Board of Health
November 15, 1999
To: Policy and Finance Committee
From: City Clerk
Subject: Management Structure for Public Health Dental Services
Recommendations:
The Board of Health recommends the adoption of the joint report dated November 4, 1999, from the Medical
Officer of Health and the Commissioner of Community and Neighbourhood Services, subject to amending
Recommendation No. (4) by deleting the words "if this model is approved by Council", so that such
Recommendation reads as follows:
"(4) the Medical Officer of Health work with the Human Resources Division to conduct an executive search to
recruit a qualified Dental Chief/Advisor at the earliest possible date".
Background:
The Board of Health on November 15, 1999, had before it a joint report (November 4, 1999) from the Medical Officer of
Health and the Commissioner of Community and Neighbourhood Services recommending that:
(1) Option (4) as outlined in the report of the Berkeley Consulting Group be adopted as the model for restructuring the
dental management complement in Public Health. This model includes seven FTE managers, three of whom are dentists,
with one assigned as the Dental Chief/Advisor at a total cost of $635,665.00;
(2) given the scope and complexity of the school dental program and the increased volume resulting from the expanded
dental program, an additional program co-ordinator position be added to support the managers responsible for the
mandatory programs in schools at a cost of $64,260.00, this position being critical to support the recommended
management structure;
(3) this report be referred to the Budget Advisory Committee for consideration during the 2000 operating budget process;
(4) if this model is approved by Council, the Medical Officer of Health work with the Human Resources Division to
conduct an executive search to recruit a qualified Dental Chief/Advisor at the earliest possible date; and
(5) the Medical Officer of Health report annually to the Board of Health over the next two years on the accomplishments
and outstanding issues in the dental program, including those related to the management structure (and its complement of
dentists), along with recommendations for improvement.
Mr. Jim Mackay, Managing Partner, and Ms. Julia Scott, Associate Consultant, The Berkeley Consulting Group, gave a
presentation to the Board of Health in connection with the foregoing matter, and submitted a copy of their presentation.
City Clerk
Trudy Perrin/lm.12
c. Medical Officer of Health
Commissioner of Community and
Neighbourhood Services
(Joint Report dated November 4, 1999, addressed
to the Board of Health and Community Services Committee
from the Medical Officer of Health and
the Commissioner of Community Services)
Purpose:
This report transmits to the Board of Health and the Community Services Committee, the final report of the external
consultants retained by the City regarding options for the management structure for Public Health dental services. This
report should be considered in the context of the review of the expanded municipal non-mandatory dental program and the
review of alternative delivery models for the public health dental treatment program.
Financial Implications and Impact Statement:
The dental management model proposed by the Berkeley Consulting Group represents a $200,000 savings over 1998
immediately post amalgamation. In addition, the model incorporates more lower paid non-dentist management staff
together with a Dental Chief/Advisor. This option separates the management positions for preventive (mandatory) and
treatment (non-mandatory) dental services. Positions dedicated to non-mandatory functions are not cost-sharable with the
Ministry of Health.
In total, the management structure option proposed by the consultants costs $635,665 plus $64,260 required for an
additional program co-ordinator to deal with service volumes and to support the managers responsible for mandatory
programs in schools (see Attachment No. 1). This additional position is critical to support the proposed management
structure. Hence Option 4, the model proposed by the consultants, represents a $40,000 net increase over the current Public
Health budget for dental management. The 1999 approved budget for the dental management complement in Public Health
is $660,195, or 5.4 percent of the total Public Health dental program budget of $12,100,000 (post-expansion).
Finance staff have been consulted regarding this report.
The Chief Administrative Officer has confirmed his acceptance of the recommended option (see Attachment No. 2).
Recommendations:
It is recommended that:
(1) option 4 as outlined in the report of the Berkeley Consulting Group be adopted as the model for restructuring the dental
management complement in Public Health. This model includes 7 FTE managers, 3 of whom are dentists, with one
assigned as the Dental Chief/Advisor at a total cost of $635,665;
(2) given the scope and complexity of the school dental program and the increased volume resulting from the expanded
dental program, an additional program co-ordinator position be added to support the managers responsible for the
mandatory programs in schools at a cost of $64,260, this position being critical to support the recommended management
structure;
(3) this report be referred to the Budget Advisory Committee for consideration during the 2000 operating budget process;
(4) if this model is approved by Council, the Medical Officer of Health work with the Human Resources Division to
conduct an executive search to recruit a qualified Dental Chief/Advisor at the earliest possible date; and
(5) the Medical Officer of Health report annually to the Board of Health over the next two years on the accomplishments
and outstanding issues in the dental program, including those related to the management structure (and its complement of
dentists), along with recommendations for improvement.
Background:
Please refer to the attached report from the Berkeley Consulting Group (see Attachment No. 3).
Comments:
In the 1999 budget process, staff recommendations regarding the dental management structure were accepted by the Board
of Health, but set aside by the City's Budget Committee. Budget Committee's concerns regarding the staff-recommended
model were based on the proposed six management positions all being held by dentists. However, the Committee approved
an increase in funds for dental service harmonization contingent upon an external review of both the number of dentists
required to be in management positions and the number, configuration and qualifications for dental program manager
positions in general. At the same time, Budget Committee imposed a hiring freeze on dental managers.
As a consequence of the hiring freeze, the dental program has been left with a management complement that is highly
stressed and a structure that is not sustainable. Stability and clarity of future directions are urgently needed to restore staff
morale and to fully harmonize public health dental programs on a city-wide basis. Any definitive decision that puts these
outstanding issues to rest will be welcomed at this point.
