Dental Care for Medical Card Holders: Discussion with Irish Dental Association

I welcome the representatives of the Irish Dental Association to discuss dental care for medical card holders. 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 they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. I am sure this will not be necessary but I shall continue. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they 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.

The association's paper has been circulated. I apologise for running over time but the subject matter is important. The committee would like to hear Mr. Hourihan's executive summary, following which members will have a number of questions.

Mr. Fintan Hourihan

I will introduce my colleagues. Dr. John Nolan is a dentist in Glasthule, County Dublin, and he participates in the medical card scheme; Dr. Jane Rehehan, chair of our public dental surgeons group. She works in Blanchardstown, Dublin, and supervises the administration of the medical card scheme in north-west Dublin, Dr. Billy Davis, a dentist in Dublin and president of the association, and Ms Clare Dowling, an official with the association.

This scheme is essentially there to benefit the elderly and those with severe medical conditions and it is important that we see the scheme as being essential to avoid people being left in a situation where they are relying on a diet of jam and toast. The typical profile of patients is female, over 40 and wearing dentures, very often with poor diet and gum disease. I ask that members try to imagine if in the morning they lost their teeth what that would mean in terms of not being able to eat, converse, smile or talk to people. The scheme has the benefit of tipping the balance between a healthy lifestyle and ostracisation and poor health.

I am sure the committee does not want me to labour the recent background and history but, to summarise, the scheme has worked successfully for a number of decades. The HSE has now decided at 24 hours notice to effectively restrict the scheme to emergency cover only for 1.6 million people. We believe this will cause chaos, hardship and confusion to patents. In our summary, we detail that on pages 13 to 32 and if I were to ask that members only read one section, I would ask them to read the evidence given in the first tab where we give a sample of the experience of a number of dentists. We are now seeing the denial of treatment to cancer patients, special needs patients, the elderly, patients requiring dental checks ahead of major surgical operations, patients with acute infections and many others dentists believe fall into high risk circumstances. That is graphically illustrated in the examples we give.

Clearly, it has implications for the 1.6 million people and their families and for dentists. It also has implications for children and special needs patients. I listened with interest to the previous discussion and I am fearful there will be a spillover in regard to the availability of care for children with special needs. We have evidence in our submission of the cost benefit. It is a value for money scheme. Not only is prevention cheaper than short-term savings; this is an extremely cost efficient, value for money scheme. The fees paid to dentists are controlled by the State. They are half of what dentists charge ordinarily privately for most of the major treatments so there is no question it is a good scheme, which should be kept. The damage being done now is profound and will cause untold hardship for the very people who most need the assistance of the State.

The scheme operates on the basis that eligible persons are provided with routine dental treatment. That would comprise pain relief, preventative care such as cleanings and fillings, emergency care, which would be extractions or root canal treatment, and denture and denture repairs. It does not give me pleasure to remind the committee that the last time we were here we warned of the possibility of the rationing of dentures. Unfortunately, we are now seeing that come to pass and it is quite despicable that the very people who most need the assistance of the State are now being punished in addition to cutbacks to the PRSI scheme. It is important to point out that the people who hold medical cards have rights and entitlements under the Health Act 1970 and that these rights extend to include dental treatment. Therefore, there is every possibility that people may choose to go to the courts to vindicate their rights. There has been an increase of more than 300,000 in the number of medical card holders since 2005. However, in the recent budget the Government decided to restrict spending to 2008 levels, despite the fact that in the past two years alone, we have 270,000 more people whom the HSE wants treated. The funding in 2008 was obviously sufficient for 2008, but now when we have more than a quarter of a million extra — 270,000 more people — the HSE thinks the service can still be provided with 2008 funding levels.

