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A cautious welcome for dental reforms, but concerns remain about underlying systemic problems with health “system”

Further to the previous post, the dental reforms announced yesterday have been widely welcomed, but concerns are also being raised that they do not address wider structural problems in the healthcare system or address the underlying causes of poor oral health.

Below are some comments from Croakey contributors and links to other analyses.

 ***

Critical systemic issues remain unaddressed
Vern Hughes
Social Enterprise Partnerships in Victoria and convenor, the National Campaign for Consumer-Centred Health Care

Sooner or later, health reform advocates are going to have to stop focusing on the quick and easy options (such as subsidised dental treatment for children) and start wrestling with the critical systemic challenges facing them in turning a provider-centred illness-management system into a consumer-centred health maintenance system.

Subsidising dental treatment doesn’t touch this question, or come even close to it.

It is a modified financial arrangement for the payment of certain treatments, and it fits the now well-established pattern in Canberra in thinking about health care –health care financing is the sole item on the Commonwealth’s agenda.

Anything to do with integration of care in consumer-centred formats for a health maintenance purpose is just too hard.

***

Acute care is important – but where is the oral health promotion agenda?
Margo Saunders
Public Health Policy Researcher/Writer

While the usual lip-service is given to prevention, it is not entirely clear what the Government has in mind in terms of effective strategies for improving oral health, particularly for rural and disadvantaged adults and children.

Australia has no national health literacy strategy and, with the Australian National Preventive Health Agency focusing on tobacco, alcohol and obesity, we need to know more about how appropriate preventive approaches for oral health will be developed and implemented.

While providing acute care is desperately important, we must hope, at the very least, that once dentists have patients in the chair, they will take advantage of that all-important ‘teachable moment’!

***

 Extending fee-for-service model is not such a good idea
 Associate Professor Gawaine Powell Davies
CEO, UNSW Research Centre for Primary Health Care and Equity

It’s very good to see a significant investment in teeth, and targeting of limited resources. I wonder whether older people with significant dental problems will get prompt/enough attention, but recognise that we have to start somewhere. Glad that the Greens are on board.

We have already moved a long way from universal service provision: even Medicare depends upon there being a private provider being willing to offer services in your area at a price you can afford.

We need a broader debate about genuinely universal access – or universal genuine access – that takes account of these larger issues.

From this perspective, it is worrying to see an extension of the fee for service model without more attention to the problems it brings.

***

A cautious welcome with many questions about impact and implementation
Dr Tim Senior
GP working in Aboriginal health

The new dental reform package is to be broadly welcomed. The basic idea of including dental care as part of health care seems to be so obvious that it’s odd a case needs to be made at all.

There are clear links between oral health and other chronic diseases, so any strategy to close the gaps in health outcomes must include this. The headline figure of $4bn sounds like a significant sum.

The previous system, where GPs were able to refer people with a chronic disease and had a Chronic Disease Management Plan in place, was certainly used. I am sure I was not alone in using it for dental access for my patients, and it was reasonably well liked.

However, any scheme that uses Medicare billing by GPs for access depends on GP access by definition, and this is better in the well-off suburbs of cities. It is likely that if the Chronic Disease Dental Scheme was designed to allow the less well off to access dental care then it was poorly targeted. (You could argue equally that it was designed to allow people with chronic diseases to access dental care – in which case it was probably well targeted!)

The teen dental scheme will also be scrapped, and I’m not aware that this was widely used or that many will mourn its passing too much.

There are many details of the new program that remain to be worked out, and its success will be determined by the impact it has on oral health, and whether it is able to close gaps in health inequalities relating to oral health.

To do this, it will have to improve access for Aboriginal and Torres Strait Islander people, for those in remote, rural and outer-metropolitan areas with fewer dentists, and for those unable to afford care normally – these groups overlap, but are not the same.

Viewed with this in mind, there are some important principles about implementation that will need to be kept in mind.

One of these is that the workforce capacity will need to be increased in many areas, including not just dentists, but dental assistants and Indigenous dental workers.

Many Aboriginal Community Controlled Health Services have dental services, often funded through State government, and it is important that these are added to, not just replaced. If this is to become a sustainable program over a long time, it will be important to train up new professionals, and it will be interesting to see if any thought has been put into this.

