CONSUMER HEALTH: RADICAL THINKING is needed to avoid future crises in access to dental services in Ireland. Throwing more dentists at the problem won't fill the gap in provision in a sustainable way, writes SÍLE RYAN
Access to dentistry is an issue in both the north and south of Ireland. A recent analysis by the PA Consulting Group of acute health demand to 2020 projected an increase in demand of 55-60 per cent on the island because of age, population increase and lifestyle changes.
Many of these factors will drive dental demand, particularly if the focus on preventive dental care is significantly increased.
In Northern Ireland, recent steps have been taken by the Department of Health, Social Services and Public Safety (DHSSPS) to improve access to dental care by adding more public dentists to the system.
Towards the end of last year, NI Health Minister Michael McGimpsey launched the first dental service in Northern Ireland to be directly employed by a health board – the Dalriada Urgent Care in Ballymena.
This year, the DHSSPS awarded a new £17million contract for the provision of additional dentists in access “hotspots” – mainly in rural areas – across Northern Ireland.
Adding additional capacity is a positive step. It provides immediate relief through public system expansion. It removes the perverse incentives many associate with the balance to be struck between public and private listing and treatment. It also recognises the drift by dentists towards the private sector, a major reason for reduced public dentistry capacity, and tries to provide an attractive public sector alternative for dentists.
But this is unlikely to stop the flow of dentists to the private sector. A better informed population is adopting an increasingly consumerist approach to dental care and in doing so is driving demand. Conditions in public practice struggle to compete with private practice.
In the Republic, unprecedented numbers of dentists are leaving the Dental Treatment Services Scheme (DTSS) public patient scheme for a variety of reasons. Fees paid to dentists treating medical card patients have been cut. Capacity pressures make public practice unsustainably stressful for many. Public waiting lists are lengthening as the credit crunch causes previously private patients to move across.
The Health Service Executive (HSE) recruitment embargo has been extended – meaning that dentists inclined towards public practice are not being recruited.
This has led to closures of dental clinics, removing access to some of the vulnerable groups. This includes clinics for children and those with special needs.
Dentists employed directly by the HSE look after the dental needs of about two-thirds of primary school children.
This situation creates immediate access issues, as well as storing up unnecessary longer-term demand due to delayed treatment and missed dental health promotion and education opportunities.
In addition to the shift of dentists to private practice, there are indications that most general dental practitioners (GDPs) aim to strike a better work/life balance through part-time working, flexible working patterns and career breaks and many aim to retire early. This does not bode well for future dental supply.
There are other ways of dealing with the dental deficit but more radical thinking, based on sound analysis, is required to avoid future recurrent crises in provision.
It is necessary to think differently about how dental services can be provided. This requires a better understanding of demand for services.
We need to find the reasons why dental services are accessed – ie the distribution of diagnostic and preventive, surgical, restorative and other dental visit types.
Some of these services could be provided by people other than dentists, such as dental hygienists, dental technicians, dental nurses and therapists. The current system of regulation requires that consumers must go through a dentist before they can benefit from the services of a dental hygienist.
In many other countries, dental hygienists can offer a specific set of largely routine, preventive, dental services independently of dentists.
In Ireland, only dentists can provide dentures directly to the public yet clinical dental technicians are permitted to fit and sell dentures to the public in many countries, including the UK, Australia, Canada, Denmark, Finland, the Netherlands, New Zealand, Sweden and the US.
Analysis of current demand data would allow us to examine how population coverage can be improved without adding extra dentists to the system.
The National Institute for Clinical Excellence (NICE) now says that the interval between appointments should be tailored to each patient’s needs. Some patients with more problems with their teeth would see their dentist more frequently, while others might not need to see their dentist as often.
For example, NICE recommends that the interval for adults should be between three and 24 months. Extending the interval between routine check-ups for those with good oral health would free up dentists’ time, allowing them to provide services for a larger group of patients.
In is also important to consider groups with access challenges; these often include people with restricted mobility, culturally isolated groups, the poor and the working poor.
It is too simplistic to assume that increasing the number of dentists will necessarily improve access to services for these groups.
This issue needs to be addressed and it is not as simple as considering the number of dentists per population.
An analysis of demand would also facilitate an informed debate about the extent to which there is a fundamental shortfall in the number of dentists required to care for the population.
In a context of rising demand over the past 15 years, training places in Ireland have remained static.
As both patients and dentists move between north and south to access and provide care, it is is important to undertake this analysis on an all-island basis.
A better understanding of demand and supply is required to allow us to think differently about improving access.
- Síle Ryan is based in PA Consulting Group's Dublin office. She specialises in healthcare consultancy and has led reform projects in Ireland and internationally. PA Consulting has offices in Dublin and Belfast