We present our comprehensive 2024-2025 Pre-Budget Submission to the Victorian Government. In this submission, we have outlined a series of recommendations that align with our mission to pursue greater oral health outcomes and access to dental care for Victorians.
Click Here to Download a PDF Copy of the Submission
Victorian Oral Health Alliance Budget Submission 2024-25
The Victorian Oral Health Alliance (VOHA) represents a membership of 20 plus key professional, provider, consumer, and community-focused organisations (see Appendix B) committed to improving the oral health of Victorians and addressing the current inequities in access to timely public dental care. Below we discuss both the chronic under-funding of public dental care in Victoria and the severe consequences impacting the accessibility of critical services. Only one out of every seven 1.5 million eligible Victorian adults are currently able to access public dental care annually, exposing a glaring inequity in the Victorian health system.1 The consequently long waiting times were recognised by Health Minister Thomas as recently as 9th November.
While we recognise recent investments for children (Smile Squad) and the one-off post covid catch-up funding and their benefits to consumers, these initiatives ultimately fall well short of addressing the significant funding and resource inequities that are pervasive in the public dental system. Below we highlight the key short and longer-term initiatives essential to create a responsive dental health system for Victorians, including those that:
- Deliver high Impact for low cost;
- Address chronic under-funding of essential dental services.
WHAT ARE THE KEY ISSUES?
1. Inadequate focus on prevention – low hanging fruit ignored.
Poor oral health is a silent and pervasive epidemic. It impacts people’s everyday lives and disproportionately affects vulnerable and disadvantaged Victorians. It both prevents people from fully participating in society (for example getting a job or going to school) as well as contributing to poor general health, such as an increased risk of heart disease and diabetes. This is particularly prominent for older people. About 20 per cent of aged Australians have lost all their adult teeth and instead rely on dentures.
Despite poor oral health being highly preventable, the current lack of investment in prevention is a major lost opportunity to significantly reduce future ill-health and care costs, especially given the existence of robust evidence-based strategies. Without adequate investment in prevention in Victoria (and throughout Australia), we will continue to constantly fight a tide of oral disease with inadequate resources that is ultimately produced by a funding formula which privileges treatment over prevention.
Further, evidenced-based clinical and non-clinical health promotion initiatives, including the expansion of fluoride varnish programs and modification of output-based funding formula offer high-impact, low-cost opportunities to address poor oral health.
Short-term Recommendations to Increase Investment in Oral Health Prevention:
Expand Water Fluoridation in Rural Victoria to Three Further Towns in 2024-25:
- Water supply fluoridation is a stand-out cost-effective strategy, yet the Government estimates 12% of Victorians are not covered, with high impact on individuals and future system costs.
- It has been estimated that fluoridation has saved the Victorian community about $1 billion over a 25-year period through avoided costs of dental treatment and days absent from work and reduced hospital admissions for young children.1
Amend the Funding Formula for Care (DWAUs) to Enable more Strategic and Effective Preventive Clinical Approaches
- This would include initiatives such as targeted fluoride varnish programs to adults, for example the ‘Heal and Seal’ Program.
- There is strong evidence that the application of fluoride varnish or silver fluoride to children’s teeth has positive protective benefits, leading to lower use of oral health services.2
Ensure a Minimum 5% of Dental Health Expenditure Flows to Evidence-Based Disease Prevention and Health Promotion
- Change funding allocations to ensure a minimum 5% of ongoing dental health expenditure flows to evidence-based (non-clinical) disease prevention and health promotion, in line with the targets set by the National Preventive Health Strategy.3
- Promote lower sugar intake.
- 105 countries have now introduced taxes to reduce consumption of sugary drinks.4 Although the introduction of a tax is a Federal matter, Victoria could both be encouraging the national government to introduce such a tax, and investing in health promotion activities that address sugar intake and start exploring other initiatives (including a floor price such as applied in some places to alcohol).
- Scale up evidence based preventive behaviour programs
- At the individual level, regular hygiene routines such as tooth brushing and flossing are highly effective very low-cost preventative measures, crucial in an era when total sugar content in foods has risen significantly. This has had strong impact on levels of oral disease but also on diabetes and obesity. Whilst Smiles 4 Miles, Healthy Families, Healthy Smiles and Lift the Lip programs have been very successful programs for children under five and pregnant women, 1 not all have been scaled up to cover more children. Nor have similar age and culture appropriate programs been widely funded.
