Committee Transcript 1991-Aug-13 | Legislative Assembly of Ontario

Regulated Health Professions Act, 1991, and companion legislation / Loi de 1991 sur les professions de la santé réglementées et les projets de loi qui l'accompagnent

Ontario Association of Medical Radiation Technologists; Board of Radiological Technicians;

Ontario Association of Radiology Managers

Council of Ontario Faculties of Medicine

Governing Board of Dental Technicians of Ontario

Psychiatric Patient Advocate Office

Shelley O'Neill

Jim Fraser

Bruce Cairnie

Sandra Lecce

Royal College of Dental Surgeons of Ontario

Ontario Dental Hygienists' Association

Canadian Memorial Chiropractic College

Governing Board of Denture Therapists

Stephan Abrams

Peter Apse

Ontario Dental Nurses and Assistants Association

Ontario Herbalists' Association

Adjournment

STANDING COMMITTEE ON SOCIAL DEVELOPMENT

Chair: Caplan, Elinor (Oriole L)

Vice-Chair: Cordiano, Joseph (Lawrence L)

Beer, Charles (York North L)

Haeck, Christel (St. Catharines-Brock NDP)

Hope, Randy R. (Chatham-Kent NDP)

Malkowski, Gary (York East NDP)

Martin, Tony (Sault Ste Marie NDP)

McLeod, Lyn (Fort William L)

Owens, Stephen (Scarborough Centre NDP)

Silipo, Tony (Dovercourt NDP)

Wilson, Jim (Simcoe West PC)

Witmer, Elizabeth (Waterloo North PC)

Substitutions:

Grandmaître, Bernard (Ottawa East L) for Mrs McLeod

Harrington, Margaret H. (Niagara Falls NDP) for Mr Martin

Huget, Bob (Sarnia NDP) for Ms Haeck

Jackson, Cameron (Burlington South PC) for Mrs Witmer

Waters, Daniel (Muskoka-Georgian Bay NDP) for Mr Malkowski

Wessenger, Paul (Simcoe Centre NDP) for Mr Silipo

Clerk: Mellor, Lynn

Staff: Drummond, Alison, Research Officer, Legislative Research Office

The committee met at 1002 in committee room 2.

REGULATED HEALTH PROFESSIONS ACT, 1991, AND COMPANION LEGISLATION / LOI DE 1991 SUR LES PROFESSIONS DE LA SANTÉ RÉGLEMENTÉES ET LES PROJETS DE LOI QUI L'ACCOMPAGNENT

Resuming consideration of Bill 43, the Regulated Health Professions Act, 1991, and its companion legislation, Bills 44-64.

Reprise de l'étude du projet de loi 43, Loi de 1991 sur les professions de la santé réglementées et les projets de loi, 44 à 64, qui l'accompagnent.

The Chair: I call the meeting to order. We are holding public hearings on the Regulated Health Professions Act and its companion legislation, Bills 44-64, inclusive. We have agreement from the Progressive Conservative caucus that we can begin the hearings on time and expect that they will be here very shortly.

The first item of business is the tabling of the subcommittee report, which I believe all members have. With the agreement of the subcommittee, the committee will meet Monday, September 16, and Mr Schwartz, the co-ordinator of the Health Professions Legislation Review, will be in attendance. The agenda for the afternoon will be to have a briefing from ministry staff.

Second, on September 17 we would be able to have people from the Ministry of Community and Social Services as well as any other experts we would like to invite in on those two days. One request that has been made is that because of the high holidays on the 17th, if we could adjourn by 3 pm and perhaps work into the lunch hour if we needed additional time, that would be appreciated.

That is the report of the subcommittee. Can I ask for agreement and concurrence from the committee at this time? All in favour for approval? Any opposed? Agreed.

ONTARIO ASSOCIATION OF MEDICAL RADIATION TECHNOLOGISTS BOARD OF RADIOLOGICAL TECHNICIANS ONTARIO ASSOCIATION OF RADIOLOGY MANAGERS

The Chair: I welcome the Ontario Association of Medical Radiation Technologists, the Board of Radiological Technicians and the Ontario Association of Radiology Managers. Introduce yourselves, and you have 20 minutes for your presentation.

Mr Hamilton: I am John Hamilton, representing all three bodies. I will ask the members to introduce themselves as we go across.

Mr Roberts: My name is Richard Roberts and I am the representative from the Ontario Association of Radiology Managers.

Ms Morgan: Janet Morgan, chairman of the Board of Radiological Technicians.

Ms Lachance: Mary Jon Lachance, past president of the Ontario Association of Medical Radiation Technologists.

Ms Pope: I am Hilda Pope. I represent the magnetic resonance imagers.

Ms Ayre: I am Mary Ayre. I am representing sonographers from the Canadian Society of Diagnostic Medical Sonographers, Ontario region.

Mr Scott: I am Dave Scott. I represent the nuclear medicine technologists, and I am also a member of the Board of Radiological Technicians.

The Chair: I would ask that you leave some time at the end of your presentation to allow for questions from the committee. The time begins now.

Mr Hamilton: The submission of the three bodies is in the hands of the members of the committee. I intend to refer to a few points very briefly and leave most of the time for questions, if that is appropriate.

The first point deals with Bill 43 and is a matter of considerable concern. In clause 28(b) it provides that a student must be "under the supervision or direction of" a registered person in order to perform certain acts. There is no definition of either of these terms. It appears to us it should be "supervision and direction."

Looking at it in its worst possible light, a registered person could, from off the site, phone a student and say do a particular thing. The student is under the direction of the registered person but not under the supervision, and no matter how careful the student is, no matter how dedicated the student is, the public may still be at risk because of being treated by someone who is not registered. It is our submission that the word "or" should be changed to "and." It is again a matter of protecting the public.

The second point has been partly covered by the proposed amendments to Bill 54; that is, it is now provided in the proposed amendments that not only is ionizing radiation covered, but also any other form of energy prescribed by regulation. This is for diagnostic purposes. However, this does not cover therapy. There are other forms of energy now being used for therapy and there may well be other forms coming downstream. In this increasingly technological age, who knows what is going to turn up next week?

The submission is that the same provision should be made for therapy as for diagnosis; that is, provision in the regulations to add other forms of energy if, as and when appropriate. Again, it is a matter of protecting the public, but also a matter of not having to come back to the House to allow some other form which needs to be added. A matter of regulation is, as you all know, somewhat simpler than getting legislation passed, although there are times with when regulations you wonder a bit, too.

The other point we have is strictly an editorial one. In Bill 54, I think there is a misprint. It refers to members of council who are "selected" and I think it means "elected." To my mind, it does not seem to make complete sense saying "selected." But there are members of council who are "elected," and if the council may make regulations dealing with the matter of election of its elected members, obviously council cannot do anything about those who are appointed by the Lieutenant Governor in Council.

Those are the three points. I have the experts with me who may, I hope, be able to answer any questions.

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Mr Beer: Thank you very much for your submission. I think it is probably fair to say for all of us lay members of this committee that your field, one always has the sense, is continually pushing the envelope. I think how we deal with new developments then does become important. I just want to make sure I understand your point 2 you raised, so that on page 3 of your submission that is the way you would suggest we deal with that, which would then mean that required regulations would be able to be passed to bring that under.

Mr Hamilton: Yes.

Mr Beer: Did this come up when Schwartz was looking at this, or has this appeared in any earlier form?

Mr Hamilton: It has been discussed for many years and for a long time the answer was, "There aren't any other forms of radiation which are liable to do any harm to people." As far as I know, I pass to the experts, but I think the jury is out on a number of forms of --

Mr Beer: If this was not there the concern would be, you would need to come back for a specific change in legislation to then be able to do that procedure.

Mr Hamilton: Right.

Mr Beer: On the supervision and direction issue, in terms of your present rules of operating, what is the situation?

Mr Hamilton: Supervision.

Mr Beer: Okay, so just that one word is used and therefore is your concern that with the two, one is a lesser meaning, or what does it mean?

Mr Hamilton: Yes, direction could mean a lot less than supervision.

Mr Owens: Further to Mr Beer's question around the college forming regs as opposed to having to come back to the government, how would you see that furthering public protection with respect to other forms of energy?

Mr Hamilton: It would not be the college that made the regulations; it would still have to be regulations made by the Lieutenant Governor in Council. If you mean not having to come back to the Legislature every time some new form of energy has been either adapted, used or for any other purpose, it is already set up that way for diagnosis in the proposed amendments to the legislation. But I understand that right now there are forms of energy other than ionizing radiation used for treatment of cancer patients. There is heat and light to a certain extent.

Mr Owens: So in terms of serving the public interest, that would mean it would get things, newer modalities of treatment, on track faster, and perhaps be less costly.

Mr Hamilton: And being sure they are being used by persons who are properly trained; that is the main point. At present, if someone comes up with some new form of energy which is not regulated in any way, anybody can use it on patients, which in our view is entirely inappropriate, not to say dangerous.

Ms Lachance: One point to bear in mind also is that in our line of technology a lot of the harm may not even be realized until there has been another generation, so the indiscriminate use of an energy could go on for years and years and nobody would really appreciate that there was a problem. We bumped our nose many years ago the hard way so we are a little more careful now and we say that if we could control this initially, until we absolutely know there is no harm -- because it takes so long for it to show.

Mr Hamilton: It must be remembered that Mme Curie died of radiation burns.

Mr Wessenger: Yes, I believe we could have some clarification by ministry staff on some of these items.

Ms Bohnen: In terms of the proposed further amendment to the scope of practice, I think it should be pointed out that the scope of practice statement describes the activities members of the college engage in; it does not control the performance of any particular procedure. One of the controlled acts in section 26 of the RHPA is ordering or applying prescribed forms of energy. The intention is that the minister will make regulations under the RHPA, identifying as they develop or as risks are identified those forms of energy the ordering or application of which are restricted to particular occupational groups. So making an amendment to the scope of practice itself does not provide any control over who can prescribe or apply particular forms of energy. That is handled elsewhere in the legislation.

The Chair: Thank you very much for your presentation. I have no further questions from the committee.

The other point I would make today, which I did not mention yesterday to those who were here, is that if organizations or individuals wish to communicate with the committee, they may do so at any time in the form of a letter or written brief between now and the end of the committee hearings. Please feel free to do that.

COUNCIL OF ONTARIO FACULTIES OF MEDICINE

The Chair: I call now the Council of Ontario Faculties of Medicine. Welcome to the standing committee on social development. Please introduce yourself. You have 20 minutes for your presentation. I would ask that you leave a few minutes for questions from the committee at the end, if possible.

Dr Provan: I am John Provan. I am the associate dean for post-credit education here in Toronto. I am representing the Council of Ontario Faculties of Medicine. That is the body that represents the five medical schools in Ontario. I sit on that committee.

COFM, as it is called, has no major concerns regarding the act respecting the regulation of the profession of medicine except for the proposal that the number of university representatives on the council of the College of Physicians and Surgeons of Ontario be reduced from its current number of five, ie, one for each school, to three.

There are various reasons why we think this is inappropriate and why we have rejected this proposal. First, as currently constituted, the act prevents any full-time member of a medical school from being eligible for election to the College of Physicians and Surgeons of Ontario. This means that the medical schools as such cannot be represented in the electoral process. You could say we could change that situation to permit people to be elected, but I think there is a risk that then the regular representation from the rest of the profession in the province might become overbalanced.

COFM believes that a reduction is the number of university representatives on the council of the College of Physicians and Surgeons from five to three would primarily deny access to council of the breadth and depth of experience of the university representatives. These individuals over the years -- I think there has been a university representative on the CPSO council since council was first constituted -- have provided a unique resource which I think would not otherwise be available.

The university representatives have a unique administrative experience. They represent the teaching hospitals, where they often have positions of leadership. They represent the medical schools and they bring to council the representation of national and international bodies that these individuals represent as well. They tend to be leaders in the profession and they have often been chairmen of departments of medicine, surgery or other specialties as well as hospital department heads. That leadership has been very useful to the council of the CPSO in the past.

They also provide professional expertise in issues that are often not clearly understood either by the professional members of council or particularly by the public representatives on the council. These relate particularly to education, in so far as it affects both undergraduates and post-graduates in training, and particularly with regard to research. Indeed, it has been pointed out to me by people from the CPSO that the university representatives are actually the linchpin which provides experience for the CPSO in terms of medical research.

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The university representatives also have a clear understanding of issues which relate to registration and licensure. These are sometimes complex and in the interests of public protection need careful elucidation. As these are issues with which the university representatives are dealing all the time, they provide special expertise in this area. They also bring regional representation to the CPSO, and that, in itself, may be important.

I think it is also important to note that in the past these university representatives have served council extremely well. Many of them have become presidents of the College of Physicians and Surgeons. They have represented various specialty committees, such as the registration committee and the education committee of the college. They are articulate representatives of the profession. They are generally at the forefront of changes, and in the past they have provided a very useful means of interaction between the public and the college by seeing where changes in medical education and medical practice are taking place, so they have been able to improve that. Somebody wrote the other day stating that these five representatives have performed incalculable service to the college.

Finally, we believe that these university representatives, above all, have the time to serve the college well. This is a very time-consuming process, and those involved in private practice solely are often not as easily able to spend the time doing this. University representatives have a process in place which enables them to spend their time, and as university representatives, they are spending a lot of their time thinking. They are looking ahead and we believe that their creativity and innovation would be lost to the council if the numbers were reduced.

I think it is also important to note that the five universities themselves represent different facets of medicine in Ontario. Ottawa, for example, represents the francophone component. McMaster tends to take more mature and a higher percentage of female students. Kingston represents a small, compact school in a small area, and Toronto has a huge medical resource with many of the leaders in the profession, whose expertise might well be lost if they were not able to be present at the discussions of the council of the CPSO.

Mr J. Wilson: Thank you for the presentation. What does the CPSO itself think about your proposal?

Dr Provan: The CPSO has discussed this issue and, I think virtually unanimously, is against any reduction of the university representatives from five to three. They had felt, I think, very strongly that some of the issues I brought up are being of incalculable service to the council.

Mr J. Wilson: Do you have any idea how three crept into the draft legislation?

Dr Provan: No, I do not. The initial numbers put forward by the previous government reduced it from five to three, but it is my understanding that the council is not in favour of this.

Mr Grandmaître: Maybe my question would be better directed to the ministry. How did the recommendation come about for the reduction of representatives from five to three?

Mr Wessenger: I could take a guess at that answer, but I will turn it over to ministry staff.

Mr Burrows: It is unfortunate Linda is not here, because she was with the review, but it is my understanding that the review carefully considered this issue and made its recommendation to maintain an overall balance on college council. Also, it looked at the fact that medicine alone would have had a very sizeable number of academic members compared to other professions where, at most, they had two, and many only had one academic member, and the principle of equitable treatment entered into this. Perhaps Linda could elaborate a little bit on this now she is back. They are asking, Linda, for the history of the five versus three.

Ms Bohnen: The review considered the various professional interests and the public interest to be represented on the college council. In addition, it becomes something of a juggling act when you are trying to increase the proportion of public representatives on the council. The review concluded that there should be a maximum of three academics on the council of the College of Physicians and Surgeons, that this was the appropriate proportion of academic involvement in the affairs of the council. That has been retained in the bill and will be retained in the bill, even though the proportion of public representatives has been proposed to be increased, as you know, to just under half. So the CPSO will still have more academics than any other college council.

The Chair: Thank you for your presentation. We appreciate your appearing before us today. Next is the Governing Board of Dental Technicians of Ontario. Are they not here yet? In that case, we are a few minutes early. If any members of the committee would like to raise any issues at this point with the ministry, we can.

Mr Waters: I would like some clarification of this five versus three. How many people sit on the board and what do they represent?

Ms Bohnen: In this version of Bill 55, the council is composed of 16 elected professional members and nine persons appointed by the Lieutenant Governor in Council -- those are the public members, the lay people -- plus three academics. That will be revised again because of the minister's commitment to increasing the number of public members to just under half, but that is what appears now in the bill.

Mr Owens: I would like to pursue something we started looking at yesterday, around the chiropodists especially -- it seemed to be the most apparent -- and that is the issue of being able to assess and treat, but not being able to communicate the reason why you are treating. I am just wondering how we have made that leap from assessment to treatment without having the bridge of being able to communicate?

Ms Bohnen: We have not. What they were saying was that because chiropodists have not been authorized in their controlled acts to diagnose, it is their view that they cannot communicate the results of an assessment. The ministry's position and the government's position is that although they cannot diagnose, they certainly can assess their patients and communicate the results of the assessment. So we disagree with them as to the effect of not being authorized to perform the controlled act of diagnosis. That is one aspect of the issue you have heard many groups speaking about. If they cannot diagnose, how can they be assured that they can nevertheless assess their patients and discuss the results of the assessment with their patients?

Mr Owens: But without specific language around communication, I am not sure that assessment is really tandem -- assessment and communication. Not having legal training and trying to shuffle through the nuances of the language, I find it problematic in the way that it is written.

Ms Bohnen: You are not alone among individuals and groups who have problems with the way it is written. I think that is why the minister said she hoped to be guided by the committee in making some changes that would still protect the public in terms of restricting who can diagnose, but would comfort both professional groups and the public that they can be properly assessed and find out the results of the assessment.

The Chair: Any further discussion or questions of the parliamentary assistant or ministry? Is the Governing Board of Dental Technicians of Ontario here yet? The committee will adjourn for 10 minutes and reconvene at 10:40.

The committee recessed at 1030.

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GOVERNING BOARD OF DENTAL TECHNICIANS OF ONTARIO

The Chair: I call on the Governing Board of Dental Technicians Of Ontario. Introduce yourselves to the committee. We would appreciate it if you could leave a few minutes at the end of your presentation, if you wish, for questions from the members of the committee. You have 20 minutes, beginning now, for your presentation. Thank you for joining us this morning.

Mr Doel: I would like to introduce myself, Jim Doel, as chairman of the governing board of dental technicians. With me is our legal counsel, Peter Downard; Peter Ferraro, RDT, and a member of the governing board of dental technicians; and Dan Huber, RDT, and past chairman of the governing board of dental technicians.

The Governing Board of Dental Technicians of Ontario strongly endorses the many important steps which have been taken to rationalize the legislation -- excuse me, please. I am just going to get some water, here. I am a little nervous.

The Chair: Do not be nervous.

Mr Doel: No, I will not be nervous.

The Chair: No, I can tell. The committee is very friendly this morning. Yesterday I was not sure, but I can tell this morning that everyone is in a good mood. So please do not be nervous and just continue with your presentation.

Mr Doel: The Governing Board of Dental Technicians of Ontario strongly endorses the many important steps which have been taken to rationalize the legislation applicable to all the health professions in Ontario and applauds the very substantial efforts of those who have done so much to move this process towards fruition.

That being said, the governing board today wishes to explain to the members of this committee the reasons for the serious concerns we have about the Regulated Health Professions Act, 1991, and the Dental Technology Act, 1991. Our concern is shared by many other relevant participants in the dental health care system and we understand that those concerns are also fully appreciated by the Ministry of Health.

Our concern is that the RHPA and the the Dental Technology Act, 1991, as presently worded do not contain measures sufficient to protect the public. This is a matter of profound concern for the governing board, which by statute has been charged with the obligation of regulating the practice of dental technology in the public interest for almost 50 years.

In our submission today, we wish to provide you with an explanation of why it is that the adequate regulation of dental technology is so important. Second, we will explain why the RHPA and the Dental Technology Act, 1991, as presently worded do not yet adequately regulate the profession. Third, we will outline for you our proposed solution to this problem, which we understand is supported by all the relevant partners in the dental care field, as well as the Ministry of Health.

