Public Accounts Committee on Jan. 31st, 2008

[The Chair, Liberal, Shawn Murphy]

I'd like to call the meeting to order. I want to extend a warm welcome to everyone. Bienvenue à tous.

Today, colleagues, we're here to deal with chapter 4, “Military Health Care--National Defence”, as set out in the October 2007 report of the Auditor General of Canada.

I'm very pleased that we have with us Sheila Fraser, the Auditor General of Canada. She's accompanied by Hugh McRoberts, assistant auditor general, and Wendy Loschiuk, principal.

We also have, from the Department of National Defence, Major General Walter Semianiw, the chief of military personnel; and Brigadier General Hilary Jaeger, commander of Canadian Forces health services group, director general health services, and Canadian Forces surgeon general.

On behalf of the committee, I want to extend a warm welcome to all.

I'll turn it over to you, Mrs. Fraser. I understand you have a few opening comments.

[Sheila Fraser, Auditor General of Canada, Office of the Auditor General of Canada]

Thank you, Mr. Chair.

We thank you for this opportunity to present the results of chapter 4 of our October 2007 report, “Military Health Care--National Defence”. As you mentioned, I am accompanied by Hugh McRoberts, assistant auditor general, and Wendy Loschiuk, principal responsible for our audits of the Department of National Defence.

At the time of our audit, National Defence and the Canadian Forces were providing medical and dental care to over 63,500 Canadian Forces personnel on 37 military installations across Canada and abroad. Members of the Canadian Forces are excluded from the Canada Health Act. The provision of their health care falls under the National Defence Act. If a military member needs medical services, it is the responsibility of National Defence to ensure that the services are provided. National Defence spent about $500 million on medical and dental care for its members last year, and costs have been rising.

In this audit we looked at how National Defence ensures that its military personnel in Canada receive quality health care. We did not look at medical care outside of Canada on deployments such as Afghanistan, nor did we do an assessment of medical treatment or practices.

We found that National Defence needs better information to manage its health care system and to help monitor whether it is delivering quality medical care to military personnel that is appropriate to needs. We also found that National Defence needs more information to better assess the performance and cost of the military health care system.

In this regard, our audit identified three main issues: first, the lack of health care information to monitor and measure performance; secondly, the need to better demonstrate the link between service delivery and the rising cost of military health care; and finally, the need for better governance and oversight.

First, I think it is important to note that military members themselves, when surveyed by the Department, said that overall they were satisfied that the military health care system responded to their needs. National Defence has been improving access to medical care and the continuity of care for its military personnel as part of its ongoing Rx2000 reforms.

On the issue of health care information, the Canadian Forces Spectrum of Care policy states that it is committed to providing Canadian Forces members with health care comparable to that which other Canadians receive. But we found that National Defence was unable to demonstrate how it assured itself that the care it was providing met its standards and expectations of quality health care practices.

We found that, with the exception of mental health standards, 35% of the Department's policies on standards of care were out of date. These policies are used to define the current and accepted practices that medical professionals are to follow when providing patient care, and they can help to ensure that members get appropriate care wherever they are posted.

We were concerned about the lack of information needed to ensure that only licensed and certified military medical professionals were treating patients. The Department has informed us that it is working on documenting the status of its health care professionals and developing a policy on mandatory maintenance of a provincial licence. Your committee may wish to ask the Department for an update on progress.

Furthermore, the military health care system expects its medical professionals to maintain their skills, and to support this, the Department has instituted the Maintenance of Clinical Skills program. Maintenance of skills is a requirement for the delivery of quality health care. Again, however, we found that the Department does not have the information it needs to monitor the success of this program—that is, to determine whether military medical staff are using the program to get exposure to a full scope of practice outside the military clinics. Because of this lack of information, we conducted a survey and found that few military medical professionals were completing the program. Your committee may wish to ask the Department about its progress on developing a tracking tool to monitor the maintenance of clinical skills,

The second main issue that we identified was the rising cost of the military health care system. Here we also found that National Defence lacks information to determine whether levels of service for its medical clinics are appropriate according to needs and to analyze whether the costs are reasonable.

