Report of the National Advisory Council on Dental Health

Foundational Activities

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

      All four major service delivery options would need to be supported by foundational activities around workforce and infrastructure, oral health promotion and special access programs. These activities would be specifically designed to support successful and sustainable improvements in oral health for the identified priority groups, and eventually universal access.

      Building on the longer term aspirations in Chapter Five, the Council suggests some specific activities that Government could consider.

      Table 6.6 – Summary of key foundational activities.


      Core Activity

      Key Suggested Activities

      Dental workforce and infrastructure

      - Support for workforce to move to areas of under–service, including rural areas and the public sector generally.
      - Enable dental practitioners to expand and/or fully utilise their scope of practice in order to treat broader populations.
      - Consideration of a pause on additional dental education programs pending finalisation of the current HWA review of workforce supply and demand.
      - Increased investment in university and public sector facilities, clinical placement facilities, and capital infrastructure.

      Data and research

      - Improving the evidence base for workforce planning.
      - More regular national surveys for children and adults.
      - Identify and address gaps in population–level monitoring and surveillance.
      - Ongoing funding by Government of oral health and workforce research.
      - Increase in funding for clinical research in dentistry.
      - Consideration of e–health initiatives in managing dental health records.

      Oral health promotion

      - Significant increase in expenditure on oral health promotion.
      - Development of a National Oral Health Promotion Plan.
      - Implementation of a supportive legislative and regulatory environment.
      - Co–ordination of oral health messages across the country.

      Targeting groups with special oral health care needs

      - The use of Medicare Locals and community organisations to facilitate access for groups with special oral health care needs.
      - Improvements in programs to provide services to Indigenous people, rural and remote communities and aged care facilities.

      Possible mechanism for delivering foundational activities

      The Medicare Local Network forms part of the Government’s National Health Reform agenda. Medicare Locals function as co–ordination units within the community and have a role in identifying local health care needs and service gaps. They aim to assist patients in better managing their health conditions and to prevent disease in the community.

      Key Medicare Local activities include: linking GP, allied health, hospital and aged care services; training of GPs and allied health professionals; maintaining up–to–date local service directory information; working closely with local health organisations such as Aboriginal Medical Services, Local Hospital Networks and hospitals to improve co–ordination; identifying and addressing gaps in local service delivery; supporting after–hours GP services; and supporting initiatives aimed at improving prevention and management of disease.

      The Council notes that each Medicare Local is unique in its operation and has different programs, funding and capacity.

      Appendix H outlines some case study examples of the type of role that could be further investigated, including the WentWest Medicare Local in New South Wales and the Marion GP Super Centre in South Australia.

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      Dental workforce and infrastructure

      The terrain of the dental workforce has changed in recent years with the establishment of HWA, DBA, AHPRA and additional universities (including rural dental schools) for educating dental practitioners. This has provided the context to re–examine pathways for co–ordinated analysis and planning for the dental workforce.

      The main issues relating to the dental workforce are an under supply, maldistribution and mix of practitioners. These create particular barriers to access for rural and remote, urban fringe areas and special needs patients. The Council notes the potential for utilisation of the diversification of the workforce to address the needs of these patients. It is also important that the work of HWA in assessing and modelling the dental workforce is concluded in a timely way to address these issues.

      Workforce utilisation, supply and maldistribution

      The Council recognises the important work of oral health therapists, dental hygienists and dental therapists. The Council strongly recommends the removal of legislative restrictions on the provision of dental services by dental therapists, dental hygienists and oral health therapists for government programs such as CDDS and DVA Dental Program.

      The Council notes the HWA is currently reviewing the scope of practice of oral health therapists, dental therapists and dental hygienists. The Council suggests that the scope of practice of dental practitioners be considered, specifically that the scope of practice of oral health therapists, dental therapists and dental hygienists be expanded, with approval by the DBA, to allow for treatment and services to broader population groups. This would include appropriate DBA approved formal education and training, ensuring that all oral health practitioners can work within the full scope in which they are competent. These may relieve the time and cost pressures of heavily relying on dentists to perform basic services.