Expanding Fluoride Varnish Application to Broader Population through Diverse Health Practitioners
- Build on the recently announced program for Indigenous children to expand types of practitioners who can apply fluoride varnishes (mainly Aboriginal and Torres Strait Islander health practitioners) to the broader population using dental assistants, nurse practitioners and other health professionals.5
2. Insufficient workforce in the public system
Despite the availability of many unused dental chairs around the state – (see Appendix A), ongoing workforce shortages prevent their use despite high demand. Many public oral health services report struggling to recruit a sufficient workforce, especially in rural areas. Anecdotal evidence is plentiful, for example, VOHA understands that the Wimmera and Southern Mallee region of Victoria is critically underserviced – several clinics have no dentists at all. The previous year Sale and Wangaratta had similar long-term problems and Bairnsdale is currently without a dentist.
Fewer staff results in lower rates of available appointments and longer waiting lists. Whilst these shortages are not atypical within the health system currently, the oral health workforce requires recognition and dedicated focus by the Victorian Government to meet current and future demands.
On the Ground Perspectives on this Include:6
“[It has been] extremely difficult to retain good staff, many of the young ones come in to upskill, become very good clinicians and then leave. This is also hard on long term staff who spend time to upskill the younger ones and then have to do so again almost on a yearly basis.” – Senior Dentist at a Metropolitan Melbourne Community Health Centre
“Very difficult to recruit clinicians. We have been advertising all year with hardly any enquiries or applicants”. – Employee at a Regional Victorian Community Health Centre
“Pay is low and not comparative to other states and private practice, [there are] not many incentives to work in public, staff come as new grads and get experience then leave”. – Clinical Head of Dentistry at a Metropolitan Melbourne Hospital
Decline in Public Clinic Dental Workforce: 2018-2022
This decline is illustrated in Table 1 which shows the 12% decrease in FTE oral health staff numbers in public clinics between 2018 and 2022. Whilst there has been a modest (3.5 FTE) increase in OHTs during this time, this is likely related to the increased demand for Smile Squad and not for adults. In any case, this has been nowhere near enough to offset the 42.8 FTE (19%) decrease in dentists. There has been a similarly large decrease in the number of dental prosthetists which directly impacts the denture wait list times.
| DIVISION | 2018 | 2019 | 2020 | 2021 | 2022 | % Change 2018-22 |
| Dentists | 223.6 | 207.8 | 195.8 | n/a | 180.8 | -19% |
| Dental Therapists, Oral Health Therapists and Dental Hygienists | 129.2 | 128.6 | 104.4 | n/a | 132.7 | 3% |
| Dental Prosthetists | 27.4 | 28.6 | 24.1 | n/a | 22.1 | -19% |
| Total | 380.2 | 365.0 | 324.3 | n/a | 335.6 | -12% |
Uncompetitive Remuneration Affecting Staff Attraction and Retention in Victorian Public Oral Health Sector
A key factor is the inadequate and uncompetitive remuneration rates of Victorian public sector oral health staff in comparison to private sector and other states. This does not support the attraction and retention of key personnel. Examples include:
- Public sector dentists in Victoria are paid up to 28 percent less than for the same role in NSW (NSW $99k – $185k vs Victoria $77k – $168k), oral health therapists up to 27 percent less and dental assistants up to 14 percent less
- Private sector salaries are considerably higher than in the public sector (e.g. hourly rate for private dental practitioners is $53 – $58 compared to $30 – $46 in the public sector)7
- Graduates’ significant HECS debts are a disincentive to seek lower-paid public employment.
Short-term Recommendations to Build the Capacity of Oral Health Workforce:
Creating Rural Student Pathways for Training and Regional Employment
- Negotiate with and support relevant universities to develop pathways for more rural students to gain access to relevant training and later employment in the regions.
- The socio-demographic profile of students gaining entry to tertiary courses does not fit easily with current or future demand for rural practitioners, or even with the client population that public clinics serve. New training pathways are required.
