NDDN Committee Report

Introduction

The Government of Canada has carefully considered the Report of the Standing Committee on National Defence on Health Services Provided to Canadian Forces (CF) Personnel, and has taken note of the thirty-six recommendations it contains. The following Response provides an overview of the Government’s position with respect to each of the recommendations. Some recommendations were combined in order to avoid repetition while providing a more complete answer (this is the case of recommendations 15-16, 26-27, 33-34, and 35-36).

The CF Health Services is among the best in the world. Nonetheless, when men and women accept to put their life at risk to protect their country and its people, we owe it to them to strive to provide them with even better care when they need it. As such, the Government agrees with all the proposed recommendations though in some cases, proposes alternative means of implementation.

The Government of Canada would like to thank the members of the Standing Committee on National Defence for their work on this complex issue. As mentioned in the Committee’s report, challenges such as shortage of medical professionals and negative attitudes towards mental health illnesses go beyond the CF and affect the broader Canadian society. The following response should be considered within this general context.

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 Government is dedicated to pursuing a modern, enlightened and unequivocal view of mental health issues in the CF and has already taken steps to implement the Committee’s recommendation. On 25 June 2009, the Chief of the Defence Staff (CDS) made a public announcement to launch the CF Mental Health Awareness Campaign, themed “Be the Difference,” which has the dual aim of educating CF personnel on mental health issues, and building a culture of understanding. In his speech, the CDS communicated the idea that all personnel can make a difference to those affected by mental health issues. He also highlighted the success of two CF non-clinical programs: the Mental Health and Operational Stress Injury Joint Speakers Bureau, established in 2007 to educate the military community on mental health issues; and the Operational Stress Injury Social Support network, an innovative peer-based intervention program established in 2001.

CF efforts to date have had success in raising awareness and understanding of mental health issues among the leadership cadre. However, much remains to be done at the lower rank levels to ensure that they too understand that mental illness is a genuine illness and not a personal failing. As part of the CF Mental Health Awareness Campaign, commanders of commands, formations and units will also be encouraged to deliver complementary declarations to their personnel to reinforce implementation at the local level.

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.

Several authorities external to the CF have recently reviewed these issues, including the Office of the Auditor General, the CF Chief Review Services, the CF Ombudsman, the Mental Health Advisory Committee – a civil-military body with participation from DND, VAC, the RCMP and academics – to examine and make recommendations regarding mental health issues. Accreditation Canada, a not-for-profit, independent organization that is recognized as the national authority for the establishment and assessment of health care standards and the accreditation of health care institutions, also specifically assesses concordance between policy and practice. Gaps and action plans are well defined and further reviews are planned, such as Accreditation Canada’s audit of the entire CF health system and the Mental Health Advisory Committee’s ongoing reviews. In addition, an international panel of experts, led by the Deputy Surgeon General and including military and civilian experts from Canada, the United States, the United Kingdom, Australia and the Netherlands, will be reviewing and discussing each nation’s experience with suicide prevention/education, as well as current literature and evidence-based best practices, this fall (22-23 September 2009). The Government looks forward to the outcome of all of these studies and will make every effort to implement recommended measures to eliminate the policy-implementation gap and further 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.

The Government recognizes the need for CF health professionals to focus their time on the delivery of effective patient care. At the same time, recent examples within the US Veterans Affairs and the UK National Health Service have demonstrated how clinician leadership increases the efficiency and quality of care. This issue has already been addressed by a 1999 CF Chief Review Services review of the CF health system. As a result of this review, the Rx2000 project was set up to reform CF Health Services by implementing several measures to reduce the non-medical burden of clinical staff, while retaining adequate clinician involvement in key areas of administration and leadership that require such involvement. These included the establishment of a Health Services Operations Officer occupation, Clinic Manager positions, and other management staff to relieve clinicians of many administrative functions.

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 counseling, marriage and family counseling, 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.

