Veterans Affairs Committee on April 14th, 2016

[Irene Mathyssen, NDP, London—Fanshawe, ON]

The analyst is going to explain where I've gone wrong.

[Jean-Rodrigue Paré, Committee Researcher]

You're quoting from the action plan from the department, after the auditor's report. What you're mentioning is the action plan of the department, following the report.

[Michael Ferguson]

If I may, based on our recommendations we have had responses from the department. The department has put in place an action plan to try to deal with those issues.

I think to the more general point of your question, what we tried to do in both of these audits was to put ourselves in the shoes of the individual, in the shoes of the veteran, in the shoes of the Canadian Forces member who was making the transition to civilian life. We were trying to look at all of the things the person has to go through to get those services or to make that transition. I think there are some things the department needs to do, and the action plan that you're referring to lays out a number of steps that they're supposed to take.

Fundamentally, at the end of all of this, the intention is that there should be a better experience for the veteran with the types of services they are getting. That's what all the recommendations are aimed at, so it's less important. Sometimes what happens is that departments get focused on trying to do something to say they dealt with our recommendation, but what they need to be doing is to be making sure they're putting the focus on the end service, and the end experience of the individual, as a much better experience.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

You talked in your remarks, in paragraph 15 and following, about the rehabilitation program for veterans experiencing that difficulty transitioning, and the treatments and benefits, and once the veteran completes the program.

I want to go back to the experience and whether that's something we should be concerned about, because very often you can complete a program but there hasn't been the positive end result.

[The Chair, Liberal, Neil Ellis]

I apologize, we'll have to have a three-second answer on that.

[Michael Ferguson]

Well, the rehabilitation program is designed as a short-term program, but the disability program is designed for longer-term issues.

[The Chair, Liberal, Neil Ellis]

Thank you.

That ends our round with these witnesses.

On behalf of the Standing Committee on Veterans Affairs, I'd like to thank you all for coming today and taking time out of your busy schedules. We will now break for about three minutes.

[The Chair, Liberal, Neil Ellis]

For the second part of the service delivery review, we have Mr. Courchesne, director general of health professionals and national medical officer; Mr. Ross, national manager and clinical coordinator of the operational stress injury network; and Mr. Doiron, assistant deputy minister.

Thank you for attending today. We'll start with 10 minutes.

[Dr. Cyd Courchesne, Director General of Health Professionals and National Medical Officer, Department of Veterans Affairs]

Good afternoon, ladies and gentlemen. Thank you for the opportunity to appear here today and talk to you about the operational stress injury network.

I'm Dr. Cyd Courchesne. I am the director general of health professionals and the chief medical officer for the Department of Veterans Affairs. I've been in this role since October 2014, after serving 30 years with the Canadian Forces health services.

Here with me is Mr. Michel Doiron—you know him—the associate deputy minister for service delivery, who is also my boss. We also brought along Mr. Joel Fillion, who is our new director of mental health. He's sitting at the back here. He's new to the organization, as of just a few months, and he's still orienting to the department. We want you to meet him, but we thought we'd spare his having to.... Also, as mentioned, we have with us Dr. David Ross. Dr. Ross is the operational stress injury network national manager and the national clinical coordinator.

The OSI network that we present to you today is the product of 15 years of development and collaboration with our partners. This is a network that's 100% funded by the department but fully operated by our provincial partners. In my view, this is an exemplary model of federal–provincial partnership.

Together with our partners from National Defence, we have accumulated 20 years of experience in the assessment and treatment of operational stress injuries. We have more specifically focused on post-traumatic stress disorder among military members, veterans and first respondents, such as Royal Canadian Mounted Police members. I am confident that no other organization in Canada has more experience in the area than us. When I say “us”, I am referring to our military and provincial partners, as well as us, on the federal level, at the Department of Veterans Affairs. We have worked tirelessly and selflessly over the years to develop our expertise and our treatment methods, carry out research, innovate and measure our results.

