Public Accounts Committee on Feb. 25th, 2015

[The Chair, NDP, David Christopherson]

I now declare this 48th meeting of the Standing Committee on Public Accounts in order.

Colleagues, before we move to the orders of the day, perhaps I could ask your indulgence for approval for a short business meeting afterwards. We have some scheduling that I need to run by you for approval. So, with your agreement, at the conclusion of our questions I'd like to move into a business meeting. It shouldn't take too long. I guess we're in agreement. I don't see anybody violently opposed so I assume we're good on that.

Therefore, we'll now turn our attention to the matter at hand. Welcome to all of our guests. We're here to study chapter 3, “Mental Health Services for Veterans”, of the fall 2014 report of the Auditor General of Canada. The Auditor General couldn't be here but his capable and renowned assistant auditor general, Mr. Berthelette, is here.

Sir, we will begin with your opening remarks. You now have the floor.

[Jerome Berthelette, Assistant Auditor General, Office of the Auditor General of Canada]

Thank you, Mr. Chair, for this opportunity to discuss chapter 3, “Mental Health Services for Veterans”. Joining me at the table is Dawn Campbell, the director who is responsible for the audit.

As of March 31, 2014, about 15,000 veterans were eligible to receive mental health support from Veterans Affairs Canada through the disability benefits program. An additional 1,000 veterans in the department's rehabilitation program self-identified as having a mental health condition. The proportion of the department's disability benefits clients with mental health conditions has increased from less than 2% in 2002 to almost 12% in 2014.

Our objective was to determine whether Veterans Affairs Canada had facilitated timely access to services and benefits for veterans with mental illness. We focused on the timeliness of eligibility decisions made by Veterans Affairs Canada. We did not assess the appropriateness of the decisions made or the quality of care received.

For eligible veterans, the department pays for various mental health services not covered by provincial health plans. These services can include specialized psychological care, residential treatment, and some prescribed medications.

We found that Veterans Affairs Canada has put in place important mental health supports. These included operational stress injury clinics, a 24-7 telephone service, and the operational stress injury social support program. However, in many cases the department was not doing enough to facilitate veterans' timely access to mental health services and benefits.

The rehabilitation program provides access to mental health care support for those veterans who are having difficulty transitioning to civilian life. Eligibility requirements are less stringent than those for the disability benefits program, but treatment and benefits end once a veteran completes the program. We found that Veterans Affairs Canada was meeting its service standards for providing timely access to mental health services through the rehabilitation program.

The disability benefits program provides lifelong access to benefits and requires that veterans provide evidence that they have a permanent mental health condition that was caused or aggravated by military service. We found that from the veterans' perspective about 20% had to wait more than eight months from the first point of contact for the department to confirm their eligibility to access the specialized mental health services paid for by the department.

Veterans Affairs Canada needs to do more to overcome the barriers that slow down the decision as to whether veterans are eligible for support provided through the Disability Benefits Program. These barriers are a complex application process, delays in obtaining medical and service records from National Defence and the Canadian Armed Forces, and long wait times for getting access to mental health care professionals in government-funded operational stress injury clinics.

We noted that 65% of veterans—843 of 1,297—who challenged denial of eligibility decisions for disability benefits were successful. While the department knows that most successful challenges rely on new information or testimony, it has not analyzed how the process could be improved to obtain this information prior to rendering decisions upon first application.

In this audit, we also looked at what Veterans Affairs Canada is doing to increase awareness among various stakeholder groups of the supports it makes available to veterans. We found that the department delivered a variety of outreach activities that target its existing clients and soldiers being released from military service.

However, it could have done more to reach other groups who can encourage veterans to seek help, in particular family doctors and families of veterans.

Veterans Affairs Canada agreed with our recommendations. An action plan was posted on the department's website. Its implementation deadlines range from December 2014 to March 2016.

Mr. Chair, this concludes my opening remarks. We would be pleased to answer any questions the committee may have.

