NDDN Committee Report

The Committee closely examined all evidence placed before it and identified three central issues that seemed to be at the root of most, if not all, the difficulties facing the Canadian Forces health care regime. The first was the lack of a positive, aggressive, established attitude toward the diagnosis and treatment of OSI. Second, we identified a problematic gap between policy enunciation at senior levels and its implementation at the unit and clinic level. Finally, the Committee recognizes the chronic shortage of health care professionals available to meet the needs of Canadian Forces members and their families, which requires a whole-of-government effort to solve.

ATTITUDE

The Committee heard evidence that attitudes toward mental health issues in the Canadian Forces remain largely negative. Although discussion tended to remain focussed on soldiers suffering from PTSD, we realize, upon further reflection, that such attitudes also exist far beyond the Canadian Forces, amongst some Canadians.

According to the Canadian Mental Health Association (CMHA), mental illness is common. Statistics show that one in every five Canadians will have a mental health problem at some point in their lives. Mental illness is feared by many people and, unfortunately, still carries a stigma—a mark or sign of disgrace. Because of this stigma, many people hesitate to get help for a mental health problem for fear of being looked down upon. It is unfortunate that this happens because effective treatment exists for almost all mental illnesses. Worse, the stigma experienced by people with a mental illness can be more destructive than the illness itself.[33]

There are many myths about mental illness. Within the aggressive and competitive military environment it is sometimes believed that mental illness is caused by a personal weakness. In truth, it is in no way a character flaw. It is an illness, and it has nothing to do with being weak or lacking will-power. Although people with mental illness can play a big part in their own recovery, they did not choose to become ill, and they are not lazy because they cannot just ‘snap out of it’.

The Committee recognizes that men and women may be equally liable to mental illness, but we also acknowledge a growing body of research on men’s mental health issues that seems particularly relevant to the military culture in Canada.[34] Beliefs about masculinity encourage men’s general lack of interest in health issues. Western society’s view of the value of men is seen as an important factor affecting men’s mental health.
Dr. Michael Myers a psychiatrist and clinical professor in the Department of Psychiatry at the University of British Columbia, says, "In men, mental illness can be masked. We’ve known for decades that women are more apt to recognize illness of any sort and go to their doctor. This doesn’t mean women are healthier, but that some men just repress it."[35]

Evidence presented to the Committee makes it clear that Canadian Forces leadership is working hard to instil appropriate attitudes toward mental health in the Canadian Forces, but perhaps not high or hard enough.[36] As will be discussed later, such efforts do not seem to gain much traction at lower levels.[37] The Canadian Forces has led Canadian society by example in the past, on issues of gender equality, eliminating discriminatory practices and implementing an enhanced ethical framework. We think the Canadian Forces can again lead Canadian society by example in the field of appropriate attitudes toward mental health.

Proper attitudes precede appropriate action. An attitude that accepts psychological injury in the same way that physical injuries are accepted, will lead to positive practices that treat any psychological injury with the same relative urgency that is given to physical injuries. Once any injury is inflicted, there is no time to waste. To provide an example to all Canadians, we suggest that the Department of National Defence and the Canadian Forces simply, ‘get on with it’ and initiate a high-level, high-profile, public declaration to establish and embed a modern, enlightened and unequivocal view of mental health issues to be scrupulously followed by all ranks. If done properly, such a declaration will serve as an example for parallel initiatives in other sectors of Canadian society.

RECOMMENDATION 1

The Minister of National Defence and the Chief of the Defence Staff should jointly make a public announcement to all ranks of the Canadian Forces, outlining a high-profile effort to pursue a modern, enlightened and unequivocal view of mental health issues in the Canadian Forces. All commanders of commands, formations and units should also deliver complementary declarations to their personnel, to reinforce implementation at the local level.

THE POLICY-IMPLEMENTATION GAP

The second principal issue was captured in this passage from one Committee meeting:

The testimony we heard in camera was very troubling testimony about mental health services and the lack of timely diagnosis or the lack of treatment that Canadian Forces members and their families felt they had a basic right to expect.

