COMMONWEALTH OF AUSTRALIA SENATE Official Committee Hansard
COMMUNITY AFFAIRS REFERENCES COMMITTEE
Reference: Public dental services
FRIDAY, 6 MARCH 1998
CANBERRA
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SENATE Friday, 6 March 1998 COMMUNITY AFFAIRS REFERENCES COMMITTEE
Members: Senator Bishop (Chair), Senator Knowles (Deputy Chair), Senators Forshaw, Bartlett, Neal, O’Brien, Payne and Synon Participating members: Senators Abetz, Brown, Bob Collins, Colston, Faulkner, Gibbs, Margetts and West Senators attending the hearing: Senators Bishop, Bartlett, Forshaw, Knowles, Neal and Payne
Matter referred by the Senate for inquiry into and report on:
Current arrangements for the provision of public dental services in Australia, with particular reference to:
(a) the current and future dental care needs of low income earners and other disadvantaged groups of Australians and the capacity of both private and public dental services to meet those needs;
(b) the effect of the abolition of the Commonwealth Dental Health Program;
(c) the nature of the Commonwealth’s responsibility to make laws for the provision of dental services pursuant to section 51(xxiiiA) of the Australian Constitution and the extent to which the Commonwealth is currently fulfilling that responsibility;
(d) the Commonwealth’s role and responsibility in setting and monitoring national goals for oral health in Australia; and
(e) options for reform in the delivery of public dental services, including an exploration of the efficiency and effectiveness of a range of options for delivering dental services to low income earners.
WITNESSES
BELL, Ms Kathryn Harrington, Policy Officer, National Aboriginal Community Controlled Health Organisation, PO Box 168, Deakin West, Australian Capital Territory 2600 ...... 65
BLUNDEN, Mr Stephen Vincent, Chief Executive Officer, National Aboriginal Community Controlled Health Organisation, PO Box 168, Deakin West, Australian Capital Territory 2600 ...... 65
BROWN, Ms Margaret Irene, Chairperson, Health Consumers of Rural and Remote Australia, PO Box 280, Deakin West, Australian Capital Territory 2600 ...... 55
BUTLER, Dr Robert John Francis, Executive Director, Australian Dental Association, 75 Lithgow Street, St Leonards, New South Wales 2065 ...... 18 DAVIS, Ms Jill Rosemary, Director, Dental Health Program, ACT Community Care, GPO Box 825, Canberra, Australian Capital Territory 2601 ...... 78
FLEETWOOD, Dr Michael, Principal Dental Officer, Dental Health Program, ACT Community Care, GPO Box 825, Canberra, Australian Capital Territory 2601 . 78
FOLEY, Ms Michele Anne, Project Officer, Health Consumers of Rural and Remote Australia, PO Box 280, Deakin West, Australian Capital Territory 2600 ...... 55
FOLTYN, Dr Peter, Consultant Dentist, St Vincent’s Hospital, Victoria Street, Darlinghurst, New South Wales 2010 ...... 34
GILMOUR, Ms Jonine Carol, Dental Program Coordinator, Durri Aboriginal Corporation Medical Service, 51 Smith Street, Kempsey, New South Wales 2440 65
GREGORY, Mr Gordon, Executive Director, National Rural Health Alliance, PO Box 280, Deakin West, Australian Capital Territory 2600 ...... 55
HARRIS, Mrs Susan Elizabeth, Dental Program Coordinator, Durri Aboriginal Medical Service, 51 Smith Street, Kempsey, New South Wales 2440 ...... 65
KINGSFORD SMITH, Dr Elisabeth Dell, Clinical Research Coordinator, Central Sydney and South Eastern Area Health Service, United Dental Hospital, 2 Chalmers Street, Surry Hills, New South Wales 2010 ...... 39
KLINEBERG, Professor Iven, Dean, Faculty of Dentistry, University of Sydney, 2 Chalmers Street, Surry Hills, New South Wales 2010 ...... 27
LOY, Dr John, First Assistant Secretary, Health Services Development Division, Department of Health and Family Services, PO Box 9848, Canberra, Australian Capital Territory 2601 ...... 1
MARRIS, Mr Frank, Senior General Counsel, Office of General Counsel, Attorney-General’s Department, 50 Blackall Street, Barton, Australian Capital Territory 2600 ...... 1
MOSSOP, Mr Michael, Director, Special Access Programs Section, Health Services Development Division, Department of Health and Family Services, Furzer Street, Phillip, Australian Capital Territory 2606 ...... 1
SHORT, Ms Leonie Marjorie, Convenor, Oral Health Special Interest Group, Public Health Association of Australia, PO Box 319, Curtin, Australian Capital Territory 2605 ...... 48
WILKINSON, Dr Ernest John, Director of Dental Services, Central Sydney and South Eastern Area Health Service, United Dental Hospital, 2 Chalmers Street, Surry Hills, New South Wales 2010 ...... 39 Friday, 6 March 1998 SENATE—References CA 1
Committee met at 9.01 a.m.
LOY, Dr John, First Assistant Secretary, Health Services Development Division, Department of Health and Family Services, PO Box 9848, Canberra, Australian Capital Territory 2601
MOSSOP, Mr Michael, Director, Special Access Programs Section, Health Services Development Division, Department of Health and Family Services, Furzer Street, Phillip, Australian Capital Territory 2606
MARRIS, Mr Frank, Senior General Counsel, Office of General Counsel, Attorney- General’s Department, 50 Blackall Street, Barton, Australian Capital Territory 2600
CHAIR—I declare open this public hearing of the Senate Community Affairs References Committee. The committee is taking evidence into matters relating to the provision of public dental services, which was referred to the committee for inquiry and report by 30 April 1998. All non-confidential submissions to the inquiry have been publicly released and are available from the secretariat.
I welcome officers from the Department of Health and Family Services and from the Attorney-General’s Department. You will not be required to answer questions on the advice you may have given in the formulation of policy, or to express a personal opinion on matters of policy. The committee has before it the submission from the Department of Health and Family Services. Dr Loy, do you wish to make any alterations to that submission?
Dr Loy—No.
CHAIR—I now invite you to make a short opening statement and at the conclusion of your remarks I will invite members of the committee to put questions to you.
Dr Loy—Thank you, Mr Chairman. The department’s submission focuses principally on an account of the former Commonwealth dental health program, from its inception to the decision to cease it. Given the government’s decision for the Commonwealth not to have a direct involvement in the funding of dental services, we felt that some of the other terms of reference for the inquiry were more properly the province of other parties.
We have also offered you a brief bush lawyer’s view on the constitutional issues in the terms of reference, but we are very glad that an officer from the Attorney-General’s Department is here to be more authoritative on that. We touch on the developments of the National Public Health Partnership and the potential that may have for the Commonwealth and the states to take an approach to monitoring an examination of oral health as a popula- tion issue.
CHAIR—Thank you, Dr Loy.
Mr Marris—I am here to provide you with any assistance on constitutional or legal issues that might arise.
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CHAIR—I have a number of questions going down that path and we might come to you in due course. Dr Loy, what do you understand to be the government’s current role in the provision of public dental services in this country?
Dr Loy—The government decided in the 1996 budget to cease the only role the Commonwealth then had in the funding of public dental services. In that sense, the Commonwealth has no role in the funding of public dental services. The overall issue of oral health, as a health issue, is one in which we maintain an interest, but we have no direct role in the funding of public dental services.
CHAIR—Do you have any indirect role?
Dr Loy—In so far as the Commonwealth and states have arrangements for financial assistance generally, you could claim that to be a very indirect role. I think that is the same role we have in any kind of service and it is not one that involves us in the provision of the service or in the direct decision making in relation to priorities.
CHAIR—Do any obligations derive from Commonwealth involvement of the COAG process in respect of public dental health?
Dr Loy—No.
CHAIR—Does that impose no obligations at all?
Dr Loy—No.
CHAIR—Does the Commonwealth have any influence in relation to public dental services provided by the states and territories?
Dr Loy—I would think our influence is very limited. The reality is you buy influence with money.
CHAIR—How much money is provided by the Commonwealth currently?
Dr Loy—None directly for public dental services.
CHAIR—None. Is there no influence at all?
Dr Loy—That is a fair assumption. As I said, the Commonwealth and the states in partnership can look at a whole collection of issues relating to population health. Oral health could be one of those. But that is a monitoring and valuation and collection of data role rather than one related to the provision of services.
CHAIR—With the withdrawal of the Commonwealth in this area, have the states offered any comments to the Commonwealth concerning that?
Dr Loy—Yes.
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CHAIR—Would you mind outlining what their position is, state by state?
Dr Loy—I do not think I can really do that.
CHAIR—Why is that?
Dr Loy—Because I do not have material available to me. We could certainly take that on notice if you wish and provide a more detailed response.
CHAIR—Would you be generally aware of the reaction of the states?
Dr Loy—I guess the states have two reactions. One is that they, of course, prefer in general to receive money from the Commonwealth rather than not receive money from the Commonwealth. Therefore, with the cessation of the program which was providing money for state dental services, they would have preferred to keep receiving that money and they have certainly made that clear. The states sometimes argue with two slightly conflicting intents. On the one hand, they are arguing that this has somehow placed an increased fiscal strain on the states. On the other hand, they are arguing that their waiting lists have blown out because the services are not being further provided. Those two arguments are perhaps inconsistent. Either there is a fiscal strain because the states stepped in and added additional funding to their own funding for dental service, or they did not, in which case it would have to be acknowledged that waiting lists would have increased.
CHAIR—Waiting lists have increased, haven’t they?
Dr Loy—I believe so.
CHAIR—You believe so. Do you know so?
Dr Loy—We do not have any information directly that we would collect that tells us that. But I have no reason to doubt that, if the states say waiting lists have increased, they have increased.
Senator KNOWLES—Dr Loy, we have had a number of people suggest to us that we should have a denticare thing similar to Medicare. Have you any idea how much that would cost the taxpayer?
Dr Loy—One would look at the total expenditure on dental services in Australia at the moment, which is roughly of the order of $1 billion, and presume that one of the results of a denticare would be at least the transfer of most of that expenditure to the taxpayer, whereas most of it is currently privately met. We have not done any more precise figuring than that, but that seems to me to be the sort of back of the envelope calculation that gives you the order of magnitude.
Senator KNOWLES—Allison Miles from the National Centre of Health Promotion said that a percentage of funds can no longer be misappropriated. Do you believe that it has been possible for people to misappropriate funds?
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Dr Loy—I am not entirely sure what you are getting at, Senator?
Senator KNOWLES—I am just going on a quote from Ms Miles from the National Centre of Health Promotion who suggests that the CDHP was not implemented as its vision, concept and potential was intended. She went on to say that a percentage of funds can no longer be misappropriated. Have you any evidence that any of the funds had been misappropriated?
Mr Mossop—I am not aware of that. There were certainly some differences of opinion as to what the funds should and could be used for during the implementation phase, but I think they were sorted out fairly early and I am not aware of any misappropriation of funds.
Senator KNOWLES—The Australian Institute of Health and Welfare report suggests that the CDHP took state programs that did not work and added another complex layer that also did not work. It also allowed the states to pull money out of services. I know this touches on a question that Senator Bishop has asked, but can you tell the committee how much states spend on dental health now, whether it is more or less?
Dr Loy—We could provide you the information on notice as to the current expenditure on dental services in the states. At the time of the introduction of the program, as is noted in our submission, they were spending $129 million. That was in 1992-93. I am aware that, following the cessation of the program, Queensland increased its funding of dental services, and some other states may have done so to some extent. But I would be surprised if that figure is substantially increased in a real way.
Senator KNOWLES—Thank you, Mr Chairman.
Senator NEAL—Concerning the program that presently exists in the states to fund the dental care of school-aged children, are you aware of the history of those programs?
Dr Loy—Not in any detail, no.
Senator NEAL—You talk about the Commonwealth’s involvement in dental health starting in 1993 with this particular Commonwealth dental health program. Wasn’t there a program funded in the early 1970s—
Dr Loy—Yes, and we refer to that. There were two occasions on which the Common- wealth entered the funding of dental services and one was in 1973 when there was the school dental scheme. The second occasion was the Commonwealth dental health program.
Senator NEAL—My understanding of it—and if your understanding is not the same, please feel free to correct me—was that the scheme which commenced in 1973 was an initiative which provided for the care of children’s dental health. That continued for some years as an SPP and eventually—I am not sure at what stage—it was rolled into the general grants to the states on the understanding that the schemes were so well established that they would continue without the necessity of being tied. That seems to have been the case because, as you stated earlier in your evidence, the states seemed to have continued with that scheme right up until the present day.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 5
Dr Loy—Certainly, my understanding is that the scheme was commenced in 1973 and was absorbed into the identified health grant component—which was, as we say in the trade, a ‘fag with tags’. It was a financial assistance grant but it had the label ‘identified health grant’ on it, and that was done in 1981. No doubt, the kinds of considerations that are suggested in your question were part of the consideration in rolling it into that grant—as also, no doubt, the government of the time judged the view that the Commonwealth should continue to have specific purpose payments of this kind as not being appropriate.
Senator NEAL—I am sorry, but could you repeat that statement?
Dr Loy—In 1981, the then government no doubt had a view that having specific purpose payments of this kind was not appropriate; and, no doubt, this was part of a wider negotia- tion with the states and, as a result, the school dental scheme was rolled in to the identified health grant.
Senator NEAL—I suppose two matters arise out of that. One is the statement in your submission that the Commonwealth has not traditionally been involved in dental care. To some extent, the Commonwealth has been involved in dental care since 1973. The 1981 rolling-in to the more general purpose type of grants obviously meant that they did not have a direct involvement in setting the benchmarks; but, in terms of providing funds for dental care, that has been the case for some 25 years—or 22 years, if you take off the years since we got out of the direct Commonwealth dental health scheme.
Dr Loy—I would quarrel with you on that, to a degree. I would acknowledge that, during the period when the Commonwealth had a specific purpose payment for the school dental scheme, from 1973 to 1981, it was involved in the funding of dental services. But, once it was rolled in to the general purpose grants, I do not see the Commonwealth as having any more of a role than the role it has now, of saying, clearly, that the states can use some of the financial assistance grants for the provision of public dental services.
Senator NEAL—Yes, but there was one major difference between what happened 1981 and what happened in 1995, wasn’t there?
Dr Loy—1996.
Senator NEAL—Sorry: 1996. There was a major difference between what happened in 1981 and 1996, wasn’t there?
Dr Loy—In one case, there was a cessation of a specific purpose payment. In the other case, it was rolled in to overall financial grants, yes.
Senator NEAL—Yes; so, in 1981, even though the Commonwealth was not directly involved, the state still actually retained the equivalent funds.
Dr Loy—Yes; but, if I had been a Commonwealth health official in 1982 and had gone to the states and said, ‘We would like to talk to you about how you provide your school dental services,’ I would have received a fairly frosty reception.
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Senator NEAL—That may well be the case, because the Commonwealth gave up its right to be directly involved; but, certainly, there was the continuation of the provision of funds, which allowed the states to continue their scheme. As you have said yourself, the scheme that arose from that original Commonwealth fund still remains.
Dr Loy—Well, the scheme pre-existed the Commonwealth funding. The states have had school dental schemes since back in the 1950s.
Senator NEAL—Are you saying that there was provision of dental care for children at school before 1973?
Dr Loy—Yes.
Senator NEAL—Do you have any information that would support that?
Dr Loy—It would have varied from state to state, and I am afraid I do not have any one piece of historical description of that.
Senator NEAL—If you do not have that now, don’t worry. It is just that it is not a view that I have ever heard put before. If you do have that sort of information, I would be very interested if you could take it on notice and provide that to me.
Dr Loy—Certainly.
Senator NEAL—The other thing I wanted to discuss with you was your rough estimate of the cost of setting up an equivalent to Medicare in a dental care type of program. You said that the envelope would be broadly $1 million, because that is what we spend on dental care Australia-wide. I would assume that, when Medicare was first set up, the costs of Medicare would not have been the equivalent of all medical costs in the whole of Australia, would they?
Dr Loy—No, since a proportion of those were already assumed by the government and were already part of public expenditure as the proportion of government expenditure increased. But, in the case of dental services, the amount of public expenditure in dental services is relatively small, compared with total national expenditure. My suggestion is that, accepting these as very rough ball park numbers, a high proportion of those dental services would end up being public expenditure. I think that is fair to assume, when you think that, if they went on some publicly funded scheme, there would be some likely growth. But I am not claiming any sophistication for this calculation.
Senator NEAL—I understand that. I suppose I would have thought there would be deductions, in the same way as the Medicare payment for a consultation with a doctor does not necessarily cover 100 per cent of what the doctor charges.
Dr Loy—Yes; but, if you look at medical services, the proportion paid for out of public expenditure is very high—over 90 per cent. Compare that with dental services, where the proportion paid for by public expenditure is very small. All I am saying is that, if you
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 7 moved the dental services into the same circumstances as the medical services, you might be faced with that sort of bill.
Senator NEAL—But the likelihood of a public scheme ever covering 100 per cent of all dental care is very unlikely, isn’t it?
Dr Loy—I would have thought so, yes.
Senator FORSHAW—Just for the moment, anyway.
Senator NEAL—What I am saying is that, even if a dental scheme were set up, the likelihood of a scheme being established that would cover 100 per cent of dental costs is very unlikely.
Dr Loy—That is true, although one would always have to be aware of the potential for growth and the difficulty of restraining total expenditure, particularly if there were an open- ended fee-for-service arrangement.
Senator NEAL—Has the department ever prepared a discussion paper or any document in relation to the possibility of covering dental care through something similar to Medicare?
Dr Loy—Not that I am aware of.
Senator NEAL—I find that quite curious, with all the years that we have been involved with Medicare.
CHAIR—Have you finished, Senator Neal?
Senator NEAL—I will mull over that for a minute and I might come back to it later.
CHAIR—Senator Bartlett is next, and then Senator Forshaw and Senator Payne.
Senator BARTLETT—You mention in the introduction to your submission the two times that the Commonwealth has provided direct funding. Are there any other programs where the Commonwealth has provided money to the states for dental health services— through, say, dental care in public hospitals or care for veterans, and things like that?
Dr Loy—Certainly, dental services for veterans are provided. I understand that they are provided directly through DVA programs rather than through the states. The funding of public hospitals is via the Medicare agreements; and, of course, public hospitals do carry out dental procedures where a dental operation is required. To that extent, there is Common- wealth funding. But, again, that is very much on the basis of overall funding of public hospitals rather than anything specifically related to dental services. The Commonwealth funds dentist training through universities, in the same way as for every other professional training of that kind.
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Senator BARTLETT—I take it from your submission that, prior to the introduction of the school dental scheme, or the Commonwealth funding in that, there would not have been any funding provided for dental care from the Commonwealth.
Dr Loy—No.
Senator BARTLETT—In 3.1 of your submission, you mention a reduction in funding to Victoria by 10 per cent. If you do not mind, I just want to clarify something in relation to that. Information has been provided to me suggesting that that reduction in funding was found to be based on some incorrect data and that the funds were later reinstated. Is that the case or not? Do you know?
Dr Loy—My understanding is that 1995-96 funds to Victoria were reduced and the subsequent surplus, as it were, was redistributed to other states. I am not aware of it being reinstated.
Mr Mossop—I am not aware of that either. The actual reduction in funding was $2.648 million. That was redistributed to the other states and, in fact, Victoria got a share of that redistribution anyway. I am not aware that it was reinstated.
Senator BARTLETT—So the actual data that was used to generate that reduction was not later challenged or reviewed or whatever, that you know of?
Mr Mossop—Not to my knowledge, no.
Senator BARTLETT—Thank you. Could you clarify one other similar minor point? In 4.5 of your submission, you mention funding for Victoria of $295,000. I have had suggested to me that the Commonwealth funding for that, for Victorian projects, was stopped before they were completed and that actually only a total of about $251,000 ended up being paid. Do you know if that is the case or not?
Mr Mossop—I will have to take that on notice. Certainly, $295,000 was the allocation for that project. What the actual final costs and the expenditure were, I am not sure. But I will certainly find out and let you know.
Senator BARTLETT—Thank you for that. In terms of overall budgetary commitment to this, do you know whether, in the final budget of the previous government, there was an indication in the forward estimates of the continuation of the Commonwealth dental program?
Dr Loy—Yes, there was.
Senator BARTLETT—Did that have a time line where it stopped, or was it the full length of time?
Dr Loy—No. The expenditure was included in the forward estimates in the out years in the normal way. It was recorded as being continuing expenditure. That is not to say that that
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 9 was necessarily in the bag. But, at least in terms of the way the Department of Finance recorded the forward estimates, it was included.
Senator BARTLETT—Finally, I have a couple of questions about the National Public Health Partnership that you mentioned at the end of your submission. You say that this is potentially relevant to oral health. In what sorts of ways do you think this partnership might act to reduce some of the main problems with poor oral health, such as poor access to services, lack of early intervention, and that sort of thing?
Dr Loy—It is early days of the workings of the National Public Health Partnership but I think what is envisioned is an ability for the Commonwealth and the states to have an understanding of the respective roles to look at being able to monitor and evaluate data concerning population health issues—I think this is the best way of thinking of it, rather than necessarily as public health per se—and to see if strategies and approaches can be developed that take up the roles and responsibilities of the respective jurisdictions. We cannot hold that out as something that is happening right now but, if you like, it is a prospect in being for a way of working through the issue of roles and responsibilities, the monitoring and evalu- ation, the setting of national goals and so on for population health issues which could include oral health.
Mr BARTLETT—But it might not include oral health?
Dr Loy—Everything is a question of priorities. Health ministers collectively have said that Australia has five national health priority areas: cancer, heart disease, mental health, injuries and diabetes. I guess, if you like, that is the collection of priorities that are deter- mined by ministers at the moment, which is not to say that other things are ignored, forgotten or neglected. But in terms of judgments of priorities, clearly we need to take account of that set of national health priority areas.
Mr BARTLETT—If, under this partnership as it may develop, it may again lead to an extension of that sort of broadbanding of funding, would part of that be a further move for responsibility in relation to health care needs for disadvantaged people being more and more handled by the states and the Commonwealth, perhaps giving more power to the states to address those sorts of issues?
Dr Loy—Yes, I think in broad terms that is right, but with the partnership framework being used to define the goals—to have a monitoring and evaluation approach to set overall strategies but with the clear understanding that the service provision end is the states’ responsibility.
