National Defence Committee on Nov. 6th, 2012

[The Chair, Conservative, James Bezan]

Good afternoon, everyone.

We're continuing with our study on care of ill and injured Canadian Forces members. We're very lucky today to have coming back to join us Brigadier-General Jean-Robert Bernier, who is the Surgeon General of the Canadian Forces and commander of Canadian Forces Health Services Group. He's responsible for the delivery of all health care services to CF members, from primary care, to mental health care, to health care for deployed CF members.

According to the Surgeon General's report for 2010, he is also responsible for providing medical advice throughout the chain of command. From a strategic perspective, this includes advising senior departmental authorities on significant health issues, liaising with other military and civilian health organizations, formulating an overarching strategy for professional health technology, organization, policies, and procedures within the CF health services group, and maintaining a constant watch on the world's literature on health issues.

Joining him is Lieutenant-Colonel Alexandra Heber, who is a senior psychiatrist and clinical head of the Ottawa Operational Trauma and Stress Support Centre.

I welcome both of you to committee.

We're going to open it up for your opening comments, General. If you could keep them under 10 minutes, I'd appreciate it.

[Brigadier-General Jean-Robert Bernier, Surgeon General, Commander Canadian Forces Health Services Group, Department of National Defence]

Thank you, Mr. Chair, members of the committee.

Ladies and gentlemen, I want to thank you for your ongoing interest in and support for the health of Canadian Forces members. I also want to thank you for this opportunity to speak to you again on that crucial topic.

Given your interest in the mental health of Canadian Forces members, with me today is Lieutenant-Colonel Alexandra Heber, one of our senior psychiatrists. She is also the clinical head of our Ottawa Operational Trauma and Stress Support Centre.

Since my last appearance before this committee, several developments have progressed in our health programs and services. No human institution can be perfect, and the nature of some illnesses and injuries precludes cure or full rehabilitation in many cases, but we recognize the need to continually learn and improve. We have an advantage over other health jurisdictions in that the CF has central control over most aspects of our organization and population that influence health.

For example, l can direct the efforts, scopes of practice, employment, practice standards, education, and training of our health occupations in such a manner as to maximize the coherence and coordination of health services, while the non-medical leadership can control occupational elements that contribute to health, such as general health education, cultural and leadership attitudes to reduce stigma, peer support, and other casualty and family support measures, etc.

This central control of most factors related to health partly explains why the Canadian Forces can deliver a unit of care at slightly less cost than civilian jurisdictions, while providing a more extensive program in such areas as mental health, and why we can implement change fairly rapidly in response to internal and external evaluations, such as the recent reports of the CF ombudsman and the Auditor General. While all concerns listed in these reports are being acted upon, most related CF actions were under way or completed before the reports were released.

Centralized CF control and coordination are also particularly critical to mental health, for which the best outcome results from a close partnership among the medical staff, the patient, and the chain of command.

However, we have challenges that require ongoing aggressive effort and focus. Whereas the end of combat operations in Afghanistan reduced the tempo for many arms of the Canadian Forces, this is not the case for the health services with respect to mental health. Many trauma-related mental health cases take years to present. Our study of the cumulative incidence of Afghanistan-related operational stress injuries shows, for example, that we can expect about another 1,300 to 1,500 cases of post-traumatic stress disorder over the next few years, each requiring extensive care and support to minimize progression and maximize the chances of recovery.

A special challenge is identifying and getting into care all reservists who suffer service-related health conditions after their return to part-time duty. Their reserve units may be distant from CF bases in areas with limited provincial mental health services, and they may have less local military and social support at home than their regular force colleagues, given their distance from a large population of military colleagues with deployment experience.

Our challenges, however, generally affect both regular and reserve Canadian Forces members. They must be addressed in the context of a national shortage of mental health professionals, the need for strong leadership and peer support to get casualties into care early, and the nature of some conditions that can adversely affect a casualty's recognition of the need for care, compliance with treatment, and clinical improvement.

Although the objective and relative perspective continues to highlight that the Canadian Forces has perhaps the best overall health system in Canada and NATO, we must and we can keep improving. In mental health, for example, we are well-resourced and have an aggressive plan to enhance the recruitment of clinical staff, so as to further reduce wait times for care, and further enhance communication, education and treatment.

