Health Workforce Oral Health Background Paper. February 2013

Transcription

1 Health Workforce Oral Health Background Paper February 2013

2 Health Workforce Australia This work is Copyright. It may be reproduced in whole or part for study or training purposes. Subject to an acknowledgement of the source, reproduction for purposes other than those indicated above, or not in accordance with the provisions of the Copyright Act 1968, requires the written permission of Health Workforce Australia (HWA). Enquiries concerning this report and its reproduction should be directed to: Health Workforce Australia GPO Box 2098 Adelaide SA 5001 Telephone: Internet: Suggested citation: Health Workforce Australia 2012: HW Oral Health, Background Paper HW 2025 Oral Health, Background Paper

3 Contents Introduction... 1 Why do we need the HW Oral Health project? How do Australians get their oral health care?... 3 Private health insurance... 3 Public services Which population groups have greater oral health needs or face additional barriers to accessing services?... 7 Elderly... 7 Low socioeconomic status... 7 Special needs... 9 Rural & remote What does the oral health workforce look like? Demographics Registered workforce Non-registered workforce Becoming part of the oral health workforce Immigration Recent Commonwealth Government Initiatives Background policy Current schemes closed 1 December Existing schemes Dental Reform Package - Dental Benefits Amendment Bill Appendices HW 2025 Oral Health, Background Paper

4 Appendix A Quarterly dental services, total benefits paid and fees for services, September 1995 to June Appendix B Current adult oral health services provided by the States and Territories Appendix C Current child oral health services provided by the States and Territories References HW 2025 Oral Health, Background Paper

5 Introduction Health Workforce Australia (HWA) was established under the National Partnership Agreement on Hospital and Health Workforce Reform in 2009 to progress health workforce reform and addresses the challenges of providing a skilled, innovative and flexible health workforce in Australia. One of HWA s major tools towards achieving this is workforce planning. Health Workforce 2025 (HW 2025) provided Australia s first major, long-term, national projections for doctors, nurses and midwives and presented the best available planning information on our future health workforce. HWA indicated in these reports that the next steps were to expand the range of workforces covered, develop and improve methods of scenario analysis and undertake economic analysis to quantify the cost to allow an assessment of the relative affordability of the modelled scenarios. The HW 2025 Oral Health (HW 2025 Oral Health) project is the next phase of this series. Why do we need the HW Oral Health project? Having good oral health means being able to eat, speak and socialise without discomfort or embarrassment and without active disease that affects overall wellbeing. Good oral health is an integral part of good general health, and is essential to being able to participate in daily activities without limitation, or without physical or psychological discomfort as a result of poor oral health 1. Efforts to improve oral health are guided by Australia s National Oral Health Plan , prepared by the National Advisory Committee on Oral Health, which aims to help all Australians retain as many of their teeth as possible throughout their lives, have good oral health as part of their general good health, and have access to affordable and quality oral health services 2. Australia had two important achievements in oral health in the 20th century: the first was large gains in child oral health associated with widespread access to fluoride, and the second was the decline in tooth loss in adults. As a result of changes in patient preferences and dental practice, fewer Australians are experiencing edentulism (complete tooth loss) and it is now almost exclusively a condition of old age. In addition, adults who are not edentulous are keeping more teeth than in the past as fewer decayed teeth are extracted and more are treated with restorations (fillings) 1, 3. In recent years, reports from the National Health and Hospitals Reform Commission and the National Advisory Council on Dental Health have focussed on inadequacies in Australia s oral health system, highlighting pressure on the oral health workforce to meet the demand for services in particular groups of the population 4-7. Australia s National Oral Health Plan states that demand for oral health care services will continue to grow, in response to population growth and ageing, increased tooth retention into older age, greater awareness of the importance of oral health, and more advanced restorative procedures and technologies 2. On page 3, the plan describes a population health approach to oral health, in which the programs, services and institutions of public health emphasise the prevention of disease and the health needs of the population as a whole. This approach was HW 2025 Oral Health, Background Paper 1

6 developed in response to growing recognition of the importance of the social, economic, cultural and environmental determinants of health. The plan further notes a population health approach offers a way to manage the growing demand for oral health services, utilising both private and public sector resources as effectively as possible, and working across sectors and communities to maximise oral health gains and promote oral health across the community 2. What will the HW Oral Health project do? HW2025 Oral Health will address the central question of what is the right number and mix in the oral health workforce to best meet changing demographic and policy requirements to 2025? This question will be addressed through the process of health workforce planning. In the context of the plan, health workforce planning is the process of estimating the right number in the oral health workforce with the right skills and skill-mix, and in the right place at the right time, to meet future service requirements. This will also reflect the current issues and policy levers that have an effect on the workforce. The National Oral Health plan is also being updated and it will be important that the HW Oral Health project complement this work. HW 2025 Oral Health, Background Paper 2

7 1 How do Australians get their oral health care? Private health insurance With the majority of the oral health workforce in private practice, most services in Australia are provided by the private sector, with or without the assistance of private dental insurance 2, 8. The Australian Institute of Health and Welfare s (AIHW) report Insurance and use of dental services : National Dental Telephone Interview Survey 2010 states insurance may be considered an enabling factor that can assist in access to services, and having dental insurance has been identified as a buffer against the financial burden of dental care 8. For the purpose of this paper, patients with dental insurance refers to patients with general treatment insurance (commonly sold as extras cover ), which usually includes dental insurance 8. As of 30 September 2012, 54.5% of the Australian population have general treatment insurance 9. During the September 2012 quarter there were 7,827,196 services delivered and $460 million in total dental benefits paid 9. Appendix A provides quarterly data on the number of dental services, total benefits paid and fees for services, from September 1995 to June Table 1 provides annual data on the total number of dental services, benefits paid, fees for services, and average benefit per service and fees charged per service Table 1. Annual data: total dental services, benefits paid, fees for service, and average benefit per service and fees charged per service, Year Services Benefits Fees Benefit per Fees charged service per service ,999,526 1,187,205,240 2,414,323,368 $49.47 $ ,071,695 1,283,302,783 2,638,144,068 $51.19 $ ,687,191 1,414,241,884 2,925,375,186 $52.99 $ ,739,510 1,509,763,524 3,118,928,845 $54.43 $ ,829,591 1,605,632,781 3,295,090,696 $55.69 $ ,966,431 1,713,893,281 3,445,141,918 $57.19 $ Source: PHIAC, Data on services, benefits paid and gap payments by MBS Specialty Block Groupings for medical services paid by private health insurers, extracted 10 October The results of the National Dental Telephone Interview Survey 2010, conducted by the Australian Research Centre for Population Oral Health (ARCPOH), show a higher proportion of Australian adults with insurance made a dental visit in the last 12 months (70.9%) than adults without insurance (48.3%). Adults who visited in the last 12 months made 2.3 dental visits on average, and this did not vary between those with and without insurance. This indicates that while insurance may have enabled access to dental care, it did not lead to a greater demand for visits once access had been obtained (but might lead to a greater demand for more expensive services though). A higher proportion of adults with dental insurance visited for a check-up (66.1%) than adults without insurance (50.2%) 8. HW 2025 Oral Health, Background Paper 3

8 The results also show a higher proportion of adults with dental insurance had scale and clean services in the previous 12 months (83.5%) than adults without insurance (63.6%). A lower proportion of adults with insurance had fillings (37.2%) than adults without insurance (43.9%). A lower proportion of adults with insurance had extractions (10.4%) than those without insurance (19.0%). Additionally, a lower proportion of adults with insurance received dentures (3.2%) than adults without insurance (6.3%). Insurance was associated with a different reason for dental visits and a different pattern of services that was more oriented to prevention and retention of natural teeth 8. Further to this, the survey results found that dental insurance status was a much stronger predictor of visiting patterns than Australian Government concession cardholder status. The proportions of adults who made a dental visit in the previous 12 months were similar for cardholders and non-cardholders with insurance (68.3% and 73.0%) and without insurance (46.4% and 52.1%). Average numbers of dental visits were similar for cardholders and noncardholders with insurance (2.6 and 2.2 visits) and without insurance (2.4 and 2.3 visits). However, cardholders with insurance were far more likely than cardholders without insurance to have visited for a check-up at their most recent dental visit (61.9% and 40.4%) 8, 10. The results show the proportions of adults who had scale and clean services were similar for cardholders and non-cardholders with insurance (81.2% and 83.4%) and without insurance (57.3% and 67.4%). The proportions of adults who had extractions were also similar for cardholders and non-cardholders with insurance (15.2% and 10.4%) and without insurance (23.8% and 17.5%) 8. AIHW s report Trends in access to dental care among Australian children, based on data collected from , notes in general, children with private health insurance, or those covered by their parents private health insurance, are more likely to have favourable visiting patterns and are at lower risk of experiencing oral disease than those without insurance 11. In general, children with insurance are more likely than uninsured children to make a dental visit at least once a year, and are more likely to visit for the purpose of receiving a check-up rather than treating a problem. Uninsured children are generally more likely than insured children to receive extractions and fillings 11. Public services Australia s National Oral Health Plan states that while the Commonwealth continues to play a direct and indirect role in the financing of dental services, responsibility for the delivery of the major public programs for disadvantaged adults and children is managed by the States and Territories 2. A full overview of services is provided in Appendix B Current adult oral health services provided by the States and Territories, and Appendix C Current child oral health services provided by the States and Territories. For adults, public service access is largely determined by eligibility for concession cards 9. Eligible adults can generally access public dental services from age 18, with the exception of Queensland where eligibility is from above the age and completion of year The type of concession card which allows access to public dental services and the amount of co- HW 2025 Oral Health, Background Paper 4

9 payment varies across the states and territories. However, the type of services available is generally similar across jurisdictions and is limited to emergency dental care and general dental treatment. Services are delivered by public dental clinics mainly located in community health centres or on hospital grounds. Waiting times are significant, with the average exceeding two years in some states 9. For children, eligibility also varies across the jurisdictions. There are also differences in the models of service delivery. Western Australia (WA), Queensland and South Australia (SA) have dedicated school dental programs. The Northern Territory (NT) uses a hybrid model consisting of community-based services and school dental programs. New South Wales (NSW), Victoria, Tasmania and Australian Capital Territory (ACT) rely predominantly on community-based clinics 9. All dental schools throughout Australia provide clinical dental care to the community. The treatment provided by students (around 7%) is performed under the supervision of registered dentists. University-managed clinics include those at the University of Queensland, Griffith University, University of Newcastle, Charles Sturt University and James Cook University. In Victoria, South Australia and NSW public health managed clinics are run from the Royal Dental Hospital (University of Melbourne), Adelaide Dental Hospital (University of Adelaide) as well as the Westmead Centre for Oral Health and the Sydney Dental Hospital (University of Sydney). Students also provide public patient services through some student placements in public clinics. The private sector also contributes to the treatment of patients through publicly funded schemes including the NSW Oral Health Fee for Service Scheme, SA General Dental Scheme, SA Emergency Dental Scheme, SA Pensioner Denture Scheme and WA Government Subsidised Oral Health Care Schemes. The Commonwealth Government directly finances these services to eligible individuals 2 : Medicare Teen Dental Plan Veteran s Affairs programs the Armed Forces and Army Reserve Dental Scheme the Cleft Lip and Cleft Palate Scheme oral health services provided through Community Controlled Aboriginal Medical Services, (managed by the States and Territories, Commonwealth-funded) oral health services in the Christmas and Cocos Islands, and for asylum seekers in community detention some specialist oral surgery and oral radiography through Medicare, and subsidised drugs prescribed by dentists under the Pharmaceutical Benefits Scheme. Table 2 provides a summary of eligibility criteria for these programs. HW 2025 Oral Health, Background Paper 5

