Introduction by Croakey: Earlier this month the Health Promotion Journal of Australia published an optimistically titled article, ‘This year sees an opportunity for long-needed oral health reforms. Cancer patients, in particular, stand to benefit’.
The authors noted that the Australian Government’s response to the Senate Select Committee into the Provision of and Access to Dental Services in Australia was due at the end of February, and that this year should also see the renewal of the National Oral Health Plan 2015–2024.
“There are hopes that 2024 will, finally, see meaningful progress towards affordable and equitable access to dental services for all Australians,” the authors wrote.
On 18 July, the Government finally released its response to the Senate report – but its contents are cause more for frustration than optimism, reports health policy analyst Charles Maskell-Knight PSM below.
Charles Maskell-Knight writes:
As I reported in The Zap this week, the Department of Health and Aged Care has released the Government response to the report of the Senate inquiry into dental services.
The Department didn’t announce the release on the news page of its website – it just posted the response towards the bottom of the dental health page.
The response was subject to trenchant criticism from the Australian Dental Association – which characterised it as a wasted opportunity – and COTA.
COTA CEO Patricia Sparrow described the response as “mediocre at best” – to which I would add “disingenuous at worst”.
Support or acceptance?
The first issue with the response is the odd language. If I ask for and receive a recommendation for a good restaurant from somebody, I will tell them that I have accepted the recommendation and make a booking.
I won’t say that I “support” the recommendation.
In bureaucratic language “support” is used to indicate endorsement of a recommendation on its way to a decision maker. A manager will write a minute recommending a particular course of action, a senior manager will endorse the document indicating their support for the recommendation, and the Minister will then accept the recommendation – or not.
However, the response is all couched in terms of “support”, “support in principle”, or “note”. It doesn’t accept anything – nor does it reject anything.
Perhaps there has been a decree that “accept” is too concrete and active a verb, while “support” allows ambiguity and passivity? And “noting” rather than “rejecting” doesn’t hurt people’s feelings?
The Senate committee made 35 recommendations. The response indicates “support” for only three recommendations, and “support in principle” for another eight. It “notes” 24 of the 35 recommendations.
What has the Government supported?
The response supports the Senate recommendation that “the Australian Government formally recognises that oral health is an essential part of general health”.
It goes on to state that “the Government acknowledges that oral health is fundamental to overall health, wellbeing, and quality of life of all Australians. Dental policy reform has been made a priority by Health Ministers across Australia. The Government is also progressing the development of the next National Oral Health Plan in collaboration with states and territories… Together, these actions recognise oral health as an important part of general health.”
I think the recommendation was banal – but I am sure that those making it didn’t think it could be met by a couple of sentences in a bureaucratic document posted on an obscure corner of a departmental website.
They probably envisaged a statement by Ministers, backed up with some sort of policy announcement demonstrating that the Government really took it seriously.
The next recommendation to receive Government support was the one that “the Department of Health and Aged Care works to increase the role of dental hygienists and other oral health therapists in providing preventative and basic oral health care”.
The response points to amendments to the Child Dental Benefits Schedule in 2022 allowing dental hygienists, dental therapists, and oral health therapists to claim for some CDBS services using their own provider number.
It then goes on: “An independent Scope of Practice Review is underway ‘Unleashing the Potential of our Health Workforce’ to examine the barriers and incentives health practitioners face working to their full scope of practice in primary care. This will include dental therapists and other oral health therapists.”
Well, yes – but no.
The committee heard evidence that oral health practitioners were not included in the terms of reference for the Scope of Practice Review, and recommended elsewhere that the terms of reference should be amended to add them. It is clear reading the issues papers from the Review that dental issues are not under consideration.
The response also supports the recommendation that the National Disability Insurance Agency clarifies that dental and oral health supports that are directly required because of a person’s disability can be funded under the National Disability Insurance Scheme.
What has been supported in principle?
A total of eight recommendations have been supported in principle.
The response states that as “some of the recommendations do not fall within the remit of the Australian Government… in-principle support for these recommendations indicates agreement with the benefits of these recommendations but recognises that another party, including state and territory governments, are responsible for their funding and implementation”.
A clear enough principle, but it falls at the first hurdle.
The committee’s first recommendation was that to address the paucity of up-to-date data on population dental health, the Government should consider commissioning biennial national oral health studies alternating between adults and children.
Implementing this recommendation is clearly a matter for the Government and nobody else – yet the response only indicates “support in principle”.