The Canadian Forces recognize and have fully assumed their responsibility to provide necessary and adequate medical treatment to its members, both for physical and mental injuries, including soldiers returning from operational tours. The CF regularly reviews its spectrum of care to ensure that CF members have access to a full range of mental health services and supports. Through 5 regional centres, the CF provides comprehensive mental health care to members at all bases across Canada including: psychosocial, which involves short term brief interventions including marital and family work; general mental health secondary programs, which provide a full range of therapeutic services to all mental health disorders including substance abuse; and Operational Trauma Stress Support Centre (OTSSC) programs, which provide comprehensive care to members suffering from Operational Stress Injuries (OSIs). These larger centres support the 21 smaller mental health clinics. Several strategies are used to mobilize, deploy and sustain sufficient mental health professionals in these regional clinics, including the use of military clinicians, public servants and third party contractors. Where CF services are not available, the CF contracts local providers through the Blue Cross. In addition, the CF and Veterans Affairs have partnered in a Joint Network wherein OTSSCs and OSI clinics provide reciprocal services.

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 semiannually, 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.

The Government recognizes the need to review health care needs of CF members and their families, identify potential gaps and adopt measures to remedy them. The Federal Healthcare Partnership (FHP) has been fulfilling exactly this role since its inception in 1994. The FHP’s mission is to identify, promote and implement more efficient and effective health care programs through the collaborative effort of all member organizations. The FHP has seven permanent partners: Citizenship and Immigration Canada, Correctional Service of Canada, DND, Health Canada, the Public Health Agency of Canada, the Royal Canadian Mounted Police (RCMP), and VAC. In October 2008, the FHP’s Office of Health Human Resources (OHHR) was established to initiate and coordinate collective recruitment and retention activities and provide leadership and assistance to the FHP member organizations when addressing common issues and challenges in the area of Health Human Resources. Secondary to that mandate, the Office of Health Human Resources has undertaken tasks and responsibilities that relate to health delivery. Most recently, it has begun work with FHP partner organizations and Central Agencies related to the revision and/or development of new classification standards that will enable federal organizations to employ health science professionals to the full scope of practice and hire new emerging health science professionals, including physician assistants. As a member of the Advisory Committee on Health Delivery and Human Resources’ (ACHDHR) Health Human Resources Partnership and Planning Sub-Committee, the FHP’s Office of Health Human Resources is well positioned to raise this issue with the members of the ACHDHR Sub-Committee.

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.

The Government acknowledges the existing gaps in service. Available local and regional health care services are routinely identified and monitored by CF Health Services elements in Canada and abroad. It should be noted, however, that in most locations, the same gaps exist within the civilian health care sector. While Health Canada does not have the authority to conduct the recommended audit, DND and VAC will work together to examine new ways of improving their knowledge of the health care services available to the CF in Canada and around the world.

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.

These mechanisms and others are already being used by the CF to attract health care providers, but filling the established positions with personnel remains problematic due to a country-wide shortage of trained health professionals. In this context, the Government agrees that the CF must strive to become an employer of choice for these highly in-demand professionals. Beyond recruitment, the CF is also faced with a retention challenge. In the near future, the Government will be exploring ways to maximize existing programs to the fullest extent possible to attract and retain health care professionals.

Recommendation 8: The Canadian Forces should include treatment for substance abuse and addictions as part of the services offered to sufferers of OSI and PTSD.

The CF already employs addictions specialists in all its clinics across Canada. In addition, the CF Health Services Group, in partnership with VAC, has identified a number of civilian clinics across the country that provide specific treatment programs for CF members suffering from substance dependency and OSIs, including PTSD.

Recommendation 9: The Canadian Forces should ensure that members and their families are provided with information about the risk of domestic violence that is associated with OSI and PTSD, and should provide services to family members who are at risk of or suffering from domestic violence as a result of OSI or PTSD.

