Chapter 3Looking forward - key questions for the inquiry
3.1Evidence to this inquiry, and many more before it, indicates that Australia’s public dental and oral healthcare is fragmented, under-resourced and overstretched. Australians are paying more for dental care than people in many other countries, but with poorer health outcomes, and access to dental services remains deeply inequitable. People experiencing poverty, disabled people, prisoners, Indigenous Australians, older Australians and those in care are most impacted by deficiencies in the current system.
3.2The problems are clearly defined and well understood, and a number of possible solutions have been articulated over recent decades. Despite this, very little has changed.
3.3This chapter explores key proposals for reform that are emerging in the submissions received so far, and outlines questions arising from these proposals. Noting the committee’s evidence is preliminary and incomplete at this stage, this report does not draw conclusions or make recommendations. It is the committee’s intent to interrogate a variety of options and present its findings in the final report.
3.4Preliminary proposals explored in this chapter include:
integrating essential oral healthcare and preventative care into existing health assessment and care settings;
expanding the scope of public subsidies under Medicare for dental and oral healthcare, using the current Child Dental Benefits Schedule (CDBS) as a model;
implementing an Australian Senior Dental Benefits Scheme;
national administrative reforms, including establishing a Chief Dental Officer to coordinate a national approach;
improved national data and evaluation;
addressing the disparity of dental care between metropolitan, rural, regional and remote areas;
education, training and workforce initiatives;
increasing funding for state-run public dental services and addressing the low proportion of dentists working in public practice; and
initiatives to ensure services reach priority populations, in particular aged and disabled people, prisoners, and Indigenous Australians.
3.5This list is not exhaustive. Other important issues have and will be raised over the course of the inquiry. The committee will explore a wider range of issues and proposals as the inquiry progresses.
Integrate oral healthcare
3.6Submitters noted with concern that oral and dental healthcare in Australia are ‘divorced from the rest of the body’. Former member of the Australian Dental Association (ADA) expert working panel advising the Commonwealth, DrPatrick Shanahan, argued that oral healthcare—as distinct from dentistry—should be integrated into general healthcare:
Problems in the mouth are usually seen exclusively as dental problems because teeth are very visible and important for appearance and function. But what about health? The mouth has more than teeth in it. Blood vessels, nerves, salivary glands, tongue, soft tissues, and soft palate. Who looks after them?
3.7Research indicates many serious medical conditions are linked to poor oralhealth, rather than dental decay. Even those without teeth can be affected by oral health conditions, which can then lead to serious and sometimes fatal broader health complications. Dr Shanahan explained:
Dentists practice independently of medicine and outside health care. This is one of the reasons why we have problems in the health system. Preventing infection is a MEDICALLY NECESSARY service and therefore ESSENTIAL HEALTH CARE. Medicare is legislated to cover essential health care but has excluded oral and dental health from health care and allied health. It failed to make the distinction between essential health care and dentistry.
3.8Dr Shanahan suggested oral hygienists should be funded to work in healthcare, ‘under a medical umbrella as members of the medical allied health team’. Heproposed a pilot be conducted ‘to develop an evidence based (microbiology and radiography) operational model’. This would involve using oral hygienists instead of dentists in many contexts, integrating their services ‘within medical management’. Oral hygienists could also provide ‘intermediate’ restorations, which are ‘much more affordable’ than permanent fillings. Dr Shanahan concluded:
Unlike dentists [oral hygienists and therapists] are prevention, education, and maintenance. The priority is to reduce the medical risk in high risk groups through infection control not restorative dentistry. They have the right to practice independently now. This is a different dental patient, in a different setting, with different needs, different outcomes, different practices, and different abilities. The cost of this is minimal against what is presently spent. It will save more than it costs.
3.9The Australian Dental and Oral Health Therapists’ Association (ADOHTA) put forward a number of suggestions for increasing the use, scope and availability of oral health therapists, particularly to address unmet need in regional and remote communities.