For example, we found that in comparison with average provincial per-patient costs, National Defence costs are higher. The department has not developed a performance measurement system that would clearly measure what its health care system is achieving and at what cost. The department does have some indicators, but often information must be pulled together as needed, and it is still difficult to get an overall picture of the health of Canadian Forces members.

National Defence is working on an information system, and the committee may wish to be kept up to date on progress.

Third, we found that ten years after the department had identified a need to provide oversight of its health care system, there is still no mechanism that brings together all stakeholders to provide guidance and a basis for accountability. There is a need to bring together senior management responsible for providing health care, representatives for the military members using the services, and the senior military leaders who need to have healthy personnel to meet operational requirements.

Mr. Chair, National Defence has agreed with our recommendations and has developed an action plan to address the concerns raised in this report. I am pleased to see that the department has defined the outcomes it is working towards in the action plan and has set target completion dates. The committee may wish to have the department report on its progress and the results it is achieving.

This concludes my opening statement. We would be pleased, Mr. Chair, to answer any questions the committee members may have.

Thank you.

[The Chair, Liberal, Shawn Murphy]

Thank you very much, Mrs. Fraser.

And I'm now going to ask Major General Semianiw for his opening comments, but before I do that, am I pronouncing your name close to correct?

[Major General Walter Semianiw, Chief of Military Personnel, Department of National Defence]

Yes, you are, Mr. Chair.

Mr. Chairman, members of the committee, Madam Auditor General of Canada, ladies and gentlemen, I am Major-General Walter Semianiw, Chief, Military Personnel. I am accompanied by Brigadier-General Hilary Jaeger, the Surgeon General of the Canadian Forces.

In my capacity of Chief, Military Personnel— I am an infantry officer, not a doctor—I am responsible for the CF health care system, while Brigadier-General Jaeger is, in addition to being the Surgeon General, also the Director General, Health Services, and the Commander of the CF Health Services Group.

It's indeed a pleasure and a privilege that we're both here today to appear before you in order to address the Auditor General's report on military health care.

More importantly, we're here today to outline those activities we are currently undertaking to improve health care for our sailors, soldiers, airmen, and airwomen at home and abroad that address the recommendations in this report.

Firstly, as already noted by the Auditor General, the department fully accepts the recommendations outlined in this report. Our view is that the report is a fair and balanced assessment of the state of a military health care system in transition.

As a number of you are aware, Rx2000 and the Canadian Forces health information system programs represent very significant reforms that began in the year 2000. Granted, work remains to be done to fully implement these programs and to continually improve care. Nevertheless, we are fully confident that many of the initiatives already under way as part of those two programs will serve us well in addressing not only the Auditor General's recommendation but more importantly the building of a modern patient-focused military medical system.

Next I would like to acknowledge the comments of the Auditor General where she noted that previous concerns about accessibility and continuity of care have been addressed by Canadian Forces health care reform, that a high percentage of Canadian Forces personnel are satisfied with the health care they receive, and that the new model for health care is considered a best-practice approach.

Indeed, many of the changes undertaken by the Canadian Forces health services reform, such as collaborative practice and electronic health care records, were advocated in the 2002 Kirby report entitled “The Health of Canadians: The Federal Role” and the 2002 Romanow report entitled “Building on Values: The Future of Health Care in Canada”, and they continue to be supported by the Health Council of Canada.

As you are all well aware, the report itself makes eight recommendations centred on four key themes. Allow me to make a few comments relating each of these themes to the provision of high-quality health care to the men and women in uniform.

The first area of concern is that of cost. All Canadians certainly understand that health care is expensive. Providing a very comprehensive range of services for a relatively small population across national and international boundaries and subsequently meeting the CF needs and expectations as well as those of its personnel when illness and injuries occur costs more than providing a less comprehensive range of services to a more static and more centralized population. A health care system such as the Canadian Forces is therefore more expensive.

The Canadian Forces health services group runs a public health care system that has an education organization that delivers essential professional development. The Canadian Forces health services group also provides unique occupational and environmental health care that must be prepared to operate effectively under hostile conditions in any climate and terrain in the world, and it experiences frequent extraction of its health care providers for associated training and tasking requirements. But the Canadian Forces believe that it is not just a cost but also an investment that is worthwhile not only in meeting our obligations to the Canadian Forces personnel, the men and women in uniform for this nation, but as a means of fostering operational capability.