The work, however, is never done. It's a journey of continuous improvement and of learning, and we continue to improve and to grow our capability.

Just last week, Mr. Fillion and I had the privilege of being invited to the University of Waterloo for the launch of a new operational stress injury service at the Centre for Mental Health Research in the faculty of psychology, where, in collaboration with the Parkwood OSI clinic in London, Ontario, they're training Ph.D. candidates and clinical psychology residents in the assessment of operational stress injuries.

This is a significant event because, while we've been very present in the health care domain in Canada, now we're entering into the education realm, whereby future clinicians will come to us already educated and trained in military and veterans' mental health issues, and in this case, specifically in the assessment of operational stress injuries.

I would say that the greatest strength of our network is the partnerships. It's said that a chain is only as strong as its weakest link, but we've worked over the years at maintaining and strengthening our partnerships, to the point that from an outsider's point of view they could be mistaken in thinking that we own and run those clinics, but we don't. From the outside, it looks like a very cohesive and high-performing unit, and it is.

The additional partnerships we have developed over the years are another strength of our network. Our mental health strategy is based on the information we receive from the Veterans Affairs Canada Research Directorate, especially information and data stemming from the study on life after service, the usefulness and quality of which are matchless. All the information arising from the research conducted by the Canadian Institute for Military and Veteran Health Research—which has a network of more than 40 academic institutes—is invaluable to our network's growth, as is our close collaboration with our Canadian Forces colleagues. Worthy of mention are the Canadian Military and Veterans Mental Health Centre of Excellence and the Chair in Military Mental Health, which were established in collaboration with the Ottawa Royal Hospital.

I'm going to stop my comments here.

I want to highlight the fact that just recently, in January, we started up a new directorate of mental health, which is comprised of all the mental health resources that we had, but now they all report directly to me under the leadership of Mr. Fillion. Later this year, we'll be welcoming our own chief psychiatrist, a former military psychiatrist, with extensive experience in operational stress injuries and PTSD.

Thank you.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Clarke, you have six minutes.

[Alupa Clarke, Conservative, Beauport—Limoilou, QC]

Thank you very much, Mr. Chair.

Thank you for joining us today.

Veteran Affairs Canada's mental health action plan called for quarterly meetings to be held between Veterans Affairs Canada and the Veterans Review and Appeal Board. Two weeks ago, I went to the Veterans Review and Appeal Board, in Quebec City, to find out what kind of cases came before the board. Of course, I did not look into any specific cases.

I saw that one of the issues that came up the most frequently was a lack of access to medical expertise. In many instances, for a case to have a positive outcome, the individual had to provide expert medical evidence. However, some of those individuals said many times to the judge that they had gone to numerous places, be it in New Brunswick, Ontario, Quebec or even as far as Winnipeg, without being able to obtain expert medical evidence.

Can you talk to us about this problematic situation?

[Dr. Cyd Courchesne]

I will start, and my colleagues can add to my answer if they want.

When it comes to medical expertise, we carry out assessments, establish diagnoses and provide treatments. Those who come before the board are people who do not necessarily agree with the assessment or the diagnosis that has been made either by Canadian Forces physicians or by Veterans Affairs physicians who carry out assessments, or by our OSI clinic practitioners.

If we also provided medical expertise, we would be in a conflict of interest, in the sense that we would disagree with the veteran. In those cases, people have to obtain expertise from outside the Canadian Forces and Veterans Affairs Canada. They rely on the expertise from the Canadian health system.

The department provides veterans with legal assistance, but it does not provide them with medical assistance, as the same physicians would be involved and would find themselves in a conflict of interest situation because they were supposed to establish diagnoses, but not also testify on their clients' behalf.

There is probably a lack of expert resources. No one can force a psychiatrist, a specialist, to provide expertise. We are aware of this problematic situation. It is a difficult one.

[Alupa Clarke, Conservative, Beauport—Limoilou, QC]

Thank you for your answer. I understand what you are saying. Physicians are not really as available as we would like them to be.

