National Defence Committee on Dec. 11th, 2012

[The Chair, Conservative, James Bezan]

Good afternoon, everyone. We are going to continue on with our study of the care of our ill and injured Canadian Forces members.

Joining us today is Commodore Hans Jung, who is the retired former surgeon general for the Canadian armed forces. He was born in Korea and assumed the office of Canada's surgeon general in 2009 and retired in July of this year, after serving 31 years in the Canadian Forces. During his tenure he was the primary mover for the physician assistants program as well as the Canadian Institute for Military and Veteran Health Research, which we are very familiar with, which is a network of university researchers focused on military and veterans issues.

Commodore, if you want to bring us your opening comments, we are interested in hearing what you have to say.

[Commodore, Retired) Hans Jung (Former Surgeon General, As an Individual]

First of all, since I'm now retired and I'm not representing any organization per se, I really don't have any opening comments. I thought I would give you more time to ask the questions you need to ask.

First, let me say that I want to thank this committee and the membership for keeping the care of the ill and injured on the radar because this issue is not going to go away. There is a lag-time effect and it will be with us for quite some time to come.

I am now ready to answer your questions.

[The Chair, Conservative, James Bezan]

This is just for committee members. We have an hour and a half with the commodore.

Mr. Harris, you have the floor for the first seven minutes.

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

Thank you, Chair.

Thank you, Commodore, for joining us. I guess now that you are retired maybe you can speak a bit more freely about some of the concerns you may have had during your tenure since 2009 as surgeon general.

We've looked at a number of studies, particularly about mental health. I'm going from the ombudsman's reports starting in 2002 to 2008, our own committee's report in 2009, and reports out of Petawawa in 2012 which were quite disturbing. There seems to be a pattern in that the problems are being identified in terms of the ability to deliver on programs for soldiers. I'm thinking particularly in this moment about mental health services. One of the problems identified is that although the desire may be there, the actual ability to deliver is not.

I note, and perhaps you can speak to this, that you raised some significant concerns in the spring of this year after the budget directives came down. You thought the mental health services being provided were being undermined by budget cuts. Did you have similar concerns about the failure to have resources available to deal with the recommendations that were made in terms of additional support services?

I'll follow up with another question, but did you have similar concerns as surgeon general from 2009 until your retirement in July?

[Cmdre Hans Jung]

Well, I think I've been on the record, while I was the surgeon general, as saying that the issue was never resources. In fact, each year we had to turn in some of the money we could not spend.

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

As a department?

[Cmdre Hans Jung]

Obviously, as a department, but as the health services, there were a multitude of reasons for that. Number one, as you've heard many times, there is not a plethora out there of extra capacity of human resources for mental health services available in Canada that are free to be hired by some of the organizations. When you are looking for more services you are going to a market that is already fully engaged. The competition to move them into DND or the CF is not an easy one. There is not a whole lot of unemployed people looking for work.

Related to that, of course, is that as an agency of the government and as part of the public service—many of these are civilians we are looking at and we are not looking at CF members—there's not a pool of mental health care professionals in the public service who you could actually reassign or ask for through an internal competition. They are almost all external. You have to actually seek out these people from the civilian sector.

That leads you into a whole bunch of public service hiring practices, such as timelines involved and classifications. Therefore, there is a huge lag time from when you identify a person to when you can actually hire them. It's sometimes 10 months or longer. Of course, if any health care professionals out there are looking for work, they are not about to stick around for a few months, let alone 10 months to get an answer on whether or not you can offer them a job.

That part of the bureaucratic process that exists within the government was a hindrance.

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

I have to interrupt, because we only have a short period of time.

We've heard that time and again, but when clinicians have spoken out. For example, in Petawawa in 2012, one of the things they said was that the salaries are not competitive with similar positions outside the military. That's why clinicians will not work there. There is little incentive to go to a military town to work. Staff retention is at risk. There is no flexibility in the use of part-time workers, full-time workers, flex-time work, or a compressed work week. There is a high turnover of staff.

If a psychiatrist diagnoses a mental illness and needs to refer the patient, the wait time is unreasonable and the clinician ends up using supportive therapy and there's a waste of valuable resources. There seem to be barriers. It's not just that they can't find the people. There seems to be a failure to organize the work or to appeal to the people who are ready to provide the work if the conditions are right. Was that identified by your organization?

[Cmdre Hans Jung]

Yes, it was. You have to separate some of the civilian hiring between the public service and the contractors. Our hands were completely tied with the public service, because public service pay schedules are not determined by DND.

You're absolutely right. There are only a handful of doctors in public service within CF or DND, because the public service fees were just not competitive. We'd often have to hire these people through Calian, the private contractor, so we could pay them a more competitive price.

