14 minute read
Mind the gap
Christchurch City Council’s resistance to fluoridation is a case study in the ongoing battle for greater public dental health in Aotearoa New Zealand. How do gaps in political leadership lead to gaps in ratepayers’ wallets and their mouths?
Matt Shand | Journalist
Dentists say they used to be able to tell where a patient lived in Canterbury by their smile. Age groups who lived in areas where fluoride was added to the water had far less prominent dental decay and far fewer gaps.
Now Canterbury has been fluoride-free for many years and it is much harder to tell.
“We’ve normalised this idea of having bad teeth,” South Canterbury dentist Fraser Dunbar said.
Dunbar is at the front lines of the fight against dental decay in the Canterbury region, and it is a real fight. He works one day a week as a public dentist, where he sees an ever-growing parade of people unable to afford private dental care.
“It just breaks me. I could not do more than one day a week [at a public dental surgery],” he said.
“Most of the people I am giving full dental clearances [removing all their teeth] to are aged in their twenties and thirties.
“People gasp when I tell them that, but it is the reality of the state of our dental care system. They can’t afford to treat their teeth and they come to us when they get desperate.
“Every time I pull a tooth this pop of pus comes out. It feels good to be treating this patient but bad that they have been living this way.”
The Ministry of Health, under the direction of former director Dr Ashley Bloomfield, is directing councils to fluoridate their drinking water supplies in response to the growing health problems associated with bad teeth.
While some have started, Christchurch City Council has refused on the grounds it cannot afford to pay the estimated $55 million capital expenditure cost.
This contrasts with the decision that it could afford an additional $150 million when the budget blew out on the $683 million Christchurch stadium project.
Councillors choosing not to spend money on dental care mirrors 40 per cent of New Zealanders who are unable to afford dental care due to its high cost. It will, however, further widen equity gaps for dental health. Those affected by the councillors’ decision will be at the lower end of the socio-economic scale where painkillers and denial are cheaper alternatives.
For most, dental intervention will only occur once pain becomes unbearable. A significant number will have to borrow money or go without some basic needs that week. In many cases, pliers will be reached for.
“Frequently we are seeing more and more people turn up to emergency departments having pulled their teeth,” Dunbar said.
“They can have broken bits of teeth still in their gums. It’s devastating and depressing. It really hits you hard.”
New data produced by ASMS shows the private cost of dental care, for those who could afford it, was a staggering $896 million in 2021.
Canterbury residents contributed 12 per cent of that total with a spend of $108 million. The data is based on EFTPOS transactions and the national average per EFTPOS swipe at dental surgeries was $353 - about half the weekly pay of a person on the minimum wage.
Fluoride gap creates carious nights
Nights were the worst for Canterbury’s three-year-old Teuila (not her real name). Pain from her decayed teeth made sleep difficult, both for her and her family. Painkillers were used often to get her through but always the pain would return. She was referred to hospital dental services, like 8,605 other New Zealand children last year, requiring a general anaesthetic for dental health problems.
Canterbury saw 888 children put under for dental surgery last year, making up about 10 per cent of the national total. While costs are not easily recorded for these surgeries, it is estimated to be between $3,500 and $5,000 per procedure. This means Canterbury clocked up between $3.1 and $4.4 million last year in dental surgeries for children.
Going private was not a bill Teuila’s family could afford, so they had to wait. It took six months of sleep-deprived nights until Teuila would finally be able to rest easy after she made it through the clogged, public dental system. Teuila was lucky to receive assistance Navigators at E Tu Pasifika, a health provider, getting them access to dental care by making sure barriers, such as transport or other children, are taken care of.
“This child was in pain for six months before being seen,” Canterbury Dentist Tule Misa said.
“It’s not the hospital’s fault, they are doing all they can with what they have. Dental decay is preventable and we should make sure we prevent it before it reaches those stages that we need to treat under general anaesthesia.
“Oral health therapists are the main people working for community dental services treating children, which is great, but many of them are going to private practices because it pays better.
“After most oral health therapists graduate they come to work with the public health services for a year or two to build their confidence and competence and then leave to work in private practices.”
Misa says government needs to find a way to incentivise people to work within the public system. “With our dental care mostly privatised, and monetised, we need to find a way to incentivise people to work within the public system more, to keep good people here.”