The Government has already taken actions to address this issue. A CF directive has been issued outlining the steps to be followed when an incident of family violence occurs. It explains the CF policy on family violence, establishes a framework for management/implementation of the policy at both national and unit levels and assigns responsibility/authority for the various elements of the policy. The CF has also adopted an interdisciplinary team including health care providers, chaplains, Military Police and Military Family Resource Centre staff who assist in educating the CF on the prevention of family violence as well as responding to incidents. Moreover, the newly formed Mental Health & OSI Joint Speakers Bureau is currently developing new mental health educational curriculum, which will include information about the risk of domestic violence associated with OSI and PTSD, and coordinating its delivery. While the new curriculum is being developed, the focus within the CF is on how to motivate CF members to encourage their families to attend information sessions where the link between domestic violence and OSI is discussed.

Recommendation 10: The Canadian Forces should develop a formal outreach program to educate contracted health care professionals about the unique nature of military experiences encountered on international missions, particularly those involving any degree of combat.

The Government is currently working in this direction. Local level initiatives, such as the collective clinical training offered at CFB Gagetown and Valcartier for all health care professionals, are already well underway to develop such an understanding among both Public Service and contracted health care professionals, but there would be benefit in a more formal approach. To this end, the CF Health Services Group recently began developing a civilian personnel orientation package geared initially to Public Servants and civilian contractors. The package is expected to include information on the military culture, organization, terminology and domestic and international operations, including those involving combat, as well as occupational health aspects of the military. It could be completed as early as November 2009.

Recommendation 11: The Canadian Forces should formally recognize the requirement to include, where appropriate, selected family members in the treatment regime of psychologically injured personnel and take measures to ensure they are consulted and included in treatment plans, to the extent it is helpful to do so.

The Government fully recognizes the value-added of family members in the treatment of personnel injured either physically or psychologically. The inclusion of family members, where relevant to the health care of CF patients, is a long-established practice. The CF has issued an instruction on Member Focused Family Care which formally recognizes the importance of family inclusion in the care of the member and provides the opportunity for family members to be seen in CF clinics in support of the member and to participate in psycho-education programs. These programs are conducted at the regional centres. Families are brought into the clinic for an intensive one week training program to educate them about the CF members’ condition and their involvement in the care and support to the member.

Recommendation 12: Where injured Canadian Forces members require continuing assistance in navigating an administratively complex programme of treatment and care, the Canadian Forces should facilitate the use of a designated advocate chosen by the member and provide an appropriate level of cooperation with such advocate. Canadian Forces members should be advised of their right to an advocate. Given the concerns of additional stresses on family members, potential advocates could include retired members of the Canadian Forces and other professionals (e.g. medical doctors, psychologists, spiritual/religious advisors).

The Government recognizes the need to assist CF members in navigating the sometimes complex administration of treatment and care. The last thing injured personnel and their families want is an additional source of stress. There are already many professionals/entities responsible for advocating on the injured member’s behalf, including Case Managers, Peer Counselors, Veterans Affairs Advocates, the Integrated Personnel Support Centres and the chain of command. There has been an increased focus on identifying and correcting the deficiencies in the current system, including through the stand-up of the new Joint Personnel Support Unit that provides a one-stop shop for ill and injured members. Services offered by the JPSU include advocacy on a variety of issues such as the administration of health care.

Recommendation 13: The Canadian Forces should give primary consideration to the continuity of quality care for recovering soldiers, over career development options.

The Government agrees that the health of our recovering men and women in uniform should always come first and that CF personnel should not be moved from one location to the other if such a move has the potential to adversely affect their recovery. This is particularly important in the case of mental health issues such as operational stress injuries and PTSD where the stability of the relationship between a patient and his/her mental health professional is crucial to ensure the success of the treatment and the full recovery of the member. While medical officers assign military employment limitations to patients in need of particular care or treatment when necessary to ensure that appropriate continuity of care is achieved, it may not always be clear to career managers that they should avoid posting a member away from his/her unit. The Government recognizes that this is an issue and the CF is committed to look into ways of improving its record in this area. In doing so, the CF will reach for a delicate balance between continuity of care and professional development, one that will put the health of our men and women in uniform first, while avoiding being an obstacle to career progression – which could make members reluctant to report the symptoms of mental health illnesses.

