CROCOMBE, Dr Leonard Alfred, Member, Services for Australian Rural and Remote Allied Health

WELLINGTON, Mr Rod, Chief Executive Officer, Services for Australian Rural and Remote Allied Health

Evidence from Dr Crocombe was taken via teleconference—

Committee met at 09:07

CHAIR ( Ms Hall ): I declare open this public hearing for the inquiry into adult dental health services. The fundamental importance of good oral health to general health and wellbeing is well recognised. Although there have been significant improvements in oral health in Australia over the last century, the Australian Institute of Health and Welfare 2012 report indicates that almost everyone will experience an oral health problem at some time in their lives, with over 90 per cent of adults showing signs of treated or untreated dental decay. The context of the inquiry is the federal government's commitment to provide $1.3 billion to states and territories under the national partnership agreement to expand adult dental services. The aim of the inquiry is to obtain a range of perspectives which will help to inform development of the NPA by identifying priorities for action.

I take this opportunity to thank everybody for making time to speak with the committee today. I welcome representatives of Services for Australian Rural and Remote Allied Health. Although the committee does not require you to speak under oath, you should understand that these hearings are formal proceedings of the Commonwealth parliament. Giving false or misleading evidence is a serious matter and may be regarded as contempt of parliament. I invite you to make a brief opening statement before we proceed to questions.

Mr Wellington : First of all, SARRAH welcomes the opportunity to appear before this standing committee. Our organisation was incorporated in 1995 and is nationally recognised as a peak body representing rural and remote allied health professionals working in both the public and private sectors. SARRAH's primary objective is to advocate for, develop and provide services to enable allied health service professionals who live and work in rural and remote areas of Australia to confidently and competently carry out their professional duties in providing a variety of health services. SARRAH's representation comes from a range of allied health professions—and I will not go into them in detail as they are outlined in our submission—including oral health therapists and hygienists, who provide a range of clinical and health education services to individuals who live in rural and remote Australian communities.

SARRAH maintains that every Australian should have access to equitable oral health services wherever they live. As the committee would be aware, 32 per cent of the Australian population lives outside major cities. Most of the seven million live in regional cities and country towns of various sizes. People in these areas also have lower levels of access to health and other services. Almost all health professionals are less prevalent, and some dramatically so, in those settings. The need to travel to specialist services in capital cities, especially for ongoing treatment, can greatly disrupt work and family life. This situation is exacerbated further for people living in remote communities. Aboriginal and Torres Strait Islander people make up a substantial proportion of the population in rural and particularly remote areas. On average, their health outcomes are substantially poorer than those of other Australians.

I have some general comments on adult dental services in Australia. I am sure the committee is fully aware of this, but I will very briefly touch on it anyway. Poor dental health has an impact on dietary intake, health and wellbeing and social functioning. Poor oral health has been identified as a risk factor for the development of a number of chronic health conditions, including diabetes, cancer and cardiovascular disease. Poor dental health means that people in disadvantaged groups, often Indigenous and rural and remote populations, are living with painful and possibly unsightly dental issues. Poor dental health also can affect people's ability to obtain and retain employment.

Major issues for rural and remote oral healthcare include oral health workforce shortages, lack of access to and cost of both preventative and restorative oral healthcare, together with limited water fluoridation in some settings. In our opinion all governments must act in a coordinated manner to fill the gaps in oral healthcare for rural and remote and Indigenous populations by building the local workforce capacity. We mention in our submission the Productivity Commission report into the Australian health workforce. I will not elaborate on that here in my opening statement; however, what should the workforce numbers be across Australia, particularly in rural and remote settings, and how can oral health teams work better together to provide the various scopes of practice applicable to various levels of the workforce?

I think they are two key issues that should be discussed. The industry needs to get their heads together, along with other instrumentalities, such as Health Workforce Australia, to determine what is an acceptable level of workforce participants.

The ideal solution is for all Australians to have access to equitable health services through locally resident teams of health service providers that are skilled, trained, supported and funded to deliver the range of health services that meets the needs of the community in which they reside. However, as the committee would be aware, this is far from the case and not always possible.

We do acknowledge that the Commonwealth government has recently called for tenders in relation to two key programs resulting from the May 2012 budget. I understand—and I stand to be corrected on this—the Dental Relocation and Infrastructure Support Scheme tender closed last month. The second tender that was also released last month but closed last week was the oral health therapists graduate placement program. We commend the government for those programs that obviously have the objective of attracting more people and professionals to rural and remote Australia.