Committee members are aware that the PRSI scheme, which benefits more than 1.5 million people, has been restricted to examination only. Therefore, in the history of the State, we are seeing an unprecedented onslaught on dental services. Unlike medical general practice, the State offers no assistance to dentistry. Dentists fully fund their own service and what little support the State offered up to now has disappeared in one fell swoop, in one budget. We are now beginning to see the consequences of that. The text of the infamous circular, which was issued at the end of April, is detailed on pages 10 and 11 of our submission, but I will not go through it now in any detail. Suffice to say, it essentially restricts treatment to emergency circumstances only. To compound matters, there has been no definition given of emergency cover and the content of the circular is as ludicrous as it is vague. We never got a commencement date and there is no definition or guidance as to what constitutes an emergency or the procedures to be followed. Legal proceedings have been commenced and two dentists have secured an injunction, confirmed by the Supreme Court, entitling them to operate the scheme which had been agreed over many years.

The consequences of the recent changes are that more than 1.6 million people will be denied routine treatments, including fillings, extractions, dentures, denture repairs and treatment of gum disease. Hospitals, HSE clinics and services for children with special needs may well become overcrowded, because the HSE continues to be statutorily bound to provide cover or dental treatment for these people. However, it now refuses to fund it, despite agreements it already has with dentists. Besides the health cost, there is a serious financial cost for a particular group, elderly people over 50. This situation is detailed in our presentation. We estimate that a person with no natural teeth will face an additional annual bill of more than €232, while somebody who retains some of his or her teeth is likely to face an annual bill of €412, despite the fact these people are entitled to free dental treatment from the State as medical card holders. Other socially disadvantaged patients will also lose out.

Evidence of the impact of the recent changes can be seen in dental surgeries. Twelve months ago, dentists with medical card patients would have seen from 15 to 20 patients a day, but that number has now reduced to two or three patients a day. The damage in terms of patients' dental health will not become apparent for some months or years and problems that are only minor in nature now will become serious. This applies in terms of dental health and the economic cost of treatment. We present examples of likely outcomes from page 17 onwards of the presentation. As can be seen, the people who are paying the price, in terms of their health, are the most vulnerable. They are people in their 80s, people with rare medical conditions, people on Warfarin, people with special needs, people who require a dental check-up prior to major invasive surgery, people who require significant periodontal treatment, patients in psychiatric institutions who have been refused treatment and patients who are routinely denied dentures. We are aware of 84-year-old patients who have been denied clearance for dentures. We have seen nervous patients who require IV sedation being denied treatment. We have seen patients who require a certificate of dental fitness prior to surgery being denied treatment. We have seen cancer patients who require surgery being denied treatment and people with diabetes and severe dental diseases denied treatment.

This is happening in a climate where HSE staff have been given no guidance on how to deal with the situation. No operational guidelines have been issued and no definitions of emergency treatment have been provided. We are seeing nothing less than chaos in dental surgeries throughout the country. This is not fair on patients, on dentists or on anyone who has anything to do with the system. Dentists are being compromised and the HSE approach is unsafe, unworkable and unethical. We have serious concerns, which are shared by other parties, that dentists are ethically compromised by this whole approach. No provision has been made or no definition provided for emergency circumstances. Patients are being denied treatment and their functional ability to eat and speak is clearly affected, which causes unnecessary pain, suffering and embarrassment. In response to a parliamentary question, the Minister for Health and Children gave a definition of an emergency for the purpose of approval of a denture and said it was pretty much linked to the functional ability to eat and speak. However, no definition has been issued to the system at large with regard to dentures or any other treatment. There is absolute chaos in the system.

On page 27 of our presentation, we provide a summary of criticisms made by four principal dental surgeons who have responsibility for the medical card scheme. Prior to Dr. Kavanagh's appointment — which we welcome — they were the only people to whom the HSE turned for advice on this scheme. A circular attached in the appendices of our presentation demonstrates that just two months after this unilateral change, there is nothing less than absolute chaos in the system. Patients are not being treated, but being put on waiting lists and left in distress, while dentists are equally distressed because they are unable to treat them. The procedure to obtain approval of requests for treatment is not feasible because the resources are not there to cope with it. The situation previously was that dentists could proceed with certain routine procedures, but had to obtain prior approval for more elaborate treatments such as dentures and root canal treatments. Now, prior approval is required for every procedure. Members can imagine the administrative chaos this causes. No guidance is being given and dentists must ring up to obtain information. The HSE does not have sufficient dentists to treat those requesting treatment. Our worst fears never envisioned the chaos that exists.