Through our submission today, we hope to provide you with some assistance in understanding the need for and the purpose of a statutory amendment which you will be dealing with during the clause-by-clause stage of your deliberations.

The problem posed by the RHPA and the Dental Technology Act, 1991, as presently worded is best understood when one appreciates the reason why adequate regulation of the dental technology profession is necessary.

Appropriately qualified dental technologists serve as critical links in the dental health care process. They ensure patients receive dental appliances which are constructed in accordance with dentists' prescriptions and that the dental appliances have been produced using appropriate materials and methods.

The risk of harm to the public that may result from the inappropriate practice of dental technology is considerable. Potential harm arises from the possible use of harmful or toxic materials in the construction of dental appliances. The same risk arises from biologically incompatible design or workmanship. In either case, the patient can be harmed both physically and emotionally.

It must be clearly understood that mistakes or improper choices with respect to these matters may be undetectable by the dentist. Almost all dental appliances manufactured in Ontario are produced outside of dentists' offices and beyond dentists' control or supervision. Because faults in material or workmanship in dental appliances may only be detectable at the point of their construction, dentists place heavy reliance upon the professionalism of dental technologists.

In its submission to the committee, the Royal College of Dental Surgeons of Ontario has stated its strong view that, "The college understands and supports the concerns of the governing board of dental technicians that the quality of dental prostheses be protected by ensuring that only qualified persons be permitted to dispense them."

Similarly, the Ontario Dental Association stated in its submission to the Health Professions Legislation Review:

"Dental technicianry is an integral part of the practice of dentistry. Without their reliable, professional contributions, the practice of dentistry in Ontario would no doubt be much lower on the world scale than it is -- second to none. We would ask the review to recommend that anyone practising dental technicianry in Ontario be licensed by the college of dental technicians. This would ensure that continuation of standards which have taken generations to develop and on which we have all come to depend."

The fundamental deficiency of the RHPA and the Dental Technology Act, 1991, as proposed is that they do nothing to ensure that control is exercised over the materials and methods used in dental technology by an appropriately qualified person. Under the RHPA and the proposed Dental Technology Act, 1991, unqualified persons wishing to practise dental technology would be free to do so without restraint, as long as they did not call themselves dental technologists or dental technicians or otherwise represent themselves as being qualified to practise as dental technologists or in a specialty of dental technology. The legislation in its present form would do nothing to prevent unqualified persons from carrying on the practice of dental technology under some other title.

Ironically, the Dental Technology Act, 1991, creates a more elaborate administrative structure for the regulation of the profession of dental technology than has ever existed before. However, by omitting any requirement that a qualified person exercise control over the materials and methods of dental technology, it would leave the regulation of the profession without any meaningful foundation and would leave consumers without adequate protection. If left unamended, the RHPA and the Dental Technology Act, 1991, would result in the effective deregulation of dental technicians in Ontario for the first time in almost 50 years.

The problem is made all the more troubling by the fact that the need for effective regulation is currently greater than ever. Committee members may be shocked to learn that a substantial number of commercial dental laboratories are now operating illegally in Ontario. These are laboratories which carry on their activities without the slightest involvement of a registered dental technician. The governing board has undertaken a test case under its current legislation in order to address this problem.

Under the Dental Technology Act, 1991, as presently worded, such illegal operations would continue unhindered, as long as no one involved with them called themselves members of the college of dental technologists or otherwise held themselves out as appropriately qualified persons.

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The governing board strongly believes the government must ensure that the inappropriate practice of dental technology does not continue. We are therefore asking the members of this committee to approve amendments requiring that a member of the college of dental technologists supervise all dental technology work performed in this province. Without such a requirement, this government and the governing board will be powerless to protect the public from the provision of substandard and potentially harmful dental care that unscrupulous operators may provide in an unregulated environment.

In addition to the dramatic impact the proposed legislation would have upon the protection of the public in Ontario, it should also be noted that inadequate regulation of dental technology would also have a negative effect upon the post-secondary education of dentists in Ontario and on the provincial taxpayers.

The University of Toronto and the University of Western Ontario have both stated their recognition of the reliance placed by dental technologists upon qualified dental technicians. In particular, they have pointed out that they have increasingly shifted their undergraduate program away from dental technology to other priority areas, such as biological sciences. The dean of the faculty of dentistry of the University of Toronto has stated that such changes "were only possible because we were secure in the knowledge that there existed a sound infrastructure to the dental profession, namely, a well-trained and regulated licensed dental technician." If this practice of dental technology were to be effectively deregulated, the current ability of dental faculties to rely upon the dental technology profession would be dramatically undermined.

The University of Toronto has estimated that unless the wording of the Dental Technology Act, 1991, is changed, university dental faculties would have to add an additional one year to the curriculum, at a cost of $3.5 million per year and $2 million in capital costs. Dental students would also be faced with an additional year of study and an increase in the cost of their education of approximately $10,000 per student.

For its part, the faculty of dentistry of the University of Western Ontario has stated through its dean:

"There is a very strong feeling within this faculty that the abandonment of dental technology as a licensed act would have grave implications for dentistry and would adversely affect the public. It is a retrograde step and we would that it will not come about."

In these circumstances, all of the participants in the legislative review process have acknowledged that as presently worded, the Dental Technology Act, 1991, does not provide adequate measures to ensure the appropriate practice of dental technology and that it must therefore be amended to ensure an adequate protection of the public.

In the governing board's view, protection of the public may be secured by a statutory amendment requiring that no dental technology work may be performed in Ontario unless that work is done under the supervision of a member of the college of dental technologists. The supervision of a properly qualified member is essential to ensure that appropriate procedures are followed and that satisfactory materials are used in the construction of dental appliances. This policy is widely supported by participants in the dental care field, which includes the Association of Registered Dental Technologists and the Commercial Dental Laboratory Conference.

It is important that the members of this committee understand that the government has also acknowledged that the RHPA and the Dental Technology Act, 1991, as presently framed do not satisfactorily achieve the goal of protecting the public. It is the governing board's understanding that the Ministry of Health agrees in principle with the need for an amendment which will better protect the public by ensuring that dental technology work is supervised by a member of the college of dental technologists.

The governing board wishes to make clear to the committee that it is absolutely fundamental that the statutory amendment achieve two goals: First, it must ensure that no person may perform dental technology functions unless that work is supervised by a member of the college of dental technologists; second, where dental technology work is performed and is not supervised by a member of the college, the amendment must ensure that both the person or business organization carrying on the business and the unqualified person supervising the work are liable to a provincial offence.

In the governing board's view, these purposes can be achieved by the provision which we have outlined in page 10 of our submission.

The purpose of this amendment would be (1) to ensure that dental technology work is not performed unless it is supervised by an appropriately qualified person, and (2) to ensure that where dental technology work is performed in the absence of appropriate supervision, all relevant parties are liable to a provincial offence. In this regard, particularly given the existing problems regarding the growth of illegal commercial dental laboratories, the governing board considers it to be particularly important that the amendments clearly and specifically ensure that all these business organizations carrying on inappropriate activities be liable to an offence.

At this time, the governing board understands that legislative counsel has been instructed to prepare a statutory amendment which will reflect the Ministry of Health's agreement in principle that the dental technologist must be supervised by an appropriately qualified person. With other relevant parties, we await the result of legislative counsel's work. The details of appropriate exemptions from our proposed amendment for professionals who derive adequate expertise from other training, such as dentists, are also currently being refined. We are confident, however, that the existing consensus on the needs and goals of adequate regulation among all relevant parties will ensure that satisfactory amendments will soon be in a final form, and that it will form an appropriate foundation for the adequate regulation of the dental technology profession in the public interest.

The Chair: Thank you very much for an excellent presentation. Some members would like to ask questions. We have approximately four minutes. I ask that you be aware of the time.

Mr Owens: Mr Doel, thank you for the excellent presentation. I am really pleased that you raised the issue of illegal labs operating, because in my meetings with members of your industry these rumours surfaced. You can have the greatest regulation in the world. My question is, quite simply, how is it going to be more enforceable than what we have currently proposed? If we accept your amendment, how would the government or the industry be able to enforce that to ensure that these illegal operations are not up and running?

Mr Downard: In our view the amendment we propose will just go all that much further to make sure this activity is stopped. We see a loophole in the act as proposed that one can drive a truck through and we think the amendment we have proposed will close that loophole. As a lawyer, I am aware there probably has never been a piece of legislation invented that another lawyer could not find something around, but the fact remains that we strongly believe the amendment we have proposed will go a very long way towards addressing this serious problem.

Mr Beer: It is probably fair to say that all this legislation is going to provide lawyers with some interesting challenges regardless of what amendments come through.

I take it, from the end of your presentation that if these amendments that are going to be coming from the government are what you think they might be, that will end the problem. Is the issue then around the dental laboratories association? There is an Ontario or Canadian association. Are they concerned or are they the ones who did not want this change made, or where is the conflict here? Who is saying, "No, we don't want all these acts to be directed by some other body"? Where is the opposition here?

Mr Downard: As we understand it, doing the best we can to canvass all the relevant opinions, there is indeed now a consensus in the dental technology industry that dental technology should only be carried on where it is supervised by a member of the future college. That policy appears to be the subject of a firm consensus. We are in the process of refining the precise mechanism by which the policy can best be realized, and in that regard we are dealing on an ongoing basis with all relevant parties. But we are very confident that there is a firm foundation of consensus as to the essential policy.

Mr Beer: That being done, then, you would be content with the act as it would then be.

Mr Downard: That is the case.

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Mr J. Wilson: I have a quick question to get an understanding of what the current status is. You mention in your brief that there are a number of commercial entities carrying on unregulated, I gather, and unaccountable. How is that the case? You have a college now. One would assume it was supposed to be doing this or would have been given the authority to do this.

Mr Downard: There have been some concerns about the adequacy of the language of the current legislation, which I will not dwell on further here. Also, until relatively recently there was only a nominal fine structure in place for violations of the legislation, which apparently gave some operators an incentive to disregard the law and made it more difficult to face the task of enforcing the law.

The Chair: Thank you very much for your presentation. We appreciate your appearing here this morning. Please feel free at any time over the course of these hearings to communicate further with the committee in writing, although you have presented us with a very substantial brief.

Mr Jackson: Madam Chairman, would it not be appropriate, where a deputant presents a point that the government has already agreed to a substantive change, that we have that statement corroborated? That would have been my question to the ministry.

The Chair: If you wish. There are times we can do that or you can ask to do that at this point, if you like.

Mr Jackson: If there is any conflict I would like that to be flagged, if there is a disagreement on the part of the ministry. I am accepting the statement, but it is an agreement which implies to the other parties -- it would be helpful; that is all.

Mr Wessenger: Yes, we are working on an amendment, substantially as represented, to try to accommodate the interests of the dental technicians as well as the dental profession, the medical profession.

The Chair: That will be presented at a later time?

Mr Wessenger: Yes, it will be presented.

Mr Jackson: It is helpful at this point to know that, and I appreciate that.

The Chair: For the advice of members of the committee, for issues such as Mr Jackson has just raised, that is different than a questioners' list. If you signal to me that you have a question for the parliamentary assistant, I will keep a separate list and do that at the end of the presentation.

PSYCHIATRIC PATIENT ADVOCATE OFFICE

The Chair: Next is the Psychiatric Patient Advocate Office. Welcome. You have 20 minutes for your presentation, if you would begin now. We ask that you leave a few minutes for questions at the end.

Mr Giuffrida: I will indeed; I am David Giuffrida, legal counsel to the Psychiatric Patient Advocate Office. We are a quasi-independent program of the Ministry of Health that has been working in the area of rights of psychiatric inpatients in the 10 provincial psychiatric hospitals since our program began in 1983. We have enjoyed, since we began, the latitude to address committees such as yours and of course in doing so do not speak for the ministry.

I want to comment on several aspects of the Regulated Health Professions Act, Bill 43, that have ramifications for the rights of psychiatric patients and other patients. I admit to having been awakened to the relevance of this particular bill for our client group fairly late in the game. Many of the comments I am going to make to you are ones the patient advocate office and other patients' rights groups have made in other forums, in particular the sex abuse task force of the college of physicians. We have made these sorts of suggestions to regulatory bodies as well.

The first point regards compliance with laws relating to informed consent to treatment and in that regard I am sure the committee is aware of other legislative initiatives by this government, many of which have been evolving over many years and many governments, but in particular Bills 108 and 109 relating to substitute decisions for incapable persons and the Consent to Treatment Act.

In public discussions to seek feedback from members of the community about this legislation, one resounding complaint was the lack of enforceabilty, the fact that informed consent now is more honoured in the breach among health care professionals than it is honoured in practice, and the fact that Bill 108 and Bill 109 lack any penalty or enforcement provisions that would penalize health care professionals for flagrantly disregarding the requirements, that they get the personal informed consent of a competent patient or the substitute consent of, for example, a relative of an incompetent patient.

It may be appropriate that we not overly legalize the practice of medicine and the practice of other health services. However, the experience is so universal that time and again, patients who are incapable but are acquiescing are treated without any consent at all. Patients who are vulnerable, who are inpatients in provincial psychiatric hospitals and other institutions and people with disabilities are treated without personal or substitute consent. So many of these complaints have been heard that we believe it is appropriate to have some mechanism to remind professions that it is a requirement of the professional discharge of their particular discipline that they get the personal consent of their patients, or substitute consent where appropriate.

Just to pick from among many different sources, I note two decisions of the mental health review board, one in which the chair writes, "The doctor has taken a somewhat surprising position that although he believes the patient to be incompetent to consent to both ECT and medication, he has proceeded to administer medication to the patient," and another in which he says, "In this case, however, the board accepts the somewhat startling evidence of the doctor that staff continue their attempts to treat without valid consent for the simple reason that it is hospital policy to do so."

We have noted that despite amendments to the Mental Health Act in 1986 and 1987 that amply clarify the requirement to get informed consent, we observed in subsequent years whole wards, particularly of psychogeriatric patients, where treatment was administered without any regard to legal requirements of consent. That situation has improved now, but we believe it would be important if it is stated that it is an example of professional misconduct to flagrantly violate the requirements of informed consent.

In saying so, I am aware of the fact that the structure in the current Health Disciplines Act puts such lists of professional misconduct in the regulations rather than in the statute, and that may be an appropriate structure. I am just not terribly optimistic that the disciplines, left to their own devices, would decide to enumerate this as an example of professional misconduct, but I will leave that as an issue for your attention.

The second item I wanted to discuss concerns rules relating to the process of investigating complaints. Again, this can be a little difficult to get a handle on, but I wanted to share with you some of the frustration in cases I have been involved in. These have been confined to the college of nurses. In one case a complainant says: "The health care providers did X to me and I am aggrieved about that and I am complaining. I think what they did was illegal and violated my rights." The response from the college is that it will not refer it to discipline. They set out the allegations and say, "We've decided we weren't going to refer this to discipline," and the complainant is left in the dark: "Did the college make a finding that what I said happened did happen or did they disbelieve me? Did they believe the provider and not believe me? If they believed what I said happened did happen, did they believe it was an illegal act or not?"

For example, it could be forcibly confining an informal patient when the Mental Health Act says nothing in this act authorizes detaining or restraining an informal patient. None the less, they restrained an informal patient. The patient makes a complaint to the college of nurses. The college says, "We find no unprofessional conduct here." Well, did they agree that the restraint happened? Did they believe it happened but they do not think it was unprofessional conduct? Do they believe it is permissible for members of their profession to break the Mental Health Act? There is absolutely nothing responsive to the complaint. At the initial complaint stage, it is my understanding that there are no formal findings of fact made and yet an important decision must be made: Should this case be referred to discipline or should it not be?

I think the situation is analogous to a police investigation. The police and the crown attorney begin a case neutrally, but in the course of investigating form an opinion about whether this is the kind of case that could stand up if it were sent to trial if a charge were laid, if that is what the colleges are meant to be doing at the complaint stage; forming an opinion about the discipline likely being successful if this went to discipline; If not, then you should not waste anybody's time: if it would, then you should. If you decide not to refer it to discipline, I think you owe it to the complainant to explain to him why you decided not to refer it to discipline. The current practice does not do that.

The third item is rules relating to competence of a witness to testify at a discipline proceeding. I want to add this is a topic the committee is likely to hear a lot about from the sex abuse task force because the college of physicians' sex abuse task force deals primarily with a very difficult situation in which there is an allegation of sexual misconduct in a room with only two people, the complainant and the respondent, so often it turns on issues of credibility.

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It is particularly difficult if the complainant is someone whom our society has traditionally accorded less credibility than other Ontarians, someone who has a developmental handicap or is labelled mentally disordered or has a physical handicap that makes it difficult for him to communicate in ordinary spoken language.

I am aware of a case, again before the College of Nurses of Ontario, where a complainant said he was physically abused by staff while an inpatient in a hospital, and as a result of the proceedings, at the beginning, the health care professional who responded in the proceeding argued that the patient was not competent to testify and was successful. The consequence of that is that the patient never even had the opportunity to get on the stand and tell his story.

Some complainants will be incapable of testifying, but I think that is an improper procedure and looking at other law reform initiatives that are afoot having to do with the Criminal Code of Canada and the Canada Evidence Act, rather than have the zero sum, black and white, either you are competent or you are incompetent sort of notion, I support a policy that would permit anyone who agrees to tell the truth to get on the witness stand to tell his story. If the other side wishes to introduce evidence that their capacity to give testimony is impaired, let them introduce that evidence and the finder of fact, the committee, the judge, the board, will assign a certain weight to their testimony based on the clinical evidence of their capacity.

In the particular case I am thinking of, I was given information that had the case been allowed to proceed, another patient would testify that he was approached by a health care provider and offered a bribe to lie and corroborate the provider story rather than the complainant story. I think it is a travesty that the discipline committee never got to hear the whole tale and rather just threw it all out.

If there are very clear cases related to health discipline, if a physician leaves in a sponge during surgery, we will have the easiest time dealing with those sorts of cases. These are the most difficult ones relating to people who are some of the largest consumers of health care services, people who are vulnerable because of mental or physical handicaps, people who are institutionalized. We have to ensure that the complaints procedure is responsive to their complaints and can accept their evidence in a mode that they are able to give.

Finally, I wanted to touch upon the duty of hospital administrators to report a physician's loss of privileges for issues relating to conduct or competence. I wanted to say, first of all, that in the code that is a part of Bill 43, section 86 -- I was delighted to find it there -- it imposes an obligation on all people who employ regulated health professionals and obliges them to report any revocation, suspension or restriction on privileges of a member.

Another triggering event is the dissolving of a partnership or association with a member for reason of professional misconduct, incompetence or incapacity. That is good, because unlike the Public Hospitals Act which only covers public hospitals and only covers physicians, this deals with all regulated health professionals and all employers.

I contrast it with section 30 of the Public Hospitals Act. As I said, that act only covers the setting of public hospitals and only physicians, so section 86 is a welcomed addition. However, there are some other triggering events in section 30 of the Public Hospitals Act that the committee would do well to consider, for example, where the application of a physician for appointment or reappointment to a medical staff of a hospital is rejected by reason of his incompetence, negligence or misconduct.

That is another event that triggers a report to the college, the rejection of an application or reappointment or where a physician voluntarily or involuntarily resigns from a medical staff of a hospital during the course of an investigation into his competence, negligence or conduct. I think these additional events that trigger a mandatory report to the college are important and one option would be for the committee to consider their inclusion in section 86.

I anticipate section 30 will remain in the Public Hospitals Act I am aware of it because of its conspicuous absence from the Mental Hospitals Act and that is the act under which the 10 provincial psychiatric hospitals operate. There is no corresponding obligation for administrators in the 10 provincial psychiatric hospitals to report to a college a physician who is in these circumstances.

