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37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Wednesday, April 30, 2003

1535

The Chair (Ms. Bonnie Brown (Oakville, Lib.))

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ)

The Chair

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

The Chair

Mr. Rob Merrifield

The Chair

Mr. Rob Merrifield

The Chair

Mr. Rob Merrifield

The Clerk of the Committee

Mr. Rob Merrifield

The Chair

Mr. Rob Merrifield

The Chair

Mr. Wendall Nicholas (Policy Analyst, Health Secretariat, Assembly of First Nations)

1540

1545

The Chair

Dr. Mary Jane McCallum (Assistant Professor, Faculty of Dentistry, University of Manitoba; Assembly of First Nations)

1550

The Chair

Mr. Larry Gordon (Chairperson, Health Committee, Inuit Tapiriit Kanatami of Canada)

1555

1600

The Chair

Mrs. Susan Ziebarth (Executive Director, Canadian Dental Hygienists Association)

1605

The Chair

Dr. Louis Dubé (President-Elect, Canadian Dental Association)

1610

1615

The Chair

Dr. Peter Cooney (Director General, Non Insured Health Benefits Directorate, First Nations and Inuit Health Branch, Department of Health)

Mr. Greg Thompson (New Brunswick Southwest, PC)

The Chair

Dr. Peter Cooney

1620

The Chair

Ms. Leslie MacLean (Acting Director General, Non Insured Health Benefits, First Nations and Inuit Health Branch, Department of Health)

1625

The Chair

Mr. Rob Merrifield

Dr. Mary Jane McCallum

Mr. Rob Merrifield

Dr. Mary Jane McCallum

Mr. Rob Merrifield

Dr. Mary Jane McCallum

Mr. Rob Merrifield

Ms. Leslie MacLean

1630

Mr. Rob Merrifield

Dr. Mary Jane McCallum

Mr. Rob Merrifield

The Chair

Ms. Leslie MacLean

The Chair

Ms. Leslie MacLean

The Chair

Dr. Darryl Smith (Executive Council Member, Canadian Dental Association)

Mr. Rob Merrifield

Ms. Kimberly Whetung (Associate Director, Health Secretariat, Assembly of First Nations)

1635

Mr. Rob Merrifield

Dr. Louis Dubé

Mr. Rob Merrifield

Dr. Darryl Smith

Mr. Rob Merrifield

Dr. Darryl Smith

Mr. Rob Merrifield

Dr. Darryl Smith

Mr. Rob Merrifield

Dr. Peter Cooney

Mr. Rob Merrifield

Dr. Peter Cooney

1640

The Chair

Ms. Carolyn Bennett

The Chair

Mr. Réal Ménard

1645

Ms. Leslie MacLean

Mr. Réal Ménard

Dr. Mary Jane McCallum

Mr. Réal Ménard

Dr. Mary Jane McCallum

Mr. Réal Ménard

Dr. Peter Cooney

1650

Mr. Réal Ménard

Dr. Peter Cooney

Mr. Réal Ménard

Dr. Peter Cooney

The Chair

Dr. Mary Jane McCallum

Mr. Réal Ménard

Dr. Mary Jane McCallum

The Chair

Dr. Peter Cooney

1655

The Chair

Ms. Hedy Fry (Vancouver Centre, Lib.)

Dr. Peter Cooney

1700

Ms. Hedy Fry

The Chair

Ms. Hedy Fry

The Chair

Ms. Hedy Fry

Dr. Darryl Smith

Ms. Hedy Fry

Dr. Mary Jane McCallum

The Chair

Dr. Darryl Smith

1705

The Chair

Mr. Svend Robinson (Burnaby—Douglas, NDP)

Dr. Peter Cooney

1710

Mr. Svend Robinson

Dr. Peter Cooney

Mr. Svend Robinson

Ms. Leslie MacLean

Mr. Svend Robinson

Ms. Leslie MacLean

Mr. Svend Robinson

Dr. Peter Cooney

Mr. Svend Robinson

Dr. Darryl Smith

1715

Mr. Svend Robinson

Mrs. Susan Ziebarth

Mr. Svend Robinson

Dr. Peter Cooney

Mr. Svend Robinson

Dr. Peter Cooney

1720

The Chair

Mr. Svend Robinson

The Chair

Dr. Mary Jane McCallum

The Chair

Mr. Larry Gordon

The Chair

Ms. Leslie MacLean

The Chair

Mr. Greg Thompson

1725

The Chair

Mr. Greg Thompson

Mr. Svend Robinson

Mr. Greg Thompson

The Chair

Mr. Greg Thompson

1730

The Chair

Dr. Darryl Smith

Mr. Greg Thompson

Dr. Darryl Smith

The Chair

Dr. Louis Dubé

1735

The Chair

Mr. Greg Thompson

Dr. Mary Jane McCallum

Mr. Greg Thompson

The Chair

Mr. Greg Thompson

Dr. Peter Cooney

1740

Mr. Greg Thompson

Mr. Peter Cooney

The Chair

Mr. Greg Thompson

The Chair

1745

Dr. Peter Cooney

1750

Mr. Svend Robinson

Dr. Peter Cooney

The Chair

Dr. Peter Cooney

The Chair

Dr. Peter Cooney

The Chair

Ms. Leslie MacLean

The Chair

Ms. Leslie MacLean

The Chair

Ms. Leslie MacLean

The Chair

1755

Ms. Leslie MacLean

The Chair

Dr. Darryl Smith

The Chair

Mr. Svend Robinson

Dr. Peter Cooney

Mr. Svend Robinson

The Chair

CANADA

Standing Committee on Health

NUMBER 032

2nd SESSION

37th PARLIAMENT

EVIDENCE

Wednesday, April 30, 2003

[Recorded by Electronic Apparatus]

¹ (1535)

[English]

The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good afternoon, ladies and gentlemen. It is my pleasure to call to order this meeting of the Standing Committee on Health. We are going to talk about first nations and Inuit dental health.

We have some very good witnesses who've come to join us and I want to caution them. So many times representatives of organizations take the first few minutes of presentation to give us a description of their organization and tell us what that organization does, how many members it has, where it meets, what services it provides. I'll be quite frank with you. We really don't want to know that. We want to know what you think about the dental health situation, right to the teeth of the matter, if you wouldn't mind. So no big long preambles about your organization; rather, go right to the topic of the day.

Before we begin, I think Mr. Ménard has something to say. Mr. Ménard, a point of order?

[Translation]

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ): I would simply like to present a notice of motion without debate, consistent with what we agreed to at the steering committee on time allocation. I will read its content so we can discuss it in 48 hours, i.e. at our next meeting. The motion I propose would read as follows: That the time allocated to each member of the committee to ask questions to the witnesses be limited to five minutes, and that the Chair allow members of the Canadian Alliance to ask the first two questions, followed by five minutes for the Bloc québécois, five minutes for the Liberal Party, five minutes for the New Democratic Party, five minutes for the Liberal Party, five minutes for the Progressive Conservative Party, and that subsequent questions be asked, alternately, by members of the Opposition and the government party, at the Chair's discretion.

This is a notice of motion; we will deal with it at the next meeting.

[English]

The Chair: Thank you. We'll consider that notice of motion, which will be dealt with at the next meeting. I hope we will have a quorum on Monday afternoon so we can vote on this and a couple of other motions that are hanging over.

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): There's another motion they brought in that we'll deal with at that time as well. Do you have it?

The Chair: What other motion? Are you giving notice of a motion, Mr. Merriweather?

Mr. Rob Merrifield: Yes. Merrifield.

The Chair: Sorry, Mr. Merrifield.

Mr. Rob Merrifield: But I've been called worse.

The Chair: You're lucky I didn't call you Mr. Fairweather.

So, Mr. Merrifield, there is circulating at the present moment a motion on your behalf. Is that it?

Mr. Rob Merrifield: Yes, I believe there is. Is it translated or not?

The Clerk of the Committee: The minister is already scheduled to appear on May 12.

Mr. Rob Merrifield: On May 12. It was to bring the minister with regard to the estimates.

The Chair: That's already in the works. Yes.

Mr. Rob Merrifield: We've had the minister in the works before.

The Chair: No. She's always come with the estimates. It's a normal thing.

I thank you for your courtesy as we did a little bit of committee business. We'll now begin the presentations with the Assembly of First Nations, Mr. Nicholas, I believe.

Mr. Wendall Nicholas (Policy Analyst, Health Secretariat, Assembly of First Nations): Good afternoon, Madam Chair, and colleagues and members.

I would like to bring greetings to you on behalf of the Assembly of First Nations. As you've mentioned, I won't describe the organization but only say that it's our pleasure to be here today to describe to you and your colleagues some of the circumstances as we see them in the first nations. We are here to talk about aboriginal dental health. Of course, we're talking distinctly about first nations people.

I'm Wendall Nicholas and I'm a policy analyst with the health secretariat of the Assembly of First Nations. I'm here joined by Dr. Mary Jane McCallum from Manitoba, who will be doing a separate presentation.

Madam Chair, regretfully I may have to excuse myself before all the questions are done, but my colleague is here from the Assembly of First Nations, Kim Whetung, and she may enter into the record some answers to questions that members may have.

The non-insured benefits program is a key program that assists first nations people. This program, as you'll hear from my colleagues here from government, is a very expensive program. The non-insured benefits package side of what Health Canada provides is close to 50% of its budget. The dental program is one of several benefit areas of this program and has faced a tremendous amount of strain with trying to meet the need that is out there in the community.

At present, overall the program faces annually anywhere between 9% to 12% costs over and above what it is meeting, and with a population that is growing between 5% and 6%, and other factors involved, there's a tremendous amount of pressure to meet the need that is out there.

I would like to take this opportunity to share with you a brief overview of the oral health status of first nations in Canada and how we, first nations people, feel these concerns need to be addressed. The following information has been gleaned from Health Canada's report, A Statistical Profile on the Healthof First Nations in Canada.

Aboriginal people have a higher rate of dental decay and oral disease than the Canadian general population. Factors that may influence this outcome include a change to a diet high in sugary foods, lack of access to benefits, lack of access to clean potable water with fluoridation and access to oral health prevention and treatment services. The last two factors are particularly evident in remote regions of the country.

Sex, age, income, and race or ethnicity are also considered important determinants of oral health status. The only routine dental health indicator reported by the first nations and Inuit health branch is dental service utilization through the NIHB program. So this only tells us how many people are using it.

Other periodic surveys and research studies have provided limited reviews of the oral health status of first nations and Inuit populations. For example, in regard to the oral health status of first nations children in 1991, MSB's child oral health survey found that 91% of first nations and Inuit children were affected by dental decay, with five- to six-year-olds averaging 7.8 decayed teeth and 12- to 13-year-olds having an average of 4.4 decayed teeth.

The survey also found a positive association between better oral health and access to fluoridated water. Nearly 75% had access to dental care, whereas 25% had identifiable unmet dental care needs.

The 1996-97 first nations and Inuit children's oral health survey showed similar results. The surveyed aboriginal children aged 6 to 12 had two to five times the dental decay rates, defined as decayed, missing, or filled teeth, as surveyed non-aboriginal children in Yukon and the Northwest Territories.

An Ontario study compared aboriginal children's oral dental health with that of two comparable non-aboriginal populations, those born in Canada and those born outside Canada. It found that Canadian children are three to four times more likely than aboriginal children, in this case defined as first nations and Inuit, to be free of dental decay. Decay rates were two to five times higher among the aboriginal children.

¹ (1540)

In 1997, a first nations and Inuit regional health survey reported that approximately half of respondents had received dental care during the previous 12 months. Among the dental services provided to the eligible population were dental therapists and contract dentist treatment prevention programs within first nations and Inuit communities, as well as the fee for service non-insured programs.

In 1999-2000, 38% of the NIHB clients used dental services. They received at least one service. Interestingly, 44% of the claimants for the dental coverage were under the age of 20 years, whereas only 2% were over the age of 65. Overall, a higher percentage of females than males used NIHB dental services.

In 1999 the dental care expenditure of the NIHB program totalled $1.7 million. Most of that, $32.6 million, was for restorative procedures and crowns and fillings. The preventive treatment of scaling and polishing amounted to $11.2 million, while claims for diagnostic services of exams and X-rays totalled $11.1 million.

The declining oral health of first nations in Canada is comparable to developing countries such as Costa Rica, 4.8; the Ukraine, 4.4; Latvia, 4.2; and it will continue to decline unless measures are taken to address the alarming trend.

The impediments to accessing dental care are an arduous task in themselves when you live in a remote location, but for more and more first nations, trying to find a dentist who will accept assignment of NIHB, or will accept to take a first nations client via the NIHB program, is an even greater challenge. It is a tremendous challenge.

To compound these difficulties in obtaining dental services there is a new problem first nations are now encountering with the recent medical transportation framework policy unilaterally imposed by Health Canada's first nations and Inuit health branch. This will, in some regions, result in no access to dental treatment.

