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As the Senate inquiry into dental services failed to deliver, the Government must now step up

A recent Senate inquiry into dental services has been a massive missed opportunity, according to health policy analyst, Charles Maskell-Knight, who has extensive experience in national dental health policy.

Below Maskell-Knight explains his disappointment at the recommendations of the Senate committee report, and suggests some ways forward.

“A Labor Government had the vision and courage 40 years ago to introduce Medicare as a universal health insurance system – for everything except dental disease,” he writes. “It is time for another Labor Government to find the courage to initiate a plan to provide universal dental coverage.”


Charles Maskell-Knight writes:

On 30 November the Senate Select Committee into the Provision of and Access to Dental Services in Australia handed down its final reportA system in decay”.

Like many involved in dental health policy, I had hoped that the Committee would come up with a clear set of actionable recommendations to provide affordable access to dental care for all Australians.

On the other hand, I expected another Senate committee report full of anodyne generalities, interspersed with occasional specific recommendations driven by ad hominem submissions.

I regret to report that my expectations were met, while my hopes were dashed.

Banal and misguided

The Committee made 35 recommendations.

Some are banal: “The committee recommends that the Australian Government formally recognises that oral health is an essential part of general health” (Recommendation 3).

Some are hoary chestnuts which have been put forward before: “The committee recommends that the Australian Government appoints a Chief Dental and Oral Health Officer” (Recommendation 33). The Department of Health has now had a Chief Allied Health Officer for well over a decade, and I think it is fair to assert that the position has had absolutely no practical impact on health policy.

Others simply reiterate what other inquiries (the Aged Care Royal Commission, or the review of the Child Dental Benefits Schedule, the CDBS) have recommended (Recommendations 12 and 21).

Even the sensible recommendations are couched in woolly language: “The committee recommends that the Australian Government considers commissioning biennial national oral health studies” (Recommendation 1). Why on earth not recommend “commission” rather than “considers commissioning”?

Other recommendations are misguided. Improved access to tranexamic acid may be appropriate, but the Government cannot simply add tranexamic acid mouthwash to the Pharmaceutical Benefits Scheme (Recommendation 17) without an application from a supplier.

All children are currently eligible for the Child Dental Benefits Schedule (CDBS), except those in the 20 percent or so of families whose income is so high they do not receive Family Tax Benefit Part A (and are probably all covered by private health insurance anyway). Extending access to the CDBS to all children (Recommendation 22) is probably not a good use of resources.

The Committee recommends that the Australian Government “works with state and territory governments to find ways to ensure access to adequate general and oral health services for people who are incarcerated” (Recommendation 11). Access by prisoners to dental services is entirely within the remit of state governments, who own and operate prisons and employ dentists in public dental services. Fixing this problem doesn’t require Commonwealth involvement.

Non-dentist oral health professionals

The Committee makes a number of recommendations about making greater use of dental hygienists and other oral health therapists.

Several years ago the Dental Board removed the requirement for non-dentist oral health professionals to “work in a structured professional relationship with a dentist”, thus allowing them to work independently.

However, the regulatory regimes around prescribing and use of X-rays do not support independent practice, and the Committee recommends (in typically woolly language) that “the Department of Health and Aged Care assesses – with a view to reducing – regulatory barriers that limit the scope of practice for oral health practitioners who are trained and certified to proscribe [sic] and take radiographs” (Recommendation 6).

While this is important, it would still leave these practitioners without a funding source as most private health insurers will not pay benefits for the services they provide.

Dental in primary care

The Committee makes a series of suggestions to “integrate oral and dental health care into primary health care” (Recommendation 4). There are three points to make about this.

First, in many areas access to primary care may be better than access to dental care, but it is still problematic. Adding responsibility for oral health care to the already over-burdened primary care system in regional and remote areas does not seem sensible.

Second, while primary care practitioners could be trained to carry out basic oral health assessments, this will not be a trivial task. As a GP told me several years ago, “all I know about teeth is that there should be 36 of them”.

And finally, there is little point in expanding oral health assessment if there is not a referral path to timely treatment for the 45 percent of the population without private health insurance.

Funding matters

Many of the Committee’s recommendations require additional funding.

There is no point expanding the dental workforce, changing regulatory settings so that oral health practitioners can truly practise independently, or expanding oral health assessment through primary care, if funding is not available to support the services they provide or recommend.

However, the key funding recommendation at the end of Chapter 6 of the report (cutely titled “Drilling down: pathways to universal access”) is a massive cop-out:

“The committee recommends that the Australian Government works with the states and territories to achieve universal access to dental and oral health care, which expands coverage under Medicare or a similar scheme for essential oral health care, over time, in stages” (Recommendation 35).

Chapter 6 discusses for options for a future funding scheme:

Option 1: Universal public dental care, provided through Medicare, or a separate ‘Denticare’ scheme.

Option 2: A means tested scheme, which would essentially extend the Child Dental Benefits Schedule (CDBS) to health care card holders, pension card holders and those on government income support payments.

