HSE Orthodontics Waiting Lists in Ireland
I had an email in a while back asking about HSE waiting lists for orthodontic treatment. I wanted to give an honest and thorough answer, and my reply got longer and longer, so I decided to turn it into a blog entry.
As I understand it, receiving state-provided orthodontic treatment from the HSE (Health Service Executive, previously known as the Health Board) in Ireland does not depend on whether someone has a medical card, or their underlying medical conditions, or their income, or if their uncle plays golf with a minister in the government.
Apart from a small amount of patients that are actually under the care of the state, access to orthodontic treatment is entirely based on how much a person actually needs the treatment.
This is worked out by taking measurements and making assessments of the teeth and the bite using a system called the Index of Orthodontic Treatment Need (IOTN). If a patient scores high enough on this index they qualify for orthodontic treatment. If they don't, then they don't - regardless of income, medical conditions or political intervention. Having seen it in action, it does seem to be very reasonably and fairly provided.
The person carrying out the initial assessment would be a dentist working in the HSE, and they might send the patient to an orthodontist working for the HSE for a further assessment and decision. Since the orthodontist is paid a fixed salary by the government, they should be in a position to assess the patient fairly. In some other countries where the government covers the costs of orthodontic treatment, the orthodontist would be paid more for treating more patients, so it might be claimed that they would benefit from finding more patients to treat and might score the patient higher on the equivalent of the IOTN Index that they use in that country - in Ireland that conflict of interest is largely removed from the story.
Once the patient is approved for orthodontic treatment, they are placed at the bottom of a waiting list. When the HSE orthodontists finish treating a patient, and the patient gets their braces taken off, they begin treating the patient at the top of the waiting list, that patient at the top of the waiting list comes off the waiting list and the person at the bottom of the list moves a bit closer to starting their treatment. While this goes on, some more new patients are added to the waiting list and so it continues.
When you can provide the service at the same speed that people qualify for it, there's pretty much no waiting list. When you can't provide the service that fast, then a waiting list starts to build up. Sometimes, rarely, you can provide more service than there are people who require it, so there is no waiting list and indeed there are service providers that aren't as busy as they could be.
The most common source of disagreement is where on the Index the cut off point is for state-provided treatment. It's a bit like the qualifying time for an Olympic event. If they have it too high, only 6 atheletes will actually make it through to the olympics, so there's not much involvement for all the other countries. If they have it too low, then there might be 100 and they'll have to have over a dozen races just to see who gets to compete for the gold medal. I think there was one year when an Irish athlete was a fraction of a second behind the limit for qualifying, and some people wanted the qualifying time lowered so he could go to the Olympics. It turned out that if the time was reduced by that fraction of a second, the USA (or somesuch large country with good form in that event) could have sent another 20 contenders.
With the Orthodontic Index, if the cut off point on the Index is raised, then less people will be eligible for treatment and there will be more unhappy people at the clinics where the HSE assess if a person is eligible for treatment - but the waiting list will be shorter.
If the cut off is lowered, then many more people will be eligible for treatment and they will be added on to the waiting lists and they will be longer. If the HSE employs the same number of orthodontists, then a long waiting list means more time spent waiting.
The people who provide the orthodontic treatment can treat a number of patients at a time, and ideally would be starting and finishing a similar number every year. If a new member of staff joined, they would only be starting to treat new patients, and a large number of patients come off the list at once.
If an existing member of staff retired they would stop taking new patients off the list and gradually finish off patients. If someone became ill and had to stop work for a long time, they would stop taking new patients from the list AND their patients under treatment would have to have their treatment continued by other orthodontists who then wouldn't be able to begin treatment of new patients and take patients off the top of the waiting list. If an orthodontist takes a short break, like maternity leave, there would be a reduction in the number of patients that could begin treatment during this time too
If patients get added to the list faster than the orthodontic staff can begin to treat patients and take new patients off the top of the list, then that list gets longer and the people on it - especially the ones at the bottom of the list - will wait longer.
So you can see that waiting lists are a combination of the number of people with a treatment need that qualifies and the ability of the HSE to provide and support the clinical staff to carry out the treatment. Adding a patient to the list takes about 5 minutes. Treating a patient can take 2 years or more, so it's a tricky balance. When things start to go out of balance, you can end up with very long waiting lists indeed.
One last thing - if you are told that a waiting list is a particular number of years long, ask what that figure is based on. It's usually one of two things:
- an assessment of when the most recent patient to come OFF the list was originally put ON the list (eg "we're treating patients that went on the list in May 2011")
- an estimate of when the most recent patient to go ON the list is likely to come OFF the list(eg "I'm putting you on the list today, I think we'll be starting your treatment in early 2019")
Now both of these figures depend on a whole load of conditions that may have changed or will change while the patient was/is on the list and may not be the way things are now. It might all change by the time your child goes on the waiting list or while they are on it. Staff might leave or join tomorrow, and that affects it all again.
What is certain is that for many patients, long waiting lists are not a good idea.