National Defence Committee on March 6th, 2008

[John Cannis, Liberal, Scarborough Centre, ON]

Thank you.

Guests, welcome.

In the expenditure for the health services, in paragraph 2, I assume it includes the family members of military staff as well in terms of health services.

[Sheila Fraser]

No, because technically family members are not covered under National Defence policy. They would only be covered if it was judged necessary, I believe, for the treatment of the member, but family members are not covered other than that.

[John Cannis, Liberal, Scarborough Centre, ON]

Okay.

In your presentation in paragraph 5, you state that:

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.

Then I go back to paragraph 4, where you say you found that “National Defence has little information to assess the performance or cost of the military health care system”.

One contradicts the other. Can you place it for us?

[Sheila Fraser]

The survey that was done was really about the quality or the level of satisfaction of the members. What we're talking about in the report is really management information, to be able to manage caseloads, to be able to manage deployment of people, to have trends in the health care issues, to look at the costs. To really manage a system that costs about $500 million a year, you need good management information, and that's just not present right now.

[John Cannis, Liberal, Scarborough Centre, ON]

My last question is very short, Mr. Chairman.

You state here at the end that you finally “found that 10 years after the Department had identified a need for oversight of its health care system, there is still no mechanism....” Why is that so? I think that's part of the problem. Nobody is here to blame current or past governments, Mr. Chairman, but why? It's my understanding, anyway, some years ago—I've been around—that there was an effort undertaken.

Why, and what obstacles are before us, and how can we overcome these obstacles to make sure at least more progress can be made? Notice that I use the words “more progress”, meaning that there is progress.

[Sheila Fraser]

I think that would be a great question for the department.

[The Chair, Conservative, Rick Casson]

I think the department is sitting behind you, taking some notes on all of this.

Thanks to Mr. Cannis and Mr. Bouchard for being brief.

We have two minutes, that's all, I'm afraid, Mr. Lunney, and then we're going to have to break.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

I want to welcome you to the committee. You've already answered a lot of questions. That's twice today. We had you at the environment committee earlier in the day, along with Ambassador Mamedov. So welcome again.

At the environment committee the Auditor General was welcomed as a Canadian folk hero. We certainly want to recognize the good work of the Office of the Auditor General.

A quick observation, though, goes back to a question by Monsieur Bachand. One of the members opposite was asking about $66 million being spent outside of the military for health care services versus $500 million, roughly, inside. It seems to me that the Canadian average for publicly paid care is about two-thirds, and one-third of health care dollars are roughly spent on private care in the national system. So maybe if that's roughly 12% or 14%, perhaps we're doing better in the military than in the general health care services all together.

I do note that in some of your comments there was some good news--an 85% overall satisfaction rate--which probably compares favourably and maybe better than outside, and wait times are shorter in the military. So there is some good news that came in your report as well.

[Sheila Fraser]

Absolutely, and I think we know with regard to mental health care that after that survey in 2002, the department recognized it needed to improve, so it put measures in place to try to do that. I think what it needs now is to have a validation that what it has done has given it the results it expects.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Just a final one. The CMA was here on the Hill this week. One of the things they're pushing for is some money from the federal government for electronic records. It certainly seems that might be a recommendation the committee might want to follow up on. An investment in electronic health records might be a great help.

[Sheila Fraser]

As a point of interest, we are working with provincial auditors general in the majority of the provinces to audit the whole question of electronic health records across the country, because a lot of funding is going into that. Is it being managed appropriately, is a question for all of us.

[The Chair, Conservative, Rick Casson]

Thank you.

Thank you both very much for being here. This committee, as I am sure all Canadians do, looks forward to your reports as they come out, and we wish you well. Continue doing the good work you do for this country. Thank you.

We'll make a quick change to the second panel.

[The Chair, Conservative, Rick Casson]

Welcome to our second panel, and welcome back, General Jaeger and Colonel Fillion. I see you have a statement prepared and distributed. There will be time to offer that to us, and then there will be rounds of questioning.

There are bells at a quarter after five for a vote, so we'll get in as many questions as we can. The floor is yours.

[Brigadier-General Hilary Jaeger, Commander of the Canadian Forces Health Services Group, Director General of Health Services and Canadian Forces Surgeon General, Department of National Defence]

Mr. Chair, members of the committee, thank you for this opportunity to appear once again, this time to address the Auditor General's report on military health care. I am sorry I am not mentally agile enough to have incorporated any more details about some of those excellent questions in my opening remarks, but I am sure many of them will be brought out during the question period.