3.10Dental health lecturer, Dr Peter Foltyn, observed that, while ‘sexual health, mental health, disability health, [and] senior’s health’ are all supported under the Commonwealth Medicare Benefits Schedule, oral and dental health conditions are excluded for the majority. This is the case even when the condition is impacting a person’s ‘systemic health’, or needs to be treated before a patient can have surgery or other necessary treatment.
3.11Dr Foltyn recommended that oral and dental health services that are necessary before medical treatment be urgently integrated into the Commonwealth’s Medicare Benefits Schedule. He also suggested medical undergraduate training should include education on ‘the important relationship [of oral health] to systemic health’:
Because oral health care has not been seen as a priority nor fully appreciated by the medical profession and government, many doctors have a limited working knowledge of oral and dental anatomy and the close relationship between oral health and general health. … Education and prevention strategies in oral and dental health care must be put in place now for all medical undergraduate students, doctors and nurses in order to limit a disaster amongst our medically compromised, aged and disabled.
3.12Submitters noted missed opportunities where oral health assessment, education and basic treatment could be incorporated into existing health interventions. For instance, government-funded Aged Care Assessment Teams (ACATs)—which assess the eligibility of older people for care services and make health referrals—look at ‘physical, social and psychological needs’ of older people, but do not consider oral health. Dr Foltyn submitted that assessing oral health needs at this crucial juncture would be an easy way to integrate oral healthcare into general healthcare for older people. He also suggested adding oral health assessments to government‑funded ‘over 75s’ general practitioner (GP) health assessments—which are available free to anyone over 75.
3.13Medical academics, Dr John Rogers and Dr Jamie Robertson, from the University of Melbourne, argued for a similar approach. They recommended governments:
Create oral health promoting environments in pre-school, school, and aged care settings;
Extend preventative value-based dental care by employing minimal intervention approaches such as fissure sealants, Hall crowns, silver diamine fluoride and community-based fluoride varnish programs; and
Trial the involvement of other health professionals in applying fluoride varnish.
3.14Seniors Dental Care Australia argued 70 per cent of the work that dentists do ‘can be performed by oral health therapists, dental therapists and dental hygienists’ effectively, and at lower cost. The ACT Government observed that recent regulatory changes (2022) allowing these professionals to ‘opt in’ to claim under the CDBS have had low uptake so far. It suggested government considers ‘whether this will achieve greater availability and affordability for consumers nationally’.
3.15Some submitters, including Deakin Health Economics, suggested ‘non-dental health professionals’ could be trained to deliver preventative care, such as early assessment of problems and the application of fluoride varnishes. The Australian Dental Association (ADA) agreed that ‘physicians, nurses, and pharmacists, could play a helpful role in early detection, prevention, and referral of oral health issues’, noting limitations in their capacity.
3.16Dr Rogers and Dr Robertson advocated integrating oral health into ‘all relevant policies and public health programs’, enhancing the skills and knowledge-base in the Department of Health and Aged Care (the department) to improve national planning, and including oral health promotion in the remit of the new Australian Centre for Disease Control. They argued that oral health research is ‘inadequately funded in Australia’, with less than 1 per cent of National Health and Medical Research Council research funds going towards oral health research.
3.17The ADA suggested the government support and extend existing oral health promotion activities, such as its annual ‘Dental Health Week’:
Government funding and support in publicising the event and increasing awareness will create an even more impactful campaign. Current reach is significant but necessarily constrained by the budget limitations of the ADA. As the assets already exist, we would be able to rapidly scale to further provide preventative oral care advice to target demographics should Government support become a reality.
3.18DrRogers and Dr Robertson advocated the creation of ‘compatible dental and medical record systems’, that are linked to Medicare, along with other reforms to embed oral health into primary healthcare. While progressing reforms to current structures would require ‘substantial discussion [on] priorities and timelines, funding and implementation responsibilities’, Dr Rogers and DrRobertson contended it is necessary:
Universal oral health care for all individuals and communities would enable Australians to enjoy the highest attainable state of oral health and contribute to healthy and productive lives. The tattered safety net needs repair. The mouth should be brought back into the body.
