“Oral health is fundamental to overall health, wellbeing and quality of life. It is an important part of general health, affecting not only the individual, but also the broader health system and economy.” So says the 2017 Performance Monitoring Baseline Report for Australia’s National Oral Health Plan 2015 – 2024. This acknowledgement that oral health is an essential component of a healthy life is promising, but how do we know if we are moving towards enshrining good oral health for all Australians?
Despite oversight by the Coalition of Australian Governments (COAG) Health Council for setting the national strategic direction for oral health, the Performance Monitoring Report acknowledges that “It is recognised there are limited outcome measures in oral health for the NOHP KPIs”. Or, one might be tempted to paraphrase to, “We are a long way from being able to measure anything meaningful about Australia’s progress in oral health.”
We are four years into the plan, and yet we are still trying to figure out what to measure.
The report features graphics illustrating key facts and statistics relating to oral health. These might be user friendly, but closer reading reveals that much of the data quoted within the report is historic, with only some of the statistics quoted being collected after the National Oral Health Plan was implemented. We lack contemporary and comprehensive information about dental disease, patterns of dental attendance and attitudes towards dental treatment. Sadly, we know more about the barriers to accessing dental care than we do about the benefits of such care.
When discussing access, the report is surprisingly vague; “Whilst irregular dental visiting patterns could reflect a lack of perceived need, they could also reflect barriers to dental care”. We are all too aware that financial cost is a substantial barrier to accessing dental care. This has been the focus of a previous blog at Pearls and Irritations.
Those afflicted with toothache, damaged smiles, or loose teeth are highly likely to know that they need to see a dentist, but also highly likely to be unable to afford to access services. In this era where the confidence that a straight, bright and white smile brings is advertised explicitly or tacitly from every media outlet and endorsed by celebrity and consumer culture alike. Who truly doesn’t know the value of regular visits to the dentist?
So, what is being done to improve access to dental care? The report points out that “Governments have funded a range of public dental programs recognising the issue of affordability of oral health care.” While there is the desire to fund dental care appropriately in Australia, the Australian Institute of Health and Welfare reports the current funding levels for the public dental service are only covering about 20 per cent of the eligible population. The Australian Council of Social Service’s Fair Dental Care for Low Income Earners: National Report on the State of Dental Care reports the Commonwealth has spent $701 million on Private Health Insurance rebates to dental care. This emphasises the issue of equitable access to appropriate dental care in Australia; a fact that the monitoring report seems shy to proclaim.
The report also demonstrates the compromised nature of some of the data we have relating to the dental decay in children; “tooth decay rates amongst children accessing public dental services have increased (although since the early to mid-2000s the public dental data has not included NSW and Victoria).” The populations of NSW and Victoria contain the majority of Australians. Exclusion of data from these states mean that the usefulness of these statistics in drawing conclusions about the direction of oral health is greatly limited. This data is also considerably outdated: “The latest data from the NCOHS 2012-2014 demonstrates there is still a high prevalence of dental caries, particularly in children, which indicates it as one of our most significant childhood health challenges.”
Those who have followed the progress of oral health in Australia might be pardoned for sensing a feeling of déjà vu from this report. The report seems to echo sentiments from the previous plan, Healthy Mouths Healthy Lives: Australia’s National Oral Health Plan 2004–2013, noting; “Despite significant improvements in the oral health of children in the last 20-30 years, there are persistent high levels of oral disease and disability among Australian adults”. In particular, the 2004-2013 plan notes the main burden of disease being carried by Indigenous Australians, those on low incomes, living rurally and remotely and those from immigrant backgrounds, particularly refugees. It has become apparent that the progress of Australia’s oral health is inequitable and failing the most vulnerable.
We still use and cite this very old data that was collected when many current programs were not in place yet. These surveys are costly to run and are outdated at the point of their publication.