In conclusion, the burden of administrative interference is limiting access to dental care for first nations. The providers are saddled with increased bureaucracy, and I expect that my colleague Dr. McCallum will speak to that, as well as some of my colleagues from the Canadian Dental Association.

First nations patients seeking care are punished for being unaware of policies. For example, first nations patients seeking care from dentists must undergo a predetermination before they can be treated, which incurs other costly implications like doubling transportation costs. Health Canada's first nations and Inuit health branch is limiting medical transportation, and in some cases eliminating it, and implementing a prior approval procedure. The dentist is not able to provide the client with the necessary treatment on a first appointment because there is a requirement to perform a lengthy predetermination process. In a sense, what occurs, Madam Chair, is frustration on the part of the provider.

I'm conscious that I'm running out of time, so I'm going to conclude my comments. There are a number of other points I would like to make.

One in particular that concerns me is about Health Canada's approach to client motivation. This is a genuine problem; patient motivation is an issue. So we would like to see a cooperative approach in addressing this issue as opposed to having something imposed and putting the provider in a compromising situation.

We also have a problem related to what has been imposed by Health Canada with respect to the new NIHB client consent initiative. This, as I understand it, is something that is replacing the existing consent document, which is a part of the predetermination. However, there are several outstanding issues with this client consent process, and our concern is that the requirement for the consent remains too broad. It is going to cause confusion on the part of the client and on the part of the provider, and frustration, added frustration.

¹ (1545)

Madam Chair, I will conclude my opening remarks at that. Thank you very much.

The Chair: Thank you, Mr. Nicholas.

Dr. McCallum.

Dr. Mary Jane McCallum (Assistant Professor, Faculty of Dentistry, University of Manitoba; Assembly of First Nations): I am Dr. McCallum and I'm from the Barren Lands Cree Nation from Manitoba.

The consent initiative being imposed on first nations has the potential to adversely affect first nations, health professionals, and the federal government on many levels, including cross-jurisdictional and intergovernmental service delivery systems. As first nations people and health professionals, we understand the requirement for the consent process. However, the breach of trust by the first nations and Inuit health branch, FNIHB, which resulted in the violation of access and privacy surrounding the collection, use, and disclosure of personal health information of first nations, will continue to have a negative impact on the process towards integration of information technology into health practice.

The ongoing challenge will be achieving a balance between two competing interests, the individual and collective right to privacy and the legitimate need to develop and improve public policies, particularly with respect to health outcomes and safety. There are many issues on multiple levels with the consent form, but today I will voice some of the concerns from the health professional and service delivery context.

Many first nations, including the more vulnerable groups, the elderly and the disabled, have indicated that they will not sign this consent form. The disrespectful and thoughtless way that this consent initiative has been handled has turned an empowering process, which is informed consent, into a shameful and frightening experience for first nations.

The primary issue will be one of safety since first nations will be unable to access and receive necessary health care. Of particular concern are the benefit areas where life may be threatened, such as in pharmacy and medical transportation when medevacs are needed.

For me as a health professional licensed in Manitoba, the Personal Health Information Act, or PHIA, which is one of two provincial access and privacy laws, dictates that I, as all other trustees, must inform my patients as to the specific uses surrounding the collection, use, and disclosure of their personal health information in their different contexts. Since I do not have access to this information--which I have requested but not been given so far--I will be unable to provide health care, as will other health professionals, after September 1, 2003.

After September 1 FNIB has given itself authority to withhold payment for health care services if the patients have not signed the consent form. Unfortunately, this blanket consent form encompasses claims payment along with benefit utilization, many varied, non-specific contexts of the collection, use, and disclosure of personal health information as well as other administrative purposes. Personal health information will be better understood and protected if separated into their different contexts since personal health information required under one context may not be required under another; hence, the minimum requirement principle. It is irresponsible and unethical for FNIHB to manipulate the situation so that it pits health professionals and health benefits against first nations patients for non-health administrative purposes.

Under my professional code of ethics, I must provide timely care, including emergency services, to my patients, and refusal to deliver health care will put me in conflict with this code. The government will put health professionals in a catch-22 situation, violation of the professional code of ethics or violation of legislated provincial responsibilities on personal health information, which is the only legislation that binds me now until the PHIA comes into effect on January 1, 2004.

The integrity of health professionals who have provided quality and respectful care will be needlessly undermined and it will give the perception that health professionals are acting as agents for Health Canada.

Many of the first nations patients are in vulnerable situations owing to infirmity or incapacity, urgent need, lack of knowledge and power, or simply because they have needs and have to rely or depend on health professionals to meet those needs. A unique vulnerability exists for first nations because of the first nations' reliance on Health Canada to provide health needs through its non-insured health benefits program. What recourse does the patient have if he or she does not have the money to prepay for the treatment? People should not be put at a disadvantage because they elect to exercise their right to privacy.

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This process has the ability to adversely affect my relationship in providing therapeutic care to my patients. The primary reason a patient accesses care is for treatment, and the health information collected is done under vulnerable and trusting circumstances and is deemed confidential. Releasing this health information without meaningful consent may inhibit many patients from accessing further health care fully and truthfully and may jeopardize patient safety.

Emergency access to care may increase the dollars spent, but without positive health outcomes. To a health professional, being forced to refuse to provide therapeutic service on the basis that a patient has refused to sign a consent form that violates meaningful and due process of consent and may expose the patients to further psychological stress is perverse.

A complaint based on denial of service to the Manitoba Dental Association or the provincial ombudsman may result in an investigation of the health professional, through no fault of theirs. It also has the ability to increase the number of health professionals who refuse to provide health care to first nations because of administrative burden or ethical considerations. The freedom to access health care with a provider of choice no longer exists.

Questions about the contents and scope of this blanket consent include the validity or legality of the consent, because the federal regulations have emphasized the elements of disclosure, voluntariness, comprehension, and competence—and none of these exist with this consent form.

In closing, I want to say that the drafting of the new consent form has to be done by all stakeholders, with meaningful input from all parties. We need to separate the claims payment and continue paying claims on the basis of a single-use consent; that will allow health care to continue without disruption. And the breach of trust surrounding personal health information needs to be addressed so that we can start a new trust-based relationship with the government.

Thank you.

The Chair: Thank you, Dr. McCallum.

From the Inuit Tapiriit Kanatami of Canada, we have Mr. Larry Gordon, who is the chair of their health committee. Mr. Gordon.

Mr. Larry Gordon (Chairperson, Health Committee, Inuit Tapiriit Kanatami of Canada): Good afternoon, Madam Chair and committee members.

As stated, my name is Larry Gordon. I'm the executive director of the community development program for the Inuvialuit Regional Corporation in the Western Arctic. I'm here today in my capacity as chair of the Inuit Tapiriit Kanatami health committee.

First, I'd like to talk about the scope of the problem. The dental health status of the Inuit is far below that of the non-aboriginal Canadian population. This is not just in the number of cavities one might have, but it also includes their poor experience with dentists and the increased pain and anxiety associated with poor dental health.

The Inuit experience the largest percentage of destructive early childhood tooth decay within the Canadian population. This disease contributes significantly to the cost of medical travel. Treatment involves surgery under general anesthetic. Left untreated, the disease can lead to an infection, pain, and behavioural and social problems.

Oral health is essential for the routine functions of daily living such as eating, communications, socializing, and self-esteem. Early childhood tooth decay often leads to serious tooth decay throughout life.

What I find remarkable and lamentable is the fact that this situation about poor oral health has been documented for the last 35 years, and here I am in 2003. Change is needed. It may not be easy, but it is necessary. The current evidence suggests this.

There seem to be two main reasons why this situation exists. First, the system is unable to respond to the current and immediate needs; second, the resources that are being allocated are not being used effectively.

The current system, characterized by billing through the non-insured health benefits program, creates a set of structural barriers that impact the quality of dental care as well as access. These barriers affect the ability of health professionals to do what they need to do, and ultimately the access of Inuit to services needed.

Many of those working in the system are confused by the processes and policies that are in place. They also feel there are many questions that remain unanswered, particularly around the funding decisions. The status of NIHB as a public or private delivery system also causes confusion. There seems to be a general lack of leadership to address these issues and implement solutions.

Many other countries have introduced oral health strategies: the United States, England, Ireland, Scotland, to name a few. This is important, because those strategies address the oral health of the most vulnerable segments of their population. This leads well into the question about the effectiveness of resource allocations.

Canada's NIHB dental policy objective is to permit the achievement and maintenance of sound oral health. How can we be accountable to a policy without objectives or targets? There are no specific changes indicated, and there is a lack of definition regarding what standard of oral health we should aim for. If I can't state the intended outcomes of this policy, how can we measure the effectiveness, not knowing what the objective was in the first place? It's like being on a road and not really having any destination in mind, so that you drive all over the place wasting gas.

The research says poor Inuit health is a result of changes in diet and in childrearing practices and is a function of geography. This means to me it's much more than just brushing your teeth twice a day. We are talking about a complex disease that requires multiple strategies focused on many different audiences to gain improvements. Complexity lies within the social and cultural elements.

Again, I call upon the federal government to consult with the Inuit and work towards a common solution; to develop and implement a strategy that will investigate alternative delivery systems, and that will improve access to services; to develop strategies to address the inequities in oral health that Inuit experience and the gaps in public policy that contribute to oral health disease.

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We want to see the development of measurable oral health goals and strategies to attain these goals, the ability to monitor health trends so that we know the resource allocations are effective and the program is accountable, and to improve public education and awareness of dental health as a key element of an individual's overall well-being.

The Inuit are very different from other segments of this population. It is critically important that an Inuit-specific strategy be developed in partnership with public-private delivery systems, non-government organizations, and government at all levels.

One example of our uniqueness is our food. If one of the causes of the problems is the change in diet, support for traditional dietary practices could help improve dental health. Program direction that supports improved health access to country food for young families could contribute to the well-being of the Inuit.

A comprehensive strategy is needed to bring together a variety of initiatives and a variety of approaches. There are identifiable priority groups, such as children, youth, mothers, and elders.

In conclusion, we seek Inuit-specific oral health programs developed with Inuit partners that will include measurable results over time, aimed at increasing the oral health of all Inuit and contributing to an improvement of the overall health of Inuit.

Thank you.

º (1600)

The Chair: Thank you very much.

We'll move on to the Canadian Dental Hygienists Association, Susan Ziebarth and Judy Lux.

Mrs. Susan Ziebarth (Executive Director, Canadian Dental Hygienists Association): Good afternoon, and thank you.

We are pleased to be able to appear before you today. I will be making the presentation, but both Judy Lux and I will be available for questions.

Jose Kusugak, president of the Inuit Tapiriit Kanatami, emphasized the importance of providing health services in remote areas when he stated, “I believe that...the success of our health care system as a whole will be judged not by the quality of service available in the best of urban facilities, but by the equality of service Canada can provide to its remote and northern communities”.

Unfortunately, Canada has long struggled with the challenges of providing access to health services, including oral health services, in its vast, sparsely populated areas. As we heard from a number of the witnesses already, its report card in this area has very low marks.

First Nations and Inuit oral health is in an appalling state. A wide gap exists between the oral health status of this population and non-aboriginal people. In fact, the dental decay rates of first nations and Inuit people of all ages range from three to five times greater than those of the non-aboriginal Canadian population. I must also mention smoking rates, since there is a link between smoking and periodontal disease. The smoking rate of first nations and Inuit people was over twice as high as that of the general Canadian population.

The main thrust of my message today is to highlight the reasons why the non-insured health benefits program is failing to provide adequate oral health services to first nations and Inuit people. Program flaws include underfunding, a lack of coordination of services, and difficulties with benefits administration. In addition, limited numbers of professionals work in rural and northern communities, so services are sometimes non-existent or require lengthy travel.

Most eligible NIHB clients don't get much oral health care at all; only 38% see a dentist once a year, compared to 75% of the rest of us. In some communities, such as Moose Factory, eligible NIHB clients lack access to dental care, since there are no oral health care providers in those areas. Northern towns have trouble attracting new dentists, and existing dentists are opting out of the NIHB program due to lengthy administrative requirements and red tape, which we've already heard about this afternoon. For example, in the Inuvialuit region, approval for work of over $600 comes from Ottawa, but this can be a lengthy wait since X-rays must be sent by mail to Ottawa for approval.

Human resources and administrative problems are not the only problems plaguing the program. Its mandate and a cost-benefit evaluation also reveal weaknesses. The mandate to provide restorative treatment and some oral health promotion does not provide adequate support for long-term preventative oral health. In addition, a cost-benefit analysis shows that little value is obtained from the expenditures. A long-term oral health mandate that includes a strong element of oral health prevention can result in program financial savings, since children with extensive dental disease also have extensive dental disease as adults.