10 Table 2. Eligibility for Commonwealth oral health programs Service Eligibility Criteria Medicare Teen Dental Plan The Child Dental Benefits Schedule will overtake this program on 1 January 2014 and offer a subsidy for basic dental services for eligible 2-17 year olds. Veterans Affairs Armed Forces and Army Reserve Dental Scheme Cleft Lip and Cleft Palate Schemes Community Controlled Aboriginal Medical Services Oral health services in the Christmas and Coco Islands, and asylum seekers in community detention To be eligible for a voucher for a preventative dental check a teenager must be 12 : aged between years, and eligible for Medicare, and: - getting the Family Tax Benefit (Part A), ABSTUDY, Carer Payment, Disability Support Pension, Parenting Payment, Special Benefit or Youth Allowance, or - their family/guardian/carer gets the Family Tax Benefit (Part A), Parenting Payment or the Double Orphan Pension for the teenager, or - their partner gets the Family Tax Benefit (Part A) or Parenting Payment, or - are aged years and getting financial assistance under the Veterans Children Education Scheme or the Military Rehabilitation and Compensation Act Education and Training Scheme from the Department of Veterans Affairs. Important: a teenager may still be eligible if the above conditions are only met for a minimum of one day in the calendar year. Veterans who have served in the Australian Defence Force are eligible for free dental treatment but entitlements vary between Department of Veterans Affairs (DVA) White Card and Gold Card holders 13. The DVA Gold Card is also issued to dependents and widows/widowers who have access to these services 14. Employees of the Army are eligible for free dental treatment 14. If an adult or child have a cleft lip or cleft palate condition, the schemes provide Medicare benefits for a range of dental treatment including: a limited range of orthodontic work, surgical extraction of teeth, some general and prosthodontic services by a private practitioner, and oral and maxillofacial surgery by an oral and maxillofacial surgeon. A person must be registered before the age of 22 to be eligible. An eligible person receives a cleft lip and cleft palate identification card and can claim benefits until the age of 28. Once over the age of 28, card holders can only claim for the repair of previous reconstructive surgery 15. eg. Aboriginal Medical Service Western Sydney, Nganagganawili Aboriginal Health Service 16, 17 Community controlled Aboriginal health and medical services provide culturally appropriate services, including oral health care, to Indigenous persons residing in the area. Detainees on the islands have access to free oral dental care. In 2009 the Human Rights Commission noted that detainees faced long waiting lists as there is only one dentist on Christmas island to meet the needs of both the local community and detainees 18. Medicare ineligible asylum seekers are provided with health services (which normally require a Medicare Card) including public dental services in each state or territory. HW 2025 Oral Health, Background Paper 6

11 2 Which population groups have greater oral health needs or face additional barriers to accessing services? Elderly Australia s National Oral Health Plan highlights the oral health of older people as a priority action area 2. The plan notes that older people generally refers to people aged 65 years and older. On page 23, the plan distinguishes Aboriginal and Torres Strait Islander people, with a life expectancy some 20 years less than the Australian average, and defines the term old as age 45 and above for this group. Findings on the activity of dentists in private general practice from ARCPOH s Longitudinal Study of Dentists' Practice Activity show that between and the percentage of patients 65 years or more increased from 11.3% to 14.1% 19. Edentulism across all age groups decreased (3.1% in to 1.3% in ), and a trend over the period was tooth extraction replaced by measures allowing people to keep their own teeth, as reflected in a reduction in extractions and an increase in restoration work. Reflecting the decline in tooth loss, the percentages of patients visiting for denture problems decreased (30.3% to 15.8%) among patients aged 65 years or more. There were corresponding increases in the percentages of older patients attending for recall/maintenance care (11.4% to 20.9%) 19. The study found that the number of diagnostic services per visit increased among older patients, reflecting increased rates of radiograph services among patients aged 65 years or more. The rates of crown and bridge services per visit increased among older patients while there were significant decreases in rates of full dentures and partial upper dentures, yet an increase in the rate of partial lower dentures. The total number of services per visit increased among patients aged 65 years or more 19. The study concluded that there are increasing numbers of older patients who are retaining their teeth, and these patients may have complex treatment needs that require more services and take longer to complete. Such changes in oral health, demographics and use of services will impact on the practice activity of the workforce 19. Low socioeconomic status Australia s National Oral Health Plan notes that profound disparities exist across socioeconomic groups in Australia in respect to oral and general health. People of lowest socioeconomic status the poor and disadvantaged carry the highest burden of disease and the incidence of caries and periodontal disease increases as socioeconomic status decreases. Socioeconomically disadvantaged groups include low-income earners and their families, some young adults and older people, some people from non-english speaking backgrounds, Indigenous Australians, and a significant proportion of people living in rural and remote areas 2. HW 2025 Oral Health, Background Paper 7

12 In 2012, AIHW reported on the shape of the socioeconomic-oral health gradient based on the results of ARCPOH s National Dental Telephone Interview Survey , 8. The report illustrates when the adult population is divided into thirds by household income (adjusted for the size of the household), oral health improves incrementally from the lowest income group through to middle and higher incomes, as illustrated in table 3. The report notes that adults with the lowest one-third of household incomes are more likely to have lost all their teeth, and if they have their own teeth, adults on lower incomes are more likely to have more missing teeth than adults on high incomes. These differences translate to affecting everyday activities for which people rely on well-functioning teeth. Adults on lower incomes are more likely to experience toothache, to avoid certain foods and to feel uncomfortable with their appearance than adults on higher incomes 1, 8. Table 3. Oral health indicators, by household income, 2010 Group Self rated oral health (a)(b) (per cent) Edentulism (c) Missing teeth (a)(c) Experienced toothache (a) (d) (per cent) (average number) (per cent) All Australians Household equivalised incomes: Uncomfortable with appearance (c) (e) Avoided food (f) (per cent) (per cent) Lowest Middle Highest (a) Relates to dentate persons (those with any of their natural teeth). (b) The proportion of people who rate their oral health as good, very good, or excellent. (c) This question asked only for persons aged 18 and over. (d) The proportion of people who experienced toothache sometimes, often or very often in the past 12 months. (e) The proportion of people who felt uncomfortable about the appearance of their teeth, mouth or dentures sometimes, often or very often during the past 12 months. (f) The proportion of people who avoided eating some foods because of problems with their teeth, mouth or dentures sometimes, often or very often during the past 12 months. Source: National Dental Telephone Interview Survey, Oral health care is more difficult to access for those on low incomes, with often years-long waiting lists for public care, while private care can be prohibitively expensive 2. Average waiting times for general care are 27 months and can extend to five years 7. Wait lists for emergency care are significantly shorter. Many patients start on public dental waiting lists seeking preventative or restorative treatment but become emergency cases by the time they receive treatment 20. The significant wait for dental services can lead to a piecemeal approach to care, with people seeking treatment through numerous emergency dental visits 7. HW 2025 Oral Health, Background Paper 8

13 Special needs In its advice to Parliament on priorities for consideration in the budget, the National Advisory Council on Dental Health identified people with special needs, noting that this group experience much higher levels of oral disease and face additional barriers to accessing dental care 7. According to Australia s National Oral Health Plan special needs refers to people with intellectual or physical disability, or medical or psychiatric conditions, that increase their risk of oral health problems or increase the complexity of oral health care 2. Australia s National Oral Health Plan highlights the following points 2 : Approximately 2.4 million people are aged less than 65 years of age in Australia with at least one disability or long-term health condition; 6% of Australians are reported to have severe/profound disabilities; Whilst there is no published data to support accurate estimates of the numbers whose disability would increase the risk of oral health problems or the complexity of oral health care, expert opinion estimates that around 1 million people would be in the special needs category for oral health; People with special needs experience higher levels of oral health disease and poorer access to oral health care than the general population; For many people with special needs, socio-economic disadvantage adds to their risk of oral disease and difficulties in accessing dental care; Access to dental care is difficult for those with special needs, particularly for those in community-based housing; and Treatment can also be more difficult when oral health care is obtained due to complex medical conditions, physical and behavioural barriers. Special needs patients receive predominantly emergency care, rather than general dental care. Their limited access to care may be further aggravated as the treatment required by many patients is beyond the capacity of the private surgery setting. More patients therefore require treatment through hospital admission or under general anaesthesia 21. For special needs patients in supported accommodation, the move from institutions to communitybased housing has meant that some cannot access public dental services which, in the past, cared for residents in institutions 2. HW 2025 Oral Health, Background Paper 9

14 Aboriginal and Torres Strait Islanders Australia s National Oral Health Plan highlights the oral health of Aboriginal and Torres Strait Islander peoples as a priority action area 2. Although there have been a number of studies of the oral health of Aboriginal and Torres Strait Islander people, AIHW s report, Australia s Health 2012, suggests that there are a number of gaps in nationally representative data on their oral health 1. AIHW notes that methods used to collect data on adult oral health tend to under-represent Indigenous Australians, especially those living in remote locations, however all comparisons point to poorer oral health among Indigenous Australians than other Australians 1. The results of ARCPOH s National Survey of Adult Oral Health show that the rate of untreated caries was 2.3 times more in the Indigenous than the non Indigenous adult population, with 57% of Indigenous adults having one or more teeth affected compared with 25% of non Indigenous adults, and there was also greater tooth loss 22. The survey results showed Indigenous children experience more caries that non Indigenous children in their deciduous (baby) teeth, with caries rates in Indigenous children aged 4-10 years being significantly higher than for their non Indigenous counterparts in NSW, SA and the NT. The highest overall caries rate was for Indigenous six-year-olds, who experienced 2.4 times the caries rate of non Indigenous children of that age, while four-year-old Indigenous children had more than three times the caries rates of non Indigenous four-year-olds 22. Poorer oral health for Indigenous children continues among those with permanent teeth with the caries rate being 1.5 times greater for Indigenous children aged 6-15 years than for their non Indigenous counterparts 22. The findings also illustrate a significantly higher incidence of periodontal disease in Indigenous Australians (both adult and children) (34.2%) compared to non-indigenous people (26.7%). Of dentate Indigenous Australians, 19.6% have fewer than 21 teeth, compared to 14.2% of non-indigenous Australians 22. Services Currently, public oral health services give priority access to Aboriginal and Torres Straight Islanders. In NT however, Aboriginal and Torres Strait Islanders are not specifically prioritised as these patients are the core patient population. In NSW, 18 Aboriginal Medical Services, funded by NSW Health provide free oral health services to Indigenous residents 23, 24. Across urban, regional and remote Australia, over 150 federally-funded Aboriginal Community Controlled Health Organisations (ACCHOs) primarily service the health needs of Aboriginal and Torres Strait Islander people. Those with dental programs can have varying eligibility criteria, and some charge co-payments or a small contribution fee 25. In 2012, a $719 million funding investment was provided as part of Australian Government s Stronger Futures package. The Government is providing the investment over 10 years to improve the health and wellbeing of 65,000 Aboriginal people in the Northern Territory. More than 12,000 children will also have access to preventive oral HW 2025 Oral Health, Background Paper 10