Recommendation 14: The Canadian Forces should monitor the mental health of its members for five years after deployment on operational missions, to ensure effective treatment and tracking of mental health issues.

The Government supports the need for sustained tracking of CF members’ mental health. In fact, the CF monitors the mental health of its members not just for five years after an operational tour of duty, but throughout their entire career. The mechanisms for doing this include opportunities to self-report concerns through a mandatory end of deployment report and during Third Location Decompression, a mandatory enhanced post-deployment medical and psycho-social/mental health screening a few months post-deployment, an ongoing systematic program of Periodic Health Assessments for the duration of the member’s career, the opportunity to self-identify and self-present for care at any time, and a final pre-release health assessment. Supervisors also have the responsibility to monitor the well-being of their subordinates and refer them to help if necessary.

Recommendation 15: The Canadian Forces must recognize there still exists a certain culture, perhaps even a prejudice, regarding how mental illness is perceived among its rank and file.

Recommendation 16: The Canadian Forces should continue its efforts to educate all military personnel on the nature, processing and treatment of OSI, with a particular effort to eliminate any stigma associated with the condition.

The CF recognizes the stigma attached to mental health and is very pro-active in addressing this issue. The newly formed Joint Speakers Bureau, which includes mental health clinicians and OSI veterans, has been actively educating CF members and the chain of command at all stages of a member’s career on mental health and the importance of creating a supportive environment so members can come forward early for mental health care. More recently, the CDS campaign raised the importance of mental health as a leadership issue. There is evidence that these efforts to decrease stigma have been successful in that members are seeking help much earlier when mental issues arise, indicating a significant reduction in stigma as a barrier to care. Moreover, the Global Business and Economic Roundtable on Addiction and Mental Health recently “praised the military for its success in taking some of the stigma out of mental illness.” Mr. Bill Wilkerson, the Chairman of the Roundtable, stated that “the military and para-military have crossed the Rubicon in recognizing that mental illness is a real expression of ill health and not weak character.”

Recommendation 17: The Canadian Forces should embed in all leadership training courses, at all levels, material on identifying and processing personnel with OSI. Enhanced material, for commanders at all levels, should be included in all pre-deployment training too.

Information on mental health and OSI is already included in all Basic Military Qualification Training for commissioned and non-commissioned members, as well as Primary Leadership Qualification and Advanced Leadership Qualification. However, the CF is currently reviewing the detailed descriptions of the knowledge, skills, and other attributes required for all members of the CF for both officers and non commissioned personnel. This review is expected to result in the addition of OSI information to a greater number of courses. As of 1 October 2009, there will also be a standardized mental health and OSI pre-deployment education for all CF members, including leaders at all levels. This pre-deployment education will include recognition of behaviors often associated with mental health conditions, possible interventions, as well as information about available resources.

Recommendation 18: The Department of National Defence and the Canadian Forces should move to co-locate all medical facilities on military bases, in a manner that supports the concept that all injuries and ailments will be treated with equal respect and that works to eliminate any lingering stigma associated with mental health issues.

The Government adheres to this concept and has made every effort to co-locate all medical facilities on military bases. While challenges remain, these are due to infrastructure limitations rather than a lack of desire to co-locate. As new clinics are built as part of the CFHS Infrastructure Recapitalization Project, all services will be integrated in one facility. This project will ensure that all CF clinics meet health care standards and that they provide appropriate layout and space for staff to operate effectively.

Recommendation 19: The Department of National Defence should ensure that adequate resources are allocated to the establishment of a sufficient number of the Joint Personnel Support Units and Integrated Personnel Support Centres to provide this level of support and service nation-wide.

DND continually strives to improve the resources, both financial and human, to support establishments throughout the country. Up to now, there is one Joint Personnel Support Unit with 19 Integrated Personnel Support Centres in its chain of command across Canada. Work is ongoing with the CF to assess the need for additional centres.