I am accompanied by Lieutenant-Colonel Joel Fillion, our senior staff officer for mental health. In this role, Joel is responsible for the coordination of many aspects of mental health care within the Canadian Forces health services, including analysis, policy, and program development; training; and resource allocation, to name a few. And to cut through all those words, he is the guy who has to implement the mental health initiative under Project Rx2000, so he's the guy who is beating the bushes trying to find those extra mental health providers for places like Petawawa and Valcartier. It's not an easy job.

First of all, the Department of National Defence fully accepts the recommendations outlined in the Auditor General's report. We believe that the report provides a fair and balanced assessment of the sate of our military health care system, which is continuing its transition through a massive reform process.

Madam Fraser is clearly positive in her comments in a number of areas in this report and, in particular, she notes that previous concerns about accessibility and continuity of care have been addressed, that a high percentage of CF members are satisfied with the health care they receive, and that the new model for mental health care is considered a best practice approach.

Various initiatives undertaken in the CF health services reform, such as multidisciplinary collaborative practice and electronic health records, are advocated practices from the 2002 Kirby report entitled The Health of Canadians--The Federal Role and in the 2002 Romanow report entitled Building on Values: The Future of Health Care in Canada. These practices continue to be advocated today by the Health Council of Canada.

Rx2000 and the Canadian Forces health information system represent very significant reforms, and although work remains to fully implement these initiatives, I am confident many of the changes being put in place will serve us well in addressing the Auditor General's recommendations.

As you know, the report itself contains eight recommendations centred on the four key themes of governance, cost of the CF health system, performance management, and credentialing of health care providers. We have a general action plan with expected outcomes and dates for addressing each recommendation. I will focus my remarks today on some specific actions taken to date, which I believe will be of particular interest to this committee.

Prior to the release of the Auditor General's report, the determination of which medical and dental services treatments and items would be provided at public expense to entitled persons fell heavily on the shoulders of health care providers, notably me, sitting in front of you.

Subsequent to the report, and after a review of the terms of reference for the spectrum of care committee, which makes health care entitlement determinations, the Chief of Military Personnel sought and received approval to raise the level of oversight of this committee to the Armed Forces Council, the senior leadership of the Canadian Forces. Having the Armed Forces Council make decisions about CF members' health care entitlements will now better enable the CF health services system to determine whether costs incurred are indeed related, as the Auditor General noted they should be, to patient requirements and operational needs.

The inaugural meeting of this elevated spectrum of care committee took place on February 4 this year. We are continuing to improve our ability to analyze and isolate cost data, although the CF health information system, when fully implemented in 2011, will provide the true conduit for greater cost data generation and decision-making support.

A number of recommendations in the Auditor General's report involve selecting system performance indicators, setting standards of care, and measuring activities against these standards and indicators. A new CF health services performance measurement advisory group was instituted in January this year and has begun to develop a performance measurement framework to define applicable performance indicators and to set benchmarks for these indicators. The list of indicators chosen will be in keeping with the pan-Canadian primary health care and population health indicators, which were recently developed by the Canadian Institute for Health Information.

It is worthwhile noting that CF health services will be among the organizations taking a lead in institutionalizing these practices in a multidisciplinary primary care setting. Data collection in relation to certain mental health indicators has been included in the CF health and lifestyle survey set to take place later this year.

Periodic health examinations, which currently take place every five years but will be accelerated to every two years, have recently been modified to capture more mental health and deployment-related health data. This data will feed into performance indicators as the performance measurement framework unfolds.

For deployments, the initial CF theatre trauma registry, which led to evidence-based modifications to pre-hospital medical training and protocols, has now been replaced with the U.S. joint theatre trauma system, which encompasses a far broader range of data fields and quality indicators. This system also includes a complete quality assurance and improvement framework to stimulate the production and updating of clinical practices based on objective data analysis.

In addition, progress includes the development of a CF Health Services Group Quality Improvement program and a chart audit and peer review process, which is being piloted at three bases starting next month. Further refinement and system-wide application will ensue following this effort. As has already been done, CF Health Services is also continuing to measure aspects of quality through mechanisms such as patient satisfaction surveys, survey reports from the Canadian Council on Health Services Accreditation, and internal assessments such as Staff Assistance Visits, or, in other words, inspections.

