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Seanad Éireann díospóireacht -
Wednesday, 20 Mar 2002

Vol. 169 No. 12

Orthodontic Service: Motion.

I move:

That Seanad Éireann condemns the continuing failure of the Government to deal comprehensively with the acute crisis in the orthodontic service. In particular, Seanad Éireann calls on the Government to implement the following recommendations from the recent report on the orthodontic service in Ireland published by the Joint Oireachtas Committee on Health and Children:

– an expert panel consisting of three persons be established to resolve the fractious relationships within orthodontics in order that an efficient, effective and professional service can be delivered to those children who qualify for orthodontic care;

– the Department of Health and Children to prepare an orthodontic action plan within the next six months and the proposed legislation for an independent health information and quality authority to be enacted as a matter of urgency;

– guidelines for prioritising the orthodontic service to be considered by the relevant Oireachtas committee before they are amended;

– greatly enhanced training opportunities involving primary level orthodontics to be included in the primary dental degree course in Dublin and Cork; State funding for up to 18 orthodontic postgraduate training places in the Dublin Dental Hospital and school; significant increases in specialists training places and greater access to courses provided in UK and Northern Ireland dental colleges;

– specialist manpower levels based on a caseload of 250 completed cases each year per specialist orthodontist;

– a new and dynamic recruitment strategy that determines the number of and qualifications required by specialist orthodontists and seeks to attract the relevant personnel through recruitment campaigns both here and abroad;

– enhanced delivery proposals such as a review by each health board of waiting assessment lists; an automated appointment system and an accurate system of outcome measurement.

This is a comprehensive motion which goes through a group of seven representative recommendations, although there are more than this. The report was part of the work programme of the Joint Committee on Health and Children for six months. In response to the public outcry regarding problems in the orthodontic service, we set out to examine the current policy and practices as well as the education and training requirements. Uppermost in our minds were concerns about the severe delays in the provision of services. We heard a number of interesting contributions from invited groups, individuals and organisations. Mr. John Kissane reviewed the written and oral presentations and the report was agreed on 21 February.

It is worthwhile emphasising one particular point from the report, namely, the response by the Chairman, Deputy Batt O'Keeffe, to committee members. We wish this to be aired because there were contentious issues on the delivery of orthodontic services. He stated, "The Joint Committee has asked me to express its total dissatisfaction with the operations of the orthodontic service to date." This is very much in conflict with the Government amendment. He continued:

The members are not satisfied that the various stakeholders involved are working to provide a service which meets public needs. The interests of children are paramount and must take precedence over all other interests. We will have to consider the matter again if signifi cant progress is not made in implementing the recommendations in this report immediately.

It cannot be put in much stronger language. I do not expect that this will be done in the dying days of this Dáil and Seanad. I was disappointed that the Dáil had not debated the report and that it had been left to the Opposition to raise it in Private Members' business. We asked many times on the Order of Business to have it discussed.

I will focus on the first recommendation dealing with the Mid-Western Health Board, the area with which I am most familiar. It is an issue that is causing difficulty. Although I do not agree with it, it is worth looking at the recommendation, which states:

In the continued absence of agreement from all regional consultants, the areas of dispute should be referred to an expert panel. This panel should consist of an expert nominated by the three consultant orthodontists in question [Mr. Ian O'Dowling, Mr. Tony McNamara and Mr. Ted McNamara], an expert nominated by the other parties in the dispute and an independent chairman to be agreed by the two other nominees. The findings of this panel should be binding on all parties.

Three consultant orthodontists in question do not see this as resolving the issue, and, in fact, do not see this as the issue. They see the problem as lying within the Department.

The core issues have not been resolved. The waiting lists, instead of being reduced, have grown during both the Minister, Deputy Cowen's and the Minister, Deputy Martin's tenure. The kernel of the problem relates to the training programme initiated and undertaken by Mr. Ted McNamara. It was extremely effective, as is made clear in the Mid-Western Health Board's submission by Mr. Ted McNamara and Mr. John O'Brien. It started in 1985 in line with national policy and three dental surgeons were appointed. This training initiative enabled dental surgeons in the region to undertake minor cases not requiring specialist input. It suddenly ceased in May 1999 when the accrediting body failed to undertake a routine accreditation visit to the mid-west.

