National Defence Committee on March 6th, 2008

[The Chair, Conservative, Rick Casson]

I call the meeting to order. Today we continue our study of the health services provided to Canadian Forces personnel, with an emphasis on post-traumatic stress disorder.

We have two panels today. We will start with the Auditor General, Sheila Fraser, and the Assistant Auditor General, Wendy Loschiuk. We welcome you both.

We have an hour booked for you. We know we have another bell today for votes at 5:15, so we're going to have to stick to a pretty tight schedule.

Welcome, Ms. Fraser. You've been to many of these committee meetings, so you know the drill. You have some time to make a presentation, and then there will be a round of questioning. The floor is yours.

[Sheila Fraser, Auditor General of Canada, Office of the Auditor General of Canada]

Thank you, Mr. Chair.

We thank you for this opportunity to present the results of chapter 4 of our October 2007 report, “Military Health Care--National Defence”. As you mentioned, I am accompanied by Wendy Loschiuk, who was the principal responsible for the audits of National Defence when we did this work. Ms. Loschiuk has recently been promoted to Assistant Auditor General.

At the time of our audit, National Defence and the Canadian Forces were providing medical and dental care to over 63,500 Canadian Forces personnel on 37 military installations across Canada and abroad. Members of the Canadian Forces are excluded from the Canada Health Act. The provision of their health care falls under the National Defence Act. If a military member needs medical services, it is the responsibility of National Defence to ensure that the services are provided.

National Defence spent about $500 million on medical and dental care for its members last year, and costs have been rising.

In this audit, we looked at how National Defence ensures that its military personnel in Canada receive quality health care. We did not look at medical care outside Canada on deployments such as Afghanistan. Nor did we examine medical treatment or practices.

We found that National Defence has little information to assess the performance or cost of the military health care system. The Department needs better information to manage the system, and, in particular, to help monitor whether it is delivering quality medical care to military personnel.

It is important to note that, when surveyed by the Department, military members said that overall they were satisfied that the military health care system responded to their needs. National Defence has been improving access to medical care and the continuity of care for its military personnel as part of its ongoing Rx 2000 reforms.

The Canadian Forces spectrum of care policy states that National Defence is committed to providing Canadian Forces members with health care comparable to what other Canadians receive. But we found that the department was unable to demonstrate how it could assure itself that the care it did provide met its standards and expectations of quality health care practices.

We were also concerned about the lack of information needed to ensure that only licensed or certified military medical professionals were treating patients. National Defence has informed us that it is working on documenting the status of its health care professionals and is developing a policy on mandatory maintenance of a provincial licence.

As I understand, this committee is particularly interested in the issues affecting mental health care. We found that mental health care services have been reformed to better target needs. A 2002 survey on mental illness in the Canadian Forces found that only 25% of respondents who had reported symptoms of mental health problems or disorders considered that they had received sufficient help. Since then, National Defence has restructured its approach and is implementing a new model nationwide. This model uses a best practice whereby medical personnel and qualified professionals in social work and addictions counselling work collaboratively to treat patients.

The department is also conducting enhanced post-deployment screening of military personnel returning from overseas service to detect any resulting physical and psychological effects.

Unfortunately, the Department has not been able to staff its mental health services with all the professionals required. Due to this resource shortage, the system cannot meet all the demands for mental health services. As a result, members are being sent to private practitioners, where it becomes difficult for the Department to monitor their care.

Our audit also focused on several other issues that we explain in the Chapter. We found that few military medical professionals were completing the Department's Maintenance of Clinical Skills program.

We also found that while the cost of the military health care system is rising, National Defence lacks the information to know whether these costs and levels of service at its medical clinics are appropriate to needs.

Finally, we found that, 10 years after the Department had identified a need for oversight of its health care system, there is still no mechanism to bring together all parties, that is senior military officials, senior health care management and military members who could provide guidance and a basis for accountability.

Mr. Chair, National Defence has agreed with our recommendations and has developed an action plan to address the concerns raised in the chapter. I am pleased to see that the department has defined the outcomes it is working toward in the action plan and has set target completion dates. Your committee may wish to have the department report on its progress and the results it is achieving.

That concludes our opening statement, Mr. Chair. We would be pleased to answer any questions the committee members may have.

Thank you.

[The Chair, Conservative, Rick Casson]

Thank you, Ms. Fraser.

Mr. Coderre will start, and this is a seven-minute round.

[Denis Coderre, Liberal, Bourassa, QC]

Good afternoon, Ms. Fraser. Thank you for being here. I had the pleasure of hearing you talk about this matter at a meeting of another committee.

In light of everything we've heard about your report from the outset, it appears there is a data compilation problem. We don't really know how things are working. In addition, certain military members have the feeling that there is an internal confidentiality problem. When it comes to treatment for mental health problems, people may automatically not seek treatment, as was observed in the 2002 survey, because of confidentiality problems.

Do you have something to say on that subject? In your opinion, how is information handled at National Defence?

[Sheila Fraser]

We didn't look specifically at data confidentiality. In fact, most files are still in paper form. That makes information management more of a problem. It was very difficult to get data on the system as a whole, since it's in paper form. We didn't specifically study the confidentiality issue. Nor was it reported to us as a concern.

[Denis Coderre, Liberal, Bourassa, QC]

There's often talk about problems of shortages of resources and professionals. There's also a structural problem. I would like to talk about accreditation. You refer in your report to certification. Is it possible that doctors who currently conduct assessments aren't properly accredited to do so?

