Report of the National Advisory Council on Dental Health

Appendix H - National Advisory Council on Dental Health Consultation Process

The National Advisory Council on Dental Health (the Council) was established as a time-limited group to provide strategic, independent advice on dental health issues, as requested by Minister for Health and Ageing, to the Government. The Council’s priority task was to provide advice on dental policy options and priorities for consideration in the 2012-13 Budget.

Page last updated: 03 September 2012

      To help inform our deliberations, we have undertaken a consultation process with key dental health bodies, consumer group representatives, peak Indigenous organisations and leading academics in the field. We were interested in consulting as widely as possible, but given the short timeframes for our deliverables, we have conducted a private consultation process limited to key stakeholders. To date, the consultation process has involved round table consultation sessions, written submissions, direct engagement with clinicians and other key stakeholders, and visits to public dental facilities.

      The following stakeholders were invited to take part in our consultation process:

      • Australian Dental Council
      • Australian Dental Board of Australia
      • The Royal Australasian College of Dental Surgeons
      • Dental Hygienists’ Association of Australia
      • Australian Dental Prosthetists Association
      • Australian Dental Prosthetists and Dental Technicians Educational Advisory Council
      • National Aboriginal Community Controlled Health Organisation
      • National Oral Health Promotion Steering Group
      • Consumers Health Forum of Australia
      • Australian Preventive Health Agency
      • Health Workforce Australia, CEO Mr Mark Cormack
      • Indigenous Dentists’ Association of Australia
      • National Congress of Australia’s First Peoples
      • State and Territory Dental Directors
      • Australian Research Centre for Population Oral Health
      • Adelaide Dental Hospital, South Australia
      • Marion GP Plus Clinic, South Australia
      • New South Wales Ministerial Taskforce on Dental Health
      • Westmead Hospital, New South Wales
      • WentWest Medicare Local, New South Wales
      • Royal Dental Hospital of Melbourne
      • Dental Health Services Victoria
      • Dr Sandra Meihubers, Dentist and Independent Dental Health Consultant
      • Dr Glen Hughes, Dentist, Casino Aboriginal Medical Service

      In conducting the consultation process we were particularly interested in seeking views on:

      • the gaps in service delivery and unmet need;
      • how current dental programs could be improved;
      • how the current dental workforce could be improved;
      • oral health promotion and prevention strategies;
      • the capacity of the public dental sector; and
      • how the dental system could be improved as a whole.

      Unmet need

      Throughout the consultation process Indigenous Australians, special needs adults, children and the aged were identified as priority groups in need of accessible and affordable oral health care.

      Indigenous Australians

      Stakeholders acknowledged that Indigenous Australians in both urban and rural and remote areas experience poorer oral health than their non–Indigenous counterparts.

      Stakeholders identified several issues with the current system of service delivery for Indigenous patients. For rural and remote Indigenous communities in particular, stakeholders noted that most models of service delivery are intermittent, do not receive ongoing funding and involve the use of different locum dentists. It was acknowledged that such models create distrust between the community members and the providers and inconsistencies in patient records. To help reduce these inconsistencies, stakeholders identified the need for the Commonwealth’s role in the oral health sector to be clearly defined and for better co–ordination between Commonwealth, state, university and Aboriginal Medical Services/Aboriginal Community Controlled Health Organisations oral health activities. It was also suggested that the Commonwealth fund the development of a manual to assist dental practitioners, particularly locum staff, in servicing Indigenous communities in rural and remote Australia.

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      Several issues relating to the dental workforce and its impact on Indigenous oral health care were also raised. It was recommended that models of care use a multi–disciplinary care approach and the scope of service provision for Aboriginal Health Workers be extended to cover oral health preventive services. Stakeholders also expressed concerns about the difficulties in recruiting and retaining staff.

      As a further priority group within the Indigenous community, peak Indigenous organisations suggested future action for improving the oral health of Indigenous children. Stakeholders identified that in some Indigenous communities, children that require important, but not urgent, oral health care can be waiting for up to four years to receive treatment. Improving the oral health of Indigenous children will help in improving the oral health of Indigenous Australians into the future. It was recommended that Indigenous child oral health be targeted through the use of effective and consistent school dental programs.