Committee questions
3.19How can Australian governments better integrate oral health within general health?
3.20Is there a distinction between ‘essential oral healthcare’ and dentistry?
3.21Should ‘essential oral healthcare’ be funded under Medicare, while some dental services remain in the private sector?
3.22How can existing medical, disability and aged care programs better integrate oral health?
3.23Is there scope to better fund and promote the use of dental therapists and dental hygienists within the existing health system, under Medicare?
Extend coverage under Medicare
3.24Most health and dental organisations, peak bodies, think tanks, and individuals who have submitted to the inquiry advocated for systemic reform. These stakeholders are urging the Commonwealth to work with states and territories to implement radical reforms to the way oral and dental healthcare is funded, coordinated and administered. In line with the 2021 World Health Assembly resolution to embed oral health within universal health coverage, submitters including the NT Health, the WA Department of Health, and the National Health Alliance (NOHA) argued for bringing dental into Medicare, with a view to ‘putting the mouth back in the body’.
3.25Submitters outlined various proposals, ranging from extending existing Medicare coverage (the CDBS) to seniors and/or other groups, to full universal coverage of dental services for all Australians. Many submitters recommended a phased approach.
3.26In 2019, the Grattan Institute proposed a full universal dental scheme, estimating the scheme would cost around $5.6 billion per annum. The Grattan Institute updated its report for the inquiry, finding the need is now even greater, and many indicators have worsened (Figure 3.1).
Figure 3.1Most problems have become worse since 2019
Source: Grattan Institute, Submission 41, p. 4.
3.27The Grattan Institute reiterated its call for universal coverage, suggesting:
It would be impractical to move to a universal scheme overnight. The cost would be large – in 2019 Grattan estimated it to be about $5.6 billion in extra spending per year – and the oral health workforce would need to be expanded. So, the federal government should announce a roadmap to a universal scheme, including plans to expand the workforce, followed by incremental steps towards a universal scheme.
…
The first step is for the federal government to takeover funding of existing public dental schemes, fund them properly, and enable private-sector providers to deliver publicly-funded care. Coverage should then be expanded – first to people on Centrelink payments, then all children. After that, the federal government should take the final step to a universal scheme, ideally within a decade.
3.28NT Health advocated moving towards full universal coverage using an ‘incremental approach’, based on ‘the principles of value based health care’. NTHealth acknowledged that ‘achieving this vision will be challenging amidst ageing populations, increasing chronic diseases and escalating healthcare costs’.
3.29Dr Rogers and Dr Robertson suggested a ‘phased integration of basic dental care into Medicare’, starting with seniors. This should be implemented with ‘monitoring, evaluation and adjustments’, and then extended to those on low incomes and ‘people with certain chronic health conditions such as endocrine and cardiovascular disorders’.
3.30Similarly proposing a focus on seniors, Dr Shanahan noted that, when Medicare was introduced, life expectancy was around 70 and most older people had ‘full dentures’. With life expectancy now around 85, and many seniors having ‘some of their own teeth and increasingly dental implants’, the need for seniors’ dental care has changed and increased.
3.31Submitters who supported the implementation of an Australian Senior Dental Benefits Scheme (SDBS) included: Seniors Dental Care Australia; COTA Australia; NOHA; the Public Health Association of Australia (PHAA); and many others. These submitters also argued for the full implementation of the oral health recommendations made by the Royal Commission into Aged Care Quality and Safety:
NOHA views the SDBS as a priority to support people living in [residential aged care] homes, those receiving aged care community packages or those who receive the full rate of aged pension—this would ensure some of Australia’s most at-risk populations receive timely and affordable, oral healthcare. The Royal Commission recommended the SDBS should focus on essential oral healthcare to maintain a functional dentition, and to maintain and replace dentures. … The SDBS is the next step towards a unified healthcare system that does not separate oral health from the rest of the body.