I do not have time to go into that now but I will put in context the waiting lists for assessment and treatment. In 1993, no one was awaiting treatment while 1,280 were on the waiting list for assessment. In 2000, 1,488 awaited treatment and 2,752 were awaiting assessment. That issue was not addressed in this huge document despite many efforts by the members. I hope it will not be consigned to the shelf but consulted.

The capacity to respond is restricted because of difficulties in the availability of trained orthodontists – a problem here and in the UK – the cessation of training and the consequent effect on the availability of the trainee resource, the cost of referring patients to the private sector, and the absence of transitional arrangements prior to the availability of the new trainees in 2004. We must bear in mind the increased risk to patients' health and safety from lack of timely intervention.

There are both long and short-term issues. The former are the appointment of appropriately qualified personnel to chairs and professorships of the dental schools in Dublin and Cork to implement training programmes, consideration of contributions from other academic institutions, the implementation of a training programme, which takes account of the academic and practical requirements in training and post-registration, and a system of staff retention. On the last point, the members of the committee clearly indicated that a cartel in the private sector made it very difficult to recruit people into the public sector, which is not addressed in the report. The other issue is having meaningful representation from the health boards' management on the dental council.

The possible solutions are a recruitment drive to attract orthodontists to the public sector, including the overseas campaign – although that is not working – and the reintroduction, on an interim basis, of the training scheme that has been in abeyance since 1999. There should be no difficulties in obtaining accreditation nor in adjusting the balance between practice and academic activity.

Why was the training scheme discontinued when there are 35,000 on the waiting lists and waiting times are increasing? Unless there is a co-ordinated approach among the key stakeholders, lists will continue to grow with all the consequences for patient health. The Minister should have shown much more leadership and not brushed this aside to be dealt with by departmental officials. He should have intervened to come up with a compromise to address the issues. The dentists who undertook training gave a good service for five years and treated many patients, but today the present clinical load is 100 to 120 over three years, which will not solve the increasing waiting lists. The matter of the fee per item of up to €3,000 is also questionable.

Children should be seen between 11 and 13, the optimum period, but must wait five years or more during which time they move from childhood to adulthood. Therefore, treatment becomes more costly. Category C patients, that is non-handicapped cases which need treatment, are not being seen at present. I hate to say so, but I believe that the Minister's Department does not want to treat these cases in the hope that the list will shrink to manageable numbers.

There must be another examination of this report and the training system, that worked so well before, must be re-activated. We want to see new thinking in the last weeks of this Administration. It is not in this report, which does not reflect the opinions of those involved, nor address the main issue, that is the waiting lists. It is shock ing that children do not receive treatment at the correct time. Orthodontic treatment is not rocket science but a dental specialisation. There is no excuse for the growing waiting lists.

I welcome the Minister, but I must say that this amendment is a poor effort. The party on the other side of the House has been reduced to one Member, Senator Cassidy. Normally we have the glorious full list of names following the amendment.

Acting Chairman

I remind the Senator that only the Leader's name is attached to Government amendments.

I do apologise. I am so used to seeing all the names on it. It is still a paltry and disgraceful amendment and I did not know of its existence until I came into the House just after 6 p.m.

It is a terrible pun but this motion is something one can get one's teeth into. Senator Jackman spoke about the numbers in the mid-west area health board but we are talking about thousands of young people who are being actively discriminated against because they do not have wealthy parents. In the south western area health board, which represents the area in which I live, there are almost 5,000 category 2 patients. That means that a 12 year old boy or girl will be assessed and put on the list but by the time they are an adult, they will be out of the service. That is the way we are dealing with the lists. People are on the waiting lists for five and six years.

I appreciate we are treating people with grave disfigurements of their teeth and gums but I do not appreciate the fact that only those who can afford it visit an orthodontist. When my son was 13 I had to take him to an orthodontist. I do not want to give my age away but it was 15 years ago and at that time it cost me in excess of £1,200; I shiver to think what it would cost now.

I want to give the Minister of State an example of someone whose condition is not bad enough to warrant being classed as a category A patient but who is in need of orthodontic services. A nun approached me on behalf of a young boy who was in rehabilitation training, not necessarily to do with a disability. Her point was well made. She said the young boy never looked up because he had protruding teeth and he believed he was ugly. Imagine someone keeping their head down for five years. I know many of us will be keeping our heads down in the next few weeks and months but I hope we will be able to hold them up again.

Fianna Fáil espouses the cause of all and represents the rich and poor alike but its record over the past five years shows a definite preference for those who can pay. There are those in our society who are incapable of making the grade for many reasons and unfortunate young people should not have to carry the burden of not having had adequate dental intervention when they needed it.