      Adult with special oral health needs

      Special needs adults include those patients who, in addition to their oral health condition, suffer from a complex medical condition such as cancer, HIV, hepatitis, mental illness and other chronic diseases. The delivery of treatment to special needs patients is resource intensive, complex and often limited to the public sector. The facilitation of such treatment needs to be delivered by specialist providers who understand the medical implications of the patient’s health condition – unfortunately there is a shortage of these specialists in the public sector. To help this target group, stakeholders recommended increasing Commonwealth funding to the public sector.

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      Frail older people in the community and aged care residents

      The aged were consistently identified as a priority group in great need of accessible oral health care. It was noted that access to oral health services is of particular concern for those aged Australians in nursing homes and residential aged care facilities. Stakeholders suggested: including an oral health check as part of the entry assessment to aged care facilities; embedding oral health benchmarks into the aged care best practice standards; and educating related professionals such as carers and aged care workers to perform basic oral health checks. Some stakeholders recommended the implementation of a mobile dental program utilising both the public and private sectors, whereby dentists could travel to aged care facilities and use mobile dental equipment to treat the residents on site.

      Children

      All stakeholders acknowledged children as a priority target group. Stakeholders communicated the need to instil good oral health habits in children as early as possible in their lifetime. The need for a universal program for children was identified and stakeholders noted that particular attention needs to be paid to those children aged 0–4 years who are currently missing out on public oral health services in some state and territories.

      Targeted approach

      Some stakeholders suggested that non government organisations could be used to aggressively target these groups and that future strategies could be built upon existing programs that have proved to be successful in this space – e.g. ‘Lift the Lip’, ‘Sip and Crunch’, Supported Residential Services Program.

      Below is a case study of a facility that was consulted in the course of the Council’s work and could be used to target special needs groups.

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      Case Study 1: Marion GP Plus Health Care Centre, South Australia

      The Marion GP Plus Health Care Centre (the GP Plus Centre) serves as a good model for integrating oral health into broader primary health care initiatives.

      The GP Plus Centre contains a 24 chair dental facility, 12 chairs of which are reserved for permanent staff, and the remaining 12 used by dental students undertaking community based clinical placements as part of their undergraduate clinical training program. The dental clinic employs a range of dental professionals, including: dentists; dental therapists; and dental hygienists together with support staff which includes dental technicians. In order to be eligible for oral health services at the clinic, patients must be eligible for public dental services. This includes all children and those adults who hold a concession card issued by CentreLink.

      In addition to providing oral health services, the GP Plus Centre also provides services by allied health professionals, nurses, doctors and community health workers. The clinic adopts a coordinated approach using streamlined referral processes for services between these different health care providers. The GP Plus Centre also works in close partnership with local general practices and serves as a referral point for doctors and other health professionals and services within the community.

      One of the benefits of the GP Plus Centre is its prime location – the Centre is located next to a major transport hub in Oaklands Park in South Australia, which makes it highly accessible to patients. It is also close to a major shopping centre and other community service centres which makes it an attractive and convenient site for patients.

      The GP Plus Centre is particularly helpful for patients who suffer from complex and chronic health conditions and require a range of health services to manage their condition. Given the emerging evidence linking oral health to several major chronic diseases, enabling patients to access the dental clinic at the same site where they may receive treatment for their general health condition assists in the better coordination of their treatment.

      Dental programs

      Medicare Chronic Disease Dental Scheme

      Some stakeholders made recommendations on how the CDDS could be improved. Recommendations included:

      • limiting the services to basic dental care items;
      • implementing a special approval process for all high end dental items;
      • reducing the cap;
      • streamlining the paperwork involved in the general approval process;
      • limiting the eligibility criteria to certain chronic conditions;
      • including chronic oral health disease as part of the eligibility criteria;
      • introducing a means test;
      • adding hygienists to the list of providers under the legislation for the scheme; and
      • quarantining a percentage of the capped benefit for preventive oral health services.

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      Medicare Teen Dental Plan

      Recommendations on how the MTDP could be improved included:

      • extending the range of services to cover dental treatment; and
      • introducing a rule that requires providers to give oral hygiene advice as part of the preventive check.

