Chapter 2A system in decay
2.1Building upon the findings of the committee's Interim report, this chapter outlines Australia's current, inequitable dental services system, and identifies barriers to reform.
2.2Evidence to the inquiry revealed a private dental system that is unaffordable for many, and a public dental system under severe strain. These problems have been known for decades, but responses have been ad hoc or piecemeal.
2.3In this chapter, the committee looks at:
inequalities in the system;
impacts of the pandemic;
adequacy of national data; and
how Australia's dental services system compares with those of other countries.
2.4The chapter then briefly considers barriers to reform in Australia, including the nation's federal system of government, cost, infrastructure, workforce limitations, and traditional attitudes to dental and oral health.
Inequitable—Australia's dental services system
2.5Dental care in Australia is provided through a mix of private for-profit clinics, subsidised services, and state-run public dental centres and hospitals. Over 85per cent of dental care is delivered in private, for‑profit dental clinics, and Australians pay out-of-pocket for almost 60percent of all services received. The other forty per cent is funded half by governments (Commonwealth and state), and half through private health insurers.
2.6In its interim report, the committee explained that there is a two-tiered system in Australia when it comes to oral and dental health care. Around half of Australians have acceptable oral and dental health, and adequate access to services, and the other half do not. Australia's Adult Oral Health Tracker 2020 indicated that:
just under half of Australia's adults had a dental check up in the last 12months and only half brush twice daily;
tooth decay and gum disease have both increased since 2004–06, with around 32 per cent of adults now reporting untreated tooth decay;
one in five adults experience toothache; and
one in ten adults have 'severe tooth loss' (less than 21 teeth).
2.7The University of Adelaide's National Study of Adult Oral Health 2017–18 (the 2017–18 national study), funded in part by the Department of Health and Aged Care (DoHAC), is the most recent national survey of adult oral health in Australia, and one of only three ever conducted. The 2017–18 national study involved surveying 15 731 persons aged 15 and over, and conducting 5022 oral exams. This comprehensive study found:
four per cent of Australians have no teeth;
one-in-ten dentate (with teeth) Australians have fewer than 21 teeth;
just over 11 per cent wear a denture/dentures;
women are more likely to have complete tooth loss than men, and more likely to have missing teeth;
people who live outside of capital cities have fewer teeth, and are more likely to wear dentures;
people with lower levels of education, and those without tertiary or other qualifications, are significantly more likely to have tooth loss and/or wear dentures;
people eligible for public dental care have significantly worse outcomes than those who are not eligible; and
people who do not have private health insurance have significantly more tooth loss than those who do.
2.8The study also found that around 30 per cent of Australians suffer from gum disease, with incidence higher among rural and regional Australians, and those with lower levels of education and post-school qualifications.
2.9Individual Australians spend significantly more out-of-pocket on dental services than people in many comparable countries, including Canada and the United States, but this does not equate to better oral health across the population. The contribution of Australian governments to funding oral health is low by international standards, being around half of the average for countries in the Organisation for Economic Co-operation and Development (OECD). Only eight out of 38 OECD countries report a lower proportion of public funding for dental services.
2.10In 2023, Australia had 26 563 registered dental practitioners, of which 19795 are dentists. Only five per cent (or around 800) of these professionals work in the public system, which delivers around 15 per cent of dental services. There is a 'maldistribution' of dental practitioners, with regional and rural areas having less than half the number of practitioners per 100000 population than metropolitan areas.
2.11There is also a shortage of specialists, particularly those trained to treat patients with disabilities or other complex needs. For instance, there are currently no 'special needs dentists' in the Australian Capital Territory (ACT), Northern Territory or Tasmania.
2.12Public dental services are run by state and territory governments with state, and some Commonwealth, funding. While eligibility for these services vary by jurisdiction, they are generally available to health care card holders and others on government income support. However, these services are overstretched, understaffed, and the wait times are prohibitively long. Recent investments from the Commonwealth into state dental services have helped to reduce waiting lists, many of which were previously over two years long. However, with wait times remaining at 12to24months for non-urgent care, even those eligible for public dental services generally have to attend private clinics to receive the treatment they need when they need it.
