National Defence Committee on March 6th, 2008

[The Chair, Conservative, Rick Casson]

Thanks, Laurie.

That ends the first round. We'll start our five-minute round. We'll get as deep into it as we can with the time we have.

We'll go to Mr. Rota.

[Anthony Rota, Liberal, Nipissing—Timiskaming, ON]

Thank you. Thank you for being here today.

I have a quick question. It was mentioned that about 40% of MDs--and that's the one that really stuck out--aren't doing physician's work; they're doing administrative work. That would be fine if there were a surplus of MDs, but there is a shortage, and the military is contracting out.

Were you able to assess why these physicians, who are trained as caregivers, as MDs, were shifting over to doing administrative work? Was it just part of their day-to-day procedure, or was it that they were becoming managers and administrators and doing that type of work for career advancement or just because of work preference? What was the cause of that shift?

[Sheila Fraser]

I'll ask Ms. Loschiuk to respond.

[Wendy Loschiuk]

When we looked at, basically, where are the doctors and what are they doing, our concern at that time was, why is there a shortage of doctors? We were able to find that a certain number of them were applying direct hands-on patient care in the clinics, but there's also a requirement in the department to run this health care system, to have some of the doctors doing standards, doing policy, doing other types of administrative work. How many you need to do this is a very difficult question to answer.

We weren't really able to compare it to anything. It's a difficult assessment to make, because you have to look at the system by itself. So I think it's something that we really urge the department to have a look at: why are 40% of your doctors doing non-patient care, which requires you to then go out and hire civilians, hire people on contract to do the patient care?

As to why doctors are choosing to go into that field, we didn't go into that area in particular. There are all sorts of career reasons for it, and operational reasons as well, but you'd have to ask the department whether or not that's the optimum level.

[Anthony Rota, Liberal, Nipissing—Timiskaming, ON]

So it's not as simple as saying you need more administrators or more people in a certain area. It just kind of morphed in there and has become part of the fabric or the culture, but there's no identifying how it got there. Am I reading that correctly?

[Sheila Fraser]

That's not the kind of work we did as to how it got there. We certainly didn't do any kind of analysis to see if this has increased or decreased over time, but we would certainly encourage the department to go back and look at that 40% and ask whether there's any way it can be reduced and have some of those doctors actually go back into patient care.

[Anthony Rota, Liberal, Nipissing—Timiskaming, ON]

I'm going to go back to the certification, because it sounds as though a lot of us read exactly the same thing out of this report.

When a doctor is certified, he or she becomes a doctor and is in place. But with most professional designations, as time goes on, there is updating and just learning the new techniques of what's going on, where you should be at. Is that something you looked at? Did you see whether the certification these people had, had been updated over the years, or that they had kept up-to-date with modern developments in the field of medicine?

In this case, I guess what we're looking at is more in regard to mental illness. Was there anything in the psychiatric area where people were keeping up-to-date with what we're looking at as post-traumatic stress disorder or mental issues? Was that kept up-to-date, or was it just certified once and then we weren't sure exactly where they were? Maybe you can explain to me how you looked at certification.

[Sheila Fraser]

Our concern was that the department wasn't able to assure there weren't unlicensed medical professionals providing service. So we went and looked for the doctors to see if they were all certified or licensed. But we didn't go back, then, to say, okay, what are the credentials that are needed in this and have they followed all the training within a certain province. We didn't go that far.

The department itself, though, does have a training program that they have arranged with the provincial health care system so that people can go and work in hospitals—I presume in emergency wards or whatever—to keep their skills up to date. That was one area as well where we found that people weren't completing that, weren't doing that as much as was expected. So that's another area where the department needs to have better information and a better understanding of why this program that they have put in place is not producing all the results. Is it because these doctors are overworked, or the medical professionals generally are overworked, and aren't able to be freed up to go and do this? So there needs to be, again, more analysis.

Perhaps Ms. Loschiuk wants to add something.

[The Chair, Conservative, Rick Casson]

Actually, we're out of time for that portion. Keep that thought and we'll try to get to it.

Ms. Gallant, and then Mr. Bouchard.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Thank you, Mr. Chairman. I'll be sharing my time with Dr. Lunney, if there is any time left over.

To quote part of your report:

While the expenditure for health care for other Canadians in 2006 was estimated at about $4,500, the expenditure per military member was estimated at more than $8,600 (in the 2005–06 fiscal year).

It was testified in a previous meeting, prior to your arrival, that physicians and hospitals charge our soldiers a higher rate than they would somebody at an OHIP rate. Is the difference that our soldiers are being charged more in a civilian hospital--and their health care overall--a consequence of what is necessary to treat a soldier, or is it that perhaps in civilian society the proper funding isn't there, so that soldiers are getting what it costs to properly treat them, where there is a shortage of doctors and spaces perhaps?