3.32In implementing a seniors’ dental scheme, COTA Australia argued that governments must ensure:
(a)Each dental/oral care practitioner group’s scope of practice is pragmatically and fully utilised.
(b)Dental and oral health practitioners are encouraged to take up positions outside of metropolitan and large regional cities.
(c)A robust financial model is developed and agreed upon which has the capacity to sustainably underpin the Scheme and enable the delivery of a comprehensive range of oral and dental treatments aimed at optimising older people’s health outcomes.
3.33The department submitted that it has completed ‘preliminary analysis of options for a Seniors Dental Benefit Program’, and these are ‘being considered as part of the inter-governmental officials working group on long term dental reform’. Outcomes of the inter‑governmental process are ‘expected to be presented to Health Ministers for consideration and an initial discussion in June 2023’. At this time, officials ‘intend to seek Health Ministers’ views on next steps’ in relation to the National Oral Health Plan.
3.34Many submitters see seniors dental as the first step on a road to universal access. NOHA—whose membership includes a number of Australia’s most significant health organisations—submitted a ‘Roadmap to Universal Access to Affordable Oral Healthcare’ which starts with the development of Australia’s next National Oral Health Plan 2025–2034:
Universal access to affordable oral healthcare should be embedded within Australia’s healthcare system and reflected in the next ten-year National Oral Health Plan for 2025–34. It should be aligned with the [World Health Organisation] WHO’s Global Oral Health Action Plan 2023–2030. Prevention, early detection, and interventions for managing oral diseases need to be the cornerstone of universal access to affordable oral healthcare.
3.35Ms Anne Pak-Poy proposed the CDBS be used as a ‘blue print to improve the oral health of financially disadvantaged adults’. Ms Pak-Poy highlighted the ‘enormous amount of work’ done over the last decade on developing a pathway towards better oral healthcare, saying ‘there would seem to be little reason to prevent discussion and agreement on a staged implementation action plan for the next 5–7 years’.
3.36The ACT Government also noted Australia’s ‘strict eligibility criteria and limited scope of service’ for public dental. It suggested governments consider ‘all the aspects of the “coverage cube”’ when adopting a new model.
3.37This approach was widely supported in submissions. However, some submitters did not agree. Dr Shanahan argued against full coverage of dental services under Medicare, saying it would not be affordable:
In 2019–2020, the DIRECT costs of dental services were $11.1 billion for 50% of the population. The INDIRECT costs are unknown as there is no data available. It could be anything from $1–3 billion recurrent annually. If you had universal Medicare coverage adding the other 50% with all their problems and accumulated need it would probably be 1.5–2 times more. It is just not affordable. The way forward is to address the health care issue. It is the best option, most affordable, and will markedly improve everything for everyone, and in time things would improve.
3.38The ADA advocated for initiatives to provide universal access to dental services, as opposed to a ‘universal dental scheme’, which it said could cost in the region of $11 billion annually. The ADA claimed that universal dental schemes have failed to produce better outcomes, with ‘disparities in oral health’ remaining in countries like the United Kingdom and Germany. The ADA recommended ‘targeted schemes, subsidised by public funding’, including:
schemes to improve access to oral care for Australians ‘more susceptible to oral disease such as those in aged care, or those with a disability’;
a health levy on sugary drinks; and
utilising private clinics to provide public dental services via voucher schemes.
3.39In contrast, the Community and Public Sector Union/Civil Service Association (CPSU/CSA) in Western Australia recommended ‘shifting away from a “voucher” model’, favouring direct investment in dedicated public dental health services and infrastructure.
Committee questions
3.40Should oral and dental healthcare be part of Australia’s universal healthcare system, Medicare?
3.41Is now the right time to implement radical reforms in the provision of oral healthcare to Australians?
3.42What is the best way to improve access to oral and dental health services for all Australians, and particularly for those on low incomes and in other priority groups?
3.43Should public dental care be universal or means tested?
3.44If dental coverage under Medicare is expanded, how should this be progressed?
