Mr. Chair, thank you for this opportunity to discuss our audit work relating to the committee's study of service delivery to veterans.
Joining me at the table are Joe Martire, principal, and Dawn Campbell, director, responsible for audits of Veterans Affairs Canada, and National Defence and the Canadian Armed Forces.
For the benefit of new members, I would like to briefly explain the types of audits we are presenting to you today, which are performance audits.
Performance audits examine whether government programs are being managed with due regard for economy, efficiency, and environmental impact. We also look to see if there are means in place to measure the effectiveness of programs. However, while we may comment on policy implementation, we do not comment on the merits of policy, itself.
Since 2012, we have conducted two performance audits that focused on selected services and benefits provided to veterans. Veterans Affairs Canada was also part of a third audit that examined the delivery of online services by federal organizations.
In the fall of 2012, we reported on how National Defence and Veterans Affairs Canada managed selected programs, services and benefits to support eligible ill and injured Canadian Forces members and veterans in the transition to civilian life. We did not look at whether Canadian Forces members and veterans had received all the services and benefits for which they were eligible. Neither did we examine the fairness of departmental services and benefits available, nor the quality of medical treatment and care provided.
There are a variety of support programs, benefits and services in place to help ill and injured members of the military make the transition to civilian life. However, we found that understanding how the programs worked and accessing them was often complex, lengthy and challenging.
The lack of clear information about programs and services, the complexity of eligibility criteria, and the dependence on paper-based systems were some of the difficulties expressed by both clients and staff.
We also found inconsistencies in how individual cases were managed, as well as problems in the sharing of information between the two departments. As a result, forces members and veterans did not always receive services and benefits in a timely manner, or at all.
We found that the interdepartmental governance framework to coordinate, harmonize, and communicate the various programs, services, and benefits available to ill and injured forces members and veterans needed strengthening.
National Defence and Veterans Affairs accepted all 15 of our recommendations, which included streamlining their processes to make programs more accessible for ill and injured forces members and veterans.
In our fall 2014 report, we reported on mental health services for veterans. As of March 2014, about 15,000 veterans were eligible to receive mental health support from Veterans Affairs Canada through the disability benefits program. The proportion of the department's disability benefits clients with mental health conditions had 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 the department. We did not assess the appropriateness of the decisions made or the quality of care received.
For eligible veterans, the department paid for various mental health services that were not covered by provincial health care plans. These services included specialized psychological care, residential treatment, and some prescription medications.
We found that Veterans Affairs Canada had 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, the department was not doing enough to facilitate veterans' timely access to mental health benefits and services.
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 of the disability benefits program, but treatments 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 from the veterans' perspective that 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.
As in 2012, we found that a complex application process, delays in obtaining medical records from National Defence and the Canadian Armed Forces, and long wait times to access mental health care professionals in stress injury clinics continued to be some of the factors that slow down the decision as to whether veterans are eligible for support provided through the disability benefits program.
In addition, we noted that 65% of veterans who challenged denial-of-eligibility decisions for disability benefits were successful. While the department knew that most successful challenges rely on new information or testimony, it had not analyzed how the process could be improved to obtain this information prior to rendering decisions upon first application.
Mr. Chair, Veterans Affairs Canada agreed with our recommendations, and following our report, produced an action plan with implementation deadlines ranging from December 2014 to March 2016.
Lastly, in the fall of 2013, we examined whether the online services offered by some federal organizations, including Veterans Affairs Canada, were client-focused and supported by service delivery strategies with defined and measured benefits. We did not audit service standards.
We found that the government had introduced services to enable individuals to interact online with departments securely. However, multiple steps were required to set up a secure account and then enrol in a program. For example, a retired veteran wishing to interact with the Government of Canada online to access benefits and report taxes first had to set up a secure account and then follow different enrolment processes with Human Resources and Skills Development Canada, Veterans Affairs Canada and the Canada Revenue Agency, or CRA.
While a veteran would have had immediate access to a Veterans Affairs Canada account, the wait time to receive separate security codes in the mail from Service Canada and CRA was 5 to 10 days.
Mr. Chair, we hope the findings in these audits will be useful to the committee in its study. I should note, however, that we have not done other audit work since our reports were presented to Parliament; therefore, we cannot comment on progress the departments have made since then. We encourage your committee to ask department officials what progress they have made toward implementing our recommendations.
Lastly, the committee may be interested to know that on May 3 we will present a report to Parliament on the drug benefits program provided by Veterans Affairs Canada.
This concludes my opening remarks. We would be pleased to answer any questions the committee may have.
Mr. Auditor General, Ms. Campbell and Mr. Martire, welcome to the committee. I am happy to see you here today.
I will preface my first question.