CHAIR: Thank you very much for your introductory comments. Usually I ask questions first but Mr Coulton comes from an area where there are quite a few remote and definitely rural areas, so I might let him lead the questions and I will come in a little later.

Mr COULTON: I will start where you finished off. Is it SARRAH's belief that there is a workforce shortage or maybe just uneven distribution? Is it a matter of finding more dental professionals or is it a matter of relocating the ones we already have?

Mr Wellington : I will make some initial comments and then I will pass on to my colleague, Len. From our perspective, the landscape has changed a little bit but my overview comment is there needs to be a redistribution of the workforce numbers that are currently in the Australian labour market. There needs to be greater numbers in rural Australia, in rural settings. Once again this comes back to the point I touched on earlier—it is not just dentists; it is the whole workforce element around oral health. For example, as you would probably be aware, there are huge issues in regional Australia, let alone rural outer regional areas and remote areas, in terms of getting technicians to those settings to fix dental chairs. In some instances chairs remain vacant because they are broken and they cannot get anybody out to fix them. It is not just a matter of dentists, oral health therapists and hygienists; it is the broad scope of workforce that underpins that sector. I invite Len to make some additional comments.

Dr Crocombe : That is an interesting question. Basically in Australia we have had five dental schools over a century. Over the last 10 years we have had an extra four dental schools open up around the country and some in regional areas. These have also included oral health therapists. So we are getting a fairly massive change in the workforce not only in numbers. When I went through dentistry at the University of Melbourne there were only five females out of 45 in the course. Now over half of the people doing dentistry are female. We are finding that over half are of Asian origin. We are finding that young people have a different attitude to life. So we think the whole attitude of the workforce will change over time.

We do not have the evidence but anecdotal evidence seems to suggest that rural practices which have had great trouble attracting dental practitioners in the past are now getting people knocking on their doors asking for jobs. We think it may be due to the increased numbers. We have also had a large increase in numbers coming across via the Australian Dental Council examinations. That is the first thing.

The second thing is the relationship of the team that Rod related to. Unfortunately, I do not feel that the universities have been training oral health therapists, dental therapists and dental hygienists and dentists how to work together in a team. Basically what is happening is that they are still trying to work it out. They work it out via a conflict arrangement, usually via new politicians unfortunately. Health Workforce Australia is in the process of doing an assessment of the dental workforce numbers—whether there will be an oversupply or undersupply. I think their deliberations will be of great assistance to your committee. I would also hope that in the second stage they sit down to work out not just the workforce that is there now but also the workforce which is needed—more how these different practitioners can work together in a dental team which, in turn, should be part of the medical team in any case. To continue, I also happen to be a dental consultant for the agents who run the voluntary dental graduate year program. I am kind of hopeful that we might be able to start this team concept as part of a dental graduate year program.

CHAIR: Are there state differences? I noticed in my readings that some of the shortfall has been picked up by dentists from overseas who are working here on 457 visas. I wonder would you like to comment on that.

Dr Crocombe : I am not quite certain whether I understand the question completely. My understanding is that dentists who would be brought across under that visa would be fully qualified and that there would not be any great problems if they did.

CHAIR: I understand that—because they are qualified. I am wondering whether you are using dentists on 457 visas to pick up the shortfall in dentists trained here. It was a twofold question. The other part of it was: is there a difference in the shortage between states? There are two questions.

Dr Crocombe : Yes. I have not seen that visa entry has been a problem, to be honest. That is a new one to me. The vast majority of people who have been coming in have been more via the Australian Dental Council examinations. As to shortages, yes. I am from Tasmania and I kiss the states with greater decentralisation. Other states suffer from access to care. Tasmania arguably has the worst adult oral health of any state or territory and one of the reasons is poorer access to care. The Northern Territory would be in a similar situation. They have spread around fairly well but those states and territories without dental skills always have a lower percentage of dental practitioners.

Mr Wellington : If I could add that SARRAH's view on the 457 arrangement is that we are probably not the best organisation to answer that particular question. I would suspect the professional association would be in a better position, or Health Workforce Australia. We are really not aware of problems or positives in relation to that process in that sector.

CHAIR: I still think you missed my question. I was asking whether shortfalls in remote and rural areas are being picked up by overseas trained dentists. Maybe I should not have said the visa number, but that is my question.

