Wednesday, 11 April 1984
Seanad Eireann Debate
Mr. Browne: On the last occasion I said I did not think I would get my teeth into the Bill. Today I am a week older and have grown longer in the tooth since then — unfortunately I have not got all of them. I should like to deal specifically with section 7 of this Bill because it will be very important for the future of children's teeth. Many children, unfortunately, are eating the wrong food and as a result they are losing teeth.
The provision of hygienists is a very important part of this Bill. They will serve  a double purpose. They will advise children as to what is good or bad for teeth, and they will give time to dentists to deal with the problems that have arisen. It is very important that we have as much preventive dentistry as possible. It is shocking to see what used to be described as toothless terrors — young people with their teeth extracted and nothing to be done for them except to provide them with dentures. I suppose that, in its own way, is a good thing if the crisis has arisen. Section 7 which provides for hygienists could be a major step in the prevention of tooth decay where young children are concerned.
It is unfortunate that dentists are not as plentiful in the public health scheme as they should be. There is quite a queue for this service. Many times when children visit a dentist they go simply to have an extraction done. That is a sign of defeat of the whole system. We should be able to get them there in time to have fillings done to ensure that their teeth are saved. Schools must play a very important role, as well as hygienists, in helping to get across to the younger children the idea of teeth preservation. Charts are sent around to schools and are put on display. Many teachers have regular talks on the care of teeth.
For that reason the suggestion that a member of the INTO should be on this committee is a very important one, because they are dealing with the problems of teeth, perhaps in an impersonal way. They are not dentists but they see what is happening. No matter what advice children get in school, and no matter what publicity is given to it, children still eat crisps, lollipops, and so on, all the wrong foods. I ask the Minister to accept the suggestion that a teacher should be on that committee to advise on the whole question of the Dentists Bill.
Ordinary drinking water seems to have a disadvantage as against fluoridated water. Statistics prove that there is a 50 per cent drop in teeth decay if fluoridated water is used. A special effort should be made to provide people who have not got a public water supply with some system — I know different tooth paste manufacturers claim to do the same thing — to  prevent tooth decay. Some people have private supplies of water which tastes much nicer but in actual fact has no protection for teeth.
I often wonder why dentists are so scarce in the health board areas. I know there is a cutback on money, and everything else takes priority. Many parts of medicine do not seem to have the same devastating effects as the lack of dental treatment. I should like to see this question of dentists getting priority in health board areas and particularly in my own area, because we are short of a dentist. The two there work almost night and day in an effort to keep up with their work. Unless we employ dentists who are trained to look after teeth we will have an on-going problem, and we will only be catching up on the harm that has been done. Instead of preventing the loss of teeth we will be extracting teeth that have decayed. That is a pity, and I appeal to the Minister, if possible, to impress on health boards in particular that they should not cut back on the supply of dentists.
I want to emphasise the importance of the hygienists because they will play a leading role in leaving dentists free to do the jobs for which they are trained. I would like to see teachers encouraged to implement more of the advice they get in circulars, and so on, to encourage children to avoid eating some of the awful “goo” that they eat which does harm to their teeth. I should like to see the fluoridation of water as an ongoing thing and in particular for those who have their own private supply. It would be nice to think that dentists who cost the State a lot of money would give a certain amount of service to the country before leaving us to gain experience and share their skills in foreign countries.
In comparison with most other countries the percentage of money we spend on dental care is very low. I understand it represents not more than 2 per cent of  the total expenditure on health care. This compares very unfavourably with Austria, 11 per cent; Denmark, 8 per cent; Finland, 7 per cent; Iceland, 6 per cent; Norway, 7 per cent; Sweden, 9 per cent; Switzerland, 9 per cent; and the United Kingdom, 5 per cent. Compared with those countries it would appear that we are not prepared to spend in terms of our total resources sufficient money to deal with this problem.
I want to concentrate the Minister's mind for a few minutes on the people for whom we have prime responsibility. If we take pre-school children, primary school children, adolescents between 12 and 15 years, and the adult population who are eligible for medical cards, they total about 1.5 million. It seems to me on the best evidence that I can get, that not more than half of the people in all of these categories are actually treated each year. In some of our schools the position is considerably worse than that. For the age groups below pre-school level the position is even worse.
I want to make a plea particularly for the less well off and disadvantaged groups, some of them in some of our long-stay hospitals, some in mental handicap institutions and many others. I do not even know if we have any statistics as to the depth of their problems in this regard. They do not have a strong voice to represent them. As such, they form a part of society who have to undergo an awful lot of neglect in this area.