      In addition to the aggregate supply and demand balance there is significant maldistribution between urban and rural areas, and across urban areas as well as between private and public dentistry.

      The Council suggests a multipronged approach to support workforce redistribution to areas of relative under service:

      • recruitment of marginalised groups (through 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 (UDRHs) and Rural Clinical Schools,;
      • enhancement of the foundation year for dental graduates with opportunities to move to regional areas (accommodation and academic support); and
      • further expansion of the DTERP program for rural clinical schools, including increasing the support for dental undergraduates training in rural and regional areas.

      The Government could also consider the use of incentives and reward payments for various sectors of the workforce:

      • to help support public dental services to develop retention strategies;
      • to cater for patients with special oral health care needs; and
      • infrastructure grants for clinics, mobile dental infrastructure, or for relocation grants for rural and remote areas.

      Co–ordination and planning around the dental workforce

      In terms of long–term planning and co–ordination of the workforce, HWA propose to develop the National Training Plan Mark II in 2012, to be considered by Health Ministers. In addition to this work, the Council considers that there needs to be improved co–operation into the future across relevant bodies such as HWA, AHPRA, DBA and the Australasian Council on Dental Schools.

      The Council also supports using the HWA’s national training plan to guide the tertiary sector on the education of dental practitioners, potentially to modify the recruitment of international dental graduates and to stimulate reform measures within the dental workforce. The Council also suggests that HWA work explicitly consider the development of a rural dental workforce strategy.

      The establishment of three new dental schools puts extra strain on the capacity of clinical and training infrastructure. The Council’s Workforce and Infrastructure Working Group suggests a pause on new schools and programs until a new round of supply and demand projections are available and the HWA has prepared its national workforce plan and submitted it to Health Ministers.

      Academic and clinical training and infrastructure

      The rapid expansion of the numbers of dental practitioners in training, as well as introduction of the Voluntary Dental Intern Program, will put increasing pressure on the training staff and infrastructure available for students in university training. To deal with these pressures the Council proposes that the Government increase funding for both capital infrastructure, facilities and staff for universities, public dental hospital and community placement clinical facilities.

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      Data and research

      Policy development, program design and evaluation needs to be supported by sufficient ongoing funding for data and research. The Council would like to see a maintenance of existing support for population–level monitoring and surveillance of oral health, use of dental services and practice activity.

      Appropriate research activities include:

      • more regular national surveys for children and adults, so that they become an expected part of understanding the oral health of Australians;
      • the identification of gaps in population–level monitoring and surveillance and implementation of activities to fill them;
      • capturing a greater scope of process, output and outcome measures on individuals within existing and new dental programs;
      • targeted research in priority areas of emerging need; and
      • targeted research on the factors that influence dental practitioners to work in rural and remote specialist areas.

      The Council supports improving the evidence–base for workforce planning – through ongoing research. The recent publication of new data on practitioner registrations highlights the need for ongoing monitoring of the dental workforce and the periodic revision of dental workforce supply projections. The Council believes it would be appropriate for the Government to fund periodic research and analysis.

      Oral health promotion

      Australia has a world class record in health promotion in some areas, including tackling road accidents (i.e. drink driving), smoking and HIV/AIDS. We already have the capacity to be highly effective in delivering oral health strategies if funding and other supports are provided. The value of such an investment is readily seen in the Commonwealth Government’s 2003 publication, Returns on Investment in Public Health,120 which also highlights another key principle of successful health promotion work: planning collaborative approaches using multiple strategies at different levels.

      120 Applied Economics (2003), Returns on Investment in Public Health: An Epidemiological and Economic Analysis, 2003. Prepared for the Department of Health and Ageing.

      Expenditure on oral health promotion and non clinical prevention activities is very low – estimated to be around one per cent of expenditure, compared to even the highly modest two per cent of expenditure across the whole health system. This could be significantly increased to reduce the incidence of dental caries and periodontal disease. This will both improve the quality of life of Australians and reduce the demand for future dental care.

      Broader systemic support for oral health promotion requires legislative, regulatory and fiscal policies to assist in making healthy choices easier– examples in the oral health area include health promoting foods in schools or removal of taxes on fluoride toothpaste.