Mr BARTLETT—In your final paragraph, you mention that the Commonwealth’s main role is primarily a leadership role. I guess from most of what you have been saying so far this morning, particularly in terms of dental health where you say there is no direct role the Commonwealth has and you have no influence, what sort of leadership do you provide under those sorts of circumstances?
Dr Loy—That is a good question. Clearly there is always a tension in these things that we come to. You have good things like a public health partnership and the Commonwealth
COMMUNITY AFFAIRS CA 10 SENATE—References Friday, 6 March 1998 and the states will work together to define strategies and have overall priorities and monitor and evaluate, then there is a discussion about money. But can you separate the two things quite as neatly as that?
CHAIR—Can you?
Dr Loy—Probably not. I try all the time, Senator, though I do not often succeed.
CHAIR—Thank you, Senator Bartlett. Senator Forshaw, then Senator Payne.
Senator FORSHAW—Dr Loy, in your submission you refer to the Institute of Health and Welfare draft report and then you quote from the summary. You only quote one of the two paragraphs. Any particular reason why you did not include the second paragraph?
Dr Loy—No.
Senator FORSHAW—I just think it is—
Dr Loy—Is it a smoking gun?
Senator FORSHAW—I am not sure. I was going to ask you. The second paragraph states:
In the comparatively short time that it operated, the CDHP achieved improved public funded dental care for more card holders. However, card holders are still disadvantaged in terms of their oral health and access to dental care. Future initiatives to improve access to care and the oral health of disadvantaged Australian adults can benefit from more restricted targeting of eligibility and altered procedures for the provision of care so as to give emphasis to general dental care.
I wondered why you did not put both paragraphs in.
Dr Loy—A specific heading there, of course, was ‘Waiting times’ and we were using the reports to draw out the issues about waiting times.
Senator FORSHAW—No, I am actually—
Dr Loy—That was the reason we quoted that paragraph there.
Senator FORSHAW—It is not under ‘Waiting times’; it is under ‘National evaluation of the Commonwealth dental health program’.
Dr Loy—Yes, but in our submission we said that one of the outputs of the Common- wealth dental health program was the issue of waiting times. We reported what the AIHW said about waiting times and used that paragraph, if you like, as the best summary quotation of the issue of waiting times.
Senator FORSHAW—I did not actually read that reference in your submission to be just confined in ‘Waiting times’ because it is in section 5 of your submission, which is entitled ‘National evaluation of the Commonwealth dental health program’.
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Dr Loy—I am sorry, I was looking at the wrong quote from the AIHW. You are quite right; I am now looking at paragraph 5.2.
Senator FORSHAW—You would not disagree with that finding that the program, in the comparatively short time that it has operated, achieved improved public funded dental care for more card holders?
Dr Loy—Absolutely. That is obviously true.
Senator FORSHAW—The report from the institute actually details a range of benefits beyond that are just referred to in the summary.
Dr Loy—Yes, and the report rightly goes on to suggest not so much the deficiencies in the program but, if you like, how such programs, presumably including the state programs, might be better targeted. I think they are fair things to say and I have no quarrel with them.
Senator FORSHAW—It points out some limitations in the context that this was a program specifically set up at that time, it was the first of its type and it was a response to a demonstrated need. So it is in that context that one has to look at what one could call deficiencies or limitations or what might be able to be done in a better way in the future.
A moment ago you referred to waiting lists. That issue is referred to in the report from the institute and in your submission. It is acknowledged that waiting times were reduced. I think Senator Bishop may have started asking questions on this at the outset. What is the position with waiting lists now? Does the department have statistics on what has happened with waiting lists?
Dr Loy—No, we do not have any independent source of statistics on waiting times or waiting lists, so that would be a matter you would have to take up with the individual states. The AIHW is continuing to collect statistics. It may well have further and better information as well.
Senator FORSHAW—Is there a particular reason the department does not have that data? I appreciate that because it is essentially—if not almost exclusively, at least under this government—a state responsibility that they will have those statistics. I would have thought that in the normal course of information and data collection by the federal department it ought to have some appreciation of what the national position is in terms of waiting lists for dental care, as it does for other areas of health.
Dr Loy—No. We collect administrative data in relation to the programs we administer. We obviously take an interest in overall health statistics and data that is collected by the AIHW from the states and from other sources. But we are not in and of ourselves a collector of state administrative data.
Senator FORSHAW—We will get it from elsewhere, no doubt.
Dr Loy—I am not quarrelling with the suggestion that I know has been made in a number of submissions that waiting lists have increased. I am sure that is true.
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Senator FORSHAW—Yes. That is why I asked the question. It is acknowledged in your submission and I was seeking to see whether you actually have the data beyond reflecting what you have no doubt been advised by the states and the institute.
CHAIR—Senator Forshaw, I draw your attention to the time. I did indicate that we are going to stick to the time lots fairly rigorously.
Senator FORSHAW—I have two quick questions then. Do you have any data with respect to treatment in public hospitals related to dental care?
Dr Loy—Certainly, yes. In the hospital morbidity statistics we have reams of data.
Senator FORSHAW—I might have to get back to you with what I specifically want to focus on. Secondly, with the decline in the levels of private health insurance, which does provide limited coverage for dental services, that inevitably means that people are not covering themselves for dental services. Is that a cause for concern?
Dr Loy—No. I think it has not been a subject that we have paid a significant degree of attention to. Clearly, our prime interest in private health insurance is in relation to hospital insurance. Obviously, ancillary insurance, which includes insurance for dental care, is something that people do take up. Whether the decline in private health insurance results in people not seeking dental care when they should or in them paying more for it out of pocket, I do not think we know.
Senator FORSHAW—I would have a guess that it does, but I will leave it at that.
Senator PAYNE—Dr Loy, I think it was in response to a question from Senator Knowles on funding from the states for dental health where you said post the cessation of a CDHP, you would be surprised if the figure had substantially increased in a real way in terms of their funding.
Dr Loy—Yes.
Senator PAYNE—I understand it is the case that the Commonwealth asked the New South Wales government how much it does actually spend on dental health and it refused to tell you. Is that the case?
Mr Mossop—Yes, that is true. But it was not alone in that. Several states chose not to give us that information.
Senator PAYNE—Is it also the case that while the government was refusing to respond to the Commonwealth’s request the director-general of New South Wales health, Mick Reid, sent a letter to people on the dental waiting list in that state blaming the Commonwealth for the wait? Are you aware of that?
Mr Mossop—A letter was sent out and I have seen that. It did say that the reason for the delays in the provision of service was linked to the cessation of the CDHP.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 13
Senator PAYNE—Has the Commonwealth taken that up with New South Wales, considering that it is entirely possible New South Wales has cut funding to dental health services in real terms?
Mr Mossop—No. What New South Wales chooses to do in terms of its level of funding for dental services is its own business.
Senator PAYNE—Indeed, but in turn, when in correspondence to people on dental health waiting lists New South Wales blames the Commonwealth, that is an issue for the Commonwealth, I would have thought.
Dr Loy—I think we judged it as, I guess, part of the slings and arrows of outrageous fortune.
Senator PAYNE—Speaking of the slings and arrows of outrageous fortune, in reference to item 7.1 in your submission you indicate that several measures initiated under the CDHP left the states ‘in a good position to continue to improve services for their clients’. That is a quote from your submission. Could you, in general terms, give me an idea of whether the Commonwealth believes the states have actually taken up those points you have itemised and taken up from that good position?
Dr Loy—There is not a great deal I could say and, as is usual in these cases, I think the picture would vary from state to state. We would expect that certainly the better information management systems are a lasting legacy of the program and will no doubt be used effectively in at least some states to manage their programs better.
The demonstration projects are also significant in showing that there are some innovative ways to reach people who are very hard to reach, particularly geographically and in relation to Aboriginal health workers. It would be disappointing if the lessons learnt from some of those projects were not being taken up. But, again, at the end of the day that is a matter for the states.
Senator PAYNE—In terms of the National Public Health Partnership, is the Common- wealth pursuing any of those issues with the states?
Dr Loy—As I said, it is early days for the workings of the public health partnership. I think we would want not to be using the public health partnership as a way of trying to raise awkward issues but, rather, to work with the states to identify how strategies might be developed and priorities worked through against the data we both collect so as to see what positive steps might be made. I do not think it is a forum in which we would really want to try and have a difficult debate about who did what to whom.
Senator PAYNE—Thank you, Dr Loy.
Senator NEAL—On the agreements that were signed between the Commonwealth and the states, apart from the figures obviously being different were their terms the same?
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Mr Mossop—I believe they were. I would have to go back and check on that. Are you asking whether they all had the same basic set of terms and conditions?
Senator NEAL—Yes—requirements.
Mr Mossop—Yes, as far as I can recall, they did have.
Dr Loy—My recollection is that yes, they were, but that is not to say there might not have been some minor variations.
Mr Mossop—We would need to check on that.
Senator NEAL—Could you provide us with a copy of one of those agreements, just as an example, to see what terms were contained there? You say in your submission that Victoria at one stage lost 10 per cent of its grant for not maintaining its effort. Were there any other states that were—and I use the word loosely—punished in that way?
Mr Mossop—No.
Senator NEAL—Were there any other states that you had evidence were not maintaining their initial effort?
Dr Loy—If there were, we would have invoked the same clause of the agreement.
Senator NEAL—So are you saying there was no evidence?
Dr Loy—I am saying there was nothing anyone could make stick. No doubt there times when there might have been some interesting discussions between our people and state people—and where lies truth in some of these things?
Senator NEAL—Did you ever reach the conclusion that any other state was not maintaining its effort in terms of its commitment to dental health?
Dr Loy—I do not think we reached that conclusion, no.
Senator NEAL—There was a proportion of the funding used for evaluation. Was that the full amount—I think it was $4.6 million? Some of that $4.6 million was actually spent on those special projects, wasn’t it?
Dr Loy—Yes; it was spent on the national demonstration projects and on the rural initiatives, as described in 4.4 and 4.5, and the remainder was the evaluation.
Mr Mossop—Yes.
Senator NEAL—Was that the only evaluation done or were other evaluations done?
Mr Mossop—There was a series of reports written over the life of the program, and that was the last one. There are three or four in that series, maybe even five.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 15
Senator NEAL—All done in the same way?
Mr Mossop—Yes; the same sort of format and everything else—surveys, basically.
Senator NEAL—Would you have those readily available?
Mr Mossop—Yes.
Senator NEAL—We would be happy to return them to you; if we could have them for a short period, that would be appreciated.
Mr Mossop—Yes.
CHAIR—Senator Neal, can you bring your questioning to a close? I have one question to ask Mr Marris on legal responsibilities.
Senator NEAL—Okay; I will be very quick. In paragraph 4.6 you say:
It was always intended that States would pick up the successful ideas demonstrated by the projects...
That is in relation to the projects for isolated dental care. What was the basis of that statement? Where was that anticipated? Was it an agreement signed by the parties? Was it in discussions?
Dr Loy—I think the whole point of having demonstration, if you like, and research and development projects was to try out approaches and ideas. We certainly never intended to provide ongoing additional funding for the arrangements that were funded under these conditions; if they proved successful and effective, then the states would necessarily have picked them up because it made sense.
Senator NEAL—That is obviously what you say in your submission, but what I am asking is: what basis do you have for saying that? Was it ever set out in agreements between the states and the Commonwealth?
Dr Loy—I do not think it was.
Mr Mossop—I am not aware of it.
Senator NEAL—Where would it have been agreed? Obviously if it is understood two parties must understand. What was the vehicle for that understanding?
Dr Loy—No, it was intended.
Senator NEAL—Intended by you?
Dr Loy—Yes.
Senator NEAL—Was that communicated to the states in any way?
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Dr Loy—I think we made it clear. We said, ‘This funding is for these national demon- stration projects. They will not continue past their demonstration role.’
Senator NEAL—If that was communicated to the states, could you please provide to the committee where that was communicated to them?
Dr Loy—We will search the file and see what we can come up with.
Senator NEAL—In 6.2, and in fact in a couple of places in your submission, you say that there was a target of treating 1.5 million people and that somehow the program was to conclude at that stage. Where was that set out? Was that in the agreement between the Commonwealth and the states?
Dr Loy—No; it was, if you like, the developing understanding once targets for the program were negotiated, as the agreements were settled and as the funding arrangements came into place. I think it was first put specifically on the public record by then Minister Lawrence in August 1995.
The 1.5 million number strictly relates to occasions of service, rather than different individuals, so it is 1.5 million services. Obviously, numbers of clients would have received more than one service during that period.
Senator NEAL—So—
CHAIR—Thank you, Senator Neal. You might be able to pursue this at another time. We are 10 minutes over time.
Mr Marris, in your submission, you make reference in the final paragraph to there being express grant of power in the Commonwealth for provision of dental services, but then you say that the section imposes no responsibility of a legal nature to make such laws. Could you develop that for the record? What does that mean?
Mr Marris—What the Attorney-General had in mind there was that it is a legislative power conferred on the Commonwealth parliament. It does not involve a duty to make laws on the topic.
CHAIR—It is purely a choice matter for the Commonwealth?
Mr Marris—It is a matter of power—to exercise it or not as it wishes.
CHAIR—Thank you. Senator Bartlett, you had a point to raise?
Senator BARTLETT—You can take it on notice. It is the matter I raised before and the bit about section 3.1, the reduction in funding to Victoria of 10 per cent and disputes about that and possible reinstatement of funding.
Dr Loy—Certainly.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 17
CHAIR—Gentlemen, thank you for your time and your help this morning.
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[9.55 a.m.]
BUTLER, Dr Robert John Francis, Executive Director, Australian Dental Association, 75 Lithgow Street, St Leonards, New South Wales 2065
CHAIR—Welcome, Dr Butler. The committee has before it a submission from your organisation. Do you wish to make any alterations to this submission.
Dr Butler—No.
CHAIR—I now invite you to make an opening statement and at the conclusion of your remarks I will invite members of the committee to put questions to you.
Dr Butler—The Australian Dental Association has a membership of some 8,000 dentists, which represents over 90 per cent of the profession. Therefore, we are speaking as a major stakeholder in any dental public health program. More importantly, I think our submission is centred around one of our major aims, which is the promotion of the health of the public. So there is less of a representative role this morning and, as in our submission, more of the stated aim of promoting health for the public.
This inquiry recognises the hurt that has been inflicted on the Australian community since the termination of the Commonwealth dental health program, and I do not have to dwell on that particularly. What I would like to do this morning, in a short statement, is set some of the mood.
Before the introduction of the CDHP, the situation in the public sector for people who were unable to afford private dental care was that they had to wait to seek service from the public sector. Access was difficult and waiting lists were long. They were usually in the order, where there was access, where there were public dental hospitals in the metropolitan areas, of about two years for routine dental care. The situation was far from ideal.
Then, about a year before the introduction of the CDHP, for a number of reasons, some of which I am not an expert on, there was a growth in the number of eligible people. There was an increase in the number of people with health care cards, et cetera, who were eligible for public dental care. The waiting lists were under considerable pressure.
The introduction of the CDHP, with whatever warts it had on its body, produced an incredibly beneficial effect on its waiting lists. In a very, very short time these waiting lists that I have referred to as being about two years in the dental hospitals were down to below six months. That was a very, very rapid reduction. Not only was it a reversal of the numbers of people on the waiting list, but it was a growing figure before and it became a declining figure. So, it had a tremendous effect on access.
In other areas of Australia, quite apart from where there was a public service infrastruc- ture, CDHP provided access to patients where there was absolutely no access before. If you lived in a remote or rural area, or in some areas of metropolitan Sydney, you did not have access to adult dental care. There was a pretty well developed school dental service but there was no access to adult dental care. That is why the program was presumably introduced. It
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 19 allowed the states some flexibility so that they were able either to utilise their existing infrastructure in the public sector or, where it suited them better, utilise the well developed infrastructure of the private dental sector. It had tremendous effects.
What has happened since the termination of the CDHP is not just a reversal of the situation that prevailed before, but is far worse. There were lots of people in the Australian community who had no expectation of ever being able to get dental care who were intro- duced to it through the CDHP facility. Now we have a situation where those two-year waiting lists—and these are loose figures just to give you an idea—are often five-year waiting lists. What is happening now is that the patients who do get access to the public facilities are more often than not very heavily restricted to emergency care only.
I certainly know that in some major hospitals, patients are coming back every five or six months with another crisis—having another tooth extracted or something. That is the sort of dentistry that we had hoped had gone out years ago. So there is a problem with state funding. I am not entering into the politics of the Commonwealth-state relationships. It is purely a statement of fact that the introduction of those funds to state dental services provided a dramatic reduction in waiting lists. The withdrawal of those funds—for whatever reason, whether or not it was legitimate—has produced a deleterious effect that is far worse.
In our submission we have dwelt basically on some examples of where we think the Commonwealth might be involved. Clearly, we believe that the Commonwealth should be supplementing this funding. The states clearly do not have a capacity to do it and things are getting worse. We feel that the Commonwealth has a responsibility. We feel that it has a leadership role in a number of other ways. For example, the last national oral health survey was conducted in 1987-88. Due to some absolutely inexplicable inertia of the bureaucracy, it was not published until five years later, which meant it was obsolete by the time it was out.
It is now 10 years old in data, and I think that is a disgrace. As a representative of a national dental organisation that gets inquiries on almost a daily basis from overseas for data on Australian figures, it is embarrassing to say, ‘I can give you these figures but they’re from 1987.’ It certainly does not reflect very well. So we have made a point in our submission of that and, of course, the promotion of fluoridation as a public health measure. I will not waste the committee’s time in going over anything in the submission. I think that concludes my short statement.
CHAIR—Thank you, Dr Butler. I have two points to raise with you. I have read in recent press articles that remuneration for university graduates from dental schools is the highest of all the professions; it is about $40,000 per annum. I noted in the Australian, yesterday or the day before, that there is an emerging critical shortage of new entrants into dental schools in all the major mainland states and that a number of the places are not being filled. My simple conclusion is that we are entering a situation of significant long-term shortages of dentists which will probably have a major impact in the public health area. Can you confirm that and offer any comment?
Dr Butler—I can perhaps make some comment. I know that those figures which were developed were contested by some of our states where, obviously, they do not have that level of remuneration that was calculated. But, accepting those figures, certainly, dentistry
COMMUNITY AFFAIRS CA 20 SENATE—References Friday, 6 March 1998 has an advantage for new graduates in that they tend to start on a good salary income compared with lots of other occupational groups. That is reflected in those starting salaries, and I make no comment on those.
With respect to the work force areas, I do not think it is true to say that there is a difficulty in getting the places. In fact, entry into dental school is very difficult. I think what that was referring to was the top up of fee paying students that are now allowed. It is far the opposite. In fact, it is often a source of some annoyance to people who cannot get into dental school. It is the usual competition of the university entrance so it is far from that.
CHAIR—Is the balance in terms of graduates coming out of the schools adequate to cater to current levels of demand?
Dr Butler—I think the overall numbers are not too bad. Balance is the key. The distribution is the usual problem that we see so often. Everybody wants to practise in their own comfortable little area and nobody wants to go to the rural areas and there is sometimes difficulty attracting dentists into the public sector. It waxes and wanes. But it is that lack of balance that happens more than the overall numbers, I feel. By the usual numbers that are applied, in ratios around the world, they are considered to be about right. However, the distribution is certainly not adequate.
CHAIR—Turning to the CDHP, you commented that there was a significant reduction in waiting times and waiting lists whilst the program was in existence. Did you notice any shift during that four-year period in the nature of demand by dental consumers from perhaps more basic preventative or remedial work into more expensive treatment?
Dr Butler—I would doubt that that was so. I am not as close to it now as I was. I was in the public sector until four years ago, about the time this was introduced, so I do have some familiarity with it. The CDHP was quite restrictive in its range of services. Indeed, it was a criticism that our association made of it in its lack of flexibility there. But certainly there was no scope in the introduction to that program.
What it did allow, as I am informed by state public sector administrators, was a bit of a shift from the old emergency care only or wait forever for your next appointment and no possibility of recall to state organisations being able to look at the preventive aspects rather than the curative. I know in New South Wales they are even exploring the possibility of introducing a recall system.
I can tell you that, in the public sector, it was a matter of a person coming to the top of the waiting list and getting their treatment. If they wanted to come again, they had to go and put their name back on the waiting list and go through the wait all again. That is totally unsatisfactory. There was the start of a shift but unfortunately the program operated for such a short time that it did not really get developed.
Senator NEAL—Are you familiar with what is happening in the states post the end of the Commonwealth dental health scheme?
Dr Butler—I am pretty familiar with the general picture, yes.
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Senator NEAL—What has happened to waiting lists, waiting times, since the scheme ended?
Dr Butler—The waiting lists, as I understand it, have blown out to figures far worse than they were before the scheme started. I know that in Sydney at the United Dental Hospital and Westmead Hospital those figures are far worse then they were just before the scheme started.
Senator NEAL—Which particular type of demographics are most affected by the removal of the Commonwealth dental health scheme? What sorts of people are they?
Dr Butler—Firstly, its application was to the disadvantaged anyway. But, within that group, the people that are most disadvantaged are those who are not accessed by an existing public service infrastructure. They have gone from some access to no access. People within the metropolitan areas who can put their names on a dental hospital waiting list, I suppose, have gone from waiting however long it was then—it got down to less than six months—to up to five years now. So they are disadvantaged in that way. I suppose it might be little comfort to them but at least they are able to put their name on a waiting list.
But if you live somewhere out of the metropolitan area or, indeed, in some areas of metropolitan Sydney, where there is no infrastructure, or if you live in Tasmania where there is no developed public infrastructure for adult services—there is a good school dental service—you have had your entire public access taken away from you. So they are quite significant.
Senator NEAL—What sorts of people are you talking about?
Dr Butler—People who were catered for by this scheme who had health care cards.
Senator NEAL—Do you mean pensioners, elderly people?
Dr Butler—Yes, pensioners, unemployed, low income earners.
Senator NEAL—You are saying that in the fringe metropolitan areas, and regional areas, they are the ones that have really missed out?
Dr Butler—Yes, that is so. The development of public dental infrastructure in Australia has been largely historical rather than planned. For instance, in metropolitan Sydney you have the situation where you have two very large, very comprehensive and very good dental hospitals. That is great if you live in Sydney but it is not much fun if you live somewhere else.