I am aware of situations -- thankfully, they are rare, and I hope my comments are not taken as a witchhunt on physicians or any other health care professionals, but I am aware of cases in which the contract of a physician has not been renewed or a physician has been permitted to resign in really alarming circumstances.

I recall a circumstance in which the nursing staff approached the patient advocate to get the advocate's assistance in inquiring to find out if this person was in fact a doctor, because the nurses found this doctor's prescribing practices so bizarre. This doctor was permitted to resign and no report was made to the college of physician and surgeons. I would like to see reporting to be mandatory in those circumstances.

I will stop there to give time for questions and I anticipate the opportunity of filing something in a little more detail with the committee before the end of the month.

The Chair: Thank you very much for a very thoughtful presentation.

Mr Jackson: David, it is good to see you again. I enjoyed your presentation. There are a couple of areas and I will try and move through them quickly. Having read the Weisstub report and having difficulty reading it as any layperson would, I know we still have problems with the definition of competence in this province and that it is an unresolved matter. Is that at the root of why we are not as clearly inclusive in this bill, in your opinion? Perhaps you could share that with me because my background in this field leads me to that conclusion.

Mr Giuffrida: Is this in regard to the first issue I raised around informed consent to treatment? Whenever the law creates a distinction, there will be clear examples on either side of the line and there will be one real close to the line that everyone will struggle with. I do not think the problem I am describing can only be related to those difficult issues that are near the line.

I am looking at a report in which our advocates reviewed a psycho-geriatric ward in which there were just dozens of patients that the advocates could not carry on a conversation with. The advocates are laypeople, but they could not have a basic exchange of information. Reviewing the clinical records of these patients, they were considered by the physician to be competent in all spheres, financially competent, treatment competent. It just did not add up. I think the most cursory assessment of their capacity would have led the physician to conclude that they were incapable.

Mr Jackson: Item 4 raises some important points. Have you had any feedback from the government with respect to your proposed amendments and would you be able to table with us your suggestion in proposed amendment form?

I certainly support what you are suggesting here. In most other cases that we are dealing with, the public has a secondary recourse through the courts, but for your constituency, in almost all the cases, it is not. So there is moral pressure on us as legislators to ensure that this is the one and only opportunity for protection for these particularly vulnerable Ontarians.

I want to look very seriously at this and hopefully the committee will. I am asking you if the government has indicated in its informal discussions with you, an openness to look at those amendments?

Mr Giuffrida: I must apologize there because I have come to Bill 43 fairly late in the game and have not given the opportunity for the government to express its views. It has been very open in consulting with our program and with other people representing various consumer and survivor groups, so we look forward to discussions with them, but we have not had them yet on this issue.

Mr Hope: You have raised a number of issues dealing with vulnerable people. Will the legislation the Minister of Citizenship has introduced alleviate a lot of the problems dealing with advocacy, with what is going on with advocacy in dealing with patients?

Mr Giuffrida: We are quite excited about the prospect of the passage of advocacy legislation that will expand advocacy services to settings and to consumers who do not now have the services of advocates.

There are many pieces to the puzzle. Advocacy is necessary, but not sufficient. If a client approaches an advocate, the advocate investigates the situation and says, "The provider is doing X," but if there is no indication that what they are doing is wrong or no remedy to correct it, then it is an incomplete system.

In the provincial psychiatric hospitals, patients have had advocates from our program for eight years now. But particularly, for example, on the issue of compliance with the Mental Health Act, it is quite discouraging to report the level at which health care providers are ignoring the Mental Health Act despite the presence of advocates.

I have sat in the office of a medical director who basically said: "I don't care what the act says. I don't think it is in the best interests of my patient. I will not do it." That is despite having an advocacy program. I think they also need to hear from their peers. They need to hear from other groups, "No, you must behave according to the law."

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Mr J. Wilson: On your point 2 on investigating complaints, the way I read sections 24 to 27 or so -- tell me if I am wrong -- if someone submits a written complaint, a panel shall be struck. On your point about the panel not giving reasons if it does not take any action, I see there is a section here that says that the panel must give a copy of its reasons if the panel decided to take no action with respect to a complaint, or to do anything under the previous paragraphs. Is that satisfactory? Have you had a chance to look at that?

Mr Giuffrida: I am conscious of the fact that the concerns I am raising in item 2, may not be completely amenable to resolution in legislation. Some of it is just practice, and the college of nurses, to its credit, has begun publishing in full many of its decisions -- anonymized -- and it is communicated to all members. It is a very open, progressive policy. My concern is that the wording of them is not terribly responsive, and I am not quite sure how you legislate that.

What I understand to be the system is that the person within the college who does the investigating then reports back to another body which does the deciding. I am not sure why that is so. It would be, for example, as if a judge heard all the testimony of the parties and then referred the final decision to someone else who was not in the room at the time. I am not sure why that is so, why it would be wrong for the investigator to form an opinion about the possibility of success, if this were to be referred to discipline, and to share that with the complainant.

The Chair: Thank you very much for your presentation, and we will look forward to the brief you will be tabling with the committee in due course.

SHELLEY O'NEILL

The Chair: I call Shelley O'Neill. Welcome to the standing committee on social development. You have 10 minutes for your presentation, and we would ask you, if you wish to leave a few minutes for questions.

Ms O'Neill: My name is Shelley O'Neill and I am a registered nurse. I am employed in a recovery room at Women's College Hospital. I would like to thank the committee for the opportunity to discuss the Regulated Health Professions Act.

I am here today because I care about the direction in which my profession is heading and its impact on the patients I care for. Many nurses, including myself, have always referred to our certificate of competence as the licence. When I understood the full implications of being licensed, I could easily see why this profession has been forced to accept the role of handmaiden.

It is well documented that I can do 60% of what a doctor does. It does not take two sticks to rub together to see why doctors, pharmacists and dentists were originally licensed, and nurses were left to become registered. It was turf protection at its finest. So when I say to you that as a nurse I want to be licensed, why should I be any different to doctors, dentists or pharmacists, who have up to now protected and created a monopoly.

The education of a nurse is done in a very broad, general sense. We are educated to see the patient as a whole. Nurses impact on many professions and vice-versa. For example, on Saturday night I had a patient who came into recovery room after having his gall bladder removed. My biggest claim to fame in the recovery room is airway management. The act of managing respiratory therapy, as I understand it, is not listed for nursing. Airway management is the first thing that happens in recovery. The patient gets oxygen, and is usually placed on some form of monitoring. The scope of respiratory management is listed for respiratory therapists.

The act of communication is not listed for nurses in this legislation. The first thing I say to a patient is: "one, you are okay. Second, you are in recovery room and your operation is finished." I do not know if any of you have had operations, but what is the next question that comes out of your mouth? You usually ask first, "What did they do to me?" If I tell the patient that his gall bladder is out, then I am helping him reach a conclusion about his diagnosis.

The act of communicating is essential in recovery room. So now the patient requires something for pain, and he has allergies to the common drugs used for analgesics. At 2 am there is no pharmacist, and I am then dispensing a medication from a night cart. At this point, it is very clear what act I am performing, and I really should not be performing.

I think I have got this patient all sorted out. He is comfortable. He is informed, but he is complaining of a sore back. After two hours on a stretcher, I would have a sore back too. According to this legislation, I would see performing a back rub as interfering with the scope of practice and acts of a massage therapist.

Just to finish off, the patient's wife has gone into labour because of the stress of the situation, the nurses in obstetrics cannot find a doctor and she does not have a midwife. Now what do we do. Who is going to manage the labour?

I can go on and on, but these are everyday occurrences I go through as a staff nurse in this province.

I have no desire to create a monopoly, and in fact appreciate the expertise of other health care professionals. As a nurse, it is impossible to have the knowledge base of drugs a pharmacist would have, but I am certainly glad they are available to answer my questions. In terms of massage therapy, I have a limited knowledge base but the principle that massage therapy is comforting is something we can agree on wholeheartedly.

Nurses must be licensed. It is not for selfish means. Other provinces in this country have licensed their nurses, and why Ontario must remain in the dark ages is beyond me. My profession needs to be licensed. We need a legal right to define our scope of practice. As a nurse, my practice overlaps with a great many professions because I am a generalist who sees the patient as a whole.

As a nurse I diagnose, and because I am the health care provider who is there 24 hours a day, it is logical to assume I will be able to identify the needs of the patient and make arrangements for the appropriate health care provider.

In order for this profession to flourish and survive, it must be given a legal right to define its scope. The elusiveness of being a professional body is not found in higher education, but in the ability to function freely within its scope of practice. The legislation makes me feel compromised as a practising nurse, and if I cannot practise freely then the patient care in this province will be the loser.

The Chair: Thank you very much for your presentation. I have a request from Mr Wessenger to clarify on behalf of the ministry. Is that agreed by the committee? It may use up some of the time.

Mr Wessenger: Yes, I would like to have ministry staff indicate some response to this.

Ms Bohnen: Some of the speaker's concerns might be resolved by recognizing that the scopes of practice described for the other professions do not in any way detract from the scope of practice of nursing. The fact that some activities are described, such as the scope of practice of respiratory therapy, certainly does not remove it from the scope of practice of nursing, which is expressed very broadly in section 3 of the Nursing Act and it is the scope of practice that was collaborated on by nursing organizations.

Nurses have a much longer list of controlled acts than any other profession, and I guess medicine and dentistry, and those can be performed on the order of the physician, or on the order of a qualified person who may, in the circumstances to be set out in regulations, be a nurse. So within the framework of this new regulatory model, nurses have a very broad scope of practice, because as you say they are generalists and have authority to perform many controlled acts.

Mr Owens: The comment with respect to patient care suffering as a result of nurses not being licensed: I wonder if you could expand on that a little bit. I have some knowledge of hospitals, and as I have stated before the compartmentalization or specialization of medical care makes the stuff with respect to nurses a little bit more problematic. You mentioned respiratory therapists and I think Linda Bohnen just mentioned on the order of physician. Is it easy to find a doctor after 5 o'clock at a Toronto hospital?

Ms O'Neill: It is difficult to find a physician.

Mr Owens: So what do you folks do now?

Ms O'Neill: If someone comes into recovery room and I feel his breathing is compromised, what would I do first? I would put oxygen on and I would put an oxygen saturation monitor on.

Mr Owens: And then?

Ms O'Neill: That is about the extent of what I can do. At this point in time, that is what I will do.

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Mr Owens: You make a note of it that this is what you have done. Do you have to receive permission retroactively for the stuff that you do, and what happens if a physician or a person who is "qualified" refuses to write that order or to give you that permission? What happens then?

Ms O'Neill: I will give an example. If someone was COBD, chronic obstructive lung disease, he cannot tolerate high levels of oxygen. So if I put that on and something happens to that patient, I may not get an order from the physician to cover it, that says I have done it.

Mr Owens: Which puts you in jeopardy in terms of your licence to practise or your certificate.

Ms O'Neill: It is a certificate of competence; it is not a licence.

Mr Wessenger: I think we need further clarification.

Ms Bohnen: The real world, of course, of how hospitals currently operate is that --

Ms O'Neill: I know the real world.

Ms Bohnen: -- there are many standing orders in hospital protocol --

Ms O'Neill: Not ours.

Ms Bohnen: -- that permit staff to operate when somebody who is authorized to prescribe or authorize some other invasive activity to take place is not present. That is, in the ministry's view and in the government's view, exactly how they will continue to operate.

Ms O'Neill: Has the ministry ever been in the situation where it has had to accept standing orders? You make an assumption about standing orders and you have no idea of reality.

Mr Owens: If I could pose this question on the record to deal with at the end of the day with the ministry, does the ministry follow up with hospitals to ensure that standing orders are in place, whether they are appropriate, how they are utilized, if they are utilized? I think that is very important, especially with the changes coming to the nursing profession. I think you make a good point that what is on paper is not necessarily what is happening in the field. I would like to know with respect to quality assurance what is going on in the field.

The Chair: The question is noted and on the record. Thank you very much for your presentation.

Mr J. Wilson: I have a couple of questions for the ministry. First, I would like an explanation at some point today, I suppose, of the difference between licensed and registered for nurses. I have a concept of both in my mind, but I am not sure it is what the legal definition would be. Second, I was wondering whether in the College of Physicians and Surgeons of Ontario authority they are allowed to delegate controlled acts to nurses.

JIM FRASER

The Chair: Jim Fraser, welcome to the standing committee on social development. You have 10 minutes for your presentation. We would ask that you leave some time for questions from the committee.

Mr Fraser: Good morning, my name is Jim Fraser. I am a registered nurse practising in the province of Ontario and I am employed at the Toronto General Hospital in the operating room. I am pleased to be here to address some concerns about the Nursing Act with specifics about accountability of nurses.

I would like to thank the various Health ministers and their staff for the lengthy hours they put into preparing this legislation and for the opportunity to have input into the process.

At the onset, as a nurse I must say I was disappointed with the legislation. I had hoped and expected that my role as a registered nurse would be licensed and that my experience and skills would be more efficiently and effectively used by allowing me to do more controlled acts independently.

I believe the legislation neglects to recognize me as a nurse, but most importantly as an autonomous member of the health care team. The legislation puts me in a difficult position to be able to deliver the best possible health care to our patients. The legislation makes it extremely difficult for me to remain a patient advocate when I could be disciplined, fined or imprisoned if I act without an order of a qualified person.

Currently nurses must exercise their judgement in determining whether to carry out treatment ordered for patients and are accountable for exercising suitable judgement. Nurses have been found guilty of negligence for carrying out inappropriate orders. The proposed legislation would enable other governing bodies that have control under the acts to investigate. I have great concerns about this. I could be found not guilty by the College of Nurses of Ontario and by the College of Physicians and Surgeons of Ontario, but still could be prosecuted in a court of law.

I strongly believe that the college of nurses has the necessary knowledge to determine whether a nurse has met the appropriate standards of practice, and therefore the college of nurses should be the only governing body able to investigate complaints about its members.

The government, by amending the Public Hospitals Act to allow registered nurses to be part of hospital decision-making committees, began to recognize the knowledge, expertise and accountability that nurses provide to the citizens of this province. The proposed legislation does not allow nurses to perform any controlled acts independently. I feel this has turned back the hands of time, putting nurses in the handmaidens' role again, only being able to act on the order of a qualified person. Nurses have proven themselves to be competent, qualified and accountable practitioners. If nurses were legislated more independence, duplication of services could be decreased, resulting in a more cost-effective and efficient system of health care.

I also expected, to protect the public fully, that all registered nurses would become totally accountable under the legislation and to their governing body. By "all registered nurses," I mean staff nurses, nurses who are administrators, nursing management, teachers and researchers. It is worth noting that the Canadian Nurses Association has recognized this need by establishing its own standards for nurses who are administrators, educators and researchers. I have attached that as appendix 1.

It is crucial for these nurses to become accountable to their governing body in order for the public to be fully protected. Nursing administration and nursing management are so far removed from the bedside and direct patient care that they may not be making best use of the resources and their decisions may jeopardize the quality of care our patients deserve.

To give you an example, I work in an operating room. When I am working evenings, nights or weekends and the OR is quiet, I have been told by the nursing supervisor that I must go to relieve in recovery room while one of the two recovery room nurses goes to relieve in one of the intensive care units. I make my objection well known to the nursing supervisor that I am not qualified to work in recovery room, which I am required to do by my governing body, the College of Nurses of Ontario. Working for a unionized employer, I have the right to file a professional responsibility complaint or to file a grievance, but in both incidents I must obey and take action following the incident. But most importantly, by placing me in recovery room it has removed me from my specialty and has placed the patients in recovery room in a less than desirable care situation.

My scope of practice for the past five years has been in the operating room, for which I have a post-graduate certificate. All nursing units function under the minimum standards of nursing practice with required expanded roles for their unit certified under "Added Nursing Skills" as set out by the college of nurses and "Sanctioned Medical Acts" as set out by the college of physicians and surgeons. By being put in a highly skilled area such as the recovery room, I am not certified to perform any of their sanctioned acts or added nursing skills, therefore placing more of a burden on the only nurse capable of performing such duties, which results in increased risk of harm to patients and decrease in the quality of care the patients deserve, that their tax dollars pay for, and the high quality of care they have enjoyed in this province.

To cite a further example, if the nursing manager of a cardiology floor does not staff the unit appropriately: There are 24 patients, four of which are on cardiac monitoring. Two registered nurses are ill for the night shift, leaving one registered nurse and two registered nursing assistants to cover the floor for a 12-hour night shift. The nursing manager calls some of her casual staff, but no one can come in, so she calls the evening administrator-supervisor and asks her for staff for the floor. The supervisor says she will do her best.

The nurse coming in at 1915 hours is told by the shift going off that the nurse manager has made arrangements with the evening supervisor for staff to come in and help on the floor. The floor is sent a new graduate nurse, not yet registered, and a registered nursing assistant for the shift. The RN on the floor immediately calls the supervisor and tells her that this is unacceptable because she is the only qualified RN with monitoring skills and cannot leave the monitors unattended. The new graduate nurse cannot carry narcotic keys or give all medications necessary to the patients on the floor, such as intravenous narcotics, some intravenous medications that you have to be a registered nurse and certified to give. The cardiology nurse has to respond to all cardiac arrests in the hospital for the night shift, and that is impossible because of the inappropriate staffing of the floor.

The RNAs are limited by their educational background, therefore limiting their scope of practice. They can provide basic care only to patients and will not risk their registration by performing skills outside their scope of practice. The patients in this situation, because of inappropriate staffing, have had their lives put in jeopardy, but also the RN in charge of the floor has had her registration with the college of nurses put in jeopardy because she is the only one in this situation who is totally accountable to the college of nurses, because currently nursing administrators, management, educators and researchers are not accountable to the college. I refer you to appendices 2 through 5.

In closing, I would like to urge the committee to review my concerns and added appendices. I strongly believe that all professions should be licensed with definite scopes of practice, therefore ensuring accountability of their members; that registered nurses who are administrators, educators and researchers should be included in the legislation to ensure that they become accountable in order to protect the public; that the legislation should be amended to enable registered nurses to perform designated controlled acts independently; and that nurses remain the patient advocate to ensure patients receive the high quality of care they deserve as citizens in Ontario.

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Mr J. Wilson: Thank you very much for this excellent presentation, and in particular the description of a night on the hospital ward. I was wondering if you could help me in trying to understand the difference between licensing and registration. The sense I am getting on licensing is that if the nurses were licensed, the college would be able to define, really, its own scope of practice. Is that your understanding?

Mr Fraser: Yes. By being able to define their own scope of practice, hopefully with licensing we would be able to bring nurse administrators, educators and researchers in and make them totally accountable.

Mr Wessenger: I think I would like to have that clarified for the committee.

Ms Bohnen: Under current legislation some professions have a licence to practice. That means that only members of the profession can perform any function included within the scope of practice, such as medicine. Other professions are registered professions or certified professions. Nursing is currently a registered profession because nursing does not have an exclusive scope of practice, such as medicine. Other professions are registered professions or certified professions. Nursing is currently a registered profession because nursing does not have an exclusive scope of practice, but nurses have the benefit of exclusive use of the title RN, registered nurse.

This legislation abolishes the distinction between a licensed profession and a registered profession, because there are many problems with maintaining a system based on that distinction. But even if you had a system in which professions were still licensed, the profession would not control its scope of practice. The Legislature controls its scope of practice by writing in the Nursing Act or the Medicine Act what the scope of practice of the profession is. Under this new system, every profession has a described scope of practice. The controlled acts then go on to list which hazardous activities are restricted to members of the various professions. So we have really done away with that distinction between licensing and registration.

