As she begins her second term as President of the IDA’s HSE Dental Surgeons Group, Dr Frances O’Callaghan discusses ongoing industrial relations issues, cutbacks to the Public Dental Service, and the results of a recent survey of HSE members.
On the day of our interview, Frances has just received the results of a survey of HSE dental surgeon members of the Irish Dental Association (IDA). The survey has been a personal project and she is delighted to see it completed: “Last year when I took over as President, I was very conscious that staff morale in the HSE Dental Service was very low, and that many of my colleagues appeared extremely stressed. Work-related stress is hugely significant from a health and safety point of view, and I decided to commission a survey of members to try to quantify it”.
With help first from the IDA’s Sarah Gill and then from Roisín Farrelly, the survey was circulated to all HSE members and results have now been collected, with a response rate of over 50%. Levels of stress are indeed high, with 60% of respondents saying they regularly feel stressed at work, and a shocking one in five saying they have missed work due to stress. There is also evidence of unhappiness with management structures, with 70% unhappy with the level of consultation on change, and only 37% feeling they get support from management. What might surprise though is that the highest stressor for respondents was not pay or working conditions: “The lack of access to secondary care services for patients, in particular to general anaesthetic services, was identified as the highest source of stress for respondents”.
Waiting for tragedy to strike
With the closure in October 2014 of the dental emergency extraction clinic in St James’s Hospital in Dublin, waiting lists for general anaesthetic services in Dublin, Wicklow and Kildare are now up to 12 months for young children with chronic dental infection, many of whom require multiple extractions. With only limited access to some private facilities around the city, dentists are under severe pressure to prioritise the most serious cases, and Frances has strong feelings on this: “All of the children on the waiting list need dental extractions, and all require general anaesthetic to have the extractions completed. Dentists are required to prioritise cases on the basis of urgency. The most acute cases, and very young children suffering trauma, are prioritised as requiring immediate access to general anaesthetic. These are referred to the private sector and will receive treatment within a few weeks. The remaining cases, including young children often requiring four or more extractions, are currently waiting up to a year”.
The problem is not unique to Dublin, Wicklow and Kildare. Waiting periods around the country are typically six to nine months, compounded by the fact that dental cases are not included on hospital priority lists, with theatre slots regularly cancelled in favour of other general anaesthetic cases: “If a child is waiting longer than six months to have their tonsils out, the hospital is penalised, so hospitals have cancelled dental theatre slots to facilitate paediatric ENT procedures. We would argue that a child who needs a general anaesthetic in order to have painful, infected teeth extracted is just as entitled to treatment as a child with chronic tonsillitis”.
The implications of this are very serious, both for the children and for the dental professionals charged with their treatment: “Anecdotally, we are hearing of children having to be admitted to acute hospitals for IV antibiotics for oral infection. Our concern is that general anaesthetic services for dentistry will not become a priority until a child has a serious outcome from dental infection. The crisis also extends nationally for children and adults with special needs who require general anaesthetic for routine dentistry”.
The HSE Group of the IDU continues to campaign on this issue, and plans to raise it once again with Minister for Health Dr Leo Varadkar when he attends the Group’s Annual Seminar in Carlow this month.
Promoting the positive spiral
A motion at the Group’s AGM will also call for a more radical change to dental healthcare for children: “In recognition of the Minister for Health’s introduction of free GP care for children under six, the HSE Group of the IDU will be calling on the Minister to implement a policy supported by the required funding to put comprehensive oral healthcare programmes in place for young children under six in this country”.
This comes after years of cutbacks to the Public Dental Service, which have severely curtailed dentists’ ability to target children and their families at a young enough age to make a meaningful difference to their oral health: “The earliest any child receives a screening examination now is age seven to eight, either first or second class, which is too late. In some parts of the country children are not examined by a HSE dentist until sixth class. In my area (Frances is a Senior Dental Surgeon in the HSE Dublin South–East Wicklow region) we used to see children in senior infants, but we had to stop three years ago because staffing levels have dropped so much. Our staff were devastated because they had seen significant improvement in the oral health of pupils in second classes when they had seen the same children in senior infants. We were able to highlight concerns at six years of age, before there was any damage to permanent teeth”.
She quotes a colleague, who spoke of the “positive spiral of early intervention”, and ties this in with overall health policy: “The Department of Health sees obesity as the single biggest threat to our health service, and hidden sugars are seen as a major causative factor. Dentists can identify these high-risk patients very early due to the presence of caries. Working with our colleagues in the primary care team in early intervention, I think we could have a serious impact”.
Making the case for a strong primary dental care service with adequate preventive care is an ongoing problem and one that Frances thinks the profession needs to do more to address.
“If you talk about teeth to most people, [they want to talk about] orthodontics. Politicians respond to what comes to their desk. If you look through the Dáil Digest that the IDA circulates, the focus is on braces, fluoridation and dentures, and we as a profession have to take some responsibility for that.”