The management structure recommended by the Berkeley Consulting Group reflects a reduction in the total number of
dentists in management positions from six to three, one of which would be for a two year term, a separation of preventive
(mandatory) from treatment (non-mandatory) services, and centralization of staff into a city-wide dental program (as
compared to a program which is integrated into Public Health's regional structure). Compared to the current arrangement,
the total number of management FTE's would increase from six to seven while the number of dentist managers would
decline from six to three. The total management cost for Option 4 is $635,665 plus $64,260 for an additional program
co-ordinator to support the managers responsible for the mandatory programs in schools and to help support increased
program volume resulting from the expanded dental program. This position is critical to support the proposed management
structure.
Hence Option 4 represents a $40,000 net increase over the current Public Health budget for dental management. The 1999
approved budget for the dental management complement in Public Health is $660,195, or 5.4 percent of the total Public
Health dental program budget of $12,100,000 (post-expansion).
It is important to note that the proposed model represents a $200,000 savings from 1998 immediately post-amalgamation,
for the management of the dental program. This model provides a management structure that has the capacity to establish
and enforce clear system and service standards.
In the dental program, the customary challenges of amalgamation will be compounded by expectations of incremental
growth in service volumes combined with cost constraint, all of which must be managed within a mixed (public/private)
service delivery model, supported by heavy attention to change management with staff. Managing the program successfully
in this context will require strong leadership and stable resources.
Strengths of the Recommended Model:
The dental management structure proposed by the consultants is a change model which makes dental treatment services
more consistent across the 6 former municipalities of the City of Toronto. This structure is proposed for implementation
for a two year period, after which time it will be subject to further review. The model proposes establishing an information
system across the city which will enable staff to establish benchmarks, service standards and performance measures
consistently across the City. Currently the information systems vary considerably, ranging from manual to fully
computerized. In addition the proposed structure separates the management positions for preventive (mandatory) and
treatment (non-mandatory) dental services allowing clear delineation of the relative costs of these program components.
Other jurisdictions manage their dental programs in this manner.
Option 4 therefore provides for a centralized program in which dental treatment clinics are viewed as a city-wide resource.
Having a Dental Chief/Advisor position will ensure professional leadership and clear direction for program harmonization
and restructuring. There will therefore be good control over policy development, protocol harmonization, management of
information systems and program evaluation.
The report also outlines the potential to increase efficiency by streamlining the CINOT/OW administration process and by
transferring some non-clinical duties from higher paid dentist managers to other professional and/or administrative staff. In
recommending at least two permanent dentists in management, the report incorporates both professional and regulatory
requirements and proposes a balance between professional and management roles. The report specifically recommends that
these dentists be primarily responsible for management of the dental treatment clinics, where necessary professional tasks
can be combined with management ones for maximum efficiency. Managers with other professional backgrounds (e.g.
dental hygiene, health promotion) would be responsible for non-treatment program components, such as clinical prevention
and community-based education.
Concerns about the Recommended Model:
Despite recommending that the model proposed by the consultants be implemented, the Medical Officer of Health has
some concerns regarding whether the recommended complement of dentist managers will be adequate to meet the demands
of this expanding and complex dental program.
The time-limited Dental Chief/Advisor position will be particularly demanding. In addition, there is a shortage of Public
Health dentists in Canada. As a result, there is some concern about the ability to recruit a well qualified person for this job
in a timely fashion.
Public Health has expressed concerns about the possible loss of front-line efficiencies that can be realized with an
integrated program delivery structure. While it will be possible to integrate direct services (i.e. prevention and treatment) at
delivery sites under the proposed model, communication, scheduling and reassignment will likely become more complex.
An integrated model was used in the former city of Toronto, whereas a separated model was used in the former city of
North York: overall, different services and service delivery mechanisms were used in each jurisdiction. Only time will tell
if the recommended approach is optimal for the new city as a whole.
An additional implication of the consultant's report is that treatment and prevention services will have to be disentangled in
those areas (i.e. former City of Toronto and Etobicoke) where these services are currently integrated.
The final Public Health concern relates to centralization of the program, which has clear benefits in terms of consistency
and accountability, but drawbacks regarding integration with other family health programs. Other health units have
experimented with centralized and regionalized models, with varying levels of success. One of the tasks of the Dental
Chief/Advisor will be to assess the strengths and weaknesses of the dental management structure once it is implemented
and prepare recommendations on future directions for consideration by the Board of Health and City Council in two years
time.
Conclusions:
This report recommends approval of the model proposed by the Berkeley Consulting Group under Option 4. This model
has considerable strengths in that it includes a Dental Chief/Advisor position to provide professional leadership and clear
direction for program harmonization. The model also clearly distinguishes mandatory and non-mandatory dental programs.
In the proposed model there are 7 FTE dental managers, 3 of whom are dentists, plus one program co-ordinator to support
the managers responsible for the mandatory dental programs in schools and to deal with increased program volume. The
proposed model represents a $200,000 savings over 1998, immediately post amalgamation.
The Medical Officer of Health has some concerns regarding whether the recommended complement of dentists will be
sufficient to meet the demands of an expanding and complex program. Hence, the recommended model requires ongoing
evaluation following its implementation with future reports on its strengths and weaknesses to be brought forward.
Stability and clarity of future directions are urgently needed to restore staff morale and to fully harmonize public health
dental programs on a city-wide basis.
Contact:
Dr. Sheela Basrur
Medical Officer of Health
Tel: 392-7402
Fax: 392-0713
Dr. Sheela V. Basrur Shirley Hoy
Medical Officer of Health Commissioner, Community and Neighbourhood Services
List of Attachments:
Attachment No. 1 - Dental Management Cost Comparison
Attachment No. 2 - Memorandum dated October 20, 1999 from Chief Administrative Officer
Attachment No. 3 - Toronto Dental Health Services Organization (Berkeley Consulting Group)