The one redeeming aspect of this program is the use of dental therapists, who provide primary oral health care services in the territories and in first nations communities in all provinces except Quebec and Ontario. The use of dental therapists brings effectiveness and efficiencies to the program. Unfortunately, the program does not allow dental hygienists to be on the list of providers with a billing number. Even in provinces where dental hygienists can practise on their own, their services are not employed. The program refuses to make use of these independently practising prevention professionals, who can provide cost savings to the program in the long term. A dental hygienist from Sandy Lake Reserve provides a clear example of cost inefficiencies. She sees many children with cellulitis, an infection of the soft tissue related to dental caries. These children must take a one-hour plane ride to the nearest hospital in Sioux Lookout. A dental hygienist's application of sealants and topical fluoride could prevent this costly activity—not to mention the children's pain and suffering.

The NIHB program has been at the forefront of government relations with first nations and the Inuit for some time. It's time to stop talking and start acting. In order to address the deficiencies mentioned, CDHA urges the federal government to devote more funding to the community health, NIHB, and tobacco control initiatives of the first nations and Inuit health branch of Health Canada, so that there's an interprofessional approach to health and wellness involving an oral health component. Additional oral disease prevention and oral health promotion programs can be created and be carried out by dental hygienists, with a billing number—including mobile dental hygienists serving remote areas.

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A comprehensive national preventive initiative can be carried out to address dental disease in young first nations and Inuit children. The NIHB program can be streamlined to reduce administrative requirements. Adequate basic oral health programs and services can be provided, including necessary restoration, maintenance, prevention, and health promotion. Dental hygienists can conduct anti-tobacco campaigns as a cost-effective means of preventing cancer and other illnesses associated with tobacco usage.

These are the key policy issues that must be addressed to improve access to oral health services for first nations and Inuit peoples, and to narrow the gap in oral health between this population and non-aboriginal peoples.

Thank you.

The Chair: Thank you very much.

We now go to the Canadian Dental Association, and Doctors Dubé and Smith.

Dr. Louis Dubé (President-Elect, Canadian Dental Association): Bonjour. Madam Chair, I would like to begin by thanking you and the members of your committee for bringing together this group today to address this important issue. My name is Louis Dubé. As president-elect of the CDA, I hope to present to you the profound concerns shared by dentists across the country about the levels of oral disease suffered by aboriginal Canadians.

An uninsured health benefit program is administered by the first nations and Inuit health branch of Health Canada. Dentists participating in the NIHB program are given a provider kit outlining the many administrative requirements of providing care. Because there are so many requirements, and because they are so different from standard plans, many dentists must have a specially trained staff person just to deal with the extra paperwork. In addition, the plans primarily work on an assignment basis, which means that the dentist cares for the patient but agrees to be paid after the fact by Health Canada. This is an important distinction, because it means that the dentist assumes the financial risk if Health Canada denies payment. All of this means that dentists participating in the program do so because they are committed to providing much-needed care to these patients.

Unfortunately, dentists cannot achieve the goals of the program on their own. There are some serious problems with the NIHB program that prevent it from meeting the oral health care needs of first nations and Inuit Canadians. The conditions of their mouths reflect these problems. Last night I was looking at the annual report of the non-insured health benefits program, and one statistic that really caught my attention was that there were 66,000 more extractions done that year. That makes me sad and troubles me a little bit as a dentist.

Many Canadian children now grow up never having experienced a cavity. Sadly, it is not the case for aboriginal children who, by the age of twelve, experience seven or eight decayed or missing teeth on average. Untreated cavities in children can run rampant, and have implications well beyond their teeth, causing pain, inability to concentrate in school, trouble sleeping, and difficulty eating. Also, problems continue well beyond the childhood years. Periodontal or gum disease is commonplace in adult aboriginal patients. On its own, periodontal disease can be serious and can lead ultimately to loss of teeth. We know that gum disease and diabetes also occur in tandem—one making the other condition worse. Diabetes, of course, is a widespread and serious health problem in first nations and Inuit populations.

In the face of this growing need for care, it appears that NIHB is scaling back on its coverage rather than expanding services. Dentists are finding that services that used to be covered, such as root canals, are now being rejected. During the last federal budget and during the throne speech earlier, our government identified the need to narrow the gap between aboriginal and non-aboriginal health outcomes, and it committed resources to make that happen. Although it is also identified as a goal of the NIHB program, it is not a visible priority in its day-to-day operations.

The second problem is access to care. The utilization rate for the NIHB program, as we have heard today, is approximately 36%. This can be attributed partly to the fact that many aboriginal Canadians live in remote areas where there is no dentist in residence. The NIHB program covers expenses for travel to health care providers. However, because of the extensive need for predeterminations, patient may not always be treated after being flown in, but simply be assessed. The patient then is transported back home, while a treatment plan is considered by another dentist who has not even examined the patient. Needless to say, this is a very expensive way to provide care, and often results in treatment not being rendered because patients often don't return.

The final problem I want to draw your attention to is privacy and consent. Dentists first became concerned about privacy in the NIHB program as a result of the onsite audits, which required the release of patients' information without appropriate consent. We fully acknowledge the need for accountability for public funds and we are opposed to any form of fraud, but we also desire a better balance with the need to respect privacy. In working with Health Canada, we are thankful that we have been able to largely resolve our concerns with the audits. However, we learned that Health Canada has developed a new global initiative, which is a major concern to the Assembly of First Nations. Dentists share many of those concerns. If patients feel that their information is disclosed too broadly, there is a real risk that they will not feel comfortable to disclose or share those details. For dentists to provide safe and effective treatment to patients, it is critical that we get all of the information that we need.

º (1610)

[Translation]

What can we do now? I have identified for you a number of general concerns dentists have with the NIHB program. Fortunately, we can recommend a few very viable solutions, and although we would certainly welcome additional funding for these programs, many improvements can be made without a dramatic increase in budgets.

To begin with, the administrative burden of the program needs to be dramatically lightened. This lightening will reduce the budget of the NIHB program allocated to paperwork, thus leaving more money for dental care. It will also motivate participating dentists, and this in turn will improve access to dental care services.

We believe that, in its dental aspect, the NIHB program should look more like the standard dental care plan protecting non-aboriginal Canadians. A mechanism could simply be integrated to comply with the rights granted by treaty to the first nations and Inuit.

As regards administrative procedures, the situation could easily be improved by eliminating predetermination for basic restoration work, especially when the patient or dentist needs to travel. As this dental care is absolutely required, there should be no other administrative barriers, and at least, the predetermination rate should be increased to $1,000, as is the case for most standard programs found on the market. Double predetermination requirements should be eliminated when there were only minor procedures. Finally, the NIHB program should be transferred to CDAnet, as agreed.

In addition to the problems created by the administrative burden, the NIHB program includes other objectives that could have an impact on both health results and access problems. These include expanding the part of the program dealing with oral health promotion, and encouraging patients to be responsible for themselves. More efforts are also needed to recruit aboriginal Canadians as professionals in health care services such as dentistry.

First nation children need positive models. Maintaining team work for the delivery of oral health services is also necessary. Because this population has many complex health problems, a diagnostic and a complete treatment plan are required.

Finally, with respect to consent, dentistry supports the view that the patient should only be required to provide personal information directly related to care, for compensation purposes. The use of this information for administrative audits for studies on the use of drugs or other purposes should be done separately and only as required.

In concluding, Madam Chair, I would like to thank you again for organizing this meeting with the parties involved to talk about the oral health of first nation and Inuit Canadians. We all need to continue to work together to bridge the aboriginal health gap so that all Canadians can enjoy better oral health.

My colleague Darryl Smith, who treats many first nation patients in Alberta, and myself will be ready to answer the questions at the end.

Thank you.

º (1615)

[English]

The Chair: Thank you, Dr. Dubé.

We now go to the Department of Health, and Dr. Peter Cooney and Ms. Leslie MacLean.

Dr. Cooney, could you try to respond to some of the things that have been said here?

Dr. Peter Cooney (Director General, Non Insured Health Benefits Directorate, First Nations and Inuit Health Branch, Department of Health): Certainly.

Madam Chair and honourable members, we welcome the opportunity to provide the committee with an update on the dental program of Health Canada's first nations and Inuit health branch and on the actions underway to address what are clearly complex and difficult problems, as you have heard today, associated not just with the oral health but also with the general health of patients who receive benefits under the non-insured health benefits program.

The non-insured health benefits program is a public health program that provides non-insured health benefits to over 720,000 first nations and Inuit clients. The program funds dental services based on client need, taking into consideration the current oral health status, past oral history, accumulated scientific research, and the availability of treatment alternatives. The program covers a range of services, including diagnostic, preventative, restorative, endodontic, and orthodontic care.

Services are delivered through a number of providers. As you heard today, the major portion are from private practice dentists, but also from dental therapists and contract dentists—who provide services in first nation and Inuit communities through private practice—whom the client chooses in contract situations, and, of course, from dental hygienists in private practice settings.

The needs-based approach to the provision of dental benefits ensures that the client receives the services they require. Needs are assessed through a predetermination process, under which the dental practitioner completes a treatment plan for the recipient and submits it to the program for funding approval.

Given the diverse group of providers and services covered, it is recognized that opportunities exist to improve the program. To this end, an NIHB-CDA working group, with client participation, has been established to address administrative and policy issues such as the one you heard discussed earlier today. There are also ongoing discussions with first nations and Inuit groups to gather their input.

Examples of revisions made to the program include increasing the threshold to $800 now—though you heard today that the threshold was $600. In other words, $800 worth of care for a patient goes through the system without prior approval—not the $600 that was previously mentioned. Please keep in mind that the average patient receives about $420 worth of care, so when there's a ceiling of $800, this really should not be a major problem.

That is one revision. Another revision is the post-approval of selected services and the establishment of audit protocols with dental regulatory bodies—referred to by the Canadian Dental Association—to meet the needs of private practice dentists as well as the needs of Health Canada. The changes have reduced the administrative burden while also ensuring more consistent application of the program.

Is the dental program working effectively? In 2002-03, the NIHB program funded an estimated 365,000 first nations and Inuit clients to access dental care through private practice dentists, for a cost of just under $130 million. This figure does not include the services provided by dental therapy and contract dentists under the program.

Madam Chair, to address the issue you mentioned, that Health Canada may be involved in making reductions to the program, I can assure you that it is not the case. The $130 million I referred to has increased by 5% over the expenditures last year. So this program's costs are increasing at a rate of about 3% to 5% per annum. The program certainly isn't being reduced. The program as a whole, or its total costs, increased last year by about 9.5% over the previous fiscal year. So in no way are we reducing dental benefits.

Despite the expenditures, the caries rates among first nations and Inuit people still remain more than double—

Mr. Greg Thompson (New Brunswick Southwest, PC): I have a point of clarification.

Madam Chair, I know we're going to go to questions and answers, but because Dr. Cooney is getting into the overall budget and the moneys expended, I would like to ask, do those figures include the cost of transportation as well?

The Chair: I don't know.

Perhaps he could clarify that.

Dr. Peter Cooney: The $130 million is the expenditure on dental only, so it does not include the total costs and it does not include pharmaceutical or transportation costs. At a later point, I can give your committee members those numbers, if you so wish.

At first glance, the statistic that first nations have decay levels two to three times higher than those of the non-first nations, non-Inuit population does seem discouraging. However, FNIHB programs are having a positive impact on oral health. The caries rates in 12-year-old first nations and Inuit children have been reduced in the last 20 years by about 50%. They have gone from a DMFT of between nine and 10 to a DMFT of about 4.4. Clearly this is still very high, but the fact that we have reduced dental decay levels by about 50% over the last decade is an indication that at least we are on the right path. We hope to continue to do that. Of course, our ultimate goal is to ensure that the health status of kids and adults in first nations and Inuit communities is equivalent to that of non-aboriginal Canadians.

To continue improving the oral health status among first nations and Inuit, the FNIHB has proposed a children's oral health care plan. This plan is based on needs that were identified using NIHB program data, of which you heard a number of statistics earlier. For example, to cite the statistic that my colleague Mr. Gordon referred to, 25% of children under four were treated in 1999, but of those treated, over 4,000 were treated under general anesthesia for a disease that really is preventable. So the concern that has been expressed is clearly a genuine concern. In particular, why do we have little kids receiving large numbers of hospital OR sessions to repair preventable disease?

To address this, we have initiated the children's oral health care plan, which represents a comprehensive approach focused on prevention to reduce the need for restorative care. The plan provides information on techniques to pregnant women and primary caregivers; it gives preventive care to children from zero to five years of age, such as fluoride varnish cleaning; it gives preventive care, such as sealants, to six-year-olds; it provides regular follow-up preventive care for children entering school; and it provides maintenance to children seven years and up.

As my colleagues have mentioned here, the focus clearly needs to be moved away from the treatment orientation, from the filling of teeth, to the prevention of dental disease. This is exactly what we are doing with the children's oral health care plan.

Madam Chair, for the second portion of this brief address, I'm going to pass this over to my colleague Leslie MacLean, who is going to discuss some current program management issues with you.

º (1620)

The Chair: Thank you.

