Introduction

The health and wellness of Canadian Armed Forces (CAF) members are critical to overall force readiness: successfully achieving its missions while executing concurrent operations as outlined in Canada’s defence policy, Strong, Secure, Engaged. The Canadian Forces Health Services Group (CFHS), which is responsible for providing health care services to CAF members, is facing challenges similar to those experienced by provincial and territorial health care systems (hereafter, civilian health care systems) across Canada. Many of these challenges, including human resource and funding issues, were compounded by the COVID-19 pandemic at a time when, through Operation Laser, the CAF demonstrated an unwavering commitment to Canadians’ health and safety. CAF members and military families deserve the same level of dedication and support to ensure their well-being throughout their service, transition out of the CAF, and veteran life.

On 6 October 2022, the House of Commons Standing Committee on National Defence (the Committee) adopted a motion to examine health care and transition services in the CAF. In part, the motion stated the following:

That, pursuant to Standing Order 108(2), the Committee undertake a study on the military health system and provision of health services under the Canadian Forces Health Services Group, and on challenges associated with medical release and transition to civilian life with particular focus on mental health, operational stress injuries, and the availability of healthcare to CAF family members […].

The Committee held four meetings on this study between 28 April and 2 June 2023, during which 21 witnesses appeared and five written briefs were received. It also adopted a motion to consider the evidence received by the House of Commons Standing Committee on Veterans Affairs during its study on the “Experience of Women Veterans.”^[1] This report summarizes comments made by witnesses about the current state of health care services and transition services available to CAF members. The first section is focused on CAF health care and wellness services; in addition to providing an overview of these services, it examines resource challenges, specialty care and chaplain services. The second section contains observations relating to mental health services in the CAF, and the third section discusses the health care experiences of CAF women during their military service and transition to civilian life. The fourth section points out issues concerning military families’ access to health care services, and the fifth section outlines services offered when CAF members transition to civilian life. The report’s concluding section contains the Committee’s thoughts and recommendations.

Canadian Armed Forces Health Care and Wellness Services

By offering various supports and services to CAF members throughout their military career, whether they are healthy, ill or injured, deployed on an operation or transitioning to civilian life, the CFHS plays a vital role in helping to ensure that the CAF is capable of fulfilling its missions. Witnesses provided the Committee with their observations about CAF health care services. In particular, they presented an overview of those services, identified resource challenges, discussed difficulties relating to the provision of specialty care, and addressed the role played by chaplain services in providing spiritual support to CAF members.

Overview

Characterizing the CFHS as “a key enabler to [CAF] military missions around the world” through providing pre-hospital, primary, surgical and specialized care, Lieutenant-General Lise Bourgon—the CAF’s Acting Chief of Military Personnel and Acting Commander of Military Personnel Command—referred to the long-term health and wellness of CAF members, as well as the provision of high-quality health care to them, as priorities. She indicated that these goals are “achieved primarily through the Canadian Forces Health Services Group, which is responsible for the care and well-being of about 64,000 regular forces members as well as our reserve forces members on operations or in full-time service.” According to her, the CFHS provides health care services through 37 primary care clinics located across the country that are usually led by a family physician and that can also have multidisciplinary teams comprising social workers, mental health nurses, psychologists, psychiatrists, addiction counsellors and mental health chaplains. Major-General Marc Bilodeau, the CAF’s Surgeon General, identified “physiotherapy and mental health” services as the “two main areas of focus from a health care perspective.”

Senator Rebecca Patterson, a former Commander of CFHS who appeared as an individual, distinguished the CAF health care system from the civilian health care systems accessed by most Canadians. She explained that CAF members are not issued provincial health cards, and that they instead “receive health services through military health care facilities and not via a local provider in their community.” Moreover, Senator Patterson outlined that “the military system provides a spectrum of occupational health services in Canada. This includes medical, dental, [pharmaceutical], mental and physical health across Canada and around the world.” She elaborated by saying that the system “is also responsible for medical and dental procurement of material and equipment, research and development, logistics and recruitment, retention and the training of military health human resources.” At the same time, she identified a need to invest in CAF health services infrastructure.

Resource Challenges

Witnesses drew attention to some structural issues associated with the CAF health care system that have strained both financial and human resources. According to Senator Patterson, in situations where a CAF member requires health care services not provided by the CAF, such as magnetic resonance imaging (MRI), the member is referred to a provider in a civilian health care system or a private clinic. Major-General Bilodeau stated that certain CAF primary care clinics have “some diagnostic technology, such as X-rays and labs, but not … all of them. We need to outsource everything that goes beyond that, including specialty care and hospital care, because we don't have it in the military [health care system].”

Outsourcing arrangements for needs that cannot be met by the CAF health care system are typically negotiated with the provinces and territories. In Senator Patterson‘s view, the CAF’s purchase of health care services often occurs at “exaggerated rates, just like [those experienced by] non-Canadians,” with these rates affecting defence spending because funding for the CAF health care system is “from a fixed budget” within the Department of National Defence (DND). She added that, if the baseline funding allocated to that system is insufficient, the needed funds must be obtained through a reallocation from other areas within DND.