Thank you.

[The Chair, NDP, David Christopherson]

Very good. Thank you.

l would ask our guests, if you have colleagues with you, would you be kind enough to introduce them as you make your opening comments?

We'll move to Monsieur Michel Doiron from the Department of Veterans Affairs. You have the floor, sir.

[Michel D. Doiron, Assistant Deputy Minister, Service Delivery, Department of Veterans Affairs]

Thank you, Mr. Chair.

Good afternoon. I am Michel Doiron, Assistant Deputy Minister of Service Delivery for Veterans Affairs Canada. I have been in this position for just over a year, and this is my first appearance before this committee. Thank you.

Joining me today is our director general of health services, Dr. Cyd Courchesne. Dr. Courchesne leads, nationally and virtually overseas, a VAC team of health professionals at Veterans Affairs Canada. She and her team provide expert advice, guidance, and direction to me and to VAC senior management. She is also responsible for a national operational stress injury network within VAC.

Mr. Chair, as you are aware, mental illness indirectly affects all Canadians, sometimes through a family member, friend, or colleague. The Canadian Mental Health Association says that 20% of Canadians will personally experience a mental health illness in their lifetime. Mental illness affects people of all ages, education, income levels, and cultures. Our veterans, as well as our men and women in uniform, are not immune to mental illness.

In the fall report, the Auditor General looked at how Veterans Affairs was managing access to mental health services for veterans. The audit aIso examined: joint initiatives, the transfer of military records by National Defence and the Canadian Armed Forces, and information on reviews and appeals by the Veterans Review and Appeal Board.

The audit focused on three lines of enquiry: facilitating access to mental health services, providing mental health outreach, and managing the Mental Health Strategy.

The Auditor General raised key points, and we are thankful for his valuable insight and important observations. Having that independent assessment is absolutely essential in helping the department move in the right direction to improve our delivery model and place support where our veterans, men and women in uniform, and their families need it most. To that effect, my department has put into place the mental health services for veterans action plan, and I believe you have been given a copy of that action plan.

The action plan focuses on five priority activity areas: providing timely access to psychological and psychiatric assessment and treatment; reducing barriers to timely access to disability benefits; identifying trends to overturn decisions; ensuring that outreach activities are comprehensive; and measuring the effectiveness of the mental health strategy.

The plan identifies commitment under each of these five areas, and numerous advances and improvements have already been made. To name a few, the number of psychological counselling sessions that veterans, their families, and caregivers are allowed access to has increased up to 20 sessions per issue from eight sessions, and that was effective December 1.

Along with the Mental Health Commission of Canada, a mental health first aid program has been established for veterans and their families, providing them with the tools needed to be better equipped to recognize and deal with mental health issues.

In terms of investment to our operational stress injury clinic network, OSI clinics in satellite locations provide critical assessments, diagnostics, and treatment services to those dealing with operational stress injuries such as post-traumatic stress disorder. This investment will help us accelerate access to mental health services for our veterans and will include a new clinic in Halifax in 2015.

We already streamlined our disability benefit application package last October, but we are also streamlining the process. This includes the adjudication of benefits for post-traumatic stress disorder using a new evidence-informed decision model, which results in faster decisions.

Close work with our colleagues from the Canadian Armed Forces to improve timeliness of access to disability benefits and reduce the seam and transition support between serving and civilian life.... This is managed through our Veterans Affairs Canada-CAF steering committee, and through our approximately 100 VAC employees co-located with the CAF at integrated personnel support centres on or near bases or wings across Canada.

We will communicate with the Veterans Review and Appeal Board to better understand why disability benefit claims are overturned by identifying trends. This information will be used to improve policies in the decision-making process.

A pilot four-year military family resource centre will allow medically releasing veterans and their families access to support and services at seven military family resource centre sites across Canada. This will help us identify future needs and the best approach in the future.

