Committee Reports > List of Committees > Dáil > 1986 > Committee on Public Expenditure > Report No. 19 - Proposed Dublin Dental Hospital

Appendix 5

Submission of the Irish Dental Association to the Dail Committee on Public Expenditure

“IRISH DENTAL MANPOWER NEEDS”

COMMENTS FROM

IRISH DENTAL ASSOCIATION COUNCIL SUB-COMMITTEE

IDA.

25th March, 1986.

SUMMARY

1.Escalation of costs of Health Services is causing particular concern.

2.Personnel absorb 75% (approx.) of total costs of Health Services.

3.Therefore, manpower is a critical component of future health planning.

4.The number of practising dentists in Ireland in ratio to the population is 1 : 3,250 persons.

5.The World Health Organization predicts a need for 1 dentist to 3,750 persons in Ireland within the next 14 years, even if present levels of dental health were merely maintained and not improved upon.

In other words, Ireland already has more dentists than she will need within the next 14 years.

6.The prevalence of dental disease in Ireland has decreased dramatically.

7.Ireland needs to train not more than 40-45 dentists per year.

8.Even fewer dentists will be required if consideration is given to the introduction of operating dental auxiliaries.

9.In view of the fact that the developed countries are all

“in a state of at least adequacy ranging to a dental manpower surplus of critical proportions” (World Health Organization),

the days of the Irish dentist as an emigrant are over.

10.Over production of any health professional manpower is a costly wastage of resources.

11.Health Board patients (medical card holders, their dependants, national school children and those in institutional care) are not receiving the dental treatment to which they are entitled.

1,700,000 persons eligible — serviced by only 220 dentists.

Social Welfare patients

900,000 persons eligible — serviced by 682 dentists.

These patients have no difficulty receiving treatment.

12.A re-definition of the role of the Health Board Dental Service combined with a re-allocation of patients among the all too few Health Board dentists and the all too many general practitioners is required. The community could benefit from improved services by a more effective utilisation of current dental manpower.

INTRODUCTION

Escalation of the costs of Health Services throughout the industrialised world has caused particular concern during the past decade.

The situation in Ireland may be illustrated by the following:

Concern about escalating costs is exasperated by current financial economic restrictions.

The Irish Dental Association has considered this problem and is continuously debating the nature, organisation and finance of the dental health care services. In view of the fact that the health services are labour intensive and health personnel absorb up to 75% of total costs, manpower constitutes the most critical component of health planning. The Irish Dental Association has focused attention on the study of dental manpower planning and in May 1984 called on the Government to establish a Health Manpower Planning Unit as an integral part of comprehensive health planning.

THE GROWTH OF DENTAL MANPOWER

The growth of dental manpower in highly industrialised countries throughout the latter half of the twentieth century has been of massive proportions. This situation has arisen simply because of the failure of most developed countries to monitor continuously both the prevalence of dental disease and the demand for dental treatment in their communities, and to regulate their production of dentists accordingly. Having responded to the consequences of a tremendous explosion in the prevalence of dental disease in the early decades of this century by increasing the output of dentists correspondingly, few countries recognised the dramatic reversal in the level of dental disease which has been on-going for the past three to four decades. Throughout this period countries have blindly continued to produce dentists to the maximum level possible while failing, at the same time, to appreciate that the need for maximum output was rapidly and continuously diminishing. Inevitably, this has resulted in the creation of an oversupply of dentists in most if not all of the developed countries, and especially in Europe.

The Irish Dental Association’s concern regarding the failure of interested authorities to provide scientific analysis of manpower needs and, in many cases to fail to even recognise this as a most critical component of health planning was heightened by findings of the World Health Organization.

IRELAND’S DENTAL MANPOWER NEEDS

As recently as 1984, the World Health Organization (Dr. David Barmes, Chief, Oral Health Unit), predicted that if even present Irish levels of dental health were maintained and not improved upon, by the year 2000 Ireland would need only 1 dentist to 3,75ill persons. The average today is already 1 dentist to not more than 3,250 persons. In other words Ireland already has more dentists than she will need within the next 15 years

Dr. Barmes’ predictions were based on the findings of the 1980 ‘International Collaborative Study of Dental Manpower Systems in Relation to Oral Health Status’, which was carried out in Ireland under his supervision, coupled with an analysis of the prevalence of dental disease in the Irish community from 1961 up to 1980 (Appendix I).