Senator NEAL—There is a dental hospital operating where I come from in the Gosford area. I visited them fairly recently and what they tell me is that, previously, they were able to do the preventive, general dental inspections and care but that now all they can do is the emergencies—that is, the people who come in with abscesses or in severe pain—so that all they are doing is dealing with their emergency list, and their standard dental care list just remains untouched. Is that your experience around Australia?
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Dr Butler—Yes, it is. That is the sort of report we are getting from every state except for Queensland, which has a very established infrastructure in the public sector. It was able to manage the introduction of this program entirely within the public sector. The private sector was not involved in Queensland. That had the support of the Australian Dental Association because that structure was a good approach to it. The Queensland state govern- ment have infused some $10 million worth of funds to replace the CDHP. I am not getting quite the same reports out of Queensland, but they may well have problems too.
Senator NEAL—I have one last question. Obviously, there is a group generally of elderly people and those on health cards who are not accessing the public dental health scheme any more. Where are they going? Are you seeing an equivalent increase in people using private dentists or are they just not accessing dental care at all?
Dr Butler—I think largely they are not going anywhere, because they are in a position of not being able to afford any private care. It is true that some may say, ‘I am going to have to have such and such done privately.’ There would be some element of that. I suspect that most people, if they are not languishing on one of those waiting lists, are just not bothering. They are attending when they are in pain to get emergency care, and then they are going back again.
Senator NEAL—Thank you.
Senator PAYNE—Dr Butler, as I understand it, through the life of the CDHP, the ADA varied in its support for the program. Could you give me some outline of which state organisations had any opposition to it and perhaps why? In your submission, you also referred to what you described as several important deficiencies. Could you explain those as well for me?
Dr Butler—Yes, certainly. The Australian Dental Association collectively and national- ly—supported by states—supported the principle of the Commonwealth dental health program in providing funding for increasing the access of care for the disadvantaged. Our criticisms throughout the program were related to three areas, with one being fairly minor.
The first area was the restricted range of treatments that were available under the program. Initially, there were some deficiencies in obvious preventive treatments that were offered under the program and we did get some change early in the program as a result of our lobbying on that. In our submission we talk about the need for flexibility in programs. There was not that there.
The second area clearly was a lack of enthusiasm from the private sector to participate because of the low range of fees. The IDCFA—inter-departmental committee on fees allowance—fees that were set at the time by the federal government had undergone inadequate updating for some time and they were very low. Some of the procedures under the CDHP were decidedly unattractive to a private dentist and at times did not even cover costs.
There were pockets of resistance to participation, although generally around Australia the participation was quite good. That since has been corrected. I am sure many of our members
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 23 would probably be quite critical of elements of the IDCFA fee scale, but by and large it has undergone quite a considerable reformation. That was not apparent then. That was the second area. They were the two main areas that seemed to be barriers from our point of view.
The third area was just the usual catch bag of administrative problems within various states. We were criticising at a state level sometimes where the nature of the referrals were not adequate and people were having their time wasted. They were being sent sometimes by an element of the state sector to a private dentist for treatment, and then it was discovered that what they were sent there for was not covered under the CDHP anyway. There were those sorts of minor little things which all added up. It was mainly the range of services and the fee levels that attracted the criticism from this association. There was always support for the principle.
Senator PAYNE—Were there any particular of your state organisations which had those problems? Can you identify those states for me?
Dr Butler—The support for the principles was generally the same throughout. There was a very vocal group of people within New South Wales who were critical of the CDHP in a public sense, within our own publications. Certainly, the New South Wales state branch was critical of those same elements I have mentioned quite consistently. But the principle of the participation in the Commonwealth dental health program was one which was taken as a policy by the Australian Dental Association collectively at the start of it and it was still there throughout it.
Senator PAYNE—In terms of the states, Dr Butler, I think you reference on page 9 of your submission that you think that the Commonwealth should increase its funding. While all the states except Queensland seem to have refused to do so, why do you think the Commonwealth should do that alone?
Dr Butler—That was based on the fact that the Commonwealth has a provision within the constitution for dental health services. The fact is that there had been a couple of agreements in recent years, a COAG agreement and a ministerial meeting agreement, that seemed to indicate that the Commonwealth was a partner in this particular aspect. I am not a lawyer. I would not like to defend a point of law as to where the obligation is, but there is certainly provision for the Commonwealth to be a player. Indeed, it always has been, until it is probably at its lowest now where we do not even have a dental unit. We once had a dental advisory unit to the Commonwealth. We had a lot of participation in dental health services to NHMRC and other bodies. It has gradually gone down. During the CDHP time, it had a small administrative cell and that has gone completely now. We have this strange situation at times where even this association will write to the Commonwealth, say, the NHMRC, seeking the NHMRC’s position on it and some three or four weeks later I will get a letter from the NHMRC asking could we advise them.
Senator PAYNE—In relation to your references to fluoridation, in particular, would it be your observation that in fact it is the states who have really dropped the ball in this process? I would be interested to know what the ADA branches do to encourage states to pick up that ball in their individual areas.
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Dr Butler—I think it is a fair comment. You are quite correct: it is the states who dropped the ball. Indeed, Queensland is the state that stands out in this, that has not matched the rest of the community. The other states have been very good—but can always improve, and that is why we were talking about promotion.
Our state branches have been very involved. In Queensland, for instance, I think our state branch has almost bankrupted itself running campaigns, so far unsuccessfully, to try and get Brisbane fluoridated. It has provided a lot of money. It is an element that we feel is part of our duty, but there has certainly been lobbying from the various state branches. You are quite correct; the states have let the side down in this. My purpose in the submission is to suggest that the Commonwealth might provide some leadership and some stimulation, but certainly it is the states that have let it down, or one state in particular.
CHAIR—Thank you, Senator Payne. Senator Forshaw?
Senator FORSHAW—This may well be something that I would have to actually ask the department. We could do that on notice. You have talked about the blow-out in the waiting lists, and what is happening in public hospitals where people are coming along for emergen- cy treatment and so on, rather than having a strategic dental plan or whatever to try and prevent that. What is the cost of dental treatment in the public hospital system as provided? I am trying to get a handle on how much of the money that is spent on running public hospitals in this country could be attributed to providing dental services?
Dr Butler—No, I do not have those figures with me now, I am afraid. I cannot recall that.
Senator FORSHAW—Would your association have some information?
Dr Butler—Probably not as directly as the state health departments. I think they would have a better indication. I know there are statistics produced. I know the AIHW, for instance, would probably have those statistics. I think if I had to produce them, I would be going to those bodies seeking that.
Senator FORSHAW—Thank you.
CHAIR—Dr Butler, in your submission you support a dental postgraduate vocational scheme. Who do you envisage would pay for it? What are the costs involved? Do you see it meeting any of the needs of a number of disadvantaged groups?
Dr Butler—I think your third question is a lot easier than the other two, but I will try and answer them. Perhaps I can answer this way: we are involved at a very early stage at the moment with the discussions with the deans and state health department representatives to try to develop a proposal. We have support in principle. As for the first two questions, this is not a cop-out, but I do not know the costs. I would think they would be—and these are just ballpark figures—something around $20 million to $25 million. It is that sort of figure if you are having a comprehensive program. I may stand corrected on those figures as the proposal develops. As to who would pay: clearly, that would become a point of great discussion between states and Commonwealth and I will not buy into that one.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 25
The advantage, however, of the scheme as we see it and the reason that these stakehold- ers have got together to have a look at this is that we see an opportunity perhaps for it being not only valuable experience for a new graduate—they have got all their clinical training at the moment; they are registered as dentists; they are perfectly capable of carrying out a role and, indeed, they go into both the private and public sector at that stage—but an advantage to perhaps do some community service, if you like, at relatively low cost to whoever is paying. Furthermore, it would ensure that sort of distribution because, clearly, it would service the rural and remote areas and it might also whet their appetite a little bit for staying there and settling or staying in the public sector. But it is very early days. We really have not developed it.
CHAIR—Apart from that scheme, still in its planning stages, with a possible impact on rural areas, do you have any other schemes, ideas, incentives, coercions or whatever to encourage dental graduates to shift outside of the metropolitan area into rural areas? It was a recurring theme of a number of submissions—an absolute shortage of personnel.
Dr Butler—We have not. We have written to the minister in the past suggesting this is an area we would like to speak to him about—but just in discussion at that stage to see if there could be some encouragement. I know in the public sector in New South Wales there was some encouragement. The details I do not have in terms of salaries within the public sector to take up rural health positions.
I might add that in Victoria there is a postgraduate vocational training scheme on a voluntary basis that the Victorian Dental Health Services manage.
CHAIR—But the ADA as such do not have any programs for that?
Dr Butler—No, we do not at this stage.
CHAIR—You also advocate appointment of a dental adviser with support staff to the Commonwealth Department of Health and Family Services. Why is this so important?
Dr Butler—We feel there is a lack of input of dental health advice to the department. There is nobody within the department who has any expertise in this area. We, as the ADA, are often asked to provide that. I do not think that is appropriate. We are happy to help out but I think the Commonwealth should have its own dental advisory unit. For many years, it did have such a unit which would do things like advise on programs. It was not an oper- ational unit but it was a very well respected small unit, sometimes with only one or perhaps two dental advisers and support staff. Quite small, but at least it gave an opportunity.
At the moment, if the Commonwealth—be it the NHMRC or the Department of Health and Family Services—gets a submission from anybody outside, of a dental nature, we must ask who is going to evaluate the submission if it requires a technical evaluation? It has to be done in an ad hoc way, and that is the reason we proposed that.
Senator FORSHAW—I have heard, anecdotally, that more children today are under- going orthodontic work, particularly with braces. Is there any truth in that? This is fairly
COMMUNITY AFFAIRS CA 26 SENATE—References Friday, 6 March 1998 expensive procedure and even private health insurance does not necessarily cover all that much.
Dr Butler—That is correct. While it is only anecdotal, it is probably a fair assumption and reflects the affluence of the community and any changes in the community and in education. It is true it is expensive. It is not always elective, but quite often elective. In other words, the severity of the condition might vary from something that really has to be done to something that is purely of minor cosmetic nature, so it is the full range. I am sure it would be true that today there would be more money spent on that. There may be more disposable dentistry income. They are not spending money on decay and the rest of it, so maybe there is more money to be spent.
Senator FORSHAW—Thank you.
CHAIR—Dr Butler, do you believe there should be an expansion of the circumstances in which dental auxiliaries are used and, if so, why?
Dr Butler—The Australian Dental Association has supported an increased utilisation of dental hygienists in the public sector in particular. We believe that they are the auxiliary of choice in today’s age with their preventive focus and that they reflect the dental needs of the community. We have tried to urge that more of them be employed. There are very few employed in the public sector. They are mainly in the private sector.
CHAIR—Thank you very much, Dr Butler, for coming along and for your submission. It has been most helpful.
Proceedings suspended from 10.27 a.m. to 10.45 a.m.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 27
KLINEBERG, Professor Iven, Dean, Faculty of Dentistry, University of Sydney, 2 Chalmers Street, Surry Hills, New South Wales 2010
CHAIR—Welcome. Professor Klineberg is giving evidence to the committee by teleconference. The committee has before it your submission. I now invite you to make a short opening statement and, at the conclusion of your remarks, I will invite members of the committee to put questions to you.
Prof. Klineberg—I welcome the opportunity of supporting my submission by making a couple of overall statements. Firstly, rural oral health is a major difficulty in each state. Funding priorities tend to polarise to major health centres, often in urban areas, but some- times, to a lesser extent, in rural base hospitals. There is also enormous difficulty in attracting clinicians to rural areas both medical and dental. Of course, we are focusing on dental. It clearly needs a new approach to the management of this problem—rural oral health being a major concern in all states.
The idea of a national vocational training program has been on the agenda of the dental community, dental profession, for some time and it seems an opportune time for the committee of dental deans, after having debated the issue for some three or four years, to initiate a working party to develop a proposal. We have done that and submitted a copy to you.
The proposal is to put forward a work force of some 250 new graduates, bright, well trained and capable of addressing all aspects of oral health needs available to provide public health support, particularly in rural areas. At least six months of a 12-month rotation would be in a rural community, either hospital or practice based, and the further six months would be in an urban setting primarily for benefiting public health needs. We see this as an important educational initiative which has been shown to be very effective in the UK and Scandinavia, in particular, over a number of years. We see that it is important in this country not only educationally but also to address target groups for oral health needs.
My introductory letter to Mr Humphrey drew attention to the withdrawal of the Commonwealth dental health plan. That had injected $100 million nationally over three years but was withdrawn at the end of 1996 without notice. That left each of the states in a dilemma as to how to continue to operate, particularly in rural areas but also in urban communities with oral health needs. The working party that developed this proposal believes that a different approach through a national vocational training program at one-fifth of the cost would address a major component of what the Commonwealth dental health scheme is addressing.
CHAIR—Professor Klineberg, is the proposal for the national vocational training program for dentistry which you sent to the committee a final proposal or a working draft?
Prof. Klineberg—It has been worked through several drafts and the working party is happy with that final version.
CHAIR—Has it been formally accepted by the ADA?
COMMUNITY AFFAIRS CA 28 SENATE—References Friday, 6 March 1998
Prof. Klineberg—It has been accepted, in principle, by the federal ADA. On the working party, there were two representatives of that group. It is being discussed, not as I speak but soon, by their federal executive. I do not feel that there is any doubt that they will support it wholeheartedly. But they have not seen until now the full proposal.
CHAIR—Would you anticipate every dental graduate around Australia having to participate in the program or will it be purely a choice thing for those graduates?
Prof. Klineberg—No, it would be mandatory. It would introduce an extra 12 months before entering into private dental practice. We see this as an important additional step, not only in a training setting, but to expose the new graduates to a much broader range of community needs that cannot be addressed to the same extent during the undergraduate program.
CHAIR—Who would then determine where the graduates worked? Would it be their choice?
Prof. Klineberg—There would be a number of places that would be available in each state. The coordination of the program would have to operate through a linked group that would be centred within the dental health branch of the health department, the Australian Dental Association and the faculty. That triumvirate of expertise would determine where the places within each state would be. Where there is not a faculty available, such as Northern Territory and Tasmania, then it would be the Australian Dental Association and the department of health. There would be a number of places and students could bid for places. It would be expected that most students would stay within their home state but Northern Territory and Tasmania, which do not have dental training, would obviously be attractive to some.
CHAIR—What steps would you see are necessary to ensure that placement of the graduates is in accord with those areas of greatest need?
Prof. Klineberg—I think that would be clearly a local issue that each state or territory would need to identify. They know it now. The health departments know where the greatest needs are—they just have not been able to address the problem. We see this as one way of addressing the problem. They would know. They would determine those areas of need. In a sense, it is not so difficult—I am talking about New South Wales, in particular, which I know best. Rural oral health throughout the whole of the state, particularly further west, is in great need.
CHAIR—When you say further west, do you mean rural west?
Prof. Klineberg—Rural west.
CHAIR—Do you have any information as to how well such schemes have worked in any other countries that are like Australia?
Prof. Klineberg—The most notable example has been in the United Kingdom, where in order to enter a national health practice it is necessary to complete a vocational training
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 29
period. That period was voluntary for a year until the program was developed a little further. It has been compulsory since 1994. In 1998 the opportunity is available for two years—one in a practice setting, that is, a national health setting, and one in a hospital setting—before the graduate is then able to enter their own national health practice.
Because of the national health service, provider numbers, et cetera are only awarded under those circumstances in the United Kingdom. Notwithstanding the structural arrange- ment, the benefit to the new graduate and the benefit to the health system have been enormous, with this cohort of new graduates annually who are supporting, and being mentored and further trained within, the public health system.
CHAIR—Thank you.
Senator NEAL—Is the major objective of your scheme to improve the quality of new dental graduates, or is it to meet a demand in rural areas for dental health care?
Prof. Klineberg—That is a question that I am often asked. Clearly the focus is to meet a demand for oral health care, in that when students graduate they have satisfied the require- ments of the university and are therefore—currently anyway—registrable immediately. In the medical system the new graduate graduates but does not register until they have completed a period of internship in medicine. We are not looking at supporting the public hospital system, as medical interns do. We are looking at a rural focus and rural experience for our new graduates. That is why we have called it vocational training, but it is primarily to provide a cohort of graduates to do a job. In the process of doing that job they will become much more experienced in managing their own practice in the future.
One of the things that I wrote in my submission was the difficulty that there is in attracting young people to rural areas, for whatever reason—and not only dentists, I guess. Maybe veterinarians are attracted, but not dentists and not medical doctors. We see this as an opportunity that might change people’s minds, and they might become, as some have in the past, very attracted by the opportunities of living in country areas and working there.
Senator NEAL—I suppose the reason I asked the question is that this debate—not so much in relation to dentists but in relation to medical graduates—has been going on for some time. They have the same difficulty, of course—there is a shortage of young doctors in rural and remote areas. A number of similar schemes, to do with not so much the training component but variations on the general theme, have been proposed. Obviously some new graduates are not very keen on the proposition; in fact, some have gone so far as to suggest that requiring them to work in rural and remote areas is tantamount to civil conscription and a breach of the constitution. Do you have any views on that?
Prof. Klineberg—That is taking the situation a little too far. I had not quite imagined that it could have been taken to that extent. Clearly, for this to work, it needs to be a national program; it needs to be seen that each state supports it and that the Australian Dental Council, which is part of the working party, would support it. If that is the require- ment that new graduates have before they gain full registration, then that is what they do. As you say, there may well be protests initially. When anything different is introduced there
COMMUNITY AFFAIRS CA 30 SENATE—References Friday, 6 March 1998
often are. A protest could be offered by new graduates saying that they are being held back an extra year before they can go into practice.
What we are trying to do in education generally—Australia-wide, not only in my faculty—is to engender an interest in lifelong learning, the need not only to earn an income and support one’s family but to be committed to one’s profession and to maintain the highest standards. This is one aspect of that long-term commitment to clinical standards and service that I think young people, given the right opportunities, will accept.
Senator NEAL—What you are saying is that, really, you think the training component offers the most important aspect of this proposal. It is quite common. In fact, I would go so far as to say the large majority of professional graduates are required to do some sort of practical training before they are let loose on the public as it were.
Prof. Klineberg—Yes.
Senator NEAL—It is not such an unusual proposal.
Prof. Klineberg—No, but the fact is it has never happened in this country and I think it is extremely important. It is not so much to refine the training; it is to broaden their experience generally. Within a university setting, although dentistry, unlike medicine, is very much vocationally oriented and students as undergraduates, particularly in the senior years, spend a lot of time in clinics treating patients, it is fairly confined. They need to have an opportunity to experience the broader world and look at and see the broader community needs before they, as you said, are let loose on the public. I see it as working both ways. Clearly, it will benefit them in an educational sense but it will also allow us, through this program, to target special need groups. I think that is particularly important.
Senator NEAL—What proportion of this practical training course would you anticipate would have to be done in a rural or remote area?
Prof. Klineberg—If funding were available for a 12-month program, then at least six months would be part of that scheme. In fact, some graduates in some states may spend their whole 12 months. It would depend on how each state wanted to see the scheme work best for them but, to answer your direct question, at least six months.
Senator NEAL—Have you had any responses from any groups representative of young dentists or recent graduates—or even student dentists?
Prof. Klineberg—After working this up laboriously over some considerable time, it is only now in a form that we are happy about. Before it is discussed more widely in a formal sense, I am awaiting confirmation from the Australian Dental Association about their support. That will be clearly an important step.
It has been discussed informally with our students and they, in general, are happy with the plan. I think they would be concerned if it was offered to them as graduates without pay.
Senator NEAL—Thank you for that. I might hand you over to someone else.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 31
Prof. Klineberg—Thank you.
CHAIR—Would you envisage the cost of the scheme being shared by the states or would you expect there to be Commonwealth funding as well?
Prof. Klineberg—This is entirely proposed as a Commonwealth funded project. Already the states are stretched in their support for general health needs, including oral health. They would not be happy to be required to provide funds additionally for this purpose. That would then undermine whatever else they were doing.
I think the working party is very clear on the need for this to be seen as a Common- wealth initiative and hence to fit into the footprint left behind by the withdrawal of the Commonwealth dental scheme.
CHAIR—Thank you, Professor Klineberg. Senator Payne.
Senator PAYNE—Senator Neal referred to the requirements of other professions in this regard. They often require a period of vocational training; is it your understanding that that is Commonwealth funded?
Prof. Klineberg—Certainly medical graduates are in the teaching hospitals. I am not sure how many professions require this. I know law requires graduates to attend a period in the College of Law before they gain registration. I do not believe there is any other scheme for any other profession.
Senator PAYNE—Accountancy, I think, Professor.
Prof. Klineberg—I do not know. But, with respect, I think health is something special and—
Senator PAYNE—That is what the lawyers say, too, Professor.
Prof. Klineberg—No, the lawyers would say health is something special, I am sure. In terms of the health of the community, and both oral and general, there is a shortfall of personnel and funds to provide an adequate service. This is one way of partly addressing that problem. There is certainly not a shortage of lawyers.
Senator PAYNE—What would be the contribution, do you think, in the other direction from the profession then?
Prof. Klineberg—Do you mean support for the scheme or what?
Senator PAYNE—Support, financial, anything.
Prof. Klineberg—There would be a need if some of the vocational trainees were to take a period of training within a private practice. There would have to be private practices selected not only who were prepared, but where the principal was appropriately trained and willing to support such a program. There would be, I am sure, no difficulty in getting
COMMUNITY AFFAIRS CA 32 SENATE—References Friday, 6 March 1998
support from the profession in that regard, just as is the case in the UK where private practice and national health practice principals take on vocational trainees. In fact, I see the profession’s only concern would be that if it was not adequately funded, then it could not happen. I can see that would be their concern, as it would be mine too, but not the principle of it and not the support for it.
CHAIR—Professor Klineberg, one of the problems we have identified is the lack of dental services, both public and private, in rural and remote areas. If your scheme is predicated on the assumption that there be some sort of supervision or mentoring by either a private or public practice in rural and remote areas, don’t we have a bit of a chicken and egg situation?
Prof. Klineberg—There has to be a facility for this to take place in, clearly, and if there is no practice or there is no hospital facility in an area then it cannot happen. But, on the other hand, extra personnel in the work force can have a role to play even if they are based at a distance in one town allowing people to come from other towns. The hope would be not only that the extra pair of hands or pairs of hands would provide extra service but that, in doing so, these young graduates might be convinced that working in the rural setting is attractive to them.