Ms. MacLean.

Ms. Leslie MacLean (Acting Director General, Non Insured Health Benefits, First Nations and Inuit Health Branch, Department of Health): Merci, Peter.

Really, our ability to deliver health programming--and, of course, today the committee members' interest is principally in oral health--is directly linked to how well we do our program management and our review work. It's only through evidence-based decision-making that we can target benefits and identify ways to improve our programs. In order to make these informed decisions, however, we need information. We need the information on individual clients, which brings me to another important initiative underway in the non-insured health benefits program. It's the initiative around client consent.

You may be aware that our program has been required to get the explicit consent of recipients to collect, use, and disclose their personal information so that we comply with requirements under the Charter of Rights and Freedoms and under the Privacy Act. I should point out that it is normal for health insurance plans to get the consent of their recipients to collect and use that information in a very limited and protected way. We're not asking for consent that is beyond what recipients of other similar programs, such as veterans, provide.

We've always worked, in the past, with implicit consent from our clients, but based on advice from the Department of Justice, more than three years ago we began working on a plan to begin to collect the consent from our clients. So in the spring of 2000 we began to work in a collaborative way with people from the AFN and the ITK on a process about how best to do that. And representatives of both organizations are here today.

The campaign that we began in September 2002 was to give us one whole year to inform people about the requirement to get their consent and to give us time to put it in place. While recognizing the need for consent for the use of personal information, clearly, as you've heard today, first nations leaders and organizations do continue to have concerns over the consent initiative--over the process, the wording of the form and concerns around treaty rights.

We've been meeting with first nations and Inuit representatives on many levels, including on the joint consent advisory committee that was set up in June 2000 to provide advice on implementation. We have established a September 1, 2003, deadline for consent.

We've chosen that date as the best possible compromise between giving us time to consult with as many of the over 700,000 clients as possible to try to work collaboratively, while recognizing that we need to play catch-up with other plans. We need to get consent in place to formally respect our recipients' privacy, to comply with the law, and to ensure we can keep providing them benefits. So we are continuing to meet with first nations and Inuit groups in communities to provide information, to try to address questions and concerns regarding consent or other health needs.

First nations and Inuit input, combined with good program information, is the key to making sure this program continues to deliver more effective health programming and, specifically for your interests today, more effective oral health programming, and to make sure we're in a position to address other emerging health needs.

º (1625)

[Translation]

Thank you very much for your interest. Dr. Cooney and myself will be happy to answer your questions.

[English]

The Chair: Thank you.

Mr. Merrifield.

Mr. Rob Merrifield: I want to thank you for coming in. I've been aware of this subject for a considerable amount of time. I'm pleased to be able to try to get a bit of a handle on it today.

From my perspective, from what I've heard you say, there are two aspects to this. One is prevention. The other is, okay, we have a problem, how do we deal with it? If I were trying to boil it down into real layman's terms, I would say that you're telling us that when it comes to dealing with the problem, we have a massive problem with red tape, with an overburden of paperwork. It sounds to me that we have a problem with the consent side of it. I'm trying to get a bit of a handle on what the problem is with the consent side.

I don't know who would like to answer that. It's not so much on why we're asking it, but on why it's not delivered and what the problem is there.

Dr. Mary Jane McCallum: On the consent form, I only heard about this issue in April, a year ago. So very few first nations know about it at the community level. The problem with the consent form is that it's a blanket consent. It involves all the five benefit areas, so it's pharmacy, dental, optometry, medical transportation, and medical supplies. So all five areas are in the consent form. And the consent form is being collected by first nations people, so they're not even provincially or federally appointed trustees.

As a provider, I have to be the one to give the patients information on the use of disclosure, the collection, why their information is being collected. I have to make certain that they understand how their information is going to be used. I can't do that if somebody else has collected the consent form for me.

Mr. Rob Merrifield: So are you saying there's a reluctance on their part to give it, or is it too clumsy to be able to make all that happen? It's not a problem with their giving the consent; it's a problem with the mechanics of actually making it happen. Is that right?

Dr. Mary Jane McCallum: Yes, it's too clumsy.

The other thing too is that if they don't sign this consent, they cannot access the benefits. There's a reimbursement. To be reimbursed, they still have to sign the consent. The consent process is being used as a lever. It's pitting the health professionals against the patients.

Mr. Rob Merrifield: So we've just asked for this consent now, and it has to be completed by September 1 of this year. Is that right?

Dr. Mary Jane McCallum: They want all the consent collected by September 1.

Mr. Rob Merrifield: So this is new to the program, I understand, then. Up until now, what have we been doing?

Ms. Leslie MacLean: I should point out there are two kinds of consent, I think, being referred to. One is the consent that a client gives a provider for treatment. If I were having a root canal today, normally my dentist would ask me whether or not I wanted it. So that's one kind of consent.

The kind of consent that I referred to is what Health Canada is seeking, which is the explicit agreement from the recipient that we can collect the information we require to pay the bill. In the past, unlike other programs like the public service health plans, the Veterans Affairs plans, or the provincial health plans, we have not been requiring recipients to sign a form, other than for, ironically, the dental program, where we've had a consent form in place for some years.

The other service we've had in place, consent up front, has been for mental health services. So our plan is to have one form that does cover all the benefit areas in the same way as you sign a form when you reserve a service for your health plan.

I'm not sure if that responds to your question.

º (1630)

Mr. Rob Merrifield: So you sign that form when you come to access service?

Dr. Mary Jane McCallum: No, they provide us with that in the office. I'm sorry, I spoke out of turn.

Mr. Rob Merrifield: Well, that's fine. I'd like to hear from the dentists on this one as well.

The Chair: You're implying that all off us sign a form to do with our health plans--our dental benefits and all that.

Ms. Leslie MacLean: For example, as a public servant, I'm a member of an insurance scheme called PSMIP. So when I go in to access drug benefits or pharmacy benefits, in accessing that service, I pay up front and get reimbursed after the fact. Our recipients do not have to pay in the current process. They receive the benefit directly, other than for pre-approved things.

The Chair: Do you sign when you--

Ms. Leslie MacLean: Yes.

The Chair: Can anybody else tell me if they sign every time they go to the dentist?

A voice:No.

The Chair: I never do either. No signing goes on.

Sorry, go ahead.

Dr. Darryl Smith (Executive Council Member, Canadian Dental Association): Thank you. On the issue here on the consent, in a dental office in this particular program there has always been a consent signed by the patients at the time of treatment for the services done. The problem with this global consent program is that it really should be looked at as a contract between the first nations or the aboriginal client and Health Canada.

The potential problem is this. In that contract, that individual is giving Health Canada the right to collect information that may in fact be confidential between the provider and the client. Certainly from the CDA's perspective and dentistry's perspective, we believe that the time for consent of any information is at the time of services provided. If it's a contract outlining the plan, then that needs to be conveyed to the first nations people through Health Canada.

Interestingly enough, these global consent programs arrived in dental offices for the dentists to administer on behalf of Health Canada. Certainly it's not our position to provide that type of information, but that just adds to the bureaucracy in this particular program.

So I hope that clarifies some of that.

Mr. Rob Merrifield: That's some of it, but I'd like to hear from the other two.

Kimberly.

Ms. Kimberly Whetung (Associate Director, Health Secretariat, Assembly of First Nations): Mary Jane has given you a first nations provider perspective. From the first nations client perspective, many first nations clients are unwilling to sign this blanket consent form for several reasons. One is that it is a blanket consent. It covers your entire client medical and dental history. There are issues around ownership, control, access, and possession of the information, around who actually sees the information. There has been tracking done on where some of the first nation information goes.

Dr. Cooney is well aware that we tried to track it, and some of our information actually goes to the States and comes back. And it's all over. It's huge.

There's a big issue with first nation clients around privacy. They have not, in the past, had issue with the Dent-29 form, which is the current method of consent at the dentist's office. It's on a per use basis. When you have your treatment done, you sign it off before you leave. That hasn't been a problem.

They certainly take issue with this blanket form, and I will willingly say too that a lot of the problem stems from the way this has been introduced to the first nation communities. It has been introduced, from a first nation perspective, as a threat. If we don't sign these forms, we will be denied benefits, not by Health Canada, because they're saying they're not going to deny us the benefits, but by the service providers because they can't be reimbursed.

We at the AFN have been working very diligently at a technical level, both with the dental associations and with FNIHB to try to resolve the issue of client consent.

A big component of client consent from a first nation perspective is a component called the drug utilization review. That seems to be one of the hang-ups with the entire client consent process. We're trying to look at working with our colleagues at FNIHB to have a reimbursement consent and some other process by which drug utilization review can occur. We have tried to see what the veterans sign, what the RCMP signs, what other federal servants sign who have their benefits administered by the federal government. We have not yet had the benefit of seeing those client consent forms. We have had a panel of experts review this.

The privacy commissioner has said that this is a blanket consent. He doesn't think it's very acceptable.

º (1635)

Mr. Rob Merrifield: When it comes to consent, we're working on it right across Canada in every province as far as medical services are concerned, and having your medical records follow the patient. And that's likely something that will happen within the next three to five years. I think everyone is going to be working on this issue.

I'd like to get to what Dr. Dubé would add to that.

Dr. Louis Dubé: Part of what I was going to say was addressed by Ms. Whetung.

Actually, if we go back to Madam Chair's comment on whether or not you sign something when you go to your dentist, yes, you do, but what you sign is for that appointment and it's a one-time thing. What we're talking about here is very different. You sign and it's for whatever period. So it's very different. We are comfortable with the one-time consent form that we usually deal with in any other program or in any other plan, but this is not the same kind of consent that you give.

Mr. Rob Merrifield: Is this consent adding to the paperwork? My impression is that we have a backlog of paper with the program prior to this consent issue. Is that factual, or is that the way you're seeing it, or not?

Dr. Darryl Smith: The big issue that will occur September 1 is really an access to care issue. If the first nation or Inuit individual has not signed that consent package, his access to service through the program would be denied. Therefore, if a person comes in, as a provider I'm certainly ethically obligated to deal with the emergency nature of the pain that's there. But we're dealing with an access issue here that is already an access issue from many other standpoints, because there may not be practitioners in that area, because of the travel involved. There is a whole host of things making it very difficult for this client group to get the type of care they deserve as Canadians.

Mr. Rob Merrifield: So are you saying that after September 1 they come in? Before they're treated, they would have to sign the consent form, right?

Dr. Darryl Smith: They would have had to sign that consent form. It will still be--

Mr. Rob Merrifield: What would be the problem with signing at that time?

Dr. Darryl Smith: The problem with signing that particular consent form is that it is a contract between Health Canada and the individual; it's not a contract that I, as a dentist, would need to administer. I'm already doing many counselling things for first nations people that I don't receive payment for. It is another thing I would have to do, to provide counselling for the individual. It is not something I believe I have to sign.

Mr. Rob Merrifield: It sounds as if the dentists don't want to go through the administrative nightmare of filling out the forms and having them signed.

What does Health Canada say? It's all in combination, is it not?

Dr. Peter Cooney: Yes.

Just to put this in perspective, we've been receiving consents in the dental program, on the Dent-29 form, since 1998. So we have been receiving dental consents for about five years.

Mr. Rob Merrifield: It is a different consent, though.

Dr. Peter Cooney: That's correct.

One of the reasons we're moving with the generic consent is the size of the program, which was a question that you folks asked earlier. To give you an idea of the size of the program, in the pharmacy program last year we processed 10.5 million pharmacy claims, and we processed just under 2 million dental claims. The pharmacy and dental components only comprise just over half of the non-insured program. So there are potentially between 10 million and 20 million transactions every year in this program.

To try to make life easier and more acceptable to people, we came up with a generic form in working with the client groups, or a global consent for processing claims from the dental and other parts of the program, which people would be comfortable with in sharing their information. However, if people don't want to sign the generic form, there certainly is an alternative, which is that they sign each time. That wouldn't be burdensome to the dentist, but again there is going to be the problem of more and more administrative work, which we're trying to cut down on. For example, we're moving to electronic dental claims, which are actually being processed now in Alberta. We are hoping to move out in the province of Alberta such that it will reduce the paperwork of dentists by approximately half. Along with changing the predetermination level from 600 to 800, this is one of the things that we have done, so that there will be less and less, rather than more and more, paperwork.

With electronic environments, we are subject to the PIPEDA, the electronic documents act. A provider cannot transmit information to us on a patient—and rightly so. We cannot look at that unless we know that the patient consents. The intent of that consent is to allow us to look at the information, process the claim, and pay the bill. We're asking the patient to consent to this generic or global form. If they don't want to consent on a global basis, which is their decision, they can sign an individual claim for reimbursement.