A further study — “Irish Dental Manpower - 1941-2001” undertaken on behalf of the Irish Dental Board in 1984 by Professor M. A. Moran and Dr. M. J. Crowley of the Department of Statistics, University College, Cork, highlights the potentially disastrous situation which seems inevitable.

The study analysed the dynamics of the Irish Dental Register over the post 40 years to determine in particular, the rates of absorption of Irish dental graduates by the Register. Specifically this involved determining the year by year contribution, through the period 1941-1981, of each and every graduate of a dental school in the Republic to the Register. Accordingly, for every year between 1941 and 1980 the presence or absence of each Irish graduate was determined for each year subsequent to qualifying, and the percentage of graduates appearing on the Register at a given number of years after their graduation was calculated. This provided detailed information on the changing structure of the Register over time, but more importantly allowed the rates of absorption of graduates by the Register to be calculated.

In the words of the authors — “This absorption rate is crucial to an understanding of current and future trends in dental manpower”. Accordingly, the authors make projections of dental manpower levels likely in Ireland up to the year 2001.

To summarise the findings of this most comprehensive study borders on an injustice to the authors. The full report can, however, be obtained from The Registrar, The Dental Council, Merrion Square, Dublin 2.

In the section of the study which deals with “Recent Trends” and with “Rates of Absorption” in particular, the authors state — “During the decade 1971/80 used for the projections, the rate of absorption of graduates in their first year after graduation was 20%. The rates of absorption for 1981 and 1982 graduates show increases of 35% and 65%, respectively, over the pattern for 1971/80 and suggest that Irish graduates may now be much less likely to emigrate than in the past. This would imply that the rates of absorption used in the projections were conservative”. In hindsight this is hardly surprising since it is now known that an increasing oversupply situation is developing in the UK, resulting in less job opportunities for the emigrant Irish dentist.

The authors used the 1971/80 absorption rate as the baseline for their projections of the size of the Register for the year 2001. They also used an absorption rate of 20% greater than in 1971/80 and another 40% greater than in 1971/80. Against these, they evaluated the effect on the Register of the production of 50 dentists per annum by the Irish dental schools. [In 1984 the Irish dental schools produced 57 dentists and in 1985, 66 dentists. This year it is expected that 75 dentists will be produced.]

Based on these assumptions and taking into consideration a 23% projected population increase in Ireland by 2001—which is now known to be excessive — the authors concluded that if 50 dentists were produced annually in the coming years, with an absorption rate identical to the period 1971/80, there would be one dentist to 3,580 persons. If, however, the absorption rate increased by 20% over the 1971/80 rate there would be one dentist per 3,300 persons. An absorption rate increase of 40%, which seems probable, would result in a dentist to population ratio of 1 : 3,040.

It will be recalled that all of these dentists to population ratios exceed the figures given earlier by Dr. Barmes in his prediction as to what Ireland’s dentist to population needs would be in the year 2000, namely, one dentist to 3,750 persons.

Combining the findings of these two separate studies of the Irish dental manpower situation would seem to indicate that if Dr. Barmes’ predictions on dentist to populations are correct and the proportion of Irish dental graduates deciding to work in Ireland increases to only 40% over the 1971/80 figure, then the Republic needs to train not more than 40-45 dentists per year to meet its dental manpower requirement. Even fewer dentists will be required if consideration is to be given to the introduction of operating dental auxiliaries.

In addition to the problem of the rapid increase in the absorption rate of Irish dentists, the number of non-Irish dentists in Ireland is also increasing. During the period 1941-1976 the position was static at about 3%. Between 1976-1981, a sudden increase to 6% in the numbers of non-Irish dentists registering each year occurred. In 1981, and 1982 this increase was being maintained. Undoubtedly the sudden increase represents an initial response to Ireland’s entry into the EEC. It is probable that a further increase will occur as the oversupply situation worsens in Member States.