3.45Should all services be covered, or only those deemed medically necessary, along with preventative care?
Policy and administrative reform
3.46Submissions from peak dental and healthcare bodies, and academics, consistently argued for wholescale reform to the way oral and dental healthcare are administered at the Commonwealth level. This included proposals for greater national coordination and a new Chief Dental Officer.
3.47NOHA argued that the current treatment of oral health policy as ‘allied health’ policy is inappropriate. Oral health should be embedded within primary healthcare policy, and should have ‘a dedicated branch’ in the department. The role of Chief Dental Officer should be created to lead the branch and ‘support oral healthcare reform that integrates oral health within the wider healthcare system’. A Commonwealth Chief Dental Officer would work with State and Territory Chief Dental Officers and sector stakeholders to implement a national approach.
3.48The need for national coordination was also identified by the Productivity Commission in its 2017 report on introducing competition and choice into human services. In this report, the Productivity Commission proposed governments work together to develop an ‘oral health outcomes framework’ to ‘improve accountability, and provide the basis for more comprehensive reforms to promote targeted preventive care’.
3.49Submitters also noted the fragmented nature of oral health and dental services data collection, and the need for more effective evaluation of dental services and programs. According to the department:
variability in data scope between states and territories makes it impossible ‘to gain an understanding of [public dental] wait lists at the national level’;
data from private providers is limited, leaving a large gap;
data on individually-funded treatment is difficult to obtain; and
Medicare data on geographic location and Indigenous status can be unreliable or out of date.
3.50The department suggested a ‘bottom up’ approach to improving data collection:
…commencing first with what each jurisdiction is already capturing and reporting internally. Over time, reporting may converge in some areas, but in other areas may continue to reflect the differing priorities/models that apply in each jurisdiction. Nevertheless, more consistent availability of data would enable better monitoring of the provision of and access to dental services by populations eligible for public dental care.
3.51Deakin Health Economics argued that funding oral and dental healthcare under distinct legislation (the Dental Benefits Act 2008) makes it vulnerable to being de‑funded. Instead, it recommended cost-effective dental services be funded under Medicare’s Health Insurance Act 1973, and ‘subject to review in accordance with the Medical Services Advisory Committee’.
3.52The department submitted that work is well underway on national reforms, with the inter-governmental working group having ‘agreed several objectives for reform’. These include ‘increased equity of access, interface and alignment with the broader health system, financing certainty, transparency, and flexibility’. Health Ministers received an options paper on 18 November 2022, ‘based on these objectives’. Health Ministers are due to meet in June 2023 and are expected to consider further options.
3.53Submitters also noted a need for better and more up-to-date data and research to inform national reforms and ensure investment is targeted to achieving the best outcomes. The department acknowledged the lack of reliable national data sources, and suggested options for improving this may include:
working with states and territories and other stakeholders to standardise data collection about ‘characteristics of all clients and all services provided by public dental providers’; and
working with private sector stakeholders to ‘encourage them to report on’ costs and services provided.
3.54It also reported that the government has provided funding of $442000 over two years in the 2023–24 Budget for the development of ‘a new public dental National Minimum Data Set (NMDS) to collect nationally consistent activity and waiting times data’.
Committee questions
3.55Is it the role or responsibility of the Commonwealth government to support and coordinate a national approach to improving access to dental services? What is the role of the states?
3.56Why is oral healthcare situated within allied health at the Commonwealth level? Should oral and dental healthcare be reclassified as ‘primary healthcare’, and funded through primary healthcare frameworks and legislation?
3.57Are the current Commonwealth arrangements, staffing and resourcing for oral health policy and administration appropriate and/or adequate?
3.58What are the optimal administrative arrangements to ensure success of the next National Oral Health Plan?
3.59What is the role for the Commonwealth in funding and coordinating nationally consistent, comprehensive oral health and dental services data and research?
Improve rural and remote dental care
3.60A number of options for improving access to oral and dental healthcare in rural and remote areas have been put forward by submitters, including: increasing student-led services and mobile dental services; training more practitioners from rural and regional Australia; and expanding water fluoridisation in remote areas.