In the past, if one had protruding teeth, an eye defect or whatever, one was not condemned but we live in the society of the perfect body, head and eyes and children with a physical defect are being condemned to lives of misery. There is not a parent among us here who does not have teenage children who are totally aware of the need for young children to present themselves in the best possible way. In some respects we are a cruel society but that is what is demanded. There is a whole category of people who, because of lack of money, are being left on the waiting lists for orthodontic work. Such work requires much more money when these people are in their 20s but they still go ahead with it. Why are we making life miserable for young boys and girls from the age of 13 to 17 when we supposedly have a service?

Perhaps it is time to examine the whole waiting list system. Why do we keep waiting lists when we know we will never get to the end of them? It is a farce. Why can we not decide to implement a training system which would allow people to become trained in a general sense rather than have specialists who can only treat people once a year? We should decide in the interim not to discriminate against parents who do not have the money to send their children to private orthodontists and save them from being treated as a second class citizen.

The Minister may think that comment is a bit strong but it is not. In any school room today cruelty appears to be the first subject on the agenda, with young boys and girls being humiliated daily because they have buck teeth. We all remember people being called "Specky Four Eyes", and God help the boy or girl who had any physical malformation. That was in the kind days and one can only imagine what it must be like now.

The Government amendment is a very poor effort. It does not contain one positive comment. It wants us to note a report, acknowledge its importance and commend the Government. Senator Cassidy could do much better than that. This is a rush job and it is a pathetic amendment because there is nothing wrong with our motion. I thought the Government would have decided not to oppose it and we did not expect Members on the Government side even to speak against it.

An orthodontic action plan should be prepared by the Department of Health and Children within the next six months which would contain critical success factors, performance indicators and targeted timeframes. We are coming to the stage where people are being put on a waiting list at the age of 13 but may not be taken off it until they reach the age of 45. That is an exaggeration but I am concerned that we are dealing with the waiting list by a process of elimination, not by treatment. Patients are removed from the waiting list because they have become too old to remain on it. That is a disgrace.

I commend the motion to the House. It may not be accepted but in their hearts the Members on the opposite side know that what we are saying is correct.

I move amendment No. 1:

To delete all words after "Seanad Éireann" and substitute the following:

"notes the Report on the Orthodontic Service in Ireland published by the Joint Oireachtas Committee on Health and Children;

acknowledges the importance of the structural changes being introduced by the Minister for Health and Children to the delivery of an improved public orthodontic service;

commends the Government for the expansion in the capacity of the service as a result of the measures taken under the Orthodontic Initiative launched by the Minister for Health and Children."

I will endeavour to inform the Senators of the seriousness with which the Government takes the whole concept of orthodontic treatment. At the end of the quarter to December 2001, there were 20,877 patients awaiting assessment and 11,890 awaiting treatment. Approximately 20,000 new cases are referred for assessment each year. These figures show the number of patients awaiting assessment and treatment increased by 1,133 and 1,613 respectively between June and December 2001. The number of patients in treatment continues to rise and at the end of the same quarter there were 17,295 patients in orthodontic treatment under the care of the health boards. That is an increase of 3,086 patients in treatment compared to the corresponding figure for mid-1999.

Structural changes are being introduced. A new grade of specialist in orthodontics has been created which will address the issue of recruitment and retention of qualified specialists. Following arbitration the agreed salary for this grade is €97,789. A new specialist training programme is under way while a new grade of auxiliary dental worker in orthodontics has been created by the Dental Council. The caseload of each orthodontic specialist could be increased further by the employment of an auxiliary dental worker in orthodontics which the Dental Council now calls an orthodontic therapist, most of whom are highly trained dental nurses in the first instance and place the required type of bracket and bonds on the appropriate teeth under the supervision of the consultant.

The first batch of trainees will commence training next September and the course will run for one year. The trainees will spend one month in a hospital, most likely the Dublin Dental Hospital – I am not sure about the position in Cork – and the other 11 months under the direction of a consultant orthodontist. They will only be able to work under the supervision of a consultant. They will not work in the private sector but exclusively with the health boards. These are some of the initiatives that have been taken.