Our challenges, which are systemic, are being progressively addressed, and we have much shorter overall wait times for care and more mental health care providers per capita than any other Canadian institution.

The quality of our programs and our leadership in mental health also continues to be recognized by independent external authorities. For example, Senator Dallaire was told at this year's American Psychiatric Association conference that “Canada's program on operational stress injury was held as the example to be applied in the United States and, they hope, in other countries”.

Dr. Fiona McGregor, the outgoing president of the Canadian Psychiatric Association, recently stated publicly that “the Canadian Forces is right to take pride in its mental health program which has been recognized by its NATO allies and civilian organizations”.

Also, the CF ombudsman states in his recent report that the “care and treatment for Canadian Forces members suffering from an operational stress injury has improved since 2008 and is far superior to that which existed in 2002”.

This high standard of care results not only from centralized, holistic control of the military health system, but also from the extreme motivation and dedication of Canadian Forces members. Health services personnel, for example, treated many horrifically injured casualties in Afghanistan, saw death often, suffered the highest number of casualties and killed-in-action after the combat arm, and suffer suicide and mental illness, like other elements of the armed forces.

Although the medical experts who develop our health programs are non-combatants, they're soldiers first. Most have deployed to operations knowing better than anyone else that their own lives and health, as well as those of their friends, depend upon the quality of the programs and services they develop.

Strong defence leadership support also contributes greatly to the quality of our program and to our confidence that we can progressively improve to meet our challenges. This was most recently demonstrated by strong leadership participation in and support for a series of regional CF mental health briefings this year, a recent Canada-U.S.-U.K. military mental health symposium at the Canadian embassy in Washington, and the Chief of Military Personnel's mental health symposium for senior CF leaders in October.

Most significantly, it's reflected in the defence minister's initiative to increase the military mental health budget by an additional $11.4 million, for a total of $50 million annually, despite the need for all defence department elements to contribute to national deficit reduction.

As Field Marshal Viscount Slim, one of the greatest commanders of World War II, correctly noted, “More than half the battle against disease is not fought by doctors, but by regimental officers”. Efforts to promote, protect, and restore the health of CF members have been strongly supported by the armed forces leadership, and this support is expected to continue.

The CF is equally aggressive and equally recognized as a leader in other areas of military health. For example, Colonel Homer Tien, medical director of Canada's largest trauma centre, was widely recognized for his expert leadership of the life-saving medical response to Toronto's mass shooting incident of July 16, 2012.

The Canadian Forces health information system is the first pan-Canadian electronic health record system. It permits military clinicians to access the health records of our highly mobile population anywhere in the world, on land or at sea. An award honoree for this year's government technology exhibition and conference, it's held as the model for other departments by the federal government's chief information officer. We have established a Canadian Forces Chair in Military Trauma Research and are working on establishing a CF Chair in Military Critical Care Research.

Our Deputy Surgeon General was selected by NATO to chair its research committee on health, medicine, and protection, and CF Health Services personnel have a leadership role in virtually all its mental health-related research activities. This year, NATO has selected Canada as the recipient of the Larrey award for the greatest medical contribution to the alliance, in recognition of our excellence in establishing and leading NATO's first ever Role 3 Multinational Hospital in combat operations.

By virtue of the extreme risks and sacrifices accepted by Canadian Forces members in protecting our country, they merit the Canadian Forces' strong focus on providing them a standard of health care that maximizes their protection and their chance of recovery after illness or injury. National Defence leaders and the Canadian Forces Health Services are committed to maintaining or improving this standard.

I'd be pleased to answer your questions about the Canadian Forces health system to the best of my ability and to obtain any information that I can't immediately provide.

Thank you.

[The Chair, Conservative, James Bezan]

Thank you, General Bernier. I appreciate these opening comments.

We'll go to our seven-minute round.

Mr. Harris, you have the floor.

[Jack Harris, NDP, St. John's East, NL]

Thank you, Chair.

Thank you, General Bernier, for joining us today. We're pleased to have you here.

