LESLEY RUSSELL: Time to make dental care an election issue

The Victorian Government’s election commitment to a $395.8 million program to provide free dental care to schoolchildren will be welcome in a state where affordable and timely access to dental care is increasingly difficult. It’s time for a concerted campaign to ensure that improved access to dental care and better prevention initiatives are on the agenda for the upcoming New South Wales and federal elections. Governments must be persuaded that their failure to see oral health, dental services and caries prevention as essential components of health care is a false economy.

Pleasant surprised, even relief, might be the best description for policy wonks’ reaction to the announcement from Daniel Andrews of an election policy that will provide free dental care to all Victorian children who attend state schools, with a promise to consider its expansion to Catholic and independent schools by 2021.

It’s not clear whether the situation in Victoria is any worse than elsewhere in the nation, but it serves to highlight why action is needed. More than half a million Victorians say that cost stopped them from getting dental care when they needed it in the past twelve months.  Victorians who rely on the public system must wait an average of 20 months for an appointment.

This new initiative from the Victorian Labor government is a good investment for several reasons, most particularly because it offers the opportunity for preventive and early treatment services to children which is a high value investment. It will also ease the pressure on the public system (the estimate given is that it will free up to 100,000 places per year). It responds to community needs and builds on the $12.1 million announced in May to address waiting lists for public care.

It’s a long time since dental care has been an issue for any government’s election campaign or on their policy agenda once in office, despite recognition that it is increasingly difficult for many Australians to access affordable dental care and that this has costs to individuals, health care budgets, and the economy. Nowhere are the growing inequalities in health between rich and poor, rural and urban, Indigenous and non-Indigenous, highlighted more than in dental health. Today the raft of dental reforms and the funding levels to support them that were put forward by the Gillard Government in the 2012-13 Midyear Economic and Fiscal Outlook serve as sad reminders of what can be achieved.

A national Oral Health Tracker released in March presents a damning set of statistics about the state of Australians’ teeth. It also highlights the links between oral health and preventable chronic diseases such as diabetes, heart disease and cancer, and the risk factors (smoking, alcohol abuse, consumption of sugary drinks) that are linked to both these diseases and oral health.

The numbers are shocking: one in four children aged 5-10 years have untreated tooth decay in their primary teeth and one in 25 Australians aged 15 and over have no natural teeth. Some 5.7 million Australians are living with at least one dental or oral health issue. About one in five Australians do not get the recommended level of oral health care and only 50 percent of people brush their teeth twice a day. The picture is worse for Indigenous Australians, especially in remote communities where sugar-laden processed foods are ubiquitous but dental services are scarce.

Cost is the major barrier to accessing dental services. Of the total annual spend on dental care ($9.9 billion in 2015-16), individuals contributed 58 percent in out-of-pocket costs. Little wonder that 44 percent of uninsured Australians and 20 percent of those with insurance delay or avoid going to the dentist. Twenty percent of those who do go to the dentists are unable to proceed with recommended treatment because of cost.

Waiting times for public dental services are very long almost everywhere. Although the data collected under the Public Dental Waiting Times National Minimum Data set for the period 2013-14 to 2016-17 has been published, it is incomplete and inadequate to enable accurate assessments and comparisons of waiting times across the states and territories.

New South Wales and the Northern Territory have not provided any data; some data from other states is missing. Separately the Victorian branch of the Australian Dental Association has mapped the average waiting times for dental services across that state as at June 2018 – this sort of information should be produced nationally.

The awful waiting times (in 2016-17, 50 percent of patients wait more than 509 days to receive general dental services in Tasmania and more than 445 days in Queensland) relate to a minority of patients because the majority receive care through priority or emergency care arrangements which are not necessarily managed using waiting lists. This situation contributes to increased costs and becomes a vicious circle where patients on increasingly longer waiting lists ultimately end up as emergencies.

The other major issue is that Australia has a significant mal-distribution of the dental workforce. Outside the major capital cities, the distribution of accessible dental care is at best patchy and the majority of dental practices (84 percent) are located in areas classified as less disadvantaged.

The failure to invest in public dental services is a false economy for governments. When there is no access to dental care, patients seek help from elsewhere in the healthcare system.  One recent study highlighted that rural GPs see, on average, 12 patients a month for dental and oral health issues. Their usual response is “sorry I’m not a dentist” and prescriptions for antibiotics and pain relief. The cost of this to Medicare and the Pharmaceutical Benefits Scheme is unknown, but at (say, conservatively) $600 per month per GP, this could be significant.

