Orthodontic Services: Discussion with Department of Health and Children and the HSE

Before we begin, I advise that by virtue section 17(2)(l) of the Defamation Act 2010 witnesses are protected by absolute privilege in respect of their evidence to this committee. If you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to do so, you are entitled thereafter only to a qualified privilege in respect of your evidence. I am sure this will not be necessary but I shall continue. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against any person or entity by name or in such as way as to make him or her identifiable. Members are advised of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I welcome the officials from the Department of Health and Children and the HSE to the meeting. I ask Ms Teresa Cody to proceed with her presentation and followed by Dr. Dymphna Kavanagh, clinical lead on oral health, HSE. The presentations have been circulated and members have had an opportunity to read them. We will take a group of questions thereafter. We have allocated about an hour for this discussion and I hope that will suffice.

Ms Teresa Cody

I thank the committee for the opportunity to discuss the position on the implementation of the recommendations of the Oireachtas joint committee reports on orthodontics. I am also grateful for the opportunity to inform the committee on other relevant policy developments.

I am joined by my colleague from the Department, Peter Henshaw, and colleagues from the HSE. My colleagues from the HSE include Dr. Dympna Kavanagh, who was recently appointed interim clinical lead for oral health, HSE. She will update the committee on orthodontic service developments. Also present are Mr. John O'Brien, HSE west, Ms Gretta Crowley, HSE south, Dr. Marie Cooke, consultant orthodontist, HSE south, and Ms Mary FitzPatrick, Dublin Mid-Leinster.

Since our last meeting with the committee in early 2007, members will be aware of the sudden and rapid change in the position of the public finances. As the committee will also be aware, health spending accounts for approximately 27% of all Government spending and it was therefore necessary to examine this expenditure as part of the Government's strategy to restore the public finances. Due to the position of the public finances, the Government had to take action to reduce and curtail expenditure in several dental and oral health related areas. It has reduced expenditure in the State adult dental schemes. In addition to this, in an effort to achieve sustainability in the costs of delivering public services, a moratorium on recruitment in the public sector has also been introduced.

The Department recognises the delivery of oral health services needs a policy context. In this regard, since our last appearance before the committee, the Department and the HSE have been working to develop a new national oral health policy document. This process has involved critically examining the many challenges and issues facing the dental sector.

A core policy group, which includes representatives from the Department, the HSE and Professor John Clarkson, Professor Emeritus, Trinity College, Dublin, was established to drive the development of this policy. The main issues addressed in developing the new national oral health policy are a revised regulatory regime, including a new dentists Bill, the integration of oral health in the wider health care delivery system, including enhanced synergies with health promotion, children's health, and primary care. In addition, this policy will also examine oral health services for people with disabilities, those in long-stay care and services for older people.

While the draft policy will focus on patient issues, it is also intended to address the competition issues raised by the Competition Authority in its report on the dental profession. The draft policy will also consider the issues of manpower planning, specialisation and skills-mix, including recognition and the possible future expansion of the role of auxiliary dental professions such as hygienists, dental technicians, orthodontic technicians, orthodontic specialists, and the identification of appropriate training needs. We are working to finalise the policy document which should be available later this year.

Dr. Dympna Kavanagh

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.

I thank Dr. Kavanagh and Ms Cody. I call Deputy Neville.

I thank the witnesses for their contributions. I was a member of the two previous committees that made the proposals in regard to the service. The witnesses have covered some of it in a general way. Before I go into that, however, on 3 March 2010, Fine Gael tabled a parliamentary question in the Dáil as regards the then state of orthodontic waiting lists, country-wide, and it has not yet been responded to. I have a copy of the question here, incidentally. It was Question No. 146 on 3 March 2010 and we have not yet received an answer to it. I wonder whether the HSE will give us the information now, or is there any reason why it has taken so long? If I did not ask it now, we would not get it at least until the autumn, because the Dáil has now risen.

With regard to the guidelines for orthodontic treatment, the witnesses will recall that it was recommended the index should be changed and replaced by the index of "orthodontic treatment need" immediately, on a national basis. I wonder whether that has taken place. I gather from what has been said that persons classified as grades 4 and 5 in terms of the severity of their need for treatment should be then removed from waiting lists and given the requisite orthodontic treatment. I gather that grades 4 and 5 patients are still on waiting lists, despite the recommendation.