In regard to the background to the training to be provided, the Dental Council established a specialist register in 1999 with the consent of the Minister. It recognises the Irish Committee for Specialist Training in Dentistry as the body within the State to advise it on the granting of evidence of satisfactory completion of specialist training. The committee fulfilled its role through its specialist advisory committee on orthodontics. Postgraduate training programmes that do not have the approval of the ICSTD will not be recognised and the dentists who participate in them will not be allowed to have their names entered on the specialist register.

In regard to the Dublin Dental Hospital and School, the specialist advisory committee approved a maximum of ten to 12 trainees in orthodontics, depending on the involvement of the regional orthodontic units of the health boards in the school at any one time. The health boards and the school are co-operating in the provision of training. Six dentists, four from the Eastern Regional Health Authority and one each from the North Eastern Health Board and South Eastern Health Board, commenced training in October last. The Department has provided additional funding of €541,000 in 2002 for this development. The trainees concerned are expected to graduate in 2004. Three dentists are already in training and will qualify next year; two from the Western Health Board are being trained in the school while one is in training in the Royal Victoria Hospital in Belfast. This brings the total number in specialist training in the health boards to nine. This represents a significant degree of progress which is to be welcomed.

The general objective of these training programmes is to educate dentists to become specialists in orthodontics with a broad academic background and experience in different clinical treatment methods. This is made possible by co-operation between the health boards, consultants and dental teaching institutions. Discussions on providing an additional training course in 2002 are under way.

In relation to the appointment of a professor for Cork Dental School and Hospital, the Department has approved and funded the post of professor in orthodontics in the school to facilitate the development of an approved training programme leading to specialist qualifications in orthodontics. The recruitment process is still ongoing and the post remains unfilled. Capital funding of approximately €1.27 million has also been provided for the orthodontic unit for its refurbishment to an appropriate standard. The ongoing efforts to recruit a professor will be sustained.

The Department has funded the appointment of a director of specialist training from the Irish Committee for Specialist Training in Dentistry to the Postgraduate Medical and Dental Board. The director has taken up duty and will play a pivotal role in co-ordinating conjoint training programmes between the dental schools and the regional orthodontic units in the health boards.

With regard to the current position concerning the orthodontic initiative for 2001, the structural changes may take some time to impact on the waiting list. Consequently, health boards are being asked to submit proposals to make an impact on their waiting lists in the short term. An additional €6.73 million was provided in 2001 for orthodontics, of which €4.698 million was for an initiative in orthodontics. This funding is enabling health boards to recruit staff, develop training facilities and engage the services of private specialist orthodontic practitioners to treat patients. The following progress – this is important and the nub of our amendment – has been made under the initiative with developments in the health boards. Two consultant orthodontic practitioners have been recruited. Additional clinical staff, such as specialist orthodontists, dental surgeons and superintendent registrars, have also been recruited by the health boards. A six surgery facility at Loughlinstown regional orthodontic unit has been developed. It is now open and the treatment of patients has commenced. The equipping of an additional five surgery unit at St. James's Hospital orthodontic unit has been completed and is now operational. Three orthodontic managers have been recruited in the Eastern Regional Health Authority to manage the orthodontic services in that health board area.

Last year the Department approved a proposal for the Mid-Western Health Board to engage the services of private specialist orthodontic practitioners to treat patients under the initiative. The proposal provides for a scale of fees for various items of treatment up to a ceiling of €2,920 per case and for various control and monetary mechanisms. This year the Department is exploring with all the health boards new arrangements for the treatment of patients by private specialist orthodontic practitioners and an out-of-hours session by health board orthodontists.

The Midland Health Board has recruited an orthodontic consultant and also has an orthodontic specialist. It cleared the waiting list in County Longford at the end of January and hopes to clear the waiting list for County Offaly by mid-April. It is also tackling the position pertaining to counties Westmeath and Laois. With the dental auxiliaries coming onstream and the provision of the relevant infrastructure, the board is confident that this position will be ongoing. All the patients about whom I have spoke in County Longford have been assessed and their treatment has begun. There is a good story in respect of the area.

We acknowledge there is a problem, and has been for some time, in the delivery of the service, but the Government has begun to tackle it. I am sure all fair minded people will accept that there has been a significant improvement in the service, especially from the position that pertained when the Government took office.

I support Senator Jackman's remarks on the orthodontic service. It is unfortunate that there has been so little progress in the development of the service in recent years. I realise that there have been considerable difficulties with it for a long time. The Minister of State and I are long enough involved in the medical service not to realise that this has been an ongoing problem.