Lastly, our operational stress injury social support program will be strengthened with 15 more peer-support coordinators—and there will be more—focused on direct outreach to veterans.

Those are the highlights of our mental health action plan. I assure you that we are fully committed to further improving the system so that veterans and their families receive the care and support they need now and in the future.

Thank you again for the opportunity, Mr. Chair. Dr. Courchesne and I look forward to questions.

[The Chair, NDP, David Christopherson]

Very good. Thank you so much.

We will move along now to the surgeon general of the Canadian Forces health services, Brigadier-General Bernier.

You now have the floor.

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

Mr. Chairman and members of the committee, as Surgeon General, I thank you for the opportunity to speak to you about the measures being taken by the Canadian Armed Forces to address the two recommendations made by the Auditor General in chapter 3 of his 2014 report, entitled Mental Health Services to Veterans.

These recommendations relate to timely access to psychiatry and psychology assessments at specialized Operational Trauma and Stress Support Centres, or OTSSCs, and the accelerated transfer of medical records to Veterans Affairs Canada.

Also with me today is the Canadian Forces director of mental health, Colonel Andrew Downes, MD.

Access to mental health care is impacted by the demand for care, available clinician resources, and the efficiency of practices. We don't want to limit or control the demand for care but on the contrary do everything we can to encourage those who need care to come forward. We must therefore focus on maximizing clinician resources and the efficiency of our practices in striving to minimize wait times. In doing so we must be careful to avoid compromising other aspects of care such as its quality, basis of evidence, and collaborative approach.

To measure access to mental health care the Canadian Forces health services group applies the widely accepted metric of the third next available appointment. This is considered a more sensitive reflection of true appointment availability than the first or the second next available appointments because those metrics are more affected and skewed by cancellations and other unexpected events. The third available appointment, however, does not necessarily reflect the patient's actual experience. It can often overestimate true wait times since referrals scheduled for the first and second available appointments are seen sooner, particularly when there are cancellations.

The third next available appointment metric also only applies to routine referrals. Cases that are clinically deemed to be urgent are seen much sooner, and virtually all patients awaiting OTSSC assessment are under the mental health care of a primary care physician, and in some cases, a psychologist or psychiatrist from a clinic's General Mental Health Section.

OTSSCs provide monthly reports on the average wait time between receipt of a routine referral and the third next available appointment for an initial diagnostic psychiatry or psychology assessment. Our benchmark target is no more than 28 calendar days. Although few civilian health facilities achieve this target, we pursue it in accordance with the recommendations of the Canadian Psychiatric Association and the national Wait Times Alliance.

In 2014, four of the seven OTSSCs provided an annual average third next available appointment within that benchmark. The other three experienced longer wait times, averaging 49 days among them, primarily due to staff absences for such things as extended sick leave and parental leave.

By January 2015—this year—only one centre exceeded the benchmark and then by only two days.

In 2014 the Canadian Armed Forces was authorized to hire an additional 54 mental health staff. Of these, 21 were for clinics with operational and trauma stress support centres. As of mid-January 2015, 94% of our 455 authorized mental health positions were filled and efforts continue to fill the remaining vacancies. This is a dynamic challenge affected by normal staff turnover, heavy competition with the civilian sector for mental health professionals, and difficulty recruiting personnel to certain non-urban locations.

We're in the process of installing high definition secure video teleconferencing systems in our mental health clinics to help balance short-term increased demands for care in one location, with staff capacity available in other locations. This will also reduce travel requirements for our patients in outlying locations and improve their continuity of care when they're posted to a new location.

To improve efficiency and quality of care, we have hired a mental health quality and patient safety officer to review business practices in the clinics and help establish additional performance measurement metrics.

We will also soon implement the electronic mental health record and a digital outcome measurement system called CROMIS. This system, which is also used by mental health clinicians contracted by Veterans Affairs Canada, will allow for early identification of people not responding well to treatment, thereby prompting the clinician to adjust the treatment.

