Health Committee on March 23rd, 2010

[Cmdre H.W. Jung]

Should I go first?

You've identified a very clear issue in the transition from the military to the civilian sector. Obviously, as I stated in my opening comment, my mandate as the Surgeon General ceases the moment you no longer wear the uniform, so that becomes partly a Veterans Affairs issue, but the member then re-enters the civilian health care system.

I know that Veterans Affairs has taken some great initiatives by publishing instructions, guidelines, and information through the college of family practice journals to inform physicians in the civilian sector about the things they may want to look out for if they have a patient who is ex-military, things such as PTSD and so on. It provides a bit of cultural context on where they're coming from and the types of services they may be able to access through Veterans Affairs, so they are making those linkages with the civilian sector.

Obviously, from a military perspective, once you retire from the military, there's not much I can do in that regard.

[The Chair, Conservative, Joy Smith]

Ms. Smith, would you like to comment?

[Paulette Smith]

Yes, just in regard to the entire membership of the force and what they do. They don a uniform every day, as indicated, and their job cannot be duplicated, even through Canadian Forces. That is a different job, although it's similar in nature in some aspects. But it is a daily exposure to the type of work that these members--male or female--see, and it is over time that issues happen.

If these issues are addressed in a timely manner within the organization, they are treatable and preventable in every way. I am a nurse, but I also see the shortage of doctors within our hospitals. I see the shortage of nurses within our hospitals. What happens is that the patients are the ones who pay the price. In the force, because there are no funds allocated or because organizations may not be set up as such, the members, the people on the ground, are the ones who pay the price. Ultimately, then, the family is left to carry on.

Allow the members the opportunity to speak up without feeling ashamed. Allow the members to realize that what they're going through is part of their job and they are not to be ashamed of how they feel. Allow them to be treated instead of being left untreated and abandoned, which is basically what's happening, because the funding and the understanding through the physicians....

This is a topic that you just can't put your finger on. Everyone is different. Not everyone has the same symptoms and not every patient presents the same. One may present with certain issues that are definitive as to the DSM, but the issue is that not everyone presents the same. In my case, my husband presented as casebook, as textbook.

That was my issue. I don't think that.... We just need more help. We need more help.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Smith.

We'll now go on to Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Madam Chair.

I want to start today by thanking each and every one of you for being here and also by thanking those of you who don the uniform. I come from a family in which my father served in the Canadian Armed Forces for 25 years, and my uncle and my brother-in-law are in the OPP and in the RCMP. I know a little bit from the family side about the commitment you make to your jobs. I think everybody on the committee here wants to thank you for doing those tough jobs each and every day for Canada.

We've been having a lot of interesting meetings here in the health committee about human health resources. We've heard from experts and associations from across the country about the challenges that Canada is having in utilizing our health care resources the best we can, in recruiting, and in maintaining. I think one of the comments about this particular initiative was made by Inspector Boughen and was about “health professionals who get that”. With the competition from the private sector, I think it's a real challenge to keep those people in the field who actually do understand, to maintain those people.

I want to ask about the program you mentioned, Superintendent Tousignant. I was quite pleased with how you ended your presentation in stating that as of April 1 you are commencing a new position of director general for workplace development and wellness. It's going to be a new role for you in engaging experts in the field to move forward with--I liked the final line--“fit for duty, fit for life”.

Can you explain a little more to the committee what the mandate is of that new position?

[C/Supt Alain Tousignant]

Certainly. The mandate is evolving as we speak, but listening to Mrs. Smith about the tragedy that she went through, I take your comments to heart. As a husband and as a father, I take your comments to heart. I also listened to Mr. Murray's comments about some of the challenges that we face in the future.

From today, even as my mandate evolves, it really talks about wellness. Comments were made about employees and members feeling ashamed to speak out and feeling worried about their promotions and advancement in the RCMP. I actually see trying to remove those roadblocks as part of my mandate, so that our organization will be one in which our employees and members will feel very free to speak about medical conditions or the challenges they face on a daily basis.

I've been working in the north and have travelled the country. I believe I have a good understanding of the issues. To wrap up what my mandate is, it is to try to build a wellness strategy for the RCMP and really define what it means. Since 2005 or 2006, as Rich Boughen and Mr. Brown explained, we've been starting to grasp what it means and how our employees are affected when they're living in northern communities or are placed in situations in which they see different tragedies day in and day out. It's really trying to develop a strategy that encompasses all this, trying to get to the heart of it. I think we've enlisted some professionals in the business to help us develop our strategy to move into the future.

My biggest obstacle, to come back to what Madam Smith was talking about, is for the members and the employees to feel comfortable and unashamed about saying that they have a medical condition or that they're scared or that things are not working out right now and they need help. If we can get to that point, I think we'll have gone a long way into the future.

[Colin Carrie, Conservative, Oshawa, ON]

I like the idea of wellness and prevention. As Mrs. Smith was saying, the signs were there, and you can prevent a lot of these things by taking that initiative. I want to applaud you for taking that on. I think it's something that's well overdue.