3.61La Trobe University recommended including dental and oral health ‘within the health workforce scope of the Australian Government and within the scope of the Office of the Rural Health Commissioner’. It also suggested:
enabling rural communities to access student-led public dental services;
working with state governments to fund university-led dental clinics which would treat public patients; and
incentivising and funding ‘an increase in the intake of rural students in the dental schools’, and prioritising students from rural areas.
3.62The ADC reported that it has produced guidance notes to support dental education providers to implement a revised set of ‘competencies’, including some specific to rural and remote communities. This means educators must train professionals in ‘improved models of care, the utilisation of the broader health care team, telehealth, and cultural safety’.
3.63The ADA proposed government direct funding in a way utilises ‘already established dental clinics’ in remote and very remote regions:
In some cases, a practice may have reached capacity with dental demand in the area not being able to be met. The provision of capital assistance to such a practice to provide an additional dental chair (surgery) and the recruitment of an additional practitioner may be the most expeditious utilisation of funding to achieve improved dental care delivery in that community.
3.64Dr Rogers and Dr Robertson suggested governments invest in innovation in ‘modalities and programs’ to increase availability of mobile services for those who are remote or cannot travel. This suggestion was echoed by the Australian Dental Foundation.
Committee questions
3.65What are the barriers for rural and remote students in studying to qualify as a dental practitioner?
3.66What role can other health professionals play in education, prevention and the provision of basic oral health treatments in remote areas? What role can other service providers play?
3.67How much would it cost to expand fluoridisation across remote communities?
3.68What is the role of mobile oral health services and should these be increased or modified?
Address workforce and training
3.69Submitters from the dental industry identified a number of workforce and training issues, including difficulty attracting and retaining oral health academics, especially in regional areas, and a lack of supervisors for trainees. The Dental Board of Australia and the Australian Dental Council (ADC) said discussions are ‘ongoing’ with health, dental and academic stakeholders to identify solutions.
3.70Acknowledging that there are currently ‘no workforce initiatives to support recruitment or retention of dental practitioners in rural and remote areas’, the department identified some existing rural health workforce and training initiatives; but noted that these often exclude dental professions.
3.71The Community and Public Sector Union/Civil Service Association (CPSU/CSA) recommended the Commonwealth fund a National Dental Workforce Plan.
Committee questions
3.72Is the current oral and dental health workforce sufficient to meet Australia’s needs?
3.73How can the geographic distribution of dental practitioners be improved?
3.74Is there a role for the Commonwealth in coordinating a national approach to the oral and dental health workforce?
Boost resources for public dental
3.75Submitters, including the department, universally agreed that state and territory public dental services are ‘incapable [of] responding to the current needs of eligible persons in their state/territory’, due to underfunding and understaffing. Seniors Dental Care Australia said, for those in residential care and people with disabilities, ‘saying “you should go to the dentist” is like telling a person to fly to the moon’. Referral ‘pathways’ are inadequate or unclear, and waiting lists act as a major deterrent.
3.76In light of this, NOHA recommended an initial increase to the funding of $500million per annum ‘to support the immediate urgent needs of priority populations’. The CPSU/CSA made a similar suggestion.
3.77The ADA proposed a review of public dental program waiting list criteria, which would ‘consider the clinical appropriateness and equity implications of "priority access" arrangements’. This could feed into the development of ‘nationally consistent essential and medically urgent dental care criteria’. The ADA also suggested a voucher system to enable ‘overflow patients from the public system to attend private practitioners’. This recommendation was echoed by ADOHTA.
3.78The Productivity Commission has previously suggested developing a ‘risk‑based allocation model’ which would see public dental care patients triaged ‘according to their risk of developing or worsening oral disease’, rather than simply added to a waitlist.
Attract dental professionals to public practice
3.79NOHA said Australia’s National Oral Health Plan 2025–2034 ‘should articulate a readily implementable oral health workforce strategy’, including initiatives to boost the public dental workforce.
