In May 2018, Harry Cayton was commissioned as an independent expert by British Columbia’s Minister of Health, Adrian Dix, to conduct an inquiry into the operational and administrative practices of the College of Dental Surgeons of British Columbia (CDSBC) as well as the Health Professions Act.

The review was prompted by a series of complaints made against the College as well as recent controversies surrounding the College of Chiropractors of British Columbia (CCBC) and the College of Naturopathic Physicians of British Columbia (CNPBC) that had eroded public trust in the province’s professional regulatory bodies.

In December 2018, Cayton’s inquiry concluded with the submission of his final report (the “Cayton Report”), which was split into two parts. The first examined the CDSBC and made 21 recommendations to the College to improve its governance, performance, and external relationships. The second part examined the statutory framework for the regulation of health professionals in B.C. and suggested both changes that could be made to the Health Professions Act to improve public protection within the existing framework, and wider reforms that would require the creation of a new Act.

Here’s an overview of the findings in the Cayton Report, which set the stage for major reform of B.C.’s health regulatory framework.

Cayton Report recommendations to the College of Dental Surgeons of British Columbia (CDSBC)

Having spent time in the CDSBC over four months, Cayton based his findings on a number of sources, including: over 40 interviews with former and current Board members and senior staff members; correspondence with members of the public, patients, and dentists; an audit of 30 complaint files; letters and emails concerning the College’s business; and his observation of College meetings.

His report focused on three areas: CDSBC’s governance, performance, and external relationships.

CDSBC governance:

While acknowledging that some improvements had been made, Cayton noted that “the Board of the CDSBC has not been a happy, well-managed or constructive governance body for several years.” Board members told him of a concerning lack of trust between Board members and between the Board and staff, leading him to conclude that “the working relationship between the Board and the professional staff needs to be addressed with some urgency.”

Cayton also expressed concern about ethics, confidentiality, and conflicts of interest (both actual and perceived) at the CDSBC. He also identified several issues with “opaque” board appointments and conduct at board meetings, including the limitation of public participation, private meetings without staff present, use of secret ballots, and improper record-keeping.

To improve governance of the CDSBC, Cayton recommended that the College should: continue with its plans to reduce its board size and increase the representation of public members; prevent anyone who has served as an officer at a professional association from standing for election at the College for at least three years; prevent dentists undergoing investigation of a complaint from serving on committees or standing for election until the complaint has been resolved in their favor; review its committee structure with the aim of reducing the number of committees; improve recording of decisions; create a risk register; increase transparency; renew its commitment to proper procurement policies; and recalibrate the relationship between the Board and staff.

CDSBC’s performance:

Cayton found that the CDSBC met 17 of the 28 Standards of Good Regulation, which cover key regulatory functions. He concluded that the College did not meet 11 of the standards.

To improve College performance, Cayton recommended that the CDSBC should: significantly improve its internal data collection and performance management; sort out and codify the documents that assist dentists and patients; and remove the Board from involvement in the complaints process.

CDSBC’s external relationships:

Overall, Cayton observed that the CDSBC had good working relationships with dentistry and regulatory partner organizations but identified several issues surrounding relationships with other key stakeholder groups, perhaps most notably, the professionals that CDSBC regulates. He stated that “a small number of dentists are active and vocal in their criticisms of the College,” and that “the undermining of the CDSBC by some of its own registrants puts the survival of the College itself at risk of loss of public and Government confidence.” He also noted that the College’s relationship with Certified Dental Assistants (CDAs), who are also governed by the CDSBC, is “ambivalent to say the least.”

Another area of concern for Cayton was the relationship between the College and the British Columbia Dental Association (BCDA), which he described as “too close.” He noted that the College collects fees from registrants that fund the association, and there were also reports of instances when the College’s decision-making process was influenced by the BCDA. “The College cannot be an effective independent regulator of dentists, CDAs and dental therapists when it is physically, financially and humanly intertwined with the BCDA,” he wrote.

To improve the College’s external relationships, Cayton recommended that the CDSBC should: develop a stakeholder mapping and communications strategy addressing all of its stakeholders; build a different relationship with dentist registrants based on mutual respect and distance; commit greater time, respect and interest to both CDAs and dental therapists; encourage better and more regular engagement with the other three dental colleges; and resolve to stop collecting fees for the BCDA in a phased manner, with a transition period of no more than three years for the two organizations to separate.

Cayton Report recommendations on the Health Professions Act

In the second part of his report, Cayton made a number of recommendations for changes to B.C.’s regulatory framework of health professions. Noting that much has changed since the introduction of the Health Professions Act in 1979, he stated that “Quite simply the Health Professions Act is no longer adequate for modern regulation,” and that it would require “significant changes” to meet future requirements for protecting the public.

He made two sets of recommendations; one that would reform the Health Professions Act and one that would replace it with a new regulatory system.

Cayton’s recommendations for reforming the HPA:

Cayton’s first set of recommendations changed the way in which the HPA directs and enables the colleges but did not change the overall structure of professional regulation.

His recommendations for reforming the HPA included:

• Updating the HPA’s mandate to: ‘It is the duty of a college at all times; To protect the safety of patients, to prevent harm and promote the health and well-being of the public.’
• Moving to fully appointed boards combining health professionals and members of the public in equal parts; appointment processes and Board meetings should be more transparent; Boards should be reduced in size and removed from any involvement in complaints and discipline.
• Separating colleges entirely from professional associations.
• Actively encouraging and facilitating mergers to reduce the number of colleges (although he did not recommend mandating amalgamations).
• Placing a moratorium on creating any new colleges.
• Significantly revising the complaints process to make it more efficient, transparent, and fair.
• Improving the reporting of data.
• Changing the role of the Health Professions Review Board (HPRB) to help colleges improve complaints

Cayton’s recommendations for a new regulatory system:

Recognizing the limitations of working within the existing regulatory framework, Cayton advocated for replacing the HPA altogether. “Reforming the HPA will improve the ability to prevent harms, promote patient safety and hold the confidence of professions but it will not be sufficient to create a regulatory framework fit for the future of healthcare,” he wrote. “New legislation will be necessary to achieve structural reform.”

His recommendations for a new regulatory system included:

• Creating a single code of ethics and conduct for all health professions.
• Colleges should investigate complaints but not adjudicate on them.
• Establishing a single register and adjudication body for all health professionals.
• Creating a new oversight body for health professional regulation in B.C., which would absorb the functions of the HPRB.
• Introducing a risk-assessed model for determining who should be regulated

Cayton Report’s impact on regulatory reform of health professions in B.C.

The CDSBC, which Cayton commended in his report for being “unfailingly helpful” with his work and open and welcoming of the inquiry, accepted Cayton’s findings and committed to implementing his recommendations.

As for the Ministry of Health, in response to the Cayton Report, Minister Dix established the Steering Committee on Modernization of Health Professional Regulation to make recommendations on how the HPA should be modernized. Following extensive public engagement, the committee released a report with its recommendations in August 2020, which included: reducing the number of colleges from 20 to six (although all currently regulated health professions will continue to be regulated); improving college governance through changes to the composition, size, and appointments process of boards; creating a new oversight body; updating the complaints and adjudication process; and improving the sharing of information between colleges.

The next step will be to implement these recommendations by introducing new legislation or amendments to the Health Professions Act in B.C.’s Legislative Assembly, which has yet to be initiated. However, in June 2021 Minister Dix indicated that significant changes are on the horizon, stating: “We’re moving forward with the most significant reform of the health profession in the history of British Columbia. I think it will be the model for all of Canada for Health Professional Regulation.”