The change in practice has an impact on dentists' incomes and dentists with a heavy reliance on medical card holders are seeing a significant reduction of up to 80% in their monthly income. I have been informed that some dentists will have to close their practices and have no doubt this will happen. This will compound problems for medical card patients, who will have to travel further for more limited services. The changes also have an implication for services provided by dentists employed by the HSE to treat children under 16, the provision of the school screening programme and the care of special needs patients. Cork Deputies are well aware of particular problems in this regard and the four-year waiting list for special needs patients, which is outrageous. This problem will get worse and will spread throughout the country.

I would like to reassure the committee that the dental services scheme is a cost effective scheme that provides value for money. The National Consumer Agency carried out a survey of fees recently which demonstrated that fees paid to dentistry through medical card patients are only half the fees charged to private patients. Therefore, the scheme provides cost effective treatment and, as we say, prevention is cheaper than cure. Some of the committee members may recall that in regard to PRSI we commissioned a cost-benefit analysis which showed that the cost to the State of maintaining this scheme was between two and three times the cost of operating the scheme. Equally, to abolish the scheme, as we have seen with the social welfare scheme, there will be greater costs in the short term as well as in the medium and long term.

Since the budget, we have sought and suggested negotiations and meetings with the Minister for Health and Children. We have suggested that supplementary funding be arranged and we have had no response, good or bad, to that suggestion. Instead, what happened on 26 April is that the HSE issued a circular with 24-hour effect and we are now seeing the consequences. From reading the parliamentary questions, I know the Deputies are now beginning to get constituents knocking on their doors——

They do not get answered.

Mr. Fintan Hourihan

No, they do not get answers, no more than Deputies get answers to their questions from the HSE. Unfortunately, the people who are knocking on the Deputies' doors are only a fraction of the total number of patients attending surgeries who have been denied treatment by the HSE in a very callous and cynical manner.

We are not oblivious to the fact that savings will have to be made. The pity is there was not a willingness to sit down as we had suggested immediately after the budget to explore ways in which savings could be made.

The committee should use its powers to prevail upon the HSE to set aside this circular and to see what can honestly be provided to medical card holders. On one side of the equation, people have medical cards and they are entitled to treatment by the HSE. The HSE has a statutory obligation to provide that treatment and it is not happening.

I thank the Irish Dental Association for its presentation. The words, "crude" and "chaos" are used. I fail to understand why the HSE, unilaterally and without any consultation, would cut the services at the level it cut them. I can understand that savings have to be made. We all accept that. However, the daily number of medical card dental patients is down from 50 to 20 to two and three. This indicates how the situation has changed.

We all accept that oral health is very important. We were told that as children. Now there has been an intervention which counteracts that statement. We were all told about the importance of preventative work in oral health but this policy seems to have been abandoned.

I refer to a young woman suffering from major psychiatric illness who was refused gum treatment by the HSE, despite the fact that she spent the past six months in a psychiatric hospital. Her teeth were fine before admission but now she needs six fillings and gum treatment and according to the new guidelines she can only have two fillings and no provision for swollen, bleeding gums. How does one respond to that? I refer also to the case of a 17-year old girl who requires five fillings prior to commencing orthodontic treatment at Cork Dental Hospital. She was advised by the hospital to have the fillings done prior to treatment. This was clearly documented as a clinical necessity but it was not approved. The HSE did not accept that it should be done for a girl who is 17 and awaiting orthodontic treatment. Considering the waiting lists for orthodontic treatment, she must be in a serious condition. I have another example of a 73-year old woman who needs three fillings replaced. She has Parkinson's disease and tends to fracture fillings, thus the need to replace them. She was refused treatment. How can one answer this? Has the service really deteriorated to that extent?