[Sheila Fraser]

We noted a number of factors in the report that could explain the higher cost. One is simply the availability of the services. National Defence do not want their military members waiting days, weeks, and months to have treatment. So they have a much higher proportion of doctors to the population than you find in the public health care system. We say on page 15 that we found there were four times more physicians per 1,000 military members as compared to the civilian system. But 40% of those doctors are doing administrative services.

There's the physician workload we talked about earlier. There's quite a variety in workload across the country. The costs to train medical staff are included in the department's costs, which again is not the case in the public health care system. Then there's the cost of physicians on contract, which is higher than in the public system. They are paid more than even National Defence's own doctors.

Those are some of the elements. I think everyone can appreciate that the cost to provide service in National Defence will likely be higher than in the public health care system. But we expected that the department would have be able to do that analysis and say why it was costing more. Could it be because they are receiving services from the provincial health systems and they're treated as being out of province, so--you're right--the cost is higher? Is the $8,600 an appropriate level? It's that sort of information.

We make no judgment as to whether it is too high or not high enough. But we expected the department to have that kind of information and to be tracking that information to see if those costs are reasonable.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

With that in mind, is it not a greater benefit to the taxpayer for the military to hire more doctors? Was that part of your assessment?

[Sheila Fraser]

If you simply looked at the cost of a physician on contract compared to a physician within the military, of course it would be beneficial to hire more physicians.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

This Ontario government keeps a lid on health costs by limiting the number of doctors who practise. Part of the reason it's difficult to recruit doctors in the military is because there just aren't the number of doctors graduating and being licensed to handle civilian patients, let alone the Canadian Forces.

Is there any system in the checks and balances that you were looking at for DND to allocate funds and set them aside to fund spaces in medical schools or in residencies specifically for medical doctors?

[Sheila Fraser]

That's not something we looked at. We didn't look at the whole human resources component of how they go about recruiting and retaining medical doctors. That could actually be an interesting audit to look at.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

So we have a compounding problem here. I'm referring to Base Petawawa. The Province of Ontario, for example, does not fund enough medical school and residency placements to accredit doctors who've already passed all their exams to care for civilian patients. Then there aren't enough psychiatrists in the military to treat PTSD patients, so they are medically released back into the civilian system where there are not enough psychiatrists to begin with. So it really has a snowball effect.

My other colleagues mentioned the issue of portability of certification. What response have you received from DND as to their plans to fix this problem?

[The Chair, Conservative, Rick Casson]

We'll have to come back to that as well. The time has expired.

Mr. Bouchard.

[Robert Bouchard, Bloc, Chicoutimi—Le Fjord, QC]

Thank you, Mr. Chairman.

I too want to thank you for being with us, madam.

Yesterday, a witness told us how it was important to introduce a systematic screening system for mental health cases. As it was stated earlier, 57% of military members have not met with a mental health professional. He also told us that it would cost very little for National Defence to set up such a system.

Do you share that view?

[Sheila Fraser]

From what I understood at a previous meeting, National Defence systematically interviews all soldiers returning from Afghanistan, particularly when they return and a few months later. However, we didn't really examine that question as part of our audit. That would definitely be a question to ask the National Defence representatives.

[Robert Bouchard, Bloc, Chicoutimi—Le Fjord, QC]

You also told us that, in a survey conducted in 2002, only 25% of respondents said they were satisfied with the services they had received.

Do you think that's a satisfactory or poor result?

[Sheila Fraser]

I think we can conclude that it's a poor result and that the departmental people also felt it wasn't satisfactory. They subsequently adopted a number of measures, a new approach, to improve mental health services. However, I don't believe they've conducted another survey. It would be good for them to do so systematically in order to check whether forces members' satisfaction with mental health services is improving.

[Robert Bouchard, Bloc, Chicoutimi—Le Fjord, QC]

You also say that no mechanisms have been implemented to bring all stakeholders together. Do you have an idea of the reason why nothing has been done in that direction after so many years?

[Sheila Fraser]

I don't really have an answer, but that's an excellent question, which concerns a number of our audits. If it were possible to answer that question, we would see more progress on a number of fronts.

[Robert Bouchard, Bloc, Chicoutimi—Le Fjord, QC]

Thank you.

[The Chair, Conservative, Rick Casson]

Thank you.

Perhaps this is the venue to bring all those people together, which you suggest. We have that list you mentioned, and I'm sure we are going to have some from all of those here to help us with this.

I think we have time for one more spot, and then we'll make a quick change.

Mr. Cannis.