Report of the National Advisory Council on Dental Health

Executive Summary

The National Advisory Council on Dental Health (the Council) was established as a time-limited group to provide strategic, independent advice on dental health issues, as requested by Minister for Health and Ageing, to the Government. The Council’s priority task was to provide advice on dental policy options and priorities for consideration in the 2012-13 Budget.

Page last updated: 03 September 2012

      On 5 September 2011, the then Minister for Health and Ageing, the Hon Nicola Roxon MP, and Senator Richard Di Natale announced the establishment of the National Advisory Council on Dental Health (the Council). See Appendix A for the Council’s Terms of Reference.

      The Council’s deliberations have been informed by discussions with key dental health bodies, consumer group representatives, Indigenous organisations and other key stakeholders (see Appendix H). The Council provided an interim report to the Minister for Health and Ageing on 30 November 2011. This report contains options and priorities for consideration in the 2012–13 Budget.

      Structure of the Report

      Chapter One discusses oral health in Australia, including the significant improvements to oral health over the past few decades. Despite these improvements, too many Australians have difficulty accessing services. Many of these people have poor oral health, suffer from pain and social exclusion and have poorer general health. This extends beyond the individual to the wider economy through lost productivity and costs to the health system.

      Chapter Two provides an overview of the dental system in Australia, including the roles of the State and Territory and Commonwealth Governments. It also discusses the dental workforce.

      Chapters Three and Four describe the indicators of and reasons for poor oral health across the population. The burden of poor oral health is greatest in lower income groups and for rural and remote residents. The reasons for poor oral health are complex, but structural factors play a major role. In a dental system which is largely private, affordability remains a key barrier. Other factors which influence access are the inadequate capacity and funding of the public sector as well as workforce maldistribution, which limits the supply of dental practitioners in rural and remote locations. Social and behavioural factors also influence access.

      Chapter Five presents eight aspirations for oral health (based on the Principles at Appendix B), which the Council believes are necessary for achieving long–term improvements in oral health. The aspirations form the pathway to achieving optimal oral health for Australians. They require collaboration and a commitment from all stakeholders to long–term reform and investment. These aspirations are also part of the framework that underpins shorter–term options, ensuring they form a solid foundation for future reform.

      Chapter Six provides the Council’s advice on options that take into account existing Commonwealth and state and territory programs, as well as how responses to oral health could be phased, or scaled, over time and still remain integrated with the longer–term goal. However, in the medium and longer term, financing options may be required.

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      The Findings of the Council

      All members of the Council believe that the long–term goal should be universal and equitable access to dental care for all Australians. One member believes that equitable access to care should occur through the provision of targeted schemes aimed at delivery of comprehensive care to disadvantaged adults on public waiting lists and a universal scheme for children.

      The Council understands that a comprehensive response for those facing access barriers is potentially very costly. Achieving better access across the population would require a level of funding many times above current government expenditure on oral health.

      As a first step in addressing the nation’s oral health needs, the Council has focused on improving access for children and lower income adults. Children are a priority because improvements to child oral health and prevention will reduce the overall burden of disease and improve long–term oral health across the population. Low income adults are a priority because they are more vulnerable to dental disease – treating their existing and complex oral health problems will lay a foundation for more effective long–term preventive measures. These priority groups could be separately targeted. However, the Council recommends that the Government considers action to address the needs of both.

      The Council believes that in cases where funding is limited, it is crucial that measures to increase access to services, where possible, use existing service mechanisms so that funds are used efficiently. Engagement across governments to clearly define responsibilities would help policy planning and ensure funding can be appropriately applied within respective funding frameworks and service delivery models. In regard to priority groups, state and territory expertise should be used as much as possible to maximise desired outcomes. To recognise this, all options interact with the state and territory public dental system.

      To further ensure that services are delivered efficiently, the foundational activities are proposed to encourage co–ordination of existing assets as well as support for synergies between local, state and national organisations.

      The Council has structured options so that they could be articulated within a future universal access system. Furthermore, options can be scaled over time.

      The Council agrees that oral health should be seen in the context of general health and that oral health reform should also be linked to current health reforms, such as the establishment of Medicare Locals and Local Hospital Networks. Incorporating oral health within these reforms will help to identify service gaps, improve access to services and integrate oral health services with other primary health care services.

