Health Committee on March 23rd, 2010

[Cmdre H.W. Jung]

That would be a very difficult task. There would be an enormous increase. I would guarantee that. You just have to look at the U.S. TRICARE system. It is an absolutely enormous task.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Jung.

We will now go to Ms. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you, Madam Chair.

I certainly apologize for missing the testimony, and I will read Hansard to make sure I get all the information you provided.

This is one of the things I want to start to focus on. My background is in nursing, and when I was a very young nurse I had the privilege of working with a physician who was no longer with the military. He worked in a rural community and actually used a lot of the concepts he had learned. I would say that was one of the few really strong primary health care teams to which I have been witness. In our conversations and in those with previous witnesses, there has been a lot of talk about physician assistants and perhaps opportunities for physician assistants. I wonder if you could talk briefly about their role and their training. It has been mentioned many times.

[Cmdre H.W. Jung]

The physician assistant model started in the military in Canada. It's been in existence for over 40 years. It was a requirement that came strictly out of necessity. You could never send doctors everywhere. Ships have a small number of people. We couldn't send doctors there, and of course many of the army units are very far forward. You have to be a soldier also. The term “physician assistant”, and for that matter paramedics, came out of the military in the historical sense during the First World War, with stretcher bearers and so on. The physician assistants came out of the military necessity to provide acute care in a setting where there were no physicians and there were no other health care providers available. These were trained by the military using a medical model to be able to have the skills to look after acute requirements to buy time for a patient to then be evacuated back to a facility manned by physicians or to a surgical facility.

That scheme then expanded over time to beyond just simple acute care to doing primary care. Why would we in the military want to have physicians looking after colds and simple sprains and so on when we could spend more time on more complex cases? We simply evolved the physician assistants in the military. Basically you are leveraging physician services so that instead of a physician looking after 100 patients, let's say, with a PA he or she may be able to look after 180 patients with physician oversight.

Then there are nurse practitioners in our clinics who use the nurse practitioner model, but they come from a nursing model, so it's slightly different. They do have a separate origin, but they are both in the same care delivery unit. They provide similar services in different contexts with different backgrounds, but there is enough room in our system for both of them.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

You talked about perhaps lacking a little in efficiency, but have you actually reviewed it in terms of the primary care team taking care of the sort of “capitation model”, as you might put it? Have you done some effectiveness evaluations and some comparisons?

[Cmdre H.W. Jung]

I want to be clear when I say efficiency is going to go down with the collaborative model. That just means that you cannot churn through patients as fast. That doesn't mean you are providing good care. From an efficiency perspective, we just had our health care budget completely analyzed by government consulting services, and we actually came out per capita, per unit of service, actually more cost efficient than the civilian health care sector using the CIHI data. I just want to be careful about that. The lack of efficiency is that we do not have the revolving door concept. We do look after the patients.

[The Chair, Conservative, Joy Smith]

You still have a minute, Ms. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Great.

I appreciate your comments about efficiencies.

I have two more questions. I'll ask them both. One would be about outcomes. Have you done some work on outcomes?

I was recently at a function where I believe you received a mental health award for some of the work that was being done. Is that a new concept? I wonder if you could briefly respond to that.

[Cmdre H.W. Jung]

The outcome measure, as you know, is a sort of holy grail of the health care sector. Outcome is very difficult to manage. We're going to have a better handle on it as soon as the last phase of our health electronic system is implemented. Then we'll be able to extract data to see whether or not we're making a big difference in hypertension, diabetes, and so on. That is going to be coming.

In terms of the satisfaction rate and basically of feedback from physicians, I think we are having a much greater effect, particularly when it comes to mental health. I think we've made some enormous strides over the last several years in providing good mental health. I would dare to say that I think Canadian Forces is probably in the leadership role in Canada in providing holistic, integrated, multidisciplinary mental health.

In terms of our model, we look at it as involving a three-pronged approach. You have to have a good and effective mental health care treatment system. If you cannot provide good care, then who's going to come to you? Two, you have to have a good supportive leadership. Leadership in the military in many ways determines the culture of the organization. As you know, we've done an enormous amount of work in education for that leadership. The Chief of the Defence Staff recently launched the “Be the Difference” campaign. Mental health issues are discussed openly, more than ever, I suspect, in any other society in Canada. The third one is aware and engaged members or patients.

