PACP Committee Report

Under the National Defence Act, the Department of National Defence is required to provide health care for Canadian Forces members. National Defence provides medical care to more than 63,500 Regular Force personnel on 37 military installations across Canada and abroad, which costs more than $500 million annually. Approximately 3000 health care providers are employed by National Defence, and a private sector firm provides another 540 health care professionals to military clinics.

Several reviews conducted from 1997 to 1999 concluded that military health services had significant deficiencies, such as a lack of continuity of care, a lack of oversight mechanisms, deficiencies in the management of health records, and concern about the access to and timeliness of health care. These findings led National Defence to launch its Rx 2000 reform. This reform involves 22 initiatives that are planned for completion by 2011 with an overall budget of $450 million.

In 2007, the Office of the Auditor General (OAG) conducted an audit of National Defence’s management of military health care services.^[1] The objectives of the audit were to examine whether National Defence has the necessary structures, policies, and practices in place to provide assurance on the quality of health care that members of the Regular Force receive. The audit also examined the extent to which National Defence ensures that its health care providers are qualified and maintain their clinical skills. The audit did not examine the quality of the care that members receive. The audit also did not look at medical care outside of Canada on deployments such as Afghanistan.

Given the important work performed by Canadian Forces members and concerns about the management of their health care services, the Committee decided to have a hearing on this audit on January 31, 2008. The Committee heard from several officials from the Office of the Auditor General of Canada: Sheila Fraser, Auditor General of Canada; Hugh McRoberts, Assistant Auditor General; and Wendy Loschiuk, Principal. The Committee also heard from two officials from the Department of National Defence: Major General Walter Semianiw, Chief of Military Personneland Brigadier General Hilary Jaeger, Commander Canadian Forces Health Services Group, Director General Health Services and Canadian Forces Surgeon General.

On the positive side, the audit conducted by the Office of the Auditor General (OAG) found that the Canadian Forces health care system is committed to providing members with access to a full range of health care services, either through the Forces health care system or through civilian providers. Also, members who walk into their military clinic do not have to wait very long to access primary medical care, and more than 85 percent of those who responded to a patient satisfaction review were satisfied with the health care they received.

On the other hand, the audit also found a number of weaknesses in the management of the military health care system. Briefly, it found that National Defence does not have measures or indicators to demonstrate whether the present accessibility of medical services and the resulting costs are operationally necessary; the Canadian Forces is unable to demonstrate that all of its military health care professionals are licensed or certified or have maintained their qualifications to practice; and National Defence has little information to allow it to demonstrate how well the military health care system is performing or how to assess the quality of care.

The audit includes eight recommendations, and National Defence agreed to all of them. The Committee fully supports the findings and recommendations of the Office of the Auditor General in this audit.

Major General Walter Semianiw told the Committee, “We fully embrace and support the recommendations of the Auditor General.”^[2] He also said, “Our view is that the report is a fair and balanced assessment of the state of a military health care system in transition.”^[3]

Given the department’s acceptance of the findings of the audit and support of the recommendations, National Defence should be committed to implementing those recommendations. Indeed, the officials from National Defence brought an action plan with target dates to the hearing. However, the Committee would not accept the distribution of the plan because it was available in English only. National Defence should have known that the Committee operates in both official languages. While National Defence did eventually provide the action plan in both languages after 38 days, the Committee is quite disappointed that National Defence was not better prepared to provide information in both English and French.

The Committee is pleased that National Defence has developed an action plan to address the findings and recommendations of the Office of the Auditor General. The Committee strongly believes that all departments and agencies should develop an action plan in response to audits by the OAG. Action plans demonstrate a commitment by management to fix the identified deficiencies as well as be accountable for making the necessary changes. However, the Committee also believes that action plans should be distributed to the Committee prior to a hearing in order to allow members to study the plans and develop questions.

Action plans are a first step in the accountability process. Initially, it is necessary to set out what actions a department intends to take and the target dates for the completion of those actions. Subsequently, in order to close the accountability loop it is necessary to report on progress on implementing that plan. Hence, the Committee recommends that:

Recommendation 1

The Department of National Defence provide the Public Accounts Committee a detailed progress report by 31 October 2008 on the implementation of its plan to address deficiencies identified by the Office of the Auditor General in its audit on Military Health Care.

According to the audit, the cost of the military health care system is significantly greater per person than the provincial systems and is increasing. In the 2005–06 fiscal year, the Canadian Forces health system spent an average of more than $8,600 per person, compared with the Canadian average estimated health care expenditure of about $4,500 per person in 2006, despite the fact that the military population tends to be relatively healthy. The cost of delivering military health care has increased by 50 percent per person over the last five years.^[4]

Major General Semianiw gave the Committee the following explanation for the differences in costs:

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.^[5]

However, the Office of the Auditor General provided different factors for the cost of the military health care system. According to the audit, some of the factors may include: there are four times more physicians per 1,000 military members than compared with the civilian systems (though, 40 percent of military physicians are not providing patient care but are employed in administrative or other functions); there is a broad range of workload at military health clinics across the country; National Defence pays for the medical education and ongoing training of some of its medical practitioners; and in order to fill in for staff shortages some civilian health care practitioners have been hired on contract at rates significantly higher than provincial averages.^[6]