      It is the Council’s view that the essential dental services should include diagnostic, preventive and routine services. This approach allows for a focus on prevention and early intervention. However, some patients may require more complex high–end oral care that is not categorised as diagnostic, preventive or routine. In these cases, the Council recommends that there should be a mechanism whereby patients could access complex care items in exceptional circumstances. This could be the subject of further analysis in the context of implementing options.

      The Council recognises the role private health insurance plays in the assisting 11.9 million Australians with financing of health care, including dentistry. The Council was not able to consider private health insurance in any depth. Further consideration needs to be given to the interactions between the options pursued and private health insurance. This includes consideration of the potential for overlap in public subsidies for dental services and private health insurance. The Council agreed that such consideration could extend to future reforms and incentives for private health insurance as well as other methods of financing dental services.

      A summary of the Council’s proposed service delivery options are presented below, with further details provided in Chapter Six and at Appendix C. Estimates of costs have been developed by the Secretariat in consultation with Dr Martin Dooland.

      Professor Spencer expressed support for the implementation of options to be advanced into the 2012–13 year. This would allow the integration of the first steps for children and short–term activities for adults into the respective selected option. It would also have consequences for the costs for 2012–13 and the forward estimates.

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      Summary of the options for dental services for children

      The Council has put forward two broad models for a universal children’s scheme based on current dental service delivery systems. The first would utilise an individual capped benefit entitlement and provide a basic suite of preventive and treatment services. The second would expand services and improve consistency across state and territory public dental services.

      The Council believes that the options for children have both short– and long–term benefits. In the short term, they will strengthen the existing system and maintain visiting patterns for the majority of children. At the same time, additional arrangements will focus on reaching children who are receiving inadequate services. Efforts in this area will help reduce more serious decay and infection, thereby reducing admissions to hospital for removal of teeth under anaesthetic. Over the long term, the improvements in the oral health of all children will build an excellent foundation for improvements across the population.

      The child options could be scaled. This could start by targeting children of concession card holders and then moving to other groups such as low income non–concession card holders and those receiving other government payments.

      Option 1− An individual capped benefit entitlement

      This option is aimed at increasing access to basic dental services for all children up to the age of 18. This could be done by expanding existing service arrangements and eligibility through the Medicare Teen Dental Program (MTDP). The annual benefit entitlement cap would be increased to reflect the cost of accessing basic preventive care and treatment. The benefit could be used in the public or private sector (estimated cost over the forward estimates from 2012–13 − $3.0 billion).

      Option 2 − Enhanced access to public dental services

      This option is aimed at increasing access for all children up to the age of 18 to basic dental services by enhancing existing public sector services. Services for children would be improved through consistent eligibility criteria and service levels across the states and territories. Program requirements and the funding model would need to be developed through formal discussions at the intergovernmental level (estimated cost over the forward estimates from 2012–13 − $2.5 billion).

      Summary of the options for dental services for adults

      As a first step towards universal access, the majority of the Council believes that this should start with servicing those in greatest need, namely low income adults. Dr Shane Fryer supported an option aimed at disadvantaged adults on public dental waiting lists and believed this would be the most effective in delivering equitable and comprehensive dental care.

      The Council considers that there are two broad models available for targeting services to lower income adults. The first would utilise an individual capped benefit entitlement, which could build on existing legislative frameworks, such as the Medicare Chronic Disease Dental Scheme (CDDS). The second adult option would expand capacity and improve consistency across existing state and territory services. These options are designed as a stepping stone on a path to a universal access program.

      These options could include a short–term measure to fast–track services for people on public dental waiting lists. This may require additional funding to the states and territories while any other adult options are being implemented. This would be an interim measure and should not impede the implementation of other adult options.

      Adult options could be scaled up over time to include other eligible groups, for example chronic disease sufferers and low income non–concession card holder adults.

      Option 3 − A means–tested individual capped benefit entitlement

      This option is aimed at increasing access to basic dental services for all concession card holder adults with funding provided through a capped benefit entitlement scheme through a schedule of services. The CDDS could provide the service delivery platform. A mechanism for access to high–end services or caps could also be made available in ‘exceptional circumstances’ (estimated cost over the forward estimates from 2012–13 − $7.1 billion).