On the issue of credentialing of health care providers, a national credentialing cell was recently recreated and has achieved licensure verification for 100% of physicians and dentists, 96.7% of pharmacists—that's a very nice detail, but it means that one pharmacist hasn't answered the mail yet—and 79.9% of nurses. A new CF credentialing policy is set for release in the near future.

I am confident that we have made considerable progress, and I take extreme pride in being able to state that we can demonstrate trauma mortality rates in Afghanistan that are as good as those of any other nation working in that part of the world, and indeed as good as those of any leading trauma centre in Canada.

The mission of the Canadian Forces health services group is to provide full spectrum, high-quality health services to Canada's fighting forces wherever they serve. I am confident that our mission is being met, and we are working diligently to objectively demonstrate this.

This completes my introductory remarks. I thank you for your interest in the CF Health Services and for the opportunity to appear before this committee, and I look forward, with Lieutenant-Colonel Fillion, to addressing any questions you have.

[The Chair, Conservative, Rick Casson]

Thank you very much.

We'll get started right into the questioning.

We'll start with Mr. Coderre.

[Denis Coderre, Liberal, Bourassa, QC]

Good afternoon, General Jaeger and Colonel Fillion.

General Jaeger, you've accumulated three functions.

You are the Surgeon General, you are the Commander of the Canadian Forces Health Services Group, and you are the Director General of Health Services. So you're responsible for everything concerning functional authority for program delivery and everything pertaining to practices.

I'm not doubting the person in question, but from a structural standpoint, is it appropriate to hold those three offices? When authorities created three offices, was it because they wanted each to be occupied by a separate person? Do you have a little too much on your shoulders?

[BGen Hilary Jaeger]

That's a very interesting question and I thank you for it. The highest level of the CF Health Services system has changed structures a number of times over the past five or six years. When I was a major and lieutenant-colonel, a major-general and three brigadier-generals managed the system. They shared the duties.

At the time of the re-engineering, the number of generals was considerably reduced, such that only one remained, General Auger. In 1999, the Chief of Defence Staff appointed a Director of Health Services who, for the first time, was not a doctor: Major-General Mathieu. She was also the only general. We tried with a surgeon general who was a colonel. After a period of experimentation, the position of surgeon general was created for a general, but there was also the director general and the group commander at the time. General Mathieu and I worked in that context.

After General Mathieu's departure, Commodore Kavanagh and I worked as a team. After Commodore Kavanagh retired, I had to perform all the duties. Last week, we learned that, during the transfer period that will take place this summer, Major-General Devlin will be appointed Director General of Health Services. I will continue to occupy the position of Surgeon General and Commander of the Health Services Group.

[Denis Coderre, Liberal, Bourassa, QC]

For reasons of accountability, when you do your checks and balances, it's always better if... Either you completely change the decision-making structure, or you appoint people to different positions. The oversight policy requires—

[BGen Hilary Jaeger]

That will enable you to divide the responsibility to—

[Denis Coderre, Liberal, Bourassa, QC]

Yes. We're saying the same thing.

I asked you some specific questions when you appeared before the committee the first time. We were fortunate to hear Colonel Girvin answer questions, particularly concerning those drugs.

First of all, how many soldiers under medication did we send to Kandahar after they suffered post-traumatic stress disorder or any other form of major depressive or general anxiety disorder?

[BGen Hilary Jaeger]

I regret, sir, but I'm not in a position to give you any detailed figures.

[Denis Coderre, Liberal, Bourassa, QC]

Will you send those figures to the committee?

[BGen Hilary Jaeger]

I can try, but it's not necessarily easy.

[Denis Coderre, Liberal, Bourassa, QC]

It's important because this is a matter of public interest.

And the reason I'm asking that question is that when Colonel Girvin was saying she thought there were a few.... Basically, I don't feel there is enough follow-up regarding those people who are under medication.

She said, and I quote:

...probably the majority of these medications might be, for example, a sleep aid.... I believe probably a lot of them don't take their medication when they go out. In fact, they'll make that decision based on whether or not they think it'll impair them in any way to do their job.

It's important to have details on that, general. These are schools of thought. This is consistent with our professional decision, but if we send soldiers under medication to perform transportation duties, in particular, and then they stop taking their medication, I'm concerned about the safety of those individuals and that of the people around them. That's the purpose of my question.

[BGen Hilary Jaeger]

One of the important aspects of the work of a mental health professional or a doctor posted there is considering all the advantages and disadvantages of an action plan, that is to say whether you should prescribe medication or limit the duties of the position.