At the moment, we have started to come out with these forms and have received about 40,000 consent forms to date in return. So there certainly appear to be a lot of people out there who aren't uncomfortable with us. However, we respect the point that people out there may be uncomfortable with it. In that instance, those people can sign an individual claim for reimbursement, the same as you folks would do if you have private insurance, or the same as we would do as public servants. Of course, the problem with that is whether or not the patient has the upfront funds to pay the bill, which is why we're concerned and would prefer to have the generic consent, such that the patient wouldn't have to pay the bill and then get reimbursed, which is what's done under most, if not all, of the private plans.

º (1640)

The Chair: Thank you, Mr. Merrifield.

I'm sorry, but I'm going to have to interrupt the committee for a minute.

You'll recall that the meeting ended rather suddenly yesterday. We had a second motion that we had hoped to look at. I don't think it requires any discussion, because you will recall that our colleague Mr. McKay had a private member's bill that was referred to us. He has explained to us in the past that he thinks it needs more time. So Ms. Bennett proposed that, pursuant to Standing Order 97.1, the committee request an extension of 30 sitting days to consider Bill C-260, An Act to amend the Hazardous Products Act (fire-safe cigarettes).

Ms. Carolyn Bennett: I so move now.

The Chair: Thank you.

(Motion agreed to)

The Chair: Thank you to the members.

I apologize to the witnesses for the interruption. We will now carry on.

Mr. Ménard.

[Translation]

Mr. Réal Ménard: I will admit that I have a problem understanding all this, and I want to make sure I really understand. First, is this informed consent form the one that was distributed to members? Okay.

Let's take a concrete case to clarify. If I am an aboriginal from Ontario, Quebec or anywhere else in Canada and I go to the dentist for root canal treatment or a filling, for the professional to be paid, the beneficiary must fill out this form. Then, the professional will be paid. But the problem is that the form is not only used for that act but also for a more general application. Is that it?

It seems to me that this form provides personal information; it doesn't seem to provide much of any other type of information. Do you have specific examples for the committee to demonstrate that the information collected on this form would not be relevant and could cause prejudice to the beneficiary, beyond what he is claiming for health care? Is there a problem as to what this form asks for?

I for one, when I go to the dentist, I sign this informed consent form. If the costs are covered by public funds, I understand that it is required. But I'm trying to understand what the problem is. Maybe aboriginals are required to provide unjustified information that may then be used for irrelevant purposes related to privacy. I'm trying to understand.

º (1645)

Ms. Leslie MacLean: May I answer, Madam Chair?

What you have here, in the kits that were distributed, is the general form. The form we have just discussed is a specific dental form.

But you're right, here, it's really personal information: name, address, identification number. However, normally, for each transaction made by an aboriginal, a member of a first nation or an Innu, it's really transactional facts that are collected: what service was provided, at what cost? It's really information restricted to the transaction.

Under the Privacy Act, as a department, we only have the right to collect the information required for our business, and we must keep it highly protected.

Mr. Réal Ménard: Except in the case of Ms. Stewart for employment insurance. But that's another debate.

[English]

Dr. Mary Jane McCallum: There are only two provinces in Canada that have a personal health information act. I have sent the information to you, but I don't know if you have it in your packages. It specifically states that it is the only legislation binding me right now. Under it, I have to separate the different contexts of personal health information. Claims processing is one of those. So when I collect that information and I'm sending it for payment, it only includes benefit and client verification. We are only accountable for signing and saying that the services have been provided, which is all that it states.

For the other uses of personal health information, I have to give my patients a pamphlet outlining the specific personal health information uses that will be used with the program. So before I hand it over to Health Canada, I have to make certain that my patient understands that and consents to it. If I violate it—

[Translation]

Mr. Réal Ménard: Okay. But if there's a multi-million dollar program administered with public funds...

There are two possible objections: either you don't want to be a middle man for the Department of Indian and Northern Affairs--which could be understandable--or you question the fact that, if there are public funds, the information is collected to ensure the payment is made for the right purposes.

What I can't understand in what you said is what kind of information collection you are questioning. Is some of the information collected used for the wrong purpose? For employment insurance, for example, databases are cross-referenced. That, I belive, goes against privacy, but then, it's another thing.

The people who file claims and are eligible for these services are already known by the Department of Indian and Northern Affairs. So what is the problem with whether it's relevant to collect information.

[English]

Dr. Mary Jane McCallum: It's because all the issues are lumped into the one consent form.

In the States, the privacy law came into effect on April 1. They separate the claims processing away from the other uses. So it's separate, and health can go on.

They have addressed the personal health information separately. If I violate this, I'm liable for up to $50,000 a day. I may be violating it after September 1, so that's why I said we will not be able--

[Translation]

Mr. Réal Ménard: Now, I understand what you're saying, and it's important. In what is requested by the department, there is not only information on the treatment and the patient's health condition in relation with a one-time situation, but it can cover a series of situations other than health. Is that it?

[English]

Dr. Peter Cooney: Madam Chair, if I could answer, what the member is saying is correct in that it involves specific information. But, no, this information is very carefully and very, very clearly outlined as being covered and guarded under the Privacy Act and we have had a privacy impact assessment done stating that this is very necessary such that the patient knows a third party such as, in our instance, First Canadian Health Management, Blue Cross, Great-West Life, or whatever that would be, is looking at this payment of this claim for this patient.

We are asking that the patient be fully informed. We are trying to make the process very, very transparent to them. There is no intent to try to do something other than that with the information, and our hands are very carefully tied under the Privacy Act. Those in Health Canada who look at the information are mandated to have very particular training under the Privacy Act, because that is the act that governs us as public servants.

º (1650)

[Translation]

Mr. Réal Ménard: Let's take a concrete example. If I go to the dentist for a root canal treatment, this information, which is confidential and should remain between the health professional and the citizen, will never be used for other purposes than to pay the medical service provider's bill. You give me your professional word, your official's word, that in your opinion, databases containing this type of information were never used for other purposes.

[English]

Dr. Peter Cooney: I can assure you that the purposes of the use of the information are very clearly outlined. Please remember that it's not just the paying of a bill. Where there is, for example, a crown with a private insurance company, if I need a crown my X-ray will go to a dentist with Great-West Life who will review the X-ray and say, yes, Dr. Cooney needs a crown on this tooth.

[Translation]

Mr. Réal Ménard: Let's take a specific case. The Canada Customs and Revenue Agency or the employment insurance could not use this type of information.

[English]

Dr. Peter Cooney: Not at all, sir. We are very, very tightly bound by the Canadian Privacy Act. In fact, when we get asked for specific statistical information, we are bound to remove all personal identifiers, and rightly so. We are bound such that patients cannot be identified, and if there is something, for example, in the relationship of patients using AIDS drugs, if you are looking at a small community where there are a small number of patients, we are bound not to release that information, even without identifying the patients, for fear that the patient might be identified just through the low numbers.

We would be happy to share with this committee the privacy impact assessment done by the former privacy commissioner of British Columbia, who did a very detailed privacy impact assessment on the subject for us and said, you guys should do this; it's the right thing to do because you are being transparent to the patient. The patient now knows their information is being looked at by a third-party processor, but under very, very specific circumstances. We can share that with the committee.

The Chair: Did you want to respond to that, Dr. McCallum?

Dr. Mary Jane McCallum: Yes. I've worked with Health Canada for four years, in administration under Dr. Cooney. When I worked in that system, in the personal health information that came in, there was benefit and provider profiling done. The benefit profiling was not evidence based. They were looking at the benefits, and the benefits were being deleted.

One example would be dentures. Dentures, at the beginning, had a frequency of every five years, but because there was perceived abuse by providers, it was extended to eight years. So there was no evidence base, and that data was used against first nations.

So my real concern is because I've worked in the system and I've seen what people are capable of. That's why I'm saying we agree with the consent process, but we really have to look at the trust issue, because the reason this was brought forward was a violation by Health Canada on personal health information, the access and the use, and they were told by the justice department that they had to look--

Mr. Réal Ménard: Don't miss anything. I know every one.

Dr. Mary Jane McCallum: So we are looking at that trust base, and we really do know we need a consent form, but we want it to be more respectful. We want meaningful input into it, and it's vital that we start working with Health Canada and start correcting some of these. We are not refusing to go to the table.

The Chair: I have to let Dr. Cooney answer that.

Dr. Peter Cooney: Thank you, Madam Chair.

Just to use the example that Dr. McCallum discussed, which is a good example and which is true, we do look at profiles, but please remember that a provider profile is done with anonymous patient information. This is what provincial governments do.

We sat in front of your Standing Committee on Finance, who asked, are you folks doing audits? We've done a lot of work with the CDA in relation to doing audits. This is part of the management of the program. But that's completely bound and held under the Privacy Act, so the information we have is worked under the Privacy Act. But, Madam Chair, you wouldn't thank us if you or your members asked us a question here and we said we'd no idea what was being spent or what was being done.

To further the example regarding the dentures, we removed the fact that there was a frequency on dentures. We recommend a frequency, but these are looked at now, as I mentioned to you in my opening address, on a needs basis. So if somebody needs a new denture, they won't be held to the seven-year frequency; they will get it within that.

But on the basic program management, you folks have charged us, and the first nations or the Inuit folks would not thank us either if we were to come and say we'd no idea what was being done or where the money was being spent.

º (1655)

The Chair: Thank you.

Ms. Fry.

Ms. Hedy Fry (Vancouver Centre, Lib.): Thank you.

I agree with Dr. Cooney that provincial assessment is done on patient files in the same manner, as with private insurers, for information, and I understand that you need to have that information in order to be accountable.

I'm not saying you are doing anything that isn't done everywhere else, but is this information only being used--and this goes back to something we heard from the Auditor General yesterday with regard to information--purely for fiscal accountability reasons, or is it being used to build up a data bank in terms of what is obviously a high-risk particular population, and what are the things you are doing most of, and how can you prevent them, and how can you use this to provide better dental care in the long run? I would hope that is what it is being used for, so that you could do that kind of assessment of data.

What concerns me most about what I've heard here today is that obviously when you have, as you said, these young children having general anesthesia so often, it is because the situation with their dental health is so terribly bad that it has to be done under an anesthetic. I recognize that prevention should be done, and you say there is prevention being done. There are preventive measures in schools, and children are getting all kinds of preventive dentistry done on them. But if this is so, why do we still have the situation where dental health is so bad?

Are we linking things like smoking? Are we linking things like diabetes? Are we also linking poor dental health with heart disease later on in life? Are we doing those linkages that we now know exist? How could we still, after such a long time of a dental program, with such absolutely wonderful preventive care, have such bad outcomes?

Are we doing outcome analysis? Are we looking at what we're doing wrong and what we could be doing better?

Dr. Peter Cooney: What you're saying on the analysis was actually the example I was going to give back to you.

The type of analysis we do is the example that I gave you. When you look at very large numbers of kids needing general anesthesia rather than preventive care, we then refocus our efforts and say, folks, let's try to address the 0 to 5 age group. Let's try to stop baby-bottle caries, which is almost a social issue in that you have very young kids in difficult crowded housing conditions on first nations that are given bottles, basically, because living conditions are difficult. If they go to sleep with a bottle, they get dental decay.

This is the type of preventive instruction to new moms. We're working with the Canadian Dental Association and the Canadian Dental Hygienists Association and the AFN and the Inuit folks through the Federal Dental Care Advisory Committee, which is a committee that includes all of these representatives, to target strategies such as you have mentioned.

So the answer is yes, exactly, that is what we're doing. We have recently been working with the pharmacists, for example, in the area of diabetes because that's a very difficult disease to handle, and as my hygienist colleagues pointed out, this is an issue that has ramifications on the oral health and the periodontal membrane of teeth.

These things are all interwoven. Yes, the data are used on a nominal basis to do proper health strategies, to work with providers, to work with groups and to try to improve the oral health.

To answer the other part of your question, a very valid question as to why it is still so bad, again, it is not good. It has improved, and I gave you the example of over the last two decades. That is no reason for complacency. It is still very, very high. It's two to three times the non-aboriginal average, but our belief is that if we can hit the very young age groups with these preventive strategies, sealants on the six-year molars and twelve-year molars, fluoride varnish on little babies, preventive instructions to new moms and to pregnant ladies, our belief is that we will start the process.

It's going to take time, I guess, is the answer. It has been improving, but too slowly, and what we're hoping to do with these types of statistics is hasten the improvement.

» (1700)

Ms. Hedy Fry: Do I still have a little space left?

The Chair: You can have more time, yes.

I think Dr. Smith wanted to respond on that earlier point.

Ms. Hedy Fry: I just wanted to finish up.

The Chair: Then you can come back in.

Ms. Hedy Fry: I'll do that, then.

Dr. Darryl Smith: I think we're confusing something here, and that's that the consent will do.... Health Canada already has the ability to get the statistical information in terms of disease and stuff there already. The issue really is the oral health of this group of people.

The consent form doesn't deal with that. It's just another bureaucracy. It's just more paperwork. Where it will be filed, who knows? Really, the issue is how do we make sure that this statistical information that we have is getting to the treatment needs and the prevention needs of those individuals?

I wanted to say that.

