Health Committee on March 10th, 2015

[James Lunney, Conservative, Nanaimo—Alberni, BC]

You mentioned a study on advanced diagnostics like MRI and a $25-million saving. Could you tell us more about that study? Where did that take place?

[Dr. Ward MacDonald]

There's one model in Alberta which is the spinal health centre. It was an idea that started, like with many great ideas, over a beer.

A chiropractor and his two neurosurgeons were sitting around complaining about their workload. The neurosurgeons said they had a stack of faxes on their desk this thick of referrals from medical doctors for patients that have back pain and leg pain, and they knew most of them did not need surgery, but they still had to see them.

They set up a triage system where patients could be assessed prior to coming in to see the surgeon so they wouldn't have to wait two years to be told they don't need surgery and they needed to go somewhere else. The doctors were able to turn things around within weeks of seeing the patient, getting them the care they needed properly.

The patients are happy because they are getting care quickly and getting relief quickly. The doctors are happy because the patients they are seeing are high-yield patients that give them good outcomes as well. The cost of this more conservative approach was enjoyed by all.

As chiropractors we are trained as primary care practitioners, and while 95% of aches and pains that come into my office are mechanical in nature, we are still trained to pick up on the other 5% that are not, that are more serious and need a proper referral. This is where our training to be able to recognize these things and work with other providers within the community is important.

Patients trust us as well. We build a relationship with them so they will come to us with their health questions. If we don't have the answer, to have the network of supporting professionals around us allows us to serve them better.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Mr. Chair, can I ask a question that they could send us some information on very quickly?

[The Chair, Conservative, Ben Lobb]

Briefly....

[James Lunney, Conservative, Nanaimo—Alberni, BC]

You mentioned about triage with chiropractors and advanced practice physiotherapists doing triage ahead of time in several provinces. Could you at least send us some information on where that's happening, and which provinces, and whatever information you have on that?

[The Chair, Conservative, Ben Lobb]

Thank you, Mr. Lunney.

It's little bonus round today for you with the chiropractors in town.

Ms. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Mr. Chair. I want to thank the witnesses for coming today.

We're talking about scope of practice here, and as you all know the big question today is: is medicare sustainable? But it shouldn't be “is medicare sustainable?” It should be: is the delivery of health care going to be sustainable under a public system?

I think we're looking at how we shift the system, change it completely, so that chronic care and chronic management is done by community groups in a multidisciplinary integrated system.

I heard the chiropractor saying they could work in that system, and the thing is that they should be able to work in that system as we look at how we do a lot of prevention and promotion, and then move into care when somebody is sick, and then chronic management of care as they get older.

The question I have is not for you because I know you are capable of being integrated into that. My question is to the dentists and the dental hygienists because currently one of the things we know is that poor oral health leads to heart disease, etc. It's now been found to have that strong link between oral health and illness, chronic disease, etc.

I know that dentists and hygienists, although in certain sectors you are capable of working within the system, are in a private system mostly, except in certain areas like the north. Do you see a role for dentists and for dental hygienists to play within their scopes of practice, working within this multidisciplinary system? How do you see that happening?

It would mean the dentist in many places would have to move out of private practice—well, not private practice because many practitioners provide private practice out of the public system, but out of the private system you currently work in and into a publicly administered system of care.

How do you see that happening? Do you think that's feasible? We could then be able to work on getting to young children earlier, getting to dentureless seniors earlier. How do you see that working? How do you see that integrating itself into a system that would mean a huge systemic change here for the way you practise?

[Dr. Benoit Soucy]

There's no doubt dentistry is practised in isolation from the rest of the health system, but there are some very significant interfaces where dentistry is practised within the health care system.

This area is mostly in two specialties, and the two specialties need surgical facilities to do their work. Oral maxillofacial surgeons and pediatric dentists practise largely in hospital settings. Depending on the province, some of their services are covered by provincial medicare programs.