      Dental workforce

      Stakeholders raised concerns about the distribution, composition and utilisation of the dental workforce and queried whether the public and private sectors have the capacity and infrastructure to support the current and future dental workforce.

      Stakeholders noted that the dental workforce is expanding, with higher numbers of students graduating from dental courses and increasing numbers of overseas dentists registering to practice in Australia. With the expanding workforce, stakeholders expressed concern about the need to ensure there is sufficient infrastructure to meet the demand and that student clinical placements are supported.

      Stakeholders highlighted the difficulty in recruiting dental staff to work in rural and remote locations. Issues surrounding the retention of staff in the public sector were also raised.

      Some stakeholders acknowledged that the new Commonwealth Voluntary Dental Intern Program may help in addressing some of the workforce distribution issues and suggested the implementation of further incentive programs. Some suggestions included compulsory rotations for public sector staff and housing reimbursements for dental hygienists and therapists.

      With regard to the composition and utilisation of the dental workforce, stakeholders commented on the need to review the scope of practice for certain practitioners. In particular, stakeholders recommended an expansion of the types of oral health services and a lift on the age restrictions for service provision by oral health therapists and hygienists. This would allow for better utilisation of the whole dental workforce, provide efficiency of service and reduce costs to consumers. On this note, stakeholders recommended that the ideal number and mix of dental health providers be identified and strategies put in place to reach this.

      It was also recommended that other professionals and health providers, such as General Practitioners, maternal health workers, Aboriginal Health Workers, carers, aged care workers and school teachers be trained to provide basic oral health checks and possible preventive services to assist in promoting good oral health amongst target groups. This would also assist with integrating oral health into general health.

      Mr Mark Cormack, CEO of HWA, addressed the Council on the work that HWA would be undertaking over the next 18 months on assessing the supply and demand of the dental workforce.

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      Oral health promotion and prevention

      In order for oral health promotion to be successful stakeholders recommended including multiple interlinked strategies supported by strong policy and social marketing. Reaching these goals would require strong working partnerships between governments, providers and industry.

      One of the multiple strategies recommended by stakeholders was to integrate oral health into broader population health campaigns, such as those targeting obesity, alcohol consumption and smoking. To ensure oral health is considered as part of general health promotion, stakeholders also recommended taking steps to train other health professionals to perform oral health checks.

      Some stakeholders suggested that one step could involve funding the Medicare Local Network to include oral health education in its programs that train GPs and allied health professionals. Health professionals in each Medicare Local Network would then have the skills to educate patients on good oral health practices, and check patients and refer them on to local dentists for any treatment needed. The Medicare Local Network was also recommended as an avenue to promote oral health and target special needs groups. One role of the Medicare Local Network is to identify service gaps and take steps to address those gaps. It was suggested that any primary health care initiatives already being administered by Medicare Locals could be used to send out consistent and comprehensive oral health promotion messages. This would not only improve oral health promotion but target priority groups. A case study is below of one Medicare Local consulted in the course of the Council’s work.

      Case Study 2: Western Sydney Medicare Local

      The WentWest Health Division in New South Wales was established in 2002 to provide General Practice vocational training in Western Sydney. From 2006 WentWest also took on the role of providing Division of General Practice support services and worked in close partnerships with organisations in Western Sydney to not only support GPs but also primary health care workers.

      From 1 July 2011, the WentWest Division became the Western Sydney Medicare Local, covering an area with a population of over 800,000 people. The Western Sydney Medicare Local (WS Medicare Local) continues to provide training to GPs and support for GPs and primary health care workers, but the WS Medicare Local has a more community approach to health care.

      As a Medicare Local, it is expected to develop a key role over time in building effective collaborations across primary health and with Local Hospital Networks, and support the implementation of key initiatives in areas such as e–health, after hours primary care and aged care.

      The WS Medicare Local works closely with local health professionals and community organisations to create a more streamlined and efficient primary health care system. This involves using local partnership networks – the WS Medicare Local has established six local partnership networks and works closely with the Local Health District and other organisations such as the Aboriginal Medical Service Western Sydney, the Local Health District, HealthOne and Local Councils.