Ms. Hedy Fry: I want to follow up, then, on the conclusion that I came to. That is, after two decades... I mean, if this were a non-aboriginal community, after two decades of good prevention and all of these kinds of wonderful things that everyone's been doing, if we had come up with such poor outcomes, everybody would be yelling and screaming.

I still haven't got an answer to why outcomes are so bad and why it has taken two decades to admit that the outcomes are bad. The issue is not.... Putting a child to lie with a bottle in their mouth is a cultural thing. I know lots of immigrant moms who do it, lots of people do it because that's how they feel the child gets comfort.

Have you been doing culturally sensitive work with parents? I would like to hear from somebody in the community whether they believe that the preventive work with parents and with children has been done in a culturally appropriate manner that would actually reach some of the old practices and been able to modify them in a way. I still haven't had a response as to why two decades have passed before outcomes have been better, or have only been changed marginally.

Dr. Mary Jane McCallum: I have been in the dental field for 30 years. I was a dental nurse, a dental hygienist, a dental therapist, and worked in northern Manitoba. I went into dentistry and came back, I think about ten years later. I was absolutely shocked at how bad dental health had gotten.

Now I provide dental care every fifth week. I fly up north. When I fly into the communities, that whole week is spent doing emergency care. There is very little, if any, prevention going on in Manitoba—and I have been involved with the program for the last 20 years in Manitoba. We are busy. There are about 20 dentists who fly in, and all we are doing is emergency care. We don't have time to go in and work with the mothers.

The other thing is that when you look at consent, as first nations we have never had the right to consent in our lives. People have dictated what language we are using, where we live. When you have been treated like that.... Sometimes I wonder if I even own my body, because the government tells me, this is what you must do.

That's why I am fighting this consent initiative so hard: because with consent and making informed decisions, you start to take responsibility for your health, and it's the responsibility issue that is a big issue for first nations. We don't take responsibility because we can say this was imposed on us. You know, we blame the government. We have to really start looking at the consent process and make it meaningful for first nations, so that they can start taking responsibility in various aspects of their lives.

The Chair: Dr. Smith.

Dr. Darryl Smith: Thank you for the comments from Dr. McCallum. Further to the issue is that in the overall Canadian population we have had 30 years of a preventive dentistry message. We have a good model that is able to work to make sure Canadians enjoy better oral health than they did when I was born.

One of the biggest problems with this particular program is the lack of continuity. Since the early nineties what we have seen is this program constrained by budget rather than needs, and we haven't been looking at the need. We have been trying to control a budget, which in health care just does not work.

The other thing is that we certainly know that messaging depends on how many times you get the message out. In many of these rural communities—and I practised for 25 years next to a first nations community— in terms of the public health care programs that are delivered there, one year I might see a dental therapist, or a dentist, or even myself. It might be five, six or seven years before a provider comes back and delivers that message again. Well, we start to miss whole generations, and when we start to miss whole generations, we are in real trouble.

I would suggest that health care to first nations people is more like what we probably saw in the fifties and sixties. We need to recognize that and make sure we put in resources that can deal with some of those issues. Certainly there is room for providers here, and there have to be ways of providing those services. But right now the program is so bureaucratic that even to put a sealant on another tooth that's not named by us—such as, for example, tooth number 1-6, which happens to be an upper first molar tooth.... I couldn't put a sealant on a tooth anterior to that because it's not provided in the program. It doesn't make any sense.

Those are the types of problems we are facing.

» (1705)

The Chair: Thank you, Ms. Fry.

Mr. Robinson.

Mr. Svend Robinson (Burnaby—Douglas, NDP): Thanks very much, Madam Chair. I want to apologize. I had to leave at one point during the meeting to take an urgent call. I'm sorry that's the case, and if I ask questions that have already been asked, just let me know, and I'll move on.

I want to thank the witnesses who are appearing here and to say a couple of things.

I'm very glad this hearing is being held. I have believed for many years that dental health should be treated as an integral part of our overall medicare system and that this artificial divide is completely unfounded. I have to tell you, having had some significant personal experience with the dental care system and incredible people—I mean dentists, dental hygienists, and everybody else; I smashed my jaw and had my jaw wired shut for a long time—I know something of what I speak personally.

Also, in terms of first nations health, I worked with Frontier College in northern Ontario, in a community called Balmertown right near Red Lake. It was devastating to see the conditions, particularly of children. That was back in the mid-seventies. When I hear the eloquent evidence of the folks from the Assembly of First Nations—Wendall, who spoke earlier, and so on—I know not much has changed in those years. Darryl Smith has just pointed that out as well.

On the consent issue, my hope and my appeal, I guess, to the Health Canada folks would be to try again, to sit down with the leadership of first nations organizations and try to respond in a respectful way to them. I really appeal to you to do that. We've had a dialogue here today; you've heard some concerns. I would put those concerns also, frankly, in the context of the move toward self-government. I think they're an integral part of it. If you respect people's right to self-government, surely when really big warning bells are going off here, which they are, we have to hear them; we have to respond.

I would just appeal to you very directly—through the chair, of course—to take another look at this, to sit down with the leadership of the organizations we've heard from today to see if there isn't some way of perhaps rejigging the form, or maybe splitting it into a couple of forms, to see if it's not possible.

You mentioned that the former privacy commissioner of British Columbia, I think—a person I know well and for whom I have great respect—had a look at this. I don't know if the current federal privacy commissioner has looked at it yet. If he hasn't.... Maybe I could ask you that directly: have you run this by the federal privacy commissioner?

Dr. Peter Cooney: Yes, we have. We've met with their officials a number of times. We have run the whole thing through them, including the privacy impact assessment that was done by the other privacy commissioner.

» (1710)

Mr. Svend Robinson: And did you get any particular response from them on that?

Dr. Peter Cooney: To date they appear to be standing back a little from the thing, because certainly we didn't have a response up to February of this year.

Mr. Svend Robinson: I think the fact that you haven't had a response might cause some concern. I would suggest that you work with them.

Also, could I ask you directly whether you are prepared to meet with the leadership of the organizations and to have another look at this?

Ms. Leslie MacLean: Actually, I was meeting with people from the Assembly of First Nations yesterday. We've been working with people from the Inuit Tapiriit Kanatami. We have been open to alternate forums and suggestions since we began this work in the spring of 2000.

What you saw before us was, if you like, the generic model. We've been working, I hope, in a collaborative way; we have been hearing concerns; we've been doing our best to address them either through outreach at the community level or by working with leaderships. We remain committed to dialogue.

Mr. Svend Robinson: And are you prepared to have another look at this, particularly in light of some of the concerns that have been raised today?

Ms. Leslie MacLean: We are prepared to continue the dialogue and to have another look, yes.

Mr. Svend Robinson: I guess the other question would be around the issue of person power--just having enough dentists, enough dental hygienists, and so on, to meet the need.

I remember there were some really serious concerns in northern British Columbia about an ophthalmologist who went up there and was doing literally hundreds of eye exams, one after the other. Hedy would remember it well. I understand this is still a serious concern—just the availability of people—and I would say particularly, in dealing with first nations communities, the availability of first nations dentists and dental hygienists and so on.

I'm wondering what is being done by Health Canada in particular to try to put more resources into training and allowing young first nations people to have the opportunity to get the training and then to go back and serve their communities. What resources are being put into that?

Dr. Peter Cooney: We work with the Canadian dental schools and we are in direct contact with most of them on a fairly regular basis. We do fund the National School of Dental Therapy, which is a school that trains dental therapists based out of Prince Albert, Saskatchewan. It's a two-year training course, and first nations and Inuit dental therapists are trained there and go back into their communities. That's the direct training we do. We indirectly work closely with the faculties. The key for us is to have this program attractive enough for providers to want to work on it, the providers who are there.

We also, though, do direct contracts with providers. You mentioned northern Ontario. We have the Sioux Lookout program, which provides dentists throughout northern Ontario. We have a similar program, which Dr. McCallum was involved in, in Manitoba.

So we approach it from a number of different angles. A lot of the service, as I mentioned, is through private practices, but it's also through contract dentists whom we fly into communities, and through dental therapists who are trained by us.

Mr. Svend Robinson: I have two other brief questions, if I may. What about dentists? And perhaps I'd ask the representative from the Canadian Dental Association as well. I assume you also recognize, particularly in rural, remote communities, communities in which there are significant first nations populations, the acute shortage of people to respond to some of these concerns, and obviously of dental hygienists as well. Have you any suggestions that might help the committee in terms of recommendations that we make to the federal government as to how to respond to those very critical needs in those communities?

Dr. Darryl Smith: Certainly, the way the program is structured, the bureaucracy associated is one of the driving factors that causes young practitioners...because essentially in most of the situations we have it's usually our new graduates who end up trying to fill in the need. The frustration of dealing with this program on an ongoing basis certainly is something they'll talk to us about and say they just can't deal with. It's not the environment. It's not the group of people they're working with. It's not where they live. In fact, many of these people enjoy these communities. But when you deal with a bureaucracy and paperwork.... For example, in my office I basically I have one girl who's on the phone all day to First Canadian Health Management Corporation, which is the administrator of the program, just getting information so we can proceed with treatment on that day. That doesn't happen when you come into my office. The relationship is much different.

Just getting rid of those types of irritants would make it much easier for a person to say that some small community--let's say Chard or Conklin or something in northern Alberta--is a place where they would be willing to establish a practice. But when you can go to a larger city and have the ability to practise in a way that's unencumbered by some of these limitations and problems, it certainly causes those people to move.

I would certainly suggest that we get rid of the bureaucracy. We obviously have to create incentives in terms of how the program is designed to make it possible for these people to establish meaningful careers. It'll start at the first nations level, but it'll trickle down to all of rural Canada.

» (1715)

Mr. Svend Robinson: Ms. Ziebarth, did you want to add something from the dental hygienists' perspective?

Mrs. Susan Ziebarth: One of the issues in terms of access to care with respect to dental hygiene is that the primary focus of dental hygienists' practice is prevention. They are prevention professionals. Currently the program does not recognize dental hygienists without having a dentist as a filter. Dr. McCallum has indicated that when she goes in she has to deal with emergency situations. The NIHB program would require that she have a dental hygienist with her, not that a dental hygienist could go in and do what dental hygienists do on an independent basis. There are jurisdictions in Canada where dental hygienists can do that and the program does not recognize this.

Also, I wanted to add that Dr. Cooney indicated that he is working with CDHA, and this is not quite correct.

Mr. Svend Robinson: For my last question, I'd like Dr. Cooney to respond specifically to the suggestion that's been made that perhaps dental hygienists should have the opportunity to work in communities and to do the kind of good work they do, preventive work, without having to have the dentist there with them. Apparently this is done in some areas.

It makes sense to me. Maybe there's some reason that I'm not aware of, but it makes sense that this should be done. Why isn't it being allowed now? What about the suggestion that there hasn't been real collaboration with CDHA? That's something I think we should hear a response to.

Dr. McCallum also made reference--and I don't know that you answered it--to some concerns that Justice Canada had raised. I believe I understood you correctly that Justice Canada had raised some concerns around privacy issues previously. You didn't respond to that. What's your response to that?

Dr. Peter Cooney: There are three issues.

In terms of the first issue, in relation to our work with the CDHA, Carol Mathesson-Worbey is an individual we have been working with through the Federal Dental Care Advisory Committee. That's the input we've been getting. Perhaps you folks have or haven't been sharing information, but certainly we have been working with Carol. That's just to clarify this for the record.

Mr. Robinson, regarding Justice Canada, we were told by Justice Canada that legally we had to have this consent. We're not doing this for the want of something better to do. This is a legal requirement. It's a legal requirement under the PIPEDA, under the Privacy Act. They're the folks who are advising us legally. Our lawyers are actually part of Justice Canada.

So the answer to that question, sir, is yes, we have been dealing directly with Justice Canada on a regular basis, and they are the lawyers who are advising us on this.

Mr. Svend Robinson: It was suggested they may have raised some concerns about the forms. Did they? I believe Dr. McCallum wanted to respond as well.

Dr. Peter Cooney: The forms that are drafted go through Justice Canada. We have a number of different forms out there for first nations who want their own form. We accept that. But it needs to go through Justice Canada. For example, we have a different form in one of the first nations in Alberta, who are doing their own consent because they recognize the need. They changed the form, we said fine, and they submitted a form to us. They worked with Justice Canada because there were some concerns regarding that. They now have their own form and they're working with it. And I know the Inuit folks are doing the same thing. So there would be issues with various forms with Justice Canada that are worked through by the lawyers for both parties on a regular basis.

On the third issue there, billing, we pay dentists through the non-insured health benefits program. Certainly in some jurisdictions hygienists are legally entitled to work on their own without a direct dentist's supervision. This is an issue about which I think there's considerable discussion occurring between the CDHA and the Canadian Dental Association at the moment.