Recommendation 20: Reserve unit chains of command must be intimately and proactively involved in ensuring their returning personnel complete the post-deployment process on time, including all necessary administration, interviews and medical appointments. Where individual Reservists are undergoing continuing care and treatment after full-time service, Reserve unit chains of command must remain in regular contact with CFHS case managers and take an active interest in the soldier’s treatment programme.

The Government agrees that the military chain of command must be fully engaged in the health of their returning personnel. To ensure that returning Reservists complete all the necessary administration, interviews and medical appointments, DND has implemented a program known as the Reserve Medical Link Team whereby all returning Reservists are contacted and tracked to ensure that post-deployment screening is completed. To date, 90% of Primary Reserve members who participated in ROTO 5 of the CF mission in Afghanistan have been contacted, with final contact taking place 12 months after their return to Canada. Approximately 80% of Primary Reservists participating in ROTO 6 have now had initial contact. The Reserve Medical Link Team also liaises regularly with CF Case Managers and the situations of all Primary Reserve members requiring care are discussed in case conferences that review individual health care needs and management plans.

Recommendation 21: The Canadian Forces must continue their efforts to inform and educate military members and their families about the nature and treatment of OSI, but with an enhanced focus on Reserve Force commanders, personnel and their families, particularly those who reside at some distance from a military installation.

The Government has already taken steps to address the issue covered by this recommendation. The Reserve Medical Link Team has implemented a program that provides annual briefings on health benefits, entitlements, access to care, post-deployment screening and contact information. These annual briefings are mandatory for all members of a Reserve unit, with frequent additional briefings to the units' command elements, and include information on the recognition of the signs and symptoms of OSIs, as well as information on how to access treatment. This program covers a very broad range of mental health illnesses (including PTSD, anxiety, depression, sleep and other disorders, etc.) attributable to operations and each of these illnesses has its specific treatment regime.

In this program’s first year of operations, 90% of target Army Reserve units were briefed. During its second year, Air and Naval Reserve units will be included. All remaining Reservists will be included in the third year of operations. In addition, the newly formed Joint Speakers Bureau which includes mental health clinicians and OSI veterans has been actively educating CF members and the chain of command at all stages of a member’s career on mental health and the importance of creating a supportive environment so members can come forward early for care.

Recommendation 22: The Committee encourages the Minister of National Defence and the Canadian Forces to continue to strive for the compassionate application of existing regulations regarding universality of service and minimum operational standards, to allow the continued employment of recovering soldiers, as long as such employment contributes to Canadian Forces operational requirements.

DND and the CF always strive to treat their members with compassion, while also respecting the boundaries imposed by the principle of universality of service and the National Defence Act. There are currently a number of existing and planned policies designed to retain recovering CF personnel. For example, the CF is authorized to retain personnel who are unable to meet the full requirements of universality of service for a limited period of time as long as they are employable. In addition, there are opportunities available for personnel to serve in a Reserve Force component, which is not subject to the same condition of universality as the Regular and Primary Reserve Forces. Treating our injured men or women in uniform with compassion is the least we can do in respect for the sacrifice they are willing to make for their country.

Recommendation 23: The Department of National Defence should immediately provide enhanced transportation resources (such as modern multi-passenger vans or highway cruiser buses and drivers) to isolated military bases to ensure that military personnel and family members have adequate transportation for access to out-of-town health care services and medical appointments.

DND is currently looking at ways for ill and injured members, and the members of their families who are involved in their treatment, to have access to transportation to access out-of-town health care services, if required. In some locations, Base Commanders have also expended funds to secure accessible transport to enable those requiring assistance to attend appointments with health care providers.

Recommendation 24: The Canadian Forces has an obligation to remind personnel that they have an obligation to keep their families fully informed of medical and social support services available to them. The Canadian Forces must continue to encourage military families to engage those medical and social support services.