You have to have all three—if you like, a three-legged stool, and if one of them is short, it's going to tip. I think we're working on all three facets simultaneously right now.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Jung.

We'll now go to Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you, Madam Chair.

First, I would like to thank the witnesses for being here today, particularly the RCMP and the Army for all the work they do. Your presence is invaluable to the committee. I would also like to say special thanks to Ms. Smith, because I know this is not necessarily easy for her.

Since the committee began sitting, we have talked a lot about prevention. I think that is really the key word, when a post-traumatic or psychological problem arises. Obviously, first, there is a shortage of funds and resources, particularly in the RCMP. We may not be giving you all the resources that you need, to be able to put into practice ideas that you consider to be fundamental, or all the resources that might be useful for you.

On that point, I would like to hear Mr. Tousignant—and also, congratulations on your new appointment. Concerning the answer Mr. Brown gave our chair earlier, I would like to know your opinion.

[C/Supt Alain Tousignant]

We're talking about the budget. In 2008-2009, the RCMP spent approximately $70 million on treatment for employees. That is money we have no control over. It is money used for treatment for all our members. We have a budget that we control a little more at our national policy centre, which is under Mr. Boughen. The centre looks after implementing projects and initiatives to try to meet the needs we are discussing this morning, in relation to both mental health and physical health.

Obviously, if we are talking about the Office of Health, we are really talking about a three-pronged approach: mental health, physical health, and also health in the work environment. These are the three aspects we try to target with the budgets allocated. I can assure you that of the budgets we control, especially internally, all the money is spent; nothing is returned. We try to maximize the initiatives we can deploy with the budgets allocated to us.

Obviously, we are competing with the other RCMP budgets, both for operations and for human resources. It is always a balancing act, dividing up the budgets that will be allocated each year. During the year, we have an opportunity, by doing a business plan, to get funds that may be surplus, but it is still based on priorities and acceptance of the plan. That is kind of how we operate with our budgets.

[Nicolas Dufour, Bloc, Repentigny, QC]

We have talked a lot about prevention. Ms. Smith told us there was a kind of wall of shame to get over, for example, to be able to talk to a psychologist or get access to the tools to get through it. We have talked a lot about barriers. I would like to know, in your opinion, at the RCMP, what do these barriers look like that prevent your members from talking to psychologists.

[The Chair, Conservative, Joy Smith]

Mrs. Smith, do you want to comment on that, or Mr. Tousignant?

[Paulette Smith]

From being a wife and observing my husband--we were married for five and a half years, and obviously I'm not a member--their training makes them so stoic. I think they feel--and I'll use the term Mr. Brown used earlier in his speech--that they must suck it up; that speaking beyond the uniform shows weakness, and that you are maybe not able to handle a situation.

It becomes a little harder when you are six foot three and 265 pounds, versus maybe of smaller stature. As well, your superiors, your staff sergeant, your immediate supervisors, and staff in your detachment maybe go to you a bit more because you are a larger person and you tend to handle things well, versus other members. You seldom complain, because that's not your nature. I'll add that my husband was from a military family. His father was a colonel, so he knew all about what military meant and what the uniform meant. He was very proud to be a member. I know I've never said that, but he really was. Even at the end he still was.

I feel that it's almost in them as members. It's in the training and in what they're presented with on a daily basis. It's just the way the force is. You are to be strong and show strength, because you are protecting everyone else. We're forgetting that the people behind the uniforms are fathers and sons, that they have children and feelings.

They may see a child of 18 months being administered CPR and later dying, and rush the parent through at 150 kilometres per hour on a Sunday evening. But no treatment is given to them; no follow-up. They may pick up a young girl of 19 years of age who was brutally murdered, and put her in a body bag, and for over two years work with a major crime unit when it's not their position to do that--and never receive follow-up. They need help, and we need you to help them. The members are crying in their own way, telling people they need help, and I think the only way to do that is through funding.

They need to feel at ease when they're speaking to their superiors. They need to have conferences where they're told what they may be exposed to, and what they may encounter over their careers. It should be brought down to the ground level when they're training and they should be told, “Guys and girls, this is it. This is the job and what it entails. You will see things that normal people, on an everyday level, will not see. But we will follow through and we will take care of you, as we should. This is what we have in place for you. When you feel something different or wonder why you're not sleeping or eating, feel free to come to us and speak of that. Get it off your chest.” That's all it takes. It's prevention.