The percentage of female dentists on the Register in 1941 was 4% and has grown gradually, but consistently, to 17% in 1981.

In the period 1941-1980 the Republic produced 1,857 dentists while the numbers on the Register increased by 529. Emigration of dentists has obviously been the norm through the period.

ARGUMENTS PUT FORWARD TO ‘JUSTIFY’ OVERPRODUCTION

To justify, if such is an appropriate term, this highly wasteful expenditure of educational resources, two principal arguments are generally propounded. Firstly, an attempt is made to dismiss the idea of a crisis by saying that there is a huge backlog of work for those who were children and adolescents when the prevalence of caries was much higher. Equally, they point to the gap between need, as evidenced by the 1980 study, and demand, as emanating from the community, claiming that a closer approximation of the two would mean that there is no surplus of manpower.

Secondly, refuge is sought in the old familiar Irish answer to an Irish problem — emigration:

Dr. David Barmes, Chief, Oral Health Unit, WHO, put paid to both of these arguments when he addressed the Annual Conference of the Irish Dental Association in Killarney in May of 1984. The subject of his paper was “Dental Manpower Needs [in Ireland]”— which has been published in the Journal of the Irish Dental Association, April/June issue, 1984.

In respect of the first argument he said — “Those claims [backlog and closer approximation of need/demand ] were not wrong for the present, though reducing the gap and thus dealing with the backlog is no simple matter. However, both claims rapidly pass into the past tense as the effects of reducing disease ripple through the population and as efforts to reduce the backlog succeed”.

In response to the second argument relating to emigration he stated — “I must caution strongly against taking refuge in the migration theory. As you have seen, the highly developed countries are all in a state of at least adequacy ranging to a dental manpower surplus of critical proportions. Certainly, some developing countries have the opposite problem, though that problem may be minor and rapidly eliminated if preventive initiatives are successful. However, in the worst analysis, for the developing countries, there is still no haven for dentists from the highly industrialised countries because of economic problems in employing them”.

Thus the day of the Irish dentist as an emigrant are over and this factor is fundamental in the present consideration of dental manpower needs in Ireland.

THE CONSEQUENCES OF AN OVERSUPPLY OF DENTISTS

1. UNEMPLOYMENT

Looked at from an economically simplistic point of view, some observers might easily maintain that overproduction of any product could result in an economic benefit. In other words, the price of the commodity involved would fall. Regrettably, many, both in and out of Government, fail totally to advert to the decline in standards which more often than not accompanies this marketplace philosophy. Were it to be imposed on a health-caring profession, such as medicine or dentistry, the result could be disastrous for the community.

Like it or not, moral and ethical questions arise when the livelihood of medical or dental practitioners faces a challenge like unemployment.

With increasing unemployment there inevitably will be greater risk that the ‘business part of the profession’ pressures practitioners into ‘moral slips’ such as insurance frauds and overtreatment of patients. As ‘profits’ decline ‘costs’ have to be pruned and the most likely area for cost cutting is to buy-in inferior quality materials. Such drastic effects are already evident in some countries where an oversupply of dentists prevails.

Earlier this year the Department of Health and Social Security for England and Wales issued a report entitled “Report of the Committee of Enquiry into Unnecessary Dental Treatment”. The Report states —

“3.2 The evidence as a whole has enabled us to form a clear view of the general scale of the various forms of unnecessary treatment. While none of the evidence is in itself conclusive, it points to there being a small but significant and unacceptable amount of deliberate unnecessary treatment in the General Dental Service, and a larger amount attributable to an out of date treatment philosophy. We are also particularly concerned that a significant amount of unnecessary orthodontic treatment may well be undertaken. Having said that, we do not believe that the problem is so widespread that patients in general should lose confidence in their dentists. Our recommendations are the measures which we regard as appropriate to deal with the scale of the problem as we see it”.