The problem now is that everyone wants to come to the city where they think it is exciting and there are more opportunities. We have to take the initiative in trying to expose young people to alternatives because they do not all think that way. The majority do, and I would want to encourage not only those who come from rural areas to go back there, but also those who have never been to take an interest.
Just to digress a fraction, but I think it helps clarify the question, already during the undergraduate program, during the year, students spend a short term, usually a week, in a rural health centre—Wagga, Albury, Newcastle, Orange, et cetera—and they have a marvellous time. They come back glowing with excitement about what they have seen and done. During the long vacation at the end of December, students often take themselves off, quite independently, to different places. Some go overseas to New Guinea and to Fiji, but others go to rural far western Australia, often to the Alice Springs dental unit, and come back also with exciting stories of what they have done and what they have achieved. I think that it is just a matter of trying to encourage that.
CHAIR—Professor Klineberg, no-one argues with your worthy intent of encouraging students to go to remote areas or to even reside there in their professional life. It is just that the scheme you have been discussing for the last 25 minutes, as you said in answer to a question from Senator Neal, had an element of satisfying problems in rural and remote areas. We have just identified what might be a fairly significant problem that there is not already sufficient trained or experienced staff to supervise, teach, mentor, or whatever, new graduates. We might just invite you to give that angle further consideration because it might be a problem in the future.
Prof. Klineberg—Can I just say, not wanting to interrupt, thank you for those com- ments. We do not believe that is a problem, but it is something to be considered, certainly.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 33
CHAIR—Thank you for that, Professor Klineberg. Thank you for participating in this teleconference this morning. You have been most helpful.
Prof. Klineberg—Thanks, Senator Bishop.
COMMUNITY AFFAIRS CA 34 SENATE—References Friday, 6 March 1998
[11.12 a.m.]
FOLTYN, Dr Peter, Consultant Dentist, St Vincent’s Hospital, Victoria Street, Darling- hurst, New South Wales 2010
CHAIR—I welcome Dr Peter Foltyn, who will be giving evidence to the committee by teleconference. For the Hansard record, will you please state your full name, address, and capacity in which you are giving evidence today. The committee has before it your submis- sion. Do you wish to make any alterations to that submission?
Dr Foltyn—There are no alterations.
CHAIR—I now invite you to make a short opening statement and, at the conclusion of your remarks, I will invite members of the committee to put questions to you. I remind senators to identify themselves before they ask a question.
Dr Foltyn—Thank you for the invitation to participate in the teleconference. I make this submission on behalf of the dental department of this hospital. At this hospital, as I outlined in the submission, we are heavily involved in the dental care and management of patients who are medically compromised. I will not expand on the actual submission made, but I would like to state that I have just seen two patients in the last couple of days who are useful examples to add to the submission that has already been made.
One was a young man in his early thirties who comes from rural New South Wales. He had cancer in the facial region. For a number of reasons he had surgery prior to radiothera- py, but did not have any dental care at the time of the initial treatment. On Wednesday, I took out all teeth for him—32 teeth were taken out for a young man. The difficulty with something like that is that this is going to leave him without any teeth. Obviously, he needs to have dentures. The reason that we took all the teeth out here was the great concern that when he returned to his home—I think he came from Bourke—he would have had great difficulty accessing dental care related to his radiotherapy because dental care is still thought of as drilling and filling, the way dentists treated patients years ago.
What I tried to put in my submission was that times have changed; dentistry certainly exists as we know it, but the care of the mouth and, in particular, the soft tissues within the mouth, really need to be regarded as part of oral health management.
Another patient, whose dental model I have in front of me, is an elderly woman who has a cancer in the back of her mouth. Simply, what needs to happen to her is that her denture needs to be modified in such a way that the surgeon who is going to remove the cancer in the roof of her mouth can use her existing denture to obstruct or obturate the defect that he is going to leave. The difficulty is that there is nobody able to make that adjustment to her denture for her on more or less a free basis. This lady is a pensioner. The only person who provides that happens to be a dentist at the United Dental Hospital in Sydney. He happens to be on long service leave. So this woman who needs this dental treatment, let us call it, on medical grounds is going to have to pay for this herself even though this is part of her medical procedure.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 35
The thrust of my submission was on the basis that there needs to be something done for people who require dental care on the basis of health and where it is part of a medical service. The other part of my submission was that things have changed globally, and obviously in Australia as well—that is, people are living longer and the fact of living longer means that there are going to be more and more newer medications prescribed for patients. People who would not have survived 10 or 20 years ago because of their medical problems, such as people who now have heart transplants and lung transplants, are going to be on a whole range of quite toxic drugs. Many of these drugs cause major problems with oral health.
Last week we were referred a patient here at the hospital who had a kidney transplant. This lady was on a high level of a drug called cyclosporin, which is used to minimise rejection; it is an anti-rejection drug for the kidney transplant. But the side effect for a lot of the patients on high-dose cyclosporin is that there is major overgrowth of gum tissue. Hers is probably the worst that I have ever seen—the teeth have more or less disappeared in this sea of overgrown gum. The difficulty is that there is no mechanism for her to have this tissue excised, removed, by somebody with a dental background, because we are in the best position to do that, simply because it is a dental procedure and dentists are not covered under Medicare. She could certainly go to a surgeon—an ear, nose and throat surgeon, whoever—to have that done, and that would be covered by Medicare. But they would not have the same level of skill that a dentist would in excising oral tissue.
I would be quite happy to leave it at that and entertain questions by the panel.
CHAIR—Thank you, Dr Foltyn.
Senator NEAL—I do not want to get too caught up in the detail, but with your example of the lady required to have her dentures altered, isn’t there a state scheme that provides for dentures?
Dr Foltyn—There is a pensioner denture scheme, but the mechanics of that is for provision of new dentures. This is something specific in relation to her medical treatment. We are not talking about getting new dentures made for her. We are talking about using her existing dentures to provide a splint or to cover the area where she will now have a surgical defect in the palate, so it is not an obturator as such. There is a scheme for obturators, but those are for people who have had cleft palates. There is a Commonwealth scheme and there is something under the Medicare rebate schedule that covers specifically cleft palates. But this denture modification is purely in relation to the surgery that she is now going to have, which is going to be in three weeks time, and there is just no mechanism to actually accommodate her problem.
Senator NEAL—Are you advocating a Commonwealth funded scheme, similar to Medicare, for dental care or do you see it as only being limited to those fairly narrow situations that you have given us examples of?
Dr Foltyn—My submission only relates to these narrow examples. People in nursing homes come into that area as well, and we are going to see an enormous problem in the decades to come of people in nursing homes who have most of their teeth and who are going
COMMUNITY AFFAIRS CA 36 SENATE—References Friday, 6 March 1998 to need to be attended to. I think it could be either through an ex gratia mechanism or, as I have stated in my submission, maybe where there is the need for dental care when it is on prescription by medical personnel. I am not suggesting a ‘denticare’, if that is what you are referring to.
Senator NEAL—I suppose I have got the general feeling of who you are looking at. You are looking at elderly people in nursing homes—
Dr Foltyn—That is one category.
Senator NEAL—And the second category—how would you define that?
Dr Foltyn—People with specific medical problems that impact on oral health; or the reverse—the oral health complicates their medical management. For patients with head and neck cancer, very often the oral health is an integral part of their medical management; and, unless you get it right with removal of teeth or cleaning the mouth up, for example, patients who are having specific heart surgery can die. The mouth has to be clean.
I did not hear the interview, but apparently on Radio National on Monday there were some visiting English specialists here—or maybe the program was from England—and they made the statement that gum disease in particular is one of the major risk factors for patients with heart disease. In the past the importance of the mouth has been neglected. I am very concerned that not enough is being done specifically for people who need better oral health in relation to their medical management. So my submission is very narrow.
Senator NEAL—In terms of that second category, have you made any assessment of what size it is?
Dr Foltyn—At this hospital I only deal with medically compromised patients, so we do this with great frequency. I have a very large HIV-AIDS caseload, but there is specific funding for that. I do not think there has been a needs assessment. I would imagine that there would be a reasonable number of people in the community who have a range of medical problems that would come into this category: people with diabetes; people who have heart valve replacement surgery, or are candidates for that; transplant recipients. St Vincent’s Hospital alone has done over 700 heart and lung transplants in the last decade. Overall, I think we are still looking at a small number, but the effect on these people would be enhanced by having oral health covered by Medicare or through some mechanism whereby oral health care can be initiated by attending doctors.
Senator NEAL—Thank you very much.
Senator PAYNE—Dr Foltyn, I understand that you have said you are not looking at a denticare as such, but do you have any idea of what sort of money you are talking about in terms of funding for your group of patients that you have referred to?
Dr Foltyn—I have not even looked at that. The actual cost of it is not an area that I have investigated. We need to investigate it, certainly. I hoped my submission would really bring the problem to your attention. If you are interested or you feel that it is a valid area of
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 37 concern, then obviously we have to take that next step and assess the needs of the communi- ty.
Senator PAYNE—I am particularly interested in your work with HIV infected patients. Could you outline briefly the specific needs which they bear in this area?
Dr Foltyn—All people who are HIV infected need to see a dentist as part of their management. The reason is that, in the progression of HIV infection, many of the early signs and symptoms do occur in and around the mouth. We have things like thrush or oral candidiasis, which is a fungal infection and occurs in the mouth. The dentist is in the best position to identify the earliest sign of fungal infections in the mouth.
If one sees a fungal infection, it means basically that the immune system is further compromised. So if a dentist—or any health care worker—is knowingly treating somebody with HIV, we need to do that oral assessment so that we can monitor the clinical progression of the disease. A lot of patients, with the modern combination drugs that are available, are basically healthy and well; we expect they will live longer than we ever did before, but by looking in the mouth on a regular basis we are going to get an idea of whether the immune system clinically is further compromised. There are certain gum changes, and gum health deteriorates, in HIV infection.
The other key issue which is now cropping up in a whole range of areas is something called xerostamia, or dry mouth. For those of you who might have listened to the audio tape that I provided as part of my submission, dry mouth occurs when a disease affects the salivary glands. You have specifically asked about HIV. HIV affects the salivary glands— they may stop secreting totally. But salivary glands dry up when they are affected by a whole range of other illnesses and also by certain medication. If you have no saliva, it means food and debris stick to your teeth. Even vegetables and fruit develop food acids, and these stick to your teeth and lead to rapid dental decay.
People may have spent a lot of time and effort looking after their teeth but, if it is beyond their control—that is, their mouth is dry and it has become difficult to maintain oral health—they can end up with rampant dental decay around the root surfaces. That is specifically so for somebody with HIV who may have had a complete cessation of salivary flow. They can go from intact teeth to being a dental cripple in under 12 months.
So the management of dry mouth really is a preventative one and it is something that can easily be controlled by the use of things such as mouthguards, which are used for putting fluoride in, and oral hygiene instruction. These are areas for people with HIV certainly that must be regarded as part of their medical management. Simply manufacturing a mouthguard can avoid the breakdown of teeth.
You might think that avoiding the breakdown of teeth is not a medical issue but, if you have no teeth, your nutrition and diet suffers. If you loose teeth or the teeth are in terrible condition, it is very hard to be rehabilitated and get back into the work force. That certainly applies across the board to people with other medical problems.
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Specifically, dentists have to be involved in HIV because there are primarily a lot of changes that relate to the disease in the mouth. Some of the cancers in HIV, such as Kaposi’s sarcoma and lymphomas, occur in and around the mouth. With people living longer, with people with suppressed immune systems, we must expect to start to see more cancerous changes related to suppressed immune systems that will manifest themselves in and around the mouth. Every person with HIV needs to be examined on a regular basis to look at the current state of oral health, and to make sure that there are no nasties starting to appear in and around the mouth.
Senator PAYNE—Thank you. Just quickly, in relation to funding, you said that that was wrapped up in the general HIV funding.
Dr Foltyn—In New South Wales we have some specific HIV funding which supports a number of sessions per week at our hospital. That was arranged through the state govern- ment. It is not a federal government funding initiative. But I know that there are rural communities that are not able to access specific funding for HIV. We see many patients out of area because ours is the only facility where they can access free dental care.
Senator PAYNE—That is often the case for HIV treatment across the board, is it not?
Dr Foltyn—There is no specific dental funding for HIV across the board, no.
Senator PAYNE—Thank you.
CHAIR—Thank you. Your evidence has been most useful.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 39
[11.28 a.m.]
KINGSFORD SMITH, Dr Elisabeth Dell, Clinical Research Coordinator, Central Sydney and South Eastern Area Health Service, United Dental Hospital, 2 Chalmers Street, Surry Hills, New South Wales 2010
WILKINSON, Dr Ernest John, Director of Dental Services, Central Sydney and South Eastern Area Health Service, United Dental Hospital, 2 Chalmers Street, Surry Hills, New South Wales 2010
CHAIR—Welcome. The committee has before it a submission from your organisations, do you wish to make any alterations to those submissions?
Dr Kingsford Smith—Yes, there was a typographical error in appendix 4; I would like to replace that.
CHAIR—We will accept that change. I now invite you to make a short opening statement and, at the conclusion of your remarks, I will invite members of the committee to put questions to you.
Dr Wilkinson—Thank you for the opportunity to speak. Our specific submission was made on the basis of representing the experiences within the south-east and central Sydney. In those areas, there is about 20 per cent of the eligible population for the state. We provide a tertiary referral service and include one of the hospitals of the University of Sydney. We are not competent to speak for the full state; it is mainly on the experiences of our area in Sydney.
I would like to give you three pictures, if I may. These are three pictures over periods of time. The first one relates to the early 1990s, which is when the Commonwealth government recognised the needs of low income earners and other disadvantaged groups, and they broadened the eligibility for patients who were eligible for public dental care.
The result of that was that in New South Wales, there was a doubling in number of the people who were eligible for public dental care. We went from about 1.2 million in 1990 to about 2.5 million in New South Wales in 1992. That also represented in the areas that we represent an increase of about 118 per cent. Together with that, two other things occurred. One was that, because of the large numbers of recent arrivals who had greater need for dental care, it placed extra strain on the services. The other related to the geographic position of the United Dental Hospital, which is at Central Station in Sydney. Also, because of the pressure on the other state areas, it meant that a greater number of people were seeking treatment from our institution.
What happens when the task gets hard, as it has done over the years, is that suddenly we have to go back to relief of pain and immediate problem solving such as repairs of dentures or replacement of dentures rather than being proactive. This means that the backlog of active dental decay cannot be addressed, and certainly there were no opportunities for us to reach outside the walls of the hospital to address some of the community needs as far as dental disease was concerned.
COMMUNITY AFFAIRS CA 40 SENATE—References Friday, 6 March 1998
Then, as far as we were concerned, the lights came on. In 1994 to 1996, with the Commonwealth dental health program, it meant that we could, for probably the first time in our lives, start providing quality planned dental treatment for the patients that we were responsible for. It meant a 50 per cent increase as far as funding was concerned, and some remarkable changes occurred during that time. We were able to do restorative work and we started saving teeth. The numbers of extractions fell and the numbers of patients having extractions fell.
For the first time, we were probably starting to complete treatment for patients in a substantive way and we were able to start planning preventative programs as far as the future was concerned. We had never been able to do that in any constructive way in the past. We started targeting dental care programs for high risk groups in the community. We did surveys and we have provided for—specifically outreach models—service provision in certain areas. We have looked at homeless youth, people with mental illnesses, patients in boarding homes, the frail, elderly, medically compromised and so on. A whole series of programs were set in place during that situation.
Unfortunately, when the funding was cut, we had to revert again. What happened? The final picture, the third picture, is that the waiting times for general care have quadrupled. In our area they have gone from four months to 22 months. The size of the waiting list has doubled from about 17,000 to about 35,000, remembering that we see approximately 1,000 patients a day but that a large percentage of those these days are, of course, emergency patients. The waiting list numbers had been reduced to about 17,000. It is projected that they will go to about 35,000.
Dr Kingsford Smith—In June 1996 it was 17,000 and in February 1998 it was 35,000.
Dr Wilkinson—So there has been a doubling of the numbers and the actual time has quadrupled from four to 22 months. The net result of this is that change back to emergency care. One of the things we have noticed over the last six months is that 20 per cent of the time that we provide for emergency care now is actually being provided for patients who within the last six months have sought emergency treatment on a previous occasion.
This is a growing problem that is coming back to us in the sense that we are being requested to give more emergency treatment and these people are just rolling around the barrel because of the longer waiting lists. Of course, this is going to be a chicken and egg situation in that it is going to force more people on to waiting lists because we will not be able to get around to it. There has also been a reduction in the special needs programs and certainly the implementation of other special needs programs has had to be postponed.
Finally, just breaking away from those three scenarios, quite often the picture of dentistry is such that it gets separated from general health. I noticed Dr Foltyn made mention of one particular item. But it is interesting to see that, of late, research overseas—and the research he was referring to was research in the United States—is finding that there is a strong correlation now between chronic periodontal disease and heart attack because of an increased tendency towards clotting within the blood vessels. This is specific research that was just announced in the last week or so. There is no doubt that unstable blood sugar levels in persons with diabetes is directly contributed to by chronic dental disease.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 41
CHAIR—You said there was a high correlation. Is there a causal relationship?
Dr Wilkinson—At this stage I doubt very much whether it has got to the stage of actually establishing the causal, although they put it down to the fact that there is the effect of the bacteria as far as collagen is concerned, and this increases the possibility of blood clotting.
Dr Kingsford Smith—It is an independent risk factor. In their studies they controlled for things like socioeconomic group and age. It was presented as an independent risk factor. CHAIR—What does that mean—independent risk factor?
Dr Kingsford Smith—That means that it is not related to any other factors in the study. Things like gum disease are related to lower socioeconomic status due to lack of dental education, lack of access to care. But, once they had controlled for those, and removed all those other possible factors from the study by statistical methods, they still found an independent relationship between infection in the mouth and problems with atherosclerotic disease.
CHAIR—Right. But could not conclude that there was a causal relationship?
Dr Kingsford Smith—No. It was a contributing relationship to hospitalisation from needing more general medical intervention. It was the same with unstable blood sugar levels in diabetics.
CHAIR—Understood. Thank you.
Dr Wilkinson—Just to mention a couple of other medical diseases, one is that there is now research going into a proposition that chronic dental disease predisposes one to pre-term delivery for infants. Of course, there is the subject which is close to our hearts, the street kids and homeless youth. If their mouths are allowed to stay as they are you have literally got open wounds in the mouth. With the activities that they are carrying on as far as oral sex, et cetera is concerned, it leaves them open to various types of diseases—STDs, hepatitis A, B and C, and HIV.
The reason I am putting this is that it is a fact that, as far as dental disease is concerned, government funding, and many of the community, see dental as something separate from general health. But, as far as we are concerned, with the work that we are doing, I think that dental has to be included as a part of general health. One of the advantages of the Common- wealth dental health program as far as we were concerned was that it did give us an opportunity to look at many of these, and also to put in place a computer program, so we are now in the position to analyse many of the outcomes of the programs we have put in place. That is the reason why I have asked Dr Kingsford Smith to come down and speak. She has contributed to much of the submission. We are happy to answer any questions for senators.
CHAIR—Thank you, Dr Wilkinson. Dr Kingsford Smith, do you have anything to add?
Dr Kingsford Smith—No. I think that says it all in support of the submission.
COMMUNITY AFFAIRS CA 42 SENATE—References Friday, 6 March 1998
Senator PAYNE—Thank you both very much. If I could ask you a couple of questions in relation to your submission generally, in terms of the executive summary, at one point I think there was a suggestion that the Commonwealth is responsible for policy decisions, et cetera, in relation to dental care. Just to clarify that with you, how is it that the Common- wealth is responsible for policy decisions on who gets care when it is the states that actually deliver the services? Let us talk about the front end of things where states deliver services.
Dr Kingsford Smith—It is to do with eligibility, Senator Payne. Eligibility for public dental care is different from public medical care.
Senator PAYNE—I understand.
Dr Kingsford Smith—It is related to the holding of a health care card, and that is a Commonwealth responsibility for designating who receives a card.
Senator PAYNE—I understand that. If I could go to the next point in your executive summary where you indicate that, from your organisation’s opinion, there are insufficient funds available to address the issues that you have raised, what role do you believe that New South Wales health has to play in that?
Dr Wilkinson—I am not quite certain exactly how you mean? In terms of accepting the fact that the federal government has the policy in terms of eligibility?
Senator PAYNE—No, in terms of accepting the fact that the delivery of the services we are talking about here, particularly under the health partnerships, is a state and federal responsibility. What role or responsibility do you believe New South Wales health has?
Dr Wilkinson—As to the responsibilities that New South Wales health have, I cannot speak for New South Wales health in terms of policy, but they have provided funding over a period of time, and it is to that level of funding that we have been able to tailor the programs.
It is on the basis of additional funding that we have been shown the situation as far as the Commonwealth dental health program was concerned—in other words, it did contribute to an absolute need in the community in terms of the extra funding. It is on that basis that we feel that it is essential, as far as these eligible patients are concerned, that there be some contribution from the Commonwealth, particularly as we note that, say, in the early 1990s there was this recognition by the Commonwealth in terms of broadening of eligibility.
Senator PAYNE—So, Dr Wilkinson, you cannot tell us—and I understand you made this point earlier—what New South Wales health’s contribution is, and they have not told the Commonwealth either. Could you tell me from your perspective what the difference is between what you know was being spent on dental health in 1993, and perhaps 1997, at the end of the last financial year?
Dr Wilkinson—As far as I am concerned, there may be a change in real terms, but, as far as we are concerned, there has not been any withdrawal, particularly of funds, on an absolute basis.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 43
Senator PAYNE—One of the reasons I ask is this. When I look at the graph that you have presented to us as, I think, figure 2 in your submission on page 7, the trend line that you have inserted there in relation to, I think, adult general waiting lists before the introduc- tion of the CDHP is relatively flat. After the cessation of the CDHP, there is a much faster increase, and I just wonder if you could interpret that for me?
Dr Kingsford Smith—You note that the Commonwealth dental health program came in in the beginning of 1994. That flat trend was starting to rise. It was starting to rise from 1992 to 1993, Senator Payne, and it rose very steadily. For the first part of 1994 and, in fact, well into 1995, the funding was only just starting to come in.
