Tithe an Oireachtais
An Comhchoiste um Shláinte agus Leanaí
An Ceathrú Tuarascáil
Athbhreithniú ar Sheirbhísí Ortadóntacha Poiblí
Houses of the Oireachtas
Joint Committee on Health & Children
Review of Public Orthodontic Services
Table of Contents
Foreword by the chairman of the Joint Committee on Health & Children, John Moloney, T.D.
The Joint Committee on Health and Children was established in November 2002. In its 2002/03 Work Programme the Committee undertook to review the Report on the Provision of Orthodontic Services in Ireland produced by the former Joint Committee on Health & Children. In 2003 and early 2004, the Joint Committee held a number of meetings with those directly involved with the issue including Consultant Orthodontists, Officials from the Department of Health & Children and the Dublin and Cork Dental Schools.
Arising from this, a sub-Committee on Orthodontics was established in March of this year to examine the evidence already heard and the submissions received and draw up a Report containing a number of concrete recommendations. The sub-Committee held its inaugural meeting in March 2004 when it decided that it would review progress made in implementing the recommendations contained in the Report on Orthodontics by the former Committee and examine related issues.
In March 2005, the sub-Committee appointed Senator Mary Henry, who is a member of it, to produce an analysis of the written and oral presentations received. Based on this analysis, and inputs from other Committee members, a draft report was drawn up by the sub-Committee in May 2005 and referred to the Joint Committee on 26th May 2005. The report, as amended, was agreed.
The Joint Committee is grateful to the members of the sub-Committee for their work on such an important issue that affects large numbers of the nation’s children in particular. In particular, the Joint Committee would like to thank Ms. Fiona O’Malley TD, Chairman of the sub-Committee, for her stewardship and guidance and her valuable written contribution to the Report. The Joint Committee would also like to thank Senator Mary Henry for her assistance and expresses its gratitude to all those who came before the Joint Committee to give evidence and to those who took the time to make written submissions.
The Committee would also like to thank the following individuals and organisations:
Department of Health and Children:
-Mr. Gerry Gavin, former Chief Dental Officer.
-Mr. Tom Mooney, Deputy Secretary;
-Mr. David Moloney, Principal Officer,
-Mr. Liam McCormack, Assistant Principal Officer;
-Mr. Greg Canning, Higher Executive Officer.
-Dr. Triona McNamara, Consultant Orthodontist;
-Dr. Ted McNamara, Consultant Orthodontist;
-Dr. Ian O’Dowling, Consultant Orthodontist,
-Dr. Antonia Hewson, Principal Dental Surgeon.
Dublin Dental School:
•Mr. Brian Murray, Chief Executive; Dublin Dental Hospital;
•Professor June Nunn, Professor of Special Care Dentistry and Head of the Department of Public and Child Dental Health, Dublin Dental Hospital;
•Dr. Paul Dowling, Senior Lecturer and Consultant in Orthodontics of the Dublin Dental Hospital
Cork Dental School:
•Professor Robert McConnell, Head, Dental Hospital, University College Cork.
Given the current unsatisfactory situation regarding the training of Orthodontists and the delivery of orthodontic services, the Joint Committee asks that immediate action be taken to implement the recommendations in this Report. Orthodontic Services can only be provided to children within a limited time period to be effective. It is imperative, therefore, that this issue is treated as a matter of top priority by the Department of Health & Children to ensure no further children are denied the orthodontic treatment they need.
The Joint Committee also requests that the issues raised in this report be the subject of a debate in both Houses of the Oireachtas.
John Moloney, T.D.,
Joint Committee on Health & Children.
Chapter 1 Introduction.
As members of the Oireachtas we are tasked to ensure that public money is used efficiently in the delivery and development of services. Particularly, this sub—Committee is investigating that the orthodontics service in Ireland is providing timely treatment to patients in a cost efficient manner. This has guided the work of this committee in arriving at its conclusions.