This public focus on braces rather than caries (tooth decay) means that political pressure is brought to bear in relation to orthodontic treatment rather than on prevention and primary care, and for Frances, this is counter-productive: “Investment in oral health promotion and prevention is cost-effective. We have a limited budget, so we have to decide where it is best used, and in the younger age group is where we will have ultimately the best outcome in the long run. No one seems to appreciate that children losing teeth prematurely creates orthodontic problems. Orthodontics is important, but only for a percentage of the population, whereas primary care, good prevention, oral health promotion – that should be for everyone”.
There has been some recruitment of dentists in 2015, which is very welcome, but years of cutbacks and poor planning mean that the Service is still severely under-resourced. Even where posts are approved the recruitment process is painfully slow, with delays of months before a position is advertised and further delays after the interview process. This is a source of significant frustration for existing staff and is certainly a barrier to attracting and successfully recruiting quality candidates.
One of the major tasks ahead of Frances as she enters her second year as President of the HSE Group is as a member of the IDU’s negotiating team in talks with the HSE on Public Dental Service reform. These talks will reach the Labour Court at the end of this month. Along with representatives from the IMPACT trade union, the IDU is seeking to address outstanding issues from the 2011 Dental Reform Agreement, an agreement which itself was the culmination of years of discussion on proposed reform to the Service. The principal industrial relations issues for the IDU are the HSE’s failure to fill promised posts, in particular at Principal Dental Surgeon level, and the HSE’s refusal, in Frances’s view, to engage with the unions in formulating an appropriate management structure below the PDS grade. The lack of a comprehensive management structure within the enlarged service areas created in 2011 has had serious implications for service delivery, as well as depriving public health dentists of an appropriate career path.
Frances’s involvement with this process goes back to 2010, when she first joined the HSE Committee, and her disillusionment is clear: “We went to the Labour Relations Commission in December 2014 to see if we could get the HSE to follow through on filling the posts as per the 2011 agreement, but HSE Management made no effort to engage with the process in any meaningful way. Instead, HSE Management wanted to discuss a further reduction in the number of Area Principal Dental Surgeon posts from 17 to nine, to correspond with the new CHO structure. It appears to be primarily a numbers game from the Management side with no clear vision or plan to support the changes”.
The much-awaited Oral Health Policy, and what it might contain, is also a factor.
“I know the HSE may be anxious to proceed with reform, but until we see the new Oral Health Policy I don’t know that it’s realistic or wise to engage in any further serious structural change. In the interim we want to implement the 2011 agreement, and put in the sub-PDS layer of management to provide stability. Until we get satisfactory resolution to those issues, we will not be discussing any further reform. As to the future, we will not repeat the mistakes of the past. We will not accept any reform that is not comprehensive, with clearly defined roles for all grades. If the HSE strips the Service back to only nine Principal Dental Surgeons, then there will be very limited opportunity for promotion within the Public Dental Service in the future. As it stands, it has been several years since the last competitions for Principal or Senior Dental Surgeon posts. This is one of the reasons why morale is low. Dentists are professional people. There needs to be a clearly defined promotional pathway within the Service if we wish to recruit and retain highly qualified and motivated professionals.”
The negotiating team’s aims are clear: “As a priority, the vacant posts in the National Office and other vacant Principal Dental Surgeon posts need to be advertised and filled, and we will resist every effort to reduce the number of Area Principal posts below the agreed number of 17”.
Another focus for Frances is increasing the HSE dentist membership of the IDA, which has dwindled in recent years. A subcommittee consisting of Frances, Dr Jane Renehan, and Association CEO and Deputy CEO Fintan Hourihan and Elaine Hughes, has been working on this.
“The financial benefits of IDA membership for HSE members are much less than for our GP colleagues. Our indemnity is not as expensive and we can’t offset our membership for tax. Therefore, a decision was taken that loyal members would get a discount for attending the Annual Seminar. For the first time this year, anyone who is a member of three or more years’ standing gets to attend the Seminar for free, and there’s a sliding scale for others.”
Frances welcomes this acknowledgment by the IDA of its HSE dentist membership and feels it reflects her own experience as a member of the IDA Council: “This is my second year on Council and the support I get from my non-HSE colleagues, and from IDA House, has been fantastic. They have been very sympathetic to our difficulties and very supportive, in particular past President Dr Peter Gannon, and President Dr Anne Twomey, who will open the HSE Group’s Annual Seminar in October”.
A busy life
Frances qualified 28 years ago and worked in private practice in the UK for nine years before returning to Ireland to work in the then Eastern Health Board in 1997 (“I joined them for six months, but I’m completely institutionalised now!”). Besides work and spending time with her husband Declan Herlihy and three children, Éadaoin, Peter and Michael, Frances and Declan have a longstanding association with Kilmacud Crokes GAA Club, which she says has been one of the more fulfilling aspects of her life. She considers herself very fortunate, and is particularly grateful for her family’s support in her work with the HSE Group.
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