[Sheila Fraser]

Mr. Chairman, there is that kind of risk because National Defence doesn't have a system in place to ensure that doctors are all certified. We conducted an audit of certifications, and we didn't find any doctors who weren't entitled to practise. However, it was our auditors who did that work. The department itself doesn't have a system to give itself that assurance, although we're told they're going to put one in place.

[Denis Coderre, Liberal, Bourassa, QC]

When you were auditing what's going on under the Canadian Forces, did you specifically take a look at the aspects of the structure, the way decisions are made or the way we manage the issue of health care inside the department?

My understanding is that we have an amazing general who's in charge, General Jaeger, but she has several departments to take care of at the same time. Do you believe that maybe one of the issues is an issue of structure right now?

[Sheila Fraser]

Mr. Chair, I'll ask Ms. Loschiuk to respond to that question.

[Wendy Loschiuk, Assistant Auditor General, Office of the Auditor General of Canada]

Thank you.

We didn't look specifically at how the health care system was managed. We were very interested, of course, in understanding the process of management at the base level, where the base surgeon is responsible for seeing that all of the health care services are provided, and how that information is then rolled up to NDHQ. That's where we found problems, because not all of that information is generally put together.

But we also did notice--and we've pointed it out at the end of the chapter, in paragraphs 4.65 and 4.66--that the system appears to have no mechanism in place whereby people can sit down and examine just what is being delivered, and all parties can then have the opportunity to say, “This is how we feel things should be delivered.” We're talking about a mechanism where soldiers, sailors, etc., can say, “Yes, this is what we would like to see.” The medical professionals could also sit down and say, “This is how, from our medical standpoint, rather than our management standpoint, we would like to see things.” And clearly, it's the same for the operational senior management, who need to have soldiers, sailors, etc., healthy and ready to work.

Such a mechanism, I think, would put a little more accountability into the system and into the process and make sure people are getting what they're asking for.

[Denis Coderre, Liberal, Bourassa, QC]

Does the lack of accountability explain why it seems that the way we spend is a bit out of control? Right now, under the Canadian Forces it costs more than the civil system of health care. Does that explain why we have those kinds of numbers right now?

[Wendy Loschiuk]

I think there are a lot of reasons why the health care system is a little more expensive. There are certain things that the system here is required to do that perhaps other systems don't pay for--for example, a lot of the training. But it would be helpful to have an accountability mechanism, where the services that are provided and the level of services could have perhaps a second look. In that regard, such a mechanism may help--

[Denis Coderre, Liberal, Bourassa, QC]

So we don't have enough checks and balances? Is that what you're saying?

[Wendy Loschiuk]

It would provide some checks and balances.

[Denis Coderre, Liberal, Bourassa, QC]

One of the main problems, of course, is that we have the policies of our geography. At the physical and mental level it's pretty tough, but when you have rural versus urban, what's your say on that? There's clearly an issue. It costs more. There is a lack of resources, and you have to make a difference between what's going on through cities.... There are great places like Valcartier, Gagetown, and Moncton. At the civil level we don't even have enough resources to have those clinics. What do you say about that?

[Sheila Fraser]

Again, we didn't look specifically at that issue. We did note the difficulty in getting certain professionals, largely mental health care professionals. I think that would be true probably in some of the smaller areas that probably even in the public system have difficulty getting those kinds of professionals. But we didn't go into the strategies the department might have in place to recruit or to bring in people.

The only real comment we have is that when we do the comparisons, there are a number of medical professionals who come in on contract, and that was really the only place we looked at. It was in regard to the cost element and the lack of good information to determine if the level of cost is the appropriate one or not.

[Denis Coderre, Liberal, Bourassa, QC]

Thank you.

[The Chair, Conservative, Rick Casson]

Thank you.

Mr. Bachand.

[Claude Bachand, Bloc, Saint-Jean, QC]

Thank you, Mr. Chairman.

I in turn would like to welcome the Auditor General and the staff of her office. These are people whom we see regularly.

I took a brief look at the content of the report you prepared in 2007, Ms. Fraser. Could you tell me whether you yourself decided to prepare that report or whether you were asked to do so? Sometimes your services are solicited, and you accept, but I imagine that you yourself took the initiative in this case.

[Sheila Fraser]

Yes, it was our own decision.

[Claude Bachand, Bloc, Saint-Jean, QC]

Can you explain to us why the dental plan was not a selected issue? It's nevertheless an important component. You only looked at health. May we expect that you will eventually address the dental plan question?

[Sheila Fraser]

We decided not to include it in this audit simply because it's a slightly different system and the medical care system in itself was already a big subject to cover.

[Claude Bachand, Bloc, Saint-Jean, QC]

Could we hope that you will conduct a study on the dental plan in the near future?

[Sheila Fraser]

That's always possible.

[Claude Bachand, Bloc, Saint-Jean, QC]

One thing intrigued me, and that's the fact that the department appears to offer a private insurance plan to the Canadian Forces as a whole. Every member is insured by Blue Cross in the event the military clinic is not available. From what I read in my notes, it costs approximately $66 million a year, whereas the total cost of health services is $500 million a year.

Do you think this practice should be somewhat restricted, or do you think it's normal? Obviously, we'd need clinics open 24 hours a day, and that's not always possible. So when these people are sick, they're sent to receive care at locations that are under provincial jurisdiction. They use their insurance in those cases. I'd like to hear your comments on that subject.