I wanted to ask a question, too, of Commodore Jung, because it does seem that the Canadian Forces have put a real push on for developing a model that works for the Canadian Forces. I wanted to talk to you a little bit about this idea of interdisciplinary teams.

My background is that I'm a chiropractor; I worked in interdisciplinary teams with physicians and physical therapists, and just by using the right professional for the right condition, we saw a lot of efficiencies. I know that in the Canadian Forces there's been talk with nurse practitioners and physician assistants. I think you even have some chiropractors working in the field. What efficiencies have you seen since you have been there and seen how this has been integrated? Are there any lessons you have learned that you could share with other organizations around the table?

[Cmdre H.W. Jung]

The collaborative care model obviously is very in vogue today, and you hear about the PCR, primary care reform, basically everywhere you go in the health care sector.

The collaboration in the military is nothing new. It's been in existence for much longer than it existed in the civilian system. When I entered the military practice in 1985 I was actually quite surprised at how much collaboration was already in place and how much leveraging of services was already in practice. We were using nurse practitioners before the term was known. We were using pharmacists much more than giving drugs in the civilian sector. We were using physios much more robustly. That collaboration diminished during the nineties during the budget cuts, when we were closing a lot of bases and our services.

When we came back to rejuvenation in the year 2000 through the Rx2000 program, we really re-entrenched the collaborative model through what we call PCR, the primary care reform initiative. This is primary care but it's not limited to primary care. What we're talking about is continuative care whereby you have.... It's a form of capitation where members are rostered to a care delivery unit. In that unit there are physicians, military and civilian. There are nurse practitioners, physician assistants. There are medical technicians. With that core, they look after a group of people. Then we have as primary care providers physiotherapists, where a member can simply access.... If you have an ankle injury over a sports weekend, you don't have to go see a doctor to get a referral. You just go see the physiotherapist and have them look at it. If there are issues that he or she wants looked at, then they refer them back.

If you have some issues about certain self-medication, for example, again you don't have to go see a doctor. You can just go down to our pharmacy. We're one-stop shopping. They can do all of that. If you have some family issues, you can go see a social worker for family issues directly.

That is the core to which then we have secondary and tertiary care. In all of our bases, there are mental health components. Some of the larger bases have a much larger centre, where the core of the primary care is part of the mental health care team so that the communication between the primary care and the mental health is smooth. The mental health itself is not stovepiped. That is a team of psychologists, psychiatrists, mental health nurses, and social workers and pastoral counsellors who work together to look at that patient. If it's a complex one we have case conferences, and that involves not just mental health but there's the primary care team that goes into it.

That kind of stuff actually does play havoc a little bit with so-called efficiency. It takes a lot of people to look after holistically. I don't really want to get down to efficiency in that regard, but rather it is a very effective way to holistically look after the patient who's in the middle and you have the whole team.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Jung.

With the permission of the committee, I'd like to ask a question. Is that okay with all of you?

Thank you.

Mr. Brown, I heard you say that things seem to be quite different within the context of the umbrella of the RCMP.

Mr. Jung, when you were talking, it was just amazing to hear of this wonderful support system for our front-line soldiers. I have two questions, Mr. Jung. Is there a designated health care funding for the soldiers, yes or no?

[Cmdre H.W. Jung]

My budget, the health service budget, is a corporate budget controlled by the senior leadership.

[The Chair, Conservative, Joy Smith]

Okay.

Mr. Brown, when we're talking about the lack of health human resources, the lack of doctors who are actually understanding what the front-line police officers do, based on what Mr. Jung had to say, do you have any suggestions that might be very helpful for us as the health committee to know?

[S/Sgt Murray Brown]

I commented earlier about being envious of the military situation. I realize that they pick up and leave and need to be self-contained. I don't think it would ever be practical for us to do that. I think, though, that we have some similar good things happening in our organization. We are here collectively, working for an outcome. I hope that this is witnessed by your committee today. I'm not standing here as a labour person trying to attack the force. I love it dearly.

I would like to start with the budget. We don't have one. We've never had a health care budget allotted at the Royal Canadian Mounted Police. What we do is this: If it cost x million dollars last year, that's where we start you this year. What I'm asking is that money be locked in so that no one can come during the fiscal year, based on some other pressure, and extract money that's for the membership. That would be one humongous change.

In relation to the concept of holistic care, I thought we would move a little bit that way with a quarterback, if I may, which is case management. I don't know if we've advanced much as an organization, even within the case management realm. In a recent situation, a member was back to work on a return-to-work program. The person is working one or two hours a day so is no longer a priority with case management. That's tragic. That's what I refer to in my notes as an administrative gap. It's these transitions. Paulette has touched on it tremendously.

When Paul, who I knew during the years before he left Nova Scotia, came through, he fell through some tremendous gaps.

We had an attempted suicide in my division. My health services office didn't even know that the person was in our division. The person had transferred in.