For some years now the Joint Oireachtas Committee on Health and Children has been concerned about the orthodontic service in Ireland. A major review was conducted by the committee of the 28th Dáil which culminated in the publication of the Joint Committee on Health and Children Report on the Orthodontic Service in Ireland,” in February 2002.
This report was direct in its approach. The then Chairman, Deputy Batt O’Keeffe stated in the foreword “The Joint Committee has asked me to express its total dissatisfaction with the operation of the orthodontic service to date. 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. It is the intention of the Joint committee to consider this matter again if significant progress is not made in implementing the recommendations in this report immediately.”
Since the establishment of the 29th Dáil and the new Committee, the functioning of orthodontic services in Ireland has continued to feature on the committee’s work agenda. Following further hearings, the Committee became concerned that progress on the recommendations made in the Report of February 2002 has been slow. This report follows through on the commitment given to reinvestigate the orthodontic service, as sufficient progress has not been made. This report should be read as an appendix to the 2002 Oireachtas report
In order to get an accurate picture of the needs of and demands on orthodontic services, it is imperative that that every health region in the country apply the same criteria to determine eligibility.
At present, in the absence of a nationwide standard, waiting lists are not reliable, as people who are eligible for treatment in one area may not receive it in another. This is a wholly unsatisfactory situation that should be remedied by the introduction of a national uniform standard. Statistics provided to the Committee on waiting lists are unreliable for this reason as it is not clear from data if A, B and C category (using the existing guidelines) patients are being measured. The Committee is concerned that in many Health Executive areas category C patients are no longer being measured/counted/ included for consideration.
In order to bring Ireland into line with best international practice, both the Moran and the Oireachtas Report of February 2002 recommended that the Index of OrthodonticTreatment Need (IOTN) be adopted nationally as the benchmark for determining an individual’s need for orthodontic care. This has not yet come to pass but it is the belief of this Committee, that the introduction of this measuring tool will bring greater transparency to the waiting lists. As chapter 4 of the Oireachtas Report details the rationale behind this recommendation, it is unnecessary to repeat it here.
Ireland should have approved training schemes to train sufficient specialists and consultants to supply future need. The Irish Dental Council is the body vested with the authority to regulate standards with regard to Dental training in the country. This authority was conferred to the council by the Minister for Health under the Dentists Act 1985, in order to comply with European Directive 78/687.
The purpose behind and the effect of EU directive 78/687 (Council Directive 78/687 /EEC of 25 July 1978 concerning the coordination of provisions laid down by Law, Regulation or Administrative Action in respect of the activities of dental practitioners,) was to consolidate training so that mutual recognition between in relation to professional dental qualifications could be established between member states in the interest of free movement of professional people whose qualifications would them be recognised and they would be able to practice . To achieve this the Government of each member state was required to vest authority in a professional body which would determine in the accreditation of professional standards with the country. The Irish Dental Council acquired such authority and subsequently established a Specialist Register. The Irish Committee for Specialist Training in Dentistry (ICSTD) is the title given to the group who now monitor standards in training.
The Committee is concerned that the systems in place for training orthodontic specialists in the country have not proved adequate to meet the country’s needs. The Committee is aware that there appears to be a worldwide shortage of orthodontic specialists but the obvious answer to this is a less restrictive approach to training.
The ICSTD has determined that only the Dental Hospitals in Cork and Dublin are authorised to provide training for orthodontic specialists. This exclusivity has presented an enormous problem for manpower planning and delivery of the country’s orthodontic service. The position adopted by the Dental Council on the issue of training is not sustainable and not capable of serving the needs of the country.
The continued absence of a Professor of Orthodontics and Senior Lecturer in Orthodontics at the Dublin Dental Hospital, and similar difficulties in the Cork Dental School undermines these colleges ability to provide adequate numbers of appropriately skilled and qualified persons for the Irish Orthodontic service.
The Dental Hospital in Cork has not yet trained any orthodontic specialists. The Dental Hospital in Dublin as also failed to reach the targets for training outlined in the Oireachtas Report of three years ago. The consequence of this inability to reach the targets has resulted in lengthy delays for patients who are now not receiving treatment at the optimum age. The Committee is concerned at this deterioration in service.