With respect to the transfer of medical records to Veterans Affairs Canada, Canadian Forces health services group has been working jointly with VAC for a year on a project to accelerate the file transfer process. In particular, VAC and DND have created a 14-person records disclosure team with the sole focus of expediting files between the two departments, and they have established a full-time VAC adviser within that records disclosure team to provide timely and expert advice on VAC requirements.

A second team has been established to address the backlog of outstanding files due for transfer to VAC. Through their joint efforts, the backlog has been reduced by almost 50% and the overall process has become increasingly effective and efficient. We monitor the process daily and are constantly striving to pursue innovative business practices to provide the best possible service to both our serving and retired personnel.

Thank you for your attention, and I'll be happy to answer any questions you may have.

[The Chair, NDP, David Christopherson]

Very good. Thank you.

That concludes opening remarks, and colleagues, unless someone has a good reason why we shouldn't, we'll now begin with the regular rotation process, beginning with Mr. Hayes.

You, sir, now have the floor.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

Thank you, Mr. Chair.

My questions will be directed to the Auditor General's department, and I'll specifically focus on sections 3.25 to 3.29 in the report, about eligibility decisions under the disability benefits program not being timely. I really want to dig into that a little bit and make sure I understand the numbers.

It's my understanding that there are basically two streams, in terms of these. There's the veteran's perspective, so there's a process leading up to the application; and then there's the perspective of the department, which is once the application is received, then that's a stream as well.

I want to focus on the application being received. There's a standard that says the target rate is 80%. In your opinion, is that a reasonable target rate, to process 80% of the applications within a 16-week time period?

[Dawn Campbell, Director, Office of the Auditor General of Canada]

We did take a look at what standards were in place in other jurisdictions and we couldn't find anything that was comparable, and into that come different complexities in terms of the application process, etc. So for that reason, we essentially evaluated against the standard that the department had set.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

Within the rehabilitation program, that standard was also 80% being achieved, so 80% seems to be a reasonable target.

That being said, during that timeframe the department achieved 75% of that 80% target, which I think is pretty significant. You further state that it means that, of the 2,893 applicants in 2013-14, 733 veterans did not receive a decision within the 16-week standard. When you really extrapolate that, 733 weren't really expected to. If the standard was 80%, 600 were therefore not expected to receive treatment within that 16-week period. So there were really approximately 133 people who fell outside of the 80% standard.

Would that be a reasonable assumption?

[Dawn Campbell]

Yes. I think the other thing that has to be considered as well is that the measurement is taken at the point in time at which the application is deemed complete.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

Absolutely, and I'll get to the other stream later on.

Within those 733 people, or really the 144 who fell outside of the standard, if we were to go to section 3.29 of the report, some analysis was done and it basically said that you tracked 47 veterans who were on the waiting list, per se, and that:

We found evidence that 17 of these veterans received mental health care while waiting for an eligibility decision.

We can sort of extrapolate from that and there is knowledge that there are another 19 veterans who you really didn't know whether they were receiving mental health treatment within DND.

Even in the worst-case scenario, 36% of those people waiting for treatment were actually receiving some form of mental health care along the way. I just want to clear this perception. Be it 733 who were waiting, or be it 1,000 who were waiting, at least 37% of those, according to your statement in section 3.29, were receiving some form of mental health treatment while they were waiting to determine their eligibility.

[Jerome Berthelette]

Perhaps I could make two points in response to that observation.

I think the first point is that for approximately 60% of the veterans implicated in this statistic, Veterans Affairs didn't know if they were or were not receiving services.

The other point is that getting services to individuals who have acknowledged that they need mental health services is and should be a priority of the department. As I said, when we look at whether it's the standard of 16 weeks or if we look at the number who have actually received a decision within 16 weeks, the point we should not forget is that veterans are looking for the service and Veterans Affairs needs to set up a process that allows veterans to access the services as quickly as possible.