15 health services through outreach services, to improve oral health practices, and reduce dental problems. The National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people was updated and rereleased in These guidelines developed by the National Aboriginal Community Controlled Health Organisation (NACCHO) for the Royal Australian College of General Practitioners (RACGP), outline screening and appropriate health interventions for Aboriginal and Torres Strait Islander groups. While the guidelines were developed for general practice, they have wider application when considering the oral health treatment of these groups 26. In 2008, the Indigenous Dentists Association of Australia (IDAA) published its Indigenous oral health goals as part of the Closing the Gap Campaign 27. The goals include increased Indigenous participation in the oral health workforce, and the provision of high quality, culturally-appropriate oral health care to Indigenous people that is organised and coordinated regionally. Adding to this, in 2010 the Ministerial Council for Federal Financial Relations published the Implementation plan for national Indigenous mobile dental infrastructure: Alice Springs, Implementation plan for national Indigenous mobile dental infrastructure: Orange, Implementation plan for national Indigenous mobile dental infrastructure: Queensland, highlighting the increased need for indigenous-dedicated services in these areas Rural & remote Following a mid-term review of Australia s National Oral Health Plan , a supplementary action area covering residents of rural and remote areas was developed by the National Oral Health Plan Monitoring Group and subsequently endorsed by the Australian Health Ministers' Advisory Council. Additionally, ARCPOH S 2008 report Improving Oral Health and Dental Care for Australians, prepared for the National Health and Hospitals Reform Commission, highlighted rural residents as among the groups in Australia that are more likely to have unfavourable dental visiting patterns, with a greater likelihood of poor oral health outcomes. According to the report, the rates of untreated caries in rural residents is 31.7% compared with 24.8% in urban residents, and the rate of moderate to severe periodontal disease is 32.8% in rural residents compared to 26.1% in urban residents 31. For children, sixyear-olds in rural areas will have 50% more decayed, missing and filled teeth compared with same-aged children in the major cities, and 12-year-olds will have 30% more decayed, missing and filled teeth compared with their counterparts in the major cities 32. AIHW reported in Australia s Health 2012 that rural and remote adult residents are about 1.7 times as likely to have no natural teeth, and those who do have natural teeth have 25% more missing teeth than adults who live in major cities, as illustrated in table 4 1. However, this increased tooth loss did not translate to higher rates of adverse oral health effects, such as feeling uncomfortable with their appearance, avoiding foods or experiencing toothache, or to worse self-rated oral health. These variations in oral health can be attributed in part to differences in access to the means to prevent dental disease, and to differences in access to HW 2025 Oral Health, Background Paper 11

16 timely dental treatment for dental disease when it is needed. For Australians living in nonmetropolitan areas, both can be a problem 1. Table 4. Oral health indicators, by household income, by location, 2010 Group All Australians Location: Self rated oral health (a)(b) (per cent) Edentulism (c) (per cent) Missing teeth (a)(c) (average number) Experienced toothache (a) (d) (per cent) Uncomfortable with appearance (c) (e) (per cent) Avoided food (f) (per cent) Major cities Other areas (a) Relates to dentate persons (those with any of their natural teeth). (b) The proportion of people who rate their oral health as good, very good, or excellent. (c) This question asked only for persons aged 18 and over. (d) The proportion of people who experienced toothache sometimes, often or very often in the past 12 months. (e) The proportion of people who felt uncomfortable about the appearance of their teeth, mouth or dentures sometimes, often or very often during the past 12 months. (f) The proportion of people who avoided eating some foods because of problems with their teeth, mouth or dentures sometimes, often or very often during the past 12 months. Source: National Dental Telephone Interview Survey, The Royal Flying Doctor Services 2012 Dental Discussion Paper, supplied to HWA but not publically release, summarises some of the major factors impacting on oral health in rural and remote communities 25 : Poor access to dental services and care often with a history of irregular dental visits and programs which can affect continuity of patient care; Limited access to oral health advice and information; An expectation in some areas that dental care is for emergency and relief of pain, hence there can be difficulty in getting patients to return for routine care when available; People have to travel long distances for dental care and there is no financial support for transport for routine dental care, or dental emergencies; In areas of no/low dental workforce, GPs and other health staff are often the first to be consulted for dental pain and infection, leading to a higher use of antibiotics and analgesics; and Varying levels of dental infrastructure in place across the country, with no standardisation of equipment. HW 2025 Oral Health, Background Paper 12

17 Dental school clinics make a significant contribution in sustaining a rural presence. The Australian Government Department of Health and Ageing funds a Dental Training - Expanding Rural Placements (DTERP) Program. This program aims to improve the availability of rural dental care and strengthen the rural dental workforce. The DTERP program supports six Australian dental faculties to develop extended rural training programs. These faculties are the University of Adelaide, University of Melbourne, University of Sydney, University of Queensland, University of Western Australia and Griffith University. The program is designed to encourage dental students to take up a career in rural practice by providing positive, high quality clinical education and training experiences for dental students in rural areas. Capital and operational funding is provided to support at least 30 fulltime equivalent clinical placements annually (five per university) for dentistry students in established rural training settings. HW 2025 Oral Health, Background Paper 13

18 3 What does the oral health workforce look like? Demographics The oral health workforce is made up primarily of those registered with the Dental Board of Australia through the Australian Health Practitioner Regulation Agency (AHPRA). Prior to the 2010 introduction of the National Accreditation and Registration Scheme, registration was with state and territory dental boards and data from this period reflects collated state data. A majority of the data presented in this section has been sourced from AIHW s National Dental Labour Force Collections (previously administered by ARCPOH). Data from 2011 has been sourced from AIHW National Health Workforce Dataset: dental practitioners There is no systematic collection of workforce data for the non-registered - the data presented in regard to these support roles has been sourced from the ABS Census of Population and Housing. Table 5 shows the total number registered in Australia and the total number practicing in Australia from 2000 to For example, in 2011 there were 14,179 dentists registered with the Dental Board of Australia (the Board) and of these 12,734 were working in dentistry 33. Table 5. Oral health workforce headcount, 2000 to 2011 Registered Oral Health Workforce Oral Health Workforce Dentists 10,109 10,922 11,160 12,271 14,179 Oral health therapists Dental therapists (a) 698 1,559 1,364 1,383 1,165 Dental hygienists (b) ,206 Dental prosthetists 1,028 1,034 1,039 1,137 1,145 Total registered (c) 12,214 14,201 14,732 16,416 18,803 Practicing Oral Health Workforce Dentists 8,992 9,678 10,404 11,882 12,734 Oral health therapists Dental therapists 1,317 1,242 1,171 1,234 1,044 Dental hygienists ,065 Dental prosthetists ,013 1,088 Total non-registered 11,596 12,375 13,541 15,652 16,925 Dental Assistant N/A N/A 15,380 N/A 18,822 Dental Technician N/A N/A 2,556 N/A (d) 2192 Grand Total N/A N/A 31,477 N/A 37,939 Source: dentists, oral health therapists, dental therapists, dental hygienists and prosthetists sourced from the AIHW AIHW Dental labour force collection (Cat. no. DEN 218) 35 and AIHW Dental workforce 2011 (Cat. no. HWL 50) 33. Dental Assistants and dental technicians sourced from ABS Census data. HW 2025 Oral Health, Background Paper 14

19 (a) There was no registration process for dental therapists in NSW, Qld, SA, Tasmania and the ACT in 2000, Dental Labour force, Australia 2000 (AIHW cat. no. DEN 116) (b) There was no registration process for dental hygienists in NSW and Qld in 2000, Dental Labour force, Australia 2000 (AIHW cat. no. DEN 116) (c) Total registered excludes registered therapists and hygienists in states with no registration process in 2000 (d) The number of dental technician for 2011 (2,192) is a projected figure based on the growth rate from 2001 to 2006 Registered workforce Definitions for the registered workforce will be provided by the Dental Board of Australia once approved. Dentists and dental specialists Dentists who wish to become dental specialists undertake additional training and qualifications. The Dental Board of Australia recognises 13 specialist fields: Dento-maxillofacial radiology Endodontics Oral and maxillofacial surgery Oral medicine Oral pathology Oral surgery Orthodontics Paediatric dentistry Periodontics Prosthodontics Public health or community dentistry Special needs dentistry Number of dentists and dental specialists Of the practicing dentists in 2011(12,734), the vast majority (12,154) were working in clinical practice as either in general practice or as a specialist. The proportion of all practicing dentists that are specialists has remained fairly stable since 2000 (11.4%). Working dentists also includes the small proportion of dentists who identified that their main area of work is in nonclinical practice; including administration (177, 1.4%), teaching and education (244, 1.9%), research (48, 0.4%) or other areas of dentistry (111, 0.9%). About three quarters of specialists are consistently concentrated in a small number of specialties. The most popular specialties in 2011 were orthodontics (40%, 567), oral and maxillofacial surgery (11.5%, 164), prosthodontics (11.2%, 161) and periodontics (13.7%, 196). These are the same top four specialties as in 2000 with little change to the proportions, although the slight reduction in the proportion of orthodontists (44% in 2000) and oral and maxillofacial surgeons (16.8% in 2000) has been shared among the other specialties. A group of other niche specialties, including ones like public health dentistry and special needs dentistry remains a small group but grew between 2000 and 2009 (0.9% to 5.9%). HW 2025 Oral Health, Background Paper 15

20 Table 6. Registered practicing dentists (including specialists), selected characteristics by alternative data sources Total number 8,992 9,678 10,404 11,882 12,734 Average age Average hours per week (a) % female % aged 50 and over TBA Source: AIHW Dental labour force, Australia 2000 (Cat. no. DEN 116) 34 AIHW Dental workforce 2011 (Cat. no. HWL 50) AIHW Dental labour force collection (Cat. no. DEN 218) Age and gender profile As shown in table 6, the average age of a practicing dentist in 2011 was 43.5 years. This represents a departure in the trend of gradually increasing average age over the past decade (45.2 years in 2009 compared to 44.3 in 2000). The 2011 data shows a consistent growth (4.2% approx.) in the proportion of female dentists (35.6%) over the past decade (22.7% in 2000). Even though the proportion of female dentists has increased gradually over the past decade, dentistry remains male dominated (64.4% male dentists in 2011). Figure 1 highlights the age pattern of women and men with substantially more men in the older age groups and slightly more women in the youngest age group (20-34 years). Figure 1: Number of registered dentists, by age group and sex, 2011 Age group (years) Males Females ,000 2,000 1,000 1,000 2,000 3,000 Number Source: AIHW Dental workforce 2011 (Cat. no. HWL 50) HW 2025 Oral Health, Background Paper 16

21 Working patterns In 2011, the total average hours worked per week by practicing dentists was 37.4 (table 6), highlighting a gradual decrease since 2000 (when it was 39.3 hours). However, compared with 2009, there has been no change in the average hours worked per week by practicing dentists. Figure 2 shows that male dentists work longer on average (39.5 hours) than female dentists (33.7 hours). While there has been a reduction in working hours over the past decade (since 2000) for male dentists, dentists working in general practice and the specialists, there is no noticeable change in the average working hours for female dentists (33.7 hours in 2000 which is same as 2011). In 2011, specialists worked more hours (40.1 hours) on average than those in general practice (37.2 hours). Overall, the gap in hours between males and females appears to be reducing over time (males worked 7.3 hours more in 2000 and 5.8 hours more in 2011). Figure 2. Average hours worked per week by type of practicing dentist, Male dentists Female dentists All dentists All specialists All GP dentists Source: AIHW Dental labour force, Australia 2000 (Cat. no. DEN 116) Changes in service provision Trends in dentist practice activity have shown that in the past several decades the average length of a dental visit has been increasing, as has the number of services provided per visit. However as the average hours worked has not grown this has resulted in the number of visits supplied per year steadily declining 34. ARCPOH also note that per capita demand among dentate children and younger adults went through a period of growth from 1979 to 1995 and then plateaued, with adults aged 45 years and over, showing only marginal continued increases in demand up to This reduction in growth appears unrelated to improvements in overall oral health. HW 2025 Oral Health, Background Paper 17