2.13There are no standard fees for dental services, and no regulation of pricing. Average costs for the same service vary considerably by state and territory, with a tooth extraction costing around $185 in South Australia, and $231 in the ACT (data from 2020–2021). Health fund rebates also vary significantly, and health funds generally do not publish their rebate amounts. Likewise, dentists rarely advertise their prices, and private health insurance data reveals that some dentists charge different patients different amounts for the same service. The committee also heard that consumers are not always provided with a quote before work is done.
2.14These factors result in fear and hesitation for consumers, leading around 40percent of Australians to avoid or delay visiting a dentist, and around 23percent to forgo the recommended treatment when they do see a dentist.
2.15A number of other factors also influence people's choices in relation to oral health care. These include location and availability of services, fear of dental treatment, accessibility of services, and lack of awareness around services and subsidies. However, research consistently shows that cost is the biggest factor. The 2017–18 national study found:
just under one-quarter of Australians would have 'a lot of difficulty' paying a $200 dental bill;
Indigenous Australians, those eligible for public dental care, and those with lower levels of education were almost twice as likely to report difficulties paying; and
people without private health insurance were twice as likely to avoid dental treatment due to cost.
2.16Avoiding treatment due to cost has significant impacts on Australians, with over 35 per cent feeling 'uncomfortable' about their dental appearance, around 24percent describing their oral health as 'poor', and almost one‑quarter avoiding certain foods due to dental problems.
2.17While the Adelaide University national oral health studies, conducted in 1987–88, 2004–06, and 2017–18, indicate a significant improvement in certain measures of oral health over time, some measures have not improved:
more Australians now rate their oral health as 'fair or poor';
the proportion of people who visited a dentist in the last 12 months increased between 1987–88 and 2004–06, but decreased in the 2017–18 study; and
more people reported avoiding or delaying dental care due to cost (from just over 30 per cent in 2004–06, to just under 40 per cent in 2017–18).
Access in rural, regional and remote areas
2.18The committee's interim report highlighted access issues for those living in rural, regional and remote areas of Australia.
2.19Research published in 2017, which included mapping of public dental services, found that:
for those who live in metropolitan areas, 72 per cent of residents who are eligible for public dental services are located within a 5-kilometre range of a government dental clinic;
in contrast, for those who live 'outside metropolitan areas', only 38 per cent of those eligible for public dental care are located within 5 km of a government dental clinic; and
the Northern Territory had the lowest accessibility, with only 19 per cent of eligible city residents residing within 5 km, and only 4 per cent of eligible rural residents, located within 50 km of a government dental clinic.
2.20To assist in better understanding the national distribution of public dental services for adults, the committee requested mapping services from the Parliamentary Library. The figures below show the locations of adult public dental services at a 'State Suburb' level; maroon colouring indicates suburb or township areas where a service is present.
Figure 2.1Distribution of adult public dental services—Australia
Source: Parliamentary Library using Australian Bureau of Statistics (ABS) Australian Statistical Geography Standard 2016 (ASGS 2016) spatial unit State Suburb (SSC 2016) and National Map. The street addresses of Adult Public Dental Services were matched to the most appropriate SSC 2016. Note that the SSC areas (dark areas on the map) are not the service area of the dental clinic in that SSC, but an indicative location of the dental clinic/s. There may be more than one clinic in the SSC. Latitude and longitudes of the clinics were not provided to the Parliamentary Library.
Figure 2.2Distribution of adult public dental services—NSW, ACT and Victoria
Source: Parliamentary Library using ABS ASGS 2016, SSC 2016, and National Map. See details and notes above.
Figure 2.3Distribution of adult public dental services—Queensland
Source: Parliamentary Library using ABS ASGS 2016, SSC 2016, and National Map.
Figure 2.4Distribution of adult public dental services—Western Australia
Source: Parliamentary Library using ABS ASGS 2016, SSC 2016, and National Map.
Figure 2.5Distribution of adult public dental services—Northern Territory
Source: Parliamentary Library using ABS ASGS 2016, SSC 2016, and National Map.