The orthodontic report was excellent and it was a great pity that its recommendations were not brought forward by the Minister. I realise there are difficulties for him regarding training in orthodontics and in terms of the professional conflicts that have arisen in the area, but I hope he will be in a position to tackle them and examine what can be done on a national basis to improve the service as opposed to the fragmented system that appears to be in place.

It is sometimes underestimated how important orthodontics are. I am not saying, however, that the Minister of State would do so. It is unfortunate because children suffer for years not just the physical difficulties of teeth which badly need orthodontic treatment, but psychological problems because they feel their appearance is not what it should be. That also has to be taken into account. The Minister's statement that he would pay half the cost of private treatment for public patients if they had to go to private practitioners is welcome. However, this would be impossible for some people because even half the price of fees would not be within their grasp. I am not saying the Minister is uncaring in this area but this situation has continued for decades. Given that we now have a report which Senator Jackman has so lucidly brought before the House, I hope progress can be made on all the recommendations in that area.

I thank Senator Jackman and her colleagues for tabling a motion on the public orthodontic services. It provides a welcome opportunity to acknowledge the work done by the Oireachtas Joint Committee on Health and Children on this difficult issue. It also pro vides an opportunity to acknowledge the very significant structural changes which have been introduced in the delivery of orthodontic services under the Government. Finally, it provides an opportunity to recognise the progress that has already been made under the orthodontic initiative in the majority of health board areas.

The report of the Oireachtas joint committee is a very comprehensive document and contains 32 wide-ranging recommendations, including the seven to which Senator Jackman's motion refers. It is a credit to the joint committee that it has been able to produce the report within a short timeframe in relation to such a complex area. I assure the House that the report and each of its recommendations is being considered as a matter of priority by my Department and the health boards. My Department, in its submission to the joint committee, acknowledged that the extent of the waiting list and waiting time for orthodontic assessment and treatment is unacceptable and is a matter of serious concern. The prevailing situation is compounded by the fact that orthodontic services are restricted due to the limited availability of trained specialist clinical staff to assess and treat patients. This shortage has resulted from, among other things, divisions within the orthodontic community that have triggered difficulties and resistance in agreeing arrangements for training programmes.

I note the joint committee recognised the divisions within the profession and their impact on the extent of the waiting list and time for orthodontic assessment and treatment. It is significant that the Oireachtas committee reported a general consensus among all stakeholders in the orthodontic community that orthodontic problems may affect between 30% and 50% of the entire adolescent population, a situation that is unprecedented in any other medical or surgical discipline; the vast majority of orthodontic malocclusions have little dental or general health consequences; the majority of persons seek treatment for cosmetic and/or social reasons; and in the absence of guidelines to determine priority of need, between 60% and 66% of the population would seek orthodontic treatment. The orthodontic guidelines issued by the Department provide for the prioritisation of children for orthodontic treatment based on the severity of need.

The guidelines are intended to enable health boards to identify in a consistent way persons in greatest need and to commence timely treatment for them. Persons assessed as category A have severe malocclusions and should receive urgent orthodontic care. Category B cases have less severe problems and are placed on orthodontic treatment waiting lists. The number of cases treated will depend on the level of resources available, in terms of qualified staff, in an area. The chief executive officers' report on orthodontics, the Moran report, recommended the use of an alter native index of need. This is known as the index of orthodontic treatment need, IOTN.

The chief dental officer has advised that this new index should not be implemented until its implications have been evaluated in a national survey of children's dental health. This survey is currently underway and is expected to be completed this year. The purpose of the survey is to identify accurately the number of children that would benefit from orthodontic treatment and the resources needed to meet the corresponding level of care. This survey is one of a number of research contracts being undertaken this year which it is hoped will allow for the development of a new evidence based strategy for the delivery of public dental services.

A number of the recommendations of the joint committee relate to recruitment and I am confident that these will be prominent in the consideration of the report, given the difficulties which have been experienced in certain health boards. In this respect, I note that the historical difficulties encountered by the health boards were not inconsiderable. An example of this is the experience of the Western Health Board. Its current backlog of cases is largely derived from staff losses incurred between 1995 and 1999. In mid-1996, the board lost its consultant orthodontist, leaving it with no consultant cover until mid-1997 when one was recruited. Consequently, during that period, almost no patients were taken off the board's waiting list for treatment even though patients were still added to it. For 1997, the chief executive officer of the Western Health Board reported that 3,035 persons were awaiting orthodontic treatment. The position at the end of the December 2001 was that 1,605 patients were waiting for treatment. This is a reduction of 1,430 and represents clear and unambiguous progress by the regional orthodontic unit there in addressing its waiting list.

