Cork dentist: It's time to fix failings in public dental care

LAST week, the Irish Dental Association published an independently commissioned research report that called once more for the urgent reform of the medical card scheme. Within it, an alternative proposal to improve access to dental care for medical card patients was set out.

The report comes at a time when the Dental Treatment Service Scheme (DTSS) or medical card scheme is in full-blown crisis and nearing the brink of total collapse.

But none of this is new.

In the four years to December, 2021, almost one in five contracted dentists in Cork have withdrawn from the scheme while, nationally, there is thought to be less than 700 dentists treating medical card patients, which is half the number of DTSS contracts held by dentists up to two years ago.

To put it in context, that is one dentist per 2,000 medical card patients and parts of the country where there is a single dentist covering an entire town or region.

Neither is the Dental Hospital, which has traditionally been a care pathway for Cork patients, a viable option anymore given it too is over-stretched and under-resourced.

Decades in decline

The medical card scheme was established by the Department of Health in 1994; it predates both the internet and mobile phones.

Perversely, it dictates what materials dentists can use and what procedures can be carried out. Only teeth extractions are unlimited.

Following the financial crisis of 2008, reimbursement levels to dentists were reduced and treatments available to medical card holders were suspended or available in emergency cases only. This has not changed in the 13 years since.

As a profession, dentists have felt side-lined and ignored by successive governments for more than a decade, contracted to provide an extremely limited and wholly restrictive service to some of the most vulnerable and economically disadvantaged people in our communities.

As care providers, we have never understood the rationale behind a scheme that restricts the number of preventative treatments allowed, such as fillings to save a tooth, while permitting an unlimited number of extractions.

Under the parameters of the medical card scheme, we have no clinical autonomy to make decisions that we feel are in our patients’ best interests. It shouldn’t matter whether you are a medical card patient or not, but it does. We cannot use any modern-based science for our clinical treatments, which leave our hands completely tied.

A cynical person might argue that the system is weighted towards cost containment over health by providing an accelerated pathway to extraction for those who cannot afford or access the alternative. This simply cannot be allowed to continue.

A future model of care

Dentists want an entirely new scheme that reflects modern dental practice and care, one that allows people to access contemporary evidence-based dental care in their community. It is critical that we move away from a system that allows restrictions to be placed by the State on treatments which are covered.

The independently commissioned research paper by Professor Ciaran O’Neill, Professor of Health Economics at Queens University Belfast, sets out a model for a credit or voucher scheme that provides an entitlement of a given value for a specified period of time to cover a given range of services and care. In Portugal, a scheme of this type was shown be associated with improved oral health outcomes.

Professor O’Neill estimates that the annual cost of such a scheme offering a voucher of between €100 and €500 towards dental care would be a total cost per annum of approximately €108m and €232.5m respectively.

For context, the spend on the medical card scheme in 2021 was €39.6m and a far cry from the €86m spend in 2009.

Despite the suggestion of an extra €10m being made available this year, it is not nearly enough to solve the underlying problems associated with the scheme or have any substantial impact on the rapid exodus of dentists from it.

Dentists want to be able to provide care for medical card patients, but, if the reform of the scheme continues to be ignored and left in this current state of flux, the Government is leaving us with little choice but to continue to minimise our involvement or withdraw.

While we remain deeply frustrated, we want to find a sustainable solution that benefits all parties, but especially our patients. We urge the Government to engage with us as an immediate priority as the longer it is left, the less it becomes about how the medical card scheme can survive but more about how soon it will end. And that is in no-one’s interest.