I would like to come back to what my colleague Mr. Eyolfson said earlier. He felt that it was taken for granted that those who were submitting applications were faking, as they had to provide records to support their application if they wanted to receive specific services or benefits from Veterans Affairs Canada.
Mr. Auditor General, military members are under extreme pressure every day. It's an environment where people have to constantly prove themselves to their peers and their superiors. In a way, that's completely normal, as the government asks the Canadian Armed Forces to carry out missions despite sometimes insufficient resources. In addition, senior army officers have to ask their members to meet that requirement.
Here is what I think military members find difficult. The culture of military members having to constantly prove themselves is perpetuated, in a way, when they deal with Veterans Affairs Canada. For example, they have to do research to access their documents in order to prove that they have a service-related injury. I don't know whether this is true, but according to what I have been told, in the United States, the burden of proof lies with the Department of Veterans Affairs, and not the veterans themselves. Mr. Eyolfson also talked about that earlier.
My question is simple. Did you look at the burden of proof system in the United States in your audit? If so, what did you find out? If you did not look at it, what do you think about the burden of proof right now?
Thank you very much for being here today.
When I look at your 2014 report, number 12 in your results, you focused on timely access, timely decisions, and mentioned that you didn't audit whether your decisions were appropriate or the quality of care. I'm looking on this sheet of your sticky notes this morning.
The big question here is whether you think it would be good for us as a committee to recommend an audit in those areas that you didn't audit.
As someone who doesn't have people in my own family involved in the military, when I look at the mandate to improve the seamlessness between DND and veterans, I'm beginning to learn about the culture and the reality. In some ways that very much mirrors professional athletes where you take it for the team and you have to work as a team in spite of the circumstances you're in.
I think a lot of times that's why that ask for help with mental illness takes so long, or to even recognize that they need help.
I've heard over and over again whether or not more should be done preventively or educationally to prepare our soldiers to deal with mental health issues as a possibility in circumstances where they're facing direct combat.
Years ago when I was scuba diving, I faced a very bad situation way down there and survived. I still think about it. That's nothing compared to what our veterans face in combat. We know parachutists will have trouble with their knees. Those who hit a mine or watch their friends die or face a serious injury, can we not assume they need help? Is that help there in advance? Because to me this is one of the things that's the greatest barrier in achieving the ability to transition to civilian life.
Although, as the Auditor General said, we didn't look at that specifically as a separate audit objective, we did look at the services available within the Canadian Forces if someone becomes ill or injured. We spent quite a bit of time explaining that process.
As you pointed out, the context when you're in the military is much different from when you're in civilian life. In the military, the medical system is there. It comes to you. Once you're out, you're making that transition, you're basically a private individual, so it's a help to have those services.
People who are diagnosed as having medical limitations have to go through a process. If they have mental illness, there are trauma units that are available, and there are case workers. They have a whole system. Those services were there. It's what happens when you have those issues and you're identified, how you're supported, and then what happens to you when you transition to civilian life. That's where we found some of the issues back then were problematic, because of the movement from one system to a different type of system.
Good afternoon, ladies and gentlemen. Thank you for the opportunity to appear here today and talk to you about the operational stress injury network.
I'm Dr. Cyd Courchesne. I am the director general of health professionals and the chief medical officer for the Department of Veterans Affairs. I've been in this role since October 2014, after serving 30 years with the Canadian Forces health services.
Here with me is Mr. Michel Doiron—you know him—the associate deputy minister for service delivery, who is also my boss. We also brought along Mr. Joel Fillion, who is our new director of mental health. He's sitting at the back here. He's new to the organization, as of just a few months, and he's still orienting to the department. We want you to meet him, but we thought we'd spare his having to.... Also, as mentioned, we have with us Dr. David Ross. Dr. Ross is the operational stress injury network national manager and the national clinical coordinator.
The OSI network that we present to you today is the product of 15 years of development and collaboration with our partners. This is a network that's 100% funded by the department but fully operated by our provincial partners. In my view, this is an exemplary model of federal–provincial partnership.
Together with our partners from National Defence, we have accumulated 20 years of experience in the assessment and treatment of operational stress injuries. We have more specifically focused on post-traumatic stress disorder among military members, veterans and first respondents, such as Royal Canadian Mounted Police members. I am confident that no other organization in Canada has more experience in the area than us. When I say “us”, I am referring to our military and provincial partners, as well as us, on the federal level, at the Department of Veterans Affairs. We have worked tirelessly and selflessly over the years to develop our expertise and our treatment methods, carry out research, innovate and measure our results.
The work, however, is never done. It's a journey of continuous improvement and of learning, and we continue to improve and to grow our capability.
