Report of the National Advisory Council on Dental Health

Chapter Five - Long-Term Aspirations

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

      Goal

      In order to properly frame the proposals, we have developed a long–term goal. This will help ensure that the development and implementation of dental proposals are part of an overall framework. While Government priorities regarding the constraints of the current fiscal environment have determined the short–term goals of the Council and its proposals for the 2012–13 Budget, the broader goal will help to guide thinking around the future of dental health in Australia.

      The Council agreed that the following statement reflected the long–term goal for dental services:

      An integrated national oral health system, as part of the broader health system, that provides equitable access for people in Australia to prevention, promotion and clinically appropriate, timely and affordable oral health care.

      The goal embodies the principle of universal access (equitable access to services across the population) which was one of the overarching long–term issues considered by the Council.

      Council Discussions on Universal Dental Care

      The Council’s discussion of a particular model for a universal scheme in the short– to medium–term did not receive unanimous support from all members. This was partly due to concerns about whether a universal scheme would meet the dental needs of all Australians, what it would provide by way of services, what rules it may impose on practitioners, funding concerns and any impact on some current service arrangements that are working well.

      Many members support the development of a universal scheme because it is seen as an appropriate way to deal with the structural inequity within current arrangements − where significant numbers of people are excluded from accessing services because of cost. This particular universal model would allow a progressive tax arrangement to increase and redistribute dental expenditure more equitably through the system,109 with the aim of improving affordability and access in general.

      109 Mr Longshaw noted that there was no information presented or debated by the Council associated with a progressive tax arrangement, and that such an approach has not been fully considered or agreed by the Council.

      The differences of opinion on the design of a universal model were based more on practical issues relating to implementation. However, there is not only very high support in the community for creating universal access, but also an acceptance that increased revenue is required.110 It was acknowledged that an ageing population and decreased edentulism would place pressures on funding from the outset. In addition, a universal scheme would be difficult to implement over a shorter time frame, given supply constraints within the existing system. There are many areas where capacity would need to be improved before a universal scheme could operate. Maldistribution of service providers would still be an issue, as it is for Medicare–funded health services, in regional and remote Australia and across the system.

      110 Dental Health Services Victoria (2011), Australian community attitudes to dental services: research findings, DHSV, Melbourne.

      Given the above, and the short time–frame for this report, the Council did not venture into a detailed conversation about a particular universal model. However, rather than supporting a particular style or model of universality, the Council was in agreement on the principle of universal access. This reflects a view that the long–term goal should be for all Australians to access affordable dental care within acceptable timeframes when they need it. This principle of universality could be applied in many ways, including a design which includes a mix of the best aspects of existing arrangements, an expansion of these arrangements, along with other mechanisms for those who find access a problem.

      The Council believes such an approach is appropriate because it provides flexibility, accounts for divergent views and considers the long–term nature of this goal. In the Council’s view, the long–term nature of this goal makes the endorsement of particular models redundant at this time because it cannot account for long–term changes in the dental system. It would be more practical for the Government to consider its preferred model of universality across the population when it considers it appropriate. This would mean that its design could more appropriately and effectively take account of changes to the system.

      A number of actions would support the achievement of this goal and are discussed below. These aspirations are based on the principles in the Report. Not all principles have been listed separately because in some cases an aspiration will cover several principles. In addition some principles can only be met by achieving several aspirations.

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      Aspiration One

      Ensuring oral health is considered part of general health by including oral health as part of the health reform processes and the health care system.

      The National Oral Health Plan 2004–13 highlights the need to recognise that oral health is an integral part of general health.111 Dentistry emerged alongside, but independent of, the medical profession. Dental schools and hospitals provided professional support and clinical experience, like the broader medical profession, but operated independently. This may have contributed to the separation of oral health from broader health in both on–the–ground services and in policy and funding terms.112

      111 Healthy mouths; health lives: Australia’s National Oral Health Plan 2004–2013 (2004), Prepared by the National Advisory Committee on Oral Health, p.vi.
      112 Spencer A.J. (2001/02), ‘What options do we have for organising, providing and funding better public dental care’, Australian Health Policy Institute Commissioned Paper Series 2001/02, p.5.