We only had one full year of funding, and that was 1995-96. Initially, it was only emergency vouchers that were money for emergency care. So the full bite of the Common- wealth dental health program did not start to come in until some time in mid-1995. That rise was happening anyway, and only when the money from the Commonwealth dental health program started to roll through did we end up with a decline. We think that that rise is related to the increased number of eligible people—
Senator PAYNE—Right. I wondered if that was what it was.
Dr Kingsford Smith—And the time lag for those people to understand what they were actually eligible for and to access the services.
Senator PAYNE—In terms of funding levels, it is not entirely clear from the reproduc- tion of the graph, but you can probably clarify it for me. At the level 1993-94 versus the level 1997-98, can you tell me—and the reason I am asking is that the photocopying removes the colours; I think the shades are a bit blurred—
Dr Kingsford Smith—There are a few colours that are supposed to be there, too.
Senator PAYNE—That is all right. Can you tell me where those funding levels are—the 1993-94 in terms of millions, and the 1997-98 in total?
Dr Kingsford Smith—They are effectively the same.
Senator PAYNE—Right. If you then compare your waiting list levels and your waiting times, the waiting list levels double between the two, and the waiting times quadruple. Why is that if the funding levels are effectively the same?
Dr Wilkinson—What exactly has happened is that the waiting list itself is growing at a certain number—this is the net number of patients who are placed on the waiting list at the end of each month, say. But balanced against that is the number of people who are actually being taken off the waiting list. What we are finding now is that, because we have to move into the emergency mode, there is a larger number of dentists involved in emergency; plus there has been a gradual reduction in the number of dentists.
Originally, during the Commonwealth program, we had a full-time equivalent of 97 dentists working at the hospital; we are now down to an establishment of just on 76.
COMMUNITY AFFAIRS CA 44 SENATE—References Friday, 6 March 1998
Gradually, over a period of time, we have had to reduce the numbers of dentists back to the establishment it was prior to the CDHP. You find that it is not only the number of people going in but also the number of people coming off; and this is referring back to the point at which people were placed on the waiting list. Of course, this is getting further and further behind. Does that answer the question?
Senator PAYNE—Yes, I understand that. That is fine.
CHAIR—You say, on page 6, that the waiting time has more than quadrupled and the waiting list size has more than doubled, subsequent to the abolition of the program. What is the comparison like in the five years prior to the instigation of the program? Have there been increased levels of demand out there in the community for the services offered by the program, subsequent to the program becoming operational?
Dr Wilkinson—In terms of numbers? Would you like to answer that, Doctor?
Dr Kingsford Smith—We believe that the demand has increased out of all proportion to what it was before the program started. The level of dental awareness and of the rights that people had during that window of opportunity of the Commonwealth dental health pro- gram—either to be seen by us or to be given vouchers to private dentists in our communi- ty—was so great that people now have an enormous expectation that that is the level of care they ought to be getting. There is a considerable amount of anguish in the community when they understand now that those rights have been removed.
CHAIR—That would explain the significant increase in waiting time, wouldn’t it?
Dr Kingsford Smith—The waiting time really meant that there was no movement into general care for a year after the program finished. For every 12 months that passed, you could only take a few people off the waiting list; and so every 12 months the waiting time increased by about 10 or 10½ months. There is no direct correlation between waiting list size and the time you wait, when you cannot take many people off that waiting list.
Senator NEAL—So it was a very low through-put.
Dr Wilkinson—A very reduced through-put, compared with the numbers.
Dr Kingsford Smith—For a year, we could put no-one through except people we considered to be a very high risk when they came in for emergency treatment, and they always had to receive fast-tracked treatment—people in dire dental need. If people had a few, or even more than a few, problems but were not in this dire risk category, they would just go on the waiting list, because that is the most equitable way of dealing with it. It is first come, first served—except if they are in particular risk categories.
Dr Wilkinson—Just to give you an idea of the public’s perceptions of this, we did a survey just recently—on request—of some of the people in the triage areas, as far as the dental hospital was concerned. The indication was from the triage person that she sees in the vicinity of 200 or 250 patients per day. Most of the patients that come into the hospital
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 45 actually go to the triage desk first, before they go to other areas in the hospital—unless they have a very specific appointment made in one of the remote areas.
She said—and I would rely on her estimation—that about 50 per cent of the patients were aggravated to the point of almost personal abuse. Of those, only 70 per cent, at the end of the discussion, resiled to the point that they decided to apologise for their attitude. In other words, about 70 per cent of them were still intent on shooting the messenger, at that stage. So there is still a large degree of angst, as far as the community is concerned, in this area.
Senator NEAL—The submission from the Commonwealth department of health stated, not exactly clearly, that one of the reasons for the government terminating the program was that the program would have met its target of 1.5 million people—it actually says ‘people’, but they clarified that and said it was actually 1.5 million attendances—by December 1996. I assume both of you have been involved since the program was established?
Dr Wilkinson—Yes.
Senator NEAL—Were you aware of any understanding that the program would end, once 1.5 million people had been seen?
Dr Wilkinson—I might answer that. We have discussed this issue, because I know that it is an issue that does come up from time to time. These are only personal opinions. No, we had no understanding that there was particularly set in place a sunset clause with regard to this program.
Senator NEAL—The program finished in December 1996. When the agreement was originally signed, what date was it meant to conclude? Was it December?
Dr Wilkinson—It was due to conclude at the end of that financial year—which, I believe, was June 1997. But earlier, in May 1996, there was an indication to us that the provision of future funding would be limited to the supply period. There was an indication to everyone at that stage that the program itself was certainly under review, and I think it was at that stage that everyone started to look to what direction they should go in the future.
Senator NEAL—When the agreement was first signed for a period of four years, was it your understanding that that meant four years and then it would be over? Or were you of the understanding that, once the four years were concluded, there would be a review and a possible rollover?
Dr Wilkinson—There was no discussion with regard to it being the end of the program, as far as I am aware, in any of the discussions that I had at state level.
Dr Kingsford Smith—From our understanding, because we contributed to the evalu- ation, it was the evaluation that at the end of four years was to determine how successful the program was.
Senator NEAL—And the evaluation would determine whether or not it continued?
COMMUNITY AFFAIRS CA 46 SENATE—References Friday, 6 March 1998
Dr Kingsford Smith—That was the understanding that we had, and we made a significant contribution to that evaluation for those reasons.
Dr Wilkinson—As far as my understanding goes, it was not that the evaluation was with a view to the program ceasing, but that the evaluation was with a view to seeing what shape the program might take as far as future planning was concerned. Do you agree with that?
Dr Kingsford Smith—Absolutely.
Senator NEAL—There is some suggestion that I have heard from time to time— although it certainly was not supported by the department this morning—that some states had misused the Commonwealth dental health money and that that was a factor in the program ending. The department told us there was one occasion where Victoria had its funding cut for that reason—for not maintaining its present expenditure itself. Are you aware of any issues relating to states not expending the money they previously had spent?
Dr Wilkinson—Certainly not that I am aware of, as far as any of the areas I can speak for. It was not something that arose. As far as New South Wales was concerned, there was concern to make certain that there were no cuts to the program from the state point of view, so that it would not undermine the agreement with the Commonwealth.
Senator NEAL—In terms of the state government expenditure in its dental area, subsequent to the Commonwealth scheme being wound up, has it stayed the same or been increased? Are you aware?
Dr Wilkinson—As far as I am concerned, it has stayed the same.
Senator NEAL—Thanks very much.
CHAIR—Thank you, Senator Neal. Dr Kingsford Smith or Dr Wilkinson, on page 10, there are two photographs of some teeth. You make a reference there to the dental health status of persons participating in the joint department of immigration on-arrival accommoda- tion and the UDH program. Can you advise us of any numbers of newly arrived migrants or humanitarian refugees who participated in that program?
Dr Kingsford Smith—The program lasted for four months. It was one of the programs that, as the funding got to its full level, we could actually implement. These individuals had been coming into our emergency department because their needs were so great. We identified those needs and put a proposal to the immigration department’s Parramatta office for on-arrival accommodation, and we organised this streamlined program for them because we actually had the resources to do it. That got going in July 1996. Because of the budgetary constraints, it lasted only until September-October. At that time, in that three-month period, we had 110 people participating in that program. The majority were from Iraq and the former Yugoslavia, because they happened to be the groups that were coming in through the humanitarian program at the time.
CHAIR—Was there greater demand from the humanitarian side, as opposed to normal migrants?
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 47
Dr Kingsford Smith—Yes, Senator Bishop, principally because they have the same underlying health concerns, coming from the same regions as a lot of immigrants do, but overlaid on them are their deprivation, trauma and other issues—and certainly malnutrition. In a group of Iraqis that we saw was the 29-year-old woman shown in the top photograph, and they had been in a refugee camp in Saudi Arabia for the previous five years, where the only dental care that was available to them was an extraction in a chair sitting outside. The highlight of their time in that five years was going to the supermarket—which the Saudis had really kindly set up—where they spent the small amount of money that they had on Coke and sweet biscuits.
CHAIR—So that program had a life of four or five months?
Dr Kingsford Smith—Yes.
CHAIR—Was it essentially a Sydney based thing because of the large number of migrants here?
Dr Kingsford Smith—It was a United Dental Hospital based initiative, as part of the outreach programs that we were planning. I have just followed through on the outcome of that program and, for those 100 patients, over 70 per cent completed their treatment. They had an average of seven appointments each. The patient who had the most appointments had 20. They need an extraordinary amount of care. The woman shown in the top picture is 29, and she had two small children, both born in the refugee camp, and she was pregnant again. We had a time frame of about six weeks to get her healthy before she entered the third trimester, when we were not going to be able to do any treatment for her. She needed nine extractions. They were very extreme cases. I presented a paper at a research conference that compared them with emergency care patients from the United Dental Hospital in the same age groups, and they are statistically far worse off than the average emergency care patient, who is far worse off than the average Australian.
CHAIR—Thank you, Dr Kingsford Smith. There are no further questions. Thank you both for coming along and for being of assistance to us today.
Proceedings suspended from 11.57 a.m. to 1.07 p.m.
COMMUNITY AFFAIRS CA 48 SENATE—References Friday, 6 March 1998
SHORT, Ms Leonie Marjorie, Convenor, Oral Health Special Interest Group, Public Health Association of Australia, PO Box 319, Curtin, Australian Capital Territory 2605
CHAIR—I call the committee to order and I welcome Ms Leonie Short of the Public Health Association of Australia. The committee has before it a submission from your organisation. Do you wish to make any alterations to this submission?
Ms Short—No, I do not wish to change the submission.
CHAIR—I now invite you to make a short opening statement and at the conclusion of your remarks I will invite members of the committee to put questions to you.
Ms Short—Senators, on behalf of the Public Health Association of Australia I would like to commend you for initiating and participating in this Senate inquiry. The Public Health Association is delighted to contribute to the process of this inquiry and to be involved in such an important issue as the provision of public dental services. I would like to discuss five main issues.
Firstly, I worked as a school dental therapist in the Murray health region in the 1970s. In other words, I worked in a caravan drilling, filling and extracting teeth for years along the Murray River, and I realised then that I was getting nowhere and that other strategies would have to be used to complement the treatment of oral diseases. Therefore, we call for a balance between the promotion of oral health, the prevention of oral diseases and the treatment of oral disease.
We affirm that a public health focus must be taken in order to utilise scarce resources in the most efficient and effective manner. For this we need to move from that individual to a population focus, and for many clinicians, including dentists, this is a very difficult thing for them to do. We also need to move from an illness focus to actually looking at health, and we need to see oral health as part of general health. It is also strengthened through the adoption of a primary health care philosophy, which means affordable, accessible and appropriate health services close to where people work, live, love and play.
I will refer back to the Ottawa charter of health promotion. I could not be a good health promoter without raising this. I think we need to mobilise this so that oral diseases can prevented and minimised in the most cost-effective manner. These strategies are: developing personal skills; strengthening community action; developing healthy public policy; creating supportive environments; and reorienting health services.
In our submission we did mention some of these projects. We said perhaps we should look at the sales tax on toothpaste; perhaps we should look at the investment in fluoridation of water supplies; and we suggested lobbying with food and water manufacturers. I mean the sports drinks and things like that that are very detrimental to people’s oral health. In the submission we suggested the development of healthy school canteens and the advancement of oral health promotion projects.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 49
I know Dr Peter Foltyn spoke to you about his excellent projects, and my respected colleagues from the Central Sydney Area Health Service are at the leading edge of these programs in Australia. I should mention also the program that I was involved with at the Moree Plains Shire Council with the Aboriginal communities.
We also need to link in with programs to combat diabetes, cardiovascular disease and injury. We need to work with teachers, Aboriginal health workers, local governments and dental supply companies. We need to have advocacy and mediation with consumers. We also need to do our clinical prevention, and we also need to do our treatment.
The Public Health Association has the expertise and is willing to assist in the planning for the provision of public dental services in Australia. Thank you.
CHAIR—Thank you, Ms Short.
Senator KNOWLES—On page 3 of your submission you say: The CDHP was not without its problems or detractors.
Would you care to expand on that a little bit more please?
Ms Short—One of the problems for us was that the CDHP really concentrated on treating disease and not on the promotion of oral health or the wider prevention of oral disease, so it was that treatment focus that we would criticise.
Senator KNOWLES—And how about the detractors?
Ms Short—The people who did not participate? At the start of the program there were a lot of people who said they would not, but at the end of the program there were many dentists participating. From my experience living in a rural area—I have lived in rural areas for a third of my life—some of the private dentists were not used to the type of person, the patient, who was coming to see them.
For example, people were coming to see them through the CDHP with poor oral hygiene and a lot of work that needed to be done. For a private practice person in some areas, this was unusual and they found it difficult to deal with these people. In some research I did with Professor Charles Kerr at the University of Sydney, some dentists even referred to these patients as dirty and unhygienic members of society, and those sorts of statements I find disturbing.
Senator KNOWLES—The participation rate was very varied. I think it was 90 per cent in South Australia and down to 25 per cent here in the ACT, and totally unknown for Queensland. It was very mixed. Do you put it all down to your description that some were reluctant to participate because of the nature of the work?
Ms Short—A lot of it was to do with ideology—I am a sociologist—and some private dentists saw it as a sort of socialised dentistry coming in the back door. They were a bit hesitant to participate from that point of view, but once the scheme got going and dentists were participating I thought it took on a much better approval rating and now the ADA—
COMMUNITY AFFAIRS CA 50 SENATE—References Friday, 6 March 1998 they spoke to you this morning—would probably be supporting a scheme, not the same as what we had before but some other scheme.
Senator KNOWLES—On page 4 your call for action seems not to want the CDHP restored but to seek a new program. Am I right in believing that in your submission you see the Commonwealth as having a leadership role through the National Public Health Partner- ship?
Ms Short—Correct. We do not need all specific oral health programs; we can actually link in with other programs that are already running, for example, in Aboriginal health, diabetes, injury, et cetera. So, when all these funding arrangements come up between the Commonwealth and the states, I think we can slot the oral health into those other programs with perhaps some specific oral health. They are public health strategies.
Senator KNOWLES—In that process do you believe that the states should maintain the main carriage of the service provision?
Ms Short—Probably the service provision, but I see the direction, monitoring, surveil- lance and policy direction coming from the Commonwealth. We have an unusual state of play at the moment whereby we do not have anyone really doing any oral health policy in the Commonwealth.
Senator KNOWLES—The way in which it has been effectively run for 93 out of 98 years is the general direction that you think should be actually happening?
Ms Short—But I think we need somebody at the Commonwealth level. They could even be contracted to work. It may not have to be a full-time position, but I think we need some policy direction at the national level.
Senator KNOWLES—But through that national health partnership?
Ms Short—Yes, and linking in. We need to link oral health in with other health issues. We cannot have it on its own.
Senator KNOWLES—Have you been approached at all by Lawrie Groom and Associ- ates on this issue, acting on behalf of the dental health services in Victoria?
Ms Short—They asked the Public Health Association and Australian Council of Social Service to participate in their seminar in Melbourne in January, which we did. We were not a co-sponsor, but we were represented there.
Senator KNOWLES—Do you believe that the concerns that you have expressed would really be overcome if there was a greater financial commitment from the state and territory governments to the whole process?
Ms Short—We need a financial commitment to get that policy work and programs up, but I am confident that we will tackle the issue of unmet need and demand in oral health through more prevention and promotion. If we just did the treatment, we could be treating
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 51 and treating, just like I did in my caravan along the Murray River. It did not work for me in the seventies and I do not think it will work for me in the nineties.
Senator NEAL—We always have that constant debate about whose responsibility it is, state or federal. A lot of people in the community really do not care where the money comes from so long as the problem is dealt with. I suppose that is a fairly natural approach. Do you think that the Commonwealth government is in any way in a preferred position to play a leadership role in oral health than the states, and if so, why?
Ms Short—Yes. I think the Commonwealth can see the overall picture, and particularly the data collection, surveillance and policy, but I think it is up to the states to actually implement it. The states do implement oral health services or dental services in different ways. For example, Queensland never contracted to private practitioners for the Common- wealth dental health program. It was all through the public sector. People would not even know the words ‘Commonwealth dental health program’ in Queensland. I think we can still have those state differences, but I want some actual directions.
Senator NEAL—Going back to a minor point that was raised before, to some extent that explains the differing rate in the private dental participation scheme—because, as you say, in Queensland they never used private dentists.
Ms Short—That is right. It was solely put into the public sector, yes, for the employ- ment of more public sector dentists and equipment. There were no private dentist people in Queensland.
Senator NEAL—What sort of programs in terms of preventative oral health do you think the Commonwealth could run?
Ms Short—I am very interested in the care for older adults, and I presume that Dr Peter Foltyn would have spoken about that this morning. In particular we have dental therapists— like myself—and dental hygienists who could be employed very efficiently and effectively to work with older people in their homes, in hostels and nursing homes. That could be a wonderful strategy—doing some prevention and promotion with those older people. Again, I would go more to ethnic communities and those sorts of groups. We cannot keep justifying therapists working solely with children anymore. We need to be more multiskilled.
Senator NEAL—Why do you say particularly elderly people?
Ms Short—Probably the greatest threat to somebody’s oral health is their ability to pay for good food and dental services. Therefore, I think poverty and unemployment are the biggest threats to oral health. Therefore, when I think of poverty, I think of older people, unemployed people and sick people. They are the target groups. When I look at young people and see them with badly decayed front teeth, some of those young people with badly decayed front teeth will find it very difficult to find employment.
Senator NEAL—I am playing devil’s advocate a bit, but a lot of people might say, ‘So what? An elderly lady has not got perfect teeth. Is that really a problem?’
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Ms Short—I was privileged to work on a National Health and Medical Research Council grant in rural New South Wales a few years ago and it was in nursing homes, hostels and day care centres. For these people, ill-fitting dentures, painful teeth or abscesses meant that they could not chew their food properly. They were not smiling. They were eating their meals in their room instead of eating in the shared dining room. It is a very big factor and it affects their quality of life.
I would argue very strongly for these people to have socially well functioning teeth or dentures. It is very important for the older people.
Senator NEAL—I have one last question. Since the Commonwealth dental scheme has finished—and we heard evidence earlier today that they are really back to doing just emergency work—what happens, in your experience, to either those elderly people or health cardholders who cannot get into that scheme anymore? Do they go somewhere else?
Ms Short—They do. They go to general practitioners and outpatients for pain-killers and antibiotics. It would be very interesting to try to explore some system whereby there were some referral patterns from outpatients or from GPs to dental providers.
Senator NEAL—But are they going anywhere else for standard dental car, like checks- ups and cleaning?
Ms Short—What actually happens when your income drops is that the regular check-ups drop off also. You only go for the toothache and the extraction.
Senator NEAL—If you are in pain.
Ms Short—In fact, when I did that rural health work with Professor Charles Kerr, one of the dental providers said, when she could not believe that they were not going for their regular check-ups anymore because of the drought and the rural recession, ‘They don’t just feed their cattle when they are hungry, do they?’ In other words, you have to give cattle food regularly, like you go to the dentist regularly; you do not just go when you have got a toothache. I think that sums it up well.
CHAIR—Are the oral health care needs of the community changing and, if so, how?
Ms Short—Yes, they are changing because more people are retaining their natural teeth. When Dr Alan Patterson and I did that work in the nursing homes and hostels, we inter- viewed the registered nurses working there and some of the nurses said it was actually easier if people had their teeth extracted before they entered the nursing homes, because it was easier for the nurses to clean dentures than it was to clean people’s natural teeth. That was quite shocking to us, but I can understand where they were coming from. We have actually got these personal care assistants and nurses who are saying that. For somebody like me, who is 42, the thought of having my teeth that I have looked after for 42 years extracted upon entering a nursing home is just frightening.
Senator KNOWLES—You are not ready for a nursing home yet.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 53
Ms Short—No, but just the thought of it in 30 years time. My mother has a lovely set of teeth. They are heavily filled, but she has all her own teeth. I am concerned. I want somebody to be able—whether it is in her home or her nursing home—to provide some of that care. We can do that with therapists and hygienists.
CHAIR—What particular oral health care needs are currently not being met? What do you identify as a priority?
Ms Short—Older people and unemployed people. Then we also have Aboriginal communities, migrant communities and people who are medically compromised. They are the ideas and, if the Commonwealth was to going to be involved in some programs, it would be those target areas that I would go for.
CHAIR—On page 4 of your submission, you refer to four things you would like to see in future public dental care: a voucher scheme, vocational training for new dental graduates, increased training of auxiliary staff and priorities for high need groups. Can you describe how you see each of these operating and what would be the benefits and costs as well?
Ms Short—Training auxiliaries would be the therapists and hygienists with their expanded role working in nursing homes and hostels. With the priority groups, it would be the older people, unemployed people and people in rural and remote areas. What were the others?
CHAIR—The voucher scheme and training for new graduates.
Ms Short—Training for new graduates refers to an idea that is being well accepted at the moment. After you finish your dental training, you have an internship for a year. That means that the public sector dental work force would actually have more dentists there to work with. For myself as a dental therapist, when I trained with the health department, I was bonded for two years. That is why I ended up along the Murray River from Tumbarumba to Wentworth in my caravan.