Your responsibilities are of course legion, to use a military term, but obviously force protection is extremely important for a military operation, and the care of wounded and ill soldiers is one responsibility that we're studying now.

As for one of the concerns we have, or that I certainly have, based on some recent events, including your predecessor's concerns about being forced to make reductions on the administrative side, and in light of General Leslie's report, of course, of which I'm sure you're aware, as well as some comments of the Prime Minister the other day at the change of command for the CDS, I guess the crude way of putting it is to ask, do you see your work as part of the tooth or the tail of the Canadian Forces?

Are you concerned that you'll be considered part of the tail and that your ability to administer your programs can be affected?

[BGen Jean-Robert Bernier]

Thank you for that question, sir.

There is sometimes a perception, particularly with long periods of peace, that the health system constitutes more of a sustainment arm, because we do have the dual role of maintaining the domestic, static health system, the whole Ministry of Health function, with elements of the Ministry of Education, Ministry of Labour, etc—everything related to health. But all of that is now recognized, particularly after a decade of operations in Afghanistan. Virtually all military commanders who have deployed to those kinds of operations dearly recognize the force protection role and the impact on morale.

There have been some who have approached me arguing that we should be considered a combat support arm, at the very least, rather than a combat service support, because of the critical importance. Our clinicians, particularly our medical technicians, but even our physicians, are out forward with the infantry at the pointy end, either on patrol or in a forward operating base and that kind of thing. The commander of the army has told me several times that the morale of the troops, their willingness to fight, and their willingness to sacrifice are very much related to their confidence that they will be well looked after and will be given every chance of survival by the medical system should they be injured.

Equally, I'll just mention incidentally that the support of politicians and the general public also plays a great role in their motivation and their willingness to make sacrifices.

I'm confident, particularly after 10 years of operations, that the visibility in some operations—for example humanitarian assistance operations in Haiti—the medical service is the supported arm rather than the supporting arm of the service. There's widespread global recognition, not just at the senior leadership level but across the armed forces, that the health system is critical, and many elements of it are considered to be at the pointy end.

[Jack Harris, NDP, St. John's East, NL]

I take it, then, that you agree with your predecessor that any reduction in support for the medical services would be detrimental to the ability of the Canadian Forces to continue to operate effectively.

[BGen Jean-Robert Bernier]

Any reduction to the health resources would have some impact, but most or virtually all elements of any impact can be mitigated in various ways. We can achieve many efficiencies. We are extremely efficient as a result of a Public Works and Government Services Canada review by an independent auditor, which found that we were less expensive than civilian health systems. There are various ways—financial means—of mitigating and ensuring that the services our soldiers need medically will be provided in one way or another.

The clinical coal-face support to the troops will carry on in one way or another. We'll maximize. Like all elements of the defence department, we have a responsibility to the taxpayer to maximize our efficiency and to avoid any unnecessary costs. We're undergoing the same kinds of reviews that all elements of the defence department and all elements of the government must undergo to make the most responsible use of taxpayers' money.

However, that being said, the services that the soldiers need will continue to be provided.

[Jack Harris, NDP, St. John's East, NL]

One issue that's come up from time to time—and you've mentioned it here today—is the difficulty in recruitment, which is shared by other health professions, particularly the mental health professions. It was raised at this committee as part of its study a couple of years ago.

We see, for example, complaints from people providing these services, such as what took place in Petawawa back in April. The suggestion then was that the clinical services were suffering because the caseloads were very high and there was an actual lack of flexibility on the part of the Canadian Forces. They said their salaries weren't competitive compared with those for similar positions outside the base; that staff retention was at risk because of complete rigidity and no flexibility in terms of part-time versus full-time work or flex time, etc., therefore creating a high staff turnover; and that even for a diagnosis of mental illness, the wait times to pass on to the next step, in terms of clinicians, were unreasonable.

These complaints indicate a lack of resources or a lack of ability to deploy those resources to ensure that Canadian Forces serving members receive assistance, and we're talking about serving members here, let alone their families. Do you have a solution for that, or is it something that concerns you?