      In practical terms, the community’s view of oral disease and its consequences, including infection and pain, are not viewed differently to other broader medical conditions. A person is unlikely to see much of a difference in terms of treatment and relief between a toothache and severe earache. Yet health policy treats these conditions very differently.113

      113 ibid, p.5.

      The Council believes that the ongoing policy and health system separation between oral health and general health is contributing to a lack of direction and focus. Seeing oral health and general health together is a sensible principle with practical long–term benefits, including benefits to the patient. For example, oral disease is associated with many diseases and similar causal factors can operate in dental as in general disease, such as tobacco and alcohol consumption and diabetes. These links should be recognised within the system by ensuring oral health is integrated into the work of existing health policy agencies such as the Australian National Preventive Health Agency.

      Including oral health reform as part of the wider health reform processes could help to alleviate pressures around access and cost. It is for these reasons that oral health should be integrated into general health. Practical integration could involve service mapping via Medicare Locals and practical support for service providers to implement IT and information management systems.

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      Aspiration Two

      Improving equity and access to dental services

      It is clear to the Council that equity and access are key issues for improving oral health in Australia. Access to services is influenced by a range of complex factors, with affordability for private care and waiting times for public care significant players. Maldistribution of the services and workforce is also a key influence. Adopting a long–term aspiration to improve access to dental services provides a guiding principle for policy and program development and will help design responses which are focused on the key determinants of access.

      The Council considers that a starting point for this aspiration is an acknowledgement of what access means and what expectations need to be met in terms of patterns of visiting and treatment. Currently, there are no minimum standards across Australia for the provision of dental care, including how often people should access a check–up. Because of this, some people may not visit a dentist regularly and only attend for emergency treatment. We acknowledge that standards alone will not improve access. However, defining this provides a goal for the development of policy. These goals could focus on standards of access (minimum visiting patterns) and standards for mechanisms (affordability and workforce numbers) which would help improve access to minimum acceptable visiting patterns. This could include setting a goal that Australians seeking care should have access to a dental check–up and preventive services every two years at least.

      These targets could be modified, but the key issue is that without a general understanding of what constitutes an acceptable visiting pattern and what areas need to be targeted to achieve this, outcomes on improving access could be less than desired.

      Over the long term, improving equity and access will require a concerted effort in a number of areas − some with different causes and differing solutions. At this stage, lower income affordability for private sector services, long waiting times for public general treatment and workforce constraints in rural Australia are having an impact.

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      Aspiration Three

      Investing in the future of oral health through dental programs for children

      Existing survey data shows that around 80 per cent of children have visited a dental practitioner in the previous 12 months. This may create the impression that children are at far less risk than adults of oral disease and that a focus on children may not be necessary, given limited resources. The Council has strong views on the dental health of children, with a strong bias for expanding and continuing services to children. The improvement in the oral health of children over many decades must continue because of the strong foundation it provides for future oral health in Australia. Oral health needs to be initiated in childhood where oral health is shaped. Dental disease in childhood is a predicator of dental disease in adulthood.

      The Council is concerned that recent increases in dental caries in children may signal a change in direction for the worse. If a decline in oral health of children becomes established, children will require increased services in the future – this will have impacts on long–term costs into adulthood. The Council also believes that the good oral health of all children should be an underlying principle of any dental system, with children entitled to live free from pain and discomfort for conditions which are largely preventable with oral health promotion, good oral and general health habits and access to services.

      Public dental programs for children in Australia are currently provided by the states and territories. Eligibility for these programs differs between jurisdictions and current infrastructure can limit the number of children seen each year. Furthermore, differing definitions of what age bracket defines children can mean that some young people below the age of 18 are unable to access public dental services.

      Easily accessible dental programs for children, with appropriate infrastructure, would allow the entire child population to access treatment. By treating all children below the age of 18, good oral health is likely to be attained, leading to improved oral health outcomes for their future as adults. Clearly, health promotion will play an important role in this approach and, given the common risk factors and drivers of obesity, health promotion should be integrated across these two issues (see below). Long–term investment in children and young people is an important part of long–term oral health.