…At the same time, we’ve heard from people of higher rank within the military who clearly are committed to trying to treat mental health issues properly and effectively. …But there seems to be this gap between what we’re hearing from the upper echelons of the Canadian military and what we’ve heard from soldiers, not all of whom have been soldiers who returned from Afghanistan. Some were soldiers from our time in Bosnia.

My question to you is about this gap in perception and the gap between the testimony we heard from the individual soldiers and their families, who felt they didn’t receive timely attention to their mental health issues, and the reports and testimony we heard about the desire in the higher levels of the military to ensure that they will.

Dawn Black, M.P.
June 17, 2008[38]

For every senior officer or departmental official who told us of initiatives being taken to improve military health care generally and mental health diagnosis and treatment in particular, we heard at least one junior rank who told us the system was not working for them. The phrase ‘falling through the cracks’ was heard so often it lost its notoriety. The apparent policy-implementation gap was a persistent issue that has not faded, even in the face of new initiatives by Department of National Defence and the Canadian Forces.

The Committee recognizes the fact that recent Canadian Forces patient satisfaction surveys show the vast majority of Canadian Forces members and their families think the provision of Canadian Forces health care services met their needs.

Successful care and treatment is the norm within the Canadian Forces. However, we also recognize that the number of dissatisfied people cannot be ignored and that more effective efforts must be made, at lower levels, to eliminate instances of inadequate care.

The Committee also heard evidence that Canadian Forces medical personnel are overburdened with administrative duties, spending up to 40% of their time on administrative and policy issues. While higher administrative overhead in a relatively small organization can be expected, Canadian Forces medical personnel should be focused on their primary task—front-line care for patients.

More details follow in later sections, but the main problems, according to what we heard, seem to reside in front-line clinics that are under-resourced and with case managers who are over-worked. However, at this point, the Committee is comfortable in recommending that an independent audit be conducted to determine the degree to which the policy implementation gap and administrative overhead problems exist and measures needed to eliminate them.

RECOMMENDATION 2

The Department of National Defence should cause an independent audit to be conducted of military patient case management practices to determine the extent to which a gap exists between expressed Canadian Forces policy and the actual practices applied to the continuing treatment and care of injured Canadian Forces personnel. Once defined, appropriate measures should be taken, throughout the chain of command, to eliminate the gap and improve patient care.

RECOMMENDATION 3

The Department of National Defence should cause a second audit to be conducted by an independent body, to examine the administrative burden imposed on Canadian Forces health professionals, with a view to determining whether any such administrative duties adversely impact the delivery of effective patient care.

SHORTAGE OF PROFESSIONAL HEALTH CARE PROVIDERS

There is an enduring shortage of professional health care providers in Canada. In January 2008, the Canadian Medical Association (CMA) announced a major campaign to draw public attention to the growing physician shortage. According to the CMA, almost
5 million Canadians do not have a family physician and 5 million more could be in the same situation by 2018. Canada needs 26,000 more doctors to meet the Organisation for Economic Co-operation and Development (OECD) average of physicians per population.[39]

There are two important points here. First, when Canadian Forces patients are referred to civilian health practitioners for treatment, they compete for already limited access to care with the existing patient population. Waiting for treatment can be even longer in areas of the country, such as many isolated or rural regions, where there is a severe shortage of resident medical professionals. Second, the recruitment of health care professionals for service in the Canadian Forces does not enjoy an independent source of recruits. The Canadian Forces health services compete, just like any other employer, with provinces and established medical institutions for the talents of graduating medical students. Despite attractive signing bonuses, competitive salaries and a ‘distinctive’ lifestyle, not all doctors or nurses seek a military career.