The issue of the training of orthodontists came out very strongly at those meetings and has arisen since. It has been recommended to the committee that the Minister should implement training measures as a top national policy, to ensure internationally accredited bodies are given proper recognition. This recognition would then facilitate an increase in the number of qualified orthodontists. Has that taken place? Reference was made to the training programme provided by a number of orthodontists in the former mid-west health board area, which was stopped, and it was recommended that it be reinstated immediately — this was 2002 and 2005 — with the requisite academic supports, as a means of further increasing the supply of trained orthodontists. That has not taken place, and it was a key recommendation of our committee at that time.

Would the witnesses not accept that if this was implemented, the present waiting lists of around four years in the Limerick area, would be considerably reduced? In fact if was to be introduced at present it has been suggested to us that the waiting lists could be eliminated in seven months, if there was full implementation of the training programme, which the committee looked into very carefully and satisfied itself as to its standards. It was agreed that it could treat many more patients without increased cost to the HSE and each trainee could actually take 500 children off the orthodontic waiting lists. Why has that opportunity not been taken up?

Some of us are suspicious that vested interests might have a role to play here. If a great many patients are removed from the orthodontic waiting lists, there will be less private work to be done. I know that the HSE has purchased at very high cost orthodontic treatment in the private sector, and surely there would be a considerable training pool in the event of the introduction of the system the committee was happy to endorse on efficiency and safety grounds, which is being operated in many other countries.

We suggested funding for specialist training places should be restored in the event of the State having to provide funding for orthodontic trainees who should be required to commit to the public service upon graduation. Obviously, that did not happen. If the finance was not available, the committee was of the view that on completion of their training trainees should commit to the State service for a period of time to return the value of any costs incurred.

We said five additional oral surgeons and five maxillofacial surgeons should be appointed without delay to compliment orthodontic treatment services. What has happened in that regard?

The delegates can take a number of questions and avoid mine or pick those of them that they wish to answer. That is the way the committee works, but we will be scrutinising the Official Report to read the responses received.

I am sure the committee will make every effort to ensure the Deputy's questions are dealt with comprehensively, as always.

I welcome the delegates. I welcome, in particular, the appointment of Dr. Kavanagh because the appointment of an interim oral health lead, if that is the correct term to use, has been promised for some time. It is very important that the position has been filled.

I take heart from the presentation made today. It is very positive and strong and shows an intention to bring about change, which is very welcome.

I was not a member of the previous health committees, but I have read the transcripts and received a lot of correspondence from Dr. McNamara in Limerick, in particular, whom we all know at this stage. I take heart from some of the comments made by Dr. Kavanagh in her presentation and would like to tease them out a little, following on from Deputy Neville's questions, because one of the issues was the appointment of a lead clinician, which has been achieved. There are issues surrounding training, waiting lists, the methodologies to be used and how we ensure the available expertise is fully used, not just those who have been trained in the country but also those who have been trained outside it. That is the campaign Dr. McNamara has been leading for many years, something with which Mr. O'Brien will be familiar, as he is an official with whom we all worked in the old Mid-Western Health Board. He is also very familiar with the background to the issue.

At the bottom of page 5 of her presentation Dr. Kavanagh states: "It is timely to assess if the introduction and assessment of a different approach in some areas supporting the personnel already in place and building on previous excellent initiatives should be put in place". Can I take it that the training programme which Dr. McNamara and others implemented to successfully treat a lot of patients through the orthodontic service is now an accepted part of what is provided in this country?

I received a reply to a parliamentary question. I am not sure when I tabled it, but I received the reply on 23 March. It did not refer to figures, which is what Deputy Neville sought, but to a progress report on what was happening. It read:

The specialist orthodontists trained in the UK all returned to work in the HSE in return for sponsorship of their training. The issue of cross-jurisdictional training pathways is no longer as significant as the HSE is not currently sponsoring any postgraduate orthodontic students in the UK.