People with dental pain and infections may attend Emergency Departments. A recent pilot study in two major Melbourne hospitals found dental patients made up 0.24 – 0.65 percent of ED presentations. Using 2016-16 data for ED presentations and assuming that 0.5 percent were for dental, that’s 39,000 ED visits nationally every year, the majority of which could have been better directed elsewhere. The average cost for an ED visit for patients in the lowest triage category has been estimated at $364 .

In 2016-17 there were 70,200 hospitalisations for dental conditions that could have been prevented with earlier treatment. In 2016-17, the average public hospital cost for an episode of care for diseases and disorders of the ear, nose, mouth and throat was $3,739.

An astute economist (which, sadly, I am not) could quickly calculate that savings that would accrue with better dental care and which would serve as at least a partial offset to the costs of increasing access to care (my guestimate is around $400 – $500 million / year). It’s a sad indictment that there is so little data on the costs to government and society – the situation has no improved since the National Advisory Council on Dental Health attempted to look at  these issues in 2012.

The Commonwealth Government contribution to dental services is very small. The National Partnership Agreement on Adult Public Dental Services, initially funded by Labor at $1.3 billion over four years, is currently funded at $107.8 million / year. The Child Dental Benefits Schedule (also introduced by Labor) provides access to benefits (capped at $1000 over a two-year period) for basic dental services to around 1.1 million children aged 2-17 years each year. This program could do more, but it is under-promoted and therefore under-subscribed.

The Coalition Government’s antipathy towards these programs is demonstrated in almost every Budget: the 2015-16 Budget included  a pause in indexation arrangements for the CDBS, with savings of $125.6 million over four years, and then in the 2016-17 Budget there was an attempt to terminate both the CDBS and the NPA and replace them with a new National Partnership Agreement for a Combined Child and Adult Public Dental Services, for which the Commonwealth would initially provide 40 percent of the national efficient price for services provided under the scheme. This proposal failed because Labor highlighted that it would result in $1 billion cuts to dental services.

What can we expect going into the next federal election in the first half of 2019? Sadly, it seems very likely that the Morrison Government will leave the current NPA, which expires in June 2019, unfunded. That will require an incoming Labor Government to find the funding for this (more than $1 billion over the forward estimates simply to maintain current levels) before they even begin to look at expanding services elsewhere.

Labor’s Expenditure Review Committee will have to look for offsets elsewhere (how about re-directing the money currently spent on the Private Health Insurance rebate for ancillaries from the private to the public good?). They must also be bold enough to take a longer-term approach and to realise that investing in dental services will save money in primary and acute care.

There is no silver bullet style solution here. A multi-faceted approach is needed with long-term investments in prevention. An astute Minister for Health will recognise that efforts to tackle obesity by taxing sugary beverages will also mean fewer dental caries. Public health initiatives that address smoking, the value of breast feeding, and the harms associated with excessive alcohol consumption will also help improve dental health.

I have previously put forward a number of pragmatic interventions  that are first steps towards the better integration of dental and medical care to improve health outcomes and contain overall health care spending. All of these could be undertaken simultaneously without overburdening the budget.

A key issue will be the need to develop and implement targeted approaches to ensure the best value for money and avoid the siphoning of services from the needy to the less needy. Australian dental academics have exactly the tools to do this, using geospatial analysis to identify locations where the provision of dental services could be sustainable and could deliver real health improvements.

There is clearly an important leadership role for the dental professions, who must look beyond their own monetary interests and recognise the value in ensuring that all Australians have affordable access to dental services. They must become part of the solution, not remain part of the problem. Professor Heiko Spallek has laid out the important questions for his dental colleagues – will they now take up the challenge to find the answers?

Political leadership and bravery in the face of entrenched stakeholders and conservative ideologies will be crucial to carrying forward a long-term commitment to improved dental services. But nothing will happen unless and until voting Australians let their political representatives know that they want dental health as an integral part of health care, that they understand the costs involved in doing this – and in not doing it – and that they want real, meaningful, sustained and well-resourced action now.

Dr Lesley Russell is an adjunct associate professor in the Menzies Centre for Health Policy at the University of Sydney.

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