      It also involves integrating and expanding new and existing services which are well targeted to the residents of the Western Sydney community. For example, the WS Medicare Local manages programs specifically targeted at priority groups such as school children, the Aged and pregnant teenagers. Some of these programs include: the Keep Fit School Program, which aims to educate children about nutrition and the importance of physical activity; Aged Care Programs which provide on site support to aged care people living in their home, to delay entry in to costly aged care facilities; and programs that encourage maternal health care workers to manage and coordinate service delivery and appointments for young pregnant women.

      The WS Medicare Local services patients residing in the Blacktown, Baulkham Hills, Parramatta, Holroyd and Auburn communities. These communities have a high number of Indigenous residents, socially disadvantaged residents and residents from culturally and linguistically diverse backgrounds. By adopting a coordinated and community focused approach to health care, the WS Medicare Local is providing residents in great need with the best chance of managing their health conditions.

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      As a priority, stakeholders recommended targeting oral health promotion to children. Stakeholders recommended that the best way to target children is to use the school network, noting that a holistic approach encompassing healthy food at the school canteen, oral health education in the school curriculum, on–site visits by oral health professionals is essential. Stakeholders also suggested the implementation of programs like ‘Lift the Lip’ and ‘Crunch and Sip’ on a national level. Stakeholders also stressed the importance of targeting children as early as possible and recommended including an oral health check as part of a child’s 18 month immunisation appointment as one mechanism to target infants. Targeting young children and educating parents early increases the probability of children carrying good oral health habits into adolescence and adulthood.

      The value of oral health prevention strategies in closing the gap in incidence of oral health disease amongst Indigenous Australians was acknowledged. Stakeholders emphasised the importance of preventive activities such as water fluoridation and the application of fluoride varnishes and recommended the implementation of additional preventive activities. For example, it was suggested that the Government work closely with community stores on issues affecting oral health, such as nutrition, and for oral health to be integrated into broader population health campaigns.

      To improve oral health promotion and prevention strategies into the future, stakeholders identified the need for effective research and for nationally consistent oral health messages. To this end, stakeholders recommended the continuation of funding for the National Oral Health Promotion Clearing House and the administration of national consensus workshops.

      Capacity of the public dental sector

      Consultations with the state and territory Dental Directors raised several issues regarding the capacity of the public dental system to deliver timely services. The demand for services in the public sector is high and as a result the waiting lists for treatment are long, with patients in some states waiting up to 25 months for general oral health treatment. Directors suggested increased funding from the Commonwealth to assist the state and territories to reduce these long waiting lists.

      Concerns about workforce in the public sector were also raised. Directors noted the difficulties in retaining staff in the public sector as a whole and in encouraging staff to work in rural and remote public facilities. The need to ensure there is sufficient infrastructure to meet demand and to support student clinical placements were also identified. Directors noted that the relationship between the public sector and universities needs to be improved in order for student placements to be effectively planned and supported. One recommendation to improve support for students was to implement a tutoring program to encourage private dentists to take on supervisory roles in the public sector.

      Another potential avenue to increase public sector capacity involves reshaping the public sector approach to service delivery. It was suggested that the public sector could be moulded into a specialised unit servicing the complex special needs cases only and the private sector used for more general courses of care.

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      The dental system

      When providing recommendations on the dental system as a whole, some stakeholders expressed support for the implementation of a universal dental model. However, it was noted that a universal system would need to be phased in over time and there would need to be adequate workforce and infrastructure to support the system. As a first step, stakeholders recommended providing universal access to children.

      On commenting on the current system, stakeholders raised concerns about the intermittent funding and operation of dental programs and advised that the system needs to have continuity. Stakeholders also advised that there needs to be better communication and integration between the existing Commonwealth and State programs to prevent patients ‘double dipping’ and ensure appropriate use of resources. It was also noted that communication between public dental facilities and dental educational facilities also needs to be improved.

      The Medicare Local Network was identified as one mechanism for improving patient access to oral health care on a local level. It was suggested that Medicare Locals could act as a ‘co–ordination unit’ and assign a case manager to patients to manage appointments, arrange patient transportation for dental visits and outsource services to private dentists.

      It was also noted that the current system focuses on treatment, with patients mainly visiting a dentist when a problem arises. It was suggested that the system adopt a population oral health approach which includes preventive strategies.