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

If money wasn't the problem, how is it that the minister all of a sudden comes up with $11.4 million right around the time you were making complaints? The response is that we now have four psychiatrists at Petawawa we never had before. How did that happen if money wasn't the problem?

[Cmdre Hans Jung]

The four psychiatrists we had were always there. However, psychiatrists are human beings too. They go on maternity leave, become ill, and so on. You can't always predict that there will be four full-time equivalents all the time.

I repeat, the issue has never been a lack of resources; rather, it was my inability to spend them because of the barriers beyond my control. There were the hiring practices. Every fiscal year, for example, there would be departmental directions announcing a hiring freeze because of the uncertain financial situation. There would be internal reviews. Those things all cause additional months of delay in offering positions to civilians who may be interested.

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

Someone has to cut through all of this. What could we recommend to fix it?

[The Chair, Conservative, James Bezan]

You can give a brief response, but the time has expired.

[Cmdre Hans Jung]

Well, there were 60-some positions that were approved to deal with the mental health resources. It was supposed to go up to around 440 people. With the last 60 to 80 people, we were never able to bridge the gap. There were internal obstructions even though the positions were approved and funded.

One of the things would be to simply give authority to fill those positions without having to go through the myriad levels of approval. Every single position has to be staffed and analyzed and has to be approved at various levels of the departmental hierarchy before it can be done. Right now, my understanding is there is still somewhat of a freeze on the hiring of public servants.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. Chisu, you have the floor.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Thank you, Mr. Chair, and my thanks to you, Commodore, for appearing before our committee.

First, thank you for your service. Thirty-one years is a long time in the military and I think you have seen a lot. From your experience, where would you like to see the Department of National Defence and the Canadian armed forces take health care programs in the future? What do you see for the future in health care programs? In an ideal world, what types of mental and physical rehabilitation programs would you like to see offered and integrated into the CF health care plan?

[Cmdre Hans Jung]

You have to understand that starting in 2000 the Rx2000 project, or prescription 2000 omnibus project, was started to rejuvenate the Canadian Forces health services. You have heard the comment about the decade of darkness. I have always talked about the decade of deep darkness within the health services. Rx2000 was designed to bring us back up to the standard where we needed to be. You also need to keep in mind that when Rx2000 was planned and approved, Afghanistan was not on anybody's mind. Everything we did before Afghanistan was based upon what we thought was more or less a peacetime requirement to provide health care. Subsequently, because of Afghanistan, we provided additional support. We beefed up the mental health aspect. We re-created the rehabilitation program which had disappeared in the 1990s. We rejuvenated much of the stuff.

In my mind right now, with the Rx2000 program ended and being where we are today, we have what I call an optimal health care system. I won't say it's a perfect system. No system is ever going to be perfect, obviously. This was well thought out and methodically executed. As you know, we have the only pan-Canadian electronic health record system in Canada. The Canadian Forces is a leading organization and model of care in a number of other ways.

My concern isn't so much about where we need to do more; rather my concern is that we spent literally a dozen years getting where we are today. I would be a bit concerned for obvious reasons—because of the fiscal condition of the country and a number of other stress sources with the cessation of conflict in Afghanistan—that over time, the focus on the care of the ill and injured may fade. The system we have worked so hard to develop today may start to recede. I know life is full of sinusoidal curves. Things go up and things go down, and there is a bit of a cycle. I would hate to see such an amazing system as the one we have today, which we have developed with so much hard work and with so many good people, be sacrificed slowly over time. That's why I think the work of your committee is very important to make sure we actually maintain what we have now.

In the last three years, I have said we don't need more money. We have a reasonable amount of resources. What we need is the flexibility to tailor our resources to where we need them in a rapid way, such that the ability to move in an agile manner will allow us to stay that way. For example, right now, the health care requirements, particularly in the land forces, fluctuate over time depending on their rotation patterns. As a public servant, if you hire too many people in one area and after a while that fades, it's almost impossible to shift them to a different area. It's the ability to move around and put resources where you need them to meet the surge in demand, to be really agile in that way, while keeping the overall envelope more or less the same.

If we can do that, we have a very, very good health care system. I know my NATO colleagues are very envious of the health care system we have in Canada.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

How can we maintain military physicians in the forces? For example, when I was in Meaford and other bases, I saw civilian physicians who are on contract and so on. As you said, with military personnel you can take one from Petawawa and put one in Edmonton, and something like that. As professionals, they have a different approach to the people they are dealing with. They probably understand a little better the stress and the problems with serving in the military. How do you see it? I know it was an incentive for physicians to join the armed forces. It's not a question of money. It's a question of the personnel to join the army.

[Cmdre Hans Jung]

That's an excellent question. Again, this challenge is not unique to Canada; it's a challenge for all the NATO countries that have been involved in Afghanistan.