In our view, and from what we have seen, that wasn't the case because, as we note in exhibit 3.5, to get to the 80% mark—and that is at page 10—it took 32 weeks from the perspective of the veteran who is looking for services.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

Can you give me a sense of the 16 weeks? The department can answer that.

I'm really trying to understand the benchmark from the department's perspective and from your perspective. There is no province that I'm aware of that even reports wait times for mental health services. To me, that 16 weeks or 32 weeks might be very reasonable with respect to the private sector. I did as much research as I could to actually find wait times and that is an issue with mental health across Canada, the reporting of wait times. There doesn't seem to be a benchmark.

[Jerome Berthelette]

I think it's true. I think there have been issues reported about wait times in the provincial health care system.

But in this case what we're talking about is not the provincial health care system but Veterans Affairs Canada, which has set a standard of 16 weeks from the time the file was complete. That's what we assessed Veterans Affairs Canada against. When veterans make application for mental health services that's what they expect in terms of a return in terms of the decision to get access to services.

Still, that being said, from the perspective of a veteran, for the reasons we've identified in this audit, it takes a lot longer than 16 weeks.

[The Chair, NDP, David Christopherson]

Thank you. Time has expired.

Moving now over to Mr. Allen, you now have the floor, sir.

[Malcolm Allen, NDP, Welland, ON]

Thank you very much, Mr. Chair.

I appreciate the comments. Thank you all for coming, by the way.

To my friend across the way whose comments were about provincial wait times, it seems to me that the dilemma in the provincial health care system is that one might go to a GP for mental health care, not necessarily to a psychologist or a psychiatrist, so no one knows how long you really wait to see a psychiatrist if your GP treats you, because quite often that's what happens.

For minor mental health awareness you go to somewhere like the Canadian Mental Health Association, around which I have a lot of personal knowledge because my wife worked for them for 25 years. Quite often there are different agencies in different places so you're not actually waiting, you're actually just going....

Mr. Berthelette, in questioning you were trying to talk about the wait times and the standards. If I understood you correctly, it's really the department that set a standard of 80%, which is really what they believe is fair or is a reasonable standard to try to maintain. Is that what you're telling us?

[Jerome Berthelette]

Yes, that's what I was trying to say.

[Malcolm Allen, NDP, Welland, ON]

If I thought 90% was a better standard, that would be my opinion about what I think is the better standard. I'm not suggesting the department doesn't want to do 100%, Mr. Doiron, that's not what I'm suggesting at all. I understand you have to pick a number, you have to benchmark somewhere. My preference would be that you benchmark a little bit higher.

But I think Mr. Berthelette, in this particular chapter, you pointed out that although the department has said that 80% in the 16 weeks is their benchmark, for the actual client—and I will say patient in this particular case—who happens to be a veteran or a serving member, they don't see 16 weeks as being the outcome. Is that what you're telling me in page 9, at exhibit 3.4?

[Jerome Berthelette]

Yes, that's what I'm trying to say. We did this audit looking at the wait times from the point of view of the veteran making the application.

[Malcolm Allen, NDP, Welland, ON]

To be frank, it seems to me that if I'm the person waiting for service, although a benchmark might be established internally in a department, if I wait 32 weeks, I'm 16 weeks beyond the benchmark, in my mind. Is that what this is telling me? Is that what veterans said to you when they waited 32 weeks? It doesn't say they said it exactly like that, but they said 32 weeks. They didn't seem to think they were inside the benchmark if it was double the time.

[Dawn Campbell]

If I can just clarify, too, the wait times we were looking at were the length of time it takes to get an eligibility decision, just so that we're not confusing that with how long a particular veteran would wait to obtain medical services.

[Malcolm Allen, NDP, Welland, ON]

Yes.

[Dawn Campbell]

Okay, so that's just for them to get the approval—

[Malcolm Allen, NDP, Welland, ON]

Eligibility.