At the invitation of my Department, a group representative of health board management and consultant orthodontists reviewed the orthodontic services. The objective of this review, known as the Moran report, was to ensure equity in the provision of orthodontic treatment throughout the health boards. As a consequence of this review, the Minister for Health and Children is introducing structural changes in the orthodontic service. The Moran review group recommended that appropriately trained, qualified and registered specialist orthodontists be employed in regional orthodontic units to ensure the continuation of a high quality service and that the regional orthodontic units be involved with the dental schools in the training of specialists. These recommendations are being implemented. The Dental Council has already established a register of dental specialists with a division of orthodontics. In addition, agreement has been reached in the health service employers agency on the introduction of the grade of specialist in orthodontics into the public service. This agreement resulted from complex and time-consuming negotiations and its introduction will have a tremendous impact on the future delivery of orthodontics.

The joint committee identifies enhanced training opportunities as an important element in improved delivery of orthodontic services. Notwithstanding the difficulties in agreeing training programmes in a minority of health board areas, I am pleased that there has been significant progress in this area. In October last year, six dentists from the Eastern Regional Health Authority, North Eastern Health Board and South Eastern Health Board commenced their training for specialist in orthodontics qualifications. Furthermore, three dentists from the Western Health Board and North Eastern Health Board are already in specialist training for orthodontics and this brings the total number of dentists in such training to nine.

The general objective of these training programmes is to educate dentists to become specialists in orthodontics with a broad academic background and experience in different clinical treatment methods. They are made possible by co-operation between health boards, consultants and dental teaching institutions. Discussions on providing an additional training course to commence this year are also underway.

My Department has funded the appointment of a director of specialist training for the Irish committee for specialist training in dentistry through the postgraduate medical and dental board. The director has taken up duty and will play a pivotal role in assisting the different agencies involved in dental specialist training programmes. In addition, my Department has also funded the recruitment of a professor in orthodontics at Cork University Dental School to facilitate the development of an approved training programme leading to specialist qualifications in orthodontics. Capital funding of approximately €1.27 million was also provided to the orthodontics unit there for its refurbishment to an appropriate standard.

The Moran review group also recommended that auxiliaries be employed in the regional orthodontic units of the health boards. The Dental Council has been asked to develop a scheme of recognition of auxiliary dental workers in orthodontics, to enable the achievement of greater caseloads. Workers in this grade will be known as orthodontic therapists and will support consultant orthodontists, specialists and other dentists working in orthodontic units. This will facilitate a greater volume of treatment.

The structural changes being implemented in the public orthodontic service are inherently concrete long-term measures which will serve to copper-fasten service provision and provide a framework for the expansion of service capacity. Acknowledging the long-term nature of these structural changes and the fact that they may take some time to affect assessment and treatment waiting lists, health boards were asked to develop proposals to make an immediate significant impact on waiting lists.

Investment of €6,729,000 was approved for orthodontic services last year, of which €4,698,000 was allocated to fund the orthodontic waiting lists initiative. The initiative enables health boards to recruit additional staff, engage the services of private specialist orthodontic practitioners and develop orthodontic facilities. Under the initiative, a six surgery facility at Loughlinstown Hospital regional orthodontic unit and a five surgery facility at St. James's Hospital regional orthodontic unit have been developed and two consultant orthodontists have been recruited by the ERHA.

Last year my Department approved a proposal from the Mid-Western Health Board to engage the services of private specialist orthodontic practitioners to treat patients under the orthodontic waiting lists initiative. About 150 patients have been referred for treatment by private practitioners. All ideas are being explored by the Department, the health boards and the ERHA to expand the level of services in the short term. Possibilities include the use of private specialist orthodontic practitioners and the treatment of patients in out-of-hours sessions by health board orthodontists. Other than the orthodontic waiting lists initiative, new regional orthodontic units at Navan and Dundalk have been funded and are operational and a consultant orthodontist has been recruited for the Midland Health Board.