Mr. Fintan Hourihan

Yes. Will I respond to that question now?

No, we will take all the questions first. Has Deputy Neville concluded his questions?

Yes. The Minister and Professor Drumm will be in attendance this afternoon and I will raise it with them. That is the best we can do at the moment.

It is a pretty sad and sorry situation. It seems that the balancing of books has taken priority over the needs of patients. It is not just in the circular. I have read the two appendices, the two letters from the four lead principal dental surgeons, one letter dated April and the other dated June. They are saying there is no engagement with them on the situation. A decision was made at senior level in the HSE, without any discussion with the clinical lead dentists in the four regions, not to mind the dentists themselves. They are not even told the guidelines for an emergency and yet they are the people who must decide whether a case is an emergency. This circular needs to be withdrawn and there needs to be proper engagement on the needs of patients. I cannot imagine the kind of pain that some people are suffering and the associated problems. I have read about the woman who lost a tooth from her denture and she was told that this is not a priority or an emergency so she has to live with a gap in her teeth. I refer to people in pain and those needing operations. I refer to a case of a person requiring cancer treatment but who needed dental treatment first. The cancer treatment had to be delayed because approval was required for the dental treatment. This is a crazy situation. We all read the examples in the presentation. I was struck by one from a dentist who stated that a patient came in at 5.30 p.m. on a Friday with two broken front teeth as a result of an accident. The person could not reach the surgery earlier because he or she had no car and had to get a bus. The dentist was concerned that he would not be able to get anybody to approve the treatment because it was after 5 p.m. on a Friday evening.

Deputy Neville is correct that we are being told all the time and again this morning that early intervention and preventative work is meant to be the policy throughout the health services. Clearly, in this case, it is not being implemented. People are being put in a situation where their treatment is happening later than is appropriate. The Irish Dental Association is here today but my primary concern — and I am sure that of the dentists here — is the patients, the people who are not getting the service they need. We have to get through to the HSE and the Minister this afternoon to ensure that this issue is not just left to high-level people trying to control budgets while there is no engagement at the real level, between the people deciding on budgets and those administering and implementing the patient care. Members of the committee must make our voices strongly heard on this issue.

I thank Mr. Hourihan for his presentation. I share his concern. I never want to see a patient in need of treatment, particularly urgent treatment, not receive that treatment. There is a difficulty in finding solutions to the problem. The main difficulty has always been there, sometimes worse than other times, that we do not have sufficient money to do everything we would like to do. This has always been an issue in the health service in particular. We are spending 27% of the total budget on health services in the current year. That is €15 billion.

There are competing priorities because every group we meet identifies gaps in the service it provides, which need to be filled. The difficulty is to work out how one deals with the competing priorities. The State is responsible for those depending on the health service's own dental service, namely, the contract it has with the Irish Dental Association and the dental service of the Department of Social Protection. The first issue is whether it is possible to get better value for the money spent. I am interested in hearing the views of witnesses on the matter and what their priorities would be as they are at the coal face and they can see the opportunities. It is obvious that funding is not available to address all the outstanding issues.

The suggestion was made to drop the circular. There is merit in what was said about discussions with the Health Service Executive and perhaps with the Minister and officials in the Department to see how we can ensure maximum efficiency is received by patients for the money being spent. Like my colleagues I would be glad to raise the issues the witnesses have addressed with the Minister in the afternoon.

What strikes me about the two presentations we have heard today is that it is likeAlice in Wonderland. It means what one wants it to mean or what one thinks it means. On the one hand we have an excellent strategy from the first delegation which tells us that oral hygiene in its holistic form is essential to our health. I read an article in recent months which indicated that one of the major contributors to heart conditions is bacteria that are allowed to develop in one’s mouth. That shows the importance of oral hygiene.

