A joined-up approach, designed around the needs of people, and providing services close to home

[ Words: Simon Harris ]

Smile Agus Sláinte, is a new approach to dental care, which was launched in April 2019. It provides the guiding principles to transform our current oral healthcare service and will facilitate better oral healthcare for everyone. Smile Agus Sláinte emphasises the ideals of Sláintecare, Ireland’s long-term vision for building a better health service, through a joined-up approach, designed around the needs of people, and providing services close to home.

The policy has two key goals:

• to provide the supports to enable every individual to achieve their personal best oral health;
• to reduce oral health inequalities across the population, by enabling vulnerable groups to access oral healthcare and improve oral health.

It includes 41 actions to be delivered over the next eight years, with some commencing in 2020.

The new policy will have major implications for all members of the dental team, whether they are working in private practice or in the Public Dental Service of the HSE.

“The current service is not designed to deliver prevention before poor oral health symptoms commence”

This current service is not designed to deliver prevention and advice before poor oral health symptoms commence, nor does it support the development of self-reliance in patients. This is hardly surprising, given that it was designed to provide a service to a population whose dental health differed greatly from the current population.

Since the 1970s, fluoridated water and toothpaste, fissure sealants and better diet have improved dental health. In the 1980s, eight out of 10 12-year-olds had several decayed teeth. At that time, half of older people had no teeth at all. Now, most 12-year-olds have very few cavities and teeth are retained into old age. The population in Ireland has also changed and by 2040 approximately 30 per cent of the population will be over 60. This means that unlike 30 years ago when the population was mainly young, our focus now is to ensure that the older population maintain their oral health quality of life into old age. Mobility, migration, emigration and immigration are also an integral part of our population’s dynamics. Access to modern technology ensures that the population has access to more information easily. All of these issues impact on care provision.

Smile Agus Sláinte will allow patients to choose dental practices and enable dental practices to offer their services as the ‘dental home’ for patients throughout their lives.

For dental practices, there will be opportunities to expand their role and provide oral healthcare to a wider range of the population. For the first time, children under 16 will be able to avail of State-funded care close to home in a practice which they or their parents choose. Dental practices will thus become more family-centred.

Establishing a personal ‘dental home’ and a chosen local dental practice early in life is crucial to creating good lifelong oral health behaviours and is a central philosophy in the policy. Under the Policy, all children up to 16 years will receive eight oral healthcare packages, including examinations, assessments, advice, prevention interventions, emergency care and referral as appropriate, rather than the two to three visits currently provided by the HSE to this age group.

While it is not uncommon for young children to have dental decay in their baby teeth, the only State-funded dental care provided for children under six years of age is an emergency service. The evidence shows that they attend only when they are in pain and by six years of age about one in three have attended a dentist for any reason in either public or private care. The later a child attends a dentist the more likely they are to have dental decay. Approximately 55 per cent of children who attend a dentist up to six years of age have decay, compared with the national average which is 32 per cent.

Access to early oral healthcare, especially advice and prevention, before starting school is a priority action designed to enable good oral health across the life course in line with the ‘Healthy Ireland’ policy. For this reason, the introduction of packages of oral healthcare for children aged under six is prioritised and will be introduced in late 2020.

The principles of early identification and adherence to clinical care pathways for patients who require complex and advanced care are addressed in the policy. Local dental practices will direct patients to HSE community services where needed, e.g. where a patient needs special care. Treatment that requires advanced skills and services not available from local and HSE dentists will be provided in advanced oral healthcare centres, e.g. hospitals.

Smile Agus Sláinte supports the provision of all care where possible in local dental practices where skills of the dental team are matched with the needs of the patient in line with the principles in Slaintecare. Dental practices provide a greater range of care than ever before. Even when people are referred to community or hospital services, their local dental practice or ‘dental home’, will continue to support their care.

Adults with medical cards will also have access to preventive-focused dental care throughout their lives, in addition to routine treatment and complex care. Unfortunately, not everyone has benefitted equally from the positive changes in oral health. Many, including people with disabilities and homeless people, have difficulty accessing care and this affects their oral health quality of life, which includes how a person can perform functions like eating, talking and smiling. This declines with age and is worse in poverty. It is important that we address these unmet needs identified in Smile Agus Sláinte.

With children’s services being delivered in local dental practices, the service provided by the HSE will be refocused. It will deliver health promotion programmes and provide dental services to those whose care cannot be provided at their local dentist, such as people in residential care. The oral health promotion programmes will focus on integrating oral and general health. The right advice for general health is also right for good oral health. HSE dental services will also provide preventive care to vulnerable communities. This will also be a priority in 2020.

An important element of Smile Agus Sláinte will be the introduction of a population oral health programme throughout life: Inspect and Protect. Inviting the population at key stages for these check-ups will ensure that Smile Agus Sláinte stays on track. This programme will give a reminder or a ‘nudge’ to children and adults at key ages throughout life. This is a World Health Organisation programme for the whole population and at least six extra ‘nudges‘ and dental assessments will be provided throughout life. For example, in addition to the provision of eight packages for up to 16 years, there will also be three dental ‘nudge’ assessments. This will allow a person’s oral health to be compared with that of their peers. This supports the “nobody left behind” ethos of Smile Agus Sláinte. Smile Agus Sláinte is a big change for the public but also for the profession. Education for dentists will be reviewed as a priority. More than half of our dental professionals are hygienists, dental nurses, clinical dental technicians, orthodontic therapists, and dental technicians. Enabling access to more dental professionals will give more choice to the public. There will be a greater diversity of work for dentists and dental professionals and synergy with other health professionals.

The Smile Agus Sláinte approach shows better health outcomes across all age groups in other EU countries and helps reduce inequalities between rich and poor. Such an approach is endorsed by the World Health Organisation and the United Nations. It will be challenging, but our highly skilled and dynamic profession is well placed to support this change.

The policy is evidence-informed. The research was commissioned by the Department of Health in developing Smile Agus Sláinte. Views of professionals across several disciplines, as well as the views of members of the public, were taken into account. The policy is supported by international evidence and embraces the same ideals as Sláintecare, with the needs of people at the core.

It is our intention to continue engaging with stakeholders as we move from policy development to implementation. The implementation phase will involve other lead/partner agencies identified in Smile Agus Sláinte, which may establish their own stakeholder engagement as required.

I have established stakeholder groups particularly looking at clinical care pathways and the need for changes in training and need for up-skilling for the workforce. I am grateful to those who have been engaging in this preparatory work. I look forward to further and wider engagement with stakeholders as we implement Smile Agus Sláinte.

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Simon Harris is the Minister for Health in the Irish Government.

Tags: Smile agus Sláinte