Ultimately, the Government's commitment to the delivery of orthodontic services has been underlined by the considerable and unequalled injection of funding under the orthodontic initiative. I am pleased that the initiatives I have described have had a positive impact on assessment and treatment waiting lists in most health board areas. The figures returned by the chief executive officers of the health boards show that, between June and December 2001, the number of persons awaiting assessment fell by 1,133 and the number awaiting treatment by 1,613. The number in treatment reflects the level of service provided by the regional orthodontic units of the health boards. At the end of December 2001 17,295 persons were receiving orthodontic treatment in the service, representing an increase of 3,086, or more than 20%, compared with the number in treatment in 1999.

I again acknowledge the work of the Joint Committee on Health and Children, which examined this complex issue. It is clear that many of the structural initiatives being introduced reflect the concerns raised in the committee's report and will improve the delivery of public orthodontic services in the longer term. It is clear from the returns of health boards that the immediate measures promoted by the orthodontic initiative have increased the capacity of the orthodontic service. I commend the Government amendment to the House.

I welcome the Minister of State to the House and second the amendment moved on behalf of Fianna Fáil and the Progressive Democrats. This is an important discussion, as orthodontic services are necessary. There was no orthodontic service in most health board areas a number of years ago. Having read the report of the Joint Committee on Health and Children and other documents, it is evident that we face a problem. It is difficult for any Department to overcome problems when there is a shortage of staff, which seems to be the primary issue. The shortage of trained staff to work in health board areas is not a problem which developed overnight. We need to examine all possible solutions, for example, the contracting of work to private consultants.

I am familiar with the Midland Health Board area, which does not have a waiting list. The funds made available by the Minister of State and his Department have been used properly and officials in the region have performed excellently. Orthodontic services in counties Westmeath, Laois, Longford and Offaly have improved in recent years, as the situation three or four years ago was considered quite serious. I commend those involved in the health board who have worked hard to achieve this improvement. The advice of outside consultants who were brought on board was to contract some work to the private sector. Many parents whose children were waiting for treatment have spoken of the success of this approach. The joint committee's report makes clear that some health boards continue to face problems, as waiting lists are quite long. I advise those involved to seek the help of consultants.

I recently read that about 15 Irish people are pursuing postgraduate study in the United States or the United Kingdom. Their progress should be carefully monitored by the Department of Health and Children and the health boards and their expertise used to improve Irish services and control the length of waiting lists, which are increasing. Many argue that their children cannot receive orthodontic services for various reasons and seek a relaxation in the governing criteria. If we relax the regulations, however, the number on waiting lists will increase. All Senators would like to see children who need orthodontic treatment receive it as quickly as possible, regardless of the extent of the treatment required. Having said that, we need to prioritise the cases deemed by the Department as being most urgent.

As one looks through the report of the Joint Committee on Health and Children on orthodontic services, it can clearly be seen that although the Department has made adequate funding available, there is not enough manpower. However, this problem can be addressed. The Department should ensure the number in training in Cork and Dublin is increased.

We must also seek to attract consultants from abroad. Many people may be willing to come to Ireland to work on contract in the orthodontic service. If that is the case we must ensure they are brought to Ireland.

There has been a decrease in the numbers on waiting lists. Listening to previous speakers one would think that the numbers were rising and getting out of control. I accept that the numbers are high, but we must also recognise the contribution made by those involved in the provision of these services who are substantially reducing the numbers on waiting lists.

I support the amendment and thank the Minister of State and the Government for the increased financial commitment to the boards over the years. I welcome this increased commitment and look forward to further reductions in waiting lists. I thank the Minister of State and his officials for their work on this issue. They started from a low base in that the numbers on waiting lists were high and money was not available. Thankfully money is now being made available and we look forward to improvements in the orthodontic service.

Neither the Minister of State nor speakers on the Government side addressed the issues raised in the motion. The Minister of State referred to a number of initiatives, many of which I would question. Why can the differences of opinion not be resolved? Reference was made to this issue, but nothing more. I would have thought this would have been the first issue to be dealt with.

The Minister of State referred to structural changes and the fact that 3,035 people are awaiting orthodontic treatment in the Western Health Board region. He also pointed out that at the end of December 1,605 patients were awaiting treatment, a reduction of 1,430. The Minister of State suggested that this represented clear and unambiguous progress by the regional orthodontic unit. However, we have not been told how this happened and I would query this point.

There is a need for the validation of health board waiting lists and I am sure this will be done. The issues in this regard will concern the numbers on the lists, the length of waiting time and the clinical outcome, to which I referred, in the context of 16 to 17 year olds who are no longer children.