      As is the case for many other health issues, oral health status is influenced not only by individual behaviours but structural or social factors. For example, access to care is crucial and the inequities in this are discussed. Other structural issues include those influencing diet in general, e.g. access to affordable healthy foods, heavy promotion of high sugar foods on television and at point of sale, and the way sugar treats are seen as rewards in our culture. These and other factors need consideration when designing health promotion programs.

      The Council proposes the development of a National Oral Health Promotion Plan as the cornerstone for future promotional activities. This Plan could investigate various opportunities and pathways for oral health promotion and would include developing:

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      • a multi–strategy approach to oral health promotion through co–ordination with the states and territories – based on current evidence, underpinned by social research, and underpinned by common themes, principles and oral health messaging;
      • close links to the general health promotion activities of the Australian National Preventive Health Agency, i.e. the Expert Committee on Obesity, with an increased focus on oral health;
      • a strategic system to encompass and support all oral health promotion activities, such as:
      • - targeted approaches involving conveying information and supporting healthy choices to be organised around a settings approach, for example day care centres or residential aged care facilities;
        - with information and healthier behaviour reinforced through mass campaigns and encounters with public and private dental services;
        - embedding oral health promotion in service delivery models in the education of the future dental workforce;
        - oral health screening and education:
            ° upon admission to residential aged care, and incorporated as part of the client’s overall care plan;
            ° prior to or upon commencement of treatment for diseases requiring lengthy treatment (e.g. cancer), and regular oral health checks and preventive treatment throughout treatment as well as for a post–treatment; and
            ° prior to or upon commencement of treatment for chronic conditions by including oral health assessments and preventive activities in care plans;
        - ongoing support for oral health promotion and prevention, including education, activities and campaigns to ensure that improvements in oral health are sustained over time;
      • expertise in research that is centred on oral health problems;
      • regular funding for the National Oral Health Promotion Clearing House and Steering Group and recognition of their role as the co–ordinating advisory body for oral health promotion projects;
      • designated positions for oral health champions (such as dental assistants, dental practitioners or other health workers) within state oral health services to link in to communities and schools to raise the profile of oral health and to deliver consistent national messages;
      • proposals to extend water fluoridation across the whole country; and
      • scope for leveraging the Medicare Locals network for targeted activities.

      Targeting groups with special oral health care needs

      The Medicare Local Network could facilitate access to oral health services for special needs patients by: arranging patient transportation for visits; and assigning a case manager to patients to manage appointments and follow–up visits. Medicare Locals could also act as an information gateway between the states and territories and local oral health providers. This could assist the states in identifying and addressing oral health service delivery.

      A pilot program to deliver oral health promotion could be trialled in a particular state or region to identify special needs groups (refer to Appendix H for a case study on Medicare Locals).

      To further assist these special needs groups to access care, centres of excellence could be established for developing public dental capacity to specialise in managing special cases.

      Indigenous people

      Increased access to dental services for Indigenous people could include:

      • improvements to the co–ordination of services through Aboriginal Medical Services and the states and territories;
      • upskilling Indigenous health workers in oral health education, utilising oral health competencies developed for Indigenous health workers by the Community Services and Health Industry Skills Council;
      • support for Indigenous students across dental disciplines, including developing access programs for Indigenous students to study dentistry;
      • updating the Dentistry in Remote Aboriginal Communities manual, which provides information on cultural and clinical orientation for oral health professionals working in remote Indigenous settings; and
      • Medicare Locals co–ordinating services in urban areas as well as particularly for rural and remote communities. Where appropriate, Medicare Locals could identify service needs and co–ordinate Aboriginal Medical Services to make arrangements with private and public dentists to extend the reach of services to Indigenous people.

      In addition, the Council also suggests investigating a possible national expansion of successful regional Indigenous liaison programs. These programs link with Indigenous communities and train public dental staff to work with Indigenous people, with Aboriginal workers acting as a link. These programs have been successful in making mainstream public dental services more acceptable to Indigenous people, with the number of Indigenous people treated in main stream public clinics increasing significantly.