However, I was a brand new graduate doing quadrant dentistry, for example, four fillings at a time on each child. It was an enormous amount of work for a brand new graduate. It was sink or swim. I would not really like to put new graduates in the position in which I was put at that time. If we were going to send brand new graduates out to challenging areas—whether it be geographically or with particular populations—we would need to support them a little bit more than I was 20 years ago.
The last point that you raised was the voucher schemes. That might be a way of people trying to access public dental services. The one that I am particularly interested in is the link between general practitioners and outpatients going for pain relief.
Just to sidetrack a little bit, friends of mine who are GPs say that they sometimes get people who want drugs coming to their surgeries. Quite often they will say that they have got a toothache and they will need these prescription drugs. They will open their mouth and they will have a bad hole there. Sometimes the GPs will just write the script, but others will say, ‘Just go to the dentist.’ It might even cut down on illegal pharmaceutical drug use as
COMMUNITY AFFAIRS CA 54 SENATE—References Friday, 6 March 1998 well, because for some people who are drug dependent, it would not be unusual to have a bad tooth in their mouth anyway. So I am interested in that link with the GPs and outpa- tients for pain relief.
Senator FORSHAW—As I understand it, on the one hand the quality of people’s teeth, particularly younger people today, is measurably better than it was when I was a young child. It has a lot to do with fluoridation and that generation coming through. However, on the other hand you have a lot of dietary habits today that are not necessarily as good as they may have been in years gone by. There is a lot more fast food now.
I know that this is very general. I asked an earlier witness and he confirmed that, particularly with younger children, there is a greater emphasis today on orthodontic work, braces and all that sort of thing, which is very expensive. And there is less emphasis on just filling teeth or pulling teeth out, which was the norm when I was a kid. Do you have any views or suggestions as to how we assist particularly low income people—which is one of the terms of references of this inquiry—to have access to the more expensive type of dental work which is increasingly becoming necessary, or deemed necessary, for younger children to ensure that they do not go through life with crooked teeth, bite problems or jaw problems that years ago were just allowed to exist.
Ms Short—Your comments are spot-on about the majority of children’s oral health being much better—except in Queensland. We have the worst teeth in Queensland and Brisbane is the only city without fluoridation.
Senator FORSHAW—We do not have fluoridation.
Ms Short—I suppose that is why I am up there working. It is the biggest challenge for me. That issue about the orthodontic services is one that many health services, and probably my colleagues here, will have to contend with each day. From a public health perspective, if there was limited money and I had to look at the opportunity costs, I would not put it in orthodontic services.
Senator FORSHAW—I was not necessarily suggesting that that is where it goes, and I appreciate that point. But it seems to me that we are getting a trend to that type of dentistry becoming more prevalent.
Ms Short—Just to clean somebody’s teeth or to do a little filling for somebody, or just an examination—there is not much money in it for a private practitioner. For orthodontists, there is a lot more money in that. From a public health perspective, I am looking at basic, good oral health for the majority of the population. So I am probably not the best person to answer that question. It is a difficult problem.
CHAIR—Thank you, Ms Short, for coming along and giving your evidence this afternoon. I understand that you will stay on to continue giving evidence with the next group of witnesses.
Ms Short—Yes, thank you.
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 55
[1.33 p.m.]
BROWN, Ms Margaret Irene, Chairperson, Health Consumers of Rural and Remote Australia, PO Box 280, Deakin West, Australian Capital Territory 2600
FOLEY, Ms Michele Anne, Project Officer, Health Consumers of Rural and Remote Australia, PO Box 280, Deakin West, Australian Capital Territory 2600
GREGORY, Mr Gordon, Executive Director, National Rural Health Alliance, PO Box 280, Deakin West, Australian Capital Territory 2600
CHAIR—Welcome. Ms Short, do you have any comment to make on the capacity in which you now appear?
Ms Short—I am a coopted member as someone who has done some rural oral health research.
CHAIR—The committee has before it submissions from your organisations. Do you wish to make any alterations to those submissions?
Mr Gregory—We do not, thank you.
CHAIR—I now invite you to make a short opening statement and, at the conclusion of your remarks, I will invite members of the committee to put questions to you.
Mr Gregory—Thank you, Senator. We propose, with your permission, to do it in three sections if we may: first of all, a brief submission from Margaret Brown, then one from me and, finally, one from Leonie Short.
CHAIR—Certainly.
Ms Brown—Thank you for the opportunity of coming here today. Our organisation strives to ensure that people living in rural and remote Australia have the opportunity to have input and to have a say, so this is one such opportunity. We believe that Australians’ basic right is to have dental services which is affordable and accessible. Ready access must be available specifically in times of crisis and on an ongoing basis for preventative treatment and care. I believe that this really is a vital issue, particularly in the more remote areas of Australia.
I will just cite you an example which I was told yesterday. One particular family living on a station between Port Augusta and Alice Springs at this very time have a child with an abscess. The nearest major town is Coober Pedy, which is 350 kilometres away but is unable to retain a dentist. The health commission in South Australia, in conjunction with the RFDS, have a monthly allied health fly-out from Port Augusta, and that used to include a dentist, but at this stage they cannot provide that service either because of the lack of dentists.
There is a dental technician in Port Augusta, which is 900 kilometres away from this particular station. So just giving you the picture, you have a child who is in a great deal of
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pain; yet the distance to travel to access the service is really quite incredible. And I do not think that people realise sometimes the circumstances that these families are in.
You may well say that, as I have been told before, this is a state issue, but if that is the case then people in the community need to know. One of the things I have been noticing lately is that people do not know which things the state or the Commonwealth is responsible for. So I think that somehow we need to get that information out too.
We believe that the Commonwealth, in collaboration with the states, should subsidise a quality dental health care program and that a thorough investigation of the gaps in the dental program should be made, and then programs targeted to meet the needs of people in rural and remote Australia.
I know Leonie was talking about preventative care, and I believe that when we look into the services in rural and remote Australia we also need to find out whether there is a preventative health care program going through from family day care right through kinder- garten and the schools, because nutrition and preventative health have a great deal to do with the care of people’s teeth.
I think that is where I will end. I just believe that people need to be aware that there are no 24-hour services; there is no crisis care when there is an accident or anything like that. Like most people, I would have to travel 2½ hours from where I live to obtain any sort of dental care. I am not knocking the really remote but I am isolated. So it is an issue.
CHAIR—Thank you, Ms Brown. Mr Gregory.
Mr Gregory—Thank you, Senator. The National Rural Health Alliance is the peak non- government body for rural and remote health. It comprises 19 member bodies, each of which is a national organisation in its own right.
The alliance represents both consumers of rural health services and all of the major professional providers. I should add, however, that we do not yet have specific representation on the membership of the alliance of dental professionals in rural areas, and that is why we are very pleased to be able to collaborate with people such as my colleague Leonie Short in activities such as this.
The alliance has a very broad definition of health and is interested in social and economical determinants of health status as well as in health policies and programs more narrowly defined.
Overall, the status of rural health is worse than in the major cities. In general, the more remote the individual, the worse his or her health is likely to be. This situation is exacerbat- ed by relatively poor access to health services, few options, higher costs and an adverse cultural approach to health matters in country areas. Poverty is one of the strongest determi- nants of poor health overall.
The NRHA supports the submission made in Melbourne in January 1998 by the Australian Council of Social Service. Those in rural areas who are poor are doubly disadvan-
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 57 taged. As with other aspects of overall health, the majority of oral and dental problems could be significantly reduced or prevented with appropriate care and early treatment.
The Commonwealth dental health program was clearly meeting a need for people on low incomes, including many in rural and remote areas. Evidence from Western Australia is that the CDHP was available to about 100,000 people in rural and remote parts of that states. Since its termination in December 1996, the number of people in country parts of Western Australia eligible for subsidised dental care has fallen to 65,000. In most other states, the situation is even worse—that is, even worse in terms of the number of people who now have access to subsidised dental care. It is very small in other states, with the exception of Queensland.
There are already a large number of challenges for governments in rural and remote health. Most notable among these are: improving indigenous health; providing mental health services to country areas in a time of widespread deinstitutionalisation; care of the elderly; securing an adequate supply of well trained health professionals; and providing continuity of acute care in an environment of overall cost savings and rationalisation. All of these are important but complex issues with which governments, community groups and professional organisations are currently grappling.
There is an opportunity for Commonwealth and state governments to collaborate to broaden the availability of dental health services for needy people, and the previous program shows how this can be achieved. The NRHA therefore hopes that the major political parties will both use their electoral platforms to announce a new program to meet this urgent and fundamental health need. The National Rural Health Alliance also supports the broader long- term proposals, including those relating to the oral and dental health work force and to health promotion presented to the inquiry by the Public Health Association of Australia.
CHAIR—Thank you, Mr Gregory. Does anyone else have anything to contribute at this stage?
Ms Short—Yes. I would like to just build on what Gordon Gregory has said. Particularly when I have worked in the public health field, we have seen many incentive programs there for medical practitioners. The lobby groups like the rural doctors association, rural nurses, et cetera have done a good job, but there is still a lot more to be done to highlight the issues and the disadvantages that our rural consumers face. However, the Commonwealth has actually set up many programs for medical services. We have got general practice evaluation programs. We have got general practice rural incentive programs. We have many RHSET— rural health support education and training—programs for medical and nursing and allied health professionals. Only about two or three of these RHSET programs have actually been for oral health.
The Commonwealth government invests millions—and I think the general practice evaluation program might be over $1 billion now—in particular programs to improve general medical practice in Australia. There are specific programs for rural medical practice. I am calling on the inquiry to consider similar programs to improve rural dental practice to help support the rural oral health work force and to support those rural oral health workers out
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there throughout Australia. So it would be on very similar lines to what the Commonwealth is already doing for general medical practice.
CHAIR—Thank you, Ms Short.
Senator KNOWLES—As two senators who come from Western Australia, we sympa- thise and empathise with you a lot in terms of the difficulties of remote parts of Australia. I noticed, Mr Gregory, that you said that the more remote, the worse the health, and that that can be addressed with appropriate care and early treatment. I do not think anyone would disagree with that philosophical position. How do you believe that that can be best deliv- ered? If you like, you can treat it even as a more general question and not just relating to dentistry. No-one would say that in an ideal world we would not want access by rural and remote people to every single, solitary service facility that someone would have in a metropolitan area. That would be the ideal world. But it comes down to what Ms Brown was saying about her son: no-one would want a child to go through what your son is obviously going through at the moment. How do you see that we would be able to deliver better services to rural and remote areas, and at what cost?
Mr Gregory—Thank you, Senator. I have three comments. First of all, on health promotion, the alliance believes that we have yet to find out the best means of implementing health promotion in rural and remote areas. In other words, it is clear from the national rural public health forum which the alliance organised in Adelaide last October that there are some good things going on in country communities related to health promotion. It does not matter how small a community is, if they have the right characteristics of leadership, ability, activities, options and perhaps access to telephone calls for up to maybe a couple of hundred dollars, they are able to involve themselves in useful health promotion activities. The challenge for governments is to try to find out how the communities do this and to support them and foster them in health promotion activity which will succeed in having individuals and families, however remote, looking after their own health better than they are currently doing it.
Secondly, in relation to health promotion campaigns, Australia has a good record of health promotion campaigns on a number of selected fronts. The alliance believes, however, that there is some value added to be gained from those campaigns in rural and remote areas. In other words, however successful the campaigns have been, whether we are looking at immunisation, smoking or HIV-AIDS, there is a positive suggestion that they could be tailored, perhaps at the edges, to fit better with the circumstances of rural and remote areas.
Senator KNOWLES—But how do you suggest that that is done?
Mr Gregory—The first thing to do is to ensure that the people designing, evaluating and managing the program talk to the people out there in remote areas and understand the real characteristics of remote communities. Let us talk about the remote ones because they are the most needy if you like. We need to ensure that there is good communication. Currently, the situation, as you would well know, is that remote people are deprived, not only in terms of health services, but in terms of access and information. It costs a lot more for an agency of health or any other to genuinely collaborate with a remote community than it does with a metropolitan community. But that is a cost which the alliance believes has to be borne.
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Senator KNOWLES—Do you think that the role of the Internet, for example, is going to be greater and enhance what you are trying to strive for in the foreseeable future? I realise a lot of people in the country are not on the Internet.
Mr Gregory—That is exactly the point. The alliance regards electronic communications as being a double-edged sword. It is certainly enhancing the ability of people who have access to communicate, but as you have just said, Senator, there are large numbers of people who, through no fault of their own, cannot access because of the quality of the telephone line or whatever it is. While we are dependent upon landlines, we have to be very careful, in the alliance’s view, that we do not actually increase the bipolar situation in terms of information communications. It would be a mistake, the alliance believes, to push all of our information and all the results of our research down the wire because it will make the position of those who do not have access to the wire even less equitable than it is currently. But, yes, there are some good things happening, as we all know, in telehealth. I guess the big breakthrough for the people with whom you are concerned in remote areas will be when we escape from landlines of copper wires or whatever they are made of.
Ms Short—Many years ago at a rural health conference in Armidale that I was attend- ing, the head of the Country Women’s Association got up and said that the two things we want for rural health are a telephone line and a sealed road. I do not think much has changed today.
Senator KNOWLES—I think much is changing. I think we have seen a lot changing over the last four or five years in particular but there is still a long way to go and anyone would have to recognise that. I know that these questions are far more general but, consider- ing the Democrats called the thing on just dental health and they are not here, I thought I would just actually come across and—
Senator FORSHAW—We have got that on the record.
Senator KNOWLES—They put us through this but they do not turn up. I have a longstanding interest in health care issues, particularly in rural and remote areas, and that is why I am asking you these general questions, so could you forgive me for that.
I still want to know where you are directing your efforts as to the best way we can deliver those services. It is worrying me. Forgive me for personalising it to Western Australia. If you look at remote areas in the Kimberley like Halls Creek and Fitzroy Crossing, then you come down to areas in the Pilbara and in the desert and if you get out to the goldfields and so forth, those people are squillions of miles away from anywhere.
You are the people who are really focusing on this all the time and I am interested to know how you suggest we get that up-to-date information to people. I think prevention matters are as important as anything else. From my trip through the Kimberley and so forth last year, I understood that there was more information getting out there than previously.
Ms Brown—One of the things that we use is the local media. A lot of the schools and things like that have school newsletters that go out. Sometimes the local hospitals or community health services have their own little bulletins. In South Australia where I live
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there are the stock journal and the farmers papers and we use those too because the farmer does not read anything else. The whole family seems to read these to see where the cattle sales are and all the rest of it. If you slot them in there, they often pick them up. We also use local radio.
Senator KNOWLES—Are you suggesting that government should be involved in that more so?
Ms Brown—Yes, I think so. I think everybody should be. I do not think that it needs to be an organisation. I think that we are all concerned with these issues, so therefore we all should be doing something about it.
Mr Gregory—An important general response to your general question is that the alliance observes that whenever you look at a recommendation for improving rural and health services, somewhere in its preamble there will be the statement, ‘It is critical to involve the local community in the design, evaluation, implementation and management of the local health service.’ We all believe this and it is usually encapsulated through the use of the term ‘a community development approach’ and it works for even the most remote area. But the alliance believes that we have not yet gone sufficiently far down the track of actually establishing what this means for government agencies. We have not established what this means for professional organisations.
It is lazy—I guess that is a fairly emotive word—or it is a mistake. It is insufficient— that is a better word—for us to say we have got to involve the community without enabling the community to be involved and working out what it means from the central end. In other words, what does it mean for the Perth agency or the Rural Doctors Association of Western Australia to engage actively in the community development approach to new health services? This is just as applicable to oral health and dental health as it is to women’s and babies’ health or whatever.
What the alliance would like to see is all of us working together to find out how we do this. The last part of your question, a long time ago now, was costs. There is a significant cost involved in this community development approach but the long-term result is beneficial because if you can get the community involved, you, as it were, look after health promotion and you also will have a better program. You will have a program that you know fits. There is an up-front cost in terms of doing it this different way but, in the long term, the alliance is sure that this is the best and most effective way to go.
Senator KNOWLES—I have never seen a decreasing wish list; that is human nature. I have never seen a decreasing wish list where people are saying, ‘Look, we need to ration but get a broader mix, say, for example of specialists or dentists or whatever coming through country towns.’ I have been in the Senate for 13 years and every time I go to a country town, nothing has changed in the response that you get. People say, ‘We want more dentists and more specialists to come through.’ We know the practical problems of that.
Mr Gregory—The key phrase you mentioned is ‘coming through’. In other words, it is the way we design our mobile outreach services: they have to be funded; they have to be collaborated so they go together. In other words, we all know that there are some crazy
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examples of outreach services going to Halls Creek. I am not being intentionally critical of the Western Australian government, but I bet you if you go to Halls Creek you will find that there is an imperfect collaboration between those services and agencies which visit. That is clearly one area where we could save some money immediately.
Ms Short—For example, the dentist going along with the Royal Flying Doctor Service, working together. Instead of the dentist flying in, extracting all the teeth and flying out with the teeth in the bag—which is what happens—we actually want the community working there. The debate in the inquiry might be about federal and state governments; if you were to ask me, it is about local governments.
Senator KNOWLES—Does the tooth fairy fly when the ambulance does?
Ms Short—They are really good things to think about—good work, Senator.
Senator KNOWLES—I have one final question that I would like to ask both Mr Gregory and Ms Brown. Have Lawrie Groom and Associates, acting on behalf of the Dental Health Services of Victoria, contacted either of you?
Mr Gregory—The National Rural Health Alliance has been contacted by them, yes.
Ms Brown—No.
Senator KNOWLES—Thank you for your latitude in allowing my questions across a broad range, Mr Chairman.
Senator FORSHAW—Can I rely on the same leniency from the chair and also take some latitude here to pick up on some of the issues that Senator Knowles has raised, because the discussion about the problems of access and distance is very important here?
CHAIR—Not as much, Senator Forshaw.
Senator FORSHAW—It seems to me from my experience and contact with rural and regional areas—and that is essentially in New South Wales, but also in other states—that a lot of this is driven by where the local council or local government entity is located. I am not necessarily talking about a state like Western Australia which has those huge distances— New South Wales has some fairly isolated places—but you have that and you also have the problem of where the public hospital is located. As you get further away from the town where the hospital is or where the local council is, the problems get greater.
The point I wanted to then raise is that for instance in New South Wales you have area health boards. It seems to me, at least, that maybe a lot of the focus is always on what are the hospital services and what are the problems with the hospital services—and that is important for dental health, of course. Do those area health boards in New South Wales or the equivalent in other states focus on the needs in dental care, or are they spending all their time on GPs and specialists and medicine?
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Ms Brown—In South Australia we have not had regional boards for all that long, so they are going through an awful lot of internal things, and also the smaller hospitals that are sort of on the outside of the spoke of the wheel are feeling very isolated and not like they are all part of that regional concept yet. But no, there isn’t any thought in respect of dental care.
Senator FORSHAW—I can see that the issue, say, in a town where you have problems of not enough GPs, or no GPs or GP services, always relates back to the hospital system, but dentists do not necessarily relate to the hospital system and that is what I am trying to get at.
Ms Short—In New South Wales, with the area health boards, dental services—as they are called—would come under the community health sector in community health centres, and the dental clinics were either at schools, for the children, or are now in hospitals or com- munity health sectors. The big struggle in New South Wales is that illness focus and not the health focus. When the hospital in the country town is running out of money, they try to take a bit away from community health. So community health and dental services shrink to support the hospital, to keep the hospital running. That is what we talk about: reorienting the health service, getting away from that illness treatment focus to the promotion of oral health.
Senator FORSHAW—That then leads me back to your comments in your opening remarks, that is that we need specific programs. Can you elaborate on that? We have programs, for instance, on breast cancer, on immunisation and on AIDS. Is that what you are talking about for dental health, or are you talking about something different?
Mr Gregory—The alliance supports the longer term solutions to this issue, but believes that it is so urgent that it is imperative that an access program for those of low income, in great need—and in particular from our point of view in the alliance—and those in rural and remote areas should be established. Sure, there is a cost involved, but this not an unstruc- tured suggestion.
The alliance would make two points. The Commonwealth dental health program clearly worked. What I said in my opening remarks was supposed to connote the ‘more in sorrow than in anger’ feeling of the alliance, that we have plenty of challenges in rural and remote health, some of which have been covered by Senator Knowles. We created another important one by abolishing the CDHP, because it was something that was clearly working and it was an urgent area.
So the alliance are saying quite unequivocally that we believe that there should be a program in collaboration between the Commonwealth and the states to do just that—that is, to provide preventative care on oral and dental health for those in great need, because they are poor and some of those are in rural and remote areas.
The context within which this should be done—and this is my second point—has probably changed. We believe now that thought is being given to doing this within the National Public Health Partnership. We have no quarrel with that, obviously, as long as the public health partnership is sufficiently resourced and gives a sufficient emphasis to this. The National Public Health Partnership is being widely touted as being the vehicle for this
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 63 program. We support that, as long as it has a high priority and is properly resourced, which will presumably mean increased funds through and to the public health partnership.
Ms Short—I would wholeheartedly agree.
Senator FORSHAW—I was wondering if you might be able to provide structure or an outline of how you see that type of program?
Mr Gregory—You mean in terms of eligibility?
Senator FORSHAW—Whatever issues you would want to cover, such as eligibility or access. I am talking particularly about rural and regional Australia, if that is not too difficult a task or too time consuming.
Ms Short—In the National Public Health Partnership there would be an agreement between the Commonwealth and the states on what was actually going to happen. Particular- ly we need somebody to be looking at tracking oral diseases, the surveillance of it, the policy and the oral health promotion programs. I am intimately involved in the Breast Screen Australia program. That was a good one for you to suggest. It could be run along similar lines. In that program you are screening healthy women, looking for breast cancer. In rural areas or in other areas of Australia we could be doing some other screening.
Senator FORSHAW—That program is working well in rural and regional Australia, is it?
Ms Short—Yes. There are examples of national programs out there and running that we could run with. In fact, I would like to say that one of the reasons why Breast Screen Australia is so successful is that it has the support of Australians and many consumers involved at the advisory level, the quality management level, et cetera.
Mr Gregory—The breast screening program is certainly a success story in rural and remote areas, as has been said. But the alliance is concerned that in the longer term the changes through COAG, resulting in rationalisation of activity between the Commonwealth and the states, may endanger some of those special purpose programs like breast screening.