On the other hand dentists are probably the only group to which people do not willingly go. It is not like plastic surgery. People are not going because they want to. The representatives of the Irish Dental Association know what I am talking about. They are the one group of medics where one does not walk out of the surgery with a prescription that will keep one happy for the next month. It is a case of immediate treatment which most people do not like, possibly because more than anything else one cannot see what is being done. One goes because it is necessary or because one is in such pain that one has no option. This is not a service people abuse. Two of the fundamental steps forward in terms of health care in this country in recent years were choice of dentist and choice of doctor. For people who could not afford it themselves, those were the two major steps forward in terms of health care and social development in this country. It is a retrograde step for that to be removed. We should not allow it to happen. The witnesses were dead right in their presentation. People on medical cards probably need dental care more than anyone else, yet it is limited.

No reference was made to a case study about which I am very worried which relates to a young woman whom I know who suffers from a dry mouth. Until I met her I did not know that one's saliva keeps one's teeth healthy. Her teeth are in constant need of maintenance as a result. She is now being told that she can only avail of a limited service.

As Deputy O'Hanlon indicated, we will raise the matter in the afternoon but the purpose of the meeting should be to find solutions. I am amazed to hear that each particular treatment must be approved either before or after it is carried out. I accept the Irish Dental Association desperately wished to negotiate with the Department of Health and Children but most general practitioners work on a fee per patient basis as opposed to a fee per treatment. Would dentists be open to discussing the matter with the Department in terms of the delivery of service to people with medical cards?

This is probably the one service that will not be abused in terms of people going to see their dentist every Monday morning. That is not quite how it works. It is outrageous to remove it, especially in light of all the evidence which tells us that good oral hygiene is good for one's health. We hear about primary care centres and the programme that was outlined to us today is fantastic. However, on the practical side, when it comes to the poor, a service that could keep people healthy is being withdrawn. The witnesses will have unanimous support from this side.

I will be very quick. I also welcome the delegation. This is an important meeting. I do not know why I differ from Deputy Lynch in that I am always happy to go to my dentist. I went to the same dentist for decades until the poor man died. I met him first on O'Connell Street and then he moved to Tallaght. Some may remember Dr. Walsh. I have been attending the Glenview dental practice in recent years. It is important we attend dentists. I must be careful how I phrase this. My granddaughter cannot figure out why all my teeth are in place. I always give credit to the example that was given to me.

It is a pity we are restrained by the system in the sense that we cannot have a delegation, the Health Service Executive and representatives of the Department of Health and Children in the same room. If that were the case we could challenge the perceptions. I am sometimes cynical when we hear a presentation that mentions the word "chaos" so often but from my contacts with the service I know the delegation is correct. People might be worried about my saying that from the Government benches but I am not a bit worried because that is what I hear. I am approaching an age where I feel strongly about the issue. Other colleagues have made the point that we all accept that adjustments and cuts must be made but I cannot get my head around this one. The lack of communication and consultation is clearly an issue. That is something local dentists talk to me about. I am pleased the Irish Dental Association has appeared before the committee. I hope the Chairman will advise us on how we should proceed. I do not know whether we will ambush Professor Drumm on the issue later today but a strong message should come from the committee on the matter.

I also welcome the delegation. I do not wish to cover the same ground. I share the delegation's concerns. I spoke at the previous presentation on the concerns I have about children in particular who might fall through the cracks and not be able to avail of early intervention, which they should be able to, the damage that causes and the problems that result down the line. That is a major concern for me.

I appreciate and accept that books must be balanced, savings must be made and we must get better value for money. I do not see how all of that can happen without meaningful consultation and engagement. The delegation has indicated a willingness on its part to engage. There is an onus on the Health Service Executive and the Department to facilitate the engagement. How else will the problems be rectified and a plan put in place to ensure we have an efficient and effective service where those who need treatment get it? At the same time I am mindful of the fact that there is not an infinite amount of money and savings must be made. Like my colleagues I would be delighted to raise the matter in the afternoon when the Minister and Professor Drumm are present.

