Chapter 5Maldistribution and capacity: training and workforce matters
5.1This chapter discusses training and workforce matters, and their impact on access to and provision of dental services in Australia. During the course of the inquiry the committee heard evidence regarding workforce challenges and considered the adequacy of the current dental and oral healthcare workforce, including workforce gaps.
5.2The committee examined a number of suggested future initiatives aimed at addressing the uneven distribution of dental and oral health professionals across the country.
Adequacy of current workforce
5.3Overall, there has been significant growth in dentists and other dental and oral healthcare providers over the past 10 years. The National Health Workforce Dataset reported that the number of dentists in 2013 was approximately 17 000 and increased to approximately 22 000 in 2020. However, there continues to be a maldistribution of the dental workforce.
5.4There is a skewed distribution of dental and oral healthcare workforce in Australia. A significant clinical workforce is needed in rural and regional areas, and in the public sector, and there is a shortage of Indigenous professionals and those trained and equipped to support patients with special needs.
5.5This section of the report will look at the present challenges and adequacy of the current dental workforce, as well as identified service gaps within in the industry, including:
the public dental sector;
the rural and regional workforce;
the Aboriginal and Torres Strait Islander workforce; and
Special needs dentists.
Public dental sector
5.6One of the major challenges with the oral and dental healthcare workforce is the major maldistribution of the types of practice and where they are located. Approximately 85 per cent of dentists work in the private sector, with only 15per cent working in the public sector, despite the fact that approximately 40percent of people living in Australia are eligible for public dental service. This often leads to long waiting lists for people trying to access public dental care.
5.7At the committee's public hearing in Launceston, Clinical Associate Professor Matthew Hopcraft, from the Victorian Oral Health Alliance (VOHA) emphasised the long waiting times for people trying to access public dental services in Victoria:
There are limited opportunities for people to improve their oral health because of the nature of the system. That's why the waiting lists are so long. They peaked, with more than 150,000 people on the waiting list, just over a year ago, with an average waiting time of 27 months.
5.8The Australian Dental Association (ADA) recommended a model that enables overflow patients from the public system to attend private practices using a voucher-based, publicly funded program, as a way to help alleviate waiting times. However, this would not address the broader workforce issue.
5.9Northern Territory (NT) Health highlighted the high staff turnover rates in NT public dental clinics. NT Health reported a 30 per cent vacancy rate for oral health roles, and attributed this turnover rate to:
inadequate remuneration and recognition;
professional isolation;
burden of travel and accommodation; and
the moral stress and 'burn out' associated with high disease rates and acute care, especially when working in remote communities.
5.10NT Health recommended alternative preventative based models of care be developed, such as the use of oral health therapists with a focus on prevention and early intervention. This would reduce the burden of oral disease, and subsequently reduce the long term demand for public dental services.
5.11Deakin Health Economics expanded on the above suggestion, recommending the use of other non-dental health professionals, such as:
Aboriginal and Torres Strait Islander health practitioners;
general practitioners (GPs);
nurse practitioner and midwives;
pharmacists;
diabetes educators;
speech pathologists; and
occupational therapists.
5.12New South Wales (NSW) Health emphasised the challenges regarding the short-term nature and uncertainty of current Commonwealth funding for public dental services. The limited funding leaves NSW Health offering short-term employment contracts, with a high risk of staff attrition, or leads to the issuing of vouchers for private providers to deliver dental treatment at a premium cost.
Cost of training
5.13Dentistry is one of the most expensive university courses to study in Australia. In Australia, only nine universities currently offer dentistry programs: University of Melbourne, University of Adelaide, University of Western Australia, Sydney University, University of Queensland, Griffith University, James Cook University, Charles Sturt University and La Trobe University. Of these nine, six offer a five-year undergraduate program, and three offer a four‑year graduate program. Commonwealth Supported Places can help subsidise dental programs, however the minimum student contribution is still approximately $60 000 for five years, and for full fee places the degree can cost upwards of $350 000.
5.14The cost of studying dentistry is a barrier, or at the very least a disincentive, for students opting for this pathway. Cost influences graduates' decision to seek employment in the public or private sector, and cost can have flow-on effects to patients, as dentists increase costs to help recoup the cost of their education.
5.15The committee heard evidence in Launceston that highlighted the impact of university debt on graduation employment:
As well as the selection of oral health students, we need to support that with remuneration. We know the private sector pays significantly more for students who graduate as oral health practitioners, particularly dentists. We know that their HECS bill, at the end, when they are a dentist, will be $100,000 to $200,000. I have heard that it's getting closer to $300,000. People aren't going to practise in a rural environment, in a public health service, if they're going to be saddled with a debt like that. There needs to be some thinking and incentives for people of rural origin to get some help with the debts that they're incurring while they're being trained. I think it's really important we do that.
