in a support structure of primary care dental practitioners providing services to some of the more simple and less complex cases, in many cases this will prevent orthodontic conditions from worsening. This means, in effect, that a child will not have to be compelled to be treated by a specialist or consultant down the line, if there is much earlier intervention with much simpler treatment.
As alluded to by my colleague, in the longer term we should like to look at the possible impact of skill mix such as orthodontic therapists, but the first priority is to look at the influence and impact of the primary care team approach in dental practice being more involved in care. The benefits of this holistic approach, skill mix and team working only become apparent when the outcomes are clearly measured using an overall oral care plan approach. In simple terms each child may have several different team members, from a consultant to a specialist to the general dental care practitioner involved in his or her care, but these individuals will be working to a single plan. A single clinician will have clear clinical oversight. Rather than the old fashioned concept which was the norm in dentistry before, of simply delegating tasks and patient treatments to another professional, this is a much more holistic and a different type of approach. Clear clinical audit is essential right from the start. There is good practice in the country already, but we want to build on that and have it as a national system.
Moving on, I want to talk somewhat more about the waiting list initiative. I want to highlight the fact that in some cases there have been particular reasons for backlogs to occur, particularly in the south, and we can talk about this later. A backlog has occurred there because of the unexpected death of an orthodontic consultant, and this was an extra service burden. A new consultant has been appointed, however, and will take up the post shortly, so hopefully the problem will be alleviated in the future through adherence to the strategy. In other areas the waiting lists have been affected by the recruitment moratorium.
A system has been put in place to track waiting lists and quality initiatives nationally. This has gone a certain way in that we looked at the overall times for waiting lists. However, we need to refine the collection of the data because it is not clear and transparent from the existing information what the different categories of patients are. Some of them have very severe classifications and it is clear that those children are being prioritised in some areas. Indeed, their waiting lists are not long. In many cases they are only waiting six months or a year, at most, before intervention. That is masked by many of the other categories of patients on the waiting lists. The data, then, need to be more clear and transparent.
I am proposing that we look at a service waiting list initiative, particularly around the treatment assessment. It is important that waiting lists are clinically validated to ensure that those who will benefit most from early intervention will be assessed first and treated early. It is also important that those children who will not benefit to the same extent are clearly identified and pulled out separately from the waiting lists. The initiatives will be piloted and evaluated, and will only be rolled out in a phased manner from the lessons learned. It is important, too, that we look at a closely monitored support system that might be put in place, where general dental practitioners would have a more active role in providing services.
Finally, the publication of the national oral health strategy in the future will facilitate us in the development of the specialist services, at national, regional and local levels. I am also recommending that within the HSE we should reactivate the original orthodontic review group that put forward the recommendations. However, I want this broadened. I want to see whether oral surgery, maxillofacial surgery, special care dentistry and other specialist services can be involved in that orthodontic review group. In the event, it would be a specialist review group, with primary care having a very strong voice as well, so that we could have a much more holistic approach as regards the development of oral health services.