Oral diseases including dental caries and periodontal disease are among the most prevalent and costly diseases in Australia today. Around 5.4% of Australia’s health dollar is spent on dental services totalling around $2.6 billion, 84% of which are delivered through the private sector (AIHW 2001). The other 16% is spent providing public sector services in varied and inadequate ways. While disease rates among school children have declined significantly in the past 20 years the gains made among children are not flowing on to adult dentitions and our aging population will place increasing demands on an inadequate system into the future (AHMAC 2001). Around 50% of adults do not received regular care and this has implications for widening health inequalities as the greatest burden falls on lower income groups (AIHW DSRU 2001). The National Competition Policy agenda has initiated, Australia-wide, reviews of dental legislation applying to delivery of services by dentists, dental specialists, dental therapists and hygienists and dental technicians and prosthetists. The review of the Victorian Dentists Act 1972, was completed first in 1999, followed by the other Australian states with Queensland, the ACT and the Northern Territory still developing legislation. One of the objectives of the new Victorian Act is to ‘…promote access to dental care’. This study has grown out of the need to know more about how dental therapists and hygienists might be utilised to achieve this and the legislative frameworks that could enable such roles. This study used qualitative methods to explore dental health policy making associated with strategies that may increase access to dental care using dental therapists and hygienists. The study used a multiple case study design to critically examine the dental policy development process around the Review of the Dentists Act 1972 in Victoria; to assess legislative and regulatory dental policy reforms in other states in Australia and to conduct a comparative analysis of dental health policy as it relates to dental auxiliary practice internationally. Data collection has involved (I) semi-structured interviews with key participants and stakeholders in the policy development processes in Victoria, interstate and overseas, and (ii) analysis of documentary data sources. The study has taken a grounded theory approach whereby theoretical issues that emerged from the Victorian case study were further developed and challenged in the subsequent interstate and international case studies. A component of this study has required the development of indicators in regulatory models for dental hygienists and therapists that will increase access to dental care for the community. These indicators have been used to analyse regulation reform and the likely impacts in each setting. Despite evidence of need, evidence of the effectiveness and efficiency of dental therapists and hygienists, and the National Competition Policy agenda of increasing efficiency, the legislation reviews have mostly produces only minor changes. Results show that almost all Australian states have regulated dental therapists and hygienists in more prescriptive ways than they do dentists. The study has found that dental policy making is still dominated by the views of private practice dentists under elitist models that largely protect dentist authority, autonomy and sovereignty. The influence of dentist professional dominance has meant that governments have been reluctant to make sweeping changes. The study has demonstrated alternative models of regulation for dental therapists and hygienists, which would allow wider utilisation of their skills, more effective use of public sector funding, increased access to services and a grater focus on preventive care. In the light of theses outcomes, there is a need to continue to advocate for changes that will increase the public health focus of oral health care.

Despite an annual expenditure of the order of £400 million and administrative arrangements which in a number of respects are significantly different from the other arms of the National Health Service, the dental health services have attracted little scholarly attention. The recent Royal Commission on the National Health Service drew attention to this point (Report, para. 9.1) and in a sense the thesis represents an attempt to fill this particular lacuna. The central question addressed is why the performance of the dental health services has neither realised the more general goals (such as equal treatment for all or the relating of access to treatment to need) which were behind the assumption of public responsibility for health care nor overcome the more particular problems associated with the provision of dental services. The thesis seeks to locate the answers in the particular approach adopted to public supply and to this end some considerable space has been given to both the origins and character of this approach. An examination of the pressures that led to public involvement in the provision of dental care is followed, in the main part of the thesis, by an account of the implementation and subsequent operation of the services. Using material from the files of the Ministry of Health and the British Dental Association as well as the numerous public enquiries which have focussed on different aspects of the services, an attempt is made to relate the shortcomings in performance to the adopted approach to supply and more particularly to the inadequacies of the assumptions which underpinned it. The central conclusion is that problems associated with both the power of those involved in the services and the values inherent in the processes of public administration have been responsible for the untenability of these assumptions and that in consequence neither the administrative capacity nor the degree of political control on which policy achievement had been postulated have in fact been realised. The whole policy has become centred on the arrangements for paying individual practitioners in which wider community goals have generally been ignored and in which considerations other than equity or dental need have governed both the supply of, and access to, the available treatment.

Thesis (PhD)--Stellenbosch University, 1998. / Some digitised pages may appear illegible due to the condition of the original microfiche copy / ENGLISH ABSTRACT: see item for full text. / AFRIKAANSE OPSOMMING: sien item vir volteks.