[BGen Jean-Robert Bernier]

It is a concern, and it's a problem that afflicts all health authorities in Canada and in most of the world, but I can tell you that the obstacles to fully staffing our ambitious targets for mental health personnel, for example, are not related to resources. They're related to geographical difficulty or convincing people to go to relatively remote and rural locations when they have the opportunity, in the context of a national shortage of mental health professionals, to find work in larger urban centres. That's the main one.

Another one is simply that the public service hiring process takes time. However, we have an out; we have a third party contractor called Calian that will pay market rates to attract people and has a much faster hiring process. The problem, though, is that even with Calian paying market rates, even with the speed with which they can employ people, even with all of that, some people are simply not willing to move to certain areas of the country or to displace themselves.

[Jack Harris, NDP, St. John's East, NL]

Surely that would be true of some people, but if they're complaining of lack of flexibility, lack of competitive incomes, lack of part-time work, etc., there seems to be something more fundamental than just not wanting to go to a rural area.

[The Chair, Conservative, James Bezan]

Your time has expired.

Moving on, Mr. Alexander is next.

[Chris Alexander, Conservative, Ajax—Pickering, ON]

Thank you very much, Chair.

Surgeon General, it's wonderful to have you back with us.

I'd like to begin first by paying tribute to you and all of your colleagues in the Canadian Forces Medical Service.

From personal experience, from everything we have heard on this committee, and from everything we have all read, I honestly think that one of the untold stories of valour and achievement for Canada in the Afghanistan mission has to do with your service—your service in the plural—in that Role 3 hospital and all across the board within ISAF, within the Canadian contingent.

You have our unreserved thanks—I think from all members of this committee—for that unbelievably brave and professional work. There's a long tradition of this in the Canadian Forces.

I think of Sir Frederick Banting, whose name is now on Colonel Tien's chair of research, where he's trying to be a bridge for some of the experience of Kandahar, to bring it in to clinical trials and application in civilian life. We'll hear more about that later we hope in these hearings.

I think of Private Richard Thompson—not known to that many people—from the South African War, who won the very highest honour, even higher than the Victoria Cross, the Queen's Scarf, for bravery there as a stretcher-bearer.

I also think of a visit this weekend to Mr. Opitz's riding, where a Victoria Cross winner lies in a cemetery near where we had a Remembrance Day ceremony. Corporal Frederick George Topham, who was literally a medical orderly but who showed enormous bravery on the east side of the Rhine in March 1945.

You are at the front line often and your work is absolutely central to morale and to what the Canadian Forces set out to achieve.

Given that we still have troops in training roles in Afghanistan in harm's way, could you lay out for the committee what would happen to a Canadian soldier were they to be injured today in Kabul, in Mazar-e-Sharif, or at some other place of deployment? Take us through the stages of treatment that soldier would undergo—some Canadian, obviously, and some international—and then the forms of support that would be available in Canada for a person with a serious injury. Could you describe in general terms how that service, that process, has changed now compared to 10 years ago?

[BGen Jean-Robert Bernier]

Thank you very much for those comments, sir, and for the question.

For our folks deployed overseas now, in the event of a serious injury or illness, we always deploy at least a minimum amount of primary care with those individuals. Sometimes it's pre-hospital care. Depending on the size and extent of the mission, we may send them all the way up to a full tertiary care hospital to support them—or at least one with surgical capability.

Because health resources are difficult and scarce for all of our NATO allies, there are probably greater multinationally integrated health resources than there are in many other elements of the armed forces. Where there's a smaller mission, as in the case of the current operation, Operation Attention, in which Canadian troops are mentoring Afghan National Army folks, because our people are dispersed everywhere we provide Canadian Forces members with immediate acute care at the primary care level—physicians and medical technicians—but we're relying primarily on the U.S. or in some cases the French military hospitals to provide the tertiary care.

So there's always a pre-hospital care component, where people with additional training in tactical combat casualty care.... Very acute life-saving measures are applied within the first 10 minutes to control those things that tend to cause death early, like airway management and excessive bleeding. They apply that kind of care within the first 10 minutes. Then there's always a rapid medical evacuation process to try to get people onto the operating table, if necessary—if surgery is required—within an hour or a maximum of two hours, followed by stabilization in a tertiary care centre before tactical evacuation to, usually, a higher-level hospital.