Regarding ability to pay, the option has been held open for dentists to charge a gap fee, and this has the ability to stop this program from working at all. We know that many people already can’t afford their medical care – either paying for medications, or seeing doctors or other health care professionals.

Adding dentists to this list will just serve to increase the number of people who have to make a choice between food or health care. Health insurance is not a solution for these people either.

And we should not forget that there will be people who also need access to dentists, who may or may not have had access under the old schemes, who still need access, and it is not clear who these people are or what their options will be.

Of course, just seeing a dentist (or, indeed, a doctor) is no guarantee that your health will be better. The actual interventions need to be effective too, though this will often depend on clinical judgement.

There are guidelines about effective preventive measures, including dental interventions, and having these implemented in practice across the whole of primary care would be helpful. (Declaration – I was involved in writing these guidelines – see p 29 of this PDF for the recommendation)

And good oral health will depend on so much more than just the provision of dental care. Communities should have access to a fluoridated water supply, schools should not be stocking soft drinks or using chocolate for fund raising. Doctors should not be using lollies for rewards (use stickers instead!)

Finally, we should watch where the funding comes from. It seems likely that it will come from other areas, and we should watch and advocate that withdrawal of funding doesn’t pull in the opposite direction.

So, in summary, a big, cautious welcome. It’s the details, in how it serves to increase capacity and improve access, and whether it pulls funding from related programs, that will determine the success. It’s unlikely to be perfect right at the start, so we should be prepared to measure its effects and advocate for changes further down the line.

These are personal reflections only and do not reflect the positions of any organisations I work for.

***

Focus on the upstream factors affecting oral health

Dr Matt Fisher, Research Fellow, Southgate Institute for Health, Society & Equity, Flinders University 

The introduction of the new dental reform package is certainly to be welcomed.

However, it must also be viewed with a note caution regarding its potential to improve dental health among disadvantaged sectors of the community.

Better access to dental care is certainly desirable, but it may have little effect on a range of social and economic factors impacting on dental health and relevant health behaviours, including diet.

To reduce social inequalities in dental health requires treatment strategies to be dovetailed with a wider public health programs and measures able to address upstream factors affecting dental health; as argued here <http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0528.2007.00348.x/full> .

***

Doctors Reform Society statement: Reforms are welcome but gaps remain

The joint announcement by Minister Plibersek and Green’s health spokesperson Di Natale of a new dental reform package is welcome and long overdue,” said Dr Tracy Schrader, president, Doctors Reform Society.

“The package targets the most vulnerable 60% of children through a capped fee for service scheme run by the Federal Government and the most vulnerable 30% of adults through an expanded State public dental service.”

“This is a better directed scheme than previously but it does not commit to any extra funding and nor is there any commitment to a progression towards a universal access scheme”, said Dr Schrader. “Thus, despite this being clearly better than the existing schemes, there will remain many people struggling to access dental services when needed.”

“The lack of commitment to a future universal access scheme is puzzling for a party which introduced Medicare decades ago with such an aim in mind for medical services.”

“The question must be asked: Does the current Labor Party believe in equity?”

***

Some other ideas for helping those in greatest need
Dr Andrew Pesce
Sydney specialist, former AMA president

Without doubt access to dental care is one of the failures of our health “system”.

There is a significant barrier to access to care and a properly targeted funding approach could make a real difference.

The problem is not that not enough money is spent on dental care.

AIHW 2011 figures show private dental services attracted 6.6% of total health spending in Australia, compared to all private medical services share of 18.3%.

The problem that there is insufficient allocation of available funds to the areas of highest need:

1.      School aged children from lower income families

2.      Older Australians, whether living in aged care facilities or in the community

3.      Adults on low incomes requiring restorative dental work.

Early detection of emerging dental problems in children is vital, and even if funding to access private dental services is available, it is often the highest risk and most needy children who don’t get any dental care.

The most effective intervention for this group of children is the School Dental Clinic, where with parental consent children receive dental review and interventions including where necessary cavity restoration and extractions from trained dental therapists during school hours (the mountain coming to Mohammed).

My wife was a Dental Therapist working in co-located School  Dental Clinics in the southwest and west of Sydney, and for a time taking a mobile school dental clinic van to outlying areas around Lithgow/Bathurst. The unmet dental care needs she saw were staggering.