Misa says part of the reason dentists leave public practices is due to working conditions. Some areas, like the West Coast, have no public dentists left to service the community. “I think we need to reward people for working in these communities and providing basic health needs to rural communities,” she said.
Money gap speak volumes
Teeth are unique in our health system as they are treated separately. While healthcare is predominantly serviced by publicly funded organisations, nearly all dental work is performed by privately-owned dental practices in a user-pays model.
“We have a health care system, but our dental health care system is too disconnected from it,” Otago University Professor Jonathan Broadbent said.
“Oral health conditions have severe consequences for well-being, both physical and mental. We need good teeth in order to be healthy overall.”
Broadbent says dental health has not been taken seriously in New Zealand for a long time and, as a result, dental decay, and a culture of pulling teeth has become a norm again.
“WHO have just released their Global Oral Health Status Report, which calls for universal health coverage for oral health by 2030,” Broadbent said. “The WHO report discusses how health conditions are treated like an expensive non-essential healthcare issue, but this should not be the case.
“We need universal coverage for basic oral health services – no New Zealander should have to experience dental pain or disfigurement and be unable to receive quality care”
Dental treatments can cost in the thousands of dollars should they get out of hand and there are only a few public ways to receive help in New Zealand.
The first is a $300 grant from the Ministry of Social Development. The second is a Dental Treatment Advance from the Ministry, which needs to be repaid. The figure for the grant has not increased in 30 years but will be moving up to $1000 before the end of 2022.
Demonstrating the growing need for financial assistance is the fact that the amount granted for dental care by the Ministry has doubled in the past five years, from $23 million to $48 million per year.
Christchurch City had the second highest number of applications with 6,678 people seeking financial assistance last year.
Juliet Gray
Broadbent says we need to create rules about how the additional MSD money can be spent to ensure it is used efficiently.
“MSD should set a price list for what procedures cost and health providers should not refuse service to anyone seeking MSD-funded care,” he said.
“There is also a need for more salaried positions for junior dentists to work in the public sector to provide basic dental care services.
“This will help fill gaps in our healthcare system and allow people to visit the dental offices closest to them and be sure that these limited funds are being used in the most efficient way possible.”
Leadership and thinking gap
Earlier this year Christchurch City councillors voted not to pay a cent towards the price of fluoridating their water supply. Fluoridation has been a major debating point within council chambers around the country. Many councils breathed a sigh of relief when the decision to fluoridate was placed under the jurisdiction of the Ministry of Health.
Now the Ministry has decided fluoridation should go ahead and it is up to local government to follow central government’s directive.
Recently Christchurch City Councillor Pauline Cotter, who retained her seat by 16 votes, told Stuff.co.nz “Firstly [councillors] unanimously agreed that this is actually a health issue. So it’s not a city council issue, it’s a health issue, therefore the Ministry [of Health] should fund it.”
“And secondly, Christchurch, we’re quite different and special. I like to say we’re special because we have a multitude of wells and therefore it’s going to be very, very expensive.”
Funds have been made available by the Ministry of Health, but Christchurch’s estimate is more than five times the total that has been put aside.
Te Whatu Ora Waitaha dental public health specialist Martin Lee said the council cannot just shrug off its responsibilities to the government and the needs of its people.
“Fluoridation makes a big difference to the population of a city,” Lee said. “We’ve seen this time and time again and the science is very well proven now.
“I’m unsure why Christchurch thinks it can get off scotfree without any cost. The Council has been difficult to engage with and we have never managed to engage with the mayor on dental health over the last two decades.”
Tule Misa says, “It could make a world of difference. Fluoride helps everyone, it is an equitable treatment.”
Like many local authorities, Christchurch has adopted a Health in all Policies (HiAP) approach. Christchurch has even gone further by establishing a regional HiAP partnership, where it has embedded health experts working alongside decisions makers. Though it is sometimes not immediately obvious, many policies made at a local council level have far reaching health implications, such as rubbish collection, housing zoning laws or alcohol policies.
“Councils play a big part in public health,” public health physician and co-lead of the Health in all Policies team in Christchurch Anna Stevenson said.