Dr Crocombe : They have been used a lot in the public sector. How does that sound? There is a Public Sector Dental Workforce Scheme under which dentists from overseas can enter the public sector. Prior to sitting the ADC examines, they have to sit the Australian dental public examinations within three years, I think; it is within a relatively short time period. If they fail the examine, they have to leave the country, basically, and not practice dentistry. That is done under the supervision of a fully qualified dentist.

From the point of view of overseas dentists, I think that might be part of the reason that we are finding dentists knocking on the doors of practices in rural areas, which has not happened before. The problem there, of course, is that we need to ensure that they do become part of the community. Rural communities are very tight-knit. We could have people from completely different cultural backgrounds and they would need support when moving into towns, I would have thought.

Mr COULTON: I have a lot of questions here but I will ask one and then let my colleagues have a go. One of your recommendations is around the Chronic Disease Dental Scheme; it was obviously discontinued. If you were going to replace it, would you replace it with something the same? How would you change that chronic disease scheme to maybe make it work a little better?

Dr Crocombe : I will tackle that, if you like, Rod. First of all, as you know, it was budgeted, as I understand it, to be about $100 million a year and it ended up being about $100 million a month, and so I think there would be a few things I would do. First of all, I would probably put an income limit on people who could access the scheme. I would set up a set of criteria of the diseases. In other words, it was based on the principle that a physician would make a call on whether a person's oral health was affecting their general health but what diseases oral health could affect was not defined. So whether you were referred under the scheme really depended on how enthusiastic your physician was in filling out the paperwork and referring you on to a participating dentist in the scheme. I would have liked an expert committee to get together and say, 'We know that oral health affects disease A, B and C,' such as diabetes, people who are having radiation treatment for cancers and things along those lines. They are two things.

I think the final thing is that I would have either put a limitation on the types of services that could be given or at least put a mechanism in place so that before you do the more expensive kinds of services you have to satisfy a set of criteria. So, before you rushed into crowns, bridges and implants, you would basically have to satisfy that all active disease had been treated and explain why these more expensive items were required rather than something that did not cost as much.

Mr COULTON: Thank you.

CHAIR: Mr Georganas has a question.

Mr GEORGANAS: My apologies for coming in late, and I hope you got my message. Were rural and remote areas accessing the former scheme? As a member in a city seat, I am aware that many people were accessing the former scheme. But were people in rural and remote areas, even though there was the $4,000 per person, able to access the services?

Dr Crocombe : A good question, and I am going to be a bit vague in the answer. Basically, you would expect that there would have been a difference between rural and metropolitan areas simply because of access to care. I will put my other hat on, if you do not mind. I am a chief investigator with the Centre of Research Excellence in Primary Oral Health Care, and I have just got access to the data of the Chronic Disease Dental Scheme. It was going to be a research paper of mine over the next few months to sit down and see if the type of care that was accessed in rural areas was different from the type of care that was accessed in metropolitan areas. From what I have seen, the capital cities did access it much more than the rural areas, and that could possibly be simply because of reduced access again.

Mr LYONS: I apologise, I was late as well. How should the NPA be structured to allow progression to a universal dental scheme?

Mr Wellington : Len, are you happy to take it?

Dr Crocombe : All right, yes. It is good to have a fellow Tasmanian here. I will just repeat that Tasmania has arguably the worst oral health of anywhere in Australia. But we move. I think that a Denticare or universal dental scheme would be very expensive. A think that it is going to be more expensive than some of the figures which have been bandied around. I think that it would be very wise for anyone who is designing a dental scheme to talk to the dental people in the Department of Veterans' Affairs who have had a scheme for returned veterans going since the end of the Second World War. They have learned lots of things about how to run these things so that the budget does not blow out through the roof. That is my first step: I would advise you to talk to DVA people.

The second step would be, I think, an incremental introduction to basically learn from the mistakes made—and there will always be mistakes made. I would suggest ensuring that people in the more needy group, for example, Indigenous people, people in rural areas and people with special needs, have a system established to ensure that they get access first, and then take it to the next step of expanding gradually and more universally as the government can afford to do so. That would be the way I would go.