The delegation can hear the strong support from committee members for the case that has been made. We hear many presentations at this committee but very few that have been put together as well as this one. The document is very useful to us. It is fortuitous the delegation is present this morning in that we are to meet Professor Drumm and the Minister for Health and Children, Deputy Harney, this afternoon.

I echo the remarks of Deputy Conlon and others to the effect that when one considers the budget for the dental treatment services scheme, €63 million, which sum is set at the 2008 level, one assumes that active engagement would have taken place with the Irish Dental Association after the initial decision to determine how value for money could be achieved. While the HSE has many major achievements to its credit, one of its great failings is the failure to communicate with the groups with which it must communicate to achieve results. We will have to raise that this afternoon.

Deputy Lynch referred to costs, which subject we raised with the last deputation before us. Pharmacy costs have been lowered and dental service costs need to be lowered. They will not be lowered if there is no engagement with the Irish Dental Association. Has the association ideas on how this could be achieved?

Mr. Hourihan stated the cost of dental treatment for medical card holders is 50% of the cost for the public. Even at that, the figures compare adversely in this jurisdiction in respect of an individual being treated privately. People are travelling out of the country for treatment. What is the profession doing to lower costs in order that people will not be crossing the Border or going to Romania or elsewhere for surgery? What is it doing to allow us to be sure of the standards that apply and that follow-up care is guaranteed?

Mr. Fintan Hourihan

I will address that and a few of the other comments. To anticipate what the HSE will say to the members on the lack of engagement, I believe there is a deliberate policy on the part of the HSE not to engage with professionals' representatives. From legal proceedings, I know its argument tends to be that it intends to consult after introducing a circular. That is not an acceptable answer and I anticipate that is what members will hear from the HSE this afternoon.

With regard to costs, professional fees for dentists were reduced last year. There is another exercise in this regard taking place at present. The fees paid to dentists for medical cards, which fees are set by the State, are well below those paid in Northern Ireland. While a medical general practitioner receives an average of €50,000 to €60,000 towards his running costs before a patient walks in the door, no such support is made available to dentists. Dentists, when setting fees for private patients, must cover their costs. They have no support from the State. The running costs in the Republic are €100,000 greater than——

Is Mr. Hourihan talking about the ancillary supports for clerical and administrative staff, IT equipment and so on?

Mr. Fintan Hourihan

Yes. Members have all been in a dentist's surgery and will know it is not simply a matter of going in and sitting on a chair. There is very elaborate and expensive equipment in addition to disposables and other materials. My colleagues would be better able to speak about this.

The running costs in the Republic are €100,000 greater than in Northern Ireland. The State offers no support, although it rightly does offer it to medical doctors. The fees paid for medical card patients are well below those paid in Northern Ireland. When talking about medical card patients' treatment and fees, it is important to understand that, whatever one may feel about private fees, for which there is an explanation, the issue to which I refer does not arise.

Deputy Rory O'Hanlon asked about the solution. The short-term solution will either involve considering the range of treatments provided or examining the fundamentals of the existing scheme which involves entirely free provision. The medium-term to long-term solution involves capitation, to which Deputy Lynch referred. The international consensus on dentistry is that the ideal solution would involve a blend of capitation and fees per item. Capitation encourages prevention. It is correct that there is no possibility of the money being anything other than well spent because it is only provided for treatments provided.

The medium-term to long-term solution, which could be effected even sooner, is probably a blended system. When the HSE and the Department indicate they are prepared to talk to us, I have no doubt that will be part of the agenda. The more immediate solution is to consider the range of treatments and the basis on which they operate. It is completely dishonest on the part of the HSE, in addition to being insulting and completely unprofessional, to write a circular without even consulting its own dentists or talking to dentists at large. One will note there have been no notices to the public advising it as to its current entitlements. Honesty on the part of the HSE, in addition to willingness to talk to us, is the first requirement if the problem is to be resolved. There are steps that can be taken in the medium to longer term and I have no doubt they can be worked through.

Did Mr. Hourihan say it was unacceptable to meet the HSE after the issuing of the documents? The Irish Dental Association would obviously have liked to meet it beforehand.