In essence, what I am saying is that we have a paper eligibility for a great number of people who do not have available to them any satisfactory service. The previous speaker made reference to a number of positive areas where we can try to encourage people in so far as preventive medicine is concerned to highlight deficiencies in our food and diet, and so on. Human nature being what it is, many people will have to rely on the actual service itself. This will inevitably involve on the one hand, the employment of more dentists and orthodontists and on the other hand the whole dentists' profession. They will have to come out of isolation and provide more of a total community service.
 With these few brief remarks, because we are under pressure for time this afternoon, I should like to welcome the Bill and ask the Minister to indicate to us if he can hope to make any strides in dealing with the huge numbers of people, and particularly young children, who are without any adequate service in this regard.
Minister for Health (Mr. B. Desmond): I should like to thank all the Members of this House who contributed to the debate on the Dentists Bill. Some speakers drew attention to various deficiencies in the health board dental service. The Dentists Bill is not about the delivery of a dental service. It is primarily concerned with the regulation of the practice of dentistry within the State. Nevertheless, it does contain certain provisions that would have implications for the quality of the dental service that can be made available by the health boards for eligible persons. In particular, the establishment of classes of auxiliary dental workers who might be employed by the health boards could have a very beneficial effect on the quality of the health board dental service.
Although there are waiting lists in some areas and screening of school children is not always carried out as frequently as one would wish, the fact remains that the level of the service being provided now, in terms of manpower, is as high as it ever has been. There are difficulties in some areas in recruiting staff to full-time posts but, whenever possible, temporary staff are engaged in order to maintain the service. At present there are over 260 dentist posts in the health board service. In 1970 the number of dentist posts was only 116. Due to the embargo on additional posts in the public service it is not possible to recruit additional dentists at present but the approved manpower level is being maintained.
Senator Fallon suggested that there should be special provision for the treatment of handicapped and institutionalised persons. The handicapped and the institutionalised are among the categories of patients who figure on the priority  lists of health boards for dental treatment purposes.
It was Senator Lynch who commented on the salaries of public dental officers and said that the poor salary level was the cause of recruitment difficulties. There have been recent arbitration proceedings in relation to the salaries of public dental officers and the recommendation of the arbitrator should be available shortly.
What is known as the ad hoc dental scheme, under which dentists in private practice treat eligible persons on behalf of the health boards was introduced in 1979 to supplement the service provided by the health board dentists. About £1.5 million is now being spent each year on this scheme.
It must be remembered that prior to 1979 there was no ad hoc scheme at all and the dental service for all eligible persons had to be provided by the health board dental staff whose numbers were then considerably lower than they are at present.
The orthodontic service for eligible persons is the most criticised area of the public dental service. In nearly all health board areas there are long waiting lists for treatment. This is due to the increased demand for orthodontic treatment in recent years coupled with the absence of qualified orthodontic staff in the health boards and the shortages of money for the engagement of orthodontists in private practice. Also there is a problem in relation to complicated orthodontic treatments, involving the use of fixed appliances, which are carried out on behalf of the health boards by orthodontists in private practice.
The Department have been endeavouring for a number of years to get agreement with the private orthodontists on a scale of fees for this type of treatment and for more than three years only a few extremely urgent cases have been authorised to proceed. Recently a scale of fees acceptable to both sides was arrived at but the orthodontists wanted assurances from the Department that the health boards would each make specific allocations of money annually for orthodontic services provided by the private  orthodontists. The allocation of money for specific purposes is entirely a matter for the individual health boards, so the Department could not give the assurances sought by the orthodontists. Discussions are continuing and I am hoping for an early settlement of the fees issue. One thing to be borne in mind is that when this matter is resolved the health boards will still have the problem of finding funds to enable them to avail of the services of private orthodontists.
The recruitment of five full-time consultant orthodontists should greatly improve the orthodontic service for eligible children. Applications received for the five posts advertised in October 1983 are being processed at present by the Local Appointments Commission and it is expected that some appointments will be made soon.
I feel it necessary to say a few words here about the greatly increased level of demand for orthodontic treatment. A good deal of this is arising, it seems, from pressure from parents to have relatively minor defects or anomalies in the alignment of their children's teeth corrected. Most of these do not interfere with function, nor do they damage other structures in the mouth, and treatment is therefore sought for purely cosmetic effect. One must seriously question this. Could it be held, for instance, that on the medical side a public health service should meet the cost of the alteration of facial features of children which are not fully acceptable to their parents, such as the shape of a nose or the set of ears? I think not. I am having the question of the criteria which should apply before orthodontic treatment is undertaken examined with a view to issuing guidelines to health boards which will ensure that only real treatment needs are met.