As noted by the Auditor General in a 1990 review of the health services, willingness to fight is influenced by members' general state of health and by their confidence in the health system's ability to provide prompt evacuation and treatment of casualties.

I was pleased to note that Madame Fraser recognizes these unique military health system requirements and acknowledges that drawing a direct comparison with the cost of running a civilian health care system is indeed difficult. While the Canadian Forces health services currently capture significant cost data, full implementation of the Canadian Forces health information system will help to refine further analysis of the relative impact of different cost drivers.

The next area of discussion is performance measurement. A number of Office of the Auditor General recommendations revolve around choosing performance indicators, setting standards of care, and measuring activities against these standards and indicators.

A recently instituted Canadian Forces health services performance measurement advisory group has begun to develop a performance measurement framework to define applicable performance indicators into set benchmark standards and reporting requirements. The list of indicators chosen will be in keeping with the pan-Canadian primary health care and population health indicators that were recently developed in consultation with the Canadian Institute for Health Information.

It's worth noting that Canadian Forces health services will be among the organizations taking a lead in institutionalizing these practices in a multidisciplinary primary care setting.

The third concern that needs to be addressed is the accreditation of health care providers. As part of the Rx2000 reforms, it was decided to reinstitute external accreditation of CF health services. As part of this process, a Canadian Forces national credentialing cell was recreated in mid-2007. To date the cell has achieved license verification for 100% of physicians and dentists, 96.7% of pharmacists, and 79.9% of nurses. A new Canadian Forces credentialing policy is set for release in February 2008.

Let me now turn to governance of the Canadian Forces health care system. It's not the sole purview of the providers of health care and services to determine which medical and dental services, treatments, and items should be provided at public expense to entitled personnel. After a review of the terms of reference for the spectrum of care review committee, which makes health care entitlement determinations, I sought and received approval to raise the level of oversight of this committee to the leadership of the Canadian Forces.

Having the Armed Forces Council, the leadership of the Canadian Forces--the Chief of Defence Staff, the Vice-Chief of Defence Staff, the Chief of the Air Staff, the Chief of the Maritime Staff, and the Chief of the Land Staff--make decisions about Canadian Forces personnel health care entitlements will help Canadian Forces health services ensure that costs incurred are indeed related to patient requirements and operational needs.

Mr. Chairman, members of the committee, Auditor General, ladies and gentlemen, this completes our introductory remarks.

Thank you.

[The Chair, Liberal, Shawn Murphy]

Thank you very much, Major General Semianiw.

We're now going to go to the first round. I believe that we have time for an eight-minute first round.

Mr. Wrzesnewskyj, you have eight minutes.

[Borys Wrzesnewskyj, Liberal, Etobicoke Centre, ON]

Thank you, Mr. Chair, and I'd like to thank the witnesses for coming before us today.

My questions are for the witnesses from the Canadian Forces.

As we know, Afghanistan is an extremely stressful environment. Many returning soldiers have had the difficult experience of seeing their brothers in arms or sisters in arms suffer the loss of limb or life, or the horrific experience of seeing civilians caught in crossfire.

What percentage of soldiers who return...? First of all, I assume that all soldiers, upon their return, are screened to assess their state of mental health. If that is in fact correct, that all soldiers returning have an assessment done of their mental health, what percentage return with mental health issues such as post-traumatic stress?

[Brigadier General Hilary Jaeger, Commander, Canadian Forces Health Services Group, Director General, Health Services, and Canadian Forces Surgeon General, Department of National Defence]

Thanks for that question.

In fact we are watching the mission in Afghanistan and its effect on the overall health of our soldiers, particularly the mental health of our personnel, very closely.

We have a well-developed process in place to assist them while in theatre. A psychiatrist, a social worker, and a mental health nurse are deployed with the task force at all times to provide service in theatre and to stay abreast of the general state of morale and mental health of the troops deployed.