5.16Due to limited funding for public sector dental services, the salaries offered to public dental and oral health professionals is less than in the private sector. Public dental services are therefore at a significant recruitment disadvantage. Without rectifying the pay inequalities between the public and private sector, it will remain difficult to attract and retain dental professionals in the public sector.
5.17Cohealth recommended that public oral health funding models and enterprise bargaining agreements deliver competitive employment conditions for oral health practitioners.
Rural and regional workforce
5.18The Office of the National Rural Health Commissioner reported that approximately seven million people live outside of metropolitan areas in regional, rural and remote areas of Australia. People who live in these areas are more likely to experience poorer health outcomes, shorter life expectancy, and greater burden of disease compared to those living metropolitan areas.
5.19In Australia, there is a shortage of dental and oral health practitioners in rural areas, compared to metropolitan areas. The National Rural Health Alliance reported that there are 4.5 times fewer dentists in Modified Monash (MM)5 (small rural towns) compared to MM1 (metropolitan areas) (Figure 5.1).
Figure 5.1Registered dental health professionals by Modified Monash Model
Source: National Rural Health Alliance, Submission 105, p. 10.
Registered fill-time dental professionals per 100 000 by MM1 to MM7. National Rural Health Alliance analysis of National Health Workforce Dataset and Australian Bureau of Statistics estimated resident population data by MMM for 2021.
5.20In regions without dental services, people must travel to access these services, and this travel is often postponed until the need becomes critical. This results in higher dental-related hospitalisations as rurality increases. The Office of the National Rural Health Commissioner reported that there is a disproportionate number of people who have to travel longer that one hour to access dental and oral health services in regional areas.
5.21The National Rural Health Alliance recommended the implementation of appropriate funding mechanisms to support flexible public oral health service delivery to rural Australians, so that they have access to services within a 60-minute drive time, either through a permanent service or visiting clinic and supplemented by timely access to telehealth facilities.
5.22The Dental Board of Australia reported that, over a five-year period, the number of dental practitioners had decreased in very remote areas; remained constant in remote areas; and increased in regional areas of Australia. It indicated the dental workforce continues to be maldistributed towards major cities (Figure 5.2).
Figure 5.2Changes to workforce across remoteness areas, 2017–2022
Source: Dental Board of Australia, Dental practice now: Workforce at a glance, 30 June 2022, [p. 3] (accessed 7November 2023). Registered dental practitioners listed by remoteness in 2017/18 compared to 2021/22.
5.23Currently, dental health training courses are mainly provided in metropolitan areas and are geared towards metropolitan students. These courses produce graduates who are more likely to practice in metropolitan areas. The Office of the National Rural Health Commissioner emphasised that these programs are not producing the necessary number of graduates required to provide services in rural, remote, and very remote communities.
5.24The committee heard that medical graduates from rural and regional areas of Australia, and those who undertake placements in these areas, are more likely to return and practice rurally after graduation. The National Rural Health Alliance suggested a similar model would be effective for the dental workforce.
5.25However, cost is a major barrier for rural and remote students considering dentistry at university. Relocation to a metropolitan area to study dentistry can be expensive, and also has social impacts, including caring responsibilities.
5.26La Trobe University recommended that rural and regional university placements should be given, as a priority, to students from a regional or rural background.
5.27The committee heard that the cost of regional or rural placements limits student opportunities to experience clinical placements in these areas. At the committee's public hearing in Perth, Mr Robert Anthonappa from the University of Western Australia emphasised the lack of funding for placements in regional and remote areas of Australia:
Currently, there's no established funding model for placements of students in rural and remote areas. Like John mentioned, they go to the KDT, or the Kimberley Dental Team, to provide some services, but there's no established model…So if you're talking about workforce, in the first place you need to get the students to go and be familiar with these areas, to provide services and to be culturally competent to provide those. If you do that, if you can start anew and you have a sustainable model, then I think that will continue for them to go back and give. So (1) is to establish it and (2) is to sustain it, which we currently don't have. Dental doesn't fall in line with the medical school or medical rural funding model, the RHMT [Rural Health Multidisciplinary Training Program]. Dentistry is not part of it and there is no funding allowed or available for these. I think that is a model, an area that we can actually work on where there are possibilities.