In other words, in an environment where both the states and the Commonwealth are trying to reduce their expenditures, including on health, the alliance is concerned that the framework of agreements agreed to by COAG and which affect the public health partnership, as well as women’s health and other things, should not be allowed to adversely affect the availability of that sort of program to rural areas.
Senator FORSHAW—That is the message for the government on another issue, but it is relevant. Could I ask one final question, and this is something that we can no doubt check with the department? Are you aware whether or not the National Health and Medical Research Council has a specialist representative on the council with respect to dental care?
Ms Short—We do not have an oral health person, but we do have public health. I do not think we have rural health.
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Mr Gregory—I am not sure.
CHAIR—It has been suggested to the committee that there should be dental postgraduate vocational training, whereby recent dental graduates work with guidance in designated areas. This morning it was suggested by Professor Klineberg that that would be particularly appropriate in rural and remote areas. Do you have any comment to make on his suggestion?
Mr Gregory—I am not familiar with the specific suggestion, but certainly the general health work force challenge is being successfully met by the placement of health work force trainees at all stages, undergraduate and postgraduate. Afterwards, as we well know, it works for nursing and medical practitioners.
CHAIR—It would be a placement of six months, 12 months or up to two years.
Mr Gregory—Yes. One of the specific things which works in order to recruit and retain health professionals in rural areas is exposing them to rural areas. Some of them find they like it; some of them find they do not. The downside for these sorts of programs is that it may well reinforce people’s worst fears or prejudices about going to rural areas. In some cases, a six-month or a 12-month placement in a rural area has the result of making that individual realise that it is a good life and that the health practice is more challenging. In some instances it works well and lays the basis for good recruitment and retention in years to come.
Ms Short—As an extension of that, we have rural health training units throughout Australia for doctors and nurses. It would be very easy for dental to be taken on. What I am trying to get across is that we do not need special programs just for oral health people. We can tap into what is already there in our rural health networks. We just have to be careful that we are not sending—as I was over 20 years ago—the least skilled people to do the most demanding work.
CHAIR—Thank you all for coming along this afternoon.
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[2.08 p.m.]
BELL, Ms Kathryn Harrington, Policy Officer, National Aboriginal Community Controlled Health Organisation, PO Box 168, Deakin West, Australian Capital Territory 2600
BLUNDEN, Mr Stephen Vincent, Chief Executive Officer, National Aboriginal Com- munity Controlled Health Organisation, PO Box 168, Deakin West, Australian Capital Territory 2600
GILMOUR, Ms Jonine Carol, Dental Program Coordinator, Durri Aboriginal Corpora- tion Medical Service, 51 Smith Street, Kempsey, New South Wales 2440
HARRIS, Mrs Susan Elizabeth, Dental Program Coordinator, Durri Aboriginal Medical Service, 51 Smith Street, Kempsey, New South Wales 2440
CHAIR—The committee has before it a submission from your organisation. Do you wish to make any alterations to this submission?
Mr Blunden—No.
CHAIR—I now invite you to make a short opening statement and at the conclusion of your remarks, I will invite members of the committee to put questions to you.
Ms Bell—I might just begin by saying a few words about the Aboriginal community controlled health sector and the role of NACCHO. I would then like to pass over to my colleagues from the Durri Aboriginal Medical Service, who would like to say a few things about the situation at their service to illustrate the points that we have made broadly.
The Aboriginal community controlled health sector is made up of around 100 Aboriginal medical services around Australia, which are run by boards of management elected from the local community. Those individual organisations are NACCHO’s members. Durri Aboriginal Medical Service is therefore just one of our members. Although they have made a detailed submission about the situation in their area, it should not be taken as a one-off situation; it is a very broad problem.
The Aboriginal community controlled health services aim to deliver holistic primary health care. Our position is that that should include dental health, because dental health is part of the overall wellbeing of people. Also, it is a very serious issue in Aboriginal communities. Aboriginal dental health, as we have pointed out in our submission, is very poor for a number of reasons—including limited access to services, poverty, diet, lack of education and awareness, lack of fluoridated water, and so on. This leads to a high level of dental caries and periodontal disease. The consequences, of course, are pain, infection, impaired speech and, basically, the lack of an ability to participate fully in the life of the community.
Most Aboriginal people do not have access to dental clinics through Aboriginal com- munity controlled services. Most currently have to access government dental clinics which
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have lengthy waiting lists. They need to prove their concessional status. There is often a culturally inappropriate approach, and so on. Of course, the abolition of the Commonwealth dental health program has had a major impact.
There are serious work force issues impinging on Aboriginal dental health. There are difficulties in recruiting and retaining dental staff in some areas. There also is a lack of training for Aboriginal health workers who have a very important role in delivering health care to Aboriginal communities.
Our overall submission is that the Aboriginal community controlled health service sector needs better resourcing to be able to provide dental health care as part of overall primary health care. Also, there is a need for a coordinated national approach to Aboriginal dental health. There is a need for the federal government, in consultation with NACCHO, to set targets and to work to implement those targets and goals.
Dental health is part of primary health care; we need to be resourced to carry it out. That means health promotion as well as treatment. I would now like to hand over to Jonine Gilmore and Susan Harris, who are the dental program coordinators at Durri Aboriginal Medical Service.
CHAIR—Before you do that, Ms Bell, you might just tell me: do you answer through ATSIC, Aboriginal affairs or the department of health?
Ms Bell—NACCHO is a non-government organisation. It is funded by the Office for Aboriginal and Torres Strait Islander Health Services in the federal health department. The responsibility for Aboriginal health was handed over from ATSIC to the federal health department about 2½ years ago.
Ms Gilmour—I am a part-time dental program coordinator at Durri Aboriginal Medical Service, Kempsey, New South Wales. I have been proudly associated with this organisation for the past nine years. I job share this position with my colleague Susan Harris, who sits to my right.
My baseline training is as a dental therapist, graduating in 1983 from Westmead School of Dental Therapy, Westmead, New South Wales. My position at Durri Aboriginal Medical Service entails the following: the delivery of dental health services to school children in the age group of three to 18 years residing in the MacLeay, Hastings and Nambucca areas; responsible for the delivery of an early intervention dental therapy program; also assisting in the delivery of, and improving accessibility to, dental health services for the adult communi- ty members residing in the MacLeay, Hastings and Nambucca areas.
In geographic terms, both Susan Harris and I are responsible for meeting the dental health needs of Aboriginal people who reside in a radius of approximately 120 kilometres. Kempsey is situated on the mid north coast of New South Wales, halfway between Sydney and Brisbane. It is classified a rural area. Kempsey encounters problems such as lack of accessibility to general and specialist dental and medical services. It also contends with the following: an unemployment rate of 13 per cent—that is 60 per cent above the state average; and the fact that 60 per cent of the town’s residents receive benefits such as jobsearch,
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disability allowance, homeless allowance and sole parent allowance. The source of this is the Department of Social Security.
I would now like to take this opportunity to introduce you to Mrs Susan Harris. She was going to take dental diseases from the pages, and she was going to discuss some slides with you.
Mrs Harris—I am also a dental therapist. I graduated from Westmead School of Dental Therapy in 1979. I job share my position with Jonine and share the same work responsibili- ties. I have been proudly associated with Durri Aboriginal Medical Service for the past seven years.
I would have liked to have shown you some slides which would have graphically illustrated the level of dental problems encountered not only in Kempsey but throughout Australia. Unfortunately, the committee were unable to provide the resource of a slide projector, so my colleague Jonine will discuss some case studies that may assist you in visualising the extent of dental problems experienced by Aboriginal people throughout Australia. Thank you.
CHAIR—Thank you, Ms Harris.
Ms Gilmour—I will attempt to impart to you all the true effects that the abolition of the Commonwealth dental health program has had on Durri, Grafton, Taree and Awabakal, which is Newcastle, the Aboriginal community controlled organisations, and the public dental clinic located at Kempsey District Hospital.
I could well imagine that the following cases that I will impart to you are occurring on a state and federal level in all the Aboriginal community controlled organisations and in the public dental health clinics across Australia. I will use examples of cases that have occurred in the last two months at Durri Aboriginal Medical Service.
This is case 1. On day 1, a 28-year-old male presents at Kempsey District Hospital with a severely swollen face, so much so that I do not recognise him. Kempsey District Hospital administers antibiotics. The patient is in pain and has not had a full night’s sleep. Day 2: the facial swelling is still severe, no sleep for the second night, and in constant pain. Durri AMS doctors admit the patient to Kempsey District Hospital, but require a dental surgeon. There is none on staff. Day 3: the facial swelling is still present; no sleep for the third night and he is in pain. The patient is visibly stressed and exhausted. He is a health care card holder and is entitled to receive dental treatment through the public dental health clinic. He still requires a dental surgeon. There is none on staff.
The patient is an in-patient at Kempsey District Hospital who is then referred to a private practitioner for treatment. Kempsey District Hospital does not pay for this. The patient cannot afford the treatment, which is going to cost $150, for an extraction of two permanent front teeth and a radiograph. Durri AMS assists the patient; Durri AMS bears the costs for which we have no funds. Swelling subsides; the patient can sleep. I can now recognise the patient, but he is less two front teeth. He is a young man in his prime.
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Case No. 2 is a 26-year-old male, slightly abusive, visibly upset. I requested my boss, Stephen Blunden, chief executive officer, to assist. Stephen came down and asked, ‘What is wrong, my brother?’ ‘Steve, I’ve got no teeth, brother. I can’t even smile to go for a job interview. I need false teeth. I need to get a job, brother.’ The young man was at this stage crying in our waiting room. Stephen consoled the young man and I was greatly saddened. Our organisation again bears the cost for which we have no funds. The next time that young man came to Durri AMS he came with a smile on his face and a grateful thankyou to his unrelated brother.
Case No. 3: on Monday, 23 February 1998, a two-year-old child presents in pain to Durri AMS. The diagnosis: baby bottle caries, substantial decay; requires a possible general anaesthetic to extract decayed teeth; needs the dental office to assess prior to the scheduling of general anaesthetic. They are not working until Wednesday and can only be booked in on that day because it is now a relief of pain clinic only.
The patient’s mother has to ring at 8.30 a.m. on Wednesday for an appointment. They have no telephone. All children under five years of age have to go to Port Macquarie dental health clinic for an assessment. That is approximately 50 kilometres away. They have no car. The organisation transports the mother and patient; that is our duty of care.
The assessment by the dental surgeon is that the child needs a general anaesthetic. The theatre list is full for Friday, but maybe the next theatre list. The appointment is on Tuesday, 10 March 1998. The patient needs to be transported to Port Macquarie Base Hospital by 7 a.m. on that morning. They have no car. Durri AMS will have to provide the transport. The patient has tolerated intermittent pain for close to one month, but perhaps she cannot tell her mummy that because she cannot speak properly as she has no front teeth.
These are the sorts of cases that we deal with on a daily, weekly and monthly basis at Durri AMS. It is interesting to note from a discussion with the staff at Kempsey District Hospital dental clinic that they are being briefed on conflict resolution, and on handling difficult abusive clientele, by the mental health team to assist in controlling situations arising with clientele presenting at the clinic. The dental clinic is a relief of pain service only.
I would now like to discuss orthodontic sponsorship. We currently have access to a necessary orthodontic service in the north-eastern region in the Aboriginal community controlled organisations and in the public dental health clinics. We may lose this specialist service without sponsorship of the clinician. Yet again, the rural sector of New South Wales loses out. The current patient load delivered by the clinician is approximately 750. This service is provided at eight dental health clinics throughout New South Wales; seven are located in the north-eastern region. There is Redfern Aboriginal Medical Service, Taree, Grafton and Durri Aboriginal Medical Service, Kempsey District Hospital, Coffs Harbour, Ballina and Lismore District Hospital.
These patients, if services are lost, will be required to complete their treatment at private orthodontic specialists. The costs, perhaps borne by the state and federal departments, may be equal to $270,000. This is calculated on the basis that private orthodontic specialists charge approximately $3,600 for full bands and there are 750 patients. A commitment for three years ensures that continuity of dental services to these clinics will be given in return
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 69 for this sponsorship, something that will be of great value to our children requiring orthodon- tic treatment for years to come. It is imperative and expedient for all concerned to retain these services for the Aboriginal community controlled organisations and the public dental health clinics, and I refer to the addendum document provided.
It must be fully realised that Aboriginal community controlled organisations provide culturally appropriate dental health services. This is an effective and efficient delivery mode. We at Durri AMS have proved this with the documentation provided in the adult dental report 1997. It is required to have an executive level officer to support all the aims and objectives of the Aboriginal community controlled organisations to bring about positive, long-term dental health changes for the indigenous people of Australia.
These are hypothetical cases. A patient presents to Durri AMS in pain, then they would say perhaps, ‘I have been up all night, I have taken eight Panadol already and I have got a toothache.’ I would like to be able to say, ‘Yes, I can see your pain. Please take a seat. Our dentist will be with you in 15 minutes.’ Then there is an adolescent who says, ‘My teeth are very crooked and I cannot clean them properly. It is not my fault and I do brush them. The other guys bag me and they call me Fangs.’ The staff reply, ‘Okay then, if you want that change to happen, you keep your teeth clean by toothbrushing, make sure you eat a good diet with low sugar, and we will book you in to an orthodontist who can straighten your teeth,’ and they would show a picture of straightened teeth.
In conclusion, I would like to say that today you have the ability to initiate a national change for an improvement of dental health services for Aboriginal community controlled organisations throughout Australia. The evidence mentioned and supporting documentation provide you with a true account as to the effects of the abolition of the Commonwealth dental health program on the dental service of Australia. There is one word in our language that is short and sweet and brings smiles to big and little faces. That word is yes. Do you have the ability to say yes and can you help us? Thank you.
Mr Blunden—Mr Chairman, I would like to thank you very much for allowing us to come here today. The evidence that has been put before you is just an example of what is widespread throughout Australia. Our people are in need. In particular, when the Common- wealth dental program was slashed from our communities it affected lots of organisations. In New South Wales on the east coast you have got Katungul at Narooma, Newcastle, Taree, Kempsey, Grafton. The New South Wales government, with this Commonwealth dental program, spent $150,000 on capital grants to put in place chairs and clinic rooms, and today we have not got the money to employ a dentist to operate those facilities. It is appalling that, on one hand, we receive all the capital money to put in place these facilities and, on the other hand, the money is just taken away and we cannot provide the service. We were thinking about having a garage sale, but that would not solve our problem.
We really want to stress the point that years ago the department of Aboriginal affairs did provide direct funding to organisations such as the Aboriginal Medical Service in Redfern for dental service provision. They provided direct funding to Durri Aboriginal Medical Service in the early days as well. But most of the organisations now are denied that through OATSIHS—the Aboriginal unit within the federal department of health. Probably a handful of Aboriginal medical services receive continual funding from OATSIHS to run dental
COMMUNITY AFFAIRS CA 70 SENATE—References Friday, 6 March 1998 programs, but there is a bit of a problem between state and federal governments about who actually has the responsibility of providing funding to the services which have been denied it. We have put this information before you today and I am saddened that we did not have a projector to show you the slides—
CHAIR—Just for your own information, we have received a significant number of photographs of a range of persons with distressed teeth and that type of thing.
Mr Blunden—I appreciate that.
CHAIR—So the general picture is clear to members of the committee. Have you concluded, Mr Blunden?
Mr Blunden—Yes. Basically as an executive of NACCHO I have come here with my colleagues here just to be a witness.
CHAIR—Can I ask you one question at the outset, or perhaps it might be appropriate for Ms Bell to comment. Someone referred to the fact that you want culturally appropriate service or treatment for Aboriginal persons. Can you explain to me what that means, because that is a recurring theme in a number of inquiries I have been involved in.
Secondly, having discussed that point, is it your core point that you want to be able to offer a separate and distinct Aboriginal controlled health organisation to service the needs of indigenous people and not be associated with the mainstream, or would you be involved within the mainstream provision of dental and oral services?
Mr Blunden—With Aboriginal people, for many reasons, in particular, racism, our people tend to not attend facilities like hospitals for treatment until the very last moment— until they really, really need to go. An example would be this young bloke with a swollen face. Ultimately, it is past repair. He had two teeth extracted from the front, where maybe, if he had attended earlier—
CHAIR—They could have been saved.
Mr Blunden—They could have been saved, but it was not the case. Basically, by setting up an Aboriginal community controlled organisation, in particular the dental side of it, we have an environment where the people feel comfortable by coming in early, and they do present early. Some people have actually travelled from Kempsey to Sydney just to get some root canal therapy done at Redfern AMS. Redfern are finding it very difficult to continue looking after all the Aboriginal people of New South Wales. If other medical services around the state were funded, it would reduce their burden.
In local hospitals, we are working in partnership; we are developing health plan strategies at the grassroots level with local hospitals to overcome this problem. We are finding that, as Ms Gilmour has mentioned, there is a huge waiting list in that hospital. At the moment, the hospital is only providing relief of pain. That is the problem we are facing in rural communi- ties—and perhaps even in Sydney, in urban areas.
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Ms Bell—Can I perhaps add to what Stephen is saying and go back to your other question about whether the community controlled health services wish to deliver a separate service. Yes, certainly, they do operate autonomously, but many are also working very closely with local hospitals and so on, providing referrals back and forward to specialist hospitals, et cetera. As Mr Blunden said, the clients will present much earlier to the Aboriginal health service, because it is a place where they feel comfortable.
The other thing to bear in mind is that Aboriginal people carry a very high burden of illness, disease and so on. Generally, if a person walks into a clinic, they will not necessarily be walking in with a single problem. They may have a multitude of health problems and issues that need to be addressed holistically. So the Aboriginal community controlled health service is a place where they will receive that holistic, whole of person care and will not be sent off somewhere else unless it is absolutely necessary.
Mr Blunden—Just to add a little bit further, we are finding on the ground that when we had the Commonwealth dental program operating we were looking after non-Aboriginal people as well in our community—people who maintain a health care card. Even today, we find in Kempsey that doctors will not bulk-bill any more and our Aboriginal medical service is receiving a huge influx of non-Aboriginal people into our medical service for general treatment, apart from dental.
Senator FORSHAW—Can I follow that up? I might say at the outset that it is nice to see people from Kempsey here. I have holidayed quite a number of times at Hat Head, so I am familiar with it. I actually know that you have an office in the main street, I think, in Kempsey.
I was going to ask you a number of questions. Firstly, you have mentioned that you do actually provide services to non-Aboriginal people. But you have got this real problem at the moment, haven’t you, where Kempsey hospital services are really pared to the bone from what I understand? That is a double whammy on top of the problems that you have outlined.
Mr Blunden—Senator, I am basically a director of the aerial service board too on the mid-north coast, but I am not representing in that capacity today. Ultimately, with the changes in funding, the new formulas which are set up by state health, there is no equity for our aerial service. We are short of maybe $20 million to $25 million to operate effectively at the level of other aerial services. In taking that into account, we have major problems in attracting doctors to the rural area as well.
I remember one time I mentioned to Dr Wooldridge that perhaps young doctors being trained should be like policemen or teachers where, basically, before they are sent out, they are given a job to do in a particular community out in the rural area for two or three years. Issues like that need to be looked at.
Senator FORSHAW—What proportion of the Aboriginal clients and also non-Aborigi- nal clients that the service would see would have dental problems? They may have a combination because, from the condition that you have described, by the time they come to see you the dental problem has become a medical problem; they have got a serious infection in their system.
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Ms Gilmour—I would have to say that 95 per cent of the clientele that we see at the Aboriginal Medical Service have some dental related disease present.
Senator FORSHAW—And of course, the problem you then have is that at the moment the GPs are not bulk-billing. But even if they were bulk-billing you cannot fund the service through the Medicare system. I could probably ask you a lot of questions about the local situation, but thank you. Thanks very much for your evidence and your submission.
Senator KNOWLES—First of all I would like to ask Mr Blunden whether you have been contacted by Lawrie Groom and Associates, acting on behalf of the Dental Health Services of Victoria?
Mr Blunden—No, I do not believe I have.
Senator KNOWLES—Have you, Ms Bell?
Ms Bell—Not to my knowledge, no.
Senator KNOWLES—I was interested, Ms Gilmore, in what you were saying about there being no dental surgeon on staff at Kempsey hospital, and you were portraying that as something that was unusual.
Ms Gilmour—No, it is commonplace. At the present moment, the dental surgeon is on two days clinical duty, delivering services, and three days administration duty.
Senator KNOWLES—But you are portraying it as something unusual—that in the past it used to be—
Ms Gilmour—In the past we had access to the Commonwealth dental health funds, and the abolition of that has affected us greatly.
Senator KNOWLES—Was there a dental surgeon on staff at the hospital full time?
Ms Gilmour—Not in a clinical capacity full time, not actually clinically delivering dental health services to alleviate pain in a full-time capacity.
Mrs Harris—Also, there is no locum brought in when he is on holidays.
Senator KNOWLES—How many country hospitals have a full-time dental surgeon to be available on call at the snap of fingers when someone comes in?
Ms Gilmour—I would hope in the Kempsey district area there should be one on call at any given moment.
Senator KNOWLES—No, that is not my question. My question is: how many country hospitals have a full-time dental surgeon? I spend a lot of time in the country and that is why I am interested in knowing the answer to the question.
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Ms Gilmour—I do not know the answer to that question.
Senator KNOWLES—I think you will find that there are very few. Fifty per cent of my time is spent in the country, and I am yet to find a country hospital where there is a full- time dental surgeon available when someone comes in off the street. So I am just wondering why you see Kempsey being a different case from every other country hospital in Australia.
Ms Gilmour—Why I see Kempsey as a different case? Because I deal with the cases on a day-to-day basis and that is my responsibility and that is my duty of care.
Senator KNOWLES—How much do you think it would cost to put a full-time dental surgeon into every country hospital in the way in which you would like one in Kempsey?
Ms Gilmour—It is not my level of expertise to answer that question.
Senator KNOWLES—But do you think it would be a rather large cost?
Ms Gilmour—I cannot answer that. That is not in my level of expertise.
Senator KNOWLES—Do you think they would come for nothing?
Ms Gilmour—No. I know that they come for money.
Senator KNOWLES—How much work would a full-time dental surgeon do on a full- time basis—and presumably you would have to have a minimum of two or three if they were going to do eight-hour shifts? How many people would they see a day?