Can I take it from that answer that there is no longer a conflict in terms of the training provided in the dental hospital and the United Kingdom in terms of what is right and wrong? We need to get rid of this from the system. We need to ensure those who need dental and orthodontic treatment receive the best possible treatment in the fastest possible time, which is why I am encouraged by what has been said, in referring to the use of the primary care system integrated with the follow-up system and ensuring it happens at the best possible level of service and those with more complex needs will be assessed and receive treatment early, rather than placing everyone on the same waiting list. That is what I understood Dr. Kavanagh to say. If I heard her correctly, that is what she proposed. I would like to hear specifically when that will be achieved. Dr. Kavanagh said there would first be a pilot programme. How long will that take? Where will it take place? She suggested there might be centralised waiting lists in order to ensure those who most need treatment will not be kept waiting and that there will be standardisation across the country. I ask her to clarify whether there will be centralised national or regional waiting lists and how this will impact on the service.

We all want to achieve the best possible service. There have been huge issues and conflicts, beyond which we want to get. As a committee, we also want to ensure that in getting beyond these issues we will use all of the expertise available in the country, including that of Dr. McNamara and the scheme he has piloted. I want to ensure that service will be part of what will be provided in the future.

I welcome the delegates and thank them for their presentations. I also welcome the appointment of Dr. Kavanagh. I agree with a lot of what she said. It all makes perfect sense when we are sitting here and listening to her, in particular her comments on the need to develop a holistic approach. The habits children learn early in their lives stay with them.

As a relative newcomer to the committee, I find that when I meet different groups from the HSE, they are all doing a great job within their own areas, but there is a huge lack of communication within other disciplines. I refer, in particular, to the importance of primary care centres and how well the system will work. There is a need for a greater level of communication between public health nurses, dentists, doctors and all the other disciplines involves to ensure this happens.

I share Deputy Neville's concern about the information we have not received on waiting lists, that is, the numbers involved, and waiting times. There are huge variations throughout the country. We need to tease this out a little more to determine why that is the case. A delegate referred to a case in which the consultant had died. However, there have to be other reasons there are huge waiting lists in some areas of the country, while a very efficient service is run in others. I will give one example. I understand that under the school dental scheme children's teeth are assessed in second, fourth and sixth class. My daughter finished fourth class this year and there was no note, word or mention of a dental check for her. I am fortunate. We visit the dentist every six months. However, there are others who are not in a position to do this. If one is referring to the need for early intervention, the children concerned have missed out and it may be another two years before they receive another opportunity. Are dental clinics run throughout the summer when the schools are closed to make sure as many as possible of those in fourth class are checked? It is a huge concern because if there are problems, they need to be detected early. If they are not, they will become a bigger problem later in their lives.

The other question relates to the number of dentists, the number in training and the numbers who will qualify this year, who I assume will be used in the service. I am aware of moratoriums and so on but if there are waiting lists, we must do whatever is possible to ensure they are reduced as soon as possible.

My last point is in respect of costs for orthodontic treatment. Deputy Neville referred to the private work. Many people, me included, are paranoid about their children's teeth. While I probably did not get the treatment I should have received when growing up, I am conscious that they get the best possible treatment and if they need orthodontic work that it is done. There are people who are not in a position to do that and they may fall between two stools. One considers going private and the cost of the private work, and the differences in costs North and South, and in some other countries where people are going. I had a case two weeks ago of a person trying to get a passport because of a dental appointment. That is the reality. While these clinics and orthodontics are, I am sure, reputable, one does not know, but people take the risk. If the treatment is not available here at an affordable cost, what are people supposed to do if that is the choice they face? Perhaps the delegation can provide some clarity on those issues.

I welcome the delegation and especially Ms Gretta Crowley, with whom we work all the time. I have listened to Dr. Dymphna Kavanagh's outline of what is intended in the area of orthodontics and the entire dental service. The service has been a disaster up to now. It would great if what is being proposed comes to fruition but it seems like Valhalla to us listening to it. I cannot let the meeting pass without mentioning Ian Dowling who, for many years, fought for and provided an exceptional service in Cork under very trying circumstances and also Ted McNamara who lobbies us continuously but always in the interests of others. That is something one has to take on board when people are determined in their campaign on behalf of others. We all respect him for his efforts.

If I heard correctly, another orthodontist has been appointed to the HSE for south Cork and will take up the position shortly.

Ms Gretta Crowley

Yes. The second consultant is in post.