5.28The Office of the National Rural Health Commissioner recommended increased scholarships, traineeships and pastoral support for students from rural and remote regions to increase access to training and rural clinical placement opportunities.
5.29Professor Hopcraft recommended the establishment of Higher Education Contribution (HECS) debt or fee reimbursement and relocation support initiatives to help incentivise dental graduates to practice in rural and remote areas of Australia.
Rural Health Multidisciplinary Training Program
5.30The Rural Health Multidisciplinary training (RHMT) program is a Commonwealth-funded rural health workforce program aimed at increasing the number of health professionals working in regional, rural and remote areas of Australia.
5.31Currently the RHMT program supports a network of Rural Clinical Schools, and University Departments of Rural Health for medical, nursing and allied health student placements. It also supports six metropolitan based dental schools to provide rural placements for dental students through the Dental Training Expanding Rural Placement Program.
5.32The National Rural Health Alliance recommended the RHMT program be expanded to support more placements, and the number of placement locations in rural and regional areas of Australia be increased, especially in areas that have high levels of poor oral health.
Bonded Medical Program
5.33The Bonded Medical Program provides a Commonwealth Supported place in a medical course at an Australian university, and in return students commit to working in an eligible regional, rural, and remote area of Australia for threeyears after graduation.
5.34The committee heard evidence that suggested a similar scheme could help address the workforce maldistribution for dental practitioners in rural and remote areas of Australia.
5.35Professor Alastair J Sloan, Head of the Melbourne Dental School noted that the implementation of a bonded dental program, that requires oral health therapy and dentistry graduates to work in rural and remote areas of Australia would be a logical option.
Aboriginal and Torres Strait Islander workforce
5.36The National Aboriginal Community Controlled Health Organisation (NACCHO) reported a critical workforce shortage in Aboriginal Community Controlled Health Organisations (ACCHOs), which is exacerbated in remote areas of Australia.
5.37At present there is a very limited number of Aboriginal and Torres Strait Islander people are registered as dental practitioners. The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) remarked that, in 2018, there were only 108 Aboriginal and Torres Strait Islander people registered as dental practitioners, compared to 23 730 total dental practitioners. VACCHO suggest there would need to be an additional 700 Aboriginal and Torres Strait Islander dental practitioners to reach parity to the proportion of the Australian population who identify as Aboriginal and Torres Strait Islander.
5.38In many cases the necessary infrastructure to deliver dental services, such as dental chairs and appropriate rooms is available in remote areas, but there is no available dentist or oral health practitioner to provide services. The ongoing challenge in recruiting and retaining dental and oral healthcare workers to service Aboriginal and Torres Strait Islander communities—especially those in rural and remote areas—makes providing regular and accessible dental services difficult.
5.39Due to the lack of available dentists in Aboriginal and Torres Strait Islander Communities, there is often a subsequent lack of appropriate and timely referral pathways. This results in an increased use of primary care medical services, and emergency room visits for dental related issues.
5.40To expand the Aboriginal and Torres Strait Islander dental workforce, VACCHO recommended increased investment, specifically long-term funding to ACCHOs to support the recruitment and retention of suitably skilled and culturally safe workforce. Additional funding and resources is required for cultural mentoring, and for incentivising people to practice in regional and rural areas of Australia.
5.41Ms Laura Stuart from the Central Australian Aboriginal Congress Aboriginal Corporation stressed the workforce shortages in rural and remote areas of Australia, and recommended the following:
We're facing a workforce crisis in remote Australia. Strategies to address the maldistribution of the workforce could include providing tax relief for all practising dental health workers working in MM7 regions where there is a significant Aboriginal population and to fund traineeships, scholarships and cadetships to enable Aboriginal people to enter, develop and progress within the oral health service profession.
5.42NACCHO recommended that ACCHOs and Aboriginal and Torres Strait Islander Community Controlled Health Registered Training Organisations (ACCHRTOs) be appropriately resourced to co-design and deliver training to support Aboriginal and Torres Strait Islander Health Practitioners to deliver preventive dental services.
Special needs dentists
5.43Special Needs Dentistry (SND) is one of the newest dental specialities. The scope of SND is broad, it aims to provide services for people whose needs and health status require additional support, such as disabled people, people who are facing socioeconomic barriers such as homelessness or domestic violence, or people who experience physical or mental health challenges.
5.44As of 30 June 2023, the Dental Board of Australia reported that there are only 26practising special needs dentists in Australia. This is less than 1.5per cent of all dental specialist in Australia. Currently, there are no practicing special needs dentists in the Australian Capital Territory, the NT, or Tasmania.