There's a lot of variability at that level, and there are some contradictions. If you go to the hospital in Quebec to have your wisdom teeth taken out, it will be covered by RAMQ. If you get that in a private office, it won't be. The same service, different setting, different coverage.... That is something we've learned to deal with and to manage to the best of our ability.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Sorry, Dr. Soucy, you're talking about acute care hospital care, and I think the thing is that it's moving out of the acute care hospital care system into chronic management and early intervention or early prevention.

Do you see your scope of practice broadening to fit into that area through a public administrative model?

[Dr. Benoit Soucy]

You talked about the correlation between a lot of periodontal disease and general health, systemic health, and that is forcing us into those areas. The model of care is changing within dental offices so that instead of treating only acute problems, we're treating chronic problems. We're following patients. A lot of times patients will come twice a year to dental offices. In one visit they will see the dentist to get a diagnosis. The second time they won't even see the dentist. They will work with the hygienist and receive the care they need at that level to maintain the situation that has been diagnosed. Those things are happening.

The only thing that is problematic, that is difficult, is how you move that into a public setting. The private part works extremely well for a large number of Canadians, so you don't want to disturb that. You just want to make sure that those who do not have access get access appropriately through targeted programs that look at their needs specifically and try to improve them and help them to receive the care they need at the time they need it.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I would like to see if we could explore that as we move through this, because, as you well know, physicians and chiropractors and a lot of health care providers actually run private practices even within...because the system is public administration, not public delivery. The thing is that if you wanted to move dentists into an integrated system, obviously there would be professional push-back. Come on—that's just reality. But how would you see that happening if, say, we started by saying that all children up to the age of seven could be moved into the public system? How would that work? How would dentists react? As we look at seniors care, would dentists see themselves automatically moving into an integrated system for seniors care?

[Dr. Benoit Soucy]

We actually used to have that for children. When I grew up in Quebec, children under the age of 18 were all covered by RAMQ, and we got very good care. Saskatchewan was the pioneer in that area. It was also the first to cut back on its program. One of the impacts we see is that we're going back to levels of cavities in children that were seen before those programs existed.

I don't think you would get too much push-back with regard to programs targeted at children, because we have experience with those and we know they work.

Seniors are more problematic, and the reason they're more problematic is that we are too successful in our work. We're keeping teeth in the mouths of those seniors for a long time, and when they retire and lose their employment benefits, they end up with a lot of teeth that require a lot of care and they have no coverage of any kind. We haven't found a good way to address that problem.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Can I get a quick one-two from the hygienist? I know I talked to you about this, but go ahead.

[Ann Wright]

We have a little bit of a different perspective on this. Certainly it's not a human health resources numbers issue with dental hygiene. As I said, there are 26,000 dental hygienists in Canada, so there are a lot of dental hygienists who wish to practise in all different areas.

The issue for dental hygiene has been awareness of what we do and what we can do, and with the rise of self-regulation, meaning dental hygienists are self-regulated, we have the opportunity now to work interprofessionally, and we want to work interprofessionally in public health, in hospitals, and in interprofessional groups.

The issue is informing the people who are the decision-makers that we are a great group to include in these programs. What I outlined in my oral presentation had to do with family violence, because 50% of injuries associated with family violence occur in the head, neck, and face. Who better to recognize something than your trusted dental hygienist, who you see on a friendly basis in more cases than not?

As I said, we are very proud to have been invited to the minister's round table.

[The Chair, Conservative, Ben Lobb]

Thanks very much.

Ms. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you. I too would like to thank all the speakers for coming here today.

I'm actually going to pick up on some of the discussion around dental care and the dental hygienists.

Dr. Soucy, you said the dental therapist program is not being funded anymore. Is it still in place, and how long is that program?

[Dr. Benoit Soucy]

There are about 200 dental therapists who are still practising in Canada. The majority of them are practising within dental offices in Saskatchewan and Manitoba, and they're providing care to children.