The Government recognizes the important role families play in enabling the operational effectiveness of the CF and appreciates the unique nature of military life. Every effort is being made to encourage CF members and their families to use the support resources that are made available to them. In 2008, DND’s Chief Military Personnel initiated a transformation initiative, specifically targeting the enhancement of support to military families. Throughout 2008 and 2009, extensive, broad-based consultations with CF leadership, families and service providers revealed deficiencies in the family support system, and recommended solutions to close the gap between identified family requirements and available services. The CF is examining these solutions and will consider making necessary adjustments to the services currently provided by the Military Family Resources Centres to ensure military families are aware of, and have access to, available medical and social support services in their community.

Recommendation 25: In conjunction with other Federal Healthcare Partnership stakeholders, the Department of National Defence, Veterans Affairs Canada and the Canadian Forces should hold an annual national conference on best practices and advancements in military health care overall, with special emphasis on mental health care.

The Government has begun exploring ways of increasing the interest of Canadian mental health professionals in CF and Veterans issues. In this spirit, a joint VAC-DND Mental Health Information Exchange Symposium, featuring mental health experts was held on 22 January 2009, in Ottawa with participants from DND, VAC, the RCMP and other Government departments. In addition, staff from VAC, as well as from VAC-funded OSI clinics, present in major conferences in relation to operational stress injuries, such as those of the Canadian Psychology Association, the International Society for Traumatic Stress Studies, and the Canadian Centre on Substance Abuse. The Government of Canada will be providing further opportunities for the sharing of best practices and advancements in mental health care by organizing a symposium on psychological trauma and operational stress to be held in 2011 in partnership with the International Society for Traumatic Stress Studies. The Government will also continue to leverage regional education events/conferences that build upon the work already carried out by the CF Health Services Civilian-Military Co-operation Team, with the “Care to the Wounded Soldier Initiative.” This initiative involved a series of educational events that brought health care providers and senior health care administrators within geographical regions together to participate in briefings on the health needs of the CF ill and injured soldiers, including mental health care needs, and proved very successful as a forum for information sharing.

Recommendation 26: The Canadian Forces should ensure that personnel in units returning from operational tours of duty are exempt any (sic) further non-operational deployment away from their unit for the defined duration of the post-deployment reconstitution phase, unless to do so would negatively affect patient well-being according to mental health professionals.

Recommendation 27: The Canadian Forces should ensure continuity in the chain of command in units returning from operational tours of duty, particularly at lower levels, remains in place, as much as operational requirements allow, during the post-deployment reconstitution phase.

The Canadian Forces issued a policy imposing a mandatory respite period of 60 days. The Army has extended this period to 90 days. During that time, soldiers are not subject to short- or long-term postings, or temporary duty. Rotation dates are normally deferred to preserve the continuity of the chain of command and ensure that personnel have a chance to re-adjust at home before reporting to a new chain of command. These personnel tempo policies are based on extensive research that demonstrates the value of spending time close to the family during a soldier’s reconstitution phase. However, the Government recognizes that some exceptions to this rule may be unavoidable in particular cases. For instance, personnel returning from operational tour may be sent to training establishments in order to bring their recent operational experience into the training being dispensed to the next generation of soldiers. But waivers to the mandatory respite period are only authorized by the Commanding Officer for operational and training necessity, unique military occupational category requirements or temporary tasks when no other solution is possible. These exceptions take into consideration any restriction imposed by a health care professional as well as the member's preference. When training away from home cannot be avoided, all efforts are being made to privilege distance learning with a short residency period. The Army also brings training closer to home by offering courses in more locations throughout the country whenever possible.

Similarly, the Navy manages personnel tempo in accordance with current policies although again, exceptions may occur. For instance, if the ship enters a period of inactivity, it may be necessary to send crewmembers to the active ships according to need or undertake necessary professional training, which is not possible at other times during the operational cycle of a ship. While the duration of the training can vary, it should be noted that posting from the unit does not necessarily mean a posting from the geographical area. With only two bases and a number of different units on each base, it is normal for a sailor, as opposed to a soldier, to spend the vast majority of his/her career being posted between ships, schools and shore units on a single base. This, coupled with a strong divisional system wherein all the information necessary to effectively manage personnel is maintained and moves with the member, leads to rapid establishment of effective crewmember and supervisory relationships. Finally, all naval deployments include an inherent period of decompression while the ship transits home, which can take weeks.