Mr J. Wilson: Thank you; that is helpful. I had a similar discussion with nurses yesterday on that. Given that we have gone to this model, the scope of practice model, and I do not think the government is going to change its mind and go back to licensing -- this is what I told nurses yesterday, for instance -- would you be satisfied if we tried to accept some of the amendments that have been brought to us by the union, for instance, in expanding the scope of practice for nurses? I think that is the only remedy we can come up with as a committee. Would you be prepared to come back to us with some suggestions on where you feel you are not being given authority now and should be given authority, given that you have given us a very good example of what it is like on a ward?

Mr Fraser: Yes, I would be willing to come back with amendments.

The Chair: Let me clarify for you that all future correspondence would be in writing. When Mr Wilson asked if you will come back, it is by writing and communicating with the committee your thoughts and ideas as the hearings progress.

BRUCE CAIRNIE

The Chair: I would like to call now Bruce Cairnie. You have 10 minutes for your presentation and we would ask that you leave a few minutes for questions from the committee at the end. If you could begin now, we would appreciate it.

Mr Cairnie: I am very pleased to be able to be here with you today and to present to you my feelings about the Regulated Health Professions Act as a Presbyterian minister and also as a concerned member of the community.

I feel basically that the health professions act has a sound beginning and a good thrust at its introduction, but I have a concern about the way it will affect the ministry I carry out in the community in which I live, and the way it will also affect all other ministers in the province. We routinely find ourselves in situations where people ascribe a great deal of trust to the things we say. That is the nature of our function. Routinely people, when they are unwell, come to us and ask: "What is wrong with me? Why am I feeling this way?" We routinely respond and could be committing what might be called a controlled act, because seeing symptoms in a person, we respond with our assessment of what that might reveal in that person. We cannot diagnose diseases, but the definitions of disorders and dysfunctions are such that many things we deal with are covered. I would like to explain three situations and show you specifically how they affect people's health.

As a minister I work regularly with people who grieve. Customarily we think of grief in terms of bereavement, but it is also a common response to any sense of loss: a loss of work, of friends, of a marital partner, of a community through a move to another area. All of us grieve in different ways, but there are some common signs of grief that arise. They can be loss of appetite, loss of sexual desire, restlessness, insomnia, all sorts of different things like that, things for which we would customarily consult our doctors. But as I am told of such a thing by a person who is grieving, it is responsible for me as their pastor to see if there is some connection between their loss and the symptoms they are displaying. As I talk with them, those things, those connections, come to light.

For example, a woman who was bereaved came and said to me, "I'm feeling like I'm getting ill now." We began to talk about what it meant that her husband, to whom she had been married for many years, had died and she was suddenly alone. It was her loneliness and her sense of empathy with his sickness that she was beginning to discover in her body which was affecting her health. But as we talked, she found that those symptoms began to lessen and disappear. It would be irresponsible for me to say, "You should not go and see your doctor," because the person could be genuinely ill, but at the same time, if we veil the symptoms that arise with antibiotics or other medications or even just sleeping pills, the real healing that the person needs in responding to his loss cannot happen. That is a concern I have.

Who but the minister, I wonder, in the community in which I live especially, a town of about 2,000 people, is capable of dealing with grieving people? Our services are not duplicated in the town where I live.

The second situation deals with the problem of guilt. Some people find themselves burdened with an overpowering sense of guilt and can find it affects their health through the stress and anxiety that it contributes to their lifestyle. Again they might come to me. I do not even mean here just people who are members of the two congregations I serve, but people in the broad community. They could come and want to talk. I cannot turn away from them, but instead I propose that we talk of forgiveness and of how God's forgiveness in particular can affect them body and soul. As the person receives forgiveness in time, when he is able to do that, he might be freed from the anxiety and stress and the wear and tear it puts on his physical health. It is a day-to-day problem for many people, guilt, whether it is real or perceived, and they need to deal with it. It can affect their health, but it is a condition primarily of the soul and it demands the attention of a pastor far more than a doctor.

A third situation is one which might arise more in my community service on a broad scale. It is very normal for me to be invited into homes when I do not know the people at all, or to speak with people as I walk past them on the street. It is not unrealistic at all to envision myself being in a situation where I can easily observe evidence of overdrinking. It could be just after lunch and already the person is smelling very strongly of alcohol. As a person who is commissioned by the church to care for the members of that church and the whole community, it is responsible for me to investigate as I can and observe this person to see if he really does have a problem with his drinking, and then, making a conclusion, suggest to him, if I think there is a problem, that he deal with it through Alcoholics Anonymous or some other channel.

In doing that I would be anxious, if this legislation were passed, that I could be found guilty of doing something wrong simply in looking out for the better interests of an individual and the community, because I would have made a diagnosis and communicated it to a person.

All of these are routine situations that ministers encounter. They are not things that are fanciful. My colleagues and I encounter them all the time. But if we were to overlook them, I sincerely believe we would be abandoning the posts we are called to as pastors.

I also have a secondary concern which is purely a practical one. In the small town where I live, none of these services are duplicated. They are available maybe 40 minutes away, but people are not so likely to drive that far. They need them in their area, and the clergy are the one group of people in town who are able to offer this.

In proposing the diagnosis clause in the act, I believe the protection of Ontario's population, which is a valid concern, is being taken too far. I fully agree people must receive only genuine health care, but I maintain the pastor's work is part of that. No responsible person works beyond the level of his competence or outside his expertise. I do not diagnose diseases, but I can work in diagnosing disorders and dysfunctions. I am competent to do that.

Surely this work is part of the constructive and desirable role the clergy play within the community. Theologically I view it as part of the work we do in establishing God's kingdom, a place where wholeness and reconciliation are achieved. Today we are charged with working towards that, and so by backing away from what might be determined as controlled acts, I back away from something to which God has called me. That is where the crisis of conscience arises for myself and other ministers. Do we step back and obey the government we have elected and let our communities down, or do we go ahead with something that is a proper part of our caring presence?

It is a complex question, but I believe my answer is simple. I must obey the higher authority. With all due respect to my government, I must obey God, who has given me a particular role. I cannot step out of the role He has given me.

I appeal to the standing committee on social development to recognize the predicament in which the clergy of Ontario will find themselves should this legislation be passed with its current wording. We will find that we are at risk before the law for fulfilling the function we serve properly as caring people in the community.

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Mr Hope: These are some of the concerns I brought up at the beginning of the hearings. I think it is important that the ministry address some of the concerns this individual has put forward dealing with some of the issues I talked about. I think some clarity needs to be brought across.

Ms Bohnen: I believe this is the first speaker who is a member of the clergy who has addressed the committee so far. You have heard the clerical aspect of the problem in the controlled acts dealing with diagnosis, and in distinguishing between those diagnostic communications that only certain care givers like physicians should be able to provide and all of those other communications that the clergy must be able to continue to provide -- the counselling services that are necessary and must be protected. In the end, I think that after hearing all of these concerns, you will then be in a position to suggest possible changes to the wording so that activities such as counselling provided by the clergy can be protected.

Mr Hope: I guess the concern you have dealing with the language in itself is "diagnose," or is it "disorder" and "dysfunction"? Is it all three or just two of the three?

Mr Cairnie: All three. Plus, in the role I play, I am in a circumstance where people perceptibly rely on what I say. That is the other part of the introduction. I think it is section 26 that says -- I could do it in the circumstance where people do not rely on what I say, it sounds like, but if they do rely, I could be in trouble. It is impossible for me to step out of that situation.

Mr Beer: I guess what is difficult with this, in relation to yourself, is that one can think of other people, teachers for example, who may also at times be in that kind of situation. In terms of the kind of exemption, you will recall there was a discussion of a harm clause. Do you have a definite view as to how to handle this, or just simply that it needs to be clarified?

Mr Cairnie: I am not sure I have a specific solution. I am torn between appealing for an explicit exemption for clergy and recognizing the concerns that other groups have. The reason I am torn is because I feel there are two different sources of authority we are functioning under. I function with a spiritual authority, whereas other groups may function with a societal authority. That is where my indecision arises. I would like to ask for an exemption, but in sympathy to the other groups, I am not altogether willing to say that is what I want.

Mr Beer: As long as what is achieved is that you do not have to be concerned about it.

Mr Cairnie: Yes, as long as what is achieved -- and that might sound selfish -- but that is my big concern, that I am allowed to function without any anxiety before the law.

The Chair: Thank you very much for your presentation. We appreciate your coming before us today.

SANDRA LECCE

The Chair: I call Sandra Lecce. We have 10 minutes for your presentation and we ask that you leave a few minutes, if you will, for questions from the committee at the end.

Ms Lecce: My name is Sandra Lecce and I am a general staff nurse at a 300-bed community hospital in northwest Toronto. I am pleased to have the opportunity to address my concerns regarding this proposed legislation, the Regulated Health Professions Act.

After reading the proposed legislation, I was disappointed and dismayed. Instead of an expanded role for nurses, we once again find ourselves not being recognized as an equal and participating member of the health care team.

I understand that the intent of the legislation is to protect the public from unqualified, incompetent and unfit health care providers. In order to accomplish this, the legislation must enable nurses to practise safely and efficiently.

Under the proposed legislation, "The practice of nursing is the assessment of, the provision of care for and the treatment of health conditions by supportive, preventive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal function."

Under the existing Health Disciplines Act nursing is not licensed and there is no defined scope of practice. Now, instead of licensing any professions, acts will be licensed and these are called controlled acts.

Any member of the public can assess, provide care and treat health conditions as long as they do not call themselves nurses. Anyone, according to this proposal, can administer an oral medication. Does this mean that the camps in Ontario that currently employ nurses will not need to hire nurses next season? Will they simply hire a member of the public to treat their campers and save on the salary they would normally pay to the nurse? Will this legislation affect the camping association standards?

There are 13 controlled acts listed in the legislation, only three of which nurses would be authorized to perform while engaging in the practice of nursing. The committee is well aware of the 13 controlled acts. Nurses are authorized to perform the following while engaging in the practice of nursing: the second controlled act, "performing a prescribed procedure below the dermis or a mucous membrane on the order of a qualified person."

Nurses in the home sector, who often only have doctors visit once a week, will not be able to treat a bedsore. I know that when my grandmother fell and broke her hip and was eventually confined to the infirmary of a nursing home, it was the nurses who diagnosed and treated any bedsores. When she developed mouth cankers, it was the nurses who initiated the salt water gargles and mouth swabs that helped to cure them. Would the same be true under this legislation?

"Administering a substance by injection or inhalation" is number five. The emergency department at the institution where I work can be very busy. It is a common occurrence to be dealing with two or three urgent situations simultaneously. Does this mean that if the doctor is busy treating a cardiac arrest, a child who comes into the emergency department in the middle of an asthma attack cannot even receive oxygen because the physician is too busy to see the child and order it? If the nurse administers it without an order, is she facing a fine or imprisonment? If she does not administer it and the patient does poorly and suffers damage as a result, will she face a lawsuit?

At the hospital where I am employed we also have a critical care nursery. Can the nurse administer oxygen to a baby in distress? If it takes 15 to 30 minutes to get a response from the doctor, this could do irreparable harm to the infant.

Does this act include ongoing parenteral infusions, such as IV solutions, blood or blood products, medication through peripheral, central and arterial lines? It is not clear in the act. As an IV nurse, this concerns me. I believe these acts should be controlled. At the present time, we must be certified for these acts.

Will the radiology technician inject dye in the X-ray department? Does he or she know the difference between a dye allergy and an insulin reaction? Will I be restarting more IVs because the line has run dry and become occluded in the X-ray department?

Number six is "putting an instrument, hand or finger" -- on the order of a qualified person -- "(i) beyond the external ear canal, (ii) beyond the opening of the nostrils, (iii) beyond the larynx, (iv) beyond the opening of the urethra, (v) beyond the labia majora, (vi) beyond the anal verge, or (vii) into an artificial opening into the body."

If the ICU doctor has not yet written orders on a fresh tracheotomy patient or a newly intubated patient, the ICU nurse will not be able to suction. These nurses who defibrillate and administer lifesaving agents in life-threatening situations must now request an order for an aspirin or a suppository. At the same time, according to this proposal, any member of the public can administer oral medication. It is not a controlled act.

Controlled act number one involves communicating a conclusion identifying a disease, disorder or dysfunction. This is not a controlled act for nurses. Until recently, nurses in our day surgery unit routinely obtained consents and in our outpatient department, chemo clinic and radiology nurses are still obtaining the consents. If we cannot discuss it, how can we ensure that the consent obtained is informed? Even in cases where the doctor obtains a consent, it is still necessary to ensure that the patient understands the procedure.

When I worked in the OR, I once had a patient who was to undergo a bowel resection with colostomy. Upon talking to the patient, I realized that he did not understand what a colostomy was. Under this legislation I would not be able to discuss this any further with the patient. I would have to go searching for the doctor to explain the procedure to the patient again, all the while putting up with his glares and sighs, and then I would have to endure an earful about not doing it myself and dragging him away from something important.

Number eight is prescribing and dispensing medication. In my hospital, the pharmacy is open from 8 until 5. Will the hospital have to hire another pharmacist for off hours? If so and he is on call, will the patients have to wait up to an hour for the necessary medication? Can the staff nurse on the floor no longer give medication from the stock cupboard without every RN being certified?

Number 12 is managing labour and conducting the delivery of a baby. Nurses are presently involved in various aspects of labour and delivery and in many cases are the only health care givers present until the actual birth. Many experienced obstetrical nurses can manage labour and deliver babies better than most doctors.

Four years ago I was present at the labour and delivery of my godchild. Labour progressed very quickly and my goddaughter arrived before either the obstetrician or the anaesthetist. She not only arrived safely, but her mother did not even suffer any perineal tearing. If it were to happen under this new legislation, would the nurse simply have to watch? For the sake of the unborn children, I certainly hope not.

What happens to exercising reasonable knowledge and skill and care criteria? What happens to standing orders? All of the controlled acts are to be done on the order of a qualified person. How many qualified persons will be writing orders on the same patients? It will be the nurse who is left holding the bag.

Many nurses have been forced to work in situations where they are understaffed. I would like to look at the following hypothetical situation.

I am short-staffed and not able to give the required care to Mrs Jones. Mrs Jones's family reports the incident to the college and my practice is investigated. At the end of the process, I am found guilty of incompetency and my registration has a restriction placed on it. The family also reported the head nurse, the co-ordinator and the VP of nursing, as they did not provide an adequate staffing complement. Their registrations are restricted, but they appeal the college decision. On review, the courts decide that the college has no jurisdiction over the head nurse, co-ordinator or VP of nursing because they do not give direct care.

The definition of "practice of nursing" in the proposal does not include the components of administration, education and research. Judicial review under the present Health Disciplines Act has been found time and time again to apply only to those giving direct patient care. Administrators, educators and researchers in nursing are not accountable to the college; only those giving direct patient care are accountable.

This legislation does nothing for the nurses to relieve my profession from the triple jeopardy we find ourselves in while engaging in the practice of nursing. I am accountable to my patient. I am accountable to the college of nurses to maintain the standards of nursing practice. I am accountable to my employer. The employer must share the accountability for what a nurse does or does not do as a result of insufficient staff or budget.

In conclusion, I would ask you to consider that, all professions should be licensed to practise with a defined and specific scope of practice, that researchers, educators and administrators should be accountable for their practice, and that the RHPA does not protect the public.

Health care will become more fragmented. Nursing is the only profession that looks at a patient as a physical, mental and spiritual being, as a whole person. Nurses are with the patient 24 hours a day, 7 days a week, not 9 to 5, Monday to Friday, and we are the hands-on practitioners. I love my profession and I deliberately chose it. I have worked as a nurse full-time for 17 years. I wish to contribute more, not less, to the care of my patients.

The Chair: The committee very much appreciates your presentation and I know will take it into consideration during its deliberations. The committee now stands adjourned until 2 this afternoon.

The committee recessed at 1205.

AFTERNOON SITTING

The committee resumed at 1404.

ROYAL COLLEGE OF DENTAL SURGEONS OF ONTARIO

The Chair: The standing committee on social development is now in session. I call on the Royal College of Dental Surgeons of Ontario. Begin your presentation by introducing yourselves and leave a few minutes at the end for questions from members of the committee. You have 20 minutes for your presentation.

Dr Beyers: My name is Dr Beyers, and I am the president of the Royal College of Dental Surgeons. Mr Bromstein is our legal counsel and Dr Dunn is formerly a registrar of the college. Dr Dunn is also the founding dean of the dental school at the University of Western Ontario and the immediate past-president of the Royal College of Dental Surgeons. He will begin our presentation.

Dr Dunn: The royal college is most appreciative of this opportunity of presenting a few highlights from its submission which we have left with you today.

The royal college is the governing body of the dental profession in Ontario. We are not entirely lacking in experience because at the first session of the first Legislature in 1868, the college was formed by the Dentistry Act of Ontario. Appearances to the contrary, I was not around at that time, but it has been functioning fairly well since that period.

I would like to say too that the college has worked harmoniously and co-operatively, both with the review during the developmental stages of this and with the ministry, particularly the professional relations branch, since the report was presented.

The history of this legislation, in my view, is probably unique in the sense that it was established, first of all, through the efforts of the then Progressive Conservative government. The report then was presented to a Liberal government in which Bill 178 eventuated with your distinguished name attached to that, Madam Chair, and then subsequent to that, Bill 43, which is now under discussion, plus the associated acts. I have to say that when one reviews 178 in juxtaposition to 43, there are only something in the order of 37 or 38 amendments, none of which, in my judgement, is a substantive one.

We are not so naïve as an organization as to think this is a statute that is going to be terribly volatile, because there is already a pretty reasonable consensus in terms of the approach that is being taken.

Because the legislation which is proposed in this bill is, again to the best of my knowledge, unique in the entire world -- we know of no other jurisdiction anywhere which approaches the governance of health professions exactly on the basis of Bill 43 -- therefore, we urge upon you, because we have only a very brief time, to read the submission which we have offered. We think we have done this responsibly. We are speaking on behalf of the college, and we recognize absolutely, unequivocally, that our role is one that must serve the public interest and conscientiously we have attempted to do that.

It is no secret that we are concerned about the controlled act concept. We are particularly concerned about the fact that the statute or the bill does not appear, at least to us at this moment, to deal effectively with the prosecution of illegal practice, that is practice which is inimical to the welfare of the public.

You may recall that in the review report section 27.04 was proposed which was to address itself to the enforcement; prosecution, if you like. That was eliminated in Bill 178 and it still continues not to be present in Bill 43. Although we had some problems with 27.04, I would again have to remind you that in December 1989 the Ministry of the Attorney General, through the crown law office, having been requested to present an opinion in this regard, said that it was vital that there be something akin to 27.04, but the crown law office did indicate that 27.04 did not do it.

We have proposed in appendix A a possible substitution for 27.04 and we would direct that to your attention because we think, and we agree with the crown law office, that this is absolutely vital to a consideration of this issue.

We are concerned also about the issue of diagnosis. We recognize that this has been somewhat controversial. We are a little bit concerned this is not simply a communicating of a conclusion and that sort of thing, but I have to tell you that diagnosis is absolutely central to what dentists do to pursue the treatment of a wide variety of treatment requirements. Without having previously done an effective diagnosis in our judgement would be totally irresponsible professionally. So we are simply saying that we believe that diagnosis is fundamental and that it should be retained as a controlled act.

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In respect of controlled acts for dentists we have two observations. It comes as no surprise that dentists perform services on teeth and yet we can find nothing in the controlled acts which deal with this. And there are a wide variety of activities such as pit and fissure sealants and the like which we believe really need to be addressed. We are recommending an additional controlled act of performing procedures that alter the surfaces of teeth and we would ask you most objectively to give some consideration to that.