It attempts to justify this position by acknowledging that regular studies are important for understanding the effectiveness of the current oral health system, and then listing the current studies it supports: the triennial National Dental Care Survey (previously the National Dental Telephone Interview Survey); the decennial National Child Oral Health Study; and the decennial National Study Adult Oral Health.
It goes on to say that “the Government will consider opportunities to optimise the frequency of studies”.
Really? Responding to a Senate inquiry is an obvious opportunity.
As Minister Mark Butler is fond of saying, “the best time to do this was five years ago. The second best time is now”.
Finally, having rejected the idea of regular biennial studies, this section of the response goes on to say that “regular studies provide an ongoing evidence base in relation to specific cohorts whose oral health needs may differ from those of other Australians. This would support improvement to targeted dental programs such as the Department of Veteran Affairs (DVA) programs for veterans”.
This can only be read as a calculated insult to the reader.
Space – and my blood pressure – doesn’t allow a detailed exegesis of the other seven “support in principle” responses, which deal with:
- commissioning research based on existing longitudinal data sets;
- implementing the recommendations from the Report on the Fifth Review of the Dental Benefits Act 2008;
- funding evidence-based programs to incentivise dental and oral health providers to practice in regional and remote areas of Australia;
- expanding existing medical student rural subsidy programs to include dental and oral health students;
- putting into place incentives to study oral health therapy and providing scholarships for students from regional areas and Aboriginal and Torres Strait Islander students;
- recognising the need for Aboriginal Community Controlled Health Organisations to train general healthcare providers in delivering basic and preventative oral health care; and recruit and retain dentists, and other oral health practitioners, to work in regional and remote areas of Australia.
Suffice to say that all of these recommendations are directed at the Government and require it to take specific actions. None of them require action from state and territory governments.
If the Government was committed to action it could have “supported” the recommendations – or even better, “accepted” them.
“Support in principle” is code for doing nothing.
What has been noted
The response “notes” no fewer than 24 recommendations.
Of these 24, 13 involve action by the Government alone: for example, commissioning a study into the impact of cancer and cancer treatment on dental and oral health; implementing the oral health care recommendations from the Royal Commission into Aged Care Quality and Safety; introducing a remote area loading for services delivered under the Child Dental Benefits Schedule; or appointing a Chief Dental and Oral Health Officer.
There is no room for ambiguity: either the Government will do something, or it won’t. “Noting” is a fig leaf concealing a wilful dismissal of the recommendation, sometimes on the flimsiest pretext.
The discussion of the recommendation to introduce a remote area loading for services delivered under the Child Dental Benefits Schedule says that “introducing loading for services in remote areas is complex and would require legislative change”.
That’s the point of government – it deals with complex issues and controls the legislative agenda!
The response then goes on to describe the “long-term funding partnership with the Royal Flying Doctor Service to provide essential primary healthcare in rural and remote areas” under which the RFDS provided 58,976 dental health services across Australia in 2022-23.
This is completely irrelevant to the recommendation.
I have argued in the past that calls for the establishment of a Chief Dental Officer are based on a fundamental misconception of the role such a person could play. But if the Government agrees with me – and it appears it does – it should have the moral fortitude to “reject” or “not accept” the recommendation, not weasel out of responsibility by “noting” it.
Most of the remaining 11 “noted” recommendations involve the Government working with other bodies (states and territories, universities, the Dental Board, or the sector) to achieve something.
However, using the principle set out at the start of the response, these should be “supported in principle” if the Government believe they have merit – or rejected if they don’t.
Another wasted opportunity
In an article in Croakey when the Senate committee released its report, I said it had missed the opportunity to come up with a sensible plan to improve access to dental services. I argued that it was now time for the Government to find the courage to initiate a plan to provide universal dental coverage.
So far it has failed to do so.
However, the Senate report did set out a number of sensible recommendations to improve access to some existing services and to enhance the knowledge base about dental health issues.
In its response the Government has effectively dismissed all except one of them (better access under the NDIS).
What now?
I expect that in ten years another parliamentary inquiry will be held to identify and grapple with the same issues.
• 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.
See Croakey’s archive of articles on oral health
The mouth has again been forgotten.
But I was surprised to note that the report contained this sentence when talking about options. 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’.
As can clearly be seen from the current access problems under Medicare, a Denticare type system is not universal access to care. It is universal access to a rebate which, in the case of Medicare is woefully inadequate monetarily and does nothing about geographical inequities. It may be great in ACHCO but that’s because the rebate income is pooled and the Federal Government then adds a supplement. It would almost certainly improve things but from the very low base that exists now.