22 In their Dentist Practice Survey 2010, the ADA found that 44% of practices were increasing in workload. Only 17% of dentists reported their practice was not as busy as they would have liked, however this had increased from 12% in Dental therapists, dental hygienists, oral health therapist and dental prosthetists Table 5 seen earlier in this report shows the number of Oral Health Therapists (OHTs), dental hygienists and prosthetists has been increasing with each wave of the AIHW collection since 2000, with the most noticeable growth seen in the recently added OHTs. However, dental therapists have declined slightly in overall numbers since Table 7 shows the breakdown of jobs in Table 7. Principal area of main job (2011) Dental Hygienist Dental Therapist Dental Prosthetists Oral Health Therapist General Dental Practice Orthodontics Periodontics Prosthodontics Paedodontics Public health dentistry Special needs dentistry Other Not stated All 1,065 1,044 1, Source: AIHW Dental labour force collection (Cat. no. DEN 218) Age and gender profile Dental therapists, OHTs, dental hygienists and dental prosthetists are highly gendered, with almost all OHTs, dental therapists and dental hygienists being female and the vast majority of dental prosthetists being male. Table 8 does show subtle changes to the gender profile of OHTs as well as dental prosthetists over the past few years. Table 8. Proportion who are female, 2000 to OHTs Dental therapists Dental Hygienists Prosthetists Source: AIHW Dental labour force collection (Cat. no. DEN 218) AIHW Dental workforce 2011 (Cat. no. HWL 50) HW 2025 Oral Health, Background Paper 18

23 The gradual increase in the average age of dental therapists is consistent with the lack of growth, reflecting the aging of the current stock of therapists (table 9). While prosthetists have the highest average age (49.3 years), hygienists and OHTs appear to be regularly supplementing their stock, having younger average ages (37.1 years and 32.6 years respectively). In the case of OHTs this may reflect the new bachelor degrees increasingly attracting younger students directly from high school. Table 9. Average age, 2000 to OHTs Dental therapists Dental Hygienists Prosthetists Source: AIHW Dental labour force collection (Cat. no. DEN 218) AIHW Dental workforce 2011 (Cat. no. HWL 50) Working patterns Figure 3 shows that dental therapists, hygienists and OHTs consistently worked fewer hours per week on average (in 2011, it was 28.8, 29.1 and 33.3 hours respectively) Compared to dentists (figure 2). The lower average hours is likely to have been caused by the higher proportion of the workforce working part time (that is, less than 35 hours per week). Both measures of working patterns shown in Figures 3 and 4 are in line with the increased concentration of female workers. Similarly the increase in the proportion of part time prosthetists between 2000 (20%) to 2011 (30.5%) shown in Figure 4 reflects the coinciding increase in female prosthetists shown in table 8. Figure 3. Average weekly hours, 2000 to OHTs Dental therapists Dental Hygienists Prosthetists Source: AIHW Dental labour force collection (Cat. no. DEN 218) AIHW Dental workforce 2011 (Cat. no. HWL 50) HW 2025 Oral Health, Background Paper 19

24 Figure 4. Proportion working part time (less than 35 hours per week), 2000 to % 60% 50% 40% 30% 20% 10% 0% OHTs Dental therapists Dental Hygienists Prosthetists Source: AIHW Dental labour force collection (Cat. no. DEN 218) AIHW Dental workforce 2011 (Cat. no. HWL 50) Table 10 shows the proportion of oral health workers who work mainly in the public sector. Dental therapists primarily work within the public sector as a result of their strong link with the school dental programs. The reduction in the proportion of public dental therapists between 2006 and 2009 may be related to changes in legislation in 2000 allowing their employment outside of the public service 36. Table 10. Proportion of the oral health workforce whose main practice is in the public sector Dentists Hygienists Dental therapists Oral health therapists Prosthetists Source: AIHW Dental workforce 2011 (Cat. no. HWL 50).. data not available Non-registered workforce Dental assistants and dental technicians Dental Assistant A dental assistant prepares patients for dental examination and assists dentists, dental specialists, dental hygienists, dental therapists and/or oral health therapists in providing care and treatment. Dental Technician A dental technician constructs and repairs dentures and other dental appliances. For the non-registered workforce definitions are based on the ABS Australian and New Zealand Standard Classification of Occupations. HW 2025 Oral Health, Background Paper 20

25 As previously mentioned, the support roles of dental assistant and dental technician are not registered with the Dental Board of Australia. Therefore, there is no labour force survey data to describe this workforce in detail and we need to rely on the ABS Census to understand the profile of these workers, as displayed in the table 11. Table 11. Dental assistants and dental technicians, head count and average hours worked Non-registered workforce Head Count Average Head Average Hours Worked Count Hours Worked Dental Assistant 13, , Dental Technician 2, , Source: ABS Census of Population and Housing, Customised Data Report Becoming part of the oral health workforce Successful completion of an accredited training program is a requirement to register with the Dental Board and practice in Australia. The Australian Dental Council (ADC) is responsible for accreditation of education and training programs on behalf of the Dental Board of Australia. Table 12 shows the number of programs available in Australia for non-specialists. Training programs which lead to registration are largely provided through the university sector. There are 10 dental schools in Australia. Five of these are located outside capital cities. Three of these are new dental schools established since 2006 in response to a perceived shortage in the oral health workforce arising from recommendations of the National Oral health Plan The first students of these new schools began graduating in Training which leads to registration as a dentist has traditionally been offered as a bachelor degree. It should be noted that there is a current move at some universities to replace the Bachelor of Dentistry with a Doctor of Dental Surgery (University of Melbourne) or Doctor of Dental Medicine (University of Western Australia and University of Sydney) as the qualification providing initial entry to dentistry. Admission involves a combination of criteria, including performance in any bachelor degree, the Graduate Australian Medical School Admissions Test (GAMSAT) and for some schools, an interview. In addition to the dental schools, one qualification for dental hygiene and the training programs for dental prosthetists are provided through VET training. There are 33 specialist dentistry training programs available; the majority of these are 3 year doctorate degrees based at universities. The remaining two are fellowship based training programs through the Royal Australasian College for Dental Surgeons in oral and maxillofacial surgery and the Royal College of Pathologists of Australasia in oral pathology. HW 2025 Oral Health, Background Paper 21

26 Table 12. Dental Board of Australia Number of approved programs of study leading to registration Approved programs of study NSW QLD SA Vic WA Australia Dentist Dental Hygienist 1 1 (b) Dental Therapist 1 1 Oral health therapist 2 (a) 3 1 (b) Prosthetist (a) Specialist (b) Source: Dental Board of Australia, Australasian Council of Dental Schools Oral Health Therapy programs will also qualify graduates for registration as a dental therapist and a dental hygienist. (a) Griffith university has an approved course but it has ceased taking students in (b) There is one dental hygiene course at RMIT with an initial intake in 2013 and one bachelor of oral Health (Therapy/Hygiene) at Holmesglen TAFE (in conjunction with CSU NSW) which was to commence in 2013 but did not have an intake. Most of the programs shown in table 12 for dental hygienists, dental therapists and oral health therapists refer to three-year bachelor of oral health degrees which allow graduates to register as a dental hygienist and/or a dental therapist and/or an oral health therapist. This is a relatively new type of course which amalgamates the previously offered courses in dental hygiene or dental therapy. A small number of additional courses still exist that are specific to dental hygiene, dental therapy and oral health therapy, which are at the graduate diploma and associate degree level. Dental assistants and dental technicians usually have completed a VET sector based qualification (e.g. diploma, advanced diploma, certificate) in dental assisting or dental technology. It is also possible to become a dental assistant or dental technician through a traineeship program. Dental assistants can undergo further training to allow them to take dental radiographs, perform technical procedures or to work in oral health promotion. Students Table 13 and table 14 below show data provided to HWA by the Australia Council of Dental Schools (ACDOS). The data shows the number of students who are currently in courses in Table 13. Total Domestic and International dentistry students 2012 School Year 1 Year 2 Year 3 Year 4 Year 5 Total Domestic International Adelaide CSU Total All Griffith James Cook La Trobe HW 2025 Oral Health, Background Paper 22

27 School Year 1 Year 2 Year 3 Year 4 Year 5 Total Domestic International Melbourne n/a Queensland Sydney n/a UWA n/a Total All Total Source: Australian Council of Dental Schools 2012 Table 14. Total BOH/Dental Therapy/Dental Hygiene students 2012 School Adelaide CSU CQU Curtin Griffith La Trobe Melbourne Newcastle Queensland Sydney TAFE-SA Title of Program Bachelor of Oral Health Bachelor of Oral Health Therapy Bachelor of Oral Health Bachelor of Science Oral Health Therapy Bachelor of Oral Health in Oral Health Therapy Bachelor of Oral Health Science Bachelor of Oral Health Bachelor of Oral Health Grad Dip Dental Therapy Bachelor of Oral Health Bachelor of Oral Health Diploma of Oral Health Diploma of Dental Technology Course length Year 1 Year 2 Year 3 Bridging Total n/a Total Source: Australian Council of Dental Schools 2012 Table 15 data has also been provided by ACODS it shows the growth in students since It includes the following program: Dentistry Dental therapy/ Dental Hygienists/ Oral Health Therapist HW 2025 Oral Health, Background Paper 23

28 Dental Hygiene Dental Therapy Oral Health Therapy Dental Technology Table 15. Total students School Griffith Adelaide Sydney Queensland Melbourne UWA La Trobe Newcastle Charles Sturt James Cook TAFE-SA NR Curtin NR CQU 28 Total Source: Australian Council of Dental Schools 2012 Data from Department of Industry, Innovation, Science, Research and Tertiary Education (formerly DEEWR) shows the trend in increases in dentistry graduate numbers. As this data does not yet capture the first graduates from the new dental schools, it can be inferred that this trend reflects increases in student capacity of the pre-existing dental schools. Figure 5 also shows that the proportion of international student graduates has increased since Figure 5. Number of dentistry student course completions, 2007 to 2010 Number of completions in dentistry Domestic Overseas Source: DEEWR Higher education statistics, extracted 2012 HW 2025 Oral Health, Background Paper 24

29 Teachers The proportion of working dentists who identify their main role in dentistry as a teacher or educator has fluctuated somewhat from 2006 (1.8%); reducing in 2009 (1.2%) and returning in 2011 (1.9%). As an example, this represents a ratio of one educator per 3.28 graduate dentists in The percentage of dental hygienists and oral health therapists that identified their main role as a teacher/educator was in line with that of dentists in 2011, with the exception of dental therapists at a higher percentage (3.4%). Immigration There are several pathways for those qualified overseas to register with the Dental Board of Australia to practice in Australia. Those registered in New Zealand receive mutual recognition. Dentists with an eligible qualification from New Zealand, the UK and Ireland may receive recognition and be eligible to apply for general registration in Australia. Under the National Registration and Accreditation Scheme, the Dental Board of Australia also provides a pathway to general registration for overseas-qualified individuals who have a qualification from the Board s published list of approved qualifications from overseas jurisdictions, which at this stage includes only selected dentistry courses in Canada and has some additional requirements of the applicant. Dentists with other qualifications can become eligible for registration in Australia by completing an Australian qualification or have their qualification assessed by the Australian Dental Council and undertake the ADC examination procedure. This includes an initial assessment, English language test and a written and a clinical examination 36. A pathway for overseas qualified prosthetists is yet to be developed and is reflected in the lack of prosthetist migrants in the tables below. Despite this, prosthetists are currently included on the skilled migration list, along with dentists, specialists, hygienists, dental therapists, and dental technicians. Recognition of overseas qualified dental specialists is overseen by the Dental Board of Australia. Overseas qualified specialists may apply to have their qualifications assessed and may require additional assessment by the Australian Dental Council if deemed necessary. Table 16 and table 17 below show that within the oral health workforce, dentists and dental technicians are those most represented among permanent and temporary migrants. Permanent and temporary migrants tended to be younger adults aged mostly in their 20s and 30s, with some permanent migrant dentists aged in their 40s and dentist specialists tending to be aged in their late 30s and early 40s. Table 16. Permanent visas granted, 2006 to Dentist Dentist Specialist Dental hygienist HW 2025 Oral Health, Background Paper 25