That is very good. Until now, we have had a consultant orthodontist in Cork North Lee, Ms Gretta Crowley. Mr. Ian Dowling's substantial list was transferred in its entirety to Ms Crowley. The list in North Lee was even more substantial because there had been an additional waiting time of a year and a half with no consultant orthodontist in place. At this point we are talking about a five-year waiting list for the combined lists. I understand the lists will be split again because a second consultant is in place but what will be the waiting list now for Cork North and Cork South Lee? I presume Dr. Kavanagh's proposals for downstream upskilling will be put in place.

In regard to people with special needs, because of the need for anaesthetists and anaesthetics in the majority of cases, with one clinic per month and only two patients dealt with, the waiting list is five years. These are not people who can go to the private sector. It is an entirely different cohort. People with an intellectual disability can go to a private dentist but because of their additional needs they usually have to be dealt with in a very specialised clinic. What will be done about that? Will additional clinics be available for emergencies. If the waiting list is five years there will be emergencies.

In the event that one or two of the consultants in place must take time off, is there any facility to replace that person, even for a short period? That was the difficulty in the past.

I thank Ms Cody and Dr. Kavanagh for their presentations. I wish Dr. Kavanagh every success in her new post. What is the number of orthodontists and the distribution of same and are some areas well served and other areas not well served? When it comes to Dublin North-East, we have a problem. Very often the figures appear exceptionally good for Dublin North-East but when separated out for Dublin, they look bad for Dublin North-East. For example, when the home care packages were introduced the figures looked extremely good but when we analysed them they were all in Dublin.

On the issue of budgetary constraints, how will the orthodontic service in Ireland deal with the whole question of better value for money. How much of the savings will be effected through better value for money rather than reducing the level of service? What analysis has been done on productivity in the different areas? There appears to be a variation in the return on investment in terms of productivity in some areas more than others. What is being done to identify best practice, and ensure it is implemented, and find ways and means where that can be better value for money? It may be related to the amount of time staff spend travelling to outlying districts. When resources are scarce it is important to try to effect as much saving as possible through better value for the money that is being spent.

In regard to the criteria and the categories one to five, categories four and five are taken as the most serious. Dr. Kavanagh referred to the oral health needs and the overall needs. One of the areas not always considered is the psychological implications for some people of having teeth out of place which may not fit into category four or five. Is any account being taken of that in the review of needs given that it is a serious issue for a small number of young teenagers, who are very embarrassed because of the condition of their teeth, who do not fit into category four and five but they need to be addressed.

My final question is on the orthodontic review and the whole question of oral health. I have been informed that an increase in oral cancer is being detected by some dentists. Is that an issue?

I welcome the delegation and thank it for its presentation. The focus is on the new national oral health strategy, which is welcome and sounds good on paper but I hope that is the case when it is rolled out, and that there will be an end to waiting lists. It is all about primary care and early intervention at an early age.

Like my colleague Deputy Condon, however, I would be worried about people who have been missed over the years because while children might be assessed early, they do not get treatment until they are 15 or 16, when their teeth have developed. There are many children and worried parents who are anxious to get access to treatment but who cannot afford it. Will the new strategy help those people? Orthodontic treatment is very expensive.

Early intervention and primary care are vital, it should go without saying. The old adage, a stitch in time saves nine, is right in this case.

I am from the south east. Why is the waiting list in my region longer than in the rest of the State? Is it because of the consultant who died? I am glad to hear the new consultant has been appointed.

I welcome the delegation. I wanted to mention Crumlin and Tallaght, the areas serviced by the HSE in Old County Road. My attitude to dental care and, indeed, to my own teeth, can be traced back to the Old County Road health centre. It was half a century ago but it was there I learned what I should do about my own teeth. It is important to make that point in supporting the service, that is where young people learn about dental care.

Since I served on the health board, I have been aware that orthodontic treatment was a problem. I know from Old County Road that about 90 patients every three months are sent for further assessment and treatment to St. James's Hospital. The problem then arises that the assessment is done quickly but the treatment does not happen quickly. There is not a month where I do not have representations from people lamenting that delay.

It is important we get the message across about dental care. We should also stress that when children have problems, they should be assessed properly and treated. I have difficulties accepting the criteria for the delivery of treatment because we have all seen cases where people seek the HSE service but are told they do not fulfil the criteria. They go to an expensive private practice that then tells them differently.