Mr. Fintan Hourihan

Absolutely, we would need to meet the HSE beforehand.

Has the Irish Dental Association requested talks with the HSE? Does it not want to talk if the circular is not withdrawn?

Mr. Fintan Hourihan

We have said we would like to talk to the HSE. We feel the first step should be to suspend the circular to allow talks to take place. That is standard practice in such circumstances. There is no way one can operate on the basis of continuing with the circular, the changes and the chaos they are causing. One should not tell a person one is making a decision and ask how one feels about it after it is made.

Is the Irish Dental Association prepared to meet the HSE if the circular is not withdrawn?

Mr. Fintan Hourihan

Absolutely. We would meet its representatives this afternoon if it withdrew the circular.

On that point, the HSE's big guns are to be before the committee after lunch. Without the circular being withdrawn, the Irish Dental Association is prepared to meet the HSE at a minute's notice.

Mr. Fintan Hourihan

No, I said we will meet them on the basis that it is withdrawn.

Is it correct that if it is not withdrawn, the Irish Dental Association will not be prepared to meet the HSE?

If it is not withdrawn, Mr. Hourihan will not talk to the HSE.

Mr. Fintan Hourihan

I will talk to them in that I will do anything to try to deal with this problem. We have indicated that if the HSE suspends the circular – it can be a suspension rather than a complete withdrawal – we will be happy to meet it. Why does the HSE make changes at 24 hours' notice and then say it will talk to us? That is not a basis on which to operate.

I am sure it is not the first time for the HSE to do that. What is the income of dentists in the medical card scheme by comparison with that of private dentists?

Perhaps some of Mr. Hourihan's colleagues will answer that.

Dr. John Nolan

It varies depending on one's area.

What is it nationally?

Dr. John Nolan

There are different regions. Different socioeconomic areas would have——

Is there a 50:50 ratio?

Dr. John Nolan

No, we are talking about a different landscape now. Last year the PRSI scheme applied, as did the medical card scheme. In a city practice, perhaps 30% of patients are PRSI patients, 20% to 40% are medical card patients and the remainder are private. In inner city practices, 60% to 70% of patients may have medical cards. These practices are being decimated.

I am one of the beleaguered clinicians trying to make sense of the chaos and I welcome the sympathy of the committee. We have signed a contract to treat medical card patients on the basis of the fees we agreed. We have no argument with that. Naturally, we were hoping to improve the scheme because developments in dentistry since the inception of the scheme in 1994 have greatly improved dental health. We now are faced with a situation in which we have received a circular telling us that we may only treat patients in emergencies. However, we do not know what constitutes an emergency as its definition has not been described to us. We must contact someone like my colleague, Dr. Renehan, who is a public dental officer, to get approval for this. As we sometimes cannot get such approval, what should we do in that situation? We are on the ground, know what we must do and know what is best for the patient but are being prevented from so doing by this arbitrary circular. This pertains to the most beleaguered section of society. While I acknowledge the landscape has changed in the past two years in that the number of medical card patients has increased dramatically and the funding is not available, all we have to do is to negotiate and come to some sort of arrangement to get these poor patients out of this beleaguered position.

Dr. Jane Renehan

Like my colleague, Dr. Nolan, I welcome the understanding and empathy evinced by members. They obviously are meeting patients and know what is happening on the ground. If I may expand a little, I am a principal dental surgeon and am responsible for the running of public dental services in the area of Dublin north-west. It is an expanding area with many young children and has a considerable elderly population. I am responsible for 34 contracted dentists and, at present, approximately 42,000 patients have medical cards. In my experience of being a manager in the area, the dental treatment services scheme, DTSS, has been a wonderful scheme that has worked for the patients. Each medical card patient has been able to walk into one of those 34 dentists to receive either basic routine care or emergency care. In my role as principal dental surgeon monitoring the scheme, I saw all the approvals that came from the practitioners. The money was well spent, any queries that needed to be made about taxpayers' money were monitored and I hope I did the duty charged to me. This scheme was very well run and there was no fat in the system. It is very difficult to find savings from a scheme that has been well operated and that has served the public well. Moreover, I am impressed by the type of bona fide work that was done in many cases by many of my practitioners outside of the scheme.