Just last week, Mr. Fillion and I had the privilege of being invited to the University of Waterloo for the launch of a new operational stress injury service at the Centre for Mental Health Research in the faculty of psychology, where, in collaboration with the Parkwood OSI clinic in London, Ontario, they're training Ph.D. candidates and clinical psychology residents in the assessment of operational stress injuries.
This is a significant event because, while we've been very present in the health care domain in Canada, now we're entering into the education realm, whereby future clinicians will come to us already educated and trained in military and veterans' mental health issues, and in this case, specifically in the assessment of operational stress injuries.
I would say that the greatest strength of our network is the partnerships. It's said that a chain is only as strong as its weakest link, but we've worked over the years at maintaining and strengthening our partnerships, to the point that from an outsider's point of view they could be mistaken in thinking that we own and run those clinics, but we don't. From the outside, it looks like a very cohesive and high-performing unit, and it is.
The additional partnerships we have developed over the years are another strength of our network. Our mental health strategy is based on the information we receive from the Veterans Affairs Canada Research Directorate, especially information and data stemming from the study on life after service, the usefulness and quality of which are matchless. All the information arising from the research conducted by the Canadian Institute for Military and Veteran Health Research—which has a network of more than 40 academic institutes—is invaluable to our network's growth, as is our close collaboration with our Canadian Forces colleagues. Worthy of mention are the Canadian Military and Veterans Mental Health Centre of Excellence and the Chair in Military Mental Health, which were established in collaboration with the Ottawa Royal Hospital.
I'm going to stop my comments here.
I want to highlight the fact that just recently, in January, we started up a new directorate of mental health, which is comprised of all the mental health resources that we had, but now they all report directly to me under the leadership of Mr. Fillion. Later this year, we'll be welcoming our own chief psychiatrist, a former military psychiatrist, with extensive experience in operational stress injuries and PTSD.
I will start, and my colleagues can add to my answer if they want.
When it comes to medical expertise, we carry out assessments, establish diagnoses and provide treatments. Those who come before the board are people who do not necessarily agree with the assessment or the diagnosis that has been made either by Canadian Forces physicians or by Veterans Affairs physicians who carry out assessments, or by our OSI clinic practitioners.
If we also provided medical expertise, we would be in a conflict of interest, in the sense that we would disagree with the veteran. In those cases, people have to obtain expertise from outside the Canadian Forces and Veterans Affairs Canada. They rely on the expertise from the Canadian health system.
The department provides veterans with legal assistance, but it does not provide them with medical assistance, as the same physicians would be involved and would find themselves in a conflict of interest situation because they were supposed to establish diagnoses, but not also testify on their clients' behalf.
There is probably a lack of expert resources. No one can force a psychiatrist, a specialist, to provide expertise. We are aware of this problematic situation. It is a difficult one.
What an excellent question.
It's interesting. The reason I say, “Thank you for asking the question”, is that all too often in mental health we look at outputs, but we don't look at outcomes. We look at how many hamburgers we put through the door, but are they edible?
We've been concentrating on developing a way to track veteran self-reported outcomes. We have a national server-based system set up, which allows veterans on their way to a session to answer a couple of brief questionnaires. That data goes to a secure server, it's scored, the results are analyzed, a report is generated, and that report is ready for the vet by the time they show up at the clinic. The system is called CROMIS. It uses industry-standard measures that track their overall well-being, but can also track specific outcomes with respect to the identified primary conditions like post-traumatic stress disorder or major depression.
When you're talking about outcomes, that is one of our primary measures. Now it's not the only one. Of course, we're looking at the other domains, social and vocational satisfaction, and their medical well-being as well. That's why the clinics are organized using interdisciplinary teams, so that each person does the assessment, we come together, and we look at the person in as well-rounded a manner as possible. As we intervene, we're trying to iteratively evaluate the outcomes, so that we can make real-time decisions and adjust the treatment plans, so it's really tailored to that particular person.
That's very important because people tend to talk a lot about best practices, but all those best practices data are all based on group outcomes. The reality is that in a clinical intervention, you always need to adapt those best practice interventions to the particular needs of that particular person. The best way to do that is to track their vital signs, just like they do in medicine, so it's like tracking blood pressure or body temperature.
We're the only network that uses that. I believe DND is working on starting up their own version, but we actually specifically track outcomes in real time and report the results back collaboratively with the veterans.
I'm going to start and then turn it over to Dr. Courchesne.
I think the first part has to do with when the OAG talked about 32 weeks. We have to recognize that during the first 16 weeks a lot depends on the delay. There is some interpretation that comes into that 16 weeks. Needless to say, there is a delay before we get a completed application and it's entered into the system. We've had lots of discussion with the OAG about the 16 weeks. Some of the data they were taking was from the get-go of the first phone call. It's hard to open a claim when you only have a phone call.