The Air Force also complies with the 60-days respite period policy when members are returning from an operational tour of duty. Moreover, as much as operational requirements allow, returning members remain within the same chain of command. As with the Army and the Navy, there are situations where it is necessary to move personnel from one unit to another, but for the most part, they are retained within the same geographical region. Two exceptions are notable, however. First, Aurora aircrew, for operational necessity, must travel to Greenwood ( Nova Scotia) to re-qualify immediately after their post-deployment leave in order to return to flying duties. Similarly, due to high operational tempo and personnel shortages, some of the tactical helicopter aircrews are required for domestic operations within the 60-day respite period.

Recommendation 28: The Canadian Forces should develop health services doctrine to cover the care and treatment of Canadian Forces casualties from the point of evacuation to recovery or release and transfer to Veterans Affairs Canada support.

The Government is committed to providing CF personnel with comprehensive care, services and treatment. VAC and the CF have a strong partnership and collaborate closely to harmonize services policies and programs so that CF members and their families can have continuity of support and successfully transition from military to civilian life. DND and VAC will continue to work together to review and improve the policies, processes, and protocols that exist to support injured CF members and their families, and to identify gaps, duplication/fragmentation of services and issues requiring resolution. Separate CF doctrines exist for the full spectrum of health care from point of wounding until evacuation to Canada, and various policy and guidance documents address care within Canada until release, recovery, or transfer of care to VAC. The Government recognizes there may be value-added in having an overarching approach that would ensure continuity of care and support for CF members and their families as they transition from the CF. While it is the sole responsibility of the CF to develop health services doctrine associated with caring for their sick and wounded members, it is important that any overarching approach include early involvement by VAC in the transition process prior to releasing members.

Recommendation 29: The Canadian Forces should ensure their extended health services doctrine includes measures addressing OSI from recruitment through to retirement, with particular emphasis on the preparation of soldiers to endure psychological traumas before they engage in combat operations. The Canadian Forces should investigate best practices in psychological preparation for OSI and PTSD.

The CF has already taken actions to improve the pre-deployment psychological preparation of soldiers including investigating best practices. Recently, work has begun on a standardized pre-deployment package on mental health. This package will be used across the CF with an anticipated delivery date of fall 2009. The CF continually investigates best practices with respect to OSI and PTSD. Moreover, the Canadian Forces utilize evidence-based best practices as endorsed by organizations such as the International Society for Traumatic Stress Studies. In developing a comprehensive health services approach, DND will make sure to include measures to address OSI at the pre-deployment stage. In addition, the Mental Health Education Advisory Committee is currently working to harmonize all mental health education for CF personnel, throughout the career and deployment cycles, to give them tools and skills for early psychological intervention. All educational content is based on the most recent and relevant research on best practices in psychological preparation for military operations.

Recommendation 30: The Department of National Defence and the Canadian Forces should institute a program, in concert with Provincial and Territorial governments, to monitor best practices for the cooperation and integration of Canadian Forces health services with local community health and social services, and implement common high standards.

The Government appreciates the importance of monitoring best practices for cooperation with local community health and social services. The implementation of common high standards of patient care for all patients in Canada should be a priority for all care providers whether they are under a Federal or Provincial healthcare system. The CF will leverage their Health Services Group’s valuable experience regarding cooperation with civilian health services in the provision of care to CF members. The CF Health Services Group will continue to strive to share relevant best practices with civilian and military health care providers across the country, while respecting provincial/territorial jurisdiction in health care.

Recommendation 31: The Canadian Forces should ensure that a military padre or contracted religious/spiritual advisors are available at any third location decompression centre and are included in the Canadian Forces strategy on mental health care.