Figure 2.6Distribution of adult public dental services—South Australia
Source: Parliamentary Library using ABS ASGS 2016, SSC 2016, and National Map.
Figure 2.7Distribution of adult public dental services—Tasmania
Source: Parliamentary Library using ABS ASGS 2016, SSC 2016, National Map.
2.21Chapters 5 consider options for improving workforce coverage and better servicing rural, regional and remote communities, including Indigenous communities.
'COVID cavities'
2.22The 2017–18 national study is still the most widely used oral health data set. However, this study was conducted prior to the pandemic. Submitters suggested the COVID-19 pandemic impacted the dental services system and the oral health of Australians, and these impacts are still being felt in 2023.
2.23Access to routine dental care was stopped during the early stages of the pandemic, with thousands of appointments for non-emergency treatment cancelled. Early in the pandemic, National Cabinet recommended dental practices restrict dental treatments that 'generate aerosols' and defer 'all routine examinations and treatments'. Victorians were most acutely affected by these decisions, as they experienced 'more than 200 days of restrictions impacting on dental care'.
2.24The Victorian Oral Health Alliance (VOHA) submitted:
Over the period of March to September, there were 881,454 fewer dental services provided in 2020 than in 2019, with the largest decline seen in April when there was a lockdown affecting all of Australia. The greatest decline was in preventive and diagnostic services. A second wave of COVID-19 in Victoria saw 198,609 fewer dental services provided from July to September2020 than in 2019. Dental service provision had still not returned to pre‑COVID-19 levels across Australia by September 2020.
2.25COVID restrictions, along with patient hesitation in attending dental facilities, led to a backlog of patients needing care in Tasmania. This has resulted in 'longer wait times for access to general dental care services' (post pandemic), and 'recruitment challenges'. In Western Australia, services saw an overall drop in patient care and a significant increase in 'urgent care' as a proportion of services provided. In 2022, there was an increase of almost one-third to public dental waitlists in that state (compared with 2019).
2.26The pandemic also led to changes in 'health-promoting behaviours', increased anxiety and stress, and a measurable upsurge in opioid and analgesic use for oral health conditions. This impact has been more keenly felt by older Australians, those with disabilities, the disadvantaged (especially children), and those with chronic health conditions. COTA Australia quoted one older Victorian:
My dentist closed shop to all but emergencies. My husband of 56 years had a serious infection and was in agonising pain, but I could not make an appointment for him with our dentist or any other local dentist for 4 days even though they all agreed it was an emergency. He was screaming with the agony of it. He has advanced dementia and is a diabetic, but I had no option but to dose him with strong pain killers.
2.27According to DoHAC, in 2020–21, the proportion of adults aged 15 years and over who 'delayed seeing or did not see a dental professional in the last 12 months due to COVID-19' was:
higher for females (14%) than males (9.4%)
higher for people living in major cities (13%) than people living in inner regional (9.8%) or outer regional, remote or very remote areas (7.4%)
higher for people who self-assessed their health as fair/poor (15%) than people who self-assessed their health as excellent/very good/good (12%)
higher for people with a long-term health condition (14%) than people without a long-term health condition (11%).
2.28The Royal Flying Doctor Service (RFDS) was unable to deliver services at various stages during the pandemic, as well as being limited in terms of what services it could provide, once able to travel again. This impacted remote Indigenous communities in particular, and led to worsening oral health among the cohorts the RFDS serves.
2.29Aboriginal Health organisations and community groups reported that strict lockdowns in remote communities 'severely impacted' oral health service delivery in 2020 and 2021. The Department of Social Services (DSS) reported recent data indicating:
… that at that time [2020], a significant number of Indigenous youths needed a dentist but did not see one, with a large majority of these youths indicating that COVID-19 was a reason for not getting the service they needed.
2.30Some submitters highlighted the difficulties experienced by those in residential aged care in accessing oral health services, with one submitter (name withheld) saying this remains an issue, as residents 'remain vulnerable to COVID infection'.