      Option 4 – Enhanced access to public dental services

      This option is aimed at increasing access for concession card holder adults to basic dental services by enhancing the public sector. Services for adults across the public dental system would be improved through capacity building and consistent service levels. Program requirements and the funding model would need to be developed through formal discussions at the intergovernmental level (estimated cost over the forward estimates from 2012–13 − $3.0 billion).

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      An integrated model for card holder adults and all children

      The Council also considers that implementing the adult and child options at the same time would improve services across all age cohorts. The possible combination of options for children and adults could also differentiate Commonwealth and state responsibilities for dental health. Additionally, they would help ensure that each level of government continues to maintain its effort in providing or funding dental services.

      The Council examined each possible combination of child and adult options. One example of an integrated approach demonstrates a possible division of responsibilities between the Commonwealth and the states, and uses existing systems in the short term, expanding its reach over time:

      • The states and territories have a long standing involvement in school dental services and could develop the capacity to care for all children, particularly focused on those most in need. In this combination of options, states would be responsible for delivering services to children. States would also undertake additional activities to reach those children who currently do not have access to adequate care.
      • The Commonwealth would take responsibility for concession card holder adults for preventive and treatment services. This could be built around an altered CDDS framework. Eligible adults would access services in the public or private sector. Phasing of this option could provide short–term assistance to the 400,000 adults on public dental waiting lists.

      The total estimated cost for this option would be in the order of $10.1 billion over the forward estimates from 2012–13. Other combinations of options and lines of responsibility are possible. Part of the dental reform process could include discussions between states and the Commonwealth (formal discussions at the intergovernmental level) on responsibility for children and adults or other options, including shared responsibility for particular groups.

      Foundational activities

      All service delivery options require foundational activities around workforce, capital infrastructure, oral health promotion and special access programs (for population groups that face barriers), which are specifically designed to support successful and sustainable improvements in oral health for priority groups and, eventually, universal access.

      The range of activities would require an appropriate delivery framework. Appendix H highlights the work of a Medicare Local in Sydney, providing an example which could be the foundation of a future delivery framework.

      Dental workforce and infrastructure

      The terrain of the dental workforce has changed significantly in recent years, with the growth in the combined number of oral health therapists, dental hygienists and dental therapists (noting that there are variations within the individual professions). This has provided the context to re–examine pathways for co–ordinated analysis and planning of the future dental workforce.

      The Council recognises the important work of all dental practitioners working together – dentists, oral health therapists, dental hygienists, dental therapists, dental prosthetists and dental specialists. However, workforce foundational activities would also require action on workforce utilisation, supply and infrastructure, and academic and clinical training and infrastructure.

      Data and research

      The Council supports improving the evidence base for workforce planning through ongoing research. The recent publication of new data on practitioner registrations highlights the need for ongoing monitoring of the dental workforce and the periodic revision of dental workforce supply projections.

      Policy making, program design and evaluation needs to be supported by sufficient ongoing funding for data and research. Existing support for population–level monitoring and surveillance of oral health, use of dental services and practice activity could be maintained. The Council believes it would also appropriate for the Government to fund periodic research and analysis.

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      Oral health promotion

      Australia has a world class record in health promotion, including tackling road accidents and drink driving, smoking, and HIV/AIDS. However, expenditure on oral health promotion and non–clinical prevention activities is very low – estimated to be around one per cent of expenditure, compared to even the highly modest two per cent of expenditure across the whole health system. This could be significantly increased to reduce the incidence of dental caries and periodontal diseases. This would both improve the quality of life of Australians and reduce the demand for future dental care.

      Groups with special oral health needs

      The Council suggests a range of activities targeting Indigenous people, people residing in rural and remote areas, people in residential care, homeless people and people with disabilities. Medicare Locals could be particularly useful in coordinating services for these groups.

      By undertaking these foundational activities, workforce maldistribution between rural and urban areas, as well as the public and private sectors, could be reduced. Appropriate infrastructure may help to both educate dental practitioners from under–represented groups and provide improved service levels to the population. Improved research can allow for groups with special oral health needs to receive appropriate dental care and targeted oral health promotion. These foundational activities are complementary to each other and would help to target services appropriately.