This type of programme seems to have fallen out of favour, which is a shame as there is no way one can imagine schoolchildren from lower income families in such outlying areas would ever access private dental services, even if they were paid for.

The School Dental Clinic is the ideal “targeted” scheme, where funding is combined with facilitated access to services.

What could be the equivalent for adults? Funding for Dental chairs in higher volume medical centres and, where they exist, Superclinics, and outpatient dental services in hospital outpatient clinics.

There is lots of opportunity for improvement, we are starting from a very low baseline.

***

Where is the focus on heart disease?
Vicki Wade
Public health advocate

I cannot see the link between low SES, poor oral health and links to heart disease anywhere in the communications. This is a very important point.

A colleague has advised me that:

There will definitely be a stiff resistance from the private dental practices – with serious fluctuations in the fee they charge for basic treatments.

Those under the Chronic Disease Dental Scheme will need some sort of a stop gap support. Chronic diseases, especially medications associated with them and also secondary complications, have severe oral health implications.

What do they mean by “support for rural and regional areas”? These are the areas that need dentists as waiting times in public hospitals is nearly 2 years. Private dentist are minting money in these places!!

There should be some sort of legislation that ensures all dental graduates be deputed to rural and remote areas for 2 years at least.

***

Rural focus welcomed
Dr John Dowden
Australian Prescriber

Anything that improves access to dental services in rural areas is a good thing.

***

We need to build rural capacity
Vahid Saberi
Chief Executive Officer, North Coast NSW Medicare Local

North Coast NSW Medicare Local welcomes the dental announcement.

We will have to wait and see how the delivery and funding will be structured. This is often the key to success. Previous programs such as Chronic Disease Dental Scheme, in addition to other shortcomings, had deficient delivery structures in that those who needed the service the most received only a small proportion of the funds.

Redirecting the Teens Dental Care Scheme funds is also welcomed.  This program only went half the distance – it provided assessment without funds for treatment, this being of little benefit to those who needed the service the most.

As far as the regional and rural areas are concerned, the public dental service has no additional capacity. To this end, the $225 million capital and infrastructure funds will be of significant help.

Regions such as the North Coast of NSW are expecting new graduates out of dental schools and optimistic that some will readily move to non-metro areas. What we need to ensure is that there are sufficient mentors and supervisors to support these new graduates. This is a capacity that needs to be built in rural areas.

***

Universal coverage must remain the goal
Melissa Raven
Research Fellow, Primary Health Care Research & Information Service (PHC RIS), Discipline of General Practice, Flinders University

It is a good move, but it does not address the arbitrary and anachronistic annexation of the mouth from the rest of the body.

The targeted delivery will be good in the short term, in terms of addressing the serious disadvantage that has developed; but in the long-term we need universal coverage of basic health-related dental care.

***

Good news on the reforms, but why are schools even selling softdrinks?
Professor Gavin Mooney
Health economist

This is great and at last we have a health minister with teeth (sorry about that!) and I love Rosemary Stanton’s comment (at the bottom of this post) on the mouth being part of the body at last.

But at a more general level and the move away from universality of health care, the question of where the money is to come from is easily answered. We are a low taxed country so raise taxes!

Again the idea of phasing out fizzy drinks in ACT schools is welcome and Katy Gallagher, the Chief Minister, is to be congratulated on that. However, she is quoted as saying: ‘We’d like to start in primary schools but if it is successful and we see big demand for this then of course we want to see it rolled out across the school system but we’re going to let schools make those choices for themselves.’

Three questions. Why are fizzy drinks being sold in schools at all? And why try to bribe schools – at taxpayers’ expense – to stop such selling? Why give schools choice on this? Just ban them!

***

A great investment
Dr Catriona Bonfiglioli
Senior lecturer, media studies, UTS. PHAA member

This move to improve access to dental treatment, and hopefully preventive oral care, for children and people on low incomes is an essential step towards a full Denticare program.

Any move to reduce the inequalities in dental health and access to oral disease prevention is most welcome.

Prevention is vital in dentistry so barriers to preventive care should be removed.

This significant move in the right direction should be supported by further efforts to give all Australians access to fluoridated water or fluoride treatments where water fluoridisation is not feasible.

Oral health and preventive dental care should be universally available to all children in Australia no matter what their financial status. This is a great investment in Australians’ health and well being with enormous potential to reduce or remove significant and costly disease.