Ms Gilmour—I would say that they would be able to see approximately 15 patients a day, at 20-minute intervals.
Senator KNOWLES—Amortise that over 24 hours: it is not a lot of people, is it?
Ms Gilmour—I am not a figures person, I am sorry.
Senator KNOWLES—Fifteen by 20 is not a lot of people. That is three hours. I just cannot quite come to terms with what you are suggesting to me, because one of the other cases that you talked about was a young chap who needed false teeth. The CDHP did not provide dentures, so I am trying to figure out what you are alluding to there.
Ms Gilmour—I am specifying that these are cases that we deal with on a day-to-day basis, and the abolition of the Commonwealth dental health program has affected Aboriginal medical services and community controlled organisations. These are the cases that we have to deal with. These are the cases that we have resolve on a face-to-face value.
Senator KNOWLES—I just come back to the point that I made. The CDHP did not provide denture facilities.
Ms Gilmour—No, it did not provide denture services.
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Senator KNOWLES—So what is the connection?
Ms Gilmour—The connection is perhaps that the delivery of denture services should be reviewed—when you have like four years waiting lists for denture services.
Senator KNOWLES—And who are you suggesting pays for that?
Ms Gilmour—Either the state or the federal government. Somebody must take responsi- bility.
Senator KNOWLES—How much do you think that would cost?
Ms Gilmour—That is not my level of expertise.
Senator KNOWLES—I am trying to get a bead on what you are trying to do on a wish list.
Ms Gilmour—I am trying to achieve that there is—
Senator KNOWLES—Just let me finish. Are you providing a wish list to the commit- tee, regardless of what the cost is to the taxpayer and saying that that is what has to be done to meet a need?
Ms Gilmour—I am trying to express to the committee that we have problems in the rural sector of New South Wales and perhaps Australia-wide—that there are problems with dental health services. My aim and my objective and my commitment are to the organisation that I work for—
Senator KNOWLES—Were you here to hear the evidence immediately before you, with the rural health organisations?
Ms Gilmour—No.
Senator KNOWLES—We were going through in great detail there, or in as much detail as time would allow us, some of the problems in delivering health services in rural and remote areas. So there is great empathy on the committee for the problems associated. But no government—and I do not care what political flavour that government might be—has a blank cheque book, because governments only have what taxpayers give them. This problem that you are identifying now is not necessarily a new problem or a discrete problem. I am just trying to find out where you think the money comes from to provide all these wonderful services that are provided on your wish list.
Ms Bell—Could I respond to that? I think NACCHO’s submission has been not only about providing dentists in public hospitals but certainly about providing dental programs through community controlled health services. We recognise that that is not budget neutral, that that is going to cost money, but the point that we are making is that there is a huge amount of unmet need out there in the community. We are not talking about cosmetic issues.
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We are not talking about playing around on the fringes of healthy populations. We are talking about people actually dying in some cases from dental infections.
Senator KNOWLES—I am not doubting that.
Ms Bell—We recognise that it will take money to solve those problems, but I do not think that we should step back from that because it costs money.
Senator KNOWLES—I am not doubting that. You are the one who is giving the evidence and I am the one asking the questions. I am just trying to flesh out some more information on the information that you have provided. You also mentioned that there was no transport or telephone for prospective patients. I am wondering what that has to do with the CDHP.
Ms Gilmour—As stated, 60 per cent of our clientele—or a predominantly high propor- tion of the clientele that access the services—are on health care cards or are low income earners. This disadvantages them because they cannot afford such services as telephone and cars. In the rural sector, as you would understand if you have been in the rural sector, you have to travel great distances, and to travel great distances you need money for petrol.
Senator KNOWLES—What has that got to do with the CDHP?
Ms Gilmour—If we had a dental surgeon on the premises at Durri Aboriginal Medical Service, the assessment would not have to go to Port Macquarie. The assessment could be done in-house.
Senator KNOWLES—Yes, I realise that. The same would apply if we had a dental surgeon in Kununurra and Fitzroy Crossing and Halls Creek and Broome and Derby and Leonora and all of those places. Do you think that is practical?
Ms Gilmour—In some cases, yes.
Ms Bell—We ask not only whether it is practical but also whether it is necessary. Our focus is not so much on the program boundaries for the Commonwealth dental health program; it is on the need that is out there in the community.
Senator KNOWLES—Do you not at some stage when representing your organisations have to be cognisant of the fact that we have to deal in realities as to what is achievable and not what we would all like? I would be the first one to put my hand up and say, ‘Yes, put a dental surgeon in every single country town in Australia.’ I am also a realist: I know we cannot do it. I am asking you, as the people who are dealing in the area, what you believe is the balance that we need to get in all of that?
Ms Bell—We believe the federal government should be prepared to meet the basic dental care needs of the Aboriginal community—and we are not talking about cosmetic surgery; we are talking about people who are dying from dental infections and we believe that it is very reasonable to expect the government to meet those needs.
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Mr Blunden—In terms of where we could find the money, there is all the money that Australia provides overseas for different aid to other countries. It may be bold to say, but perhaps we ought to be cleaning our own backyard first and not helping other countries.
CHAIR—Senator Knowles was making a point and we all understood the point she was making. Whether we cut migration programs or humanitarian programs, I do not think it is necessary for you to involve yourself in a barter situation of government funds.
Mr Blunden—The point I made though is that our medical service actually treats non- Aboriginal people as well. People who are on the lower level of income in the community come in because they feel our services are appropriate to them as well. It has even shocked us to see that clientele coming in but the people do come in. I am not sure who is going to take this responsibility, be it state or federal, but there are people out there in need. The hospital waiting lists go out three to four years. If a person in Kempsey wants dentures, they will be waiting 18 months to two years before they can even get in and have an appoint- ment. That is the extent of the problem.
Senator FORSHAW—It is not just Kempsey. Let us get something on the record here. One of the reasons that the Durri centre is located in Kempsey is that it caters for a lot of Aboriginal people that come from that region and surrounding areas, as I understand it. There is a large Aboriginal population in that area. You have a nursing home in Kempsey that was funded with federal and state money. I have forgotten the name of it but—
Mr Blunden—Booroongan-Djurgun.
Senator FORSHAW—That primarily caters for Aboriginal people who stay at that nursing home but it also has some non-Aboriginal people there.
Mr Blunden—It is a fifty-fifty mix.
Senator FORSHAW—Yes. Frankly, I do not find it a problem that you can come along to this committee and tell us what the realities are of the problems that you face. It is for us as governments to try to find the solutions, not just ask you to add up and subtract the dollars.
Mr Blunden—It is a difficult question.
Senator FORSHAW—It was not a question, Mr Blunden; it was a comment, and you do not need to respond.
Mr Blunden—If I can respond?
Senator FORSHAW—You can, yes.
CHAIR—What Senator Forshaw says is the point. You have identified a problem. It is a problem that is common in Aboriginal communities right throughout Australia. You have a perfect right to make it. What happens from there is another issue.
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Senator FORSHAW—There is a private hospital at Port Macquarie, and many patients get referred from Kempsey down to Port Macquarie if they have private health insurance. Do they have access to a dental surgeon in Port Macquarie, do you know?
Ms Gilmour—On public level 1.
Senator FORSHAW—That is one of the difficulties in this region, that a lot of the services are being directed away from Kempsey.
Mr Blunden—That is exactly right.
Senator FORSHAW—Where they are critically needed, particularly for the Aboriginal community.
CHAIR—Thank you, ladies and gentlemen, for coming along today.
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[2.47 p.m.]
DAVIS, Ms Jill Rosemary, Director, Dental Health Program, ACT Community Care, GPO Box 825, Canberra, Australian Capital Territory 2601
FLEETWOOD, Dr Michael, Principal Dental Officer, Dental Health Program, ACT Community Care, GPO Box 825, Canberra, Australian Capital Territory 2601
CHAIR—I welcome officers of ACT Community Care. You will not be required to answer questions on the advice you may have given in the formulation of policy or to express a personal opinion on matters of policy. The committee has before it a submission from your organisation. Do you wish to make any alterations to that submission?
Ms Davis—No.
CHAIR—I now invite you to make a short opening statement and, at the conclusion of your remarks, I will invite members of the committee to put questions to you.
Ms Davis—Thank you, Senator. The comments that we would like to make initially are additional to the remarks that we made in the submission, but we will be very brief. We would like to point out that the dental health program in the ACT is responsible for providing services to adults as well as to young people and children. One of the main issues that we deal with, without adequate funding, is attempting to balance the immediate treatment needs of adults with the more long-term preventive needs of young people.
We also believe that dentistry is an integral part of a comprehensive primary health care system in Australia, or in any country, and we believe that oral health is a public health issue. We believe that it is only a policy question that dentistry is excluded from national public health insurance systems like Medicare. We do not believe that it is excluded on medical or constitutional or legal grounds.
We would like to say that before the Commonwealth dental health program was introduced, the ACT, like all other states, had significant problems with waiting lists and, for public patients, higher rates of extraction and lower fillings than privately treated patients. The ACT had, at that time, lower than average expenditure per eligible person on public dental care. Again, the withdrawal of the dental health program has had a similar impact on us as other states—rapidly increasing waiting times, higher extraction rates, fewer fillings and increasing dissatisfaction with public dental services.
CHAIR—Thank you, Ms Davis.
Dr Fleetwood—I think our main concern is that we are rapidly returning to a pre- Commonwealth dental program situation where we had card holders and people whose circumstances have a significant element of deprivation having significantly poorer dental health than the rest of the community. This has been referred to in a number of reports. Background paper No. 9 made reference to this. Our experience is that we see this situation returning. We have now gone from the end of the Commonwealth dental program whereby
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 79 we could accommodate patients and provide restorative care within a matter of weeks, to a situation now with a waiting list which runs into years rather than weeks.
The clinical perspective of this is that usually, when a patient presents with pain, it is too late to carry out simple restorative procedures to save teeth. One is either into complex root canal treatment, a high cost item, without as good a prospect of success, or one is facing the situation of tooth loss.
I would commend to the committee an article that recently appeared in a British dental journal on the emotional effects of tooth loss and edentulous people. There is no doubt that people do view the loss of teeth in much the same way as the loss of other bodily parts are viewed, and there is evidence of reduction in confidence, less ability to interact socially, effects on employment prospects and all sorts of repercussions. I think our concern is: does it represent good value for money to restrict the ability to carry out the sort of treatment that can prevent this type of situation from arising?
Our contention would be that to invest in good oral health makes good economic sense. We need to adequately manage and prevent a preventable and treatable condition which has a direct impact on people’s lives and affects their ability to reach their full potential.
CHAIR—Thank you, Dr Fleetwood. With the cessation of the CDHP, what is the role of the ACT government now in the provision of oral health in the community?
Dr Fleetwood—The ACT government has responded to the situation in two ways. Initially they introduced a fee scale which has improved the resources to the program by setting contributions at a level which are very significantly less than the fees charged by private dentists, and are generally affordable by the eligible population.
CHAIR—Is that a co-payment type of system?
Dr Fleetwood—There is a co-payment system, yes, and that has given us an increase in resources—not a full replacement of the Commonwealth dental program funding—and we have also—
Ms Davis—Internally within the program we have made many efficiencies. We have amalgamated clinics. We have cut our overhead costs significantly which has made a contribution, as Dr Fleetwood has mentioned, and we have introduced the patient contribu- tion. But it is probably only achieving about a 20 per cent replacement of the funds we had under the Commonwealth dental health program.
CHAIR—Both of those measures.
Ms Davis—Together. And through the last election the government also announced further additional funding to the dental health program.
CHAIR—Are there any disparities between the provision of public dental care in the ACT and other states?
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Ms Davis—In what respect? Do you mean per head of population?
CHAIR—Yes. In terms of service to the population.
Dr Fleetwood—I think that we probably represent a sort of middling type situation, really. We are neither the best provided nor the worst. Queensland probably have more resources than we do in the ACT. I think Tasmania is probably the least well resourced. In fact, I think the figures that appeared in background paper No. 9, with some variation, still apply.
Ms Davis—We would be at about the same place in the league scale as we were before the Commonwealth dental health program.
CHAIR—Going back to that co-payment—has there been significant consumer resistance to that new thing?
Ms Davis—There are fees in the child and youth program and fees in the adult program. It is quite a different scheme in both cases, but we have had a reduction in the numbers using both programs. We expect that some of that is a result of fees, although there are exemptions for certain groups of people. We are hoping to investigate this through some research a bit later in the year, but we believe it is some kind of a barrier to some people. On the other hand, there are quite a few people who appreciate paying the fee; so there are people who are valuing the service more because they are making a small contribution.
During the consultation phase on the proposal, there was very little public resistance to the introduction of the co-payment. We believe part of the problem is that it is to the same group of people that other fees for other services are being introduced as well. It is people on health care cards who are being asked to pay for other services as well as dental care; so it is a cumulative effect.
CHAIR—I see.
Senator KNOWLES—The question I have asked everyone else—I may as well ask you—is: have you been contacted by Lawrie Groom and associates?
Ms Davis—I cannot actually recall being directly contacted by them, but we have worked with the other states, in particular Victoria, which have, I believe, used that company to assist in the coordination of information sharing and responses. We haven’t at all worked through that company; we have worked directly to the Victorian Dental Services.
Senator KNOWLES—Thank you. I just want to come back to participation rates. I am a little bit confused, because participation rates in South Australia were 90 per cent. According to my figures, you are, in the ACT, down the bottom of the scale at 25 per cent. If the Commonwealth dental program, combined with your services, gave only a 25 per cent coverage, then how do you claim that it was such a success here?
Ms Davis—We increased the participation rates by about 10 per cent—it was 15 per cent—up to 25 per cent within a fairly short period of time—approximately 18 months to
COMMUNITY AFFAIRS Friday, 6 March 1998 SENATE—References CA 81 two years—and that was rapidly increasing. We imagine, with a couple of further years of funding, that that would have been the majority. I cannot comment on the South Australian figure. I am not aware of that to be the case.
Senator KNOWLES—I just cannot understand when you say that other states and territories have a far better participation rate than yourselves.
Ms Davis—I do not know if that is the case. All I can say is that, in our case, the participation rates were rapidly increasing. We were at the point at the abolition of the program of going into a recall cycle so that we could actually get people back for preventive dentistry as well as increasing the numbers who were using the service.
Senator KNOWLES—But everyone else was at the same stage of the program as the ACT.
CHAIR—Senator Knowles, the witness has said that she has no knowledge of what occurred in the other states; so she cannot answer the question.
Senator KNOWLES—I am not asking the witness to answer anything about any other state. I am simply asking a question in relation to the ACT participation rate.
CHAIR—But you are asking her to make a comparison. She cannot do that, by definition, if she has no knowledge of other states.
Senator KNOWLES—I am simply talking about the participation rate of 25 per cent in the ACT. I am saying that by comparison to the other states, who have been running at the same time as the ACT, to have only 25 per cent participation rate in the ACT begs the question as to what went wrong here.
CHAIR—No, it does not, Senator. It does not beg that question at all, Senator Knowles. The witness answered that the ACT had increased their rate from 15 per cent to 25 per cent. That is an increase of two-thirds. But she is unable to compare it to the other states. That is the point I am making.
Senator KNOWLES—If the question has been ruled out of order, that says it all. That is fine. I am quite happy to go with that. I have to put on the record that I find the answer to the question to be totally and utterly unsatisfactory, and it is a shame that the chairman has taken that attitude to the question because it is a very serious question.
With that decision being made by the chair, I will now move on to refer to page 2 of your submission where you say:
In July 1993, there were 3,916 people waiting for restorative and denture treatment services.
Further through:
Although the CDHP did not provide denture services...many more people were being seen and many had denture needs as well as restorative needs.
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Further through:
The denture list had also begun to reduce.
Further through:
. . . and denture services...
You say that in the last paragraph. I cannot quite understand how you are placing so much emphasis on denture services in an inquiry about the Commonwealth dental health program when that did not cover denture services.
Ms Davis—Our submission was to the broader questions raised in the inquiry’s terms of reference which were about public dental services, not just the Commonwealth dental health program. Denture services are a very important part of the overall dental needs of our patients.
Senator KNOWLES—I do not deny that.
Dr Fleetwood—This was an ongoing issue during the duration of the Commonwealth dental health program, that the promotion of the program was tending to bring new clients in. There may be some debate about exactly how we define and measure the participation rate, but certainly our front line experience was that more clients were coming in, and some of those clients required dentures, and there became an increasing disparity between the ability to deliver restorative care and the ability to provide dentures.
This was an ongoing concern. We did take the liberty in this submission of drawing the committee’s attention to this problem. It would be our hope that if there was any future consideration of enhancing public dental services this matter would be addressed because, whilst the long-term aim is undoubtedly to save teeth, there will for many years be a population which requires the maintenance of partial and full dentures.
Senator KNOWLES—How much did ACT Community Care pull out of dental health cover over the life of the program?
Dr Fleetwood—Nothing.
Ms Davis—Funding has been increased—
Senator KNOWLES—Over the life of the program?
Ms Davis—Yes, from ACT funds. There were increases based on CPI plus additional equipment needs. There were absolutely no cuts—quite the contrary. In last year’s budget, immediately following the withdrawal of the Commonwealth program, additional funds were provided, and again will be in the next budget.
Senator KNOWLES—You say on page 3 of your submission:
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It is a simple equation: the ACT Dental Health Program has lost almost 50% of its adult budget with less than six months notice.
Had you been playing by the rules it would have been significantly less than 50 per cent. Therefore, I ask the question: how much funding was reduced by the ACT because you should not have lost 50 per cent?.
Ms Davis—I do not understand the question. What rules are you referring to?
Senator KNOWLES—The rules of the program at the time?
Ms Davis—Do you mean on a matched funding type of basis?
Senator KNOWLES—I am just saying that under the rules of the program, the contribution between the states and territories and the Commonwealth, it should have been less than the 50 per cent funding that you lost.
Ms Davis—It was not a matched funding program.
Senator KNOWLES—I know it was not matched funding, but it should have been less than the 50 per cent that you lost.
Ms Davis—Mr Chairman, I am unclear as to the question.
CHAIR—I am also unclear, Senator Knowles, as to the point you are making. The witness said that the ACT government had not reduced its funding.
Senator KNOWLES—I know what the witness said.
CHAIR—Yes, and the point here is, as they say in their submission:
. . . the ACT Dental Health Program has lost almost 50% of its adult budget with less than six months notice.
You then draw a conclusion that they have been, as I understand it, engaging in activities outside the purposes of the grants. You then try to say that they have done something wrong. Is that the sequence of logic that is involved here?
Senator KNOWLES—No, I am just asking a funding question. You are drawing a succession of questions together; I am asking separate questions. This question is on funding. This question is not on the denture thing.
CHAIR—What is the point of your question on funding, because neither the witness nor I understands it?
Senator KNOWLES—I will start again.
CHAIR—Okay.
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Senator KNOWLES—You say that since the cessation of the program that has led to a funding loss of 50 per cent. On the funding basis under which the program was structured, had the funding of the Commonwealth been withdrawn, that funding reduction should have been significantly less than 50 per cent. So for it to impact at 50 per cent of reduction means that there is less money going in.
Ms Davis—I thought I had understood the question. As far as I understood, the Commonwealth dental health program allocation was based on the number of eligible people, not on the ACT budget itself. If I could just summarise it, the adult budget at the time of ACT money was approximately $1 million we lost and the Commonwealth money was approximately $1 million. We lost $1 million, we had a million left, which is approximately 50 per cent. In the case of a matched funding type of arrangement of a dollar for a dollar, which is a common grant formula, I can understand the question but in the context of the way it was funded, which was on a dollar amount per head of the eligible population, it was a different type of formula.
Senator KNOWLES—You are suggesting that dental treatment should be included in Medicare. How much do you think ‘denticare’ would cost?
Dr Fleetwood—That depends very much on the extent of the denticare coverage. On the one hand, you might have just a limited denticare type cover which possibly might have a few hundred dollars or something of that sort per year and limited range of basic services or, on the other hand, it could be a comprehensive service, and there are all possible stations in between. It is merely a concept rather than a definite funding proposal.
Senator KNOWLES—Just for your information, I asked the department this morning how much denticare would cost according to the suggestions that you have made—a billion dollars.
Dr Fleetwood—That would be dependent on the service provided by such a program.
Ms Davis—I believe that is why alternative options have been proposed that would not extend to that.
Senator FORSHAW—Whilst we are talking about the costing for so-called denticare, I presume you are aware, no doubt, that many private health insurance funds, if not all funds, include options for covering dental care. Are you also aware that this government has allocated $1.7 billion as an effective subsidy to private health insurance?
Ms Davis—Certainly we are aware of that issue.
Dr Fleetwood—We are.
Senator FORSHAW—So it is reasonable to at least conclude that a significant sum of federal money is actually going to subsidise people being able to claim a proportion of their dental costs from health insurance?
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Ms Davis—The majority of our clients, being health care card or other concession card holders, do not hold health insurance.
Senator FORSHAW—No, but there are other people who do. That is why they are not card holders.
Ms Davis—Very commendable.
Dr Fleetwood—I think some of the concerns about health insurance from the consumer perspective relate to the medical aspects of it rather than the dental cover. In fact, my understanding is that many of the members of health funds highly value the dental coverage.
Senator FORSHAW—Even though it does not provide either total coverage or indeed in many cases even half what the costs are.
Dr Fleetwood—That is correct, although it does not create the situation whereby someone, by opting out of an insurance cover situation, can receive a free service because it is only really health card holders that have access to that. It is very much that one is better off having it than not having it, as it were. Those issues do not relate to the dental cover.
Senator FORSHAW—My point is more a comment in relation to some of the discus- sions that have emanated between you and Senator Knowles. A person who takes out private health insurance is able to get a rebate of $450 and if you take out private health insurance, irrespective of what the cost is for the hospital cover, the cost of getting the additional dental cover is minuscule and therefore public money is subsidising, to some extent, people who have private health insurance including dental cover.
Ms Davis—They are largely different populations.
Senator FORSHAW—I do not expect you to comment. I am just making that point.
CHAIR—Okay, thank you. Further questions, Senator Forshaw?
Senator FORSHAW—No.
CHAIR—Senator Knowles? Thank you, Dr Fleetwood and Ms Davis, for coming along this afternoon. I declare this committee adjourned.
Committee adjourned at 3.11 p.m.
COMMUNITY AFFAIRS