For us, it will usually be Landstuhl Regional Medical Centre in Germany for additional stabilization and additional detailed surgery before strategic medical evacuation back to Canada to a quaternary care hospital, where all additional care and rehabilitation can occur as close as possible to the maximum social supports and the adequate clinical supports that are necessary.

One of the big changes that has occurred is recognizing the value of providing clinical care as far forward as possible. So for the tactical combat casualty care component with that initial life-saving care, with specific procedures that in Canada may often only be done by an emergency room physician, we've pushed forward and trained not only our medical technicians but our combat arm folks to be able to do a number of those procedures. That intervention within the first 10 minutes will buy a lot of time.

We have good data from something called the joint theatre trauma registry, which was used widely in Afghanistan to demonstrate that we can extend the time to do necessary surgery by up to two hours before, and still maintain the same life-saving capability.

That's a quick summary of the process.

[Chris Alexander, Conservative, Ajax—Pickering, ON]

Congratulations on your recent appointment, by the way.

Could you quickly add a couple of comments about your own experience in Afghanistan and Kandahar and what you think Canada should be doing to ensure that we apply the medical lessons of that combat operation as fully as possible in order to be prepared for the next mission?

[BGen Jean-Robert Bernier]

I was the director of health service operations, so the commanders of all the medical units in Afghanistan reported to me in Ottawa at the height of the conflict. We're extremely highly respected by all of our allies for the speed and nimbleness with which we could modify our program. Our participation in that joint theatre trauma registry and system permitted us to essentially do research, with almost real-time modification, of clinical protocols and process that resulted in life-saving.

For example, through that system, the Americans in Iraq were able to reduce mortality by up to about 15%, simply as a result of that data analysis. We have developed tremendous lessons learned as a result of that operation. We've incorporated those into our process. We've published them as widely as we can, including in the NATO Joint Analysis and Lessons Learned Centre, so the whole alliance has that kind of benefit.

We need to continue conducting research and continue maintaining the capabilities we've developed, even at a skeleton level, so that will require us to maintain all of the capabilities. We don't know what will happen next. We can't base our lessons and our restructuring of the armed forces on the past conflict, because the next one will always be different.

We need to have a capability-based structure where we have at least a skeleton capability in virtually every area to be able to meet every kind of operational threat and health hazard, so that we're ready to magnify, expand, and deploy it should the next operation not be what we expect.

When the Americans went into Iraq, the last thing they expected was to have to perform offensive manoeuvre operations again with armoured forces, after the end of the Cold War, but they were ready and they were able to maintain those capabilities. We have to do the same thing. Publication, ongoing research, and maintenance of our current structure with capability in all different areas are what is required for us to be ready the next time Canada needs us.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. McKay, you have the last of the seven-minute rounds.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Thank you, Chair.

Thanks to you both for coming.

I want to get your comments on Fortitude Under Fatigue, Pierre Daigle's report, because the picture you're painting in your presentation seems to be at some variance with what Mr. Daigle said. In recommendation 5, he indicates:

The most significant is the considerable gap which remains between the capability to deliver the care CF members with OSIs need and deserve, and the actual capacity to deliver it. This gap is primarily the result of a chronic inability to achieve, or come close to achieving, the established manning level of the mental health function. The impact this has had on the frontline delivery of care, treatment and support to CF members with PTSD and other OSIs and their families has been profound.

I'm sure you've read his report, and I'm sure you've had time to think about it, but it does strike me as being at some variance with what you're saying. I'd be interested in your observations.

[BGen Jean-Robert Bernier]

Mr. Daigle is correct, and we welcome those kinds of external reviews;everything is relative, however, and we need to continue improving. I mentioned the obstacles to our ability to achieve the number of mental health professionals that we need. We're working hard. We have an aggressive recruiting plan to deal with that. We have additional commitments to try to accelerate the staffing process for those individuals who we need to fill the gaps in mental health staffing.

Wait times, however, are far less than they were. In Petawawa, for example, in the last few months we've reduced the wait time to less than half of what it was previously, so it's now at about one month for a specialized Operational Trauma and Stress Support Centre assessment. For the general mental health assessment, we've reduced it by 30%. I don't think any civilian authority in Canada can meet those wait times. They're dramatically lower than pretty much anywhere else.