It is generally accepted that in the case of dental disease prevention is far more cost effective than treatment. The fluoridation of water supplies, which was raised again this afternoon, has been proven to be an effective means of reducing the incidence of dental decay. The maintenance of the correct level of fluoride in the water supplies is, therefore, of  paramount importance. Traditionally the installation and replacement of fluoridation plant have been a charge on the revenue allocations of the health boards and the boards have been inclined in recent years to cut back in this area as a means of cutting their costs. I am at present examining the possibility of funding fluoridation schemes from the Department's capital programme.
During the years there have been many calls for the extension of eligibility for State-funded dental services. The wives and other dependants of insured workers are groups for which there have been calls to extend eligibility. It is easy to extend eligibility, but unfortunately it is not so easy to find the funds to provide an adequate service for those who are eligible. The Joint Working Party on Dental Services which reported in 1979 recommended that those adolescents, those between the ages of 12 and 16 years, who do not have eligibility at present should be given priority if any extension of eligibility was being considered. The working party indicated, however, that no extension of eligibility should be contemplated until such time as there was an adequate service available for those who were already eligible. I am afraid that the service available at present for eligible persons could not be regarded as satisfactory.
I was asked by Senator Lynch how many dentists are being trained in the country at present. In the next few years a total of approximately 80 dentists will graduate each year from the Trinity College and UCC Dental Schools.
Reference was made to the poor dentist-population ratio in this country, and various figures for other countries were quoted. First of all I would like to clarify one matter, and that is that there is no internationally recognised dentist-population ratio.
The appropriate dentist/population ratio for any particular area would depend on the dental health status of the population, which would in turn depend on a number of factors such as whether water supplies are fluoridated, the type of diet followed and the level of oral hygiene practised.
 In this country we could do with more dentists in the health board service, but it is doubtful if private practice could sustain any significant increase in the number of practitioners. The shortage of dentists in the health board service is not due to any shortage of graduates from our dental schools. It is due to the lack of finance and to the embargo on the creation of additional posts in the public service. Also, there are some locations in the country which, due to their comparative isolation, have always given rise to great difficulty in attracting dentists to take up full-time posts. It was suggested that graduate dentists should be compelled to give a specified period of service to the health boards before being allowed to emigrate or to enter private practice. Although this may sound an attractive proposal it is not really practical. The question would undoubtedly be asked as to why doctors, engineers, architects and members of other professions should not also be compelled to give a period of service to the State upon graduation.
To get back to the general provisions of the Bill it has been suggested by a number of Senators that the INTO and indeed other teachers' organisations, should have representation on the Dental Council in view of the role they can play in encouraging preventive dental care in school children. While I appreciate the valuable contribution teachers can make in this regard, representation on the Dental Council would not necessarily help. The Dental Council are, after all, primarily concerned with matters relating to the regulation of the dental profession, the education and training of dentists and the standard of dentistry, rather than with the delivery of dental services.
Senator Dooge asked if I would indicate to what extent graduate dentists are being attracted into the health board dental service through sponsorship, as recommended by the Joint Working Party on Dental Services. As the Senator said, the North-Western Health Board have sponsored a number of student dentists in the past few years, though none is being sponsored at present. Last year the board sponsored four and the year  before three students, all of them in their final year. Sponsored students were paid £1,500 per year plus their course fees by the health board. In return the students are committed to one year's work for the board for each year of sponsorship. Apart from this scheme, the restructuring of the health board dentist grades, which also followed on recommendations of the joint working party, provided for a new grade of dentist — clinical dental surgeon, grade I — which would be recruited from newly-graduated dentists who would not have had any work experience. Due to the general embargo on the creation of additional posts in the public service it was not possible to recruit dentists to this grade since it would have involved an overall increase in staff numbers. Nevertheless, a number of graduates have been employed in this grade, notably by the Eastern Health Board, but they are occupying full-time posts, which, for one reason or another, are unfilled and they are not increasing the overall staffing level of the board.
Senator Dooge had a number of queries in relation to the provisions of specific sections of the Bill. He mentioned that the reference in subsection 2 (e) of section 27, which deals with eligibility for registration, to a provision contained in the 1928 Act is the one blot on an otherwise excellently drafted Bill. This reference, however, he points out makes it necessary for one to consult the 1928 Act in order to understand what is provided for under section 27. The provisions in the Bill relating to eligibility for registration are the subject of detailed consultation with the Dental Board and I will probably have some suggestions to put forward on Committee Stage which could take care of the point made.