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      Aspiration Four

      Supporting oral health promotion across the population

      The Council views oral health promotion as an integral part of improving oral health across the population. The Council’s view of oral health promotion is broad, focusing on integrating oral health promotion across a range of activities and levels and using a similar multi–dimensional approach applied so successfully to tackling road accidents, smoking and HIV in Australia. Oral health promotion underpins the long–term improvements in oral health. The other aspirations and oral health promotion are integrally linked and together form part of a broader strategy for improvements across the population. The reason for a broader perspective of oral health promotion is to improve effectiveness and long–term outcomes. For example, promotion without improved access to services would be less effective, because individuals cannot access preventive or treatment services.

      The National Oral Health Plan 2004–13 highlighted that oral health promotion and prevention “needs to address oral health at both the individual and population levels, based on the identified needs of the community”. This includes: extending fluoridation of water supplies; timely access to primary care; promoting oral health; a common risk factor approach (common oral and general disease risk factors); advocacy by oral health providers; and up–to–date data to help with planning and evaluation.114 Promoting oral health should start at a young age, be aimed at parents and children and be integrated into education systems and service delivery mechanisms. It should extend beyond oral health messages and be linked into broader general health promotion with links to oral health, such as diet, exercise and smoking. Both population oral health activities and service providers should play a role.

      114 Healthy Mouths, Healthy Lives; Australia’s National Oral Health Plan 2004–13, (2004), Prepared by the National Advisory Committee on Oral Health, p.16.

      A national oral health campaign, co–ordinated with the states and territories, that uses successful oral health messaging and is underpinned by social research is recommended. This national campaign would also link to the general health promotion activities of the Australian National Preventive Health Agency.

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      Aspiration Five

      Clarifying roles and responsibilities of the states and territories and the Commonwealth

      The separation of government responsibilities for dental services in Australia has largely seen states and territories provide public dental services to eligible lower income populations, while the majority of the population is served through the private system. The Commonwealth role has been sporadic, with varying forms of intervention largely through funding and subsidies to support affordability of services. One example was the previous CDHP, which started in 1994 and was closed at the end of 1996. Funding for this program improved access for public patients, but when funds were withdrawn in 1996 waiting times increased again and public patients’ access to services declined.115 This sporadic approach has inhibited the ability to improve the long–term oral health of public patients. In combination with funding constraints within state and territory budgets, public patient access has remained a problem, with subsequent effects on overall oral health. Waiting list numbers and waiting times have decreased in recent years following some increases in state and territory expenditure. However, access is still far poorer than when the CDHP was operating in 1994–96.

      115 Dooland, M., (1998), ‘The Cessation of the Commonwealth Dental Health Program’, New Doctor (Winter), pp.4–8.

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      The Commonwealth has in recent years become a dominant funder of dental services. Some of this is the result of legacy programs. This is to be expected, with changes in government leading to varying areas of focus and funding. Even changes to legacy programs, consistent with the Government’s priorities, would leave funding allocated across a range of overlapping priorities. Improved integration of these programs, linked to clear objectives and lines of responsibility, should be considered as well as integration with state and territory programs and responsibilities.

      The Council believes that with limited resources, efforts need to reduce duplication and make effective use of limited dollars. This would begin with a change in approach with more clearly defined responsibilities at all levels of government. The Council sees the state and territory system as the foundation of public dental service provision. The states and territories have particular skills and efficiencies in the organisation, delivery and funding of public dental services. This responsibility should continue albeit with increased funding.

      The Commonwealth’s role has been as a funder of dental services rather than a service provider. With a clear delineation of responsibilities in terms of service provision, the question lies more in focusing funding responsibility. For example, states and territories are funding public dental services for both children and adults, while current Commonwealth programs, the CDDS and the MTDP, fund respectively adults and teenage children. As at the time of writing, the current Government’s policy is to abolish the CDDS and introduce a CDHP.

      The Council agrees that for public dental services, one level of government should be responsible for delivery. In addition, funding should be directed through a single funding pool for adults and a single funding pool for children which should improve co–ordination and integration.

      Clarifying the roles of the states and territories and the Commonwealth is essential in effectively directing funding to those population groups identified earlier and tailoring programs to meet demand and ensure access, not just entitlement, through outreach programs and collaboration with other community–based services. This is a long–term goal that is crucial in making every dollar work by focusing funds on the most efficient service delivery mechanism(s). In an environment where fiscal limitations are paramount, sparse resources could be directed to the needy and focused on improvements in access to dental services. A long–term increase in resources and commitment to public dental services would make a significant contribution to improving child and adult oral health and build an excellent foundation for further oral health initiatives.

