Thank you, Mr. Chair.
Good afternoon, everyone. I'm Benoit Soucy the director of clinical and scientific affairs at the Canadian Dental Association. Kevin Desjardins is the director of government relations.
It's our pleasure as the national representatives of Canada's dental profession to participate in your study of best practices and federal barriers related to the scope of practice and skill training of health professionals. There are more than 18,000 dentists in Canada. All are licensed by a provincial or territorial authority. Thanks to the work done in relation to chapter 7 of the Agreement on Internal Trade, all can move between Canadian jurisdictions without any need to have their professional competencies retested.
The majority of dentists work in private offices, either as solo practitioners or with one partner. The largest practices in the country can involve as many as as 30 to 40 dentists. Independently of their practice setting, all dentists involved in the delivery of oral health care in Canada share an important characteristic. They could not provide services to their patients at the same level of quality and as efficiently without the support of a dental team where each individual has a clearly defined role to fulfill.
Some members of the dental team, such as receptionists and practice managers, are completely unregulated because they are not directly involved in patient care. Others, such as assistants and dental hygienists, are regulated under models that vary from province to province and that in many cases provide for independent self-regulation, placing these occupations outside the purview of dental regulators.
In addition to these members of the dental team, three other occupations are involved in the delivery of oral health care in Canada: dental technicians, who are mainly involved in the fabrication of devices used by dentists in the treatment of their patients; denturists, whose scope of practice is related to the independent delivery of removable prostheses to those who are partially or completely missing teeth; and dental therapists, who are trained to deliver limited restorative and surgical services under the direct supervision of dentists.
Of these occupations, dental therapy is likely the one that has the most relevance to the work of the committee. Outside of Ontario and Quebec, where they are not allowed to practice, dental therapists have been used to improve access to care for children and for remote populations. In many cases they have been employees of the federal government working for the first nations and Inuit branch of Health Canada.
The National School of Dental Therapy, NSDT, was created in 1972 operated with funding from Health Canada until 2011 when the funding was discontinued. This was done because, in spite of its ongoing funding of the NSDT, Health Canada had chronic difficulties filling the positions it had available to serve first nations and Inuit living in remote areas, as the graduates of the program preferred working in urban dental offices in Saskatchewan and Manitoba, the two provinces where they could get licensed to practice.
The failure of the NSDT program to provide access to care in areas where it was intended does not mean that such results cannot be accomplished through actions related to scopes of practice. As mentioned above, dentists rely on the presence of dental assistants and dental hygienists in their offices to deliver quality care efficiently. Changes to provincial regulations, such as the introduction of scaling modules that allow an assistant to provide that service in provinces experiencing a shortage of dental hygienists, continue to improve the dentist’s ability to do so.
The presence of dental therapists in Saskatchewan improved access to care for children while economic evaluations of the federal program have demonstrated that dental therapy is a cost-effective means of providing care to children under specific circumstances. Outside of Canada, the use of dental therapists in New Zealand and Australia has been a success while preliminary evaluation of the impact of their use in Minnesota showed benefits that included direct costs savings, increased dental team productivity and improved patient satisfaction.
To achieve those positive results, these programs had to limit the new providers' ability to perform independently in the private system. Evidence has shown that, in many cases, the availability of additional types of providers will not reduce care prices or improve access to remote regions. They had to find ways to address the fact that dental fees in public programs do not meet the minimum amounts that are required to keep practices solvent, especially in remote locations with low population density. This was done by defining scopes for new providers in a fashion that allowed for reduced training times and reduced cost to the system, and by making the new providers salaried employees restricted to work in certain health settings to ensure they went where they were needed most.
In addition, successful programs provided sufficient, stable funding and managed to maintain the cost savings related to the reduced training time through careful management of the new providers' scope of practice over time.
Based on the experience of the programs discussed above, the Canadian Dental Association sees the following as best practices in relation to the scope of practice and the training of health care providers.
Only regulate occupations where the risk to patients justifies the cost of regulation.
Support regulation at the provincial levels with national systems of accreditation of educational programs and of certification of individuals to promote labour mobility.
Design scopes of practices for each of the involved occupations so they fulfill a real need and contribute to the safe and efficient delivery of care.
Identify all of the factors that could impact the success of new models for the delivery of care before they are implemented and put in place strategies to mitigate them. Such strategies will usually include reducing training time and costs to the system, preventing changes of scopes of practice that erode these savings, limiting the practice settings available to the new provider groups, and hiring them on a salaried basis to ensure they practice where they are needed.
I hope this short review of the experience of oral health care, with attempts to improve access to care through the introduction of new occupations and the broadening of the scopes of practice of others, will be useful to your work.
I thank you for your attention and will gladly answer any questions you may have.