2.31According to RFDS, the pandemic also had detrimental impacts on the dental health workforce servicing rural and remote communities, with many practitioners having 'retired early … moved interstate or returned overseas'. This was echoed by DoHAC, which said workforce shortages due to COVID-19 have increased the already lengthy waitlists for adult public dental services.
2.32According to Abano Healthcare, the pandemic also led to an increase in preventable hospitalisations due to dental conditions:
Figure 2.8Visualisation of potentially preventable hospitalisations due to dental conditions highlighting the impact of the COVID-19 pandemic
Source: Abano Healthcare, Submission 111, p. 10.
2.33In 2023, the impacts of the pandemic continue to influence uptake of dental care. COTA Australia, the Health Care Consumers' Association Inc (HCCA), the Australian Dental Association (ADA), and others noted cost of living pressures may now be leading even more Australians to defer dental treatment.
National data: comparing apples and oranges
2.34An issue raised again and again throughout the inquiry was the need for more reliable, consistent data, especially at the national level.
2.35Current sources of data on oral health and utilisation of dental services include:
surveys from the Australian Bureau of Statistics (ABS) and the Australian Institute of Health and Welfare (AIHW);
the National Oral Health Survey, and the National Child Oral Health Study, conducted by the Australian Research Centre for Population Oral Health, based at the University of Adelaide;
publicly available Medicare data on the type and number of dental services provided under the Child Dental Benefits Schedule (CDBS); and
annual data from Private Healthcare Australia relating to dental services provided in the private sector under private health insurance.
2.36Measures relating to children's oral health are also collected in DSS's longitudinal studies—the Longitudinal Study of Australian Children (LSAC) and the Longitudinal Study of Indigenous Children (LSIC), as well as the Household, Income and Labour Dynamics in Australia (HILDA) studies. DSS submitted that this longitudinal data from LSAC and LSIC could be used to understand 'dental habits, dental issues and dental service access' with respect to demographic factors, as well as to 'explore these (now) young adults to inform on the economic, health and other social benefits of early life access to dental services and good dental practices'.
2.37The University of Queensland School of Dentistry observed that oral health surveillance in Australia is mostly done through 'ad hoc sentinel surveys', there is 'limited tracking of outcomes', and no 'clear guidelines or a strategy for an oral health outcomes approach'. Health policy analyst, Mr Charles Maskell-Knight commented that there is a lack of 'secure, on-going' funding, the children's data is over ten years' old, and the last adult survey was five years ago.
2.38Mr Maskell-Knight recommended the Australian Government:
(a)fund the AIHW to commission either a biennial population level oral health survey, or adult and child surveys in alternating years;
(b)work with the Dental Board to expand registration data to include more granular data on type of employment; and
(c)fund the Australian Bureau of Statistics to carry out a biennial survey of dental practices to gather data on the provision of dental services and the ownership structure of the sector.
2.39This approach was echoed by oral health academics, John Roberts and JamieRobertson, who recommended a national system be established to 'measure and monitor oral health equity, use data from private dental practices and dental insurers, and enable linkages with broader health data systems'. DrRoberts and Dr Robertson argued for five-yearly oral health studies, alternating between child and adult oral health.
2.40Deakin Health Economics said existing data is 'limited and narrow in scope'. While states and territories collect information through public dental services, this does not capture the majority of dental service provision, which occurs in private practice. Also, the data collected by states and territories is difficult to access, generally requiring a formal request to state authorities. DoHAC noted that state and territory data varies in scope, making it impossible to 'gain an understanding of wait times at the national level'.
2.41While there are a number of other ad hoc studies that include relevant information about oral health, Deakin Health Economics was concerned that data collected may not 'always reflect consumer needs', or be 'clinically appropriate', and that there is presently 'no evidence that the public oral healthcare that are currently provided are effective and cost-effective'.
2.42DoHAC noted limitations in national data collection, including:
difficulty accessing data from private practices;
limited data collection by states and territories (mainly focused on wait times);
no data from private hospitals or dentists on services that are fully self‑funded; and
limitations of Medicare data for reporting on regional access and the health of Aboriginal and Torres Strait Islander people.