5.45The low number of dentists who specialise in SND can be partially attributed to the barries that disincentivise dentists from specialising in SND. Thesebarriers include cost of studying which can upwards of $130 000 in addition to dentistry study costs, few scholarship opportunities, and uncertainty about future employment.
5.46At the committee's public hearing in Brisbane, Dr Peter King highlighted the lack of employment opportunities for special needs dentists:
… There are 26 special needs dentists in Australia, and we're all in agreement that the issue isn't so much the cost but believing that at the end of it you'll have a job. Special needs dentists haven't chosen to take high income opportunities. They're thinking: 'We'll probably work a lot in public health. We'll maybe get a bit of private practice going as well'… it's not the money; it's giving them the chance that there are going to be multiple positions across the country with units that focus on special needs dentist.
5.47At the committee's public hearing in Perth, Dr Amit Gurbuxani from the ADA of Western Australia recommended that the government fund scholarships for dentists specialising in SND.
Suggested initiatives
5.48This section looks at future initiatives suggested to the committee that would aim to help address the current dental and oral health workforce challenges. The following initiatives and program models will be explored:
Primary Care Rural Integrated Multidisciplinary Health Services;
virtual care and training models; and
alternative university pathways for rural students.
Primary Care Rural Integrated Multidisciplinary Health Services
5.49The Primary Care Rural Integrated Multidisciplinary Health Services (PRIM‑HS) is a model proposed by the National Rural Health Alliance that aims overcome the professional, financial and social barriers associated with practicing in rural areas of Australia.
5.50The suggested PRIM-HS model would employ a variety of primary healthcare professionals—including GPs, nurses, midwives, dentists, rural generalists and allied health professionals—to provide comprehensive continuity of care for rural and regional communities, that is tailored to the community. By tailoring services to communities, the National Rural Health Alliance stated that it would provide a more equitable distribution of the oral and dental health workforce.
5.51This model aims to provide a solution to the barriers affecting recruitment and retention of healthcare professionals, including dentists, to rural and regional areas of Australia. PRIM-HS would negate the need to establish independent practices or businesses and would provide an opportunity for oral healthcare workers to practice alongside other healthcare professionals.
Virtual care and training models
5.52As a response to the COVID-19 pandemic, which resulted in limited access to dental services, virtual care innovations were accelerated. This included the use of tele-dentistry, which can be used to deliver certain aspects of dental care where appropriate.
5.53Incorporating virtual care models into both metropolitan areas and rural communities, could increase the provision of and access to dental services, providing more responsive care, increased clinical effectiveness, and improved service efficiency.
5.54The Australian Healthcare and Hospitals Association emphasised the importance of virtual care in residential aged care, where staff can video residents' mouths if they believe there is a dental issue, and the video can be reviewed by a dentist. This allows dentists to triage severity and reduce unnecessary travel for older people.
5.55The Consumer Health Forum of Australia highlighted the possible use of virtual options in training and placements in rural and remote areas of Australia. Tele‑dentistry could assist graduates, dental practitioners and other healthcare professionals to increase their scope of practice and deliver treatments in settings where there is no supervising dentist.
Alternative university pathways for rural students
5.56The committee regularly heard that students from rural and regional backgrounds are more likely to practice in these areas after graduation. However, university entrance requirements are a barrier for these students when applying to dental schools.
5.57The Australian Tertiary Admission Rank (ATAR) is a prohibitive factor for some rural and regional students, as ATAR results for schools in rural areas are significantly below that of schools from metropolitan areas.
5.58At the committee's public hearing in Launceston, Mr Nick Bush from VOHA emphasised this barrier students from rural backgrounds face when applying to dental schools:
There will need to be some work done on the entrance requirement, the ATARs. We know that in rural communities the ATAR scores are well below those in metropolitan areas and especially those elite areas of the eastern suburbs of Melbourne and Sydney. We need to make some concessions and provide support for rural students to qualify as oral health practitioners.
5.59Dr Heather Cameron, from Western NSW Local Health District, recommended that universities should set aside positions for rural and regional students, as defined using the modified MM. DrCameron also recommended that universities either accept recommendations from school principals, or allow lower entrance scores for rural students.
5.60Another barrier for rural students studying dentistry is the requirement to relocate to study, as most dental schools are located in metropolitan areas. In some circumstances, relocating for university is untenable for a variety of reasons, such as cost and caring responsibilities.