As for conflicts of interest, you do provide legal assistance to veterans, and that really surprised me. I recognize that fact and I think it is fantastic. A veteran can use a lawyer who is under your authority, but is still independent.

Don't you think it would be possible to do the same thing when it comes to physicians?

[Dr. Cyd Courchesne]

The decisions on eligibility to a treatment or benefits are not made by the same people. Legal assistance is independent from the department in terms of operation, although it is part of it.

There are generalists on the legal side, but when it comes to expertise, an expert is needed for each medical specialty. We could not have such resources.

[Alupa Clarke, Conservative, Beauport—Limoilou, QC]

How many front-line mental health clinics are there currently in Canada?

[Dr. David Ross, National Manager and Clinical Coordinator, Network of Operational Stress Injury Clinics, Québec Regional Office, Department of Veterans Affairs]

There are 11 of them.

[Alupa Clarke, Conservative, Beauport—Limoilou, QC]

When exactly were those 11 clinics created?

[Dr. David Ross]

The first one was created in 2002-2003, and the last one just opened in Halifax.

[Alupa Clarke, Conservative, Beauport—Limoilou, QC]

I have one last question. What exactly does your first aid program for veterans consist of?

I understand that the question is broad.

[Dr. Cyd Courchesne]

I will begin, and will then let Dr. Ross complete the answer.

Those are not front-line clinics; we are talking about third-line care.

Front-line care is provided by family doctors. In this case, we provide specialized and even ultra-specialized care targeting mental health issues among veterans and military members, especially operational stress issues. That is a very specific and specialized service. As I said, those kinds of injuries have been around for over 20 years—in fact, for as long as soldiers have been around.

Front-line care is closer to the clientele. Those are not drop-in clinics, but well-organized clinics that refer people to those services.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mrs. Lockhart.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

Thank you for being here today.

With your centres, what outcomes are you looking to achieve?

[Dr. David Ross]

What an excellent question.

It's interesting. The reason I say, “Thank you for asking the question”, is that all too often in mental health we look at outputs, but we don't look at outcomes. We look at how many hamburgers we put through the door, but are they edible?

We've been concentrating on developing a way to track veteran self-reported outcomes. We have a national server-based system set up, which allows veterans on their way to a session to answer a couple of brief questionnaires. That data goes to a secure server, it's scored, the results are analyzed, a report is generated, and that report is ready for the vet by the time they show up at the clinic. The system is called CROMIS. It uses industry-standard measures that track their overall well-being, but can also track specific outcomes with respect to the identified primary conditions like post-traumatic stress disorder or major depression.

When you're talking about outcomes, that is one of our primary measures. Now it's not the only one. Of course, we're looking at the other domains, social and vocational satisfaction, and their medical well-being as well. That's why the clinics are organized using interdisciplinary teams, so that each person does the assessment, we come together, and we look at the person in as well-rounded a manner as possible. As we intervene, we're trying to iteratively evaluate the outcomes, so that we can make real-time decisions and adjust the treatment plans, so it's really tailored to that particular person.

That's very important because people tend to talk a lot about best practices, but all those best practices data are all based on group outcomes. The reality is that in a clinical intervention, you always need to adapt those best practice interventions to the particular needs of that particular person. The best way to do that is to track their vital signs, just like they do in medicine, so it's like tracking blood pressure or body temperature.

We're the only network that uses that. I believe DND is working on starting up their own version, but we actually specifically track outcomes in real time and report the results back collaboratively with the veterans.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

I'm happy to hear that you're tracking that as well, because quite often we hear a lot of anecdotal feedback. When you have data to start backing up some of these things, over time we can continue to improve.

[Dr. David Ross]

If I could, I would like to add one little thing too.

When you look at this best practices literature, it gives you group outcomes, but sometimes those populations are not our people. They're not Canadian veterans.

We set the system up so that we'll be able to speak directly to how we're doing with our people over a set period of time.