Senator Dooge asked why the council are not being required to produce an annual report as well as annual accounts. Normally annual reports are required of bodies, such as health boards, which are engaged in the delivery of particular services, and the annual reports serve as a measure of their performance during the year. The functions of the Dental Council, on the other hand, are primarily regulatory and could be held not to warrant  this type of accountability. I am not, nevertheless, opposed to the idea of annual reports and will consider this further on Committee Stage to meet the wishes of Senator Dooge in this regard.
Questions were raised as to the power to be given to the Minister under section 15 to direct the Dental Council to discharge a function assigned to them under the Bill. It was suggested that use of this power could mean that the council would lose their autonomy, particularly in relation to their discretionary powers. While it would be possible for a Minister to issue a direction to the council compelling them to exercise a discretionary power, I cannot envisage a situation in which section 15 would be used for this purpose. The power is intended to enable the Minister to deal with the situation which could arise were the council to refuse to carry out a function which they were obliged to exercise under the Bill, and which should clearly be exercised in the public interest. Such a situation could come about if the council were, for instance, to refuse to carry out the mandatory functions assigned to them in relation to “fitness to practise” under Part V of the Bill. There is nothing new or revolutionary about the giving of such a power to the Minister in regard to this type of body. Section 22 of the 1928 Act gave the Minister powers in relation to the Dental Board similar to those proposed in section 15 of the Bill.
It is worth noting that no Minister for Health has ever found it necessary to use the powers conferred on him by section 22 of the 1928 Act. Other Acts give the Minister similar powers to direct the carrying out of functions by regulatory bodies. Examples are powers given under the Opticians Act, 1956 in relation to the Opticians Board and under the Medical Practitioners Act, 1978, in relation to the Medical Council. In these cases, also, no Minister has had to invoke the powers. I must emphasise that I would only consider doing so if a situation seriously affecting the public interest were to arise, and I am confident that any future Minister would do the same. But because of the possibility that such a situation could  arise, however unlikely, it is necessary to take the power to deal with it. I do not consider that it would be a practical proposition to make the exercise of the power by the Minister subject to annulment by the Houses of the Oireachtas.
It was asked whether, under Part IV of the Bill, consideration had been given to the establishment of internship for dental students before registration, as in the case of students of medicine. I am aware that there are moves in this direction in Britain. The new Dental Council will have responsibility for ensuring that the education and training of dentists, including practical knowledge and clinical experience, are adequate and suitable. The question as to whether internship is necessary, desirable or practicable in our circumstances will be one for the council to consider in the first instance.
The need for the provisions relating to setting up of a register of dental specialists was questioned. As I said on the introduction of the Bill these provisions do not compel the Dental Council to set up such a register but give them the facility to do so at some future date should this become necessary or desirable. While there is an EEC Directive concerning the mutual recognition of specialist qualifications there is no directive under which registration of specialists is required. Some member states do already register their dental specialists and the tendency is for this practice to spread. The whole question of the training of dental specialists is being considered at EEC level. It would be only reasonable to expect that specialist registration may well become necessary in the future under the terms of a directive. In the circumstances it would be remiss of me not to take the opportunity to give the council an enabling power in this area. There is also a public interest aspect to this matter. Registration of persons in establishing specialties would be indicative of special qualification and would be of considerable interest to members of the public requiring specialist treatment.
Senator Dooge asked if there was any significance in the change of wording which in section 31 of the 1928 Act reads “felony or misdemeanour” and which in  section 42 of the new Bill reads “an offence triable on indictment”. The change of wording, I am assured, has no significance other than to bring the legal wording into line with modern practice in this respect.
The Senator inquired about the numbers of dental surgery assistants in the country and whether it is intended formally to recognise and register them as a class of auxiliary dental workers. I do not have any accurate figure on the number of dental surgery assistants as many of them work in private practices. Since they are normally employed on a one-to-one basis with practising dentists, I would expect, however, that the number is something in the region of 900. The question of registration will be one for consideration by the new Dental Council in the first instance. They will have to face the difficulty posed by the absence of a nationally recognisable qualification for the grade which could provide a basis for registration. While our two dental schools operate training courses at the end of which a qualification is awarded, those with this qualification represent only a minority of dental surgery assistants.
Senator Dooge asked also what the present position is in relation to the training of dental mechanics, with which AnCO were involved, and what future developments ought to be expected in this area. Again this will be something for the new Dental Council to tackle. The trade of dental craftsperson is a designated trade within the meaning of the industrial training legislation, and as such the training of apprentices is the responsibility of AnCO. The apprentice mechanics who complete the AnCO course do not sit any examinations nor do they receive any certificates or similar evidence of qualification. It would not be possible to use this Bill as a vehicle to alter this situation.