2.43DoHAC reported that previous attempts to develop national key performance indicators for public dental service provision were unsuccessful. However, the Australian Government is providing funding of $442000 over two years to develop a new National Minimum Data Set on public dental services and wait times. This work will be progressed by the AIHW.
2.44The Department of Veterans' Affairs (DVA) acknowledged it only collects 'administrative data, such as the program expenditure', and the age and sex of clients, and has no data on outcomes. Asked if it was possible for DVA to collect data on outcomes, First Assistant Secretary, Ms Veronica Hancock said it is possible, but would require seeking consent from participants.
2.45Geelong Parent Network highlighted the paucity of data on the experiences of disabled people generally—and those with intellectual disabilities in particular—in accessing oral health and dental services. The network argued for connecting national oral health strategies with national disability strategies, and suggested the new National Centre of Excellence in Intellectual Disability Health, being established in 2023, may also have a role to play.
2.46Former Head of Oral Surgery, Medicine and Diagnostics in the Sydney Dental School, at the University of Sydney, Professor Hans Zoellner argued that current data sources do not provide sufficient 'granularity … for advanced oral health planning', meaning it is not possible to identify how many 'oral surgeons, maxillofacial surgeons, or endodontists the nation needs, or of the true national cost of managing these conditions'.
2.47To address these issues, the University of Queensland School of Dentistry proposed the development of clear, national guidelines aimed at achieving 'desired oral health outcomes', integrating oral health data into general health databases, and providing better access to oral health data for researchers.
2.48Dr Shalini King also argued for integrating oral health measures into existing health records and assessments, saying: 'We need to start including simple measures like a tooth count or risk for gum disease in general health records which will enable measurement of community oral health outcomes'.
Oral health care coverage in other jurisdictions
2.49Dental care costs citizens more out-of-pocket than other types of health care in most OECD countries. However, out-of-pocket spending is particularly high in Australia—almost 60percent of total expenditure, compared with the OECD average of 17 per cent. By way of comparison, Canada and the USA have out‑of‑pocket expenses of around 40percent.
2.50Most OECD countries provide more and higher subsidies for oral and dental health services than Australia does. A 2010 survey of 29 OECD countries found that, at that time, 'five (Austria, Mexico, Poland, Spain and Turkey) covered the full cost of dental care and six (Belgium, Finland, Germany, Iceland, Japan and United Kingdom) covered 76–99% of the costs'. Most other OECD countries covered up to half of the costs for dental services.
2.51Deakin Health Economics noted that 'global oral healthcare systems are highly variable', with Scandinavian countries, Japan, South Korea, Thailand, and Taiwan funding 'universal oral healthcare', and many other countries subsidising treatment through private providers for certain groups.
2.52While most countries with universal health care systems have excluded, or only partly integrated, oral health care into these systems, in 2004 Brazil integrated dental and primary medical care through a national policy called Brasil Sorridente (Smiling Brazil).
2.53Most OECD countries provide higher or additional coverage for priority groups, including those on low incomes, the elderly and indigenous peoples. TheAustralian Dental Foundation noted that a number of countries, including Canada and the United Kingdom (UK), 'provide comprehensive dental coverage for individuals with disabilities through their national healthcare system'.
2.54Some countries are moving towards greater public funding of dental care, including Canada and the UK. Canada is investing $13 billion over five years to implement a 'means-tested dental care plan for publicly uninsured Canadians', and the UK has introduced 'significant ADA changes', including: 'initiatives to support higher needs patients; establishing a minimum unit price for dental activities; and changes to the workforce including the way overseas qualified dental practitioners are recognised in the UK'.
2.55The ADA argued that comprehensive oral health care programs in other countries, such as Germany and the UK, have 'resulted in oral health outcomes worse than those of Australia', and that all countries, 'including those with universal dental schemes, exhibit disparities in oral health'.However, Deakin Health Economics submitted that the extent to which government funded universal dental schemes improve oral health outcomes 'remains unknown because there is a gap in evidence and the existing issue about service access in priority populations'. According to Deakin Health Economics, American research has demonstrated 'potential benefits of an initiation to remove cost barriers':
Under the implementation of the Patient Protection and Affordable Care Act, there is an increase in private insurance for young adults and increase dental service for low-income adults. Studies have shown significant reductions in dental-related emergency department visits for jurisdictions that expanded the coverage of public dental services for low income households.