It was interesting that the Minister of State made no reference to grant-in-aid for eligible patients. Many parents were under the impression that they would receive 50% funding from health boards if the patients moved from public to private care. It appears that the Minister of State deliberately failed to refer to grant-in-aid.

The report of the joint committee outlined that the issue of grant-in-aid for eligible patients was raised in submissions it received. It also pointed out that such aid is not allowed under existing health legislation. Full funding of private fees is allowed and this is an essential element of orthodontic treatment. New legislation to provide clear statutory provisions or entitlements is proposed. Why did the Minister of State not tell the House that, even in the dying days of this Administration, new legislation might be introduced to allow for the provision of 50% funding? The joint committee made a recommendation regarding the provision of grant-in-aid. The Minister of State said he is happy with the committee's recommendations as they would help to reduce the backlog and advance the date of treatment for patients.

The joint committee suggested that an option of a grant-in-aid should exist for patients on waiting lists who reach the age of 16. The issue of age is very important as such people have moved into adulthood. The committee suggested that this aid should be available on the basis that consultants should indicate the nature of the treatment required and a maximum appropriate fee, a list of private orthodontists which patients may or may not use, 50% of the fee to be provided by the health board and 50% paid by the individual and a 20% or 42% tax refund to be available to those who pay income tax. Why not deal with this issue which was part and parcel of the press release? Parents thought they were to get 50% funding.

Senator Ridge referred to the psychological effects. The Mid-Western Health Board is seeking research on the psychological effect on young people who have not had the benefit of orthodontic treatment.

A number of speakers besides myself referred to the fact that 150 patients have been treated in the mid-west region involving the fee agreement with consultants. What is the problem in the mid-west regarding the training initiative which existed since 1985? It has been stated that this programme was fully accredited by the special advisory committee. Why is this initiative not in operation given that a trainee of Mr. Ted McNamara received a gold medal in Edinburgh?

It is extraordinary that the Minister of State should blandly read his script which includes only a vague reference to difficulties, but does not refer to divisions within the orthodontic community which have triggered problems regarding agreed arrangements for training programmes. It is extraordinary that the shortage of trained orthodontists and the length of waiting lists have resulted from these divisions. The obvious thing to do is to try to resolve these difficulties instead of painting the three consultants who have a problem as the main reason for the shortages and the length of waiting lists. It is extraordinary that the Minister has not dealt with this issue. Given that this system had a good throughput of chil dren, why could it not exist in harmony or even in transition until we have the required number of orthodontic surgeons or specialists? We could then resolve the issue itself.

The Minister of State should tell the Minister, Deputy Martin, that it is unsatisfactory that top professionals are disillusioned, disenchanted, effectively sidelined and unable to deal with the same number of patients with whom they dealt prior to 1999. Such professionals could make a welcome improvement regarding a number of recommendations.

Where can we get additional consultants? The availability of trained orthodontists is a problem. The three consultants involved are excellent, but they are not allowed to give of their expertise. If they were allowed to do so more children would be treated prior to the age of 16 and during the crucial period between the ages of 11 and 13. In a small country where everybody knows everybody else it seems extraordinary that this issue cannot be resolved.

The Minister of State should bring these points to the attention of the Minister. He should tell the Minister not to let these matters fester, but to address them instantly.

Amendment put and declared carried.
Question put: "That the motion, as amended, be agreed to."

Bohan, Eddie.Bonner, Enda.Callanan, Peter.Cassidy, Donie.Chambers, Frank.Cox, Margaret.Cregan, JohnDardis, John.Farrell, Willie.Finneran, Michael.Fitzgerald, Liam.Gibbons, Jim.Glennon, Jim.

Glynn, Camillus.Kiely, Daniel.Kiely, Rory.Lanigan, Mick.Leonard, Ann.Mooney, Paschal.Moylan, Pat.Nolan, M. J.O'Brien, Francis.Ó Fearghail, Seán.Ó Murchú, Labhrás.Ormonde, Ann.Ross, Shane.

Níl

Burke, Paddy.Caffrey, Ernie.Coogan, Fintan.Doyle, Joe.

Henry, Mary.Jackman, Mary.McDonagh, Jarlath.Ridge, Thérèse.

Tellers: Tá, Senators Gibbons and Lanigan; Níl, Senators Burke and Ridge.
Question declared carried.

When is it proposed to sit again?

At 10.30 a.m. tomorrow.

The Seanad adjourned at 7.35 p.m. until 10.30 a.m. on Thursday, 21 March 2002.

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