Also I have to advise you that dentists do use various forms of energy to perform procedures within the oral/facial complex: lasers for cutting both hard and soft tissues, cauteries, electric stimuli for pain control, electrical pulp testing and the rest of it are all procedures which dentists perform. And we note that for physicians there is an authorizing act applying or ordering the application of prescribed forms of energy and we believe that this should apply as well to dentists and therefore that would need to be tidied up in Bill 49 as well.

We are concerned about the controlled act as far as denturists are concerned. Denturists currently are legally permitted to fit and dispense full and upper and lower dentures, and under the supervision of a licensed dentist, are able as well as to deal with partial dentures; and these are prostheses that utilize the patient's own natural teeth for retention in the replacing of one or more missing teeth. And to perform removable partial denture service properly, a clinical and X-ray examination of the adjacent teeth and soft tissues in our view is essential.

It is necessary too that the supporting teeth be prepared by cutting or grinding and not infrequently built up by a restoration of some kind in order to provide a path of insertion for the removable partial denture and for its retention and support and for a proper bite to be achieved between the upper and lower jaws. Such needed changes are irreversible and soft tissues too frequently require attention or surgical alteration. And inasmuch as the controlled acts for denturists does not differentiate between full dentures and partial dentures, we believe that such a fundamental departure is totally inappropriate in the absence of technical submissions to be carefully and conscientiously considered.

The bill as you know provides for an advisory council. If you look at subsection 11(c) you will find that the advisory council does have an opportunity to consider these, and we would strongly urge that the status quo be maintained until such time as the advisory council can receive technical submissions and deal with the issue at that time.

I think it is fair to say too that we have a modest concern with the powers of the minister. While we are quite confident that current ministers and past ministers are not going to exercise powers unreasonably, the fact is that the statute in effect says that the minister has the power to do absolutely anything which a council of the college has, and if you extend that to its, maybe, unreasonable limits: the power to appoint a registrar, the power to buy and sell property, the power to send things to discipline. And it just seems to us that given the fact that slightly less than 50% of the council will be appointed by the Lieutenant Governor in Council, considering the fact that the regulations are only regulations when approved by the Lieutenant Governor in Council, considering the fact that any bylaws must at least be filed with the ministry, at which time presumably observations and comments can be made, we think that expense of power is something that is inimical to the self-governing concept which we understand this entire report has been based upon.

We have made recommendations in our submission in respect of manner of publications of discipline hearings. What we are indicating in this is that there should be some flexibility so that these issues can be brought to the attention of the profession without the necessity of having them lodged only in annual reports. The publication of members' names is another concern of ours. There are certain instances our discipline committee could tell you about in which we have been advised strongly by psychiatrists that if certain names had been published at a certain time, the results could have been extraordinarily serious.

We are concerned about the way the statute talks about referral of complaints to the discipline committee. We believe as currently worded the public is being better served, rather than the wording that now applies, and we have made observations in respect of that.

The power of the registrar to investigate is another area that concerns us, because when that happens usually it is necessary for some immediate action to be taken on the part of the registrar because of some serious difficulty. The current bill requires the registrar to get the approval of the executive committee, about five people, sometimes very, very difficult to get together in a short time. We are recommending that the registrar, if you feel this is necessary, could be any one of the president or the vice-president or the executive committee.

The sexual misconduct in terms of witnesses: We totally support the view that the identity of that person should be maintained, but we also suggest that in the event the charge being brought against the individual is not a valid one, the same should apply to the individual against whom the charge is being laid. On a finding of guilty of course it could be published anywhere.

The final comment I want to make is simply that we strongly support the governing board of dental technicians in respect of a controlled act for dental technology. I cannot overstress the importance of the registered dental technician in terms of the quality of prosthetic services dentists perform. I think it is essential that somehow or other the services technicians render can be recognized by some controlled act. That, Madam Chair, is a very brief summary and we would attempt to respond to any questions which you or the members of the committee would pose.

Mr J. Wilson: Thank you for the presentation. You have given us a lot to think about, but on powers of the minister you do make a good point, that it does seem rather strange that the minister would have the same powers as the council. It does seem to cut into the self-regulating principle. Can you give us any practical examples where you could see a conflict there?

Dr Dunn: I mentioned two or three things. We cannot even imagine the minister determining who the registrar is going to be, our chief administrative officer. We would be concerned that, for the referral to discipline, which is an extraordinarily important area, there be good checks and balances in that system to make sure we are acting appropriately.

If the minister has the total power of the council, the minister unasked, uninvited could indeed do this. All I am saying is that anything the council can do according to the way it is written could also be done by the minister. As you said, I do not think that reflects what self-governance is all about. We do not mind the checks and balances in terms of regulations, and even the minister can require the council, giving it 60 days, to enact regulations in certain areas. We have no problem with that one either, but we have problems with this one.

Mr J. Wilson: Except that it gives you 60 days and if you do not, then the Lieutenant Governor in Council does it anyway.

Dr Dunn: That is true.

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Mr Beer: I would like to pursue the question around the denturists. The other day as well, I believe, a representative from the dental schools was in and made the same point. I just want to make sure I understand clearly what is at stake in this case. Basically, you want to ensure that a denturist performing or preparing a partial denture would be done under the guidance or direction of a dentist. Can you just explain a little more clearly? The present provision allows them to dispense partial dentures, is that correct?

Dr Dunn: No. Partial dentures under the supervision of a dentist. With full dentures, of course, they are totally, legally within their jurisdiction to do that.

Mr Beer: All right. What is the key thing, in the view of the Royal College of Dental Surgeons of Ontario, that they cannot do or why they are not able to do the partial, what element of training or education? Why does that have to come into play here? I gather it was Alan Schwartz who recommended that change at the end of his review, and we are going to be meeting with him later. I just want to make sure I understand because it is the one place where there has been a change in the scope of practice.

Dr Dunn: Perhaps a practising dentist could deal with that.

Dr Beyers: My understanding at the present time is that the training of denturists does not qualify them to attend to natural teeth and also the supporting structures of the natural teeth, the bone support and the gums which surround these teeth. From a practising dentist's point of view, you have to understand that the patients within my practice who currently wear partial dentures I would classify loosely as my critical-care patients, in the sense that they need more detailed and more careful attention, if you will, in order that the partial denture does not have an effect of causing deterioration to the natural dentition and to the surrounding bone and gums.

Mr Beer: What would your role be, then, in working with a denturist? How would that work? Would they send a patient to you or would this be a denturist working directly with you if they were to do a partial denture?

Dr Beyers: In current legal practice in Ontario there are some denturists who have a joint practice relationship with dentists. The dentists do the diagnosis and evaluation and tend to natural teeth and supporting structures and then the therapist or the denturist performs the impressions and the mechanical work to deliver that partial denture.

There is a strong need for the public to understand how important it is to maintain those natural teeth. There is a very common clinical entity out there where a member of the public is wearing a full upper denture and could use a partial lower denture. If they seek the services of a denturist without seeing a dentist first to get this partial lower denture, they may assume that all of their needs are being met and that they are receiving safe treatment. The fact of the matter is that these natural teeth are not being addressed within the isolated practice of a denturist.

Mr Owens: In terms of your submission with respect to the publications of member's names after being disciplined, what would you recommend as a check the public could count on if the college decides not to publish a practitioner's name? In the area of sexual assault or sexual misconduct, I think there is a fine balancing act we are following here: the right of the public to know that this dental practitioner is guilty of sexual assault.

Mr Bromstein: I think the college is looking for some flexibility where, during a hearing -- and it is usually during the penalty portion of the hearing -- there is clear evidence under oath given by experts testifying to the fact that the publication of the member's name would cause certain irrevocable harm. In the instance that Dr Dunn was referring to, we actually had two experts testify that it would likely result in the suicide of an individual.

To bind them to publish, if they provide for suspension, for example, would effectively put them between providing a suspension, which might be the proper penalty, but then requiring the publication of the name or providing for some lesser penalty in order to avoid the publication and the possible result of harm to the individual. They are just looking for some flexibility in those very unusual circumstances. The suggestion the college made was that there be a power to exempt in circumstances where the discipline committee is satisfied, based on the evidence, that the publication of the name would result in significant physical and mental harm. We tried to clarify -- it is legal language -- to provide some suggestion to the committee in that regard.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee today. All members have received a copy of your brief.

ONTARIO DENTAL HYGIENISTS' ASSOCIATION

The Chair: I call on the Ontario Dental Hygienists' Association. Please come to the table. Start your presentation by introducing yourselves. All have received a copy of your presentation. You have 20 minutes. We would ask that you leave a couple of minutes at the end for questions from members of the committee if you wish. Please begin now.

Ms Dempster: I would like to begin this presentation by introducing the members sitting at this table: Margaret Walsh and Carole Ono, and my name is Laura Dempster. Collectively we represent various factions of dental hygiene, including public health, education and clinical practice. We are all members of the ODHA's steering committee for the College of Dental Hygienists of Ontario, of which I am the chair.

I would like to take this opportunity to thank you, Madam Chair, and the committee for giving us the opportunity to give this presentation and let you know that we will be addressing the key points that we feel are necessary and are drawn out in our brief. I would like to say at this time as well that the ODHA continues to be supportive of the proposed health legislation, and we certainly look forward to a new, innovative health care system at such time as it becomes proclaimed.

I thought I might start off by telling you a little about the dental hygiene profession. Dental hygienists are licensed health professionals required to pass a licensing exam upon completion of their educational program. They provide a comprehensive range of preventive and therapeutic services. We are currently regulated by the RCDS, the Royal College of Dental Surgeons of Ontario, but we are looking forward to self-regulation under the Regulated Health Professions Act.

We are predominantly a female-dominated profession and work in collaboration with other dental health care personnel, primarily dental assistants and dentists. As dental hygienists, I think we are particularly concerned about the delivery of dental health care to all segments of the population, but especially those which are currently not served or are underserved. By those we are also indicating groups that tend to be at high risk to dental disease. Seniors is one group, particularly those in chronic care facilities, in nursing homes and those who are home-bound.

Certainly, with the decline in dental caries, there has become an increased focus on periodontal disease. Some of you might know the term more familiarly by the word pyorrhoea, which is what it used to be called. With that increased focus on periodontal disease, there is now an increased demand for dental hygiene services. Certainly, looking at the demographics, it indicates that there are going to be an increased number of seniors in the near future, one of those high-risk groups. The epidemiological studies tend to indicate that those seniors are going to be retaining those teeth and requiring more preventive and periodontal services, which are the services dental hygienists primarily provide.

This, then, I think represents a market for dental health care that we did not have previously. A lot of people lost their teeth by the time they reached their senior years or felt that it was just an inevitability that their teeth would be lost. We know now that is not the case. Certainly the need to ensure affordable, accessible dental hygiene care to the public is essential, and this forms the basis of our comments in this presentation and in our brief.

The first point relates to Bill 47, which is the Dental Hygiene Act. The additional page that was distributed relates to the controlled acts for dental hygiene. Unfortunately there was an error in the printing on page 2 of the document, but we will do our best to forward you a revised copy of that as soon as possible. That additional page outlines the two controlled acts for dental hygiene.

Our first comment relates to the provision of dental hygiene services, and more particularly those two controlled acts. As you can see, both of them are to be performed on the order of a member of the Royal College of Dental Surgeons of Ontario. Our concern is that restrictions will be placed on dental hygiene care by the interpretation of "on the order" of a member of the Royal College of Dental Surgeons of Ontario.

In the past, Ontario has had one of the most stringent interpretations of supervision in Canada and thus limited the delivery of preventive dental health care services. The ODHA stresses the need to define such an order so that it does not perpetuate dentistry's control over the dental hygiene profession or support dentistry's economic self-interests, and as such possibly limit access of those dental hygiene services to those who need it the most, the high-risk groups, the ones that we mentioned previously.

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At present, institutions and community service agencies outside of the scope of public health are required to employ a dentist and have him or her present in order for the dental hygienist to provide his or her services. Certainly the economics of this requirement renders the implementation of many preventive programs financially unfeasible and results in gaps in the provision of services.

Using seniors as an example, because I have a number in my neighbourhood, many seniors, as we know, are on fixed incomes and many more have limited access to dental hygiene care. This is particularly because they have dropped out of the system, the dental health care system, and they dropped out a long time ago and they really do not know how to get back into it. Therefore, often the majority of services that are required by seniors are of a preventive nature: regular cleanings, oral hygiene instruction, patient education, denture cleaning, those sorts of things. We feel that dental hygiene care needs to be both affordable and accessible for these individuals and that the scope of practice of dental hygienists must not be restricted in such a manner as to limit the availability of services provided by dental hygienists.

Our next point relates to the topical application of controlled agents. We support the RCDS in suggesting that there are substances that, when applied to the surface or on the tooth, alter the surface of that tooth and therefore should be controlled. In the practice of dental hygiene, the topical application of controlled agents, including such things as topical fluoride and pit and fissure sealants, differ from other topical applications by other health professions in that our application is in the mouth and the potential for systemic ingestion of a toxic substance is considerable.

Pit and fissure sealants are the one example that comes to mind. They have been around for many years, and certainly those of you with children might be more familiar with them, because you have taken your child to the dentist to have these sealants placed over the biting surface of the tooth. It is a preventive measure that looks to help prevent decay from occurring and therefore keeps the teeth filling-free. Certainly the technique in the application of pit and fissure sealants is critical to both the success and the safety of pit and fissure sealants.

Therefore, we recommend that the application of controlled agents be considered a controlled act and be restricted to qualified individuals -- dental hygienists and dentists -- who are fully cognizant of the toxic or irreversible nature of the agents and recognize the necessity for appropriate techniques to ensure the safety of the public.

Our third point relates to scope of practice. Admittedly, this point probably falls more under housekeeping, but we felt it was worth raising at this point. The Regulated Health Professions Act defines the scope of practice for dental hygiene, Bill 47, section 3, as follows:

"The practice of dental hygiene is the assessment of teeth and adjacent tissues and treatment by preventive and therapeutic means and, on the order of a member of the Royal College of Dental Surgeons of Ontario, the provision of restorative and orthodontic procedures and services."

This scope statement is inconsistent with other regulated health professions in that it includes the wording of a controlled act in the general statement. It is unnecessary for the phrase to appear in the scope of practice, as it is in the controlled acts section, and we recommend its deletion. As well, the authorization for provision of services, the "on the order" portion, is not included in any other profession's scope of practice. So in terms of consistency throughout the document, we thought it worth raising this point at this time.

We therefore recommend that our scope of practice statement read, "The practice of dental hygiene is the assessment of teeth and adjacent tissues and treatment by preventive and therapeutic means."

The last point that we have relates to the Regulated Health Professions Act, Bill 43, and more specifically the delegation of controlled acts. The concept of controlled acts identifies specific procedures that by virtue of their potential risk of harm to the public may only be performed by qualified individuals. While there are controlled acts to protect the public from unqualified individuals, there is also the power to delegate controlled acts to a totally unqualified individual. Although we can appreciate the need for delegation in specific situations, we question the rationale in permitting this generalized delegation of controlled acts.

In conclusion, certainly the development of new health legislation has been a long and arduous process for everyone involved. However, we are confident that the time and resources invested by all will result in a better health care system for both health care providers and consumers. I would like to again thank you for your time in listening to us and I would be happy to answer any questions that you have at this time.

Mr Beer: Thank you for your presentation. In terms of the statement in your scope of practice, what is the current situation in terms of how you practice? Is it similar to "on the order" of a member of the royal college? Does that describe the reality by which you work today under the existing legislation?

Ms Dempster: Currently, dental hygienists work under the direction and supervision of a dentist. The RCDS, which currently regulates dental hygiene, has interpreted that to mean that the dentist must be physically present in the suite of offices. That is primarily for private practice, although in public health there is somewhat of an exception in that dental hygienists do not work under the physical presence of a dentist. The reality, though, is almost a slightly different question, in that dental hygienists do work certainly in offices, in a dental office primarily, but the dentist does not always authorize the treatment that is going to be provided.

You are referring to our scope of practice statement or "on the order"?

Mr Beer: I was interested in how it is done today, and then I wanted to read that in terms of under the new act how it would operate, because one of the things I was interested in was your comment about the changing demographics of society, seniors and so on, and whether you could only practice in effect with a dentist, or would you see your role developing where you are going out into a senior's home, let's say, who is living by herself or by himself to do certain procedures and could that be done under the new act, where there would not necessarily be a dentist with you but you would have the authority to do certain procedures in the home.

Ms Dempster: Right now dental hygienists work under the direction or supervision, which means the dentist has to be physically present. At this point in time, community centres, nursing homes, anything outside of the public health system really cannot provide dental services unless the dentist is physically present, and that becomes economically unfeasible because a nursing care institution would then have to hire a dentist to come in and supervise the dental hygienist in the provision of the services that she provides. We feel that because of the demographics, because of the need that seniors have, particularly because there are going to be more of them and particularly because they are going to be retaining their teeth and have more preventive and periodontal needs, we need to ensure that dental hygiene services are going to be accessible to that group. Under the current system, the way dental hygienists are regulated now, that is not the case. What we have presented to us in this draft legislation is that we will function on the order of a dentist. We are not sure how that is going to be interpreted and we just want to be clear that we need to make sure that dental hygiene services are not restricted if that "on the order" is defined in a similar way to the way we practice now.

Mr Owens: In terms of your comments with respect to the application of topical fluoride and the application of pit and fissure sealants, you recommend that it be restricted to hygienists and dentists. Is that the current practice now?

Ms Dempster: Yes, it is. Topical fluoride and pit and fissure sealants, that service is provided by both dentists and dental hygienists at this time.

Mr Owens: So a dental assistant is not involved in any of that?

Ms Dempster: That is correct, because outside of taking X-rays or radiographs, upon a dental assistant having taken a specific course, and outside of preventive dental assistants, who are another level of assistant who can provide certain services -- sorry, dental hygienists and dentists and preventive dental assistants can provide topical fluoride.

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Mr Owens: So your amendment is in fact maintaining the status quo, or legalizing the practice that you are already undertaking?

Ms Dempster: Yes, I guess you could say it is maintaining the status quo. We felt that there needed to be a reconsideration of the application of topical fluoride and pit and fissure sealants as a controlled act. It was issued as a controlled act at one point much earlier on in this whole process and then it was deleted as a controlled act.

Mr Owens: Do you have any idea why that was?

Ms Dempster: There were a number of reasons given. The primary reason that I remember Alan Schwartz giving was that in order to provide consistency in the legislation, there was topical application of a number of different agents by a number of different health professions, and if they made the topical application in our situation a controlled act, they would have to make topical application in every other health profession a controlled act. Our argument is that our topical application is different in that it is intra-oral, potentially systemic, those sorts of arguments. But I believe it was a consistency argument that Mr Schwartz presented as his primary argument for deleting it from our scope of practice.

Mr Jackson: Are you familiar with procedures in other provinces as they relate to this specific issue of the delivery of your services to seniors in institutional and non-institutional settings?

Ms Dempster: Yes.

Mr Jackson: Can you share briefly with us what differences might occur nationally?

Ms Dempster: With respect particularly to seniors?

Mr Jackson: In particular to the concept of supervision as it relates to community-based --

Mr Dempster: Okay. I might pass that to Marg Walsh. She is our public health expert.

Ms Walsh: Currently, British Columbia allows an arm's-length practice of hygienists in delivery of care. In most of the other provinces there are not the numbers of hygienists. It is not that there is not the demand, but there is not the number of hygienists to be able to service that demand that is there and there is not movement in that area. Supervision requirements change drastically throughout the provinces. Most of them are under supervision.