In attempting to determine the principal causes of this unacceptable development the Report states —

“3.10 The change in the demand for the services of dentists has been dramatic. The Royal Commission, reporting in 1979, was still concerned that there were not enough dentists to undertake the work that needed to be done. When the numbers entering dental schools were contained, there would be too many dentists by the end of the century to do the available work, and recommended a 10% reduction in the intake into dental schools. This has been implemented. Despite the reduction in numbers coming out of dental schools and the recent controls on the immigration of foreign dentists, we received comments that the number of dentists was still increasing in many area of the country without a corresponding increase in demand for their services [although overall the number of courses of treatment continues to rise]. We should add the reservation that in some parts of the country, there are too few dentists to provide a comprehensive and speedy service to patients”.

To substantiate the comments made on the imbalance between the oversupply of dentists and the shortfall in the demand for dental services, the Report presents figures which show clearly the pattern of increase in dental manpower [dentists only] in recent years.

“3.9 The number of dentists working in the General Dental Service in England and Wales has increased considerably in recent years. The figures are:

In the past, the vast majority of newly qualified Irish dentists emigrated to the UK, because of good job opportunities. but this situation is changing and will do so even more rapidly in the immediate future because of diminishing job outlets.

Quite clearly, therefore, it is in the best interest of the health of the community that a reasonable balance is struck between the numbers of dentists being produced and the demand by the community for their services.

2. LEVELS OF UNEMPLOYMENT

Statistics released from the Nordic countries in 1985 indicate the levels of unemployment amongst dentists at present, and the projected levels for 1990.

In all of the countries listed, with the exception of Iceland, part-time unemployment of dentists runs at a level of about three times the full-time figures shown.

3. CUT-BACKS IN THE PRODUCTION OF DENTISTS

With the possible exception of Italy, Greece, Spain and Portugal, where dental and medical education are so intermingled as to allow of the practice of both professions by the same individual, all other European countries, Canada and the United States of America are cutting back on the production of dentists.

Examples of these cut-backs are as follows:

4. THE COST TO THE COMMUNITY

The findings of a study to determine the cost to the community of overproducing 54 new, potentially unemployed, dentists per year has recently been completed in Sweden.

The study arose out of the fact that the present intake of dental students in Sweden is 260 whereas it is estimated that this number should not be in excess of 200. Allowing for the fact that in Sweden approximately 10% of students leave dental school before taking their examination, the calculations were based on a net number of 54.

The financial loss to the community consisted of two factors:

1.The cost of undergraduate dental studies

2.The loss of production resulting from the dentist not taking up his profession.

The authors of the study concluded thus — “The total cost to society, based on a initial 60 students of which six leave before completion of their studies, would consequently amount to SKR. 78.4 million for every year that too many students are admitted”.

Obviously the cost to the Irish community of overproducing dentists needs to be expertly and objectively determined. Meanwhile, extrapolation from the Swedish findings is possible, if only in a rudimentary way, by comparing the GNP per head of population. In 1982 the figure for Sweden was $14,000 while that for Ireland was $5,000. Thus the approximate costs of overproduction in Ireland would be 5/14ths of the Swedish figure. This is, of course, an extremely conservative estimate, especially when one considers the differing hourly earning rates (after tax) between comparable professions in both countries. Official figures put this at $6 for Sweden and $4.60 for Ireland.

Based on the findings of the Swedish study and on the relative GNP figures, however, the estimated cost to the Irish community would be of the order of IR. £50,000 per student for every year that too many students are accepted for dental training.

None of these calculations, however, gives due consideration to an equally important issue that of wastage of intellectual capacity.

Since university entry requirements for medicine and dentistry are higher than for most other disciplines, over recruitment from among school leavers who achieve high grades must constitute appalling mismanagement of the nation’s human resources.

5. THE ADVERSE EFFECT ON THE DEVELOPMENT OF A COST-EFFECTIVE STATE-FUNDED DENTAL SERVICE

Health manpower planning has the basic objective of providing the right type of education and training for the right number and type of people needed to render effectively and safely, the right types of service when and where required by the community. Essentially, therefore, it is the process of estimating the number of persons and the kind of knowledge, skills and attitudes they need to achieve predetermined health targets and ultimately, health status objectives. Such planning also involves specifying who is going to do what, how and with what resources. Consequently, the process has to concern itself not only with professionals but with the use of other types of health personnel so that the total health team can provide the range of health services required in the most cost-effective manner possible.