Major General Semianiw told the Committee that National Defence is committed to providing the resources needed for the military health system. He said, “I would add that the leadership of the Canadian Forces and the department did tell Brigadier General Jaeger in the month of October that she is directed to spend whatever money she needs to get it right for soldiers, sailors, airmen, and airwomen.”^[7] While it is important to ensure that members of the Forces have access to sufficient health services, it is also important that those services are delivered in a cost effective manner. Brigadier General Jaeger did acknowledge that improvements could be made. She said, “Can I be more efficient in some areas? The answer is yes. But I need management data to tell me where I can make those efficiencies.”^[8]

The Committee does not wish to tell the Department of National Defence how to manage its health care system or identify areas for improved efficiency. However, it does believe that more transparent information about the costs of the military health care system would allow observers to compare those costs to the provincial systems and to the military health care systems in other jurisdictions. Consequently, the Committee recommends that:

Recommendation 2

The Department of National Defence provide information in its annual departmental performance report on the aggregate costs of the military health care system, as well as the number of physicians, nurses, dentists, pharmacists, medical technicians, and physician assistants employed in that system.

In response to a request for information, National Defence informed the Committee that as of January 31, 2008, there were 4,917 active mental health cases within the Canadian Forces, and these individuals are accessing specialized mental health care services. In 2002, a survey on mental illness in the Canadian Forces found that only 25 percent of respondents who had reported symptoms of mental health problems or disorders considered that they received sufficient help. National Defence has since restructured how it delivers mental health care and began conducting post-deployment screenings of personnel returning from overseas service to detect any resulting physical and psychological effects.  

The Committee was surprised to learn that a significant number of personnel returning from overseas deployment to Afghanistan are returning with psychological difficulties. Brigadier General Jaeger described the findings from their post-deployment screenings:

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.^[9]

While National Defence did have information from their post-deployment screenings, the department does not have overall information on the mental health situation in the Forces because it does not have the necessary information systems in place. This makes it difficult to determine the mental health care needs of Forces members and to direct services to where they are needed most. They can only say that six months after a base gets its personnel back from deployment, their mental health clinic experiences a doubling of their mental health workload.

Given the prevalence of mental health difficulties for military personnel returning from deployments, the Committee believes it is vital that those personnel have access to sufficient mental health services. However, the audit found inconsistent levels of service available. Some base mental health services could not meet demands due to a lack of staff, while others could offer all the services requested. Some bases reported a shortage of mental health professionals to meet needs and relied on services from civilian private practitioners, if and when available.^[10] In addition, while there is no legal obligation to provide mental health services to military families, National Defence offers some help to families when it is in support of a member’s health, but bases with large numbers of members returning from deployment in Afghanistan were unable to extend care to families due to resource shortages.

The Committee recognizes that as part of the Rx2000 reform, National Defence is adding $90 million to mental health services, involving an additional 200 mental health practitioners. Yet, the Committee remains concerned that National Defence’s mental health care services may not be meeting the needs of members and their families. As many things have changed since 2002, when the last survey took place, the Committee believes that National Defence needs once again to determine the state of mental health of members in the Forces and the quality of mental health services they and their families receive. Consequently, the Committee recommends that:

Recommendation 3

The Department of National Defence conduct a comprehensive survey by 30 June 2009 of the state of mental health of Canadian Forces members and the quality of mental health care services they and their families receive, with a special emphasis on those returning from overseas operations.

One of the more significant findings from the audit is that National Defence does not have an information system that would measure what the health care system is achieving, at what cost, or what needs to be improved in the provision of health care. While some information is available at clinics, National Defence could not provide information on the results and outcomes for the medical system overall. Indeed, the witnesses from National Defence could not provide response to numerous questions from Committee members because they did not have data on the information sought by members. An information system would help National Defence better manage its health care system, identify efficiencies, and direct resources to where they are needed most.

National Defence is developing a system that will collect performance information, called the Canadian Forces Health Information System. This database is expected to capture information on health indicators, costs, and trends. Development of the System began in 1999, and it is scheduled to be completed by the end of 2011 at a planned cost of $108 million. Brigadier General Jaeger assured the Committee that the system was on schedule. She said:

When will the automated system be in place so that we don’t have to rely on that base-by-base, case-by-case reporting? Well, that depends on Treasury Board approval of increased third phase funding for the Canadian Forces Health Information System. We are supposed to, if all goes well, begin implementation in May of this year. It will be substantively complete by 2010, and we’ll have the dotting of the i’s and the crossing of the t’s on the project done by 2011.^[11]

However, the audit found that National Defence had excluded due to lack of funding the possibility of following the Canadian Institute for Health Information’s guideline on medical information management.^[12] The OAG was concerned that progress on the system since 1999 was slow.

The Committee has expressed its concerns with the development of large information technology projects in a previous report. These projects have a history of overspending, delays, and performance shortfalls. Given the importance of the Canadian Forces Health Information System to the management of the military health care system, the Committee would like to have more public reporting about the status of this system as it develops. The Committee recommends that:

Recommendation 4

National Defence report in its annual departmental performance report on the status and implementation of the Canadian Forces Health Information System, including whether the system is on budget and on time.