And, as I said, with the Medicare Chronic Disease Dental Scheme, I would be ensuring some sort of income criteria. I would be ensuring that the services provided before you went into a more expensive scheme would make sure that the disease had been treated and, after that, before you went into more elaborate situations, that a set of criteria would be put forward, evidence-based criteria I would hope. And the other thing I would do—if I can throw this in—is that before any state government got access to any Commonwealth funding, I would strongly recommend that all towns which can be fluoridated feasibly should be fluoridated. It seems to be a complete and utter waste of time to allow disease to go rampant when we have got proven prevention measures which the World Health Organisation has labelled as one of the top 10 prevention measures of the 20th century.

Mr LYONS: So fluoridation is your number one priority, I presume. What would be your next priority for dental services?

Dr Crocombe : I would say the special needs people who live in the rural areas. It is like a double-whammy for them. And I guess number three is that we are heading towards a crisis of care in the aged care sector simply because the baby boomers—of which I am one, and I think you are to, aren't you—

Mr LYONS: Yes, join the club.

Dr Crocombe : are heading towards retirement; we are ageing. The days of walking through a nursing home and seeing lots of plastic lower dentures in cups beside the beds, I think, are going to disappear, because we are going to hit the nursing homes with teeth, some of which have had some pretty heroic dentistry to keep them there. Then, when we hit the nursing homes, we will start getting infections with these teeth. We might even get a bit senile and forget whether we have cleaned our teeth. Our diets will change. I can see that we are heading for quite a crisis in that area. And, as I used to tell the students at Adelaide university, it will not be my problem because I will be the one dribbling in the corner! 'What are you going to do about it,' was my usual question.

Mr Wellington : If I could just add to that, Len, our perspective is also that there needs to be greater coordination between Commonwealth and state services—

Dr Crocombe : Yes.

Mr Wellington : which is not the case at the moment, and obviously the public and private sector service providers also fall under that comment. A final point that we would like to raise, once again for rural and remote areas, small towns in particular, is that, as you would be aware, the practitioner needs to be able to handle many areas of dentistry that, in a metropolitan setting, would otherwise be referred on to other service providers. That is not necessarily an option in rural and remote Australia. So it gets back to that point about the scope of practice and the skill set required in metropolitan settings and what is required in rural and remote settings, which is completely different.

Mr COULTON: Chair, can I just follow on from that very point. There is a movement now in medical practice for GP generalists—someone who is a GP but who has extra skills. Is there a training program or something similar being mooted in dentistry for a dental generalist, for want of a better word—someone who has a broader range of skills than maybe a dentist practising in a narrower field of dentistry?

Mr Wellington : I will flick that to Len shortly. Perhaps it is a logical way to go. For example, with the rural generalist program that the Rural Doctors Association of Australia have been—

Mr COULTON: It has been going in Queensland for some time.

Mr Wellington : Yes—which is very successful. Health Workforce Australia are currently looking at a rural generalist role for allied health professionals. It is very much in the embryonic planning stages. But, Len, you might want to comment directly on Mr Coulton's question.

Dr Crocombe : The short answer is: no, there isn't. I think it would be fantastic if there was. What tends to happen is that dental practitioners learn in the field, as it were. So I agree that it would be great for it to occur. I like to call it a supergeneralist—how does that sound? Many rural dentists are already, although they have not gone through a formal training process. Most of my working life has been in rural areas. But, basically, it would also help solve the problem with this team concept. As these rural dentists get into subspecialty areas, that opens up the area below them, if you like, for the oral health therapists and hygienists and dental therapists, for a team to actually come together. I guess I have been trying to push for this for quite a while. It would be great idea. I even wondered—and I think we put this in the submission—whether rural dentistry should be akin to a specialty.

Mr LYONS: Can I go back to your point about the coordination with states. Also—this is something that comes before this committee a lot—we tend to have silos of funding, and there do not ever seem to be bridges between the silos, or, if there are, they are just a personal thing within a particular area. I worked at the Launceston General Hospital for a long time, and we used to have dental patients because they had to be unconscious for their operations. Then there was always this fight about who was going to pay for what. Have you got an answer for that?

Dr Crocombe : It gets worse than that. Dentistry has been siloed out of medicine and health since the beginning of the 20th century, basically, and it is continuing. Oral health was excluded from the Medicare Locals process. It has been excluded from the electronic process and a whole mass of other things. Yes, it is a major hassle, and not only that. The states do not seem to talk to each other either, as well as the breakdown between the Commonwealth and the states in who does what.

