Contextual background

In 2005, it was projected that there would be a dental workforce shortage in Australia by 2020 (AIHW 2008). Australia’s Future Health Workforce, Oral Health (AFHW – Oral Health) provided oral health workforce planning projections; the 2012-2025 workforce projection scenario results for dental practitioners other than dental prosthetists indicated that supply was

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projected to exceed demand in almost all scenarios (Health Workforce Australia 2014). In contrast, the results for dental prosthetists indicated that demand was projected to exceed supply in almost all scenarios (Health Workforce Australia 2014). These scenarios plotted workforce supply projections to meet the current demand for dental care, not the need for dental care. The demand for dental care would be expected to increase if the Australian Government increased funding for dental care. Australia-wide, there are less dental practitioners by population in rural than metropolitan areas, and this mal-distribution increases the more remote the region (Table 1).

Table 1-1: Dental practitioners, by remoteness area (a), FTE per 100,000 population

Practitioner type Major cities Inner regional Outer regional Remote/very remote Australia Dentist 64.3 42.2 36.1 21.5 56.9 Hygienist 5.8 2.7 2.8 1.7 4.9 Therapist 3.4 4.3 5.6 4.5 3.8

Oral health therapist 2.6 2.8 2.6 1.4 2.6

Prosthetist 5.6 6.4 3.2 0.5 5.4 It is evident from the national statistics (Dental Board of Australia 2015) and the HWA Dental Workforce Projections (Health Workforce Australia 2014) that that there is now an oversupply of dental practitioners in Australia, but with the majority working in major cities and ongoing workforce shortages in rural areas. These low dental practitioner numbers per size of the local populations of many rural areas has occurred despite an increase in the number of dental schools, skilled dental migrants entering Australia, and new Australian dental graduate numbers.

Dental practitioners provide important primary health care services through the provision of preventive and restorative dental services. Oral health is integral to overall general health, and poor oral health can have negative effects on general health and quality of life (Petersen 2003). This is particularly important for people residing outside the capital cities, as they have poorer oral health than their city counterparts (Crocombe, Stewart et al. 2010). Research identifies several groups in Australia who have poor oral health: frail and older people (Chalmers, Carter et al. 2002), rural residents (Crocombe, Stewart et al. 2010, Crocombe, Stewart et al. 2012, Crocombe, Mahoney et al. 2013, Crocombe, Bell and Barnett 2014), Indigenous Australians (Slack-Smith, Read et al. 2011), Australians with physical and intellectual disabilities (Pradhan

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A, Slade GD et al. 2009), and people of low socio-economic status (Chrisopoulos, Luzzi et al. 2013).

1.8.3.1 Population distribution

The population distribution of Australia is concentrated in urban centres, approximately 90% of the Australian population live in major cities and inner regional areas (Phillips 2005). The remaining 10% of the population live in rural and remote areas, scattered across the country (Australian Bureau of Statistics 2013). Australian rural areas are diverse geographically, economically and socially, and have higher rates of poverty than in capital cities. Rural location can play a major role in determining the nature and level of access to and provision of oral health and other health services (Smith, Humphreys et al. 2008).

1.8.3.2 Provision of dental treatment in Australia

There are some similarities between the Australian rural medical workforce and the rural dental workforce, there are, however, several key differences. Dental treatment is provided and paid for differently to medical care in Australia, the latter being mainly government subsidised through Medicare. In Australia, dental services are largely provided by the private sector (85%) (Kruger and Tennant 2015), and the burden of payment falls to the individual, so that the cost of treatment is a common reason for people to avoid dental treatment (Harford, Ellershaw et al. 2011). Private health insurance covering dental treatment can also affect use of dental services (Chrisopoulos, Beckwith et al. 2011).