[The Chair, Conservative, Joy Smith]

Ms. Smith, allow me for a minute to tell you that your testimony here at this committee is of paramount importance, because it opens up all of our eyes to what happens with police officers, the military, and others like that. I know it's very hard for you, but it's very much appreciated.

We'll now go to Ms. Davidson.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thank you, Madam Chair.

I too would like to thank our presenters here this morning and apologize for missing your presentations. I will definitely be checking Hansard, as will my colleague, to make sure that I don't miss anything.

I just want to say this to Ms. Smith. I certainly hear your voice and feel your pain. I lost a very dear and close friend who was a member of the police force and was not getting the attention that he needed. He was dealing with undercover units in a very nasty world, and there needs to be something there.

I also have a husband and a son who are emergency responders in the fire service. I understand some of the tension that families go through and some of the assistance they need, as well, to deal with the issues that our loved ones deal with as a matter of routine, almost.

So I'm certainly glad and thankful that you were able to come here and give your testimony today.

I want to ask a couple of questions to the Department of Veterans Affairs, to Ms. Bax and Ms. Flett, please.

I understand you are part of the federal health care partnership movement, and I think that's great. I want to hear a bit more about it, and I hope I'm not asking for things to be repeated that I missed.

I think the face of Veterans Affairs is changing greatly and changing rapidly. I am speaking of the demographics and what we had traditionally been accustomed to with veterans, and now, with today's world, what we are faced with with the veterans in the demographic area.

I'd like you to address some of the challenges that presents, if you could, please. Are we looking at different shortages, different types of shortages for specific specialties, or are things remaining much the same?

[Hilary Flett]

With regard to the nature of shortages, if we compare the study of 2007 and the shortages today, the actual requirements with regard to filling indeterminate, permanent public service positions haven't changed, partly due to how departments are opting to deliver their service, such as the example you raised within Veterans Affairs. They have chosen to go with a third-party contract model for their occupational stress injury clinics. So their requirements, with regard to their medical officers and their district nursing officers, remain the same and their overarching requirement remains the same for indeterminate public servant physicians, and the same applies with the other departments.

So to answer your question, no, the shortages have not changed in the past three years.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Okay. Can you elaborate a bit more, then, on how the federal health care partnership has best allowed you to optimize the mix of professionals that you require? How has it been a benefit to Veterans Affairs?

[Janet Bax]

Madam Chair, it's very important to point out to the honourable member that while we are housed in Veterans Affairs, we're actually not Veterans Affairs. We are a partnership of seven departments, so we don't actually deliver direct services. What we do is provide the means to work collaboratively. Through the establishment of the Office of Health Human Resources, the issues that all of our partners are experiencing in dealing with the challenges they have of finding physicians, psychiatrists, psychologists, nurses, and so on are brought to the table, so that a good practice that has been adopted and has worked for one partner can work for another. But our raison d'être is economies of scale, so we don't actually deliver the services for the RCMP, we don't actually deliver the services for Veterans Affairs.

I think, Madam Chair, it's important that the honourable members understand the nature of the work of the partnership. So the study that was done in 2007, the work that we continue to do, is aimed at helping departments deal with their challenges.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Flett, for pointing that out. Ms. Davidson and some of our members did not get a chance to have the preliminary introduction. That's a very good question and a very good reminder. There are seven partnerships that encompass this health human resource initiative.

Now we'll go with shared time to Ms. Murray and Ms. Duncan, and remember it's five minutes.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you, Madam Chair. I know Ms. Duncan has questions on this very important committee testimony.

I am seeking unanimous consent to propose a motion, which is as follows:

That, in the opinion of this committee, the government’s G8 maternal and child health initiative for the world’s poorest regions must include the full range of family planning, sexual and reproductive health options, including contraception, consistent with the policy of previous Liberal and Conservative governments and all other G8 governments last year in L’Aquila, Italy; that the approach of the Government of Canada must be based on scientific evidence which proves that education and family planning can prevent as many as one in every three maternal deaths; and that the Canadian government--

[The Chair, Conservative, Joy Smith]

I'd like to stop you right here, Ms. Murray, because--

[Joyce Murray, Liberal, Vancouver Quadra, BC]

I'll just finish my motion.

[The Chair, Conservative, Joy Smith]

No, because you need 48 hours' notice, which is the requirement for a motion, unless we have unanimous consent--