The soldiers go through a process known as third location decompression. That's a bit of jargon. All it means is that they're given some time to rest and recuperate in a place that is neither the theatre of operations nor their home base. So it's a third place, and it's currently in Cyprus.

While there they undergo a period of four to five days of rest and what we term psycho-education. These are briefings on what to expect with the transition from Afghanistan to home life. What is the normal set of experiences during that transition, and what are the warning signs that things may not be progressing normally? They're also given instructions on the many ways to access both health care and non-clinical support services through the operational stress injury social support program. All our soldiers clearly understand that help is available and know where to get it.

The most elaborate follow-up is done four to six months afterwards. That's because we want some time for the differing emotions related to return to settle down. There's euphoria. There's perhaps some disappointment. There are a whole lot of conflicting things.

The data collection is still ongoing. Of course every rotation is a little bit different, but the data we have so far from these four- to six-month detailed screening follow-ups suggest that about 27% of people coming back have some difficulties. The vast majority, about 16%, have hazardous drinking behaviour. So more than half of that 27%--16% of the total deployed--show hazardous drinking behaviour. But an important number of people are struggling with more serious mental health issues, depression and post-traumatic stress disorder being the two most notable.

[Borys Wrzesnewskyj, Liberal, Etobicoke Centre, ON]

Thank you.

[MGen Walter Semianiw]

Mr. Chairman, maybe I could just kind of build on it and give it a finer point.

In 2005 I commanded Canadian military operations in Afghanistan for six months. Prior to deployment, there was screening of my soldiers, sailors, airmen, airwomen, and myself. We had the mental health care providers with us to watch, and a place where people could go and talk if issues came up, to see what was happening. At the same time, prior to leaving we did screening. Then they go through the third location decompression. Then once we're back home, we do it again.

Having gone through all of that, there are three stops or checks now in that process to ensure that we try to capture as many individuals as possible and help them through the process.

[The Chair, Liberal, Shawn Murphy]

I would just make a comment before going back to Mr. Wrzesnewskyj.

We're dealing with a very important issue, and I appreciate the attendance of everyone here. I should have mentioned this in my opening remarks, but I'd ask all questioners to keep your questions succinct and relevant to the report, and I'd ask all witnesses to be very brief and relevant in your answers, so that we can cover as much material as is necessary.

Mr. Wrzesnewskyj.

[Borys Wrzesnewskyj, Liberal, Etobicoke Centre, ON]

Thank you, Chair.

So 100% of all soldiers get screened, and it appears that 27% have some form of mental health issue, including issues of substance abuse, and 16% of those have issues of substance abuse.

What is the concrete number, as opposed to a percentage? How many thousands? If we take all those rotations, how many soldiers who have served in Afghanistan are facing mental health issues? Do we have a number, or can you extrapolate a number for us?

[BGen Hilary Jaeger]

If I were to give you a number, it would be an extrapolation based on multiplying percentages times the number of people, and that's not where I'm at. To link it to the Auditor General's report, I do not have a data collection system with which I can look across the Canadian Forces and ask, “How many active patients do we have right now with post-traumatic stress disorder?” I can't say that.

[Borys Wrzesnewskyj, Liberal, Etobicoke Centre, ON]

If 27% suffer and we have rotations, potentially there are thousands of soldiers out there. We saw that 85%, when they were questioned, were quite happy with the medical services they received. However, 75% of soldiers did not feel that they received adequate support or help with mental health issues.

What is being done to address, potentially, thousands of soldiers out there who are suffering in silence, or agonizing? That's not acceptable, that 75% number, that three out of four suffering soldiers are not getting the help they deserve.

[BGen Hilary Jaeger]

Thanks for the opportunity to clarify. That 75% number comes from a survey we commissioned Statistics Canada to do on our behalf in 2002, which was before we implemented the changes under the Rx2000 reform. I would expect that were we to repeat that survey—which we have plans to do in the future, but that's probably not going to happen for a couple of years—that number would be vastly improved.

[Borys Wrzesnewskyj, Liberal, Etobicoke Centre, ON]

You touched on something else: soldiers with issues of substance abuse. Major General Walter Semianiw had mentioned that you pre-screen as well. As regards people with substance abuse problems, he said 16% of returning soldiers have these sorts of problems. What percentage have these problems going into Afghanistan?