We should support the service. There are constraints, with those on medical cards not getting service, another appalling vista. I am not ambushing the witnesses but we are saying to young people that they should be careful about their teeth but then failing to deliver a service. That is the challenge.

I join with other members in commending the presentation. It displayed an admirable ambition to improve a system that needs radical change. We wish them well and will assist and encourage them in their work.

Deputy O'Hanlon mentioned the complement of dentists and orthodontists working in the public system. How many of them are there, how many vacancies are there and how is the public sector recruitment moratorium impacting the system? Following the death of the consultant in the south, how long does it take for the HSE to fill such a vacancy?

Members have alluded to the cost of treatment here and the significant numbers now travelling abroad to access treatment. While one would expect treatment across the Border to be of a high standard, what about who travel to other European countries? It is one thing to go for initial treatment but what happens if something goes wrong? What is the follow-up care like?

We have seen the HSE acting effectively and forcefully to deal with the cost of medication in the system and have seen the confrontations it has had with the pharmacy sector. What is the HSE doing to drive down costs in dental services? On average, how many consultations would a HSE dentist have in one day?

Having had discussions with Dr. McNamara, it would be remiss not to refer to the training programme he has devised. The passion he has for his profession and the capacity he displayed to deal speedily with the waiting list system are admirable. Is the course he has plotted reflected in the system Dr. Kavanagh is putting in place?

Dr. Kavanagh's title refers to Dublin and Mid-Leinster. Does her responsibility stretch beyond that to the entire State?

Dr. Dympna Kavanagh

It is national.

What happens to those children who might not benefit from early intervention, who need to be allowed to develop? At the moment, they simply fall off the radar.

Given Deputy Neville's pessimism at the start about his questions being answered, those might be addressed first.

Ms Teresa Cody

Deputy Neville asked a question about a delay in answering a parliamentary question. There was industrial action under way.

Deputy O'Sullivan's question was answered.

My question was asked earlier. The answer was issued in March but the question went in before that.

Ms Teresa Cody

There was a delay due to industrial action.

That line is being regularly trotted out as an excuse.

Dr. Dympna Kavanagh

I was only appointed a week ago but I am happy to chase up the question.

This is certainly a baptism of fire.

Dr. Dympna Kavanagh

The index of treatment need was also raised. It has been introduced nationally since 2008 and all areas are now participating, with children being assessed in accordance with the index of treatment need, with the top two categories, the most severe categories, currently entitled to public HSE care. The introduction of the five categories means there has been an increase of 24% in the number of children eligible for care. It varies in different regions but it has opened up entitlement for children instead of restricting it.

What is the waiting list for categories 4 and 5?

Dr. Dympna Kavanagh

When I spoke about having more clarity around waiting lists, some areas put category 5 lists as separate and those waiting lists, the most complex and severe, are generally seen within six months to a year. In other areas they are not listed separately, an initiative I want to look at. It is crucial that those children are pulled out separately and looked at. As part of that complex, I will ask the clinician to comment on it. There is also a particular category of patients where it is not in their best interest to see them early, we must stand back, and I would argue that they should not be part of the overall waiting list. It does not make the waiting list transparent.

Dr. Marie Cooke

When talking about patients with growth deficiencies or anomalies, many of them must finish growing at 18. We keep them under review so they come back and we track their growth. Some children, even when they reach the age of consent, may decline treatment. The majority of those patients would be those for facial surgery, orthognathic surgery, which ties in with our oral maxillofacial surgeon. Some of these patients are sent to us at age eight and we know at that age they will have a large bottom jaw, for example. We keep track of them and at 18 invite them to visit the oral maxillofacial surgeon and put the treatment plans to them. The majority then make their own decision.

Some patients with growth anomalies or syndromes benefit from earlier surgery so those patients are not put on the waiting list, they are treated when they are ready. It is the same with children with cleft lip and palate. There are different stages of treatment for them: age nine for bone graft, orthodontics in their mid-teens and then potentially facial surgery when they have completed their growth between 17 and 19. They go on a waiting list technically but come off almost straight away. They are closely tracked. They are my high priority patients.

We want a national approach to children with cleft lip and palate. We must sit down and consider them in addition to those with special needs.