2.56Research published by the World Health Organization (WHO) in 2020 noted that, in Europe, countries which provide public dental services have been found to have 'lower inequalities in the usage of dental care'. Researchers concluded that '[universal health systems] inclusive of dental services can help promote equity in terms of access to care and oral health outcomes that have individual, societal and health-care system benefits'.
2.57Research from 2020, comparing oral health inequalities in Japan and the UK, found that Japan's wider public dental coverage was associated with significantly lower levels of inequality than those seen in the UK, where coverage is less comprehensive.
2.58The Western Australia Department of Health noted direct comparisons between Australia and other countries are difficult to make, and suggested a National Chief Dental Officer could 'represent dentistry in Australia on a global level', making it 'easier to learn from and share data with other countries'.
2.59A number of submitters highlighted international efforts to improve oral health world-wide, as outlined in the WHO's 2022 Global oral health status report: towards universal health coverage for oral health by 2030. The WHO found that 'the status of global oral health is alarming and requires urgent action'. The report outlines the problems and provides global measures. It also discusses challenges and opportunities and provides a 'road map' towards universal access to oral health care.
2.60Representatives from DoHAC were asked if the department was looking to oral health models in other jurisdictions to see if aspects of these systems could be adapted for Australia. Dr Chami Jayasuriya confirmed the department has 'preliminarily explored what the UK and Canada have been doing to support some of the reform work'.
Japan's 8020 campaign
2.61Commentators regularly cite Japan's 8020 Campaign when promoting the benefits of publicly funded oral health care. The 8020 Campaign was initiated in 1989 to address a high prevalence of oral disease and an ageing population. It is a long-term national oral health promotion strategy, incorporating education, subsidised services, and changes to health infrastructure:
The rationale was built on the premise that if people can keep at least 20functioning teeth by 80 years of age, they have a better chance of remaining healthy because of their ability to chew effectively, eat a range of foods, and maintain good nutrition, thereby providing a positive influence on general health and well-being.
2.62ADA suggested the 8020 Campaign has been successful, as demonstrated by a 2016 survey which indicated 'more than half of the people aged 80 years retained 20 or more teeth'. However, ADA argued that outcomes of the 8020Campaign have 'not been well evaluated in terms of reliable evidence'.
2.63Consultant dentist at St Vincent's Private Hospital in Sydney, Dr Peter Foltyn, noted the success of Japan's focus on geriatric dentistry, highlighting new nursing home programs staffed by dental hygienists, and 'innovative community education programs'. He said oral health students in Japan 'regularly attend Residential Aged Care Facilities as part of their undergraduate training', and:
Japanese aged care research has shown that better oral and dental health in the elderly leads to better nutrition, increased confidence, better socialization, better communication, reduced risk for aspiration pneumonia and better overall health.
Like pulling teeth: barriers to reform in Australia
2.64There are a number of barriers to reforming the funding and provision of dental and oral health care services in Australia, including:
a historical belief that dental care is an individual, rather than a social responsibility, and is of lower priority than general health care;
the existing legislative and structural separation of dental and general health care;
reluctance of Commonwealth governments to take a national approach to what is currently primarily a state and territory responsibility;
significant costs associated with increasing subsidisation of oral and dental health care; and
limitations imposed by workforce size, structure and distribution.
2.65Along with these barriers, some submitters argued 'the reluctance of the dental profession' is a barrier to reforming how dental services are provided; especially to the idea of including dental services under Medicare.
2.66Despite a broad, long-standing consensus that reform is needed, change has been modest and incremental. A number of inquiries and commissions have explored the idea of a universal dental scheme, but cost has been seen as a key barrier to implementing any such reforms. Professor Jane Hall, ProfessorMichael Woods, Professor Kees van Gool, and DrPhillip Haywood submitted that:
In 1998, a Medicare-based dental scheme was estimated to cost around $1 billion (Senate Community Affairs References Committee, 1998).