We do a very poor job. I don't mean to be mean or critical. On isolated and remote posts, those men and women should be followed up maybe at six months or a year. Then we can wean them off the corporate eye, so to speak. At least the membership would know that the system has followed them during those experiences. Paulette touched on that when she answered Mr. Stoffer's question.

If we were more attentive, instead of saying that you're one over.... If I sprain my ankle, I can go to a physiotherapist. In my organization, I can go so many times, but if I don't have another injury, I'd better go to a doctor to get a referral. It doesn't have to be so complicated, and in our organization it is. Everything needs permission. We're paying as much now for permission as we are for the service.

Are there possible efficiencies? There are.

I look forward to working with Alain in his new position—with all due respect to the rank—but in all fairness to Alain, he's just been put in that position. Again, this is not a criticism. It's an observation. Now, instead of being able to go directly to the chief human resources officer, I have a stopgap. I will see how well this stopgap works out. Alain and I talked about it this morning. I can't go as high now, directly, but I can go to Alain. We'll see how that position works out. I am optimistic. I'm optimistic because he found the interest and the time to come here today, because he wasn't originally in the program.

I really believe—and I said so to both gentlemen this morning—that we have the occasion to have a fresh start.

I hope, Madam Chair, that this gives you some context.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Brown.

We'll now go into our second round of five minutes of questions and answers. We will begin with Dr. Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thanks very much.

I thank particularly Ms. Smith for really painting a picture of what this is like, and how really helpless you feel when somebody's designated fit to serve and you know that's not true.

I would like to explore how we can do a much better job in terms of wraparound care, first by identifying people at risk and then by providing some sort of continuous support. I don't think somebody who's there three days per week--and if you see a different person each time--is the way we sort this out. In most jobs people have to say “I'm okay, Jack” and get on with it. As a family doctor, you know when somebody is not himself or herself. You actually do need somebody with a continuity of care.

Maybe we should also be exploring how even in Nunavut people are able to do mental health visits electronically. To be able to see the same person each time, even with Skype, would be using the technology that we used in other parts of the services for this most important thing, our health human resources.

Even though, Ms. Smith, you had difficulty in terms of the clinical psychologist, I have to say that after the problem with Colonel Williams at Trenton a great number of my friends commented that we don't as yet have clinical psychologists in uniform in the military. Although you have operational psychologists, without clinical psychologists, who use the kinds of tools Ms. Smith described that we use for broken bones.... There are tools you can use to find out these things. I guess we're the only force without clinical psychologists but we also seem to be unlike the U.S. Air Force. We don't seem to do a pre-psychological assessment of our pilots.

I want to know how we can help. Another piece for which a number of us have been fighting for a very long time is that people are moved all over the country, particularly in the armed forces, and the soldiers receive care but their families do not. In my experience as a family doctor, if I'm not having the wife or the kids tattle on whoever's having trouble, I might not know what's going on.

What would it take, Dr. Jung, for us to be able to provide services of the highest possible quality for the military and their families?

[Cmdre H.W. Jung]

On the first issue about clinical psychologists, you're right that we do not have them, but we hire them as civilians. One reason is that the requirement to be in uniform is absolutely required for deployment. Because we have psychiatrists, mental health nurses, social workers, and padres on deployment, the unique acute care requirement of psychologists is lacking in the operational theatre. A lot of this has to do with the limits of the size of the force, so that is probably unlikely to change in the foreseeable future, although as I said, we do have civilian psychologists embedded in our mental health teams so that they can provide the same therapy and screening.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Are you saying that when somebody is deployed, there's no ongoing surveillance? If somebody has had a bad experience, is there no testing for that until it's time for them to come home?

[Cmdre H.W. Jung]

No. Number one, if somebody has some kind of illness, whether it's physical or mental, we have--

[Carolyn Bennett, Liberal, St. Paul's, ON]

But it's not an illness yet. They've just been put through a terrible situation. It's not an illness until he or she says it's an illness.

We're doing a better job testing when people come back, but actually there in theatre, is there some sort of prevention—anticipatory approach—that could be afforded by clinical psychologists?

[Cmdre H.W. Jung]

Pre-deployment, everybody is screened to make sure they're both physically and mentally stable to be able to deploy. At every deployment there is a pre-deployment screening that includes a psychological screening.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Unfortunately, that's not the case in the RCMP.

[S/Sgt Murray Brown]

That wasn't the case with Paul Smith and his wife when they went north. Does it happen? Yes, it does happen. We found out a little while ago that officers weren't pre-screened prior to departure. We understand we've closed that gap now. Those are things we worked through, and I can provide the correspondence to senior management at another time.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Madam Chair, if I may--

[The Chair, Conservative, Joy Smith]

Your time is up, Dr. Bennett. I'm sorry.

[Carolyn Bennett, Liberal, St. Paul's, ON]

I'm just wondering if Dr. Jung could table what he thinks would be an estimate for the difference in their budget now, just looking after soldiers, and what it would be if they looked after soldiers and their families.