Dr. Dympna Kavanagh

I emphasise once again that there must be greater clarity on the interpretation of that waiting list. It is not just a block waiting list, and that is what the initiative is about: putting in place different categories so the list is clearer and less worrying for people looking at it. They will be able to see why clinicians are waiting and where the problems lie. In some cases there are problems but we want to address and target them by putting the initiative in place.

Ms Gretta Crowley

About 10% of our waiting lists, as we are currently counting them, fall into that category at any one time.

Dr. Dympna Kavanagh

International accredited bodies were mentioned.

I raised the McNamara project, which was doing very well in Limerick but was then pulled.

Dr. Dympna Kavanagh

The Deputy asked specifically where the pilot would be carried for the initiative. We have an agreement with the integrated service area in the mid-west that the pilot will take place there. The local consultant has been involved in discussions on it. That is an area where I am concerned about the waiting lists, so it is important to look at some of the early intervention in other parts of the country. We estimate that 26% of children on the waiting list may benefit from that early intervention. We could see similar results in the mid-west, then look at the prioritisation on the waiting list to achieve real numbers.

I am not familiar with the previous training scheme but if it had a primary care element, it was about primary care, intervention and support. This is about supporting the specialists and consultants in place, it is not about replacing them; that is the distinction. It is not about doing the same work because they are trained to do a particular type of work. It is work that is completely within the general dental practitioners' capacity, although there must be some upskilling and we will look closely at that in a clinic audit of outcomes. It is a good way forward and with the support of the mid-west managers, the ISA, and the local consultant we are optimistic about the pilot in the mid-west.

Mr. John O’Brien

I re-enforce Dr. Kavanagh's point. I support the initiative in the mid-west. We met the consultant and he is happy that the initiative is under way. It is not quite the same scheme as 11 years ago but the consultant is satisfied with our thinking.

I am not happy that the recommendation from two committees in 2002 and 2005, that the training programme provided by a number of orthodontists in the former Mid-Western Health Board area should be reinstated immediately, has been ignored.

Mr. John O’Brien

I attended at least one of those committees and fully supported the recommendations at the time. There was an issue about getting accreditation and achieving recognition here and elsewhere.

The trainees got gold medals for their work.

Mr. John O’Brien

I am well aware of that and they are still working with us. We are trying to address the situation at present. We have discussed that fully with Dr. McNamara. I am confident we can make a serious impact now in the mid-west with the waiting list.

Ms Gretta Crowley

With regard to the question about the number of trainees, and how many clients they take off our waiting list, in the Cork programme, the postgraduate programme had its first intake in 2006, when four students were placed on the programme. They were sponsored by the HSE with a commitment to enter employment. As part of the programme, each student took on 125 clients for treatment over the three year programme, so the postgraduate training programme took 600 patients off the waiting lists. They qualified successfully in 2009, with a number of treatments to finish, because orthodontic treatment can take a long time. We decided, in conjunction with the postgraduate training school, that it would be better for those students, who are now employees of the HSE, to complete those treatments. They spent one day a week when they started with the HSE completing the treatments. The fact that a fifth of their working week was taken up in that way impacted on their ability to take on new clients but we felt it was in the best interests of those clients at that point in their treatment.

Four more students were then taken in. Because of the increase in supply in orthodontists, no sponsorship was offered to these four students but they undertook the programme anyway. Those four students are now taking on another 125 patients each from the waiting lists in the HSE south-west region.

Our four postgraduate qualified students are now employed in the HSE fulfilling their sponsorship requirements. Our initial plan for those students was that they would tackle the waiting lists, which were extensive. They commenced with us in October and then, unfortunately, on 10 October, Dr. Ian O'Dowling passed away, much to our surprise. It was a tragic event. He was prolific in his work and he had a caseload of approximately 600 clients, who we had to take over for transfer. In that regard, we had to assess all of the clients, arrange for their transfer and take those transfers over. Those clients have been distributed to the consultant and the specialist orthodontists. In the interim, we had employed two additional specialists, and we have employed now a total of six specialists for HSE south, that is, Cork and Kerry, which is a significant increase on what we had. They have taken on the clients.