5.61During the committee's public hearing in Launceston, Dr Jane Mills, Dean of LaTrobe Rural Health School emphasised the difficulties of online options for dental students:
It is full time on campus. This is the thing with dentistry. Because of the very hands-on nature of it, it's very difficult to be able to offer anything online. Even though we try to increase the amount of flexibility, and we've spent a lot less time sitting in classrooms listening to three-hour lectures and the like—those days have gone—and we're using quite modern learning and teaching strategies in terms of the delivery of content, it's very hands-on. From the moment they start in first year, they're in that preclinical training environment.
5.62However, Dr Mills also remarked that, during the COVID-19 pandemic, the university utilised remote pre-clinical training labs, run with a local dentist, to allow training to continue during the pandemic. Remote pre‑clinical training labs could be used in rural and remote Australia to train students from these areas, noting this would rely on local dentists.
Committee view
5.63The committee acknowledges that Australia has seen significant growth in the dental industry in the last ten years. However, there continues to be an uneven distribution of the dental workforce, affecting some parts of the population more than others.
5.64The committee is concerned about the inadequacy of the current workforce in regional and remote areas, and how this disproportionately affects:
those trying to access public dental services;
people living in rural and remote areas of Australia;
Aboriginal and Torres Strait Islander people; and
disabled people.
5.65While around 15 per cent of dental services are provided in the public sector, less than five per cent of dentists work in public practice. Pay and conditions in the public dental system need to be improved to attract more dentists and other oral health professionals to choose to practice publicly.
5.66The committee recommends that the Australian Government works with the states and territories to improve remuneration and conditions for dentists and oral health practitioners practicing in the public sector, so these may be more competitive with the private sector.
5.67Despite the fact that approximately seven million people live outside of metropolitan areas, there is a concerning shortage of dental and oral health practitioners in rural and remote areas of Australia compared with metropolitan areas. Dental health training is mainly provided in metropolitan areas and is geared towards metropolitan students.
5.68The committee recommends that the Australian Government considers supporting universities located in regional areas to establish dental schools, or expand current courses to accommodation more students.
5.69The committee recommends that universities be incentivised to implement alternative entry pathways, such as Principals' recommendations, and allocate specific course places for regional and remote students to study dentistry and oral health.
5.70The committee heard consistently that students from rural and regional backgrounds are much more likely to practice in these areas after they graduate. Providing alternative university pathways for rural students would help alleviate workforce shortage in rural areas over time. Currently, there are multiple programs that incentivise medical students to practice rurally, but most of these exclude dental students. Expanding these programs to include dental and other oral health students would increase the number of dental graduates practicing rurally.
5.71The committee recommends that the Australian Government considers funding evidence-based programs to incentivise dental and oral health providers to practice in regional and remote areas of Australia.
5.72The committee recommends that the Australian Government expands existing medical student rural subsidy programs to include dental and oral health students.
5.73The committee recommends that the Australian Government investigates implementing a requirement for a 12-month compulsory paid placement working within the public health system following graduation in order to qualify for the dental license/complete their studies.
5.74As discussed in Chapter 3, transitioning the focus of dental care to more preventative treatments may help address workforce shortages in regional and rural areas. Preventative care could be provided by oral health therapists, and non-dental health care professionals, including pharmacists and GPs. This would help alleviate the burden of oral disease and reduce the long-term demand for public dental services.
5.75The committee recommends the Australian Government works to increase the size of the oral health therapist workforce by putting into place incentives to study oral health therapy and providing scholarships for students from regional areas and Aboriginal and Torres Strait Islander students.
5.76The committee recommends that the Australian Government adequately recognises the need for Aboriginal Community Controlled Health Organisations to:
train general health care providers in delivering basic and preventative oral health care; and
recruit and retain dentists, and other oral health practitioners, to work in regional and remote areas of Australia.
5.77The committee is concerned that the limited number of Aboriginal and Torres Strait Islander people registered as dental practitioners in Australia is impacting the availability of culturally safe oral health care in communities. There are currently only 108 Aboriginal and Torres Strait Islander people registered as dental practitioners, compared to over 23000 total dental practitioners. Supporting Aboriginal Community-Controlled Health Services with long-term secure funding would support the recruitment and retention of a suitably skilled and culturally safe Aboriginal and Torres Strait Islander dental workforce.
5.78The committee is concerned about the incredibly small number of Special Need Dentists practicing in Australia, especially as some state and territories do not currently have a practicing Special Needs Dentist at all. This shortfall has been mainly attributed to both the costs associated with specialising, and the lack of employment opportunities. The committee heard recommendations that funding scholarships to specialise would encourage dentists to go into this specialisation. However, the committee also notes that most Special Needs Dentists work in the public system, and there needs to be well-paid, available positions for graduates to go into.