In the circumstances in which there is an oversupply of professionals —— some or many of whom are unemployed —— the idea of developing dental auxiliary personnel is unrealistic and must be relegated to a long term perspective.

6. THE FUTURE OF THE DENTIST AND DENTAL EDUCATION

In commenting on the quality of education for dentists Dr. Barmes stated —— “One day soon, the dental profession must face squarely the issue of whether a high level university graduate, educated over an exacting five year course, is the appropriate performer for routine scaling, application of sealants or other preventive substances and class one restorations.

In contrast, there is an ultimate level of referral for high technology procedures in surgery, periodontal, prosthetic, orthodontic and general medicine procedures related to oral health which require very high level training but for a diminishing operator to population ratio. As I have often said, I have had doubts and still retain them, that even today’s dental graduates are being adequately prepared for this level of performance. There is thus the danger for the profession of falling between two stools, over-trained for moderate technology and under-prepared for high technology over a broad spectrum of what are now regarded as dental specialists and for a type of practice which will be very different in age structure and in the needs of each age group from what is seen as traditional. You can see by that statement that I believe there will be no room for specialty groups in dentistry in the future.”

In support of Dr. Barmes’ comments, on the training of dentists, the Health and Resource and Service Administration Report of 1984 to the US President and Congress stated — “current planning assumptions and implications indicate that the dental curriculum of the future needs to be more oriented toward primary care practice, resulting in a graduate who as a general practitioner would be more capable of delivering many services now provided by specialists. Concepts of practice and productivity management will receive increasing emphasis. In other words, the dentist of tomorrow will become an oral health team manager, with a broader range of specialised skills for more demanding cases — the “SUPERGENERALIST” concept.

7. ESTIMATION OF DENTAL MANPOWER NEEDS

There are essentially two approaches to the estimate of dental manpower needs.

The first is based on the ‘needs’ (normative) of the community as determined by epidemiologists from data on the prevalence of dental disease.

From this data, estimates can be made of the amount of treatment required, that is, the ‘treatment need’ and in some cases this can be presented in terms of the manpower or costs involved in carrying out that treatment. Although superficially attractive, this method has several short-comings which will be discussed later.

The second approach is based on projections of probable trends in the supply of dental treatment and the demand for it. In Ireland we are fortunate in having the results of widespread surveys of dental health and much detailed information about the work of Health Board Dental Services and the Social Welfare Dental Benefits Scheme. Any additional information required for the projection of trends is relatively simple and can be collected easily and cheaply.

An essential feature of this approach is a common measure of both supply and demand. Depending upon the manner in which statistics are presented, the common measure could be a course of dental treatment, the number of patients treated annually or even the dental visit itself.

The shortcomings of the epidemiologically or ‘normative needs’ based approach are threefold:

Firstly, there may well be substantial differences between the diagnostic criteria employed in the study and those which would be used by clinicians. Thus the estimate of treatment requirement is unlikely to be an accurate prediction of what would be provided if the patients actually attended for treatment. Secondly, the estimate applies only to the initial treatment and does not allow an assessment of the volume of dental care required for maintenance over an extended period. Thirdly, it is not possible to make proper allowance for the attendance rates in population. Not everyone will attend for dental treatment and there is no way of knowing whether the attender will be typical of the population as a whole. For these reasons cross-sectional epidemiological studies taken on their own are not a satisfactory basis for the assessment of long-term manpower needs. This does not imply the epidemiological data is of no value. Information about the overall dental health of the population will always be important, especially if the trends can be measured over a period of time.

Irrespective of which of these two approaches is used to estimate dental manpower needs consideration must also be given to the phenomenon of the emigrant Irish dentist, a phenomenon which is unknown in other European countries.

In this regard, the study of Moran and Crowley, to which previous reference has been made, is of considerable importance. However, since the study covered the period 1941 -1980, it obviously needs to be updated if the current and projected dental manpower supply in Ireland is to be fully appreciated. Cognisance must also be taken of the oversuppy situation which exists in Northern Ireland.