What is a simple solution? I noticed in the last budget that oral health promotion is being funded separately from health promotion. The things that we have found associated with poor oral health include low socioeconomic status, being in a rural area and all this type of stuff. The causes of poor oral hygiene and most of the other things, other than fluoride, are basically the same as they are for poor general health. So you find the two linked together. So I always find it difficult to understand why we have a separate oral health promotion campaign from medicine. Maybe by doing so we are confusing the public out there. So I guess that possibly the first step could be to ensure that promotion campaigns are linked together rather than having separate ones altogether.

Mr Wellington : Could I just jump in there. Len has touched on this: perhaps there might be an option in terms of the Medicare Locals. It is a bit of the blame game still occurring. If we had a crystal ball, it would be wonderful if the oral health funds, both state and federal, would go to one single point which would be responsible for program management and financial management. But that is not the case at this point in time, as you know. But there is a structure, for argument's sake, through Medicare Locals.

CHAIR: That is a recommendation you are making to the committee, is it?

Mr Wellington : We believe so. That may overcome the dual funding arrangement, but that is assuming that the Commonwealth and state governments at the various levels are going to agree to that. But it would overcome a lot of the duplication and lack of coordination on the ground level, particularly in rural and remote Australia. Given that Medicare Locals are a structure in place and their key role is to look at primary health care, health and wellbeing and to provide services for their local communities, I would suggest that that would be a good starting point.

CHAIR: Thank you.

Mr GEORGANAS: In terms of services being delivered to people that have special needs and are living in these rural and remote areas—for example, fly-in fly-out people that work in remote areas—what sort of structure or services could we offer? For example, could there be services that come in and go out? I am thinking of very isolated, remote communities. Is there any idea how that would work in terms of getting people to go in, provide the services and go out?

Mr Wellington : That is a great question.

Mr GEORGANAS: Assisting transport schemes and other arrangements.

Mr Wellington : Indeed—the patient assisted transport scheme. Once again, that varies from state to state and jurisdiction to jurisdiction, as this committee would know. From memory, there were some interesting recommendations in the report of the House of Reps committee inquiry on fly-in fly-out and drive-in drive-out that was chaired by Tony Windsor last year. Those principles would also apply to oral health and dental services. The ideal scenario would be to have professionals delivering services as locally as possible. That is the ideal scenario. We understand that is not possible, particularly for remote communities. Therefore, if that is not possible, what is the next best option? The next best option is to have, perhaps, a hub-and-spoke or fly-in fly-out arrangement but ensuring that the practitioners that are delivering those services, where possible, are the same people so you do not have a different dentist flying in once a month so that a patient has to go through the process of identifying and covering old ground in terms of what their history is. I think that would be a key issue in terms of the fly in, fly out and drive in, drive out arrangement. The practitioners, whoever they are, whether oral health, medical or allied health practitioners, need to be the same person within reason.

Dr Crocombe : To extend that, with dentistry the equipment is extremely expensive, so it would probably increase the hub-and-spoke model, particularly for people with special needs who often need even more special equipment—such as for people in wheelchairs, so that they can roll into a special platform which leans them back whilst they are in their chair. It is a complicated area. We also do not have many special-needs dentists in Australia, and that is something the committee could look at to see whether it could encourage people to take it up.

CHAIR: What do you think the priorities for the NPA should be and how should it transition from providing emergency services to a more preventive service or approach?

Dr Crocombe : As we said before, linking any funding from the Commonwealth to fluoridation of water supplies would be No. 1. No. 2 would be an incremental introduction of a scheme that allows those with poor assisted care entailed with poor oral health to come access care. From the point of more preventive services, over the 20th century we have found that people who access dental care on a regular basis have not had lower rates of incidence of disease, which does not mean that it is a waste of time. What it means is that those who regularly access dental care have their treatment done whilst the disease is at an early stage. We need to encourage the use of evidence-based, preventive, in-surgery processes. Hence we need to—and yes I am a researcher—encourage research into those types of areas. We are talking about things such as fluoride varnish and things along those lines.

Mr Wellington : People who reside in rural or remote Australia, in our opinion and in that of other industry groups, do not get their fair share of services for a range of reasons that we have outlined in our submission and talked about here this morning. We are of the view that that needs to change, so we need to start seeing action rather than continuing to talk about it. At the end of the day oral health is a key element to primary health care.

CHAIR: Thank you very much, and we greatly appreciate you appearing before the committee today. We will send you a copy of your contribution for you to check its accuracy and send it back. If you think of anything else you would like to add please feel free to contact the committee secretariat.