Lyn Allison (Victoria, Australian Democrats) Share this | Hansard source

It was encouraging to see that money was finally being allocated to dental care in the 2007-08 budget—or, more correctly, to assist those people who do not have private health insurance. The government spends about $400 million a year in paying 30 per cent of the cost of dental care for those able to afford private ancillary dental health insurance cover. The Minister for Health and Ageing has consistently argued that dental care was not his responsibility and that it was all up to the states. He conveniently ignored the Constitution, which clearly recognises the role of the Commonwealth in the delivery of dental services. Of course, once it looked like dental health was going to play a part in the federal election, the coalition was forced to do something to take the heat off. That is their standard response when it comes to health: wait until there is a public hue and cry, and make some quick announcement that will quieten things down and then move on. Unfortunately, these announcements do not usually tackle the real issues or provide any long-term solutions, and this announcement is no exception.

Ten years ago the Howard government shirked its responsibility for dental care by walking away from the former Labor government’s $100 million-a-year Commonwealth dental scheme and ordinary Australians had to face the consequences. Hundreds of thousands of people are on waiting lists for public dental care around Australia. Estimates put that figure at 650,000 people, with an average waiting time of 27 months. So that it is one in every 30 Australians, and it is probably an underestimate because anecdotal evidence suggests that lots of people are simply not joining the list because they do not think there is any point. Those 650,000 do not include the many who are not eligible for the public system—people who do not have a health card but cannot afford the private system, where dentists can charge whatever they like.

Dental fees have increased much more quickly than other health services and faster than the CPI. Too many people put off attending to preventive treatment and fillings and cavities, as more urgent bills pile up at home—and their oral health continues to deteriorate. A recent survey by the National Oral Health Alliance estimates that as many as 40 per cent of Australians could not access treatment when they needed it because of costs and a severe shortage of dentists. By 2010, Australia will be short 1,500 dental workers, mostly dentists—that is 3.8 million dental visits that will not happen. The shortage of dentists is already acute in rural and remote areas.

The Australian Dental Association recently released figures showing that on average Australia had 47.4 practising dentists for every 100,000 people. A breakdown of that figure shows that while major cities might have 56.2 dentists per 100,000 people, remote areas had just 22.9 dentists for the same number. Regional areas do not fare much better either. Inner regional locations have 33.6 dentists and outer regional areas 26.6 dentists per 100,000 people. So there is a growing inequity in dental health and care in Australia, whether we are talking about geographic inequalities between rural and urban Australians or between socio-economically disadvantaged communities and their wealthier counterparts. Low-income adults without private dental insurance are 25 times more likely to have all their teeth extracted than high-income adults with insurance. Children in lower income families now have twice as many rotten teeth as those in wealthier groups. Dental health is an area which very clearly illustrates one of the major problems with Australia’s health system: the lack of priority given to prevention and early intervention.

Rather than spending money on education, checkups and early treatment, the federal government is spending millions of dollars a year on GP visits and hospital care for dental problems. It is very difficult to get good data, but reports suggest that up to one in 10 GP visits are for dental problems, costing Medicare hundreds of millions of dollars a year. People come in for repeated prescriptions for antibiotics and painkillers because they cannot find and cannot afford dentists. If you are in pain with a dental infection, it makes sense that of course you would go to your local GP for drugs. But that sort of treatment does not work, which is why people turn up over and over again. GPs cannot fix teeth, they can prescribe antibiotics and pain relief, but the underlying problem remains and it keeps coming back. Eventually things get so bad that people end up in hospitals. More than 30,000 people are hospitalised every year because of a dental condition.

And they are not all older people. The No. 1 reason why children under the age of five are admitted to hospitals is for their teeth. Of course, there is increasing research and awareness of the connection between oral and general health. We know that the failure to treat dental problems can lead to or exacerbate other illnesses elsewhere in the body. Poor oral health has been linked to arthritis, diabetes and cardiovascular disease to various degrees. And this is not a failure of policy. In 2004 the national oral health plan, called Healthy mouths healthy lives, was a comprehensive approach to improving oral health and was endorsed by all health ministers. But three years down the track there has been very little improvement. Unfortunately, the changes to the Medicare enhanced primary care scheme for people with chronic and complex conditions proposed in the Health Insurance Amendment (Medicare Dental Services) Bill 2007 will do little to fix the underlying and ongoing problems. On the surface it seems as if, at long last, the Howard government is acknowledging its responsibility for dental care, but it has allocated the money in such a way that most people will not be able to get the help they need. The government has selected one group of people to help, and they will have to go to a doctor and show that they have a condition with complex care needs and receive care under a written management plan.