Finally, it cannot be emphasised too strongly that since health manpower planning is an imperfect science any projections made of manpower needs at any time must be subjected to constant review and re-evaluation. That this should be the remit of a Health Manpower Planning Unit is self-evident.

8. IMPROVED DENTAL SERVICES FOR THE COMMUNITY - BY THE EFFECTIVE UTILISATION OF CURRENT DENTAL MANPOWER

Economic factors such as redundancy and unemployment in the community are leading to a serious increase in the workload of Health Board Dental Officers and a decrease in that of the General Dental Practitioner.

Under the Health Act 1970, in the year 1983/84, 1,7 million people were eligible for Health Board Dental Services.

Under the Social Welfare Acts, in the same year, 900,000 PRSI workers were eligible for dental treatment.

In that year there were some 220 Health Board Dental Surgeons employed to meet the treatment needs of 1.7 million people, that is a ratio of 1 dentist to 7,700 persons.

In the same year, there were 680 General Practitioner Dentists in the Social Welfare Panel to meet the needs of 900,000 Social Welfare Patients, that is a ratio of 1 dentist to 1,322 persons.

In 1983, of those eligible under the Health Act, only 6½% of adults; 14% of handicapped children in institutions and 31% of children and adolescents (up to 16 years of age) were examined and treated.

Only one conclusion can be drawn from these figures. The Health Boards are in breach of their statutory obligation to provide dental services to eligible persons. Statutory entitlement is irrelevant unless services are available and accessible.

Thus Health Board Patients (Medical Card Holders) are simply not getting the treatment to which they are entitled.

Apart from the injustice to the community, it is grossly unfair to the Health Board Dental surgeons to expect them to deal adequately with the Health Boards’ statutory obligation to provide dental services for so many.

There are two ways of overcoming this problem. Firstly by considerable injection of manpower, materials and money into the Health Board Dental Services or, secondly, by changing the role of the Health Board Dental Service. It is obvious that the role of the service needs to be changed to ensure that Health Board patients (Medical Card Holders) receive the treatment to which they are entitled. How then should the problem be resolved ? By a considerable increase in manpower, materials and money ? Not necessarily; at least not without due consideration being given to the root of the problem … the remit of the Health Board Dental Services :

Throughout the past ten years this matter has been receiving particular attention in the UK and the role envisaged by the Dental Strategy Review Group (1981) for a public dental service would seem to have considerable merit. The role envisages two categories of tasks.

Firstly, activities not involving the clinical treatment of patients; screening, dental health education and community based preventive programmes, data collection for planning and evaluation purposes and the organisation of the transfer of patients to the General Dental Service, that is, general dental practitioners.

Secondly, clinical tasks for population target groups such as handicapped persons, long-stay institutionalised persons and possibly persons in areas with few dentists. To this group of clinical activities should, in our view, be added the dental health care of children up to and including 12 years of age. There are both legal and management reasons for our recommending the inclusion of the children group. Legally and ethically, the Health Board Dental Surgeon, being salaried, can advertise and seek out his patients through the Health Board system while, in terms of management, the latter can plan and evaluate the extent and range of services to be provided by it.

All other persons deemed to be eligible under the Health Act (1970) for Health Board dental services would, in these circumstances, be contracted out by the Health Board to general practitioners, renumerated on an agreed basis. A system comparable with that which operates in the Medical Services area but which would be more effective possibly than the present GMS scheme, should be considered. Consideration might also be given to a ‘capitation’ system especially if the outcome of a pilot study of this system being undertaken in Scotland at present, proves to be satisfactory to all of the parties involved.

By adopting this revised role for the Health Board’s Dental Services not only would the service provided be brought into line with health legislation, but the efficiency and effectiveness in the delivery of the service, to the all important groups indicated, would be considerably improved.

As part of the overall manpower examination, the Irish Dental Association calls on the Departments of Health and Social Welfare to examine the role of the Public Dental Services and to make changes necessary to ensure that patients entitled under the relevant Acts may receive treatment.

25.3.1986