Expanding Clinical Professional Development for Rural Workforce Due to Limited Specialist Access
- Increase access to clinical professional development among the rural workforce, especially given their typical broader scope of practice demanded due to less specialist accessibility.
- Public sector dentists in Victoria are unable to work to full scope of practice in which they are trained and are competent. This is influenced largely by rising costs, inadequate funding, and demand pressures including for emergency and general dental care that well exceeds capacity.
Graduate Year Program for Structured Entry into Public Dental Sector
- Strengthen graduate year programs for structured entry pathway into the public dental sector.
- Redesign the Voluntary Graduate Year Program
Plan for a Sustainable Workforce
- Develop a workforce strategy that addresses critical shortages in dentists, oral health therapists, dental prosthetists, dental assistants, and dental technicians especially addressing recruitment and retention issues in regional and rural Victoria, as well as mental health and wellbeing of oral health workers generally.
- A 2023 report8 found that 32.0% of dental practitioners are currently experiencing moderate to severe psychological distress, with one in four participants (24.8%) classified as likely to be experiencing burnout. These results were even more profound in public sector practitioners.
3. Limited access to dental care means very significant inequity
There is very significant inequity in access to oral health care in Victoria. Private dental care is relatively expensive as it is not covered by Medicare. Hence consumers nationally pay at least 60% of the total costs of dental care (compared to 17% for primary medical care).9 This makes access to low-cost public care vital for 2.5 million eligible Victorian children and adults. Whilst the Victorian Government has invested in children’s oral health through Smile Squad, adults are still relatively neglected. The 1.5 million Victorian adults who are eligible for public care (and not in a priority group) remain severely disadvantaged with funding only allowing care once every seven years on average – a period wildly outside any clinical guidelines.
One of these particularly vulnerable cohorts is older adults, who may face additional challenges due to mobility issues, chronic conditions, and financial constraints. More than 220,000 Australians live in residential aged care, and many more receive assistance to live at home. For too long, the most basic oral care needs of these residents have been neglected.
Average wait times for general care as of June 2023 (remembering 50% of clients waited longer than these figures):
| Service Provider | Average Wait Time |
| South West Healthcare | 38 months |
| Sunraysia Community Health Services | 32 months |
| Latrobe Community Health Services | 30 months |
| Bass Coast Health | 25 months |
| Maryborough District Health Service | 25 months |
| Bairnsdale Regional Health Service | 23 months |
| Service Provider | Average Wait Time |
| North Richmond Community Health | 44 months |
| Merri Health | 28 months |
| DPV Health | 25 months |
| Inspiro Community Health Service | 24 months |
| Service Provider | Average Wait Time |
| North Richmond Community Health | 47 months |
| Maryborough District Health Service | 36 months |
| Latrobe Community Health Service | 35 months |
| Inspiro Community Health Service | 35 months |
Note that Victoria has the second-highest median wait-time in the country, and around 60% longer than NSW.10
A Vicious Cycle
For the majority of patients, the waiting times quoted do not include the 12-month wait after their last treatment before they can go back on the list. So, 36 months can in real terms be upwards of 48 months for patients to continue regular care. Lengthy waits mean many dental problems get worse with sometimes lasting impacts on a patient’s oral and general health. This often means more emergency appointment are required (many services use more than 50% of clinic appointment times for these) instead of for people on the waiting list.
Short-term Recommendations for Investment to Ensure Vulnerable Victorians Can Smile Again:
Aligning Outsourced Dental Services with DVA Fee Schedules and CPI-Adjusted DWAU Rates
- Align any outsourcing of dental services with the relevant DVA fee schedules (the lowest acceptable benchmark for dental services), i.e. increase DWAU rates for managing these, and increase annually by CPI.
- Note the post-Covid catch-up funding made very high use of the private sector, as well as public. The former was typically funded through a voucher, tied to DVA rates. Public services are increasingly finding private practitioners unwilling to offer care at these rates which are falling behind costs.