The Government recognizes the value of religious or spiritual advice in addressing mental health issues. In fact, the CF already provides two military padres to third location decompression. In addition, chaplains with an advanced degree in counseling are part of the interdisciplinary team of care providers providing spiritual care to CF members at Operational Trauma Stress Support Centre Programs.

Recommendation 32: The Canadian Forces should regularly review the composition of the Operational Trauma Stress Support Centre multi-disciplinary teams and remain open to the addition or use of clinical professionals not traditionally found in the military health care system, such as registered marriage and family therapists and that the services thereof be added to the dependents’ Extended Health Care schedule of covered benefits.

The Government has already taken action in this direction. The present teams are composed of the following professionals who are members of a professional regulatory organization with the accompanying provincial statutory authority: family physicians, psychiatrists, social workers, mental health nurses and psychologists. Presently registered marriage and family therapists are regulated only in Quebec and are seeking regulatory status in other provinces. Once they are regulated the CF will assess their potential contribution to the care of CF members and their families, as well as their potential addition to the dependents’ Extended Health Care schedule of covered benefits.

Recommendation 33: The Canadian Forces should provide this Committee, the Auditor General of Canada and the Department of National Defence and Canadian Forces Ombudsman with a full, unclassified update of the status of the Canadian Forces Health Information System, along with a meaningful explanation of when it will reach full operational capacity.

Recommendation 34: The federal government should move immediately to provide the necessary resources to reach full operational capability of the Canadian Forces Health Information Systems project, with the assistance of a database.

The CF Health Services Group would be pleased to provide additional briefings on the Canadian Forces Health Information System (CFHIS) and its future needs. As such, the CF Health Services Group will develop a presentation and make arrangements to set up briefings for the Committee, the Auditor General and the CF Ombudsman as outlined in recommendation 33. These briefings could take place this fall. A revised schedule and costing should be available this fall and will be shared with the Committee, the Auditor General and the CF Ombudsman as part of the briefings.

The CFHIS will improve the management of health information that is created within CF facilities. However, CF members also receive care from the public health care system. Accordingly, full operational capability of the CFHIS will not be realized until the CFHIS is rolled out to each CF Clinic and then connected to the emerging pan-Canadian Electronic Health Record. This will then allow care providers in both the CF and the public health care system to have complete health information. As recommended, the CF, as a member of the FHP, is collaborating with other federal organizations with similar needs in a whole of government effort towards identifying the requirements for federal participation in the pan-Canadian Electronic Health Record.

Recommendation 35: The federal government should initiate cooperative programs with provincial and territorial governments, to offer incentives to qualified professional health care workers, to provide their services to Canadian Forces personnel and their families, in locations where there is a shortage of such services.

Recommendation 36: The federal government should continue to work in cooperation with provincial and territorial governments to enhance relationships between local community health and social services to enhance and Canadian Forces health care services.

In fact, much of the mechanics to facilitate such cooperation are already in place. As indicated in Recommendations 5 and 25, forums for discussions with Provinces and Territories and regional and local health authorities are in place. These include, but are not limited to, the Advisory Committee on Health Delivery and Human Resources, the Health Human Resources Partnership and Planning Sub-Committee, and the activities led by the CF Health Services Group. In Ontario, Memoranda of Understanding between the CF and the Local Health Integration Networks are being developed to facilitate access to community health services. As previously mentioned, the FHP Partners have also instituted the Office of Health Human Resources to build health services capacity within the federal government enabling the CF, for example, to better service its members, including families. The FHP, appreciating the value of further developing the relationships with Provinces and Territories, has invited one of the Co-Chairs of the Advisory Committee on Health Delivery and Human Resources to attend FHP Executive Committee meetings. This  provides a vehicle to keep the FHP partner organizations up to date on activities with Provinces and Territories and a forum through which the FHP partners can raise issues they are facing and on which they would like to work collaboratively with Provinces and Territories to address.