In 2003, the Australian Consumers Association estimated a scheme for universal public dental coverage could cost between $2.5 and $4.5 billion (Select Committee on Medicare, 2003).
The proposal for Denticare from the National Health and Hospitals Reform Commission was estimated to cost the Commonwealth Government around $3.6 billion, with the suggestion that this could be funded by an increase in the Medicare Levy by 0.75% of taxable income (National Health and Hospitals Reform Commission, 2009).
Again, the issue of the expense associated with a comprehensive dental program was highlighted as a barrier to an immediate universal scheme by the National Advisory Council on Dental Health (2012).
2.67Instead, the Commonwealth has introduced and abolished a variety of different schemes, with mixed success. Introduced in 2004, the Chronic Disease Dental Scheme (CDDS) provided coverage for dental treatment for people with chronic health conditions, such as diabetes or cardiovascular disease. The scheme was not means tested and has been criticised as going dramatically over budget, encouraging 'fraud and overservicing', and failing to provide 'disease‑control benefits'. The scheme was discontinued in December 2012, with costs having 'blown out' from the initial estimate of $90million per year, to around $80million per month.
2.68According to Private Healthcare Australia (PHA), the means tested Teen Dental Plan, introduced in 2008, had 'disappointing' results. The Plan provided up to $160 per year to cover a preventative dental check-up for eligible teenagers aged between 12 and 17 years old. The scheme achieved only a 32 per cent uptake, was underutilised by Indigenous youth and teens in rural and remote areas, did not provide funds for any follow up work, and was criticised as being exploited by dentists.
2.69The Teen Dental Plan was replaced by the CDBS in 2014. The CDBS provides more funding and covers more services. However, take-up is still low, and the scheme is not reaching priority populations. Further analysis of the CDBS is included in Chapter 6 of this report.
The Federation Funding Agreement on Public Dental Services for Adults
2.70The Federation Funding Agreement on Public Dental Services for Adults (FFA) is the mechanism by which the Australian Government provides funding to the states and territories to support the delivery of dental services to eligible adults. The latest agreement—worth $107.75 million—was designed to increase service delivery through public dental services across Australia, specifically to assist in reducing waitlists. The FFA was due to expire on 30 June 2023 but has been extended to 2024–25, while more substantiative reforms are discussed.
2.71The Tasmanian Department of Health submitted its concerns that the current FFA Schedule is 'short-term', and 'no indexation has been applied to the funding'. The Schedule also uses what the Tasmanian Department of Health described as 'outdated 2013–14 baseline [Dental Weighted Activity Units (DWAUs)] activity targets' and fails to 'adequately acknowledge the ongoing impacts of COVID-19'.
2.72Director of the Dental Section at DoHAC, Dr Jayasuriya said the department is responding to these state and territory concerns by 'exploring internally how [DoHAC] can revise the performance targets'. The process is taking some time as it requires the design of a new methodology.
2.73Mr Maskell-Knight suggested the short-term nature of FFAs creates 'uncertainty' for public dental services, impacting their ability to employ staff and deliver care. He argued the Commonwealth should provide 'substantial additional funding' for these services, but do so through a statutory mechanism, rather than the current, temporary Commonwealth-state funding agreements.
2.74In its 2023–24 Budget, the government announced funding of $215.6 million over two years 'as an interim measure while decisions on future funding arrangements for dental service provision are finalised through an inter‑governmental senior officials working group'.
Long-term policy reform
2.75While dental care is currently primarily a state and territory responsibility, many submitters argued that the Commonwealth should take over the responsibility. According to the Grattan Institute, a national dental scheme, funded and coordinated by the Commonwealth, in conjunction with state governments, would:
ensure 'equity among citizens' in different jurisdictions;
be more viable, as the Commonwealth has a greater capacity than most states and territories to fund services to meet demand;
leverage existing Commonwealth regulatory, payment, and management infrastructure, which is already in place for primary medical care;
be constitutionally sound, as the Commonwealth has 'the power to regulate and fund dental services, as with other types of health care'; and
create opportunities for 'nationally consistent oral health education messages'.