Mr Jackson: What I am thinking of is that as we evolve in this province to a more community-based model for long-term care, hopefully one would suspect that dental services form part of that continuum of care. If that is the case, we are looking at expanding access in this province. Certainly the last two governments campaigned at one point in time during their history on that specific election promise.

Given that we may be moving in that direction, perhaps I can direct this question to staff, Madam Chair. If we are in a position to be discussing other ministries at the end of these hearings, perhaps we should have closer access to the draftspersons of the long-term care working paper to see its relationship to dental care for seniors in this province. That might be an appropriate line of questioning or access for this committee to that body. I understand the terms of reference are not even drafted yet for that public document, but hopefully they will be before this committee completes its activities.

The Chair: Comments are noted, Mr Jackson.

Thank you very much for your presentation. I would just mention for all groups that please feel free, at any time over the course of these hearings, if you wish to communicate with the committee, you can do so in writing, with a written brief or with a letter to any member of the committee, through the clerk. We would be pleased to hear any further comments that you have to make.

CANADIAN MEMORIAL CHIROPRACTIC COLLEGE

The Chair: I call next the Canadian Memorial Chiropractic College. Begin by introducing yourselves. You have 20 minutes for your presentation and the committee requests that you leave a little time for questions at the end of your presentation. Begin your presentation now, please.

Ms Moss: Madam Chair, members of the committee, I would like to introduce myself and my associates. I am Jean Moss, president of the Canadian Memorial Chiropractic College, and with me are David Dainty, academic dean, and John Mrozek, the director of our clinical sciences division.

I wish to thank the committee for allowing us to appear before you on this important occasion. At the outset, I should tell you that my term as president began on August 1, 1991. It is auspicious that one of my first orders of business is to appear before a committee dealing with what must surely be one of the most historic matters facing chiropractic and health care in decades.

The process of the Health Professions Legislation Review, and now the Regulated Health Professions Act, over the past eight years has provided Ontario with the unique opportunity to adopt an innovative approach towards regulation of the health care professions. This act is exceptional in that it has been supported by each political party during its term in office. All parties are to be complimented on their progressive approach to health care for the citizens of Ontario.

The Canadian Memorial Chiropractic College, or CMCC as we are fondly known, is a non-profit, charitable corporation registered in Ontario in 1945. For more than 45 years it has educated chiropractors for practice throughout Canada and around the world. This education has allowed patients to confidently seek chiropractors as their portal of entry into the health care system.

CMCC is unique among major health care educational institutions because it is funded only by its students and the membership of its alumni. We receive no direct funding from any level of government. It is the only chiropractic college in Canada and one of the most respected chiropractic institutions in the world.

CMCC joins with the Board of Directors of Chiropractic, whose mandate is protection of the public, and the Ontario Chiropractic Association, which speaks on behalf of the chiropractic practitioner, in acknowledging that there are two concepts which must be reconciled -- the mandate of the practitioner and the protection of the public. Imposed upon CMCC is the added dimension of education for a broader jurisdiction than Ontario.

CMCC is concerned that the mandate of the institution be maintained. The fact that it is the only educational institution in Canada for chiropractors has placed upon it a special responsibility and burden. It is incumbent upon us to prepare students to practise in the various jurisdictions. We at CMCC would ask that you consider in your deliberations that Ontario has a special responsibility to the education and practice of chiropractic throughout Canada.

The issues of the qualifications leading to acceptance as a member of the profession and to educational and academic licensure are also of concern to us. We have, however, been assured that these issues will be dealt with by regulations enacted subsequent to the final legislation. We must rely upon such assurances and leave these matters for future consideration.

A further issue, one which may be peripheral to this committee but is of importance to us, is accreditation. CMCC is accredited by the Council on Chiropractic Education (Canada) Inc, which establishes standards for the education of chiropractors. A change in the breadth of diagnostic scope would potentially affect our accredited status.

Chiropractic has been legislated within Ontario since 1925. This has allowed the public of Ontario the freedom of choice in health care for more than 65 years. This freedom has allowed the patient to obtain the benefits of chiropractic to the point where we are the second largest general, primary contact health care profession in Canada. CMCC would ask that you help to ensure that the Ontario public continues to have access to its choice of health care provider and that chiropractic students are exposed to the same broad range of clinical experience as currently exists.

As a provider of health care to the public through our three teaching clinics, we are concerned with the proposed legislation. Of particular concern are the scope of practice and the authorized acts in so far as they relate to the practice of chiropractic. In our opinion, it is essential that a chiropractor be allowed to continue to diagnose conditions related to other articulations, or, in the words of the act, "the joints of the extremities." These conditions have historically been diagnosed by the doctor of chiropractic. The practitioner is well educated to make such diagnoses, as approximately 600 hours of our program are devoted to the diagnosis and treatment of non-spinal articulations.

The education of the chiropractor is conducted in the classrooms, laboratories and clinics of the institution. We recognize that the educational process is separate from practice. However, 25% of the student's education at CMCC is spent in clinical experience dealing with the public, and therefore governed by the laws of practice in Ontario. A change in the legislation has the potential to affect a large portion of our educational program.

The satisfactory resolution of these issues to the benefit of both the public and the profession is CMCC's primary reason for making this presentation. Although we are in favour of the spirit of the legislation and where it is taking health care in Ontario, we have concerns, as expressed above, about the impact the new act, in its present form, would have on the education of chiropractors in Canada.

We wish to thank you again for allowing us to appear before you. We would be pleased to attempt to answer any of your questions.

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Mr Owens: Let me begin by congratulating you on your election to the position of president. I think all committee members from all three parties share your concerns around standards of education, standards of practice, and making sure we have accreditation processes that reflect the public's concern around safety and quality and efficacy of treatment. I think we can resolve your concerns satisfactorily.

You seem to be fairly happy with the legislation as a whole, if I am hearing you correctly, and the intent of the legislation. I am wondering if you could tell the committee how this legislation will benefit yourselves, but also benefit the public in terms of accountability, access and issues like that.

Ms Moss: With regard to the legislation, we are basically happy with it, with the exception of the inclusion of other articulations, or "joints of the extremities," as a diagnostic area for chiropractors. We see this as an area of concern for us.

Mr Jackson: Because it is not included.

Ms Moss: It is not included, yes.

Mr Beer: I just wanted to be clear on "the joints of the extremities." At the present time you diagnose those conditions, or chiropractors may do that?

Ms Moss: Yes.

Mr Beer: In the education program at your college, you can teach that and presumably could still teach it in the educational setting, but the concern would be that 25% of that instruction is practical, and if it is not clear that you are allowed to practise that, this obviously has an impact on the profession. Have there been any discussions with the medical profession? Are they opposed to your being allowed to diagnose the joints of the extremities? Where is the essential conflict that would seem to prevent you from doing something that you have been doing, if I understand your brief?

Ms Moss: We have not been involved in any discussions with the medical profession, and so I am unaware of any opposition from the medical profession. I cannot really respond to your question more fully than that.

Mr Beer: Was there a reason, in terms of the discussions and the development, why this was not made specific?

Ms Moss: Not to my knowledge. Most of those discussions were held with the Board of Directors of Chiropractic, and I am sure they would be able to answer that question. They will be making a presentation later in the month to the committee.

Mr J. Wilson: That was essentially my question: Why are we being asked to narrow your scope of practice? Perhaps we will take a run at it again.

Just out of curiosity, what are the educational requirements? Do you have to have a post-secondary degree prior to entering your college?

Ms Moss: Entrance to the college requires that a student have two years of university education, with prerequisites in certain subjects. Approximately 85% of our students have a prior degree, either an undergraduate degree or, in some cases, graduate degrees.

Mr J. Wilson: And it is a three-year course?

Ms Moss: It is a four-year program.

Mr Jackson: I am having difficulty with the notion of the reduced diagnostic capacity per the extremities. I personally use, and am a big supporter of, chiropractic services. Before we prorogued, I sustained a baseball injury. I went through my physician, spent a pile of money having it attended to, then went to my sports physio and spent several hundreds of dollars in the process there, and still had no use of my arm. In the process of telling my chiropractor that my shoulder muscle is now somewhat atrophied, because I have no use of my arm, he immediately realized that my wrist was my problem. Within five minutes he had relieved me of the problem, which the X-rays did not show and which the physio had confirmed was probably my problem. He had been unable to do the manipulation, but only work with the muscles.

I relate that story simply because the more I use your services, the more I realize how much less an expense to OHIP these things become when the kind of counselling I was being given from -- that is not to undermine in any way the good intentions of my physician. He is a sports expert himself. But I really have a hard time believing the work you are doing should somehow be limited when in fact it works so well. Certainly Dr Bob Wingfield, who has had senior positions with the Ontario board, who takes care of me -- I was quite impressed by the fact, by those points I want to share with you.

So we will be looking at this list, but I wanted to put on the record my bias in support of your concerns because I certainly am impressed by what I think we can save OHIP by the process of allowing these procedures.

The Chair: I have a request for Mr Wessenger to clarify the ministry's perspective.

Mr Wessenger: The perspective I would like to give from the ministry's point of view is that under the regulation under the Drugless Practitioners Act at the present time, there is no right of diagnosis given to chiropractors. It is really just a question of what treatment they give, and so we see it as an expansion of rights. If you look at the new act, you will note that the chiropractor is given the right of "the assessment of conditions related to the spine, nervous system and joints of the extremities." So they have the jurisdiction over the assessment of the joints of the extremities, and they do have, of course, the diagnosis, which they did not have before, with respect to "disorders arising from structures or functions of the spine." So we see it as giving them an increased jurisdiction in this whole matter. That does not mean we cannot consider the representations made, but I think it should be made clear that they are getting an increase in jurisdiction under this act.

Mr Jackson: On that point, though, using my own example, we have limited chiropractors' ability to utilize access to X-ray facilities in hospitals -- the Chair would be very familiar with this ruling in this province -- yet had my chiropractor seen the X-rays of my wrist, he would have been able to diagnose it, when the X-ray technician and the physician both missed it.

I know we are talking about semantics here, and the difference between "diagnosis" and "assessment" may not be lost to legal counsel, but I can assure you that in practice out there, there is some concern being expressed here by the deputants. Perhaps we should ask if they concur with that statement of the parliamentary assistant, but in my own example my chiropractor does not have access to those X-ray services at the hospital should he need them to perform a diagnosis or the proper assessment of my wrist.

Mr Cordiano: I want to ask for a clarification from legal counsel.

Mr Wessenger: I think I will ask ministry staff, but I think we are on an issue that is somewhat not related to this act, which is the whole question of access of health records to other professions.

Mr Cordiano: I would rather concentrate on this question again which crops up from time to time. The distinction between diagnosis and assessment, I think, is what we are dealing with.

Ms Bohnen: Okay. We are dealing with two issues here. First of all, as you say, there is the problem of the distinction between assessment and diagnosis, but the other issue for chiropractors is a little different. The review recommended that chiropractors be authorized to diagnose dysfunction and disorders of the spine and the effects of those spinal disorders and dysfunctions on the nervous system, and that would include disorders and dysfunctions of the articulations that arise from the spine. What the review recommended that chiropractors not be authorized to diagnose are disorders and dysfunctions of the articulations that have no connection whatsoever to the spine. What I believe the chiropractic profession is seeking is statutory authority to diagnose in relation to these unrelated articulations.

As I said, that narrow issue was superimposed against this assessment/diagnosis issue. I think I have stated the issue correctly.

The Chair: Thank you for your presentation.

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GOVERNING BOARD OF DENTURE THERAPISTS

The Chair: I would like to call the Governing Board of Denture Therapists. We ask that you introduce yourselves to the members of the committee and if you wish to leave some time at the end of your presentation for questions from committee members, you have a total of 20 minutes for your presentation.

Mr Southby: Good afternoon. My name is William Southby and I am the chairman of the Governing Board of Denture Therapists. With me are René Tremblay, a member of the Governing Board of Denture Therapists, and Robert Gaspar, a dental therapy teacher at George Brown College. We are all practising denture therapists.

The Governing Board of Dental Therapists appreciates the opportunity to make a submission to the standing committee on social development with respect to Bill 50, the Denturism Act, and Bill 43, the Regulated Health Professions Act. The governing board has actively participated throughout the consultation process which has brought us thus far, and we commend all those who have worked long and hard to develop this new legislation. Reform of the several pieces of legislation currently governing the health disciplines is long overdue, and we support the spirit and intent under this Bill 43.

Currently, there are 450 licensed denture therapists regulated under the provisions of the Denture Therapists Act. The governing board has regulated denturists since 1974. Presently, denturists engage in two types of practices: (1) an independent practice providing complete upper or lower dentures directly to the public; and (2) a supervised practice in a dentist's office providing partial dentures to the dentist's patients who retain some of their natural teeth.

Under the current legislation, denturists are not permitted to provide partial dentures directly to patients in their private practice. Many denturists practise both independently in their own offices and in dentists' offices.

Primarily, we wish to support the proposed scope of practice for denturists contained in sections 3 and 4 of Bill 50. These provisions permit denturists to provide partial dentures directly to the public in their offices. It will no longer be necessary for denturists to travel to a dentist's office to provide this service. From the regulatory perspective of the governing board, the simplification of the provision of denture services to the public appears appropriate.

Historically, in 1980 the Ontario Council of Health commissioned Professor Bernard Dickens, PhD, LLD of the faculty of law, University of Toronto, to conduct a review of denture services provided by dentists and denture therapists in the province. Professor Dickens's report was submitted to the council in April 1981 and later that year the council's statement on denture therapy was submitted to the then Minister of Health, Dennis Timbrell.

Professor Dickens recommended that the Denture Therapists Act, 1974, be amended to permit registered denture therapists to design, supply, adjust and repair partial dentures without supervision of a dental surgeon. His report goes on to say, "The intention of this recommendation is to permit exercise of professional judgement on referring patients to dentists before work on partial dentures is undertaken. Professional judgement is reinforced both by legal accountability and by professional disciplinary action for incompetence and professional misconduct." Professor Dickens's recommendation was not implemented.

More recently, the same recommendation was made by Mr Alan Schwartz, co-ordinator of the Health Professions Legislation Review, whose work has resulted in Bill 50, and the omnibus Bill 43.

Entrants to the profession are graduates of the denture therapy program at George Brown College of Applied Arts and Technology. Currently, the program is three years in length, and we attach appendix A which details the components of the curriculum for the program. From this, you will note the number of hours of instruction devoted to subjects such as anatomy, biology, histology and pathology, as well as the more technical aspects of denture services.

For graduates, the governing board conducts an ongoing continuing education program which has included training by licensed dentists on topics such as oral pathology, oral radiology and removable partial dentures.

When Bill 50 becomes law, it is our intention to provide an upgrading program conducted by the George Brown College for practitioners already in the profession to enhance their qualifications to provide partial denture services independently.

Presently, up to 60% of denturists have significant experience providing partial dentures in a supervised setting, and many of our members are also trained dental technicians and therefore have significant experience in the technical end of providing partial dentures.

Attempts have been made by some dentists to discredit denturists by suggesting patients have suffered harm caused by partial dentures made by denturists without supervision of a dentist. However, when the governing board attempts to investigate these allegations, supporting information is not forthcoming. Indeed, when the governing board receives information about illegal partial dentures, it comes from sources such as insurance companies or social service agencies, not from complaints from the public.

The annual reports published by the governing board attest to our record of enforcement of the current legislation. During the past seven years, the governing board's discipline committee has dealt with 16 cases of denturists exceeding lawful scope of practice of making unsupervised partial dentures. This record also indicates the public and the denturist profession have difficulty in accepting the current restrictions. It appears from the cases we have investigated and prosecuted that the public's demand for the services of partial dentures from denturists is based on cost and quality of service.

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As regulator of the denturist profession, the governing board supports the current bills. We have three suggestions for improving the legislation:

1. Paragraph 26(2)11 of Bill 43 controls the following act:

"Fitting or dispensing a dental prosthesis, orthodontic appliance or a device used inside the mouth to protect teeth from abnormal functioning."

This provision does not protect the public, however, from the repair or relining of dentures by completely unqualified persons. If a denture is repaired or relined improperly, it can result in occlusion problems, ill-fitting dentures, oral tissue damage, loss of mastication and even temporomandibular joint dysfunction, which is the hinge of the jaw.

We would suggest that paragraph 26(2)11 of Bill 43 be reworded as follows, "Fitting, repairing, relining or dispensing a dental prosthesis..." etc. A corresponding amendment would have to be necessary for section 4 of Bill 50.

2. Communicating conclusions. Paragraph 26(2)1 of Bill 43 controls the following act:

"Communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the conclusion."

As presently worded, the provision is overly broad. It would include, for example, a statement by a denturist to his or her patient that maybe the porcelain piece on their dentures was causing damage to the opposing dentition or the patient's natural teeth. A simple solution would be to exempt communications made by a member within the scope of practice of the member's profession.

3. Holding out. Subsection 15(3) of Bill 50 states:

"No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as a denturist or in a specialty of denturism."

This provision only prohibits people from pretending they are registered. It does not otherwise prevent unqualified persons from misrepresenting their qualifications. If the phrase "to practise in Ontario" were deleted, a more appropriate level of protection from misrepresentation would be provided. The provision would then read:

"No person other than a member shall hold himself or herself out as a person who is qualified as a denturist or in a specialty of denturism."

The governing board would like to thank the standing committee for the opportunity to make these submissions.

Mr Beer: Thank you for your presentation. At the present time, how do people come to a denturist? Would most come through a dentist? I am trying to understand how you function in relation to dentists.

Mr Southby: Presently, we are completely independent regarding, we will say, upper and lower dentures. Most of our patients, those who have been in business for a while, come on recommendation, signs and advertising. We are just like a dentist's office really, except it is a denture therapy clinic.

Mr Beer: At the present time, if somebody comes who requires a partial denture, what do you do?

Mr Southby: We inform them of the act. If we decide to make the partial denture, we make arrangements with a dentist to do the supervision.

Mr Beer: What would that mean in real terms?

Mr Southby: In real terms, as I said, they usually have to go to the dentist's office with the patient and perform the necessary function.

Mr Beer: So the denturist would go with the patient?

Mr Southby: Yes, or meet them at the dentist's office. But the patient is the dentist's patient. The patient has to pay the dentist for this service, not the denturist.

Mr Beer: In terms of what Schwartz recommended and the earlier study that you noted by Professor Dickens, they both recommended you be permitted to do the partial denture independently.

Mr Southby: Without supervision.

Mr Beer: We have heard a couple of presentations that question that, because of the education of denturists, not being able to see perhaps some of the problems that might arise with a partial denture. I know in your brief you mention some of the programs and courses denturists must take. In your judgement, is that similar to what a dentist would be taking who was also going to be dealing with partial dentures? What would be the difference?

Mr Southby: The big difference is that the dentist is a professional trained in what we term as preventive dentistry, who would X-ray, do the usual things and fill, clean, extract and do whatever is necessary in the mouth to make the mouth completely healthy. From there on in, with this knowledge, in co-operation with a dentist, not supervision, the denturist could make the partial denture with the knowledge he gets from the dentist. The patient would be so much better off economically, if nothing else, because he basically does the same thing under the so-called supervision of a dentist, but the dentist gets the fee for the partial denture.

You see, the dentist is paid for anything the dentist does when he fills your teeth, cleans them and X-rays them. That is not included in the cost of the partial. In regard to their pricing, this is how it is done. What we are saying is that we can provide this partial denture without the supervision of the dentist. Many of us have been doing it for years and years. We need the co-operation of the dentist, but not the supervision.