That said, we accept the fact that it's long. We accept the fact that we had to simplify. What we have done since the OAG report is to accelerate our disability process for mental health. We have done it for many other items, not just mental health. But since we're talking mental health, I will specifically talk about it.
If they have a diagnostic and they come in to us and they've served, especially if they've been in any SDAs or special duty areas, they are in the club. To really decrease...whether it's 32 or 16, to me at this point is not important. The important thing is to get that down. While they're waiting for this, there are avenues for them. We can't forget that we have the 1-800 network. We'll give the veteran 20 sessions with a psychiatrist or a psychologist within 24 to 72 hours. We pay for that. There is no adjudication process.
As long as they're a veteran or a veteran's family, we take care of the bill. There is no delay. There is no waiting. You call that number. You need help. Somebody referred to the crisis line earlier. If you need help, we will help you. We'll get you into mental health. It is not the OSI clinic, I agree, but at least you can get help immediately, pending a lot of this stuff. We pay. There's no billing. It's with Health Canada. They bill my division directly and we take care of it.
I'll turn it over to Mr. Courchesne or Dr. Ross.
First, I'd like to thank you for being here today and for the work that you're doing to address post-traumatic stress disorder. I have a couple of questions, but I am going to premise my questions with an apology because it may sound harsh.
We've just heard from the Auditor General, and I have to say that I'm a little concerned when I hear that 65% of cases are overturned, but I hear that in those cases, whether it be because of a lack of documentation or errors, the payments are not retroactive.
My questions are more for the ADM. Currently are there KPIs in VAC, or is there management by objectives with employees? Do employees have a performance-based incentive? What kind of quality control is in place? If there are errors happening, is there training so that these errors stop? If it's a performance problem, are people, are their jobs... I don't want to say that people are making... But they're making mistakes on the backs of the veterans.
Who is keeping track to make sure that if errors are being made, they are being addressed, that training is provided for folks, and that you're capturing the data of what kinds of errors are happening? But what happens to the data? Is it just in a report somewhere? My concern is what's happening.
I'm sure the employees wouldn't feel so great if they were told, “Well, we're going to take 16 weeks of your salary back.” My question is, what's happening?
I can probably answer all of those.
First of all, it is no longer 63%, but an 83.3% approval rate, on first applications. That has increased by 20 percentage points.
I have to back up to answer part of the question.
Army people—and I think a lot of people here have mentioned and Mr. Clarke has spoken of it—have this ethos that when you're serving with your group of people, you do not fill out the famous form, something 98, to say that you've been injured. It doesn't go into your medical file because you want to be a contributing member of your team and you want to support your partners and your colleagues. I think Mr. Clarke spoke to it well earlier.
Our legislation is written in such a way that two or three years ago we would go in to try to find proof that you were injured. That means we had to look over 500, 600, 700 pages of medical files to try to identify when you injured your knee and if you filled out a form that said you had injured your knee.
Now serious injury cases are not an issue. When we are talking serious injuries, there is a medical file. It is more about these injuries that happen over time, so what we've done is undertaken a review. Actually that started before the OAG came in, but we put a lot of effort after the OAG came in to move that from... Somebody at the OAG talked about the burden of proof, but shifting the burden of proof from the veteran to Veterans Affairs in the sense that, for an injury... I'm not talking illness, as I think I referred to last time. I'm really talking injury here. Illness is a little bit more complex.
If you were a SAR tech and you've jumped out of helicopters and planes for 30 years—who knows how many jumps you've had?—you're going to have bad knees. You're going to have a bad back; you're going to have a bad something. So we've done a lot of work with the institute of research that's over at the military site to say what the injuries are related to. Is it a certain trade? And if you come in, you have to have a diagnostic. I still need a diagnostic. A doctor has to say that your knees are gone.
We have them in Edmonton, Calgary, and Vancouver.
I like Saskatchewan. My partner is from Humboldt, Saskatchewan. I know Saskatchewan.
When the clinics were established, they were established where there are big bases such as Valcartier and Edmonton. We collocated close to the forces clinics so that we could catch the people coming out. That was the premise at the time. There's also Moose Jaw, which is a training base, with fairly young people there, young people who want to be fighter pilots and all that, but there wasn't that critical mass, so it's not because we don't like Saskatchewan or that they were overlooked. I think it was critical mass that dictated it at the time.
Now in our research, we look at where are the veterans and where is the need. I don't want to leave you with the impression that I wanted more mental health clinics. I think, except for Saskatchewan, which we'll take under consideration—
Some hon. members: Oh, oh!
Dr. Cyd Courchesne: But where we are, we need to expand there, because they already have critical mass there and expertise, and they're well under way. That was my...it was about expanding the clinics in size, not in numbers.
Mrs. Cathay Wagantall: Okay.