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      People residing in rural and remote areas

      The proposals to address work force maldistribution would also improve access for rural and remote areas. In addition, rural Medicare Locals could be used to identify dental service gaps in those areas and to assist with the co–ordination of dental service delivery.

      A preferred service delivery model would have dental practitioners reside in remote and rural locations on a more permanent basis. This could be supported by retention incentives and infrastructure grants. For small communities, however, fly–in–fly out models like the Medical Specialist Outreach Assistance Program could be appropriate, but with designated communication strategies with existing dental and non–dental professionals.

      Frail older people in the community and residential care

      These people in the community and aged care residents have difficulties maintaining oral hygiene and accessing dental care. The following strategies could be investigated and developed:

      • wider use of all dental practitioners in home and aged care facilities;
      • the non–dental workforce, which are providing health services to older Australians, could receive further training in oral health, including reintroducing the successful Nursing Home Oral and Dental Health Plan (and including referral pathways for active treatment) and using oral health competencies developed by Community Services and Health Industry Skills Council;
      • existing oral health screening, assessment and simple care planning could be evaluated and improvements could be built into existing assessment and care planning processes such as those undertaken by Aged Care Assessment Teams (ACAT);
      • - Many of the existing ACAT Comprehensive Assessment Forms (CAFs) have some standard questions to determine the basic Oral/Dental Hygiene status of the client.
        - The Department of Health and Ageing has developed an Aged Care Assessment Program Toolkit for use by ACAT assessors and includes an 'Oral Health Assessment Tool'. At this time the use of the toolkit is not mandatory. However, the Department is in the in the process of developing a standardised National ACAT CAF.
      • current accreditation standards, under expected outcome 2.6 and 2.15 the Aged Care Act 1997, could be assessed to see if they are effective in assessing and care planning for oral health and in the implementation of these care plans in aged care facilities. This could be examined as part of the Department of Health and Ageing’s pilot of revised Accreditation Standards, which is anticipated to be undertaken this year.
      • greater employment of mobile dental clinics and dental equipment in providing services to aged care residents with mobility and transport issues;
      • attention could be given to including oral health as part of TAFE and university nursing course curriculums; and
      • a strategy to educate the dental workforce in managing aged care. This could include the use of scholarships, such as those available through relevant Funds established by the Commonwealth in the 2011–12 Budget and administered by the Department of Health and Ageing. This could include specific scholarships for dental therapists and oral health therapists to work in aged care facilities, with a particular emphasis on working in rural and remote facilities.

      The Council is also aware that the Government provides funding to the Department of Education, Employment and Workplace Relations under the National Workforce Development Fund, which allows eligible organisations to apply for funding to support the training of existing workers and new workers in the areas of identified business and workforce development need. Aged Care training has been specifically identified as an area for development through this funding and has been allocated $25 million towards skills development in 2011–12.

      The Council also is aware of other policy initiatives for improving overall clinical health, including dental health, for residents in aged care facilities. Opportunities for synergies between this and other activities could be investigated to strengthen the reach and effectiveness of dental health interventions for this vulnerable group.

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      Homeless people

      These population groups not only face barriers accessing dental services but also have difficulty accessing other health services. This will require strategies for marshalling social assets in the community, e.g. the Medicare Locals, the Local Hospital Networks, Community Health Services, and non–government organisations.

      It would be worth investigating an expansion of the current programs that provide targeted promotional and dental treatment to all Supported Residential Facilities.

      The Council also notes the philanthropic work undertaken by the ADA, its members and other organisations in delivering services to homeless people (see Appendix J).

      People with disabilities

      Some people in the community face significant access barriers which vary greatly in scope and complexity. Access to services may require specific programs designed to meet their needs, which could require co–ordinating services through new and existing social assets and systems of service, e.g. Medicare Local networks, community health services, and non–government organisations, relevant state departments and universities.

      In addition, education and information could be developed and provided to assist dental practitioners in working with various disabled people.

      Prisoners

      The Council noted that reports of the oral health of prisoners give cause for concern. While states are responsible for the dental treatment, Council recommends that this issue is raised in the Australian Health Ministers Advisory Council (AHMAC).