The Committee is of the opinion that urgent action is required now.
Members of the Committee are aware of the training regime which operated in the former Mid-Western, Western and Southern Health Board Regions up to 1999, and were centred around the Regional Orthodontic Specialists.
These very successful services delivered prompt and efficient treatment for eligible children and provided trainees for the public service which permitted dramatic reductions in public waiting lists. These services also underwent numerous inspections and were the subject of independent assessment and were commended in glowing terms. (Spray, Report 2004. Burden 1997, Moran Report1999, Report to the Health Executives, 2002.
Because of the chronic supply shortage of persons to support the orthodontic service in the country, the Committee recommends that the Regional Orthodontic Units once again be permitted to develop collaborative training and research programmes with other European dental schools. This needs to be facilitated as a priority. Communication technologies (video conferencing etc) obviate the need for trainees to attend in person lectures and offer opportunities for engagement with a whole network of European Universities which train orthodontic specialists to a European standard.
To achieve this, the Committee recommends that the Minister for Health and Children requests the Dental Council to permit trainees to obtain the academic component of their training from other European dental schools so as to provide alternative and additional methods of training. This is facilitated by the Bologna Process to which Ireland is a signatory.
An adequate training infrastructure must be put in place immediately to deal with the capacity shortfall. This must include the restoration of the previous services provided for by the Regional Orthodontic Consultants. It is important to note that this training regime did provide a constant supply of orthodontic specialists to the public service and this contributed greatly to the efficiency of the public service.
Members are concerned that the Department of Health & Children is now required to pay for the training abroad of orthodontic specialists. This is not entirely satisfactory as the training is costly, facilitates a lucrative career and offers no guarantee of holding the specialist in the public service.
It is our job as Oireachtas members to scrutinise where a public policy has failed to deliver expectation. Many members of this house have expressed dismay at how the Orthodontic service has developed over the years since 1999. Why is it that we are left with a much diminished service which cost a lot more and which does not serve patients as well? Patients shall always be at the centre of public health policy and where their interests are being compromised it is our duty to act to remedy the problem. This report attempts such a remedy.
It is important to note that the difficulties which characterised relationships in this field, continue. It is the Committees opinion that progress is next to impossible unless and until this matter is finally resolved. The Committee urges all parties to work together to recreate the excellent services we once had.
Chapter 2 Conclusions & Recommendations
1. 2.1. GENERAL.
•The existing guide-lines for Orthodontic Treatment (Categories A, B and C) should be replaced by the Index of Orthodontic Treatment Need Code (IOTN) on a national basis immediately. Persons classified as Grade 4 or 5 under the IOTN in terms of the severity of their need for treatment should be then be removed from waiting lists and given the requisite orthodontic treatment.
•The Minister for Health & Children should implement measures, as a top national priority, to ensure international accrediting bodies are given proper recognition. This recognition would then facilitate an increase in the number of qualified Orthodontists.
•The Training Programme provided by a number of Orthodontists in the former Mid-Western Health Board area that was stopped should be reinstated immediately, with the requisite academic supports, as a means of further increasing the supply of trained Orthodontists.
•The outstanding issues at the Dental School in University College Cork (UCC) should be resolved as a matter of top priority so that Orthodontic training can commence there in the very near future.
•Funding for Specialist Training Places (funded by the Department of Health & Children and attached to Health Authorities for a 3 year period) that was stopped should be reinstated immediately. In the event of the State having to provide funding for orthodontic trainees, these trainees should be required to have a public service commitment upon graduation.
3. DELIVERY OF ORTHODONTIC SERVICES.
•A Chief Dental Officer should be appointed to the Department of Health and Children as a matter of urgency to replace the vacancy that has been there since 2004. The salary and conditions should be commensurate with recruiting a professional of the highest calibre with the requisite skills to deliver on a national dental strategy.
•At least 5 additional Oral Surgeons and 5 Maxilo-Facial Surgeons should be appointed without delay to complement Orthodontic treatment services.