Mr Owens: I would like to touch on a sensitive area, that is, the area of complaints. You mentioned that you have had 16 cases of denturists exceeding the scope of practice by making unsupervised partial dentures. How many complaints did you receive from patients or organizations about actual harm that had been done to patients?

Mr Southby: To my knowledge we have not had any. There was one article in the Ontario Dental Association journal that purported that harm was done and even published a photograph of it, and when it was investigated it was found that it was not a denturist at all. It was an illegal dental technician or somebody who had made the denture.

Mr Owens: To follow up on that, do your patients know how to complain? Is there some procedure outlined in your office code of ethics?

Mr Southby: We have a complaints procedure, but patients complain usually because their dentures do not function. They either hurt or they cannot chew with them or something is wrong, so they go back to the practitioner. If they do not get satisfaction from the practitioner, then they come to the governing body with a complaint, which is then investigated.

Mr Owens: Where would these cases we have heard from different representatives of the dental profession come from: improper plates, teeth that are misaligned and all sorts of horror stories? Are these manufactured stories?

Mr Southby: They have to be, because when we investigated these things there was no follow-up with this evidence. I do not know what they have told you, but we do not know that this was done. If it was made illegally, for some reason they will quite often say, "Oh, a denturist made this," whereas it was a dental technician who did it on the side or something like that. A lot of people do not know the difference between a denturist and a dental technician.

Mr Jackson: Perhaps it would be helpful to the committee if you were to get us a copy of the case you cited. I am a little uneasy with your suggesting that you think it might have been a dental technician. If that is the basis of your recollection, I would rather you got us the exact case.

Mr Southby: Yes, we have it on record. Our investigator went right to the office.

Mr Jackson: I would like a copy of that. You said you thought it was something like a dental technician.

Mr Southby: Yes.

Mr Jackson: I would like to read the case as opposed to leaving that impression in my mind.

Mr Southby: Fine.

Mr Jackson: My second question is for legal counsel. On page 6 there is a statement made about the holding-out provision with the deletion of "to practise in Ontario." Is that legal counsel's interpretation of the effect of --

Mr Southby: Yes, it is.

Mr Jackson: I am directing my question to legal counsel.

Ms Bohnen: I am not sure I understand.

Mr Jackson: I am asking if you agree with the assertion that the effect of deleting the words "to practise in Ontario" is that it affords a greater level of protection. I am really asking, do you concur with that statement?

Ms Bohnen: It would afford different protection. It would preclude someone who is qualified, let us say, to practise as a denturist in Quebec from saying that, even though it may be correct. The harm we were trying to get at and the way it is drafted is misrepresentations that someone is qualified to practise in Ontario.

Mr Jackson: If time permits, are there other examples where that broadly based statement exists in health professions to ensure that you cannot set yourself out as having been accredited unless you are capable of practising in that province?

Ms Bohnen: To my knowledge, the existing health professions legislation in Ontario does not speak to the issue of jurisdiction at all.

Mr Jackson: Okay. I will pursue that with you later, then.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee today. We have all received a copy of your brief and as the committee hearings go on, if you have anything further you wish, please feel free to communicate in writing with the committee.

Mr Southby: Thank you. Mr Jackson, should I send it directly to you?

Mr Jackson: To the clerk, and other members of the committee will be able to have a copy.

1520

STEPHEN ABRAMS

The Chair: I call Stephen Abrams and ask that you come forward now. You have 10 minutes to make your presentation and we ask you to leave some time for committee members to ask some questions.

Dr Abrams: I would like to thank the committee for giving me the opportunity to address you today on the factors and techniques involved in fabricating a removable partial denture. As background, I am a practising dentist and upon graduation I was involved in establishing a group practice in Scarborough, Ontario, which has been providing a full range of comprehensive oral health care services to the community for the past 11 years.

The focus of my presentation is the replacement of a patient's missing teeth utilizing a removable partial denture. It is fundamental to diagnose the patient's oral health status prior to deciding what options are best to restore missing teeth. A partial denture is not necessarily the best option in each instance.

I have selected a fairly typical case, or a typical patient, in our practice in order to illustrate for the committee the various techniques used in the delivery of this service. The patient has given consent to having the photographs you have in front of you used today. I have also supplied the committee with a model so you can actually see what a partial denture is. This particular patient arrived in our practice in May, 1991 with the smile that you see in figure 1 in front of you. A view of the upper jaw in figure 2 revealed a few missing teeth and some old fillings that needed some attention.

Due to the nature of the work required, we took a panoramic X-ray, which revealed a number of hidden problems, which is in figure 3. There were two very infected roots in the back of the mouth, and I have labelled those A; a large back tooth with extensive decay and an abscess around the root, which I have labelled B; and finally, a front tooth with an abscess or an infection, which I have labelled C. None of these was readily visible to the naked eye, as you can see from going back to the previous picture. A thorough examination of both gums and supporting jawbone revealed that the upper right back tooth and front tooth had inadequate supporting bone and, as such, any type of false tooth should not add additional stress to these teeth. The construction of any prosthesis must take this into consideration.

Our patient was now given three different options for replacing these missing teeth. We suggested a series of dental implants, fixed bridgework consisting of a series of caps and false teeth or a removable partial denture. In this situation, both the patient and I believed that a removable partial denture was the best treatment option. It would provide our patient with a complete set of upper teeth in a very short time frame and, if designed properly, it would fit firmly without exerting undue pressure on the existing teeth. The partial denture could also be modified very easily if down the road one of the teeth were lost.

With this decision made, treatment commenced. The infected, buried roots were removed to allow the gums and bone in the area to heal properly and provide additional support to the teeth that we were going to use for anchorage. The upper right front tooth and the upper right back tooth both had root canal treatment performed on them in order to save these teeth and treat the infected nerves in them. Old, worn-out fillings were replaced and new ones designed with a view to being involved in anchoring the prosthesis. The areas of tooth decay were also restored utilizing materials that would wear well once the partial was placed.

Along with the restoration of the teeth, I also had our hygienist clean and polish all tooth and root surfaces, removing harmful tartar and stain. Our hygienist, who was apprised of the design of the denture, spent time teaching our patient how to care for his teeth and the new denture. With this phase completed, I reviewed our final X-ray, which I have provided for the committee in figure 4, to make sure that all the problems had been treated, and examined the health of teeth and gums.

The denture design involved resting the denture on both teeth and gums. In this way, chewing forces would be evenly spread and no one area would be exposed to harmful, excessive force. The denture was to be cast in a very light metal which was thin and strong. I provided the committee with a sample of it. It has never been in a patient's mouth and I encourage you to sort of move it on and off the model to see how it works.

Figure 5 shows a picture of the denture resting on a model of the patient's mouth. The metal pieces I have marked A are areas where the denture actually rests in depressions we have cut in the tooth. Not only do these rests or depressions allow the denture to seat firmly, but they also transfer the chewing forces to those teeth which can best withstand these forces. If the denture were to rest solely on soft gum tissue, these chewing pressures would force the denture against soft gum tissue, stripping it away, and with it the bone which anchors the teeth in place.

The areas on figure 5 that I have marked as B are clasps or hooks that engage only the strongest teeth to help anchor the denture in place so that it will not come out when eating. As you can see, we did not anchor the denture on a tooth marked C, as this is the one we alluded to earlier which is not a very strong anchor tooth but does provide an adequate rest.

One final observation on that particular figure is an area I have marked D. This particular clasp design is designed to provide a very good grip on the teeth involved without coming out on to the front surface, where it would be visible in a smile. In order to do this, I removed some enamel from the side of the tooth where it rests. This does not endanger the tooth but will provide a very firm anchorage for the rest of the teeth.

Figure 6 shows a mirror image of the denture in our patient's mouth, and figure 7 is our patient wearing his new denture. At this stage, the false teeth, which I have marked A, blend very well with the existing front teeth except for one of the patient's own teeth, marked B. This tooth, which we described earlier, had required treatment for an infected nerve or root canal. One of the problems with a long-standing infection is that these types of infections will discolour teeth. By applying the correct tooth-coloured filling material to this tooth, we were able to match and blend the colour with the other teeth, and the result is what we see in the bottom photograph you have in front of you marked figure 8. Our involvement does not stop here; it continues. Our patient returns to our practice to ensure that the denture is fitting well and that there are no sore spots, and also to review home care.

We also emphasize the importance of a semi-annual dental checkup. I have already arranged this appointment for the patient. These checkups provide us with the opportunity to monitor the health not only of the teeth and gums, but also to monitor the fit and wear of the prosthesis. Not only will we clean our patient's teeth at this time, but we will also clean the denture and tighten the clasps, which are not designed to be too rigid. The bit is also examined at each annual checkup and as the denture ages, the wear of the denture teeth are monitored so that all teeth, both natural and denture teeth, contact evenly when chewing.

This case illustrates the importance of a comprehensive approach to the delivery of dental care. I emphasize that partial dentures are but one small part of the overall treatment and cannot be made without consideration for the following areas: the health of the anchoring teeth, gums and bone; the strength of the fillings used in the anchoring teeth; the patient's chewing pattern; the colour and shape of both the natural and denture teeth; the anticipated lifespan of natural teeth; and other methods of tooth replacement.

These factors are all part of the diagnosis a dentist does before commencing work. These factors are not part of the range or training of a denture therapist. Because of the lack of training and education in dental radiology, gum problems and root canal problems, methods of filling and restoring teeth and pathology of the mouth, the denture therapist cannot even begin to consider any of these factors before manufacturing a prosthesis. Had any one of these factors been omitted from the case I have shown you today, the results would have been disastrous.

Costs of these services are also a consideration. The range of procedures I have provided here today are available to all. This particular individual we have used as an example was on a welfare assistance program at the time. With support from the municipality, we were able to restore the dentition to the state you see them in today. Furthermore, maintenance should be very inexpensive.

Partial denture construction also involves cutting natural teeth in order to allow the denture to rest properly. Improperly designed rests will cause tooth decay and excessive and harmful forces on anchoring teeth, which may lead to their eventual loss. This will also increase the cost of the service.

Finally, partial dentures are part of a long-term oral health care plan developed by dentists and patients. The patient understands how to care for the prosthesis and what potential problems may be encountered. The dentist watches and cares for the remaining dentition, the prosthesis and the overall oral health of the patient.

Having considered the facts, I strongly believe that dentists are the only professionals qualified to diagnose properly the need for partial dentures. Furthermore, a denture therapist should become involved in this service only under the supervision of the dentist.

Thank you for your time and consideration. I will entertain questions.

1530

Mr Owens: Have you kept any type of statistics or have you done any tracking with respect to patients coming to your office who have seen denture therapists who are now having difficulties? I am not talking about discomfort difficulties, but serious problems with their teeth, the denture itself or teeth going off in different directions?

Mr Abrams: When patients come into the office we usually do not ask, unless we need to get records, where they have been. If a patient comes in with a problem with a partial denture, they just want me to take care of the problem and get them out of pain and discomfort, so I do not bother tracking who did what, where. The service the patient wants me to provide is dental care, and who did what to them prior to that is not of importance. What is of importance is what is wrong, how we go about fixing what has gone wrong and how we provide something that is maintainable over the long term. So I have no idea where a lot of the things are done. In my feeling it is really none of my business.

Mr Jackson: Thank you for your graphic demonstration. It is helpful. Just for my own personal interest, how much did that whole procedure cost and how much did the municipality kick in?

Dr Abrams: The municipality of Metropolitan Toronto covered all of the procedures that you saw here today. They establish a fee guide or schedule that dentists in Ontario work by. As I can recall, I think the partial denture on that is covered at a rate of $325. For the rest of it I do not have the figures at hand that could provide that breakdown for the committee. But there was a lot of work done.

The Chair: Thank you very much for your presentation.

PETER APSE

The Chair: Mr Peter Apse. You have 10 minutes for your presentation and we would ask that you leave some time for questions if you wish.

Dr Apse: Thank you for the opportunity to come and speak to you today and address you on the issue of the treatment of the partially dentured patient. As background, I am a dental educator at the University of Toronto, faculty of dentistry. Specifically, I am a specialist in prosthodontics, which is treatment of missing teeth in patients, in people, and I teach undergraduates and graduates in specifically that kind of treatment.

In the 10 minutes or less I would like to bring to your attention two aspects. One question which was raised before: What is the education background that we provide our students upon which they can graduate and practise dentistry? Second, what are the long-term effects of our treatment of our prosthetic intervention in a patient and how is the dentist suited to deal with these?

Let me start with familiarizing you with the prosthetic course or curriculum at our faculty. Generally speaking, prosthodontics or prosthetics, which is a treatment using artificial materials to replace missing teeth, is about a 20% segment of a four-year course. It is also one of the more complex subjects that we deal with in the sense that it encompasses every aspect of dentistry: radiology, radiographs, as you were shown by Dr Abrams, fillings, gum disease, surgery, pathology, hygiene, orthodontics and jaw joint problems, all of which are integral parts in the decision-making on the type of treatment that we can render the patient, how we are going to render it, the design of it and what are the long-term effects.

I am going to outline the approximate four years in very quick order. In the first year of a DDS, doctor of dental surgery degree, the student is trained in dental materials, which provides a background in the properties of materials, specifically in properties of materials used in prosthetics, their biological compatibility and their effect on the host, in this case, the patient. Also within the first year, referring only to subjects that are directly related to prosthodontics, the students are introduced to the intricacies of occlusion, which consists of how the jaws come together, the masticulatory system, how we chew, how we open our mouths, how we speak; all these factors are taken into consideration.

It is an exquisitely sensitive structure, as you may know, since you can very readily discern minute particles in your mouth that you can quickly and deftly bring to the forefront with your tongue. We also know that if the dentist has inadvertently left a restoration somewhat high, even microns high, we are subject to some discomfort which, if we relaid it or moved it laterally, we can say if we put a partial denture in, which you have seen examples of, that this factor will certainly introduce some aspects into our bite, into our occlusion, into the muscles of the jaw, into our joints.

Going to the second year, the first official prosthetic course is presented, approximately 140 hours of clinic or laboratory time and lecture time. That does not include reading time that the student has to do, which is another approximately 50 to 75 hours. That is in the second year of the course.

We start off with in effect giving the student an understanding of what happens when we lose teeth, what happens when we lose one tooth. Simply, the loss of a single tooth will affect the arch, both the arch in which the tooth is lost and the opposing one. The effect of loss of one tooth will upset the balance, the continued movement of the teeth that occurs one against the other, the back tooth bracing against the one in front. All of a sudden we lose one segment, we lose the continuity of that arch, the tooth starts drifting forward, tilting forward and the opposing tooth starts erupting out.

Another subtle, perhaps not so subtle at times, change that occurs with lost teeth is that we lose face height. We have all seen patients, people, who do not wear dentures. They walk in and their chin is approximating their nose. That in effect is extreme, but if we take it down back to where we lose some of the back teeth and we lose the support of our bite, which can be quite severe, then we will gradually lose this face height and the chin will come closer and closer to the nose. If we do not deal with that problem, it can have repercussions in what we call the temporomandibular joint, jaw joint, muscles of mastication.

After we have brought the students to an understanding of the effect of tooth loss, we then follow through with the principles of the partial denture. This involves the marriage of the mechanism of the partial denture, how it is held in the mouth -- I mean, it has to hold in there somehow or it will just fall out when we eat -- and the biological aspects of the retaining teeth. The teeth are going to hold this partial denture in place. Unless we consider the biology of teeth, we can very readily overload them and we can very readily cause their premature loss. It is therefore the dentist's responsibility to balance that risk that we put on the retaining teeth with the benefits to the patient of using a partial denture.

During that second year, and we are still in second year, students take treatment plan design and consider the construction of partial dentures for approximately 10 cases.

In the third and fourth year prosthodontics course, the students are exposed to what we call fixed prosthodontics, in other words bridges and crowns, a treatment plan, and fabricate partial dentures for clinical patients on the clinic floor. Students at this level are expected to integrate their knowledge of medicine, in other words, they have to take the health of the patient into consideration, the bite or occlusion, periodontium, which refers to gums, radiography -- all these aspects in the design and fabrication of a partial denture. This interrelationship between different disciplines that we are exposed to at the faculty ensures that the patient's dental health is the prime consideration in our treatment.

Furthermore, the student is made aware of the importance of long-term follow-up and maintenance of the mouth at optimum health. Oral hygiene, diet, frequent recalls, are an integral part of the overall treatment that the student is taught. Prosthetic treatment is like the hub of a wheel with the student borrowing from the other aspects of dentistry in designing and preparing the prosthetic treatment. It is not just a technical procedure, but rather the integration of biological aspects with mechanical ones. One without the other will end up in catastrophe.

The second part I want to allude to is the relationship of a partial denture with the continued health of the patient. We have put something in a patient's mouth; how is that going to affect the patient? Missing teeth generally result in aesthetic problems; in other words, the appearance of the patient may not be to his liking, missing front teeth particularly, functional problems where the posterior teeth, the back teeth, are missing, he cannot chew very well, or both. A well-designed partial denture that has taken into consideration remaining tooth health, and the ability to sustain the increased loading as we might expect from a partial denture, is often a solution, a good solution, to the problem. It is very frequently used in practice. Although technical and biological factors are considered, the mere presence of a foreign object, such as a partial denture, will induce ecological changes in the mouth. We are going to get changes, whether we like it or not.

The Chair: I have to ask you to sum up now, please.

Dr Apse: With the presence of a partial denture, the bacteria and plaque increase placing the patient at greater risk. These risk factors can be minimized through long-term care of the patient. The provision of prosthetic treatment for the partially edentulous patient is not just a mechanical one. It is and should be rooted in a strong biologically based background such as is provided in dental education. We are not selling partial dentures, we are selling a health service.

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ONTARIO DENTAL NURSES AND ASSISTANTS ASSOCIATION

The Chair: I call next the Ontario Dental Nurses and Assistants Association. Begin your presentation by introducing yourselves to members of the committee. You have 20 minutes for your presentation and we would ask that you leave a few minutes at the end of your presentation for questions from committee members. All members have received your written remarks.

Mr Miller: My name is Jeffrey Miller. I am an executive director of the Ontario Dental Nurses and Assistants Association. With me is Charlotte Peer, our president. The Ontario Dental Nurses and Assistants Association was formed in 1931 as a registered, non-profit voluntary organization for dental assistants. We estimate there are just under 10,000 dental assistants in Ontario. ODNAA's current membership is 6,537. Approximately 93% of our membership maintain voluntary certification as a verification of occupational competency.

The Ontario Dental Nurses and Assistants Association recognizes: (1) the need for more educational opportunities for dental assistants to upgrade their skills in the areas of restorative and preventive dental health care assisting; (2) in light of the current health crisis, all dental assistants require access to appropriate dental health care education in prevention of disease transmission; and (3) that the regulation of dentistry should have the statute that refers to the preventive dental assistant revised and updated to include a mandatory recognition of allocation of duties to an Ontario certified dental assistant level 2 or the preventive dental assistant. The council of the RCDS has agreed with our proposal for an Ontario certified dental assistant level 2 program.

Dental assistants in the province of Ontario are employed in private practice, hospitals, public health units and educational institutions such as colleges of applied arts and technology. For the most part, except in the rare instance of an educational institution, dental assistants are employed by dentists and supervised by dentists.

Appended information on the next page basically outlines where we are as of now. Dental assistant education, that is, where dental assistants are educated: (1) certificate programs offered at community colleges; (2) three Ontario secondary schools offer diploma programs in dental assisting education, concurrent with secondary school graduate diploma requirements; (3) certificate diploma programs offered in Ontario at private vocational schools -- there are four of those and they have different campuses throughout the province; (4) on-the-job training is still an acknowledged avenue for dental assisting educating in Ontario, and that is pretty well the way it is right across North America; and (5) out-of-province dental assisting education is recognized and currently in great demand, and it is the only opportunity available to achieve preventive dental assistant status in Ontario.