There is no longer a training program for new therapists, so we expect that number will go down over the next few years.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

What my question is, and this is where I perhaps can talk to the hygienists because we know up north we have the significant issue that dental therapists used to provide some good support in a northern community. What was within the scope of a dental therapist? You have a great scope of practice. Are there things in the scope of a dental therapist that are not in your current scope that could be easily attained? Is this where we should be doing a bit of thinking about a shift? I'll let both of you respond.

[Victoria Leck]

That's a great question.

Actually, the federal government released a great report in 1971, the ad hoc report on dental auxiliaries. You may want to dig that out of the archives and take a look at it. They talked about this very same issue, about access to care for vulnerable populations and making equitable access for all Canadians. The recommendation from the committee at that time was that dental hygienists' scope of practice could be expanded to include some further opportunities for them to intervene.

There was a program where dental hygienists in the military, after a certain number of years, were eligible to go back and receive additional training and become a dental therapist. This model is also being used in other jurisdictions around the world where they have dual designation as a dental hygienist and a dental therapist, similarly to a nurse practitioner going back, after becoming a nurse, for additional training to become a nurse practitioner. A similar model has been used elsewhere for dental hygienists to become dental therapists, to have the dual designation.

But there are some things that are in our current scope of practice that we can do to intervene and to provide temporary relief of situations where there is no dentist available. An expanded scope of practice for dental hygienists could be considered.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

I understand the dental association—

[Dr. Benoit Soucy]

The scope of practice of an oral health care provider is essentially divided into three tiers.

Dental assistants and dental hygienists can provide care that is reversible. Any act that is reversible can be done at that level according to the regulations. Obviously, assistants have a very restricted scope of what they can provide directly on patients. Hygienists have a much broader scope, but the services they are providing are essentially reversible.

Dental therapists are intermediate mid-level providers because they can do irreversible services. They can do simple extractions. They can do restorations. They can remove dental material to do restorations.

The thing that none of these groups can do outside of Alberta—Alberta is a bit of a special situation—is diagnosis. Only the dentist can provide the whole meal deal providing the restoration, doing the irreversible acts, and base the care on a diagnosis that has been done of the patient.

That's really where you have the difficulty moving from one scope to the other.

In order to be able to do reversible acts you have to have a certain type of training. In order to do the diagnostic you have a certain type of training that is based on a lot of fundamental basic science courses that are not necessarily provided to the other occupations. That's where the transfer becomes difficult. There is no doubt that the hygienist who goes back to dental school, gets a lot of credits, and can go through dental school easily because they have some of the work that was done before, but they still need to learn all of those additional skills.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

I think we talked about our northern populations and how there is a lack of care. We talked about a pretty big pool of practitioners who could do great work in those settings. What would it take to move to that therapist level? I would think it would be a much simpler program than the dental therapy program as it did exist.

[Ann Wright]

We've just completed a bachelor of competencies for degree-entry practice for dental hygiene across Canada. That's something that we feel very strongly about with changes in technology, changing with what dental hygienists do.

I'm glad you mentioned dental therapy because that's the primary reason that we are now working with the Nunavut program, because there are no dental therapists who work in Nunavut and there were almost no dental hygienists working up there. This was, again, a very innovative program to bring dental hygiene up to Nunavut. As I said, we only have a year under our belt but the preliminary results are very encouraging for what we do.

Just to correct Dr. Soucy a little bit, dental hygienists do communicate a dental hygiene diagnosis, they don't complete a complete oral diagnosis.

[The Chair, Conservative, Ben Lobb]

Thanks very much.

We're going to suspend for a minute or two. We're going to excuse our guests and bring in our next panel.

[The Chair, Conservative, Ben Lobb]

Welcome back, ladies and gentlemen. We're back in session. We have three more guests to present this afternoon.

We have the Canadian Association of Occupational Therapists, Canadian Physiotherapy Association, and the Paramedic Association of Canada.

First up is going to be the Canadian Association of Occupational Therapists.

Ms. Guitard, you have 10 minutes.