Option 3: A seniors dental care scheme, available to holders of Commonwealth seniors health cards, pensioner concession cards and health care cards, who are 65 years or older.

Option 4: A scheme under which the Commonwealth funds preventative care only for all Medicare card holders.

Problematic costings

The Committee asked the Parliamentary Budget Office (PBO) to cost each of these options in two ways: as a capped scheme, with biennial expenditure limited to $1,052 per person (the current limit under the CDBS); or as an uncapped scheme.

There are a number of substantive issues about these options.

First, applying the biennial cap of $1,052, which applies under the CDBS to a scheme designed for adults is ridiculous.

Children on average have good dental health, and are unlikely to need lots of treatment. Only 12 percent of children claim more than $900 under the CDBS. Adults with poor adult health who have not been attending a dentist regularly are likely to need far more than $1052 worth of treatment over two years.

While a dollar cap may limit expenditure, it is a blunt instrument. As I suggested in my submission to the inquiry, it is far better to limit expenditure by reference to the sort of care provided. The Aged Care Royal Commission recommended that the Seniors Dental Benefits Scheme should be limited to “treatment required to maintain a functional dentition”, and that approach should be adopted for any future dental scheme.

Second, a scheme which provides preventative care but not remedial care is quite simply arse-about.

Preventative care is important, but it is relatively affordable for individuals compared with a lot of remedial dental care. Should government really be paying for an annual x-ray, scale and polish and fluoride treatment, but not paying for treatment required to conserve a tooth that will otherwise be extracted?

If limiting cost is the aim, a more logical approach would be to pay for remedial treatment for anybody who can demonstrate that they have paid for their own preventative care.

Third, the PBO costings (and their use by the Committee) are problematic.

The PBO have based their costings on the scope of services covered by the CDBS. However, the CDBS excludes a range of expensive services (for example, most crown and all bridge items) that are much more likely to be used by adults, and are included in the Department of Veterans Affairs dental scheme.

The PBO conservatively estimates that any new scheme would take five years before utilisation topped out at 85 percent. However, it has only provided costings (which have been reproduced by the Committee) for the first three years.

The report shows that an uncapped universal “Denticare” scheme would cost “$7.7 to $9.1 billion a year”, with $9.1 billion being the year-three cost. Based on this rate of growth, the year-five cost would be $10.8 billion, only a little less than the AIHW’s estimate of total all-source expenditure on dental services in 2021-22.

Given a universal scheme would extend access to millions of adults who currently rely on grievously underfunded public dental services, an estimate of $10.8 billion is implausibly low.

Missed opportunity

However, my main concern with the Committee’s approach to future access to dental services is that it has missed a great opportunity to set a pathway for government to follow.

The Committee received 168 submissions from governments, provider organisations and individual clinicians, consumer groups and individual consumers, insurer groups, academics and academic institutions, and independent health policy analysts like me.

Many of these submissions addressed the issue of how to expand future access to dental services, with often contradictory views. It was open to the Committee to hold a round table meeting, where organisations could discuss and defend their views with each other and with Committee members. Even if agreement could not be reached, the process would have helped the Committee reach a considered view about a way forward.

However, the Committee adopted the standard approach of public hearings where submitters gave evidence in turn.

It then extracted quotes from the submissions and the hearings and presented them in chapter 6 of the report in a “they said, then they said” style, before summarising:

“Participants in the inquiry offered different solutions to fill the gap and improve access to dental and oral health services for all Australians. At one end of the spectrum lies a universal dental scheme, where all essential oral health and dental services would be funded through Medicare, or a similar ‘Denticare’ scheme. At the other end lies the option of making changes to the existing funding agreement between the Commonwealth and the states and territories, and potentially increasing the amount of funding”.

The Committee then took a deep breath, squared its collective shoulders, and boldly recommended that governments should work together to achieve universal access to dental services, somehow, some time.

We really aren’t any further forward than we were when the Senate established the Committee in early March.

Where to from here?

As I noted in my submission to the Committee, the current inquiry was the third major parliamentary inquiry into dental services in the last 25 years. The problems are well known, and have only worsened since the Howard Government abolished the Commonwealth Dental Health Program in 1996.

The range of possible solutions is also well known – and were all advanced in submissions to the Committee. If Minister Mark Butler and his department need some help in considering the solutions, they should convene a round table of all interested groups to thresh out a way forward.

A Labor Government had the vision and courage 40 years ago to introduce Medicare as a universal health insurance system – for everything except dental disease.

It is time for another Labor Government to find the courage to initiate a plan to provide universal dental coverage.

• Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring in 2021.  Between 2003 and 2007, and 2012 and 2017, he was the senior executive with direct responsibility for Commonwealth dental health policy.

Note from editor: An amendment was made after the initial publication to acknowledge that some private health insurers do now offer benefits for services provided by non-dentists.

 Further reading


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