Physicians, nurses, pharmacists, health care professionals, join the military not just to provide day-to-day health care, because they can do that in the civilian sector and chances are they'd make more money and have better control over their lives. They do so because of the unique service they provide in the Canadian Forces, the operational exposure, the unique exposure they get. Afghanistan was, to be very blunt about it, a tremendous attraction tool. People looked to that and said, “You know what? I think I can serve Canada. I can do something unique. I can get some unique experience. This is a chance of a lifetime”. They feel they can make a difference above and beyond everyday practice.

The challenge is, and this is where General Devlin also has an issue with simply the army, how to train to excite. How do we maintain that unique excitement, that unique military culture of esprit, that sense of adventure, if you like? We have to be innovative about training our people, in the context of the future, in a much more interesting simulation to reflect what they may see in combat. As time goes along, we have to be much more interoperable with our allies to make sure that we train together to minimize costs and to increase synergy.

At the end of the day you have to excite. They're working side by side in an office, in a clinic in Canada, and the guy in uniform looks to the guy in the next office and says, “That guy's wearing civilian clothes and I'm wearing a uniform. He makes more than I do, doesn't have to do any duties, and there's no unlimited liability. What is it that makes my job so exciting that I want to be here?” That's what you have to consider. It means fostering the military esprit, the operational medicine, and giving them that opportunity to do so.

[The Chair, Conservative, James Bezan]

Thank you. Time has expired.

Mr. McKay, you have the last of the seven minutes.

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

Thank you, Chair.

Thank you, Dr. Jung, for coming, and I, like my colleagues, thank you for your service.

We had a couple of fellows here last week who were pretty much on the edge, a couple of soldiers and several suicide attempts between them. It put a human face to what we're talking about. Most of the time around here we talk about money and what our plans are, all that kind of stuff. It's difficult to comprehend how badly injured some of these fellows really are.

The conversation until now, specifically with the people who have appeared here who have been injured, has to do with alternate therapies. The military's position is largely, “We have an alternate therapy on our desk each and every day. We can't sponsor everything, and besides, there's no empirical evidence to support some of their stuff.” The soldiers are saying, “Look, man, this stuff saves my life. This dog saved my life. This horse is great for me”, that sort of stuff.

You're now providing direct medical services to veterans. What's your view?

[Cmdre Hans Jung]

I think we have to be very careful, number one, to distinguish anecdotes from a systemic pattern. We also have to distinguish what people need versus what people want.

If your standard of success is to make everybody happy in terms of what they think they need and they're happy to get, then I don't think there's enough money in Canada to satisfy everybody's wants. At the end of the day, on the one hand we're talking about budget constraints right now and pressures to not only become more and more efficient but potentially even cut, and on the other hand you're saying to give people whatever they want based upon their personal desires.

One of the things that we have be very careful of is what makes you happy subjectively is not necessarily objectively what's going to take you there in the long term. For example, if someone said, “If you would fund my application to Bahamas every year, that would make me really happy because I feel depressed and everything”, is that legitimate? There's the care involving horses. That's why in the civilian sector we have all these organizations, such as the Heart and Stroke Foundation of Canada and the Canadian Cancer Society. These are volunteer organizations that can do some of that stuff in a relatively small population basis.

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

His argument was that as a blind person needs a dog, his injury needs a dog as well. I was struck by the argument because I didn't think it was a warm, fuzzy, make-me-happy kind of argument. It spoke to an issue of the PTSD that this particular fellow suffers from. Is it beyond the realm of imagination that a physician like you could prescribe dog therapy?

[Cmdre Hans Jung]

I would never say I would prescribe it. What I would say as a private practitioner is if they can find a charitable organization that is willing to provide these services, by all means go ahead. I know OHIP is not paying for any of that. I'm pretty sure OHIP doesn't pay for dogs either. The CNIB or other organizations do that. There's a difference between what the public and the taxpayer should pay, because the problem is precedent, and where do you draw the line? If a horse is good for someone and maybe a lion is good for someone else and a trip is good for another person, you cannot run a policy—

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

I buy the argument. I understand where you're going. I think your analogy that dogs are being provided by the CNIB is good. What disturbs me is a certain rigidity, and correct me if I'm wrong, with respect to seeking empirical evidence for these kinds of alternate therapies. I know practising physicians are probably some of the most conservative people you ever want to meet, and frequently they do things because that's what they were taught in medical school, and yet the world has moved on. I'll leave that.

The second thing I wanted to talk to you about in providing direct therapy to soldiers and veterans now, is the uniqueness of your position, particularly when at one level you understand the people who are walking through your door in a way that no civilian physician could understand them. What is it about the warrior mentality, if you will, that requires unique therapy or whatever, when the warrior is injured?