Review of DWAU Funding Formula for Complexity in Public Care
- Review the DWAU funding formula to better reflect the increasing complexity of client situations encountered in public care
- Practitioners report an increasing complexity in their work, both clinically and socially. The DWAU funding formula does not adequately reflect this creating financial sustainability pressures on providers
Medium-term Recommendations for Investment to Ensure Vulnerable Victorians can Smile Again
Five-Year Strategy for $40M Annual Investment to Doubling Care Access by 2030
- Commit to commence in 2025-26 a five-year strategy to increase investment by a further $40 million each and every year to double the target number of disadvantaged and vulnerable Victorians completing care by 2030, i.e. ensuring that 750,000 more Victorians will have access to essential dental care.
New Model for Sustainable and Timely Dental Care for At-Risk Victorians
- Develop a new model that supports the effective, efficient, and financially sustainable delivery of services to ensure Victorians have access to timely dental care, especially key at-risk population groups including Victorians living in aged care facilities, and refugees and asylum seekers.
References –
1. Rogers J, Roberston J. Looking Back Looking Forward – Oral health in Victoria 1970 to 2022 and beyond. University of Melbourne; 2023. https://doi.org/10.26188/23721969.v1
2. Nguyen TM, Tonmukayakul U, Warren E, Cartwright S, Liew D. A Markov cost-effective analysis of biannual fluoride varnish for preventing dental caries in permanent teeth over a 70-year time horizon. Health Promot J Austr. 2020 Apr;31(2):177-183. doi: 10.1002/hpja.283. Epub 2019 Aug 27. PMID: 31373066; PMCID: PMC7187475.
3. Department of Health. National Preventive Health Strategy 2021-2030: Government of Australia; 2021.
4. Hattersley L, Mandeville KL. Global Coverage and Design of Sugar-Sweetened Beverage Taxes. JAMA Netw Open. 2023 Mar 1;6(3):e231412. doi: 10.1001/jamanetworkopen.2023.1412. PMID: 36988952.
5. Premier of Victoria. Delivering preventative dental care for Aboriginal children. 2023. Accessed Oct 30 2023. https://www.premier.vic.gov.au/site-4/delivering-preventative-dental-care-aboriginal-children
6. Australian Dental Association Victorian Branch. 2023 Data Collection Survey for Victorian Senior Public Dental Staff.
7. Stormon NL, Tran C, Suen B. Australian Oral Health Workforce. University of Queensland; 2021. ISBN: 9781742723501, and comparison of staff rates by cohealth
8. Hopcraft MS, McGrath R, Stormon N, Parker G. Mental health, psychological distress and burnout in Australian dental practitioners. Aust Dent J. 2023 Sep;68(3):160-170. doi: 10.1111/adj.12961. Epub 2023 May 18. PMID: 37199455.
9. Australian Institute of Health and Welfare. Health expenditure Australia 2016–17. AIHW, 2018.
10. Oral Health and Dental Care in Australia. Australian Institute of Health and Welfare, 17 March 2023, https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and-dental-care-in-australia.
11. Questions on Notice No. 460. Parliament of Victoria. Acessed Oct 30 2023. https://www.parliament.vic.gov.au/publication-research/questions-database/details/53/20341
APPENDIX A: Wasted Infrastructure – Dental Chairs Sitting Empty
The pervasive issue of chair underutilisation in Victoria’s public dental system continues to be a major issue of concern, leading to inefficient use of resources and decreased accessibility for patients. There is an immense discrepancy between the number of available dental chairs and the limited total effective full-time staff (EFTs) of dentists and oral health therapists able to fulfil the demand for services. Dental chairs too often sit empty while the waitlists of patients in need of services continue to grow considerably. As per Question on Notice No. 460 issued to the Victorian Parliament on the 17th of May 2023, the government has confirmed that the entire Victorian public dental service is operating at an estimated 52.5% capacity. 11 This problem is often more pronounced in rural and regional areas of Victoria, where clinics often possess adequate physical dental infrastructure, but the absence of working practitioners in large geographic areas becomes a significant barrier to care, requiring residents to travel long distances even for emergency treatment. The widespread issue of chair underutilisation is one of the starkest outcomes of the staffing challenges facing public dental services, highlighting how Victoria has failed to attract and retain public sector clinicians thus resulting in a system that neglects the oral health of our most disadvantaged populations.
Victorian Oral Health Alliance 