In rural areas when dental health services are not available, people visit non-dental health providers (Walker, Tennant et al. 2013); such as GPs for short term pain relief, prescriptions, hospitalisation, and advice (Barnett, Hoang et al. 2016). A private dental practice operates as a small business, and a dental practice requires a larger patient base than a medical practice to be financially viable resulting in the many widely-dispersed rural areas in Australia not having the population size needed to support a full-time private dental practitioner (Barnett, Hoang et al. 2015).

12 1.8.3.3 Rural health disparities

Rural health is a challenging and complex discipline because there is an urban/rural dimension in accessing health care (Schwarz 2006). Australia’s rural populations have poorer overall general health than metropolitan populations (AIHW 1998, Smith, Humphreys et al. 2008). The reasons for this include: rural populations having a differing attitude towards health than urban populations (Humphreys, Jones et al. 2002, Crocombe, Stewart et al. 2012), people in rural areas commonly describe health as an absence of disease (Humphreys, Jones et al. 2002), and rural people are more likely to spend money on disease management rather than on primary care. Despite these factors, there remains geographic inequalities in access to dental care in Australia (AIHW 1999). Rural populations also experience socio-economic disadvantage, ethnicity, poorer service availability, higher levels of personal risk and more hazardous environmental, occupational and transportation conditions (Smith, Humphreys et al. 2008, Crocombe, Stewart et al. 2010) than urban populations.

1.8.3.4 Difficulties in accessing dental health services

The lack of oral health services and the greater distances involved in seeking treatment present a barrier to accessing regular dental care for rural populations (AIHW 1999). Rural people face difficulties in accessing dental health care services due to increased travel distances to services, smaller population sizes, and higher workforce turnover relative to metropolitan areas (Wakerman, Humphreys et al. 2008). However, while access to dental health services is a key reason why people outside capital cities have poorer oral health than people living in capital cities, it is not the only reason (Crocombe, Stewart et al. 2012). Living in a rural area does not always lead to health disparities, but it may exacerbate the effects of socio-economic disadvantage, poorer availability of health care services, poorer physical and financial access to services, increased waiting times for services, increased issues with transport, average lower levels of income and education, and higher occupational and environmental risk factors (Phillips 2009, Schwarz 2006, Smith, Humphreys et al. 2008).

13 1.8.3.5 Dental visitation patterns

There are differences in dental visitation patterns between urban and rural areas because geographic location is a major factor in the frequency of use of dental services and the reasons for dental visits (Adams, Slack-Smith et al. 2004). Rural populations have less frequent visitation patterns than urban populations. They are less likely to regularly visit a dental appointment for routine preventative treatment and are more likely to visit for a problem (AIHW 1999). Seeking dental treatment for a problem rather than a routine check-up may reflect the ability to access dental services in terms of availability and affordability (AIHW 1999). These factors can have a compounding effect because some of the most socio- economically disadvantaged rural areas are also the most geographically isolated from health services. This can increase the risks for rural populations of poorer oral health outcomes. Dr Rick Olive, President of the Australian Dental Association (ADA), has highlighted some of the difficulties in providing dental care services to rural communities due to these visitation patterns.

“A higher proportion of patients from these communities place a low priority on oral health.” (Dr Rick Olive,President of the Australian Dental Association (ADA), 2016) 1.8.3.6 Dental workforce

In Australia, there has been an increase in the number of new dentists entering the workforce per year; there were 200 new graduate dentists and 50 from overseas in 2008 and 581 new graduates and 230 from overseas in 2013 (Griffiths 2014). This has been reflected by the removal of dentists from the Skilled Occupation List (SOL) (Department of Immigration and Border Protection 2016); the list of occupations that are acceptable for immigration to Australia. Analysis of recent dental workforce data (Dental Board of Australia 2015) indicated that there are also demographic changes occurring in the makeup of the dental practitioner workforce in Australia including the increasing proportion of female dental practitioners. As dental practitioner numbers increase, the issue of rural dental workforce recruitment may be solving itself, as people unable to find employment in urban areas relocate to rural areas. This may lead to increased workforce turnover and skills shortages in rural areas.

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