2.76In April 2021, the national Health Chief Executives Forum 'identified long-term dental policy as a priority'; then established a national reform oversight group in March 2022. The group includes representatives from all states and territories and the Commonwealth, and is advised by oral health experts. According to DoHAC, the objectives of this reform are to 'establish funding certainty, transparency and flexibility; [improved] equity of access; and interface and alignment with the broader health system'. The reforms will focus on better meeting the needs of 'older Australians; people with disability; people in rural and remote areas; First Nations people; children; and people on low incomes'.
2.77The Oversight Group has developed Terms of Reference. However, these have not yet 'been submitted to Health Ministers’ for endorsement or public release'.
2.78The reform group's remit is to identify options to give effect to these objectives. This work will feed into a new National Oral Health Strategy, which is in the early stages of development. DoHAC is also exploring options for addressing the low up-take of the CDBS, assisted by new data:
We worked across the Australian government with a behavioural economics team within [the Department of Prime Minister and Cabinet] to explore why the uptake is low. They conducted a survey study of 5,000 parents of eligible children, as well as of some practitioners, and that study largely showed a number of findings and recommendations, which the department is considering.
2.79DoHAC is already working to revise the letter that is provided to families of eligible children to promote the CDBS. The revised letter is expected to be sent to families in January 2024.
Committee view
2.80Committee members are in agreement that Australia's current dental services system is inequitable, and public dental services are overstretched. Cost is the major barrier for many Australians seeking dental care. Cost is also the biggest barrier to implementing reforms to improve equality of access to oral and dental health services.
2.81Australians with private health insurance generally have good oral health and adequate access to services. There are some notable exceptions, including Australians in underserviced rural and remote areas, and some people with disabilities and complex needs. Conversely, Australians who are reliant on public dental services—and those who are ineligible for public services but cannot afford private health insurance—experience poor oral health and inadequate access to services.
2.82The COVID-19 pandemic exacerbated existing inequities by temporarily ceasing routine treatment and creating a 'backlog' of people in need of care. While the available data is preliminary, evidence indicates these impacts have been disproportionately felt by vulnerable populations.
2.83Efforts to reduce this gap require a national focus. More regular, outcomes‑focussed, and nationally-consistent data collection is required to ensure that investments and reforms are effective and represent value‑for‑money.
2.84The committee is encouraged by efforts underway at the national level to create a consistent national minimum dataset for public dental services data. However, this only captures part of the picture. With around 85 per cent of dental services delivered in the private system, mechanisms must be developed to capture this data, including through partnerships with the private sector and private health insurance providers.
2.85The committee notes that Australia's public investments in dental and oral health care are low by international standards, and that a number of comparable countries are reforming the way dental services are funded and delivered, with the aim of improving equality of access.
2.86The committee believes reforms to the way dental and oral health care are conceptualised, organised, delivered and funded in Australia are long overdue. We are encouraged by the intergovernmental processes currently underway, and eagerly await the outcomes of these processes.
2.87In the chapters that follow, the committee looks at the need to 'put the mouth back into the body', considers what is required to reach priority populations, and to improve workforce distribution and capacity, and weighs up the costs and benefits of proposals for significant national reforms.
2.88The committee recommends that the Australian Government considers commissioning biennial national oral health studies—incorporating consistent measures of oral and dental health, habits and practices, service utilisation and outcomes—alternating between adults and children.
2.89The committee recommends that the Australian Government commissions research using data from the Longitudinal Study of Australian Children (LSAC), the Longitudinal Study of Indigenous Children (LSIC), and the Household, Income and Labour Dynamics in Australia (HILDA) to provide insights into:
oral health status, habits and practices, service utilisation, knowledge and awareness according to demographic factors;
the way in which dental habits, oral health issues and dental service access interact with demographic factors;
how habits and practices change across the life-course; and
long-term outcomes and impacts.
The research should be used to inform design and promotion of dental programs for children and to better target funding.