30 Dental therapist Prosthetist Dental technician Total Source: Department of Immigration and Citizenship, extracted 2012 Table 17. Temporary visas granted for oral health, 2006 to Dentist Dentist Specialist Dental hygienist Dental therapist Prosthetist Dental technician Total Source: Department of Immigration and Citizenship, extracted 2012 HW 2025 Oral Health, Background Paper 26

31 4 Recent Commonwealth Government Initiatives Background policy In June 2009, the National Health and Hospitals Reform Commission (NHHRC) tendered its report to the Australian Government. To address what the report termed the demonstrated failure of Australia s healthcare system to provide adequate dental services and oral healthcare 37, the NHHRC recommended a new universal scheme for access to basic dental services, called Denticare Australia (Denticare). Under Denticare, the NHHRC proposed that everyone would have the choice of getting a basic package of dental services preventative work (such as scaling and cleaning of teeth), diagnostic work (x-rays), restorative work (such as fillings of cavities), extractions and the provision of dentures paid for by Denticare through either public dental services or a private health insurance plan. In February 2012, the National Advisory Council on Dental Health provided advice on dental policy options and priorities for consideration in the federal budget. Its Final Report outlined four policy recommendations. Briefly, these were: for children, an individual universal capped dental benefit entitlement; for adults, a means-tested individual capped dental benefit entitlement; for both groups, improved access to public dental services (by expansion of the previous Medicare-based schemes and increasing the capacity of the public dental system); and measures targeting specific at-risk groups which should be expanded over time to include the broader population. The aim of these recommendations was the incremental move towards a universally accessible dental scheme through the gradual implementation of each policy. On 29 August 2012, Minister Plibersek announced the Australian government s Dental Reform package in line with these recommendations. Current schemes closed 1 December 2012 The Medicare Chronic Disease Dental Scheme (MCDDS) provided Medicare rebates for comprehensive dental care for 1.5 million people with chronic medical conditions between November 2007 and December The MCDDS closed on 1 December No Medicare benefits were payable for any dental services provided under Medicare dental items from this date. The cost of any dental services now need to be met by the patient 38. MCDDS patients received up to $4,250 in Medicare benefits (including Extended Medicare Safety Net benefits where applicable) for dental services over two consecutive calendar HW 2025 Oral Health, Background Paper 27

32 years. MCDDS patients were those with a chronic medical condition and complex care needs which were being managed by their General Practitioner (GP) under a GP Management Plan (Medicare item 721) and Team Care Arrangements (Medicare item 723) - or a multidisciplinary care plan for residents of aged care facilities. To be eligible for the scheme, the patient s oral health must have impacted on, or was likely to impact on, their general health. Both the public and private sectors provided services under the scheme. The private sector was able to set its own fees. In some cases, patients had out-of-pocket costs. A broad range of both preventative and restorative oral health services were available under the MCDDS 38. Existing schemes The Medicare Teen Dental Plan (MTDP) was introduced by the Australian Government on 1 July 2008 to provide financial assistance to families to help assess the health of their teenagers teeth, and to introduce preventative strategies to encourage lifetime good oral health habits. The benefit payable for the service is indexed on 1 January each year 39. The MTDP currently provides dental benefits of up to $ per eligible teenager (as at 1 January 2013), per calendar year, to help with the cost of an annual preventative dental check under the Dental Benefits Act If a dentist charges more than $166.15, Medicare Australia will pay $ towards the total cost of the service and the patient will need to pay the additional amount. The program is administered by Medicare Australia using a voucher system. Each year, around 1.3 million teenagers aged years, who meet the program s means test are sent a voucher for a preventative dental check 39. The term preventative dental check refers to a preventative dental program for each patient comprising an oral examination and, where clinically required, x-rays, scaling, cleaning, and/or other preventative services, provided by a dentist registered with Medicare Australia. Dental therapists and dental hygienists can also provide services under the supervision or oversight of a dentist. These clinical services are billed under a single preventative dental check item item number in the Dental Benefits Schedule (DBS). Item is mainly used by dentists, but it can also be used by dental specialists. Once a voucher has been issued, the teenager (or their parent/s or guardian/s) can make an appointment with a dentist in private practice, and present this voucher at the time of the service. Public dental clinics (including school-based clinics) are also able to accept vouchers. Dentists in private practice may bulk bill the service and claim the benefit directly from Medicare Australia. Alternatively, dentists may set their own fee for the service and bill the patient, who will claim the benefit from Medicare Australia. Public dental clinics must bulk bill the service 39. The parent/s or guardian/s of teenage patients need to choose between claiming benefits for preventative dental checks under Medicare or their private health insurance. Patients cannot use their general treatment (or ancillary) health cover to top up dental benefits received from Medicare Australia for this service, or vice versa 39. HW 2025 Oral Health, Background Paper 28

33 The MTDP will finish on 31 December It will be replaced by the Child Dental Benefits Schedule on 1 January 2014 (refer to Dental Reform Package). Dental Reform Package - Dental Benefits Amendment Bill 2012 On 29 August 2012, the Australian Government announced a new national dental health scheme, worth nearly $4.3 billion 40. This builds on, and is in addition to, the $515 million from this year s federal budget to tackle waiting lists, invest in oral health promotion and boost the dental workforce from 1 January The package includes: a Child Dental Benefits Schedule: $2.7 billion toward giving Medicare-style dental care to all children aged 2-17 in families receiving Family Tax Benefit Part A or other certain government payments 41, 42 ; a National Partnership Agreement for adult public dental services: $1.3 billion will be provided to states and territories to expand their public dental systems to provide greater access to adults on low incomes, pensioners, other concession card holders, and those with special needs 41, 42 ; and a Flexible Grants Program: an extra $225 million in flexible grants for infrastructure and services in rural and remote and indigenous communities 41, 42. Child Dental Benefits Schedule The Child Dental Benefits Schedule (CDBS) will commence on 1 January 2014 and will provide a Commonwealth-funded capped benefit entitlement for basic dental services for children 42. Approximately 3.4 million children aged 2-17 in families who meet a means test will be eligible for benefits each year. The means test will be the same as the existing Medicare Teen Dental Plan (MTDP), which requires receipt of Family Tax Benefit Part A or certain other government payments. The CDBS will replace the MTDP from 1 January Services for basic essential dental treatment, such as check-ups, x-rays, fillings and extractions will be included in the CDBS. High end (crowns, bridges, root canal) and orthodontic items will be excluded 42. The total benefit entitlement will be capped at $1,000 per child over a two year period. This will be directly funded to eligible individuals by the Commonwealth. Services will be provided in the public and private sectors by states and private providers respectively 42. National Partnership Agreement (NPA) The Government will provide $1.3 billion to states and territories from 1 July 2014 under a National Partnership Agreement (NPA) to expand services for adults in the public dental system 42. The funding will assist up to 1.4 million low income adults to receive dental services. The NPA will provide longer-term certainty and will allow the public system to move away from a focus on emergency crisis management to prevention and oral health promotion 42. HW 2025 Oral Health, Background Paper 29

34 The NPA s deliverables will be customised for each state and territory depending on the demonstrated local needs and progress under each state and territory s dental waiting list NPA 43. As such, the Commonwealth will provide a customised grant to each jurisdiction. Services will be provided in the public sector and should be contracted to the private sector when necessary 14. Flexible Grants Program Under the Flexible Grants Program (FGP) a total of $225 million will be provided for dental infrastructure (both capital and workforce) in outer metropolitan, rural and regional areas to assist in reducing access barriers for people living in these areas. The grants may also be used for targeted programs to address other gaps in service delivery 42. Examples of projects that could be funded include: innovative models of care to help reach people in more isolated locations, building new public dental clinics in regional centres, refurbishing ageing clinics, and dental facilities in aged care accommodation. Organisations from the public and private sector will be able to apply for a grant. Further details on eligibility will be available in 2014 when the Department of Health & Ageing publishes the Invitation to Apply for funding under the program 42. Voluntary Dental Graduate Year Program The Voluntary Dental Graduate Year Program (VDGYP) is a budget measure supporting the introduction of voluntary dental graduate placements. The VDYP will support 50 voluntary dental graduate placements per annum commencing The expansion to the VGYP announced in the budget increases graduate placements by up to 50 places per year to offer a total of 100 placements each year from The expansion will provide an additional 25 places in 2015 and an additional 50 places each year from The timing for the additional graduate placements is to ensure infrastructure and resources are in place to appropriately support the placements on commencement 44. The objective of the VDGYP is to provide dental graduates with a structured program for enhanced practice experience and professional development opportunities, whilst increasing dental workforce and service delivery capacity, particularly in the public sector. Participants will include Australian dental graduates, dental mentors to support the graduates and service providers to provide VDGYP placements. For graduates, the program features: facilitation of recruitment into the public sector, or other areas of need; access to continuing education opportunities; clinical rotations or varied experiences per placement; mentor support for each graduate; graduate salary in accordance with the relevant employment award, which vary between states and territories; and bonus of $15,000 upon successful completion of the program. HW 2025 Oral Health, Background Paper 30

35 The curriculum for the VDGYP was developed by the Australian Council of Dental Schools. AITEC Corporate Education & Consulting will be responsible for the advertising, participant selection and roll out of the program in consultation with the Department of Health and Ageing, and in accordance with program requirements established by the Commonwealth Government. Where possible, placements will be located in public dental services and areas in need, which could include location, setting or population-based need. The expanded program will involve participation of more service providers, which may include more rural and remote areas and other sectors such as aged care facilities, Aboriginal Medical Services and private practices servicing areas of need. However, the final distribution of placements will be influenced by a variety of factors including jurisdictional and local capacity and will be informed through consultation with key stakeholders and determined by the program administrator. Oral Health Therapist Graduate Year Measure Oral Health Therapist (OHT) Graduate Year Measure is a budget measure that will support graduate OHT placements. The program will support 50 OHT graduate placements each year from The objective of the OHT graduate year is to provide a structured transition to practice and professional development opportunities for OHTs, whilst increasing dental workforce and service delivery capacity, particularly in the public sector. Placements will be allocated to services with suitable resources and capacity, or the ability to enhance resources or capacity, prior to the commencement of OHT graduate placement. Participants will also receive a $10,000 bonus payment on completion of their placement in addition to a graduate salary 45. Dental Relocation and Infrastructure Support Scheme The Dental Relocation and Infrastructure Support Scheme (DRISS) is a budget measure that will provide scaled relocation grants and infrastructure grants to encourage and support dentists to relocate to regional, rural and remote areas, and assist them to establish their practices. Grants will be available from The measure will help improve dental workforce distribution and service delivery capacity in regional, rural and remote communities. Dentists will be able to apply for two types of grants: relocation grants ranging from $15,000 up to $120,000, calculated according to the area the dentist is moving to as well as the area the dentist is moving from; or infrastructure grants of up to $250,000 to help with the purchase and fit-out of dental facilities and equipment. Dentists relocating from metropolitan to very remote areas may be eligible for grants up to $370,000. Eligibility and selection criteria are yet to be finalised. However, it is expected that applicants must be registered as a dentist and be applying to relocate to an area in an ASGC-RA location that is more remote than their practice location in the previous 12 month period 46. HW 2025 Oral Health, Background Paper 31

