February 17, 1999

To:Board of Health

From:Dr. Sheela Basrur, Medical Officer of Health

Subject:Dental Complement in Public Health

Purpose:

This report is in response to the Budget Committee's concerns about the need for dentists to manage the City's dental programs and the proposed dental management structure in the amalgamated Toronto Public Health Division.

Source of Funds:

Not applicable.

Recommendation:

It is recommended that the Board of Health adopt and refer this report to the Budget Committee for information.

Background:

During recent discussions on the physician complement in Public Health, Budget Committee requested that Public Health report back on the need to have dentists manage the City's dental programs, the need for the proposed complement of dental managers in the revised organizational structure for Public Health, and the feasibility of clinical dentists absorbing management functions as part of their duties.

Comments:

Management structures for dental programs in former municipalities evolved in response to the scope of dental programs and the availability of resources. The varying levels of dental services provided across the former municipalities has resulted in marked disparities in the number of management positions, the level of these positions in the organizational structure and the span of control. The one common factor across all former municipalities is that all dental managers, supervisors and coordinators ultimately reported to a dental director who was a dentist trained in public health. The presence of a dentist trained in public health at the management level in the former jurisdictions speaks to the recognition by former governance bodies of the need to have dentists manage dental programs. This ensured compliance with the Health Protection and Promotion Act and the provision of appropriate leadership in program development, evaluation, and service delivery. Also noteworthy is the wide range of spans of control in the former health units from a low of 1:1.6 up to 1:30 (management: staff).

In 1998, the Public Health Division undertook a review of all existing management structures in the former municipalities. The process was facilitated by an outside consulting team (The ARA Consulting Group and Western Management Consultants) supported by a team of internal consultants. The information gathered was used to design the new single Public Health organization at the senior management level, in particular at levels 4 and 5, which was approved by the CAO in June 1998.

The new management structure for the City's dental programs represents a decrease in dental management of 58% from 1997 - 1998 (e.g. from 10.34 FTEs to 6 FTEs). This reduction is a direct result of amalgamation and reflects a delayering of the dental management structure in some of the former municipalities and a consolidation of management functions.

Elimination of the non-dentist management layer and increasing the span of control of some dental managers capitalizes on efficiencies that can be gained through amalgamation. The span of control for the dental program across the City will now be 1:19 (management:staff). This is considerably higher than the average ratio of 1:10 recommended initially by the CAO. In addition, there is no designated dental director position in the new Public Health organization. Dental managers now report to the Regional Directors.

Organization of Dental Services in Public Health

Currently, the City of Toronto Dental Program components are as follows:

(a)Dental Screening and Education Programs in the schools

(b)Dental Treatment Programs in four of the six former municipalities

(c)Management of the mandatory Children in Need of Treatment Program (CINOT)

(d)Clinical Prevention Programs for children

(e)Dental Screening, Clinical Prevention and Education Program for Seniors in Collective (CLC's)

(f)Co-supervision and coordination of Dental Students/Hygienists etc. on field placement

(g)Management of the Ontario Works Dental Program on behalf of the Social Services Division

(h)Monitoring of fluoride content of municipal water and flouride exposure from all sources to the general population

(i)Program Evaluation

(j)Involvement in Corporate Initiatives

Currently staff provide:

(a)5,350 presentations to over 83,000 people

(b)8,410 dental hygienist assessments

(c)167,541 screenings

(d)27,193 dental indices survey recordings

(e)55,831 preventive services (17,675 oral hygiene instructions, 11,355 topical fluorides, 10,882 sealants, 13,607 cleaning of teeth, 2,312 denture cleaning and 10,720 scaling of teeth under periodontal services

(f)18,812 diagnoses

(g)19,775 radiographs

(h)47,119 restorations

(i)2,435 root canal services

(j)7,628 surgical services

(k)1,438 denture services

(l)2,953 miscellaneous services

Supervision of Hygienists

Some of the above services are provided by hygienists (e.g. screening and preventive services). However, it is a legal requirement that the hygienists receive orders from a dentist for those acts that are controlled under the Regulated Health Professions Act (e.g. subgingival scaling, application of sealants). Therefore, for the dental hygienist to legally perform these services, as required under the Mandatory Program Guidelines, supervision by a dentist is required. It is more cost-effective to utilize paraprofessionals to provide these services. Where appropriate, this is the model of service delivery utilized by most public health units to fulfil mandatory program requirements.

