Report of the National Advisory Council on Dental Health

Options for Children

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

      The options for children are based on the Council’s aspirations in Chapter Five that investment in children will provide long–term benefits for population oral health. As noted in Chapter One, although children have relatively high visiting rates, there are worrying signs of increased dental caries, with 45.1 per cent of 12 year olds having decay in their permanent teeth and 24.8 per cent with untreated decay. Recent studies have also revealed that there is a social gradient in the prevalence of child caries, with those children in the least advantaged areas experiencing approximately 1.5 times the number of caries than children in the most advantaged areas.116 However, the Council does not support an option to focus only on low income children. Caries and untreated caries are evident across all socioeconomic groups. Surprising proportions of those children affected are found in middle and upper socioeconomic groups. A universal program is the best option for reaching all children and establishing a foundation for good oral health throughout life.

      116 Spencer, A.J. and Harford, J. (2008), Improving Oral Health and dental care for Australians, Prepared for the NHHRC, p.35.

      A universal scheme for children, including an additional measure to reach out to those who do not presently access dental care will address this. States have indicated that in their experience, the treatment of children actually becomes less costly on a per capita basis over time as regular preventive services and promotion reduce the need for more complex procedures.

      The Council has developed two alternative approaches for a universal children’s scheme:

      • An individual capped benefit entitlement for individuals to be funded by the Commonwealth.
      • The states and territories delivering services for children. This could be funded and managed by the Commonwealth, or by a partnership between the Commonwealth and the states and territories through intergovernmental agreements.

      These options have been developed as alternatives, with a choice required between them.117

      117 The interaction of the children’s options with the MTDP is considered on page 76–77.

      Option 1 – An individual capped benefit entitlement

      The objective of this option is to improve access to dental services for all children through a scheme which funds the provision of basic preventive and treatment services.

      Operation

      This option would provide an individual capped benefit entitlement for basic dental services for all children aged up to 18 years. This would be funded by the Commonwealth. This entitlement could be used for a range of basic dental services, covering preventive and restorative treatments. The services available would be listed on a dental benefits schedule. The Dental Benefits Schedule already in place for the MTDP could be used as a starting point. An example of a schedule has also been developed by experts from the Council (refer to Appendix K).

      The benefit could be used to access care in the private or public sector. This would complement existing arrangements under the MTDP and allows patient choice as to the location of care.

      Services provided in the public sector would be free to the patient. Private dentists could choose to charge above the item benefit. In these circumstances patients would need to meet any additional charges out of their own pockets.

      The entitlement would be available on a calendar year basis. Dental practitioners would provide services based on the schedule of benefits, up to the value of the entitlement.

      A significant group of children are missing out on adequate dental services. These children are difficult to identify and reach. Due to the differences in infrastructure across the country, the Council proposes a fore–runner program for those children. This program would demonstrate ways to engage these individuals, through, but not limited to, Medicare Locals and other community organisations. Those individuals identified by this program would then receive treatment through the public dental system. The program could then be evaluated and the most successful methods incorporated into the universal scheme.

      Some members of the Council are experienced in local delivery of services and community development and could be consulted in the development of such a program.

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      Timing of implementation

      Moving to a system where all children visit a dental practitioner regularly will mean addressing current workforce and infrastructure capacity constraints. The Council recognises that full implementation will take some time. For this reason, the indicative costings assume that foundational activities and the programs to reach children commence in 2012–13 and the roll out of the capped benefit entitlement option would commence no later than 1 July 2013.

      Scalability

      This option could be implemented in stages. The timeframe for scaling depends on many factors, including workforce constraints and the Government’s decision on fiscal considerations. This option could be scaled down in cost by initially limiting access through a means test – for example focusing on concession card holders (two million children) and expanding access to all children (five million) at a later date. This approach would mean the option would not offer universal access in the first instance. The Council does not see a narrower scheme as a permanent stand–alone measure but rather as a staged approach to a more comprehensive universal measure.

      Scaling in this way would reduce the indicative cost of the program from $2.5 billion to $827 million over four years from 2012–13. It would result in the same fully implemented cost as the universal access scheme (approximately $904 million per year) from 2017–18, when the scaled scheme would include all children.

      The indicative costing below includes: treatment costs for all children, and development costs for improving and expanding capacity to reach those children who do not receive appropriate care.