36 5 Appendices Appendix A Quarterly dental services, total benefits paid and fees for services, September 1995 to June Quarter Services Benefits Fees Quarter Services Benefits Fees Quarter Services Benefits Fees Sep-95 3,819, ,262, ,536,923 Mar-99 3,483, ,054, ,998,128 Sep-02 5,546, ,994, ,378,520 Dec-95 3,680, ,050, ,805,276 Jun-99 3,606, ,251, ,553,977 Dec-02 5,338, ,286, ,313,460 Mar-96 3,713, ,700, ,032,044 Sep-99 3,714, ,496, ,187,324 Mar-03 5,331, ,281, ,769,990 Jun-96 3,707, ,952, ,882,299 Dec-99 3,603, ,813, ,748,491 Jun-03 5,364, ,833, ,377,323 Sep-96 3,836, ,731, ,790,742 Mar-00 3,677, ,385, ,349,061 Sep-03 5,726, ,330, ,802,031 Dec-96 3,737, ,481, ,204,809 Jun-00 3,780, ,955, ,805,916 Dec-03 5,415, ,801, ,433,365 Mar-97 3,531, ,701, ,608,898 Sep-00 4,382, ,993, ,883,495 Mar-04 5,614, ,458, ,388,834 Jun-97 3,810, ,261, ,375,030 Dec-00 4,384, ,539, ,659,337 Jun-04 5,658, ,304, ,207,235 Sep-97 3,744, ,734, ,905,874 Mar-01 4,597, ,056, ,265,166 Sep-04 5,885, ,183, ,601,118 Dec-97 3,655, ,586, ,274,182 Jun-01 4,925, ,992, ,036,618 Dec-04 5,598, ,171, ,123,704 Mar-98 3,500, ,144, ,461,729 Sep-01 5,265, ,805, ,494,101 Mar-05 5,517, ,519, ,329,107 Jun-98 3,690, ,515, ,739,621 Dec-01 5,135, ,610, ,722,070 Jun-05 6,044, ,753, ,854,654 Sep-98 3,661, ,208, ,169,331 Mar-02 5,080, ,635, ,378,602 Sep-05 6,017, ,017, ,455,625 Dec-98 3,510, ,817, ,636,373 Jun-02 5,536, ,646, ,689,436 Dec-05 5,718, ,798, ,367,374 HW 2025 Oral Health, Background Paper 32

37 Quarter Services Benefits Fees Quarter Services Benefits Fees Quarter Services Benefits Fees Mar-06 6,003, ,667, ,293,483 Mar-08 6,350, ,492, ,868,751 Dec-10 7,184, ,634, ,302,329 Jun-06 6,031, ,053, ,604,272 Jun-08 6,928, ,664, ,607,250 Mar-11 7,423, ,081, ,283,174 Sep-06 6,036, ,717, ,122,319 Sep-08 6,813, ,591, ,204,921 Jun-11 7,489, ,436, ,098,142 Dec-06 5,928, ,766, ,303,294 Dec-08 6,595, ,494, ,694,264 Sep-11 7,640, ,932, ,102,922 Mar-07 6,180, ,586, ,729,106 Mar-09 6,738, ,837, ,390,090 Dec-11 7,413, ,442, ,657,681 Jun-07 6,217, ,950, ,765,757 Mar-10 7,133, ,727, ,712,274 Mar-12 7,852, ,517, ,183,281 Sep-07 6,431, ,157, ,377,970 Jun-10 7,200, ,067, ,929,533 Jun-12 7,755, ,896, ,721,396 Dec-07 6,242, ,607, ,271,235 Sep-10 7,310, ,203, ,146,560 Source: PHIAC, Data on services, benefits paid and gap payments by MBS Specialty Block Groupings for medical services paid by private health insurers, extracted 10 October HW 2025 Oral Health, Background Paper 33

38 State / Territory QLD NSW Appendix B Current adult oral health services provided by the States and Territories Eligibility Criteria (1) Age Above the age of completion of Year years of age and older. Eligibility Criteria (2) Card Holders and other - Health Care Card - Pension Concession Card - Pensioner Concession Card (Department of Veterans Affairs) - Queensland Seniors Card - Commonwealth Senior Health Card - Health Care Card - Pensioner Concession Card - Commonwealth Seniors Health Care Card Must normally be a resident within the boundary of the providing Area Health Service. Services General and emergency dental care check-ups, oral hygiene, fillings, endodontics, extraction, dentures, oral surgery and dentures. Services provided through teaching dental facilities, and community clinics. Limited specialist dental services are available. General and emergency dental care check-ups, oral hygiene, fillings, endodontics, extraction, dentures, oral surgery and dentures. The NSW Priority Oral Health Program and Wait List Management Protocols establishes a clear and consistent patient flow pathway for eligible NSW residents who access general public dental services. In metropolitan areas, public dental clinics are mainly located in community health centres or on hospital grounds. Services are delivered by each of the Local Health Districts via community health centres and hospitals within each area. Co-payment No cost to patient. No cost to patient for emergency and general dental care in public dental clinics. Co-payments may apply for patients of some teaching services, specialist dental services and denture services. The OHFFSS requires co-payments by patients. The OHFFSS Schedule of Fees for 2013 is benchmarked to the 1 November 2011 Department of Veteran Affairs (DVA) Schedule of Fees. The OHFFSS Schedule of Fees identifies the relevant Australian Dental Association (ADA) Schedule HW 2025 Oral Health, Background Paper 34

39 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Co-payment Age Card Holders and other The NSW Oral Health Fee for Service Scheme (OHFFSS) is an alternative way of providing dental care funded by the public sector. This scheme provides dental care through a private practitioner. The Public Dental Service Call Centre or a Public Dental Practitioner may refer a patient to a private practitioner (by providing a voucher). There are three types of dental care that can be provided: episodic and general dental care, plus dentures. Eight item numbers that can be claimed for episodic and general treatment, and dentures. ADA item numbers allocated for episodic and general dental care are at the DVA dentist rate whilst item numbers for dentures are at the DVA dental prosthetists rate. Limited specialist dental services are available through two teaching hospitals: Westmead Centre for Oral Health and Sydney Dental Hospital. The specialist services include paediatric dentistry, oral and maxillofacial surgery, endodontics and perodontics. VIC 18 years of age and older. - Health Care Card - Pensioner Concession Card - Refugees and asylum seekers General and emergency dental care check-ups, oral hygiene, fillings, endodontics, extraction, dentures, oral surgery and dentures. Services provided through community dental clinics and the Royal Dental Hospital of Melbourne. The following groups have priority access: - Aboriginal and Torres Strait Islanders - Homeless people and people at risk of homelessness - Pregnant women - Refugees and asylum seekers - Registered clients of mental health and disability services, supported by a letter of recommendation from their case manager. Co-payment of $25.50 per visit to a maximum of $102 for a full general course of care. Flat fee of $25.50 for an emergency course of care. Victorians without a concession card have a prepayment of $150 with total cost based on dental need. HW 2025 Oral Health, Background Paper 35

40 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Co-payment Age Card Holders and other The Victorian Denture Scheme operates through the Royal Dental Hospital of Melbourne and Community Dental Clinics. Dentures are made by a local dentist or advanced dental technician. Fees for dentures are dependent on the type of dentures required - up to $123 for a full upper and lower acrylic denture. Services at student clinics (Royal Dental Hospital). Limited specialist dental services are available primarily through the Royal Dental Hospital of Melbourne. Fees for specialist services are dependent on the treatment provided - up to a maximum of $306 for a course of care. Special needs services provided by Royal Dental Hospital of Melbourne, or domiciliary (homebound) services. Services at student clinics (Royal Dental Hospital of Melbourne) are free for Health Care Card and Pensioner Concession Card holders. Exemption from fees for public dental services applies to priority access groups. TAS 18 years of age and older. - Health Care Card - Pensioner Concession Card General and emergency (priority) dental care checkups, oral hygiene, fillings, endodontics, extraction, dentures, oral surgery and dentures. Very limited specialist dental services are available e.g. Oral and maxilla facial surgery through the Royal Hobart Hospital. Some patients needing other specialist dental services are referred to Victoria, SA and NSW via the Tasmanian Patient Transport Assistance Scheme. All adults are required to pay a copayment towards the cost of their dental care: - general dental care, co-payment of $43; priority dental care, copayment of $43 - full upper and lower dentures, copayment of $374; full upper or lower denture, co-payment of $211 HW 2025 Oral Health, Background Paper 36

41 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Co-payment Age Card Holders and other Medically necessary dental care provided by Special Care Dental Units in two acute hospitals, primarily North West Regional Hospital. - partial dentures, co-payment varies - other denture services, copayment varies. All adults are required to pay a copayment 45. This varies between general, emergency and specialist services: - for general services, co-payment of $149; emergency services, copayment of $53 - co-payment varies for all specialist care. ADH will provide co-payment information to patient prior to treatment. SA 18 years of age and older. - Health Care Card - Pensioner Concession Card - Pensioner Concession Cards (Department of Veterans Affairs) General and emergency (priority) dental care checkups, oral hygiene, fillings, endodontics, extraction, dentures, oral surgery and dentures. Services are provided by community dental clinics. In some cases, patients may be offered authorisation to receive care from a private dentist through the South Australian General Dental Scheme, Emergency Dental Scheme, or Pensioner Denture Scheme. Patients must have authorisation from the community dental clinic staff to access these schemes. Referral to the Adelaide Dental Hospital (ADH) for specialist dental care. Students (under the supervision of qualified dentists) provide dental treatment at the Adelaide Dental Hospital, and other locations. Metropolitan patients may be asked to attend the hospital to have their care provided by students. Patients refusing an offer of treatment with a student may have their offer of treatment withdrawn. The patient will always be advised if a student is providing treatment. For dentures the co-payment varies depending if the treatment is routine or priority (emergency), and if done by a dentist or prosthetist: If provided by a dentist, - full upper and lower dentures, copayment of $ routine or $332 priority; full upper or lower denture, co-payment of $ routine or $ priority - for partial dentures, co-payment HW 2025 Oral Health, Background Paper 37

42 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Co-payment Age Card Holders and other Community dental services may refer adult patients with physical or intellectual disabilities to the Special Needs Unit at the Adelaide Dental Hospital. For people living in the Adelaide metropolitan area unable to attend a dental clinic because of severely restricted mobility, a limited home visiting dental service is available. varies If provided by a prosthetist, - full upper and lower dentures, copayment of $227 routine or $299 priority; full upper or lower denture, co-payment of $128 routine or $168 priority - for partial dentures, co-payment varies - for other denture services, the copayment varies. Co-payments also apply to student services. NT 18 years of age and older. - Health Care Card - Pensioner Concession Card General and emergency dental care check-ups, oral hygiene, fillings, endodontics, extraction, dentures, oral surgery and dentures. No cost to patient. Services provided by community dental clinics. Community clinics provide referrals for oral surgery and special needs dentistry as required, including in hospital treatment under general anaesthetic. WA 18 years of age and older. - Health Care Card - Pensioner Concession Card General and emergency dental care check-ups, oral hygiene, fillings, endodontics, extraction, dentures, oral surgery and dentures. All treatment is charged according DVA Schedule of Fees. Treatment obtained at a public dental clinic, or through a participating private HW 2025 Oral Health, Background Paper 38