      Aspiration Six

      Enhancing public dental services and academic and oral health centres

      Public dental services are crucial in helping improve the oral health of Australians. Without a well functioning public dental sector: oral health for Australians on low incomes will continue to worsen; training oral health practitioners will become more difficult; and overall cost to the system, through increased private out–of–pocket expenditure, will continue.

      Around one–third of Australians are eligible for public dental services. Only a minority of concession card holders rely on public dental services. However, there is a significant number whose only point of access is a public dental clinic. The Council would like to highlight its support for the public sector and the important foundation it provides to the whole dental system through population oral health promotion services to public patients and training and education of the dental workforce. The public dental sector provides services to high needs patients and, for the limited funding available, works hard at service delivery.

      The Council recognises that waiting times for services, especially for adults, are unacceptably long, with a public system highly skewed to emergency and urgent care, which undermines access to timely preventive care and to early intervention. But attention needs to be focused on the key cause, which is a lack of funding, not withstanding Commonwealth and states increasing funding over recent years. This has been a blind spot for all governments across Australia over decades. The Council believes that the public sector is underfunded and that long–term investment will improve access. This will also shift focus from crisis management and mitigation of complex oral disease to one of prevention and more comprehensive dental care, leading to an improvement in the oral health of public patients.

      Because of the problems in the public sector, the private sector models of delivery can be seen by some as superior and more efficient, while the public sector perceived as low quality and inefficient. The Council does not support this proposition. Private and public sector models should not be viewed as either inferior or superior, but rather as complementary, with each playing a role in the oral health of Australians. The Council wants to maintain the existing strengths of the system and ensure that the private sector continues to provide services to Australians, while at the same time focusing resources where they are needed − in the public sector − so that both the number of people and the scope of practice are expanded to meet need more efficiently.

      Focusing resources on both oral health professionals and infrastructure will help retain and attract public sector professionals, contribute to overall training of new oral health practitioners and, through infrastructure support, increase the number of services.

      Rural and regional Australians are more reliant on public dental services, especially where no private services are available. These services will need to be developed by encouraging the workforce to work in areas outside well–serviced major cities and by providing appropriate infrastructure so that the oral health outcomes for Australians living in under–serviced cities and in regional and remote areas will be improved.

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      Aspiration Seven

      Building workforce capacity for better service delivery and improved access

      The Council understands that equity and access will be difficult to achieve unless workforce supply and distribution is considered. Providing timely, affordable and appropriate oral health care to all Australians requires an appropriate dental workforce. Maldistribution of the dental workforce remains a key problem for rural and regional Australia − an issue which is consistent across the health system. Maldistribution between sectors and settings is also a significant issue. As a result of workforce maldistribution, service delivery for certain groups is insufficient to meet current needs and can impact on oral health outcomes for these population groups.

      Improving workforce capacity and flexibility is essential to meeting existing and increasing service delivery demands. There is a need for an adequate number of appropriately educated and skilled dental practitioners who can assist in improving the efficiency, productivity and responsiveness of the dental system. This includes an appropriate mix of dental practitioners across the public and private sectors and across geographical locations to help prevent, identify and treat oral health conditions. Increased funding for services alone will not necessarily improve this situation. More flexible use of different oral health practitioners should be encouraged. Workforce incentives and increased support for public sector services will be important, as will support for academic and clinical staff to educate and train the dental workforce.

      At present, larger numbers of dental practitioners work in urban areas as opposed to rural and remote areas. This has implications for access to dental services for Australians who live outside urban areas. Given the increasing number of dental practitioners graduating each year (and some from rural dental schools), there is the chance that more would be willing to work in rural, regional and remote areas. Without concerted effort this outcome is not assured. A pipeline approach with multiple strategies will be required to support workforce to move to areas of under–service. This includes recruitment of marginalised groups (such as through Puggy Hunter Memorial Scholarships and affirmative rural entry schemes for all dental professionals); supported rural clinical placements and support for dental academics within University Departments of Rural Health and Rural Clinical Schools; and support to provide dental graduates with opportunities to move to regional areas (accommodation and academic support).