And then they will have to show that they have a dental problem which significantly adds to the seriousness of their medical condition so they can get permission to see a dentist and get some care. The existing dental items in the enhanced primary care scheme have not been a roaring success, and even that has been acknowledged by the government. There has been a very poor uptake, attributed in part to the administrative complexity of the scheme and the restrictions on age eligibility. So it is hard to see how increasing from three Medicare items to 450 Medicare items will make the system any easier for people to use.

Finding dentists who would accept the rebate as the total payment has also been a problem, meaning that lots of people still face out-of-pocket expenses they cannot afford. It is true that there will be higher rebates under this system but co-payments are still allowed and some eligible patients will not be able to afford to pay the co-payment. The new system will also have a cap on it of $4,250 over two years and people will then have to cover all of the costs for any ongoing dental treatment after that. It is difficult to assess what impact this bill will have; after all, most of the detail, including the eligibility criteria for dental providers and patients, will be up to ministerial determination. But we do know that it will not help those who need to receive their dental care in a hospital environment. These patients will be ineligible for the Medicare rebates.

There are many special needs patients who, for a variety of reasons, cannot be treated in a dental surgery, whether it is because of a mental health problem, an intellectual disability or a physical illness such as cancer, leukaemia or haemophilia. Those patients with special needs that would require them to be under general anaesthetic in hospital or require other hospital-level assistance while undergoing dental treatment will miss out. Dental care is largely primary care and deserves federal funding. This is not a case of the Commonwealth taking over dental care; it is a case of it simply paying its fair share. This means more than simply extending a program that will do nothing for most of the people in direst need.

There should be specific Commonwealth funding for low-income people to get access to free basic dental care, not just people with complex and chronic conditions. The report into health funding by the Commonwealth dominated House of Representatives Standing Committee on Health and Ageing recommended way back in December last year that the federal government supplement dental care for those in disadvantaged positions. And we should extend Medicare to cover medically necessary dental care for the medically compromised—those patients who, because of their medical, physical or mental state, cannot be treated by general dental practitioners in the private or the public setting and require treatment to be undertaken within the safety and resources available in hospitals.

This group, which includes the severely immunosuppressed—such as organ and bone marrow transplant recipients, patients who require replacement heart valves and those needing radiotherapy treatment to the neck and the head—need medically necessary dental care and this should be funded by the Commonwealth. Equally, those people with intellectual or psychological disabilities that necessitate hospital based dental treatment should be covered by the Commonwealth. And there should be a much greater focus on preventive oral health programs, including dental health promotion and public education campaigns. This would include screening and dental hygiene programs in all primary schools. We should not be simply flinging money at repairing and replacing teeth. This does not fundamentally improve dental health in the country. Once a tooth is replaced or repaired it needs ongoing regular maintenance. To be effective, we need to address the major cause of oral health dysfunction—tooth loss.

We need to be supporting preventive practices, including dental-office-based fluoridation, diet assessment and education, and cleaning and scaling. And we need to fix the lack of a workforce to provide oral health care. We need long-range dental health workforce planning and more university places for dentists and dental hygienists. The federal government has increased dental training places to address the shortage of dentists, but more graduates are still needed to make the dental labour force adequate. And we need more Commonwealth supported dental places.

We also need incentives to encourage graduates to work in rural and remote areas and the public sector, and this means better salaries and conditions for all dental workers working in the public sector. We should be looking at more scholarships for dental students from rural and remote areas and exploring debt forgiveness for dental graduates who agree to provide their services in regional, rural and remote areas or in the public sector. We need to think about providing financial support for dental intern programs, as has been successfully undertaken in Britain. This would allow the immediate creation of an extensive oral health workforce in public hospitals and dental clinics, available to the most needy, as well as ensuring the availability of dentists in rural and regional areas.

We could look at providing salaried, speciality training positions for orthodontics, oral surgery and periodontics, with the requirement of one to two years return of service in a public facility—again providing better access to specialist services in public settings. There should be outreach programs for Indigenous Australians, people with mental illness, homeless people, prisoners and the chronically ill. And we need more dental health assessment and follow-up by dental hygienists in residential aged care. We do need more money to tackle the disastrously long waiting lists for basic dental services, for the relief of pain and the repair and replacement of teeth. But we also need to look to the future and prioritise training, prevention and research if we want to see real long-term gains—that is, gains that go beyond an electoral cycle.