43 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Co-payment Age Card Holders and other In remote locations, all are able to access care (although those without concession card are required to pay the full service fee). Subsidised dental services are provided by public dental clinics located in the metropolitan area and a number of country locations, as well as also some private dental clinics participating in the Western Australian Government Subsidised Oral Health Care Schemes: dental clinic, is subsidised by the West Australian Government up to a maximum of 75% of the cost of the treatment. Country Patients' Dental Subsidy Scheme provides financial assistance towards the cost of dental care for the financially disadvantaged, in country towns where participating private dental practices are located and there is no access to a public dental clinic. - Metropolitan Patients' Dental Subsidy Scheme provides financial assistance towards the cost of dental care for the financially disadvantaged, in the metropolitan area with participating private practitioners. The actual level of subsidy that a person is entitled to receive is based upon the eligibility of the person, and is assessed at the dental clinic. The Domiciliary Unit provides dental care for housebound patients. Dental care is also provided for special groups and institutionalised people. Clinics operate at the Disability Services Commission, Graylands Selby-Lemnos, Royal Perth Hospital and in various correctional institutions. The Aged Care Dental Program provides oral health services to the residents of registered Aged Care Facilities. Residents are eligible to receive an annual free dental examination and a care-plan. HW 2025 Oral Health, Background Paper 39

44 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Co-payment Age Card Holders and other ACT 18 years of age and older. - Health Care Card - ACT Centrelink issued Pension Concession Card General restorative services, emergency dental care and ACT Denture Scheme check-ups, oral hygiene, fillings, endodontics, extraction, dentures, oral surgery and dentures. There is a maximum co-payment of $300 for restorative treatment in any year. This cap excludes molar endodontics, general anaesthetic and dentures. For dentures, there is a minimum charge of $35 for a course of treatment. There is no annual cap and denture client contributions are not included in the $300 restorative treatment cap. HW 2025 Oral Health, Background Paper 40

45 State / Territory QLD Appendix C Current child oral health services provided by the States and Territories Eligibility Criteria (1) Age All resident children over the age of four and those who have not completed Year 10 of secondary school are eligible for publicly funded oral health care via Queensland Health's Child and Adolescent Oral Health Services (previously referred to as the School Dental Program). Children under four years of age are also eligible for publicly funded oral health care if they hold a concession card or are Eligibility Criteria (2) Card Holders If under four years of age must hold a concession card or are dependents of current concession card holders. If over four years of age all children are able to access the program. Services Child and Adolescent Oral Health Services include: dental check-ups, information on oral health and nutrition, x-rays, cleaning teeth, fluoride applications, fissure sealants, fillings, extractions and referrals to dental specialists where necessary. Services are usually provided on-site at schools through fixed or mobile dental clinics. Schools are treated on a rotational basis. An offer of dental treatment is issued by way of a Medical History/Consent Form. Forms are issued to all enrolled eligible students at the commencement of services within each school. It is the responsibility of parents/guardians to ensure completed forms are returned promptly. Only children whose parents/guardians return completed consent forms receive care. Some districts are centralising their service model for providing oral health care to children and adolescents at larger dental clinics located within their district rather than on-site within schools. Within school and district clinics, oral health care is provided by teams of oral health staff including dentists, oral health therapists, dental therapists and dental assistants. Limited specialist services are available in some districts. These are means-tested (e.g. Cost No cost to patient. HW 2025 Oral Health, Background Paper 41

46 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Cost Age Card Holders dependents of current concession card holders. only for concession card holders or their dependants) and eligible patients are prioritised based on severity criteria. NB. Commonwealth Medicare 'Preventative Dental Check' voucher ($166.15) may be used at both public and private dental clinics by children aged years. The NSW Priority Oral Health Program and Wait List Management Protocols establishes a clear and consistent patient flow pathway for eligible NSW residents who access general public dental services. Priority access is given to children and those aged 0-5 referred under the Early Childhood Oral Health Program. The Early Childhood Oral Health Program is delivered in metropolitan areas and Local Health Districts through dental clinics based in community health centres and hospitals within each area. These services include: dental check-ups, information on oral health and nutrition, x-rays, cleaning teeth, fluoride applications, fissure sealants, fillings and extractions. NSW All children under the age of 18 years. N/A all children who meet the age eligibility are able to access this program. Referral to a private practitioner (via a voucher) may occur through the NSW Oral Health Fee for Service Scheme. No cost for patients of public dental clinics. The OHFFSS requires co-payments by patients. The OHFFSS Schedule of Fees for 2012 is benchmarked to the 1 November 2011 Department of Veteran Affairs (DVA) Schedule of Fees. The OHFFSS Schedule of Fees identifies the relevant Australian Dental Association (ADA) Schedule Eight item numbers that can be claimed for episodic and general treatment, and dentures. ADA item numbers allocated for episodic and general dental care are at the DVA dentist rate. NB. Medicare 'Preventative Dental Check' voucher ($166.15) may be used at both public and private dental clinics by children aged years. HW 2025 Oral Health, Background Paper 42

47 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Cost Age Card Holders VIC All children aged 0-12 years. Children and adolescents between 13 years and 17 years who hold a Health Care Card or Pensioner Concession Card, or are dependants of Concession Card holders. Children and adolescents up to 18 years of age in residential care provided by the Children Youth and Families division of the Department of Human Services (DHS). Aged Health Care Card or Pensioner Concession Card, or dependant of a Concession Card holder. General dental services are delivered through community dental clinics in community health services, rural hospitals and the Royal Dental Hospital of Melbourne. These include dental check-ups, information on oral health and nutrition, x-rays, cleaning teeth, fluoride applications, fissure sealants, fillings, extractions and referrals to dental specialists where necessary. Priority access is given to registered clients of mental health and disability services, supported by a letter of recommendation from staff of developmental schools. Specialist dental services are available for children whose parents hold a Concession Card (mostly provided at the Royal Melbourne Dental Hospital). NB. Medicare 'Preventative Dental Check' voucher ($166.15) may be used at both public and private dental clinics by children aged years. Co-payments apply to children aged 0-12 who are not Health Care or Pensioner Concession Card holder or dependants of Concession Card holders. Flat fee of $30.50 per child per general course of care including an examination and all general dental treatment. Fees per family will not exceed $122. Exemption from fees for public dental services applies to: - Children and young people aged 0-17 years who are Health Care Card or Pensioner Concession Card holders, or dependants of concession card holders - All children and young people up to 18 years of age, who are in outof-home care provided by the Children Youth & Families Division of DHS - All youth justice clients up to 18 years of age in custodial care - Registered clients of mental health and disability services, supported by a letter of recommendation from HW 2025 Oral Health, Background Paper 43

48 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Cost Age Card Holders Youth justice clients in custodial care up to 18 years of age. Care is available to children with special needs. staff of special development schools - Those receiving care from undergraduate students. TAS Children aged 0-17 years. Available to all the dental treatment following examination will be free if the child is covered by a Health Care Card. Services include: dental examinations, information on oral health and nutrition, x-rays, cleaning teeth, fluoride applications, fissure sealants, fillings and extractions, and where necessary, referral to a private dental specialist. Services are provided at community dental clinics and in acute hospitals (where general anaesthetic is required). No public specialist dental services are available for children within Tasmania. Children requiring specialist care have to use the private sector (although a small number with significant needs are referred to Victoria, SA and NSW via the Tasmanian Patient Transport Assistance Scheme). NB. Medicare 'Preventative Dental Check' voucher ($166.15) may be used at both public and private dental clinics by children aged years. All children receive free examinations and preventive care. Treatment following the examination is free if the child is covered by a current Health Care Card or Pensioner Concession Card. The treatment co-payment for all other children is $77. On reaching 18 years of age the patient is no longer able to access public dental care unless they are: - part way through a course of dental care, if so the course of dental care will be completed, or - the recipient of a concession card (i.e. eligible for adult services). HW 2025 Oral Health, Background Paper 44

49 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Cost Age Card Holders SA All preschool, primary school and secondary school students, aged less than 18 years, are eligible for oral health care with the School Dental Service. Children over the age of 16 years who do not attend an educational institution and do not have a Health Care Card are not eligible to attend school dental clinics. Children who are dependants of or holders of the following concessions are eligible to receive free dental care: - Centrelink Concession Card - DVA Pensioner Concession Card - School Card The School Dental Service offers expert oral health care to eligible children at school dental clinics throughout South Australia. This care is provided by teams of dentists, dental therapists, and dental assistants. Services include: dental check-ups, information on oral health and nutrition, x-rays, cleaning teeth, fluoride applications, fissure sealants, extractions, referral to a dentist or dental specialist for further advice. NB. Medicare 'Preventative Dental Check' voucher ($166.15) may be used at both public and private dental clinics by children aged years. All dental care is free for preschoolers. Children who are dependants of or holders of the following concessions receive free services: - Centrelink Concession Card - DVA Pensioner Concession Card - School Card For primary and secondary school children who are not dependants of or holders of the above concessions, a fee will apply for each course of general dental care provided. NT All children from infancy to the completion of primary school can access free dental services through school-based clinics, community N/A all children who meet the age eligibility are able to access this program. Through the NT Child Oral Health Service, infants and primary school students can access school clinics in urban areas, and community dental clinics in Darwin, Palmerston, Nhulunbuy, Katherine, Tennant Creek and Alice Springs. Services in regional and remote areas are provided at community health centres or in mobile vans. Services No cost to patient. HW 2025 Oral Health, Background Paper 45

50 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Cost Age Card Holders clinics and mobile services. Older children (up to completion of high school) can access free dental services at community clinics. include: dental check-ups, information on oral health and nutrition, x-rays, cleaning teeth, fluoride applications, fissure sealants, fillings, extractions, and referrals to dental specialists where necessary. Some school clinics provide an assessment service only. If children require additional treatment they are referred to a treatment centre at a nearby school or community clinic. Older children in high school can access services at the community dental clinics in Darwin, Palmerston, Nhulunbuy, Katherine, Tennant Creek and Alice Springs and through community health centres in remote areas. Children whose parents hold a concession card with significant oral health needs (satisfying further clinical criteria) are eligible for publicly funded specialist orthodontic treatment. NB. Medicare 'Preventative Dental Check' voucher ($166.15) may be used at both public and private dental clinics by children aged years. WA All school children are eligible for the WA School Dental Service from the N/A All children who meet the age eligibility and attend a recognised educational institution are able to access The School Dental Service provides free general and preventative dental care including dental check-ups, information on oral health and nutrition, cleaning teeth, fluoride application, fissure sealants and fillings. Services No cost to patient. HW 2025 Oral Health, Background Paper 46