[BGen Hilary Jaeger]

I'd like to clarify, concerning the 16%, the hazardous drinking behaviour, that has not necessarily reached the threshold of substance abuse nor of alcoholism or other drug dependency. Those who work in the public health field will recognize hazardous drinking behaviour as any regular consumption of more than two drinks per day on average for males, and more than one drink per day on average for females. It's a fairly low threshold as a possible warning sign.

[Borys Wrzesnewskyj, Liberal, Etobicoke Centre, ON]

I see. So what percentage would be at that higher threshold, that perhaps it's not just alcohol but there's other substance abuse? And if they're screened ahead of time, are they removed from combat missions?

[BGen Hilary Jaeger]

We do not routinely ask the alcohol screening questions in that kind of context, pre-deployment. We do have a program for safety-sensitive drug testing, which is not part of my purview; it's not a health services function. All people going into theatre are screened for other drugs of abuse.

[MGen Walter Semianiw]

To respond further to the question, the Canadian Forces, the department, has put a new program in place composed of three parts. It has been announced in Canadian Forces and actually been made public.

The first is that we conduct safety sensitive testing of soldiers, sailors, airmen, and airwomen going into a theatre of operations. This is not just Afghanistan but into a theatre of operations. Clearly, if it is found that there are issues, they are removed. It has been done. We have removed individuals. The leadership has removed them--not doctors, but the leadership--for failing to meet the bar that we require individuals to meet in order to be safe and to be able to do what they need to do in combat.

Secondly, we've just begun blind testing across the Canadian Forces, randomly going across the Canadian Forces to draw some data.

Where we are moving in the future, in one year we'll be...to do testing as we see fit across the Canadian Forces, to additionally build on the policy and to address the issue that you raise.

[The Chair, Liberal, Shawn Murphy]

Thank you, Mr. Wrzesnewskyj.

Monsieur Laforest.

[Jean-Yves Laforest, Bloc, Saint-Maurice—Champlain, QC]

Thank you, Mr. Chairman.

Good day to all of you and thank you for joining us. My question is for the CF representatives. The audit conducted by Ms. Fraser's office looked into how many military personnel were under the care of a mental health professional. According to the report, DND was unable to provide an answer to that question.

You stated that you did not have a data base. I am very surprised to hear that and very disappointed that an organization as large and important as the Canadian Forces has not yet compiled a data base so that it can, at the very least, give members of the public and parliamentarians an accurate picture of mental health problems in the military. In that respect, I totally concur with Mr. Wrzesnewskyj's question. As I see it, we should be able to get a much more accurate picture of the number of CF members who are receiving treatment.

CF members are on assignment in Afghanistan on an important mission. How many forces members exhibit mental health problems when they return home and what kind of treatment do they receive? What kind of care do they receive to help them overcome their problems? Given your response to the AG and your statement today to the effect that you do not have a data base, are you not in fact saying that you do not want to disclose the real numbers? I think it is important for us to have that information.

[BGen Hilary Jaeger]

Thank you, sir, for your question.

I too am anxious to have a system in place that could provide me with that kind of information. Mental health is not the only issue involved. But it is an important question, since the mental health of CF members affects the general population in Canada.

We made a decision in 1995, as part of a re-engineering initiative too find ways of doing more with less. Do you remember that? The Canadian Forces were caught up in this movement, along with the health care system. As a major, I attended a meeting where we discussed which particular initiatives could be abandoned. The decision was made to stop collecting data. We have complete data on a person's medical history, but we do not have a system in place to generate information for management. This information is available on paper, but cannot be computer generated.

[Jean-Yves Laforest, Bloc, Saint-Maurice—Champlain, QC]

If I were to ask you how many CF members exhibit mental health problems when they return from Afghanistan and how many commit suicide, you would not be able to give me an answer. Is that what you're telling me?

[BGen Hilary Jaeger]

We have figures on the number of active CF members who have committed suicide.

[Jean-Yves Laforest, Bloc, Saint-Maurice—Champlain, QC]

And what are these figures?