Management of Clinics and Clinical Staff

It is also the legal requirement of the Royal College of Dental Surgeons that dentists take clinical direction from a dentist. To fulfil this requirement, those municipalities with treatment programs need managers with dental expertise to protect the municipality from liability with respect to implementation and monitoring of infection control guidelines and procedures, quality control, evidence-based treatment planning, development and maintenance of medical emergency procedures, prescription of medicines, identifying appropriate facilities for referral of those clients who cannot be successfully treated in Public Health facilities, management of patients with complex medical histories, purchasing of appropriate dental materials, dental supplies and dental equipment with respect to both quantity and quality, security of personal and medical information, calibration of hygienists, and performance reviews. Dental managers also monitor staff productivity for quality and quantity of service provided and ensure that dental staff maintain clinical competency.

Management of Children in Need of Treatment and Ontario Works Dental programs

It is required by the Ministry of Health and Ministry of Social Services, that both the CINOT and Ontario Works dental programs are managed by a dentist. This is because many services and treatment plans require predetermination and in the case of the CINOT Program some services require post-treatment evaluation prior to payment. Predetermination and post-evaluation of dental services requires the diagnostic skills of a dentist. There is also the need to have dental expertise to respond to private dentists' enquiries about available treatment options for clients.

Other management functions requiring the expertise of a public health dentist include:

(a)assessment of the oral health needs of specific populations

(b)design, implementation, evaluation and modification of dental programs

(c)ongoing development and upgrading of treatment methodologies, ensuring the use of evidence based treatment, including HIV infection and asepsis procedures

(d)development of appropriate continuing education courses to ensure that practitioners are current in their knowledge of the practice of dentistry

(e)research and policy analysis

(f)design of data collection and program evaluation methodology

(g)community liaison with school principals and parents, CLC administrators, Social Services professionals

Clinical Dentists Absorbing Management Functions

The Budget Committee also enquired about the feasibility of clinical dentists absorbing dental management functions in addition to providing clinical services. An analysis of this option reveals its ineffectiveness and inherent inefficiencies.

If clinical dentists are required to do management functions, this would place additional demands on their time resulting in dentists having less time to devote to providing clinical services to the public. To offset this loss in service, more clinical dentists would have to be hired. Management roles and functions would be fragmented, resulting in a loss of efficiency and consistency in management and increased potential liability to the City.

The responsibilities of dental managers include adjudication of claims. If clinical dentists are required to adjudicate their own claims, or that of their colleagues, then they would be in conflict of interest. Divided attention between clinical services and administrative duties could impact negatively on the quality of clinical service.

It is worth mentioning that in former City of Toronto this model of management was previously in use and resulted in waste of resources due to extensive over-ordering of dental materials and inefficient delivery of dental services i.e over 40% of patients seen had no dental disease. Because of these inefficiencies, the dental program was re-organized from a school based to a community based program and the program expanded to include services to ESL youth and a preventive clinical program for institutionalized seniors. In addition to expanding the program at no added cost, the reorganization which was managed by the dental director, saved the City $105,576. This example speaks to the benefit of having dedicated leadership for the dental program.

In the East Region (formerly Scarborough and East York), this option is not feasible as there are no clinical dentists employed in the dental program. In the North and West Region, clinics are staffed by part-time dentists and so the incorporation of management functions into their duties would reduce their efficiency. In addition hygienists who work full days would be without supervision for part of the day. In the South Region the clinics are operating at full capacity, and so there is no time for clinical staff to absorb management functions.

Conclusions:

Given the scope and complexity of the current dental programs and the need for dental expertise in management, it was the recommendation from the ARA consultants that instead of having two layers of management in the dental program, there be one layer of management with responsibility for all management functions including those that require the expertise of a dentist.

The recommended complement of six dental managers is based on the current staff FTE complement of 118.2, as well as the volume of work and the current level of service across former municipalities. All regions except for the former City of Toronto, where the management to staff ratio is 1:30, will experience reduced management support. It is anticipated, however, that the productivity and efficiency of service delivery will be enhanced through standardization and consistency in practices.

Contact Name:

Dr. Hazel Stewart, Regional Director, Toronto Public Health

Tel: 392-0442

Fax: 392-0713

Dr. Sheela V. Basrur

Medical Officer of Health