It's certainly something that Health Canada would prefer not to get in the middle of. But because we're a national program, and we base our program on national policies, we're quite happy to discuss, and to continue to discuss, with the CDA or with other parties through the Federal Dental Care Advisory Committee, the issue of billing. But at the moment our position is that because we're a national program, and because hygienists are licensed provincially to bill directly in a small number of jurisdictions, then we do not accept hygienist billing on a national basis at this point.

» (1720)

The Chair: Mr. Robinson.

Mr. Svend Robinson: Dr. McCallum said she wanted to respond.

The Chair: Very quickly, please. We still have a couple of more questioners and the time's almost up.

Dr. Mary Jane McCallum: I was going to respond to the recommendations that you were asking for. I work with the University of Manitoba for aboriginal dental health programs. We were going to be approaching Health Canada to see if they could give money to fourth-year students, and the fourth-year students would then join for two years and provide service in the aboriginal communities. The medical school does that, and because it's an insured service the province gives them the money. So we will be looking at doing that with Health Canada just to bring in more aboriginal dentists.

The Chair: I think Mr. Gordon was trying to get in a little, a few minutes ago. Do you remember what that was about, Mr. Gordon, something you were dying to talk on?

Mr. Larry Gordon: I was sitting and listening to everyone, and I have a couple of concerns.

One thing is that the reason NIHB is so costly in our area is the cost of transportation. If you want to go someplace, you have to fly. And you know the cost of transportation is extremely high.

Another concern I have is the subsidy that's awarded to cigarettes and alcohol, tobacco, etc. We've been asking for subsidies for fresh produce and milk, but it seems that the governments make more money out of selling cigarettes, alcohol, whatever.

Regarding consent, in our region in the Inuit world we have a lot of unilingual clients, and for them to understand what they're consenting to is very difficult at times because translators aren't available when needed. A lot of the times, with our elders especially, they don't know what they're signing, or they'll sign anyway just to get the benefits.

The Chair: Ms. MacLean, is this available in all these various languages?

Ms. Leslie MacLean: I'd like to note that we have been working with the ITK to finalize the form and we are committed to translate it into Inuktitut dialects when we finish that. The form is already available in English, French, Cree, Oji-Cree and Ojibwa, and we are happy to consider other requests to translate it as appropriate.

The Chair: Thank you.

I think Mr. Thompson would like to speak.

Mr. Greg Thompson: Yes, I think my patience is running out, Madam Chair. We do end at 3:30 and I think I have been more than generous in allowing others to go on, with due respect. This is the price you pay for being the fifth party in the House of Commons, obviously.

But anyway, to get on with it, I really want to talk to the two practitioners we have here, Dr. Dubé and Dr. Smith. I want to mention to you that some of your colleagues did get a chance to come up to my office today and I did meet with them. I was fascinated by their presentation, as I am by yours, because I want to put some of those practical questions to you.

We can hope that the departmental people, Madam Chair, will take note of that, because I think the people who practise it in the field.... And, again, I was interested in what Larry Gordon had to say.

I want to apologize, Madam Chair, because the practitioner, the dentist who was in to see me today with a member of your association--and you might know his name, I forget it--is an aboriginal dentist who practises in Winnipeg. Yes, it's Phil Poon. I'm glad that I could mention his name because I want to tell you how impressed I was with his presentation in stepping through this. In fact, when you have those one-on-one, eyeball-to-eyeball meetings you can cut through a lot of this, and he did that in the course of about 30 minutes or so. It was a quick education on the situation of the aboriginal community in regard to dental care, oral hygiene, if you will.

Again, Larry talked about the northern communities, because a lot of our aboriginal communities, as you know, Madam Chair, are in the north. The transportation needs are one of the things that we focused on today in relation to the high costs of bringing aboriginals into, in this case, Winnipeg for treatment, and often that treatment is denied simply because of the cost.

I do take exception to what Dr. Cooney was referring to in terms of the dollar value. The truth is, Madam Chair, as we've said here, I have more invested in my teeth probably than anyone here, including Mr. Robinson, more than the value of the car I am driving. My teeth are worth more than my automobile. I'm not saying this to in any way reflect on the high cost of dentistry, but it's just a fact of life. It's a very specialized profession, and we expect perfection, don't we? We don't mind paying for that, either. I don't think Mr. Robinson or I, either one of us, regretted paying for that service.

But the truth is that when you go to a dentist's office as an aboriginal with--and this sounds callous--a mouthful of problems, if you will, Madam Chair, it's expensive, and where the dentist could be performing good that very day, these same people are forced to go back home to northern Manitoba and suffer. The truth is, Madam Chair, the most abused drug in the aboriginal community is Tylenol 3. So often a prescription is written on the spot for this poor individual to go back home and suffer with the aid of a drug where the problem could have been dealt with right then and there.

So, Dr. Cooney, I take exception to what you said about the cost factor, because that cost factor would be a minimal level of service, to be very honest with you. When we go into a dentist's office, we often think, wow, this guy is cashing in. I often go down to my own dentist's, and you think that until you look at the staff that is required to run a dentist's office. My particular dentist has four assistants. He has a high level of equipment, state-of-the-art equipment, and again, that's what we expect. We go to our dentist, and he has huge overhead costs and all the other costs that are associated with running a business.

So I would like to know where you could go to see a dentist today with one visit and fall into the dollar figure that Dr. Cooney mentioned. That's just not, I don't think, possible in today's world.

Now I'm rattling on, Madam Chair.

» (1725)

The Chair: You're worth the wait, Mr. Thompson.

Mr. Greg Thompson Thank you very much. We have a great relationship and we only disagree on a few things.

The other point I wanted to make, Madam Chair, because this drug abuse--

Mr. Svend Robinson: This is his preamble, by the way.

Mr. Greg Thompson: And that's the luxury of coming last, Madam Chair, the luxury of coming last.

Mr. Robinson and I shared that luxury the other day when we brought, for the first time, the SARS debate to the floor of the House of Commons. We take a lot of pride in that.

You don't have to be big to be mighty in this business of politics, and it shows you that sometimes the last come first.

The Chair: Maybe they had a good look at both your teeth and they were so impressed they gave you your own way.

Mr. Greg Thompson: Absolutely. Anyway, Madam Chair, when Dr. Poon was at the office he had a look at some of the pictures on my wall and he said I probably should have had a hair transplant instead of a tooth transplant.

But getting on with it, regarding the aboriginal children, self-esteem in the aboriginal communities is very important. The other point this dentist, Dr. Poon, made today was that--and we know that, because most of us would not come into this room today if we had a tooth missing--self-esteem in the aboriginal community is a huge problem, and a lot of that is associated with bad teeth, believe it or not. If you take all of these other factors and put them together, based on all the other testimony we've heard, it's a huge problem. It goes beyond a medical problem to a social problem, Madam Chair.

I'd like to have the two practitioners here, the guys who are right on the firing line every day trying to deliver this service to the best of their ability, to comment on some of that. Perhaps they could outline two or three practical things the department could do to make it easier for those aboriginal children--and men and women--they want to help.

» (1730)

The Chair: Dr. Smith.

Dr. Darryl Smith: Actually, you have a first nations individual who is a dentist here, and I believe that's Dr. McCallum.

Mr. Greg Thompson: I'm sorry, I overlooked that fact. I looked at your credentials, along with my friend Mr. Robinson--I was a little late coming in--and I knew full well you were aboriginal, but I thought you were teaching at the university. So you have a practice as well. I apologize for that.

Dr. Darryl Smith: I don't believe Dr. Poon is a first nations individual. He has a lot of his practice with first nations people.

I just wanted to correct those two things.

First of all, what we're dealing with is catastrophic oral health among first nations people. For some quick recommendations, one is that we need to get the bureaucracy out of this program. We need to treat basic dental disease with the tools we need.

It's absolutely ridiculous that root canal therapy, basic restorations, scaling, fluoride treatments, radiographs--just basic dental services--are things we need to predetermine on a daily basis, or they're even denied. We need to change the threshold at least in terms of those basic services, so when they do arrive in our office, we can provide at least the treatment necessary to deal with disease and then start to look at the long-term question, which is what's going to be the big payoff in 20 or 30 years.

We have to realize we have to look at 20 and 30 years. That's the preventive aspect we've removed from this program.

You know, the statistics we have in the NIHB document are quite different. When I began my practice back in 1978 in a largely aboriginal community, I didn't see the types of catastrophic problems I see now. Yes, I did restorations on teeth. Generally they were small occlusal restorations. But we had the ability in those days, under the program, to provide the preventive care. We don't provide the preventive care now. The basic things--getting your teeth cleaned, getting fluoride treatment, getting instruction in how to brush your teeth--are not funded on a routine enough basis. And when you turn 17, you're put into a different category. We don't treat our adults, so we go down the road.

There is this nomenclature that it's needs based. Well, needs-based involves bureaucracy. If I have to do a needs-based procedure, I have to do a predetermination. I usually have to write a letter. I have to send additional radiographs, which may or may not be changed, just to get that procedure approved.

So basically--because I know your time's valuable--one, get rid of the bureaucracy. Let's put this plan up to at least a threshold that allows us to do those basic services. Basic services should not have to be predetermined. They're basically needs or rights for this group.

In the long term, while it's great to have programs where we have graduates going up for two years, we have to create an environment out there so practitioners will want to stay in these communities. You're never going to deal with the transportation costs. Right now, if the practitioners aren't there...and I don't care where they're from, we need to establish relationships with these communities that have the practitioners.

We have to get those types of incentives out there. And we need to start at the educational level, getting more first nations people, people who are culturally sensitive to these types of programs, into our dental schools. That's a funding issue. Those are the types of issues we need to deal with.

I hope that helps you.

The Chair: Dr. Dubé.

Dr. Louis Dubé: I don't have a lot of Inuit or first nations patients, just a few. But just with those few, I have the feeling I'm not trusted as a professional. I have to justify everything, every move I want to make.

If I diagnose a cavity, I think I have the knowledge to be able to treat that patient without having somebody in an office somewhere looking at the X-ray I sent them and saying, okay, you can do it.

There are some programs out there--and I feel a little bit uncomfortable in citing the program--for example, the children's program in my province, where there are some services covered. Some are not covered, but at least I can have the autonomy to say this kid needs fillings or a cleaning or whatever, and do it. There are some...not barriers, but constraints or controls put in place so if I don't do the right thing, they can complain to the DRAs, which are the regulatory authorities, the colleges. This is the body that can deal with those kinds of issues.

But at least I'm trusted by that government, or that program, and I can do the work I'm supposed to do, which is treat patients--treat kids, treat adults. The bureaucracy is taken away and the money in that program is used to treat patients, not do paperwork.

» (1735)

The Chair: Dr. Cooney.

Mr. Greg Thompson: Madam Chair, I wanted to hear from Dr. McCallum as well on that. I just wanted to be clear and to apologize to Dr. McCallum for overlooking her in the initial go-round.

Dr. McCallum, every time I see the word “university”, I always assume that one is at the instructional level, not practising on a day-to-day basis. I'm glad to hear that you are, and I'm really pleased that you'll have a chance to respond.

Dr. Mary Jane McCallum: I work at the University of Manitoba, where we're starting to partner with some of the dental programs in first nation communities. We and the communities are starting to look at making their dental programs community specific. We have two groups with whom we are looking at health promotional aspects, which will be coming from within the community.

My other strategy is to start bringing issues like the consent form and cultural issues to the dental students, so that they deliver more respectful care. This will benefit everybody, not just first nations people.

When I go up north, I can treat emergency cases only and can address some of the teeth only, leaving the rest of the mouth as is. When you look at cleaning up the mouth, it is sustainable. Once we have treated patients' teeth and we have looked at preventive aspects, then it's sustainable because the patients will keep those teeth.

When I worked up north, I referred about 60 patients because I could not leave them in their situations. I referred them to Winnipeg to have all of their treatments completed at once. I worked with one of the dentists. The treatments of all 60 people were completed, so that when the next dentist goes in, we can start looking at dealing with it preventively.

Mr. Greg Thompson: Thank you, Doctor.

Madam Chair, might I ask one short question of Dr. Cooney?

The Chair: Certainly.

Mr. Greg Thompson: Thank you, Madam Chair.

From the dentists here who are performing the service, we've heard some of this from a practical point of view, but can anything be done quickly to cut through the bureaucracy to make some of this happen? Again, I think it's fine to come in here and talk about it and to identify solutions, but the other thing is to do something about it.

How does your reporting mechanism work, Dr. Cooney? Who do you go back to? Who do you talk to? At what point does the minister intercede and say, listen, let's cut through this, let's make this happen, and let's see if we can make it work—even as a pilot project, for example, or with just anything—to see if we can cut through this cumbersome process?

Could you comment on this, please?

Dr. Peter Cooney: To first address the points that have been made, I would clarify that this notion of somebody flying from northern Manitoba down to Winnipeg and then flying back up again with no care simply doesn't occur. We cover all emergency care, so if a patient—

» (1740)

Mr. Greg Thompson: I want to step in here, Madam Chair, because now we're into debate. I would just like the bureaucrat to answer the question, please.