On caseloads and waiting lists, we would expect that every year a specialist would have approximately 350 persons in treatment. Obviously, the treatment goes on over a two to three-year period and we would expect them to finish out approximately 150 cases per year. Each of the specialists this year took on approximately 60 of the transfer clients and some of them were allocated to the consultant based on the complexity of the case. They have taken on 60 transfer clients each this year. We expect that they will have completed that treatment by the first quarter of next year. Each specialist is expected in 2010 to take on approximately 100 new clients off our waiting list — because they have taken 50 transfers.

On our strategy, we also managed to replace the late Dr. O'Dowling. I fully appreciate that it takes the HSE a long time with the recruitment process, but we were very luck in this instance. Ian died in October and his replacement consultant took up post in February of this year. Obviously, he was working in another area, and he is tailing off his treatments in his former place of employment and building up his caseload with us. He is currently with us three days a week and he has a two-day commitment to finish out his clients so that the other part of the HSE is not disenfranchised by our good fortune to place him.

That is a very significant investment in HSE south west. We are spending a total of €4.25 million and we have 37 persons employed in the orthodontic service at present. That includes: two consultants, six specialists and a number of dentists, and the nurses and the associated staff. That is our strategy for dealing with the waiting list and that is our expectation.

It will take us some time to get through the waiting list but we are making progress. We had a bit of a set back because of Dr. O'Dowling's untimely death, but we are confident in our strategy and we fully agree with Dr. Kavanagh's approach of trying to get the functionals in early and treated. One of our issues is the longer one is on a waiting list, the more complex one's treatment becomes. We are kind of caught up in that trap at present but we are beginning to address that. We are fairly confident that we will address our waiting lists and get back to the best practice standards for early assessment, intervention and treatment.

Dr. Dympna Kavanagh

I want to answer Deputy Conlon's question on the current school services where they go in at second, fourth and sixth classes. There must be a change in our policy. That policy was developed in 1988 originally, and then further developed from the dental action plan in 1994. We need to update that action plan. Early intervention, much earlier assessment of children, is necessary for all the reasons to which we have alluded which means that instead of starting seeing them at second class, we need to have an overall policy change. That involves putting our heads together, not just around orthodontics and the specialist services, but a huge involvement from primary care, and including the contractors involved, to see what is the best for the population and to look forward at pulling back. It is all about earlier intervention and seeing what are the interventions that will be of most benefit to children going forward. Alluding to that, I do not want to just keep focusing on those three classes, because we want to look at children's policy and the context of primary care delivery in a very different way.

It was discussed in the appointment of oral surgeons and oral maxillofacial surgeons as well. That is crucial. That is why I do not want to have it be an orthodontic review group. That is why I specifically said that when we are looking at policy, we look at it as specialists so that instead of appointing ever more orthodontists and specialists — currently, we have 44 whole-time equivalents of specialist orthodontists in place and we have a further seven whole-time equivalent senior dental surgeons in orthodontics, and a further two dental surgeons specifically around orthodontics and almost ten consultant orthodontists available — into the orthodontic service, it is now timely for us to stand back and say, in fact, to support those specialists and consultants who are currently in place, it may be more important that we now move forward into appointing more oral surgeons and maxillofacial surgeons and different specialists and consultants to support them, and different services in that regard. Ms FitzPatrick may wish to comment on the whole-time equivalents.

Ms Mary FitzPatrick

On the number of persons in training at present, there are two post-graduate students about to commence their third year training in Dublin and there are two first-year postgraduates due to commence training in Dublin this coming autumn. The two postgraduates who are going into third year have been sponsored by the HSE and have committed to a pay-back period of four years under their sponsorship agreement. The two new post-graduates are not being sponsored by the HSE.

I have a short question, which really leads into the next session. The delegation, in particular, Dr. Kavanagh, referred to primary dental care quite a bit in terms of how the services will be reorganised, etc., and also in terms of the schools in response to Deputy Conlon, but we are about to have a session on circulars that have been issued and limitations on dental interventions that are allowed, under both the medical card scheme and the PRSI scheme. I might address my question to Ms Cody. Will there be flexibility on the part of the Department of Health and Children and the HSE to permit the kind of developments in which orthodontics wants to engage, with the primary level being very much involved in the simpler treatments and also in the referrals?

Ms Teresa Cody

We will be working closely with Dr. Kavanagh and the HSE on developing the orthodontic services and oral health policy generally. Dr. Kavanagh referred earlier to our need to develop issues in skill mix and that will be an area which will be addressed in the oral health policy. We will be working closely together on those areas.

