Tuesday, 27 June 2000
Dáil Eireann Debate
Mrs. B. Moynihan-Cronin: I thank the Minister for coming into the House to take this debate tonight. While I welcome the opportunity to raise this matter on the Adjournment, I feel it should not be necessary in our current economic climate to come into the Dáil to speak about an aspect of our health services which is effectively in a shambles.
The current state of our orthodontic service is beyond a disgrace. Our orthodontic services are  among the worst in Europe; in fact, from what I can see they hardly exist. It appears that amid the crisis in our health services, the state of our orthodontic services has worsened. As orthodontic treatments are not a life or death issue, they are simply not an issue for this Government.
Deputies from all parties will know that one of the most frequent representations by parents on behalf of their children concerns orthodontic services. In County Kerry alone, a total of 960 patients seeking fixed appliance treatment are now on waiting lists in Cork. So extensive is the waiting list in Cork that they are now only dealing with referrals made in January 1997. A further 546 children under the age of 12 years are awaiting assessment in Tralee. If they ever get an assessment in their childhood years, they will need to join a new waiting list for treatment because most of them will have reached their teenage years.
I pay tribute to the consultants and nursing staff who are working flat out to deliver orthodontic treatments. However, the guidelines and criteria which govern the delivery of their services are outdated and simply no longer reflect demands. The Department of Health and Children guidelines on orthodontic services have not changed for 15 years. In spite of one of the key recommendations of the Moran report to use a more internationally accepted index for the delivery of these services, this Government has sat on its hands. As far as the treatment providers and those in need of treatment are concerned, the Moran report has sat gathering dust for too long. The report has been with the Minister and the Department for almost two years.
The disgrace of our orthodontic services is a damning indictment of our tiger economy. Throughout Europe, even in countries less prosperous than ours, children do not have to queue for essential dental treatments but receive them as a right. Is this Government satisfied that Irish children must wait until their teenage years before they can wear a brace to rectify a problem which was clearly identifiable at the age of eight or nine years? Is this Government satisfied that hundreds of people are forced to live in major discomfort because they require new appliances for their teeth? Is this Government satisfied that the right to a healthy set of teeth is only available to those who can pay for such a service? I raised this matter by way of parliamentary question in the recent past. I am not satisfied that enough is being done to update the delivery of orthodontic services. It is crucial that the Minister takes responsibility for its delivery. Where is the Moran report in his Department?
Mr. Penrose: I welcome the opportunity to contribute to this debate. Both Deputy Moynihan-Cronin and I have raised this matter, partic ularly the current state of our orthodontic services, on a number of occasions. It is worsening despite the purported economic affluence we are supposed to enjoy. It is incredulous and mind-boggling to say that the severity of a child's orthodontic problems must conform with the Department's guidelines first introduced in 1985 which are clearly outdated and outmoded. If a young girl's dental outcrop is only eight instead of nine millimetres, she falls below the Department's guidelines for eligibility for treatment through the health board. Such young people in their formative years are desperately in need of treatment. There is an old adage, a stitch in time saves nine. Surely if the condition is not treated in time it worsens and young people, particularly girls, are acutely embarrassed at having pronounced outcrops. Parents, many of whom may be unemployed or in receipt of social welfare payments, borrow up to £2,000 from their local credit union in order to get appropriate appliances or other essential dental treatment. Otherwise their children remain in discomfort.
Why has the recommendation to update these guidelines using a more internationally accepted index and the Moran report on the future of orthodontic services lain idle in the Department for over 18 months? I understand the senior chief executive officers of the health boards reported on all aspects of the matter so there is no further excuse for delay. I concur with Deputy Moynihan-Cronin that the orthodontic staff in the health boards are working flat out. The Midland Health Board is in crisis as far as orthodontic treatment and waiting lists are concerned. I appeal to the Minister to implement the recommendations of the Moran report without further delay and give hope to the young people on the waiting lists and their parents who must borrow to meet the costs.
Minister for Health and Children (Mr. Martin): I thank the Deputies for raising this issue and allowing me an opportunity to discuss orthodontic services. This is not an issue of funding. It is simplistic to put forward such a view. Significant organisational changes must take place within the orthodontic service. I am concerned about the matter. The position is unacceptable and I intend to make changes and ensure services are in place.