Is there a better way of doing this? Electronic Health Records, even the ones connected Australia’s $2 billion My Health Record system, are far from fulfilling their original intention of supporting the best possible care for all patients. Most of them, despite their technical potential, are still set up as encounter-based reporting tool to support documentation and billing. Instead of ‘counting fillings’, as we have argued previously, measuring what matters would allow dentists to switch to risk-based prevention and patient-centred, evidence-based disease management. The routine collection of caries risk assessment and dental diagnostic codes using standardised terminology could inform performance reports like this one that intend to monitor improvements on health outcomes.
Instead of focusing on such outcomes, the report suggests to ‘monitor’ over the ten-year period of the NOHP is the proportion of people who have received an oral health check-up from a dental practitioner in the previous two years. This is a service delivery measure for which there is no evidence base as the report does nothing to expand on why this interval has been chosen.
It should be noted that dental professionals work hard in their service to the public, with the vast majority of patients being highly satisfied with the individualised aspects of their care (95 per cent of people who visited one in the previous 12 months responded ‘always’ or ‘often’), show respect for their patients (96 per cent) and spent enough time with their patients (89 per cent). However, these statistics obviously omit, for instance, 107,322 adults and 13,284 children on NSW public dental waiting lists. The dental profession strives to provide quality and appropriate care to the public, especially those who are most likely to suffer poor oral health and the negative impacts on general and social health that this brings. Poor access stifles the dental profession’s ability to deliver oral healthcare to those who would benefit the most.
Our well-trained oral health workforce knows how to keep people healthy—76 per cent of Australian kids aged 6-14 years have no dental decay. However, many Australians do not access dental care, not primarily because of fear—according to this report 13 per cent provide a reason that includes fear and anxiety, but because of financial barriers (20 per cent alone). Fewer than half (44 per cent) of Australian adults with teeth had a regular dental provider whom they visit for an annual check-up. An appalling statistic when compared to other developed countries (USA, 64 per cent, England and Wales, 61 per cent, Canada, 85.7 per cent).
What happens if you can’t pay to see a dentist privately? In NSW, chances are you might end up joining the 107,322 adults and 13,284 children on NSW public dental waiting lists. Lack of access to care has resulted in human suffering, like the 132,700 hospitalisations where the patient had general anaesthesia for a dental procedure (2016-2017), or the 42 per cent of all children aged 5–10 have experienced tooth decay in their primary teeth (‘baby teeth’), or the 67,060 preventable hospitalisations for oral health conditions in 2015-16 (that’s 10 per cent of all preventable hospitalisations, at an estimated cost of some $230 million). Cynics might point out that the biggest fear about visiting a dentist is not no longer anxiety, but financial barriers.
Is there light at the end of the tunnel? The recent speech setting out Labor’s plans for Australia’s health by Shadow Health Minister, Catherine King MP, mentions dentistry only once. This omission is perhaps forgivable; certainly, the general direction of King’s speech is laudable, and let’s face it, she couldn’t mention everything! If we move past this omission, we see that the main barrier to accessing health services seems to be universal: cost. The Shadow Minister’s speech details the unavoidable choice between unaffordable private care and unbearably long waiting times in the public sector – that is certainly the case for dental care.
King’s announcement of a permanent Australian Health Reform Commission has been regarded as a positive move by some commentators. How will oral health fit into the work of this commission? It is promising that many of the issues that need attention in the healthcare system relate to dentistry and oral health because too often oral health has been seen as a cosmetic extra rather than a medical necessity.
An apolitical body that could report on health services in terms of effective targeting, efficient use of taxpayers’ dollars, improved outcomes and equity, and deliver frank assessments of the work that still needs to be done would be far more helpful than reports which attempt to demonstrate progress where none really exists. Oral health is improving, but not for those in society who are most vulnerable. Dentistry is some of the answer to this complex question, but an integrated, prevention-focused system of oral health provision is long overdue – because governments from both sides of the political arena have neglected this facet of health.
Professor Heiko Spallek is Head of School and Dean; Dr Alexander Holden is Senior Lecturer in Dental Ethics, Law and Professionalism and Head of Subject Area – Professional Practice; both at The University of Sydney School of Dentistry.