Those circulars that have been sent around might need to be reviewed in that regard, and in many other ways as well.

Ms Teresa Cody

I am not here to address the DTSS issues. That is a separate issue.

I understand that but I wanted to put down a marker.

Would Ms Cody answer my question? Now that we have two consultant orthodontists in Cork, what will happen in the event that one of them may need to take time off? Will we be going back to one doubling up for two or the list being transferred?

The truth is that we do not know.

I just think that when someone is working under severe strain there is a possibility that he or she will need time off.

That could happen anywhere, in terms of replacement of personnel.

Ms Teresa Cody

Obviously, I cannot address the issues of the local management of the service.

What about a general comment?

Just in general.

Ms Teresa Cody

In the employment control framework generally, consultant posts are generally exempt and it is a matter for the HSE to manage within the overall service now, but it will be a matter for local management.

Dr. Marie Cooke

Can I make a comment on that? One of the difficulties with recruiting consultant orthodontists into Ireland is that it is a personal reason to move to an area. I did all my training in the UK non-sponsored. We do not have a training programme in Ireland and there is not one north of the Border either.

They had one in Limerick, Deputy Neville stated, and it was abolished.

Dr. Marie Cooke

No, I am referring specifically to consultant orthodontists. There are a number of Irish citizens training in the UK at present who may express interest. That is the way it tends to work at this point.

Ms Gretta Crowley

From a management perspective, orthodontics is a matter in respect of which I have had a particular interest for a number of years. We are obliged to work under the recruitment moratorium. While it is an exempted post, there are other restrictions in terms of the numbers of clients. It is a struggle for all of us because a nurse could leave tomorrow and that could prevent something from happening. We do prioritise. I brought it this far and we managed to have the consultant replaced. We are lucky in that cross-cover will be provided by the second consultant to replace that. We have six specialists plus the other staff working in the service at present. Personally, I will be doing everything possible and using whatever means that are available to me — in the context of the Government moratorium on recruitment into the public service — to ensure that we have adequate strategies in place for replacement.

I would hate the position to revert to where it stood previously. It is obvious that we are going to make progress and I would hate to see a reversion in the future. I would like a reply to my question with regard to people with intellectual disabilities and anaesthetists.

I am going to be obliged to ask our guests to deal with one or two of those questions. I am still not clear on what they stated in respect of staffing levels. It was stated that 63 people are working as specialists, in some way or other. Are there vacancies within that cohort of 63 which have not been filled? Are there other general dentists in the mix or is that the entire cohort of staff at present? With regard to caseloads, what number of people will a typical HSE dentist see at his or her clinic?

Ms Gretta Crowley

Is the Chairman referring to specialist orthodontists?

How many people will, on average, be seen by dentists who operate in HSE clinics each day? We will not have an opportunity to deal with a number of the questions that have been asked on this occasion. We will correspond with our guests and send to them copies of the transcript of these proceedings. Perhaps they can write back to us and address some of the questions to which I have referred. We are operating under severe time constraints today. Perhaps our guests could wrap up on the points I have raised.

Ms Mary FitzPatrick

There are approximately 44 whole-time equivalent specialist orthodontist posts across the country. In common with other areas, difficulties arise when staff go on unexpected leave. That results in our being obliged to transfer cases to other clinicians, which slows matters down in respect of removing people from the waiting list.

Essentially, there are 12 consultant orthodontists operating in posts across the country. That is a significant number when one considers that if somebody is commencing orthodontic treatment and receives a new cohort of patients, he or she will see 13 patients per day, five days a week for a six-week period. That is the start-up position. After that, they might see 20 or 22 patients. It depends on the mix of cases that come before them. If they are carrying out simple procedures such as those relating to archwire changes, these might take ten minutes to complete. If they are doing bondup procedures — that is, putting in place braces on the top and bottom teeth — these will take an hour at a time. The position varies depending on the complexity of the case.

I thank our guests for their presentation. We will correspond with them in order to try to address any outstanding questions. We wish them well in their extremely important work. In particular, we wish Ms Kavanagh well. She is very good to come before us during her first week in her new position.

Sitting suspended at 12.15 p.m. and resumed at 12.25 p.m.