“However, they often don’t immediately recognise themselves as being big health players.
Fraser Dunbar
“We’ve been working with them to help grow understanding of the direct health outcomes and wider well-being of certain decisions and get them to understand their actions have public health responsibilities.”
The partnership, including Christchurch City and Te Whatu Ora Canterbury, has been running for 15 years to ensure future decisions factored in health outcomes.
“One example is the decision to improve air quality,” Stevenson said. “If you simply removed all the log burners you get cold people who will eventually get sick.
“Our team worked with ECan staff on a health impact assessment of the clean air policy. Two outcomes were the employment of healthy homes coordinators by ECan and the development of a low interest loan scheme ratepayers could use to access heating and insulation. This means we were able to improve air quality and ensure people were able to stay warm in their homes.
“It’s this change of thinking that allows for excellent health outcomes.”
Unfillable gaps in dental health
Gaps are growing when it comes to dental equity and decisions need to be made to ensure they do not widen further. Like everything, costs of dental care in the private sector are increasing year on year.
ASMS data shows a more than $185 million increase in spending at private dental facilities in the last five years, rising from $701 million in 2017 to $896 million in 2021.
With a privatised dental system there needs to be more incentive for dentists to pick up work in the public dental space.
Special care dental specialist Juliet Gray says the challenge with decision making around dental health is that most people making the decisions have not had to live with the consequences of or equity issues arising from poor health outcomes.
“Have they ever had a swollen face and been unable to sleep night after night or watched their children crying because their teeth are sore and there is nothing they can do?
“The people who make these decisions [about fluoridation and public dental funding] haven’t typically lived this life.”
There are other innovative solutions being considered in Christchurch. One is using school dental clinics after hours as walk-in clinics for adults after work. A similar idea has been employed in South Africa and has seen a big jump in dental equity. It works with dentists donating some of their time to public health and running a two-hour per week time for walk-ins.
In another, the University of Canterbury partnered with Ilam Dental and Moriarty Dental to offer 50 per cent subsidies for their students up to the value of $210. This service has been so popular it ran through its allotted funding well before the year was out.
The biggest gap to overcome remains funding. Public dentists require money. Fluoridation requires money. But as anyone who has been to the dentist after ignoring the pain for a while knows, you never really save money. You simply delay spending it and it often ends up costing more, financially and physically, in the long run.
Auckland City Mission knows 96 per cent of people needing their service have significant dental needs due to a lack of access to dental care.
They have taken steps towards meeting this need by setting up a dental clinic at their new HomeGround facility. But, as yet, they have been unable to find the funding to staff or equip it.
“Some reported to pulling their own teeth out with a wrench to remove a bad tooth causing severe pain,” Missioner – Manutaki Helen Robinson said.
“Others said they did not go to a dentist because they cannot afford it, while barriers to free dental services are hampered by a lack of transport and lengthy wait times.” So the room stands ready, missing only its chair and a dentist to staff it.
But, as brushing and flossing can prevent cavities, good public investment prevents decaying equity.
ASMS’ Tooth be told report uses treasury data to show that for each $1 invested in public access to dental care it should save $1.6 dollars in return. For each dental surgery prevented by fluoridation or education resources, it is another $3,500 to $5,000 of public health money saved.
“It’s time somebody put on their big boy pants and made this a cross-party, political issue,” Fraser Dunbar said. “Whatever colour your tie is you should know people suffering is not good politics. We need more public dentists. It’s common sense really.”
Tooth be told
ASMS has released the Tooth be told report which makes the case for universal dental care in New Zealand. Forty-two per cent of New Zealanders report having unmet dental need. Predictably the proportion rises with socio-economic deprivation. Publicly funded dental hospitalisations have risen by a third in the last decade. The report marks the beginning of a campaign seeking political commitments to greater public funding of dental.
The key recommendations include:
1. Extending subsidised basic dental care for children to adults.
2. Urgently developing a workforce plan which includes strategies to ensure services are fairly distributed nationally.
3. Make options available for dentists to be employed on salary as part of the public health system.
4. Increase the oral health learning component in the medical curricula.
5. Routinely collect and report data on the state of dental health
6. Fully implement recommendations from the 2019 Welfare Expert Advisory Group.