Just answer the question, please, and don't go into debating what this doctor said, or somebody else said. You made your points; they made theirs. Stick to the question, please.

Mr. Peter Cooney: The answer to the question relates to that, because $800 worth of dental care is covered without predetermination.

In a recent meeting, the minister made three agreements with the Canadian Dental Association to address the administrative issues.

One, the predetermination level was increased from $600 to $800 in October of last year. So the dentist in Winnipeg can do $800 worth of care on that patient, and it will go through.

Second, the minister agreed to EDI, the electronic transfer of information from the dental office to the claims processor, such that paper isn't necessary. We committed to that and are working on it. It is working now in Alberta. We intend to have a provincial roll-out in Alberta by the end of this month; so we're looking at a very short period of time. I can assure you that there will be a national roll-out after that. We're anticipating that it will reduce administrative work by about 50%, because everything will be electronic.

Third, the minister agreed to audits, a commitment that we have lived up to with the CDA as well.

So what I would say to you is that after the $800 is assessed, please also keep in mind that the dentist then asks, okay, this is a very severe case and I need $3,000 worth of care. Another dentist will review that and say, this is very fair and appropriate, and we will give you approval to do $3,000. This is the type of work that Dr. McCallum indicated she used to do for Health Canada.

So this is not a skin-and-bones program. I would like to assure you that this is a good program. If a dentist gets a patient in and needs to do more than $800 to take them out of pain, we have not seen those types of situations on one visit.

The other point I would like to make, which is a relevant point that Dr. Dubé also made, is that there is a feeling that the program is slightly different and that there may be an element of trust. There isn't an element of trust, but we are accountable with this program to you for public funds—and we're accountable to the clients. At the moment, we administer the program on behalf of the clients.

This is not a straightforward, simple insurance program; it is a publicly funded program. We need to be able to come back to you folks and to say that the money you voted to us through Parliament—the $688 million that you paid for this program last year, of which $130 million was for dental—was spent appropriately. So we need certain checks and balances.

We want to make life as easy as possible for the dentists. We have actually committed to making some of the administrative changes that Dr. Dubé and Dr. Smith referred to and to trying to make life as easy as possible for the provider. As they know, we have a committee working through the administrative changes as we speak.

But the bottom line, sir, is that this almost $700 million program does have an element of public accountability, which prior programs did not have.

The Chair: Thank you, Mr. Thompson.

Mr. Greg Thompson: If I could conclude or sum up—

The Chair: No, I don't think you need to sum up. One of the costs of being the fifth party is being second last; one of the costs of being the chair is being dead last. I hope you'll be patient while I ask a few questions.

It seems to me one of the problems here is that this dental program is still working under what I call the old model, the pathological model. In other words, somebody needs a root canal and proof of pathology has to be sent somewhere and analyzed by someone, etc. It seems to me we need a whole new look at this, which is the wellness model. It would immediately bring in the hygienists. For example, my dentist won't even look at my teeth until the hygienist has had a good look and maybe done some work. In southern Ontario, $800 would not cover my hygienist's bill in a year. You wouldn't even get to see the dentist for $800.

First of all, I applaud you for getting a $200 raise to the amount of service that can be given, but I'm saying it's still not even close to being enough. I think I could suggest to you that if you came at estimates time seeking more money for your program, a $1,000 or $1,200 baseline, this committee--my guess is--would support you.

However, I think this committee would want you to build into that the fact that hygienists are included. I don't think your response that only in certain jurisdictions are hygienists on the other plans is an excuse for the federal government not to include hygienists, because to me it's the opposite.

We have some jurisdiction in aboriginal communities right across the country. Therefore, it's up to us to show the leadership through our program in hopes that the provinces that are lagging behind will catch on and feel they have to measure up to us. If we wait until the provinces are 100% on board, well, you and I will be dead. Unanimity among the provinces is almost impossible.

We have an opportunity here to show leadership to get the hygienists on board. They should be seeing these patients before the dentist does. If they're flying up to Sioux Lookout, for example, the hygienist should go the day before the dentist even leaves town. She should be up there going through all these patients for at least one day, and the next day the dentist will look at the same people, if any of them need work done. In the meantime, the hygienist could stay an extra day and maybe do some teaching of the mothers or in the schools, talking at and teaching these people all the time he or she is dealing with the mouth in question. We have to change the whole system, in my view.

I think if you came with your estimates increased, I'm pretty sure this committee would agree with you. As a matter of fact, we might send a letter to the minister suggesting just such a thing.

On the second issue of the day, I never sign anything when I go to the dentist. I don't know how I'm getting away with that when you say everybody does. If I received this pamphlet, I wouldn't want to sign.

I'll tell you what it says: everything you receive from us, drugs, transportation, dental services, medical supplies, equipment, vision care, crisis intervention counselling--all those things you might use and all that information.... I am giving my permission that anybody in Health Canada and any agents, contractors, claims administrators or processors, first nations or Inuit organizations, or others who provide health care benefits, items, or services, can manage all my information on all those other topics. And you can share it with all those various people.

I don't want my dentist to know all about the cost of my glasses. I don't want my ophthalmologist to know I've had to have crisis intervention counselling. I don't want my pharmacist to know how many trips I've taken on an airplane. I don't know why all this has to be in one place. And then it was suggested that some of it might even be sent out of the country. Does that mean there might be an American insurance company involved here?

» (1745)

So I know the Privacy Act prevails, but you are asking a lot. First of all, the Privacy Act is new to most of us. There are extra ones in the provinces, as Dr. McCallum has pointed out. It's asking us to have a lot of faith that all this is going to be kept so sacredly secret, and particularly with a client group that has not had the world's best experience with the government. I think it's asking way too much.

Anyway, I would like to have one question answered, and if you don't have an answer today, that's fine. What percentage of the $680 million has to do with administration of the programs? Perhaps you could get back to us on that. Or do you already know?

Dr. Peter Cooney: I'll tell you, Madam Chair, it's around 3% to 4% because we have those numbers. The administration on this program in actual dollars is not huge. We can provide the actual raw data. We have given this number previously to the public accounts committee.

Would you like me to try to address some of the other issues? The issue on--

» (1750)

Mr. Svend Robinson: Would you comment briefly on the statistics? Could we also get the statistics on the number of first nations people working within this division? That would be helpful.

Dr. Peter Cooney: We can provide that too.

Regarding the $800, this is not a cap, not a ceiling. A patient can get $3,000 or $4,000 worth of dental care. It's just that after $800, the dentist submits a request of predetermination. So it's not that any patient is limited to $800 worth of care.

The Chair: I know, but you are into the proving situation when you go beyond the $800, into submitting X-rays, sending people home with Tylenol 3 who need root canal work--all those scenarios that have been so well described by my colleagues and their questions.

Dr. Peter Cooney: The pain component is covered within the $800; that is why we increased it from $600 to $800. But a patient may get $4,000 worth of care under the program. They may get $5,000. I can actually pull numbers for you, because again--and this is one of the issues Dr. Smith alluded to--what we are seeing now is high levels of dental disease in a smaller number of patients. In other words, you get very high levels of concentrated disease in first nations communities.

The second issue, though, is that regarding the administrative changes, yes, we are moving on them and, yes, we will work on that and, yes, we have given the CDA agreement to look at and modify the program. Your issue of its being a pathology-focused program is correct, and it shouldn't be. That is why we are moving towards a prevention-focused program. I guess the issue is that there is no point in having an ambulance at the bottom of the cliff to pick up the people; you want to put a fence at the top.

The Chair: Yes, and that fence is the hygienist. We need you to come up with a plan as to how you are going to pull them in to do all that preventive work, education, and everything else they do so well.

Dr. Peter Cooney: That's correct. And hygienists do work for--and do a lot of work under--the program. It's just that they bill through the dentists they work for.

However, I appreciate what you are saying, that you would like us to look at expanding. But hygienists in dental offices do a lot of work on the program. It's just that the billing all goes through the dentist's number.

The issue on consent, too, we need to clarify for you. You have raised a good question. We don't share the information on your optical benefits with a dentist. The contractors are the people who do work, such as the dentists, the opticians, but information doesn't cross contractors. This is clearly explained in the privacy impact assessment, which we will send to you.

Maybe Leslie would like to touch on this.

The Chair: I believe you when you tell me that; but the fact is that the aboriginal people who are being asked to sign this see it as a package of a story about them that is stored somewhere with a government who they don't trust. They don't trust that this isn't going to happen, and no amount of education is going to turn this around. You have to build that trust. And it would seem to me one consent form around vision.... I know it's more paperwork for you and it makes the administrative costs go up, but you can't jump from little or no trust to the tremendous amount of trust that's being expected in this signing off.

Ms. MacLean.

Ms. Leslie MacLean: I think one of the things coming out of the dialogue we have been having on an ongoing basis to try to respond to concerns is to get just those kinds of clarifications in place. For example, one of the things we had been working on with the ITK over the last month or so was when information would be shared. Those are the kinds of things we can and will put on our website to help clarify--I know people don't all go to websites, so it's--

The Chair: On your website? You're living in a different world from the rest of the people in Larry's community.

Ms. Leslie MacLean: It's also part of why it's part of our outreach to communities at the local level, because I agree with you--

The Chair: And how many people do you have out there selling, convincing, in all those communities?

Ms. Leslie MacLean: When you recognize that there are over 700,000 clients of the program across the country in a number of rural areas--

The Chair: I do recognize that; that's why I think what you're saying is ridiculous--we have people out in the communities. Are they in the 600-plus communities? You don't have 600 people out there.

» (1755)

Ms. Leslie MacLean: No, we have staff in our regional offices as part of their normal schedule of community visits, as part of their normal meetings with first nations and Inuit leaders, making consent one of the issues they're endeavouring to explain.

The Chair: Dr. Smith would like to comment.

Dr. Darryl Smith: I just want to make clarification in terms of the $800 threshold. It's a rolling number too. I want to show you some of the dynamics of the plans and why we're asking that there should be really no predetermination necessary for basic services.

If a first nations child comes in to me and I recognize that he or she needs a tremendous amount of dentistry, there's no question I can have the dentistry done. There's no question about it. However, when that child arrives back six months later and I need to do routine preventive care--in other words, check the child's teeth again, make sure he or she is motivated with hygiene, make sure the teeth are clean, clean the teeth...in this case, I do have a hygienist even though I practise in a rural community. I'm fortunate to have a hygienist in that community. However, because I have a staff who knows how to work in the program, we go ahead and get the predetermination done. If that patient arrives for a six-month date, to be assured of being paid, I need that predetermination number. The reality is, if I don't have that predetermination number, I really can't deliver services on that particular day because the patient is already over the $800 threshold.

I'm fortunate to have a dental officer who will post-approve those things, but it's just that type of frustration level you deal with on a daily basis. It's not just the dentist who deals with it. It's your front-end staff, those people you deal with--and it's also the first nations client.

It's left up to me and my staff to deal not only with that particular client but many times the band, who don't understand what parts of the program are. Anything you can do to advance this issue would be very much appreciated.

The Chair: Thank you.

Mr. Robinson has one little, tiny question--a very short one.

Mr. Svend Robinson: I will be brief. I appreciate that.

Just to pick up on the doctor's comments, it's hard enough to attract physicians and other health care professionals to rural communities, but I can just imagine what it must be like if you have to deal with this bureaucracy and red tape. That, for many people, would just be enough to make them say they're not going to do it. We need to do whatever we can do to make the job easier, it seems to me, and that's hopefully part of what our committee will be in a position to recommend.

I just wanted to go back to Dr. Cooney on the issue of dental hygienists and pick up on the chair's point. What I heard you saying, and perhaps I misunderstood, is that until the dentists and the dental hygienists can sort this out between themselves--and with respect to the dentists, I know they're nervous about this, and nervous about giving more autonomy to dental hygienists.... I think there's a very important role for them to play independently as well.

I wonder whether you couldn't agree to perhaps having another look at a more independent role for dental hygienists, and not just basically cop out by saying, well, until those two groups can sort it out--which gives a veto to the dentists--we're not going to do anything. Let's show some leadership here, as Ms. Brown said, and look at some more creative models for delivering preventive care in particular, helping to put that fence at the top of the cliff. One way of doing so, it seems to me, is to empower dental hygienists as well. Can you not do that?

Dr. Peter Cooney: We certainly will, and we have a committee structure in place that can do that with hygienists represented.

Mr. Svend Robinson: Good. Thank you.

The Chair: On behalf of the committee, we don't usually go this long, and the question and answer sessions per committee member usually aren't this long, but I thought their questions were excellent and your answers were very enlightening, so it's been a really worthwhile session for us and, I hope, for you. I hope we get some positive recommendations to send to the minister and maybe some positive things coming out of the estimates process on this topic.

Thank you very much for your patience and your time. It has been most edifying.

This meeting is adjourned.