3.80The CPSU/CSA proposed: increased wages for public sector staff to bring them into line with the private sector; higher wages and allowances for dental professionals ‘living and working in regional, rural and remote areas’ in the public sector; and improved access to ‘affordable, appropriate housing’ for rural and remote public dental professionals.
Committee questions
3.81How should the Commonwealth government approach reforming the way it funds and supports public dental services in the states and territories?
3.82Is there a need for nationally consistent criteria for determining ‘urgency’ and ‘priority’ in relation to public dental waiting lists?
3.83Are there evidence-based initiatives that could boost attraction and retention in the public dental workforce, including pay and conditions?
Better target priority groups
3.84As discussed in Chapter 2, Australia’s National Oral Health Plan 2015–2024 identified the following groups of people as ‘priority populations’:
people who are socially disadvantaged or on low incomes;
Aboriginal and Torres Strait Islander people;
people living in regional and remote Australia; and
people with additional and/or specialised health care needs.
3.85The Australian Dental Foundation (ADF) identified older Australians, disabled people, and children as key cohorts, and proposed:
more resources for oral healthcare and training in care homes;
better use of existing networks and providers to offer on-site preventative and emergency services in residential aged care;
improved access to routine and preventative services under the National Disability Insurance Scheme (NDIS);
initiatives to train more special needs dentists;
better promotion of the CDBS; and
extending the CDBS to provide funding for anaesthetic services for those with complex needs.
3.86The committee is aware that people in Australia’s prisons have significant unmet need for dental care. A submission from the Office of the Inspector of Custodial Services (WA) offered valuable insights into this additional priority population. Rather than detailing suggested approaches in this interim report, the committee has communicated its intent to hear more evidence on this issue at a public hearing, and report its conclusions in the final report.
3.87While not exhaustive, this section provides a brief introduction to some of the proposals made in submissions to address the needs of particular priority groups.
Disabled people and those with complex needs
3.88Seniors Dental Care Australia noted that, for adults, ‘dental treatment is not part of aged care, home care or the NDIS’, despite the fact that these cohorts have greater need and poorer access to services. They argued the exclusion of oral and dental healthcare from many of these programs should be removed, so persons receiving care or support can readily access quality oral healthcare.
3.89The Geelong Parent Network argued ‘crisis driven access to dental services’ for people with intellectual disabilities had led to a ‘lack of ongoing care planning’. It recommended individualised oral healthcare plans be developed ‘between the person with intellectual disability, their families and carers and their dentist’, as a priority.
3.90NSW Council for Intellectual Disability (CID) drew the committee’s attention to the 2021 National Roadmap for Improving the Health of People with Intellectual Disability. This roadmap includes oral health as one of seven priority areas for improvement and recommends:
better promotion of the CDBS and oral health services for people with intellectual disability, and research into utilisation of the service;
a feasibility study into introducing Medicare items that can ‘better support complex and difficult services, such as in hospital services under general anaesthetic’;
expanded workforce training and capacity building measures; and
nationally-coordinated work, in conjunction with the National Centre of Excellence in Intellectual Disability Health, to implement ‘hub and spoke models of care’ to connect centralised special needs dentists and community dental clinics.
3.91In relation to coverage for anaesthetic services, the department acknowledged there is a problem. The Commonwealth provides funding under the National Health Reform Agreement (NHRA) ‘for public hospital in‑patient dental services’. However, few people can access these services, as there are ‘strict eligibility restrictions and waiting lists’ in most states and territories. The department did not indicate that there are any measures under consideration to address this issue.
3.92The Geelong Parent Network said calls for better data on this poorly-served cohort have not been answered, leaving people with intellectual disabilities essentially ‘invisible’ in national planning. The government is currently establishing a National Centre of Excellence in Intellectual Disability Health, which will aim to ‘meaningfully’ include people with lived experience of intellectual disability in its structure. The Geelong Parent Network highlighted the role the centre will have in improving data and research to ‘inform practice’, including in the provision of dental care.