Our political issues, we have discussed, would be: (1) the ODNAA lobby for the expansion of responsibilities for qualified dental assistants; (2) the Royal College of Dental Surgeons of Ontario and the Ontario Dental Association are on record in support of the expansion of responsibilities of an Ontario certified dental assistant level 2 program or the reinstatement of the preventive dental assistant program; and (3) under the current system only dental assistants who attain their dental assisting education credentials in other provinces may be listed as a PDA in Ontario.

Regulatory: Dental assisting as an occupation is not regulated in the province of Ontario. However, there are two regulations that provide legislative jurisdiction for dental assistants to perform expanded functions under the order of a dentist:

1. The Healing Arts Radiation Protection Act provides for dental assistants with recognized training to take and expose dental radiographs -- training concurrently available. Note, this intra-oral duty is not in the public domain; it is covered by a listing of credentials.

2. Regulation 447, section 49, provides authorization for dental assistants who have successfully completed a course of study which has been approved by the Council of the Royal College of Dental Surgeons to be listed as PDAs. Currently, Ontario certified dental assistants must go out of province to access this educational opportunity and subsequent occupational listing by the college.

At the present time, 12 Ontario CDAs are in Prince Edward Island upgrading their skills for listing in the province of Ontario, and a second class is scheduled for September 15, 1991. Ontario dental assisting education has fallen sadly behind the national standard. Ontario residents with no alternative, being forced to seek continuing education in their chosen career in other provinces, is currently a flaw in a tired system.

I will just return to my original document with our recommendations, which are covered on page 2.

1. That the Ontario certified dental assistants level 1 -- which is a voluntary credential of dental assistants who possess recognized training -- have an opportunity to expand their dental assisting education to the national level 2 status, which includes the following duties: dental radiograph, HARP, which is currently listed; application and removal of rubber dam; taking preliminary impressions of teeth for study models; application of matrices and wedges; oral hygiene instruction; dietary counselling relative to dentistry; rubber cup polishing; topical application of anticariogenic agents, ie, fluoride; and selected orthodontic dental assisting duties.

We strongly recommend that these duties be recognized in a similar fashion as the current PDA duties and not left in the public domain. Dental assisting is a technical job and there must be a fundamental core knowledge for all those who seek expanded dental assisting responsibilities.

2. That the Royal College of Dental Surgeons of Ontario continue to list expanded-duty dental assistants such as the listing of PDAs under the current regulation. We believe this is a natural working relationship between the dentists and dental assistants of the province of Ontario.

1550

The Chair: Thank you very much for your presentation.

Mr J. Wilson: I get the impression you have a good relationship with dentists and the royal college. Is this somewhat of a wish list in recommendation 1? Which of these acts are you doing and not doing now?

Mr Miller: Basically, it is more of a revised list than a wish list per se. Right now, most of those duties are covered under regulation 447, section 49. There are a few other uncontentious subjects that have already been included in other provinces. Although the training is not here, it is a national norm list.

Mr J. Wilson: Have you wanted to be regulated as a profession at some point?

Mr Miller: We did approach the first Health Professions Legislation Review group of people and we were deleted after the first --

Mr J. Wilson: You did not meet the criteria?

Mr Miller: We did not.

Mr Beer: In terms of the education that the certified dental assistants receive right now, where do you receive that training?

Mr Miller: Actually, it is outlined on page 3, the appendix, dental assisting education. Most would be college grads of some nature. Most dental assistants do receive vocational education.

Mr Beer: So would that be where, for the expanded programs, you would see an expansion in the community college programs for dental assistants, or are you seeing that done through some other body?

Mr Miller: There are 26 programs that are community-college-based, publicly funded programs that train dental assistants; 11 of them are in the province of Ontario and they do not have extended functions.

Mr Beer: What surprises me is that you have to go out of the province for a number of these programs. Upon whom must you bring pressure to have more programs for dental assistants? Have the government or the colleges been refusing to expand their programs for more of these?

Mr Miller: In fairness to all involved, a great deal of what the government will do, I guess, relies very heavily on what comes out of the review of the health disciplines and, subsequent to that, they will train people for the new regulation. We just do not want to get lost in the shuffle. Right now, we are covered under a regulation that we would like to see enhanced, and we see an appropriate recognition of education.

Yes, it would be very nice to get this up and running. If the Ministry of Health would give the Ministry of Colleges and Universities the green light I am sure we could have this.

Mr Hope: Most presentations that we hear talk about stopping the ability to do the job. You put a lot of emphasis on education, but with the legislation that is being introduced and we are reviewing, will you be stopped from doing the job you normally perform?

Mr Miller: I would assume we would probably be doing more, based on the way it is going. The fact is, dental assisting has not really changed that much probably from the birth of the ODNAA back in 1939, and it would be ideal to have some sort of recognition of education and then provide the education through the regulation of dentistry. That would be where we are coming from.

Mr Hope: To further elaborate on that, as I listened to your comments to Mr Beer, are you running into a roadblock with the ODA, trying to get these education programs? Is that why you are seeking our assistance in making sure it is in the legislation?

Mr Miller: The Ontario Dental Association?

Mr Hope: Yes, the ones you have been lobbying --

Mr Miller: Absolutely not. We have received nothing but support. There has been no lack of support from the dentists of this province. I have a survey in front of me that indicates on a province-wide basis -- and this was done in conjunction with the Ontario Dental Association -- the large majority of dentists want their auxiliaries to have this opportunity.

Mr Hope: I posed that question because you said a lot of them get their education outside the province of Ontario.

Mr Miller: This is sort of new. The legislation sat for an awful long time before the Royal College of Dental Surgeons commenced listing people. That is why we have Toronto people going to Prince Edward Island for education.

The Chair: We appreciate hearing from you. If you have any further information at any point, please feel free to communicate with the committee in writing.

1600

ONTARIO HERBALISTS' ASSOCIATION

The Chair: I call on the Ontario Herbalists' Association. All members have received a copy of your brief. Please introduce yourselves to the members of committee and try to leave a few minutes for questions at the end. You have a total of 20 minutes for your presentation.

Mr Stelling: My name is Keith Stelling. I am a member of the board of directors of the Ontario Herbalists' Association and a member of the National Institute of Medical Herbalists of Great Britain where I did my training. I am here to show you something about herbal medicine and the importance of medical plants as part of our complementary health system in Ontario.

The use of herbal medicine goes back for thousands of years. We have documents dating back to the year 2500 BC with the Georg Ebers papyrus, an Egyptian record of medicinal plants numbering some 750 plants that are still used today by medical herbalists. You see one here you recognize of course -- hypotensive, lowers blood pressure; another one, the pine, which was used as a bronchodilator and is still used for the same purposes today; and another one, the birch, which was also discovered quite independently by our own native Canadians.

The important point about this is that these plants were discovered in different parts of the planet at different times in history.

In Canada, our own record of herbal medicine was first committed to paper by Jacques Cartier in the winter of 1525. The French of course were not experienced with our harsh winters, and the expedition which had been sent out by the King of France became marooned in the ice on the St Lawrence River. Fortunately, when the crew was struck down by a plague -- they called it la grande maladie -- there was a group of friendly native people nearby at the village of Stadacona who presented Cartier with a medicinal plant. It was this one, the thuja occidentalis, or the white or yellow cedar. Cartier's rapture about the recovery of the crew was quite outstanding.

There are a great many aspects to herbal medicine. You cannot see very well on this diagram, but you may recognize some benzene rings if you have studied chemistry. In some plants, there are over 178 different medicinal constituents. The similarity between the human cell, with those squiggly things known as mitochondria, and the plant cell -- you see the "M" labelling mitochondria again in the plant -- represents the difference between the soft medicine, or the natural remedy in the herbal preparation, and the chemical drug.

Some of the amazing things we have discovered since Cartier's time, with the harsh light of modern scientific examination, is that plants such as this one, calendula officinalis, are actually antiviral in character. They have been shown in some of the institutes of phytotherapy in Europe to inhibit the spread of cancer or to inhibit the metastasis of cancer cells.

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Another very famous one is this one, carduus marianus, or the milk thistle, which is actually a restorative for the liver and has been used to prevent the effects of carbon tetrachloride in liver sclerosis.

Another one, valeriana officinalis, or valerian, is a natural tranquillizer which does not interfere with the functioning of the mind, as most of the drugs do, and this very famous one, echinacea angustifolia, actually boosts the immune system. That is a very important remedy these days with AIDS around. It has also been shown to be effective against certain types of human carcinoma, including the Walker carcoma carcinoma 256.

Here is some of the work of Dr Paul Velaiche, who holds the first chair of phytotherapy at the University of Paris in France. Dr Velaiche takes samples from his patients and cultures them on Petri dishes such as these, and then he applies the essential oils of aromatic plants. He has found very interesting antibiotic activity among some of these labiate family plants. The interesting thing here, and in the hospitals in Europe where this has been used, is that there has been no resistance to this form of antibiotic activity.

Another way that herbs work is to work through the glands of the body; here a lymphatic cleanser, galium aparine, which is very important as a conjunction in other diseases, especially in cancer, where you are draining the glands and taking away the waste from the body.

The Ontario Herbalists' Association is the oldest body of consumers and practitioners in Ontario. It has recently introduced a code of ethics for its professional members and this autumn will begin examining all its professional members with a stringent two-hour examination as well as an oral examination in adherence to the code of ethics. There is a lot to be done in training in Canada. We are really backward. We are behind the Europeans, who are now demanding a three-year full-time course for the standard of practising herbal medicine in Europe.

One of the important functions of the Ontario Herbalists' Association in guiding the public towards herbal remedies is the educational facility. Here you see one of their herb walks or field trips. They also present a number of lectures in Toronto and throughout the province.

I mentioned in this brief that you have before you the plant dandelion, taraxacum officinale, a very important liver restorative. It has been shown to be capable of extracting heavy metals from human tissues, which is a very important aspect. Dandelion, of course, is a very safe diuretic. The leaves work on the kidney and it can be used in any quantity, but if you were, for example, to use this plant, convallaria majalis, you would find that if you went more than five mls of the tincture, that is, a teaspoon, spread out over a whole week, you would probably cause death.

The point of this is that some plants are very beneficial but dosage is critical. Can we rely on the medical profession now, which no longer has any training in medicinal plants, or pharmacists to be making such decisions? We are also leaving these things in the health food stores, without any labelling, and health food store proprietors are forbidden to advise customers on the use of the plants. As a result, people tend to self-medicate with medicinal plants. They are very powerful in some cases.

Here you can see tanacetum partheneum, or feverfew. Feverfew has been shown at the Glasgow Royal Infirmary in Scotland to be effective in a clinical trial for 70% of the patients suffering from migraine headaches. In 70% of the people, that will eliminate the migraine or cut down the frequency or the severity. This is an important aspect of the economic importance of herbalism.

We do not want to take these plants off the market, because they are saving time in loss of hours from the working place and they are also preventing long-term, chronic illnesses. But just like tanacetum, this one, hydrastis canadensis, another native of Canada, if used in pregnancy, can cause stimulation of the uterine muscle, which will cause abortion. Therefore, there must be more labelling on these products.

The British and the Europeans have a very important training program. The National Institute of Medical Herbalists of Great Britain trains people for four years in a full-time course which includes all the usual medical subjects, such as pathology and physiology and differential diagnosis. Here you see one of the training clinics and here you see one of the study gardens, with the plants laid out in ordered beds, a very important aspect of identifying plants before you use them. In Canada there has been some attempt to upgrade the training programs, but there is not enough and encouragement needs to be given both in public education and also in training of practitioners.

One of the points I want to make in this brief is that there has to be a difference between the term "drug," as referring to a chemical pharmaceutical, and a plant or a medicinal natural source, which cannot very adequately be administered by an orthodox or conventional practitioner.

Another point I want to make is that the use of inhalation has been taken away in the bill before Parliament and inhalation is a very important aspect of herbal medicine.

Here you see the eucalyptus tree. The eucalyptus is one of the plants which works as a bronchodilator on the human body and is a very helpful remedy in asthma, as is this one, melissa officinalis, or lemon balm, and again chamomile, and chamomile has always been used for children because it is so gentle, but we do not want to be lost from these ordinary household remedies. You may recall friar's balsam somewhere in your experience.

The other point which we are not clear about is whether we are being excluded from giving information on nutrition. With the Dietetics Act, it looks as though herbalists may no longer be able to advise people on the use of food as part of a medicinal therapy.

I have here a copy of the book by Dale and Applebe, Pharmacy, Law and Ethics, which was the British solution to this problem. You see at the last of the brief some explanation of how the British have handled the dilemma with the 1968 Medicines Act, by grouping a number of plants which are dosage-critical to be administered only by trained practitioners or by pharmacists, and the others for sale over the counter in health food stores. I think we also need more adequate labelling on these remedies. Also I have here the other standard textbook for herbal medicine, the British Herbal Pharmacopoeia. A new edition has come out since 1983, but this lists all the herbs with their constituents and their activities.

You can see it is a fairly complicated business and I would like your support in helping us together to unravel the dilemma that is presented to us. Are there any questions?

Mr Grandmaître: My question is not about herbal medicine or herbal treatment. What about our environment? Apparently we are losing our natural environment daily, and I am sure some of the plants you have referred to in your slides are being affected by our environment, acid rain, carbon dioxide and so on and so forth. Do you know if you are losing some of these very important plants that are in use?

Mr Stelling: Yes. Of course we are all losing, and we are losing the quality of the nutritional value of our food because the fertilizer that is being put on the fields is a chemical and we are not getting the ingredients that were once apparent, certainly before the war. Things just are not there. The other aspect is that herbal medicine is environmental medicine. We are not polluting. We are not releasing chemicals into the atmosphere.

Mr Grandmaître: No, I did not imply that.

Mr Stelling: Exactly, and that is an important aspect of it. It is a renewable resource. It does not depend on multinational corporations, and some of the Third World countries have found this as well.

We are also losing species right here in Ontario. We are losing hypericum perforatum, which is actually being partly eliminated by a program undertaken by the federal government and the previous provincial government to control it with the chrysolina beetle, and that is being wiped out wholesale. But we are losing many others because of automobile pollution and a group of urban centres, this sort of thing.

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Mr Grandmaître: Does that mean that if we are not concerned about the environment or become more concerned, you people will be out of business in 10 or 15 years?

Mr Stelling: I do not think it will be 10 to 15 years. Many people are concerned and many people are attempting to cultivate these plants. That is another important aspect of our work, recognizing them and making sure there is an adequate supply.

One of the plants I showed you, hydrastis canadensis, was once harvested in Ontario and one of the Indians at the reserve near us in Brantford remembers her mother, who was also a herbalist, showing her a dump truck full of the root of this plant being taken away from the reserve.

So we have to think ahead. We have to think about these very important renewable resources. We have to think about the aspect of the gentle plant remedy being important when we get into difficulties with the side-effects of the drugs, which is increasingly happening.

Mr J. Wilson: It is very interesting. I gather from your brief and your comments that Bill 43 and the acts may put you out of business in some aspects of your practice. Were you involved in the review process at all? Were herbalists involved in making their concerns known to the Ministry of Health?

Mr Stelling: Not very much, no. We presented a number of petitions and briefs to Elinor Caplan and we received just about no replies, I think, right through.

Mr J. Wilson: How many practising herbalists are there in the province, for instance?

Mr Stelling: There are at least 20, but there are many who are practising herbalism along with another form of therapy. There are over 440, I think, consumer members of the Ontario Herbalists' Association and that has grown from 100 two years ago. There is a great interest on the part of the public.

Mr J. Wilson: I know there is some growing interest in my own riding, for instance, and among consumers. I am not aware at all what the legal status now in some of your practices might be. Are you recognized in any of the health acts now?

Mr Stelling: No, there is no recognition for herbalists, and as far as we understand, we are allowed to practise as long as we do not commit any of the forbidden acts. However, we are a small group and we have never had a college or any sort of self-regulation. Our efforts recently to get people accredited professionally, I think, are the first steps in that direction.

Mr Wessenger: I would like to call on the staff to clarify on this matter.

Ms Bohnen: It is not our view that this legislation will put herbalists out of business. First of all, the provisions dealing with the sale and distribution of drugs are the provisions of the Health Disciplines Act, which is not being amended by this legislation. This legislation primarily, of course, regulates pharmacists and others who prescribe drugs. It does not alter in any way the definition of "drug" currently used in the Health Disciplines Act. Entry to the marketplace, in Canada, of drugs and substances which are categorized as drugs is primarily a federal responsibility. This legislation also does not restrict who may provide counselling services to individuals. So it is not our view that this will have an adverse effect on herbalists.

Mr Stelling: I think the concern of the herbalist is that the administration of drugs in this document is under the control of the College of Physicians and Surgeons. We do not know whether ultimately, if there is some animosity against these non-licensed practitioners, the tide could go against us that way and we would like to see some form of protection.

Mr J. Wilson: I think you also said many of your remedies are not really included in the definition of "drug."

Mr Stelling: That is the whole enigma in Canada at the moment. Is a substance a drug or is it a food? There was a special advisory committee convened by the federal government and its findings put herbalism in a separate third category. We would like that result to influence your own work here.

Mr J. Wilson: Do the Ontario statutes use the same definition of "drug" as the federal laws?

Ms Bohnen: Yes. I think Mr Burrows could add to what I can say about this.

Mr Burrows: Yes, in Ontario there is a definition of "drug" in the Health Disciplines Act and it is compatible with federal legislation. Herbal remedies have always been a relatively grey area under the law, and with all due respect it would appear to me there are two issues here. One is herbalists as a profession or as a group of professionals regulated or unregulated, and the herbal remedies themselves. Some herbal remedies are drugs by definition. A good example that is well known is digitalis, which requires presciption in the province of Ontario -- in Canada for that matter. It is also true that many of the remedies that are available have fallen into disuse. It is equally true that things have a way of coming around again, and whether they are used as herbal remedies or drugs are extracted from the natural source products, there is certainly still a future for those sorts of products.

But the issue here needs to be clarified as to what the association perhaps is looking for. If it is looking for recognition of herbs in some sort of special cagegory, then we control the conditions of sale here in Ontario, but the basic proof of safety and efficacy is the responsibility of the federal government, and with respect, I would recommend that the direction be there. If on the other hand the concern is how the pharmacy part of the Health Disciplines Act currently -- which I would point out is administered by the college of pharmacists, not the College of Physicians and Surgeons of Ontario. If there is an issue there, then that section of the existing Health Disciplines Act is not being altered, as Linda pointed out, by this package. It is in fact being left intact and renamed. I suppose it is conceivable that at some point the Legislature might want to look at that particular package of legislation and its relationship to this issue. With respect to the regulation of a profession, then the advisory council, perhaps under this legislation if it is passed with the advisory council intact, might provide an opportunity for dealing with that issue.

Mr Cordiano: I was simply going to say that you have made some good suggestions. In so far as it impacts on what we are doing here, I appreciate there is some question whether we have jurisdictional responsibility for that. But you make some good points with respect to safety of some of the medicines currently on the market, and I am quite concerned about that. Just a personal note, some of the recommendations you have made should probably be brought forth at the federal level, as appropriately pointed out here. That would be something your association should bring forward.

The Chair: Thank you for your presentation before the committee. The committee will reconvene tomorrow morning at 10 am. I want to thank all of you for attending today.

The committee adjourned at 1619.