We will continue to develop orthodontic treatment services in accordance with the dental health action plan. My Department continues to provide funding to health boards for the development of the service. This year my Department made an additional £1,450,000 available to health boards for such development.
The demand for orthodontics is much greater than can be provided in any developed country. The provision of fixed appliance orthodontic treatment is expensive. It is important, therefore,  that resources be used efficiently. In that context, health boards must assess patients for treatment in accordance with guidelines issued by my Department and, where appropriate, place individuals on waiting lists. The dental health action plan provides for the development of a consultant led orthodontic service by each health board which ensures a high level of high quality service. Seven of the boards have now established a consultant led service and the Midland Health Board avails of the services of orthodontists in private practice.
At the invitation of my Department, a group representative of health board management and consultant orthodontists assembled to prepare a report on orthodontic services. The objective of this review of the orthodontic services is to ensure equity in the provision of orthodontic treatment throughout the health boards having regard to the provision of additional resources provided under the dental health action plan. The report was made to the chief executive officers of the health boards. Recommendations in the report include the following: that all boards use the same severity index to determine need, the internationally recognised index of treatment need, that resources be provided in this context and that provision of orthodontic treatment should be on the basis of priority need; that regional orthodontic units provide courses of continuing education to maintain and upgrade skills and standards; that dental schools continue to be involved in service provision as part of their training programmes in collaboration with the relevant health boards; that a standard model for costing orthodontic treatment be developed and implemented for each regional orthodontic unit; that appropriately trained, qualified and registered specialist orthodontists be employed in regional orthodontic units to ensure the continuation of a high quality service; that regional orthodontic units be involved with the dental schools in the training of specialists on a rotational basis; that hygienists-auxiliaries be employed in the regional orthodontic units to complement the role of the specialists, provided that appropriate training and registration is facilitated; that existing dentists in the regional orthodontic units be provided with an opportunity of achieving specialised orthodontic qualifications and that a system of outcome measurement and audit be implemented in the orthodontic services.
One of the main contributory factors that service targets are not being met in health board orthodontic units is that the majority of support staff available to consultants have been trainees and are, therefore, not capable of meeting the target levels appropriate to fully trained staff. Health boards are fully supportive of dentists who wish to pursue a specialist qualification in orthodontics.
 Specialist training programmes in orthodontics within the State are currently provided by the Dublin Dental Hospital and School. I have recently approved funding of £100,000 per annum to support the appointment of a professor in orthodontics at Cork Dental School so that priority can be given by the school to the provision of specialist training in orthodontics for health board dentists in the orthodontic units. It is essential that both schools have specialist training programmes available to dentists working with the orthodontic units. Full co-operation between the units and the schools will be required. Regrettably this co-operation has not always been achieved in times past. On the setting up of a specialist register it will ultimately be a matter for the Dental Council to satisfy itself as to the adequacy of training programmes for specialist registration.
As yet there is no recognised grade of specialist orthodontist in the public health sector. Health boards experience a high turnover of staff in the units who reach specialist level owing to the attractiveness of private practice. However, in line with the recommendations of the Moran report, my predecessor, Deputy Cowen, gave consent to the Dental Council for the speciality of orthodontics to be recognised for registration purposes. I am confident that with the setting up of a specialist register in orthodontics and the creation of the grade of specialist orthodontist in the health service, a substantial improvement will be made in the recruitment and retention issues and, consequently, in the efficiency and effectiveness of the orthodontic service. The issue of a specialist grade in orthodontics within the health board service is currently being progressed through the Health Services Employers Agency.
The waiting times for orthodontic treatment are unacceptably long. We know that a delay does not mean there is a negative impact on a successful clinical outcome. Heath boards are committed to reducing waiting times over the next few years. I have asked the dental council to consider the creation of a grade of auxiliary dental worker to work in the orthodontic area. This grade would act as a support to the consultant orthodontist, specialists and other dentists working in the orthodontic unit, thus enabling greater caseloads to be achieved.
I have met all the chief executive officers of the health boards and asked them about their plans for cutting the waiting lists for orthodontics. I recently had two further meetings with the chief executive officer of the ERHA and his team in relation to orthodontics and the management team of the Southern Health Board, two regions that are particularly bad with regard to unacceptably long waiting lists. I put it to them in no uncertain terms that I want plans brought for ward that will dramatically reduce waiting lists. In terms of the index, that will come into being shortly. It has gone on too long. It is time for reform and change, and that will happen.
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