Nevertheless, our troops require additional focus because of the extreme sacrifices and threats and stresses they encounter, so they merit that kind of support, and nevertheless, we're always striving to do better.

We now have, for example, over 200 applicants to fill some of our public service positions to try to achieve the 447 target that we're aiming for. Once we do achieve that 447 target, we'll be reviewing at that time—based on a Canadian Community Health Survey coming next year, conducted by Statistics Canada in collaboration with us—whether even that number is sufficient.

There is a willingness to if necessary increase that number to whatever the requirement is to provide a good level of care, keeping in mind that primary care in this country and in most of the world provides much or most of mental health treatment. So it's critical that we get a specialized mental health assessment early on, but then, most of the ongoing care in some countries and in some models, like RESPECT-MIL in the U.S., is even primarily conducted by nurses.

When a wait time for care for a specialized mental health assessment takes time, people are not just left to their own devices. They continue to be followed by primary care physicians. Their prioritization on the wait list can be changed immediately and at any time if there is an acute urgent case they'll be seen immediately.

[John McKay, Liberal, Scarborough—Guildwood, ON]

One of the things he says in his recommendations is that there is a “requirement for a national database” to accurately reflect “the magnitude of the CF's evolving OSI imperative”, which has not been met.

Your argument is that we've really improved at Petawawa, that our wait times are better and our system will stand up against any civilian system in Canada—which may be a good argument, I don't really know—but absent national data, it's pretty hard to say whether you're right or he's right. What are your comments on his desire to collect national data?

[BGen Jean-Robert Bernier]

We do collect extensive national data. The ombudsman's focus is on an OSI point prevalence case count database. We will eventually have that with the rollout of an application of the Canadian Forces health information system, where we'll be able to enter any particular diagnosis and get an instantaneous count. A PTSD diagnosis may be related to sexual assault, a car accident, or a military operation, so teasing that out is a very difficult thing to do.

We'll be better able to do that at some time with an application of the Canadian Forces health information system, but even that will not help us better determine where we should be modifying our policy program and resource allocation. We have better population level studies that we conduct for that purpose. That serves that purpose far better—for any health authority, not just us.

[John McKay, Liberal, Scarborough—Guildwood, ON]

The government has argued that this is invasive of soldiers' privacy. What's your reaction to that?

[BGen Jean-Robert Bernier]

We definitely do not want to further stigmatize mental health beyond what it already is. There is a risk that if we deliberately set up a separate database specific to post-traumatic stress disorder, operational stress injuries, and that kind of thing, it will work somewhat against everything else we're trying to do to normalize operational stress injuries to be like any other operational injury. If somebody gets on the list, it may be misperceived as being—despite the good intent—an adverse thing.

[John McKay, Liberal, Scarborough—Guildwood, ON]

There is always the argument that a soldier is going to bury whatever it is he feels, because he does feel that this will be contrary to the best interests of his career or that sort of thing. I assume that is, if you will, an underlying distortion of the data.

[BGen Jean-Robert Bernier]

For that reason, we rely on population level, on anonymous large population level studies that give us a much more reliable long-term picture of where the mental health burden is and how great it is.

For example, a case count at any given moment from an OSI database would give us only the prevalence at that moment. It may change five minutes later. It will certainly change a day later, and it will change a month later, so we look at longer-term periods with large studies like the Canadian Community Health Survey and the Canadian Forces health and lifestyle information survey and others that give us, over a longer period of time, a more reliable basis on which to make our policy and program design and to determine what our long-term burden is.

For example, the cumulative incidence study of operational stress injuries for Afghanistan, which assessed 30,000 people who deployed between 2006-08 and over four and a half years of follow-up, gave us a relatively—as far as reliability can be achieved through those kinds of studies—much, much more reliable picture of what we can expect as far as a burden coming down the road goes than would an OSI database.

[The Chair, Conservative, James Bezan]

Thank you. Your time has expired.

We're going to go to our five-minute round.

Ms. Gallant, you have the floor.