When the Minister for Finance announced in early December 2009 that funding for the DTSS was going to be reduced to the 2008 level of €63 million, all my colleagues throughout the country immediately began to put together proposals. By mid-December, we had drawn up proposals as to how the savings could be made from a clinical perspective. While we were not happy with this, we were considering some treatments that could be prioritised. Early in January, the four lead principal dental surgeons formally approached senior management within the HSE and much engagement took place. Meetings were held, proposals were made and documentation was drawn up. We worked closely while conscious that time was ticking away and that we were not being listened to. We were getting to April and still were getting no response, despite asking senior management. When we met the Minister on 1 March 2010, we asked when the changes would be made. To our frustration, on 26 April our private practice colleagues received a circular telling them what the cuts in the DTSS would entail even though we, as managers of the service who had engaged, received no communication. To date, I still not have been written to in this regard.

I do not know what the circular means because it did not reflect any of the discussions or engagements my colleagues had with senior management. The documentation received by members today reflects two of the letters that were delivered to senior management. Although I also could provide several more letters or e-mails that were sent to local health office managers or regional directors of operations, at present we continue to try to work within the circular but are unable to do so. We have been asked to budget for an allocation of €63 million this year. I checked this morning before appearing before the joint committee and to date, €59.3 million has been spent. This system is about to collapse. Were my colleague to ring me to ask whether he can examine a traumatised tooth this afternoon and were I to give approval, would he be paid? If he will not be paid by the primary care reimbursement scheme, PCRS, should he approach me to ask for payment?

My public dental service, which has eight dentists working in it, has been top-sliced and has many vacancies on foot of the recruitment moratorium. I am working with a skeleton staff in an area where the number of children attending school classes is increasing in volume and in which we are unable to get to the routine service. We cannot get to our second, fourth and sixth classes. We are closing clinics over the summer to try to save money. I was told during a telephone conference this week to make contingency plans as the HSE is running out of money and from now on I would be handling the medical card patients. This will result in 42,000 patients visiting my eight dentists who cannot perform their own service. For example, we cannot get to special needs patients. With respect to my colleagues who appeared earlier, I only caught the end of their presentation. While I am impressed that they are putting together an orthodontic presentation, the children have had cavities. They need extractions, to have their teeth examined and prevention. They need to have me talking to their teachers to get the healthy lunch policies running. Why am I straightening decayed teeth? It is a nonsense and this is in a shambles.

My point is that the managers within the service still are prepared to engage. I have attended today's meeting in my representative role as president of the Irish Dental Association's public dental surgeons' group but the real matter is that, this afternoon, I will return to the chaos and frustration involving the patients and my colleagues but I have no answers. I am failing to carry out my job because I am not getting any help from senior management.

I thank Dr. Renehan. It is to be hoped we may be able to get some answers this afternoon.

Dr. Billy Davis

If I may, I will echo Deputy Lynch's comments that the mouth is not an isolated part of the body but is part of its whole. Oral health is a very important part of general health and one often sees things in the mouth that act as an indicator of what is going on in the rest of the body. This must be borne in mind. Deputy O'Hanlon mentioned things we would like to do. We have come a long way from things we would like to do and it is about what we must do. In this context, we must get a system that works. Members have heard about all the things that are going on and this is something that must be done and that cannot be put off.

All I can say is that members will address this matter this afternoon and are amenable to further contact with the witnesses if we can be assistance on this particular matter. The joint committee is grateful to the witnesses for raising this matter with them, which members will continue to pursue as best they can. The meeting will adjourn until 2:30 p.m. when members will meet the Minister of Health and Children and the chief executive officer of HSE.

The joint committee adjourned at 1.15 p.m. until 2.30 p.m. on Tuesday, 13 July 2010.