If a new class of dental auxiliary is established under the provisions of section 54 of the Bill with a standard of education and training that would make its members competent to supply dentures direct to the public, this would not affect the status of those who remain as  dental mechanics and do not choose to qualify for any higher duties. The problem at present is that among those who have undergone training by AnCO some have attained a formal qualification but many have not. There are quite a number with no formal qualifications or training whatsoever. I would expect that the Dental Council would seek to develop proposals for necessary improvements in this unsatisfactory situation in conjunction with the other interests involved.
Section 54 empowers the council, with my consent, to make schemes for the establishment of certain classes of auxiliary dental workers. These schemes can determine the qualifications required for membership of a particular class and the nature of the dental work a member of any class may undertake, as well as the circumstances in which any such work may be undertaken. I think this section of the Bill is largely self-explanatory. Section 55 in effect sets out the parameters of the dental work that a dental auxiliary will be permitted to undertake. It provides that the limit to which an auxiliary dental worker will be permitted to go is the extraction of deciduous teeth, that is first or baby teeth, and that this work or the filling of teeth can only be done by an auxiliary when working for a health board or under the direction of a registered dentist. This will prohibit the carrying out of this type of work in private practice. Under section 54 (2) (b) of the Bill there is provision for determining the type of work any auxiliary may undertake and the circumstances in which it may be undertaken and this could, for instance, be used to specify that members of a particular class of auxiliary dental worker, such as hygienists, would work under the supervision of a registered dentist.
It was again Senator Dooge who drew attention to the fact that the Joint Working Party on Dental Services were against the introduction of denturists in this country. The working party report referred to the declining demand for dentures as more people tend to retain their  natural teeth. However, I think it is necessary to take account also of the findings and recommendations of the Restrictive Practices Commission following their inquiry in 1982 into the supply of dentures. The Commission found that the existing legislation confining the right to supply dentures to the public to registered dentists constitutes a restrictive practice. In making provision for the introduction of denturists, I am only providing for the implementation of one of two alternatives listed by the Restrictive Practices Commission in their report. The other alternative, some Senators will be aware, and the one that the commission recommended was that the supply of dentures to persons of 18 years of age or older be subject to no restrictions whatsoever. I have accepted that.
In the interests of the general public and after prolonged discussion at Government level, the Government decided to opt for the establishment of fully-trained denturists rather than for the complete de-restriction of the supply of dentures. The extent of the market for dentures in future years is something that those who would consider qualifying as denturists might be advised to take into account.
Section 56 gives me the power to direct the Dental Council to exercise their functions in relation to the establishment of any particular class of auxiliary dental workers or to establish a particular class of dental auxiliary workers for a trial period so that its value to the public might be assessed. While I think this section gives the Minister reserve powers that are necessary in the public interest I would not envisage the provisions of this particular section having to be invoked in the normal course. I would expect that schemes to establish classes of auxiliary dental workers would be initiated by the Dental Council with my consent, as provided for under section 54. I cannot be any more explicit than that on the situation.
Senator Honan queried my intentions in this regard, but I assure her that it is my intention that schemes for the establishment of classes of auxiliary dental  workers are introduced under the provisions of section 54. That is perhaps the most contentious section. It has been discussed at great length at Government. I have received numerous representations regarding this whole matter and I have adopted at this stage a firm view in relation to these provisions. Reference was made also to section 62 and it was suggested that a list of the statutory instruments made under the 1928 Act might be made available. In fact no such instruments as such were made under the 1928 Act. The provision in section 62 is a routine one in legislation of this type. It seeks to ensure that any mention of the Dental Board set up under the Act of 1928, in any other existing Act or statutory instrument will be taken in future as referring to the Dental Council which will replace the board.
In conclusion I thank all the Members of the Seanad for the exceptional attention given to this Bill and for the thorough way in which the Bill has been examined by them, as evidenced by the many relevant points made by the speakers. I trust that my replies have served to clarify matters and, dare I say it, to pave the way for a speedy Committee Stage and an early passage of the Bill by this House.
Mr. Ferris: The Minister said in connection with the work of auxiliary dental workers that “It provides that the limit to which an auxiliary dental worker will be permitted to go is the extraction of deciduous teeth, that is, first or baby teeth, and that this work or the filling of teeth can only be done by an auxiliary when working for a health board or under the direction of a registered dentist.” The word in the Minister's speech is “and”, not “or”. It is very important that it is the word “and” and not the word “or”. This clarification is for the record of the House.
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