Professors Marc Tennant and Estie Kruger are from the International Research Collaborative – Oral Health and Equity, Department of Anatomy, Physiology and Human Biology, The University of Western Australia. In this latest instalment in a series on dental services they look at the problem of, and solutions to, economic and geographic diversity.
Professors Tennant and Kruger write:
Australia has a complex population distribution that makes the design and sustainability of many community services difficult.
The provision of dental care in Australia is predominated by a free-market, small business model. The safety-net government dental services only provide 10-20% of adult care. This service arrangement has facilitated Australia to remain, on average, a very healthy society compared with much of the world.
However, Australia is not made up of 22 million average Australians. An average Australian is a statistical fantasy that in realty does not exist. Australia comprises 22 million people from a diverse range of economic prosperity, and towns and cities.
We are becoming more economically polarised with the rich becoming richer and the poor becoming poorer. This is not surprising as it is happening across the OECD.
Not only are we an economically diverse community, we are also one of the most unevenly geographically distributed populations on the planet, with a growing trend that is seeing a slow loss of population in rural and remote Australia.
These two factors, economic disparity and population distribution are at odds with the current free-market predominated dental provision model. And, the effects are becoming more clearly visible and are growing in severity over time. Economic and geographically marginalised communities, are missing out.
Clearly, in a free-market, dentists will work where they want and they have practices that match the economic reality of their business models. No dentist is going to set-up practice where it’s not viable.
Economically marginalised communities miss out. Recently it has been reported that the poor suffer facial cellulitis (usually caused by dental related conditions) some 500 times more than the wealthy. While at the other end of the scale, the rates of wisdom teeth extraction are many fold higher in the wealthy than the poor.
The story is no different for geographically marginalised communities. The geographic cores of our capital cities have some of the highest densities of practices ever recorded, and this clustering is astonishing. For example, you can stand on the roof of the main post-office in Perth and from this vantage point see over three quarters of all dental practices in WA. In other research we have shown that nationally, in suburb terms, we have about a 40 times difference in population to practice ratios between inner city suburbs and regional areas.
To address these disparities is simple in words, but hard in practice; get more dentists to work in economic and geographically marginalised communities.
The federal government has tried on a number of fronts with varying success.
A world-class outcome was the development of a series of new rural-based dental schools; these already see growing numbers of graduates practicing in rural Australia. This has been coupled with programs to get more rural students into dental schools and have more rural placements for students of metropolitan dental schools.
Whereas the federal government’s effort at supporting private dentists to provide subsidised care to the chronically ill can be at best be called of marginal benefit, and at worst some may call it a wasted $1 billion.
Geographic isolation can be overcome to provide care. New models of care have been developed in a number of places that have certainly had sustained positive benefit to remote and Aboriginal Australians’ dental accessibility. These models acknowledge the work-life balance issues and economic realities of the free-market by providing visiting services to locations where sustainable standard service arrangements would not work. Australia needs to engage in these new models to effect large scale change.
Similarly, another example is the federal governments Dental Relocation and Infrastructure Support Scheme that provides a second path to address geographic marginalisation by financially supporting dentists to set-up in areas of need, through capital and operational subsidies. Clearly, there are innovative ways forward.
State governments are responsible for dental services for economically marginalised communities. These services have the opportunities in front of them to evolve new quality care models. The opportunity is particularly available during a period of increased dental workforce (brought about by the new dental schools) and the opportunity is for them to re-enforce Australia’s dental safety-net.
To date, many have been substantially focused on child dental health, but with the substantial inroads made through dental public health, it is time these services make a concerted effort to move to address the new demographic reality of an aging population and the economically marginalised; particularly as Australia continues to become more economically polarised.
The way forward for dental care in Australia is far more complex now than it has ever been before. Dental disease is focused in the geographically and economically marginalised and service systems are substantially free-market driven.
The art and science of future government dental policy will be in balancing this free-market economics with the true social need of Australia in the next 50 years, to ensure Australia remains a just society.
Previous articles on dental care can be found here.