      Table 6.1 – Projected expenditure for Option 1.

      Option 1 ($ million) 2012-13 2013-14 2014-15 2015-16 Total cost over the forward estimates Annual cost once fully implemented
      Option - Universal access (treatment costs) *51 888 970 1,038 2,946 904
      Plus development costs 5 5 5 5 21
      TOTAL 56 893 975 1,043 2,967
      Option - Phased introduction starting with concession card holders (treatment costs) *51 133 426 466 1,311 904
      Plus development costs 5 5 5 5 21
      TOTAL 56 138 431 471 1,332

      Note: Estimates do not include the transitional costs associated with any affected legacy programs. Numbers may not add to totals due to rounding.
      * In 2012–13, treatment is only costed for the children who currently do not receive appropriate care. The broader population would receive treatment from 2013–14.

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      Comments

      Under this approach the Commonwealth has funding and policy responsibility for the program. The states and territories retain a service delivery role and the details of how this would work in practice would require consideration at a formal intergovernmental level.

      If states and territories continue to be responsible for particular population sub–groups with special oral health care needs, where the new outreach activities will draw more people into active participation in dental service programs, this would require consideration at the intergovernmental level.

      This option uses both public and private sector service delivery. States could continue to operate their existing models and approaches, while providing services under the scheme. This would also provide some flexibility for the public sector, allowing states to use either community clinics and/or dedicated school dental programs to provide services.

      Under this option, the Commonwealth Government would gain wide–ranging patient–based service data which would be available to inform planning and improvements to the scheme. A key risk of this option is that some children are already covered by private health insurance for these services. In these cases the scheme may not improve access but instead simply replace a private health benefit with a government benefit.

      Option 2 – Enhanced public sector child dental services

      The objective of this option is to improve access to dental services for all children through a scheme which funds basic preventive and treatment services.

      Operation

      All children up to 18 years would be eligible for public dental services. The Commonwealth would fund the states and territories to deliver the services, through their existing systems including school dental services, community clinics and the private sector. The dollar value of dental services per child would be set at the cost of providing the services in the public system. Services to concession card holder children would be free of charge, while non–card holders may need to make a co–payment.

      Timing of implementation

      This option would require agreements to be made between the Commonwealth and the state and territories. The Council expects that these agreements and further implementation arrangements would take at least 12 months.

      In the short– to medium–term, the take–up of the scheme is expected to be limited by the capacity constraints of the public sector. As this capacity is built up through the foundational support activities, there will be a gradual increase in take–up. Full implementation and capacity is expected to be reached around the end of 2016.

      As noted in Option 1 above, a fore–runner program could be implemented to identify and reach those children who are missing out on adequate dental care.

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      Scalability

      There is some potential to scale the implementation of this option.

      The indicative costing below includes: treatment costs for all children, and development costs for building capacity to reach those children who do not access care.

      Table 6.2 – Projected expenditure for Option 2.

      Option 2 ($ million) 2012-13 2013-14 2014-15 2015-16 Total cost over
      the forward
      estimates
      Annual cost
      once fully
      implemented
      Option - Universal
      access (treatment costs)
      *51 727 801 860 2,437 717
      Plus development costs 5 5 5 5 21
      TOTAL 56 732 806 865 2,458

      Note: Estimates do not include the transitional costs associated with any affected legacy programs. Numbers may not add to totals due to rounding.
      *In 2012–13, treatment is only costed for the children who currently do not receive appropriate care. The broader population would receive treatment from 2013–14.

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      Comments

      As with Option 1, this assumes the Commonwealth would take policy and funding responsibility for children’s treatment. The states and territories would be responsible for the delivery of services. These arrangements would need to be formally negotiated at an intergovernmental level.

      By using state and territory expertise, infrastructure, workforce and system arrangements this option is less costly than the universal individual capped benefit entitlement for two reasons:

      • the public system can provide a similar service to the private system at a lower cost thereby reducing the per capita expenditure; and
      • there are likely to be a significant number of families who will not participate in the program as they will continue their existing visiting patterns to private dental practitioners.
      • This arrangement reduces expenditure by approximately $511 million over the forward estimates and is also $187 million less per annum once fully implemented, compared to the universal individual capped benefit entitlement.

        It would also be possible for states and territories to redirect their previous investments in child dental programs to more targeted approaches aimed at reaching the children who receive inadequate dental services as described below.