      Following graduation, by providing incentives for dental practitioners to work outside of capital cities, through schemes such as those provided to medical practitioners who work in rural areas, it might be possible to increase the overall number of dental practitioners practising in or servicing rural areas. Additionally, maximising the scope of practice of dental therapists, oral health therapists and dental hygienists (with appropriate DBA approved formal education and training programs) and ensuring that all oral health practitioners can work to the full scope in which they are competent, which may allow them to provide treatment to more people, noting that this would need to be considered by HWA and AHPRA. This may alleviate access pressures for rural and remote areas by increasing the use of the whole dental workforce (although there is no evidence to support the arguments that this is not already occurring).

      Innovative workforce initiatives, not necessarily limited to increasing the supply of oral health practitioners, will need to be explored. This could include consideration of appropriate incentives for the whole workforce, both financial and non–financial. Service delivery models for rural and remote areas (such as mobile services) will need infrastructure support. This could include hub and spoke models with training and research as core elements. This will provide opportunities to train dental practitioners in a team–based environment.

      Further targeted research is required to consider the factors that influence dental practitioners to work in rural and remote specialist areas. This work can be integrated with the existing wider health workforce initiatives and knowledge but the level of infrastructure and the workforce models that relate to dental services should be reviewed specifically, as the dental workforce requires a high level of planning and co–ordination to address both capacity and distribution issues.

      Relevant government workforce bodies, such as the HWA, AHPRA and the DBA, should collaborate on better understanding and, if appropriate, shaping a future dental workforce. As noted in Chapter 2, HWA is undertaking analysis in 2012 of the dental health workforce and related issues as part of the National Training Plan Mark II. This will inform broader strategic consideration of dental workforce issues, such as co–ordination of education, employment, accreditation and regulation of workforce. However, until HWA reports, there is still scope for government to address immediate issues such as maldistribution of the workforce.

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      Aspiration Eight

      Enhancing data collection, research and analysis

      Data collection, research and analysis play an important role in policy development, program design and evaluation. The Council believes this area does not receive sufficient emphasis and resourcing, which limits the ability to positively influence policy development, program design and evaluation. While population–level data are collected through a range of activities supported by the Commonwealth Government through the AIHW, programmatic or patient–level data are far less available.

      There are also inconsistencies in the way program data is collected, which makes comparison across states and territories difficult. By collecting patient–level data in the same way and in creating nationally consistent data, any improvements that are made in delivering dental services in the public system can be accurately compared and contrasted. Improving consistency in data collection will also aid in population–level research. Over the longer term, the Council believes more consistent data collection across the public dental system will help improve analysis and outcomes for oral health policy in Australia.

      There is also evidence that delays in treatment for oral diseases are having a significant effect on the health system and economy. In particular, there may be significant health costs to the government from people seeking treatment for pain and infection. Beyond the principle of treating individuals who are in need of care, there is a policy obligation to try and ensure that existing expenditure is allocated efficiently. Further data and research into these issues will not necessarily reduce overall costs to the health system, but could improve the way dollars are spent.

      Improvements in data collection in the public system need to be matched by the provision of patient–level data in the private system. This information would help to identify service patterns for public patients receiving their treatment in the private sector as well as provide information on private sector patients.

      Australia is fortunate to have broad–based population data from research institutions such as ARCPOH. Population–based research of ARCPOH has been partly funded by the Commonwealth through AIHW and in–kind co–operation from several jurisdictions. However the value of population–level data is enhanced by building information on long–term trends which requires sustained data collection activity. Further, there are gaps in population–level data collected which should be identified and considered for new activity.

      At the broad population level, the Council believes that funding should be provided for more regular national surveys for children and adults, where data about visiting patterns and access can be measured against clinical indicators of oral health. Clinical collections should be undertaken every ten years or so to measure improvements or declines in population–wide oral health. As oral health is slow to change, more regular clinical surveys are less crucial. However, national surveys are held too infrequently due to uncertain funding. For example, Australia has had two adult surveys one in 1987–88 and the last in 2004–06. The Council would like to see national surveys become an expected part of understanding the oral health of Australians.