51 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Cost Age Card Holders year they turn five until the end of Year 11 or the attainment of 17 years of age, whichever comes first (and to Year 12 students in remote locations). the program. are provided by dental therapists under the supervision of dentists from fixed and mobile clinics located at schools throughout the state. There are a number of exclusions, e.g. specialist services and general anaesthesia facilities. Treatments outside the scope of the School Dental Service are referred to other providers and any costs are the responsibility of the parent or guardian. Emergency dental care procedures are free. For youth aged there is no out of pocket expense involved when redeeming a voucher for a Medicare 'preventative dental check' at a School Dental Therapy Centre. Any dental treatment that is planned after the 'preventative dental check' remains free of charge in the School Dental Service. NB. Students in Year 12, and 17 year olds with a Health Care Card, are eligible for general dental care at a public dental clinic. NB. Medicare 'Preventative Dental Check' voucher ($166.15) may be used at both public and private dental clinics by children aged years. For students in Year 12, and 17 year olds with a Health Care Card, there is no out of pocket expense involved when redeeming a voucher for a Medicare 'preventative dental check' at a public dental clinic. However, any dental treatment that is planned after the 'preventative dental check' will incur a subsidised fee. ACT All children under 5 who live in the ACT. All children 5-14 years who live or attend school in the ACT. N/A All children who meet the age eligibility and attend a recognised educational institution are able to access the program. Centrelink Concession Card The government program provides children and young people with the following dental services: comprehensive assessment; oral health plans based on individuals' needs; general preventative and restorative treatment such as cleaning teeth, fluoride application, fissure sealants, fillings and extractions; emergency treatments; and, referral to dental specialists as required. There is a co-payment for children whose parents do not have a Concession Card: - Children 5-13 years whose parent do not hold a Concession Card pay a co-payment of $57.00 per child per course of care. HW 2025 Oral Health, Background Paper 47

52 State / Territory Eligibility Criteria (1) Eligibility Criteria (2) Services Cost Age Card Holders Young people under 18 years living or attending school in the ACT and who are covered by a current Centrelink Concession Card. holders can access some additional services. These services are delivered from Belconnen, Civic, Phillip and Tuggeranong Health Centres. Dental treatments, such as removable orthodontic appliances, are available to Centrelink Concession Card holders (these services incur a separate charge). - Children under 5 years (who require treatment) also pay a copayment of $57.00 per child per course of care. NB. Medicare 'Preventative Dental Check' voucher ($166.15) may be used at both public and private dental clinics by children aged years. HW 2025 Oral Health, Background Paper 48

53 6 References 1. Australian Institute of Health & Welfare 2012, 'Australia's Health 2012', Australia's health series, no. 13, Cat. no. AUS 156, Canberra: AIHW. 2. National Advisory Committee on Oral Health (NACOH) for the Australian Health Ministers' Conference 2004, Healthy mouths, healthy lives, Adelaide: South Australian Department of Health. 3. Slade, G, Spencer, AJ & Roberts-Thomson, KF. (eds) 2007, Australia's dental generations: the National Survey of Adult Oral Health , Cat. no. DEN 165, Canberra: AIHW. 4. Chrisopoulos, S, Beckwith, K & Harford, J. 2011, Oral health and dental care in Australia: key facts and figures 2011, Cat. no. DEN 214, Canberra: AIHW. 5. National Health and Hospitals Reform Commission 2009, A healthier future for all Australians - Interim Report December 2008, Canberra: Commonwealth of Australia. 6. NSW Department of Health 2010, NSW Oral Health Strategic Directions , North Sydney: Centre for Oral Health Strategy NSW. 7. National Advisory Council on Dental Health, Final Report - 23 February 2012, Canberra: NACDH. 8. Brennan, DS & Ellershaw, AC. 2012, 'Insurance and use of dental services: National Dental Telephone Interview Survey 2010', Dental statistics and research series, no. 62. Cat. no. DEN 219, Canberra: AIHW. 9. Private Health Insurance Administration Council 2012, Quarterly Statistics September Quarter 2012, Canberra: PHIAC. 10. Australian Bureau of Statistics 2009, Super CUBE data set - Population estimates by age and sex, Australian Standard Geographic Classification as at 30 June 2009, Canberra: ABS. 11. Ellershaw, A & Spencer, AJ. 2009, 'Trends in access to dental care among Australian children', Dental statistics and research series, no. 51. Cat. no. DEN 198, Canberra: AIHW. 12. Department of Health & Ageing 2012, Eligibility for the Medicare Teen Dental Plan, viewed 14 November 2012, < 13. Department of Veterans' Affairs, For dental and allied health professionals, viewed 14 November 2012, < 14. Defence Jobs 2012, Benefits, viewed 14 November 2012, < 15. Department of Human Services 2012, Cleft Lip and Cleft Palate Scheme, viewed 14 November 2012, < 16. Ngangganawili Aboriginal Health Service Community 2012, Ngangganawili Aboriginal Health Services, viewed 29 November 2012, < 17. Aboriginal Medical Service Western Sydney 2012, AMSWS Dental Clinic, viewed 29 November 2012, < 18. Australian Human Rights Commission 2009, Immigration detention and offshore processing on Christmas Island, viwed 29 November 2012, < ml>. 19. Brennan, DS & Spencer, AJ. 2006, Practice activity patterns of dentists in Australia: trends over time by age of patients, Cat. no. DEN 148, Canberra: AIHW. 20. Australian Healthcare & Hospitals Association 2011, Policy Paper on Oral Health, Deakin West: AHHA. 21. Australian Dental Association 2007, 'Oral health and people with special needs', National Dental Update, September 2007, St Leonards: ADA. HW 2025 Oral Health, Background Paper 49

54 22. Williams, S, Jamieson, L, MacRae, A & Gray, C. 2011, Review of Indigenous oral health, viewed 29 November 2012, < 23. NSW Department of Health 2012, Public Oral Health Services, viewed 14 November 2012, < 24. Australian Indigenous Health InfoNet 2012, Map of Aboriginal Medical Services in Australia, viewed 14 November 2012, < 25. Meihubers, S. 2012, Royal Flying Doctor Service Dental Discussion Paper May Royal Australian College of General Practitioners, National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, viewed 3 December 2012, < 27. Indigenous Dentists Association of Australia 2008, Indigenous oral health goals, viewed 3 December 2012, < 28. Ministerial Council for Federal Financial Relations 2010, Implementation plan for national Indigenous mobile dental infrastructure: Alice Springs, viewed 3 December 2012,< 29. Ministerial Council for Federal Financial Relations 2010, Implementation plan for national Indigenous mobile dental infrastructure: Orange, viewed 3 December 2012,< 30. Ministerial Council for Federal Financial Relations 2010, Implementation plan for national Indigenous mobile dental infrastructure: Queensland, viewed 3 December 2012,< 31. Spencer, AJ & Hardford, J. 2008, Improving Oral Health and Dental Care for Australians - Prepared for the National Health and Hospitals Reform Commission, Adelaide: ARCPOH. 32. Australian Institute of Health & Welfare 2008, 'Rural, regional and remote health: indicators of health status and determinants of health', Rural Health Series, no. 9. Cat. no. PHE 97, Canberra: AIHW. 33. Australian Institute of Health & Welfare 2012, 'Dental Workforce 2011', National Health Workforce Series, Canberra: AIHW. 34. Teusner, DN & Spencer, AJ. 2003, 'Dental labour force, Australia 2000', Dental statistics and research series, no. 28. Cat. no. DEN 116, Canberra: AIHW. 35. Chrisopoulos, S & Nguyen, T. 2012, 'Trends in the Australian Dental Labour Force, 2000 to 2009: dental labour force collection, 2009', Dental statistics and research series, no. 61. Cat. no. DEN 218, Canberra: AIHW. 36. Satur, J, Gussy, M, Mariño, R & Martini, T. 2009, 'Patterns of dental therapists' scope of practice and employment in Victoria, Australia', Journal of Dental Education, 73(3): National Health and Hospitals Reform Commission 2009, A healthier future for all Australians - Final Report June 2009, Canberra: Commonwealth of Australia. 38. Department of Health & Ageing 2012, Medicare Chronic Disease Dental Scheme, viewed 14 November 2012, < services>. 39. Department of Health & Ageing, Medicare Teen Dental Plan - fact sheet for dentists, viewed 14 November 2012, < 40. The Hon Tanya Plibersek MP, Minister for Health 2012, '$4 Billion Dental Spend on Children, Low Income Adults and the Bush', Media Release 29 August 2012, viewed 14 November 2012, < HW 2025 Oral Health, Background Paper 50

55 41. Department of Health & Ageing 2012, Transcript - Dental Reform Package - The Hon Tanya Plibersek, 29 August 2012, Canberra: Department of Health & Ageing. 42. Department of Health & Ageing 2012, Dental Reform, viewed 14 November 2012, < 43. Australian Government 2012, Australian Government Budget Paper No. 2, viewed 12 December 2012,< 44. Department of Health & Ageing 2012, Voluntary Dental Graduate Year Program, viewed 14 November 2012, < 45. Department of Health & Ageing 2012, Oral Health Therapist Graduate Year Measure, viewed 14 November 2012, < 46. Department of Health & Ageing 2012, Dental Relocation and Infrastructure Support Scheme, viewed 14 November 2012, < 47. Private Health Insurance Administration Council 2012, Data on services, benefits paid and gap payments by MBS speciality block groupings for medical services paid by private health insurers, extracted 10 October 2012, Canberra: PHIAC. 48. Queensland Health 2007, Oral Health Queensland, viewed 29 November 2012, < 49. NSW Department of Health 2009, Eligibility of Persons for Public Oral Health Care in NSW, North Sydney: NSW Health. 50. NSW Department of Health 2007, NSW Oral Health Implementation Plan , North Sydney: NSW Health. 51. NSW Department of Health 2008, Priority Oral Health Program and List Management Protocols, North Sydney: NSW Health. 52. NSW Department of Health 2012, Oral Health Fee for Service Schedule of Fees for 2012, North Sydney: NSW Health. 53. Dental Health Services Victoria 2012, Dental Health Services available, viewed 15 November 2012, < 54. Dental Health Services Victoria 2012, Victoria's Public Dental System, viewed 15 November 2012, < 55. Department of Health Victoria 2007, Improving Victoria s Oral Health 2007, Melbourne: Victorian Government Department of Human Services. 56. Oral Health Services Tasmania 2012, Dental Services for Adults, viewed 15 November 2012, < 57. Oral Health Services Tasmania 2012, Co-Payments for Adult Dental Services: Applicable to 30 June 2013, Hobart: Department of Health and Human Services. 58. SA Health 2012, Dental Services, viewed 15 November 2012, < rnet/health+services/dental+services/>. 59. SA Dental Service 2012, Community Dental Service, viewed 15 November 2012, < 60. SA Health 2012, SA Oral Health Plan , Adelaide: SA Health. 61. SA Dental Service 2012, Copayments for Adult Dental Service from 1 July 2012, Adelaide: SA Health. 62. Oral Health Services NT 2012, Oral Health Services for Adults, Middle School and High School Students, Primary School Students, Infants and Preschoolers, veiwed 15 November 2012, < 63. Department of Health NT 2011, NT Oral Health Promotion Plan , Darwin: Department of Health NT. 64. Government of Western Australia Department of Health 2012, WA Adult Dental Services, viewed 15 November 2012, < HW 2025 Oral Health, Background Paper 51

56 65. ACT Government Health Directorate 2012, Dental Health Services, viewed 15 November 2012, < 66. NSW Department of Health 2008, Early Childhood Oral Health Program: The Role of Public Oral Health Services, North Sydney: Centre for Oral Health Strategy NSW. 67. Department of Health and Human Services Tasmania 2012, Dental Services for Children and Adolescents, viewed 15 November 2012, < nts>. 68. Government of Western Australia Department of Health 2008, A School Dental Service, viewed 15 November 2012, < HW 2025 Oral Health, Background Paper 52