 ***

Australian Health Care Reform Alliance statement (slightly edited): a great kick start towards a fairer dental system

This is the first but very significant and welcome step towards a fairer and more rational, national dental system for Australians, said Tony McBride, Chair of the Australian Health Care Reform Alliance (AHCRA).

“AHCRA welcomes this on several grounds. First, it is a very significant initiative addressing one of the Cinderella areas of health. There are some significant inequalities in access to health care across Australia and access to dental care is one of them. Low income people can currently wait up to 3 years for basic treatment so this package targets those with the greatest need.

“Although the Medicare Chronic Disease Program is to be phased out it did do some good work. However it was not as well targeted as it should have been, and as a result many with a greater need missed out.”

It is understood that the new funding will go to about 67% of Australian children least able to afford private dental care, and the adult funding will be directed to the 30% of adults with the lowest incomes.

There is money to create more facilities in outer urban and regional areas too – again where there is the greatest current need. So overall the package will start to create a fairer dental system, where currently there is no real ‘system’.

Second, the new scheme’s focus on children (where two-thirds of children will be eligible) builds better oral health for this future generation. The new Commonwealth funding will enable the States therefore to redirect their child dental funding to adult services in their states and receive extra Commonwealth funding on top of that, so they will have strong capacity to expand public dental services and hopefully eliminate current unconscionably long public waiting lists.

Third, the package moves towards a nationally consistent and rational system with the Commonwealth taking responsibility for children’s dental services, and the States for adults (with some significant Commonwealth financial support). So it greatly clarifies responsibilities between the levels of governments: from AHCRA’s point of view a good reform.

“Lastly and importantly”, Mr McBride concluded, “it creates the building blocks for a future universal system. Although the government did not announce such a commitment, the package starts to put in place the necessary foundations, as recommended by the recent National Advisory Council on Dental Health.”

AHCRA congratulates the Minister, Tanya Plibersek, for leading her colleagues (in a constrained financial environment) to back such a significant move towards equity. Equally significant was the role of Richard Di Natale from the Greens who negotiated this package with the Minister and has shown great commitment to the dental needs of ordinary Australians.

 ***

The largest single commitment to public dental care
Carol Bennett
CEO, Consumers Health Forum of Australia

The dental announcement by Minister Plibersek and Senator Di Natale represents the largest single commitment to public dental care ever seen in Australia.

It’s not a full universal ‘Denticare’ package, but CHF believes the package will go a long way to alleviating chronic conditions encountered by many disadvantaged members of the community including low income earners and seniors.

Importantly, preventative healthcare is central; children will be able to easily access high standards of prevention and treatment for basic oral hygiene such as cleans, scales and fillings. CHF believes targeting the package through Family Tax Benefit is the right approach – we know the biggest barrier to accessing dental care is cost.

Previous schemes such as the Chronic Disease Dental Scheme (CDDS), while well intended, were not targeted or delivered in a way that delivered value for money or the right outcomes. The CDDS was known to be easily rorted and open to high income earners who should not need to be subsidised by the taxpayer.

CHF also welcomes $225 million in competitive grants for infrastructure and training in rural, regional and outer urban areas of disadvantage. This is a positive step that should encourage dentists into areas that are currently underserviced.

CHF still has concerns for the long term future of dental care in Australia – 85% of dentists work in the private sector making cost the biggest barrier for a large section of the community, as well as access to facilities.

Australia is a wealthy nation.  We need to stop treating the mouth as a different and standalone part of the body, and include dental care in the broader system of health and wellbeing.

Targeted schemes are a good first step to fixing the problems we currently have, as well as developing a new generation of young people who don’t suffer from preventable oral and other health conditions as adults.

When arguments about the Government’s announcement focus on how we can afford to pay for the Scheme, we need to ask ourselves ‘what price does society put on our health?’

 ***

Reaction from elsewhere

• The Conversation quotes Ian McAuley, Lecturer, Public Sector Finance at University of Canberra, saying the Government deserves high marks for squeezing money out of a tight budget and for filling in some gaps, but no marks for progress on systemic reform.

• Adam Cresswell in The Australian

• Mark Metherell in the SMH

• Radio National Life Matters

• See here for previous related Croakey posts

Comments 1

  1. fredex says:

    Why can’t more Crikey articles be as good as this?

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