The Committee was also made aware of a study by the FHP, entitled, Study on Recruitment and Retention of Federal Physicians, published in 2007. The report made clear the increasing pressure of meeting demands for health care services in Canada, along with the fact that the decreasing number of professionals in this field has touched both the private sector and the government at all levels. The FHP noted that the shortage of physicians is reaching crisis proportions as “projections to 2021 suggest the number of physicians per 1,000 population will reach an alarming ratio of 1.4/1000”.[40] Adding to this crisis is the additional estimate that retirements of Canadian physicians will accelerate over the next 10 to 15 years leaving an even greater shortage.

In view of these facts, the FHP thinks it imperative that the federal government address its inability to recruit and retain sufficient qualified medical personnel. In the course of the study leading to the report, several common challenges were identified and four main themes emerged:

a)    Compensation. Federal salary levels have not kept pace with provincial and private sector realities;

b)    Pressing Operational Requirements. The negative impact of contracting services, the increasing need for specialists and experienced physicians, the high turnover of physicians and, the difficulty of managing heavy workloads due, in part, to the lack of administrative support;

c)    Pressing Administrative Requirements. Problems with regards to classification of positions and compensation level, the onerous and inflexible staffing process for the physicians population, and increasing budgetary constraints;

d)    Pressing Qualitative Requirements. Limited opportunities for career development, limited scope of practice and the clash between departmental and medical cultures.

The main issue here is recognition of the fact that the shortage of medical professionals is not only a Canadian Forces problem and therefore cannot be solved simply by providing more money and directing the Canadian Forces to recruit more health care providers. The challenge exists at both the federal and provincial levels.
Solutions are beyond single department initiatives. What is needed here is a concerted approach to mobilize, deploy and sustain sufficient medical health professionals to meet the growing needs of injured Canadian Forces personnel and their families.

RECOMMENDATION 4

It is recommended that Government recognize, despite the shortage of healthcare professionals in Canada, that the Canadian Forces has an obligation to provide necessary and adequate medical treatment to its members including returning soldiers with continuing need for treatment and services.

Just as the Canadian Forces is expected to provide treatment for physical injury, the Canadian Forces should also be expected to provide soldiers suffering from OSI with the necessary mental health and related services. Related services include, but are not limited to, addictions counselling, marriage and family counselling, occupational therapy and recreational therapy.

Recognizing that the Canadian Forces cannot implement effective remedies alone, a strategy for providing adequate and comprehensive treatment for OSI will require cooperation and support from other government departments. But regardless of the challenges, the Canadian Forces—with assistance from the appropriate government partners—must make every effort to mobilize, deploy and sustain sufficient mental health and related professionals to meet the needs of members of the Canadian Forces and their families.

RECOMMENDATION 5

It is recommended that the Government establish, within one year of the presentation of this report, a National Health Care Resources Monitoring Council, led by Health Canada, composed of health representatives from the Canadian Forces, the Royal Canadian Mounted Police, other appropriate government departments and agencies, other appropriate levels of government and other relevant stakeholders. This Council should meet regularly, at least semi-annually, to review the disposition of all health care capabilities in Canada, review health care needs in various client communities such as the Canadian Forces and military families, identify gaps and consult on measures that could be taken to remedy them.

RECOMMENDATION 6

It is recommended that Health Canada, supported by the Department of National Defence and Veterans Affairs Canada, complete a detailed audit of health care services available to the Canadian Forces in Canada and around the world, to identify the nature and scope of gaps. In Canada, this would be done in cooperation with provincial, territorial and appropriate municipal authorities. The Committee recommends particular attention be paid to large rural bases, which seem most at risk for lack of health infrastructure. Abroad, it would be done in cooperation with nations in which Canadian Forces personnel are located.

RECOMMENDATION 7

The Canadian Forces should expand recruitment incentive programs for mental health professionals, including the use of student debt relief, grants, bonuses, tuition payment and the purchase of more medical placements at universities, providing provincial assurances can be gained that the money so spent would indeed go to educate nominated Canadian Forces mental health care students.