3.93The experiences of disabled people, including those with intellectual disabilities, will be further explored during the committee’s upcoming hearings.
Aboriginal and Torres Strait Islander people
3.94Submitters to the inquiry observed with disappointment that the oral and dental health status of Indigenous Australians remains significantly worse compared with other Australians. The Kimberley Dental Team submitted that, while Aboriginal and Torres Strait Islander peoples were recognised as a priority population in Australia’s Oral Health Plan, there has been ‘little change in improving the poor oral health experienced by our First Nations peoples’ under the plan.
3.95Improving oral healthcare in Indigenous communities is a ‘wicked problem’, complicated by demographic, structural, linguistic and cultural, and economic factors. NTHealth outlined the barriers to accessing oral and dental healthcare for remote communities, in particular. It recommended the Australian Government:
support an ‘oral health scheme’ for remote communities in the Northern Territory;
establish a Remote Community Oral Health Strategy;
increase Commonwealth funding and leadership;
improve the CDBS for Aboriginal and remote children; and
implement the oral health recommendations of the Royal Commission into Aged Care.
3.96Commenting on the low uptake of the CDBS in Indigenous communities, the department said that the Fifth Review of the Dental Benefits Act has ‘looked at the uptake of the program for vulnerable cohorts’. This report is ‘currently being finalised and is expected to be tabled in the Parliament later in 2023’.
3.97Kimberley Dental Team argued that, while attracting dental professionals to work in regional and remote areas ‘is essential’, these staff must also be ‘suitably trained and equipped to work with Aboriginal children and adults in ways that feel supportive, understanding and considerate of cultural protocols and ways of being’. Sometimes residents are not made aware that a dentist is visiting their community and miss out on treatment. Services are often delivered by different people every time and provided by appointment, which may not be ‘a model that works well in remote communities’.
3.98Based on its many years of successful service provision, Kimberley Dental Team made a number of recommendations, including that:
state-wide models of care should be reviewed and made more appropriate for Aboriginal people;
more investment be directed from the states and the Commonwealth to Aboriginal oral health programs; and
the model used by Kimberly Dental Team be adopted more widely.
The team generously offered its ‘data, knowledge and expertise’ to support the proposed reforms.
3.99Derbarl Yerrigan Health Service Aboriginal Cooperation in Western Australia recommended that access for Aboriginal patients to dental care be ‘enabled through dedicated funding of dental services [to be delivered by] Aboriginal community Controlled Health Services’, and that dental services be ‘integrated in a culturally secure setting is integral to a holistic model of care’.
3.100The Royal Flying Doctor Service made similar recommendations around community-centred care, expanded eligibility in remote areas, and the need to support the delivery of culturally-appropriate care.
3.101The ADC noted recent changes to the national accreditation scheme incorporate ‘a new objective’ which ‘aims to build the capacity of the Australian health workforce to provide culturally safe health services to Aboriginal and Torres Strait Islander peoples’. Education providers are also now required to demonstrate that they include cultural safety as a core competency for future professionals.
3.102The committee intends to further interrogate the barriers to service for Indigenous Australians, and possible solutions, during its upcoming hearings.
Committee questions
3.103Should oral and dental healthcare services be better supported under the National Disability Insurance Scheme (NDIS), and aged care packages?
3.104How can residential care facilities and support workers be trained and supported to provide oral health education, prevention, basic care and referral services?
3.105How much would it cost to extend the CDBS to support patients with intellectual disabilities and other complex needs?
3.106Are there evidence-based initiatives that could be adopted to encourage more dental professionals to train and work in special needs oral healthcare?
3.107How can the CDBS be better promoted to key cohorts, including Indigenous Australians, migrants and disabled people?
3.108How can the cultural safety and capacity of oral and dental healthcare services be improved?
3.109What is the most effective way to deliver oral and dental healthcare to very remote communities?
Senator Jordon Steele-John
Chair