As well, Senator Patterson referred to a 2018 internal evaluation of the CAF’s health care system found that spending on this system rose at a rate of 0.7% between 2010–2011 and 2016–2017, which was lower than the national rate of 3.3% per year. In her view, there is a “diminished buying power within the CAF relative to the health care it is expected to provide.” To address the issue of the CAF purchasing services for its members at “exaggerated rates,” she encouraged the Minister of National Defence, along with relevant health and intergovernmental affairs officials, to “[work] with provincial governments to negotiate better rates more closely aligned with those charged within the provincial health care systems, if not the same rate.”

Senator Patterson also highlighted difficulties in two areas: ensuring surge capability; and maintaining clinical competency requirements. About surge capability, she noted that “health service personnel in the CAF are fully trained sailors, soldiers and aviators,” and that “one way the health human resource component of the Canadian Armed Forces health services is structured is that you have a military-civilian mix of teams, meaning that the backbone was always intended to be civilian care providers, allowing uniformed personnel to maintain their clinical competencies.” Moreover, Senator Patterson observed that CAF health services personnel are “posted all over the world on a regular basis, and it's extremely hard to maintain required clinical competencies.”

Discussing the health care services available to CAF members deployed abroad, Lieutenant-General Bourgon claimed that the types of services available depend on “the location of our troops. … In some areas we have our own clinic, but in some areas we only have our own integral medical support.” She added that, in certain situations, the CAF can access both medical support from allies and national medical services in the foreign country. Brigadier-General Scott Malcolm, Commander of the CAF’s Health Services Division, clarified that, in Kuwait, Poland and the Indo-Pacific region, the CAF relies on integral medical support, but that a referral can be given if a required service is not immediately available. He indicated that, for CAF personnel who have experienced a traumatic or stressful event, “the first assessment is always with our [medical technician] or the next available provider. … If there's no one in the immediate area to support them, they can be referred either to local civilian care or, if necessary, repatriated back to Canada, or if they are in theatre, to one of our locations like Geilenkirchen where we have a clinic.”

Senator Patterson mentioned the regulatory obstacles that some CAF health services personnel experience when posted from one province or territory to another. She referenced the United States’ federal health care system, which has “licensure and federally regulated care providers at the national level,” and suggested that “there is an opportunity for the CAF to lead on either a federal regulatory approval system or greater interprovincial recognition of licensing.”

Witnesses addressed the CAF’s ongoing recruitment and retention challenges in relation to health services. Lieutenant-General Bourgon indicated that the CAF has a shortfall of about 8,000 Regular Force members and commented that, “from a chief of military personnel standpoint, recruitment, retention and training modernizations are my number one priorities. All are important, and indeed the medical side has suffered.”

Senator Patterson said that health care human resource shortages are a “pan-Canadian health care issue,” and underlined that the CAF competes directly “with other sectors and the Canadian public, not only to find people who wish to wear uniforms but also to find public servants or even contractors to [provide health care services].” Regarding the CAF’s hiring of health care providers on contracts, she acknowledged that there have been “complaints” about this practice, but maintained that, “if you cannot employ a health care provider through the public service because the salaries themselves are too low, there is no other choice because to go without care means that you don't have people ready for deployment.” Senator Patterson stated that “[s]alary and quality of life are often higher outside the military for health care providers,” and urged “a review of all the occupations within the public service that deliver direct clinical care to make sure that salaries and benefits are competitive.”

Major-General Bilodeau indicated that the CAF is using a range of recruitment tools to hire for 19 health care occupations and noted that “[t]here are people working full time for us in different areas of the country where the main focus is really to recruit health care professionals on our behalf.” Referring to the CAF Total Health and Wellness Strategy, which calls for the hiring of, among other personnel, 30 more occupational therapists and 48 additional nurse case managers, he commented that the CAF has “done a first wave of hiring” for those positions and added that “[t]his year we're receiving a second wave of funding that will allow us to complete the hiring process.”

According to Major-General Bilodeau, the hiring of CAF health services personnel, including occupational therapists and nurse case managers, is ongoing. He mentioned that “a lot of people are leaving [the CAF] after their obligatory service because they've decided to do something else with their lives,” and argued that “[w]e need to do better from a retention perspective and try to make sure that we keep them excited while they’re serving.”

Specialty Care

Witnesses addressed CAF members’ access to health care specialists. Major-General Bilodeau recognized that an increased reliance on telemedicine has certain advantages, including through enabling greater access to such specialists. In his opinion, telemedicine allows the CAF to provide health services to members deployed abroad or to locations lacking a nearby clinic, and it facilitates virtual follow-up appointments if members are deployed to other locations. However, he also noted:

The challenge involves the fact that our current telemedicine system isn't fully integrated with our electronic health records system. It's a real problem, mainly in terms of coordination and logistics. These problems should be resolved within a few years, with the modernization of our various systems.

Dr. Ayla Azad, Chief Executive Officer of the Canadian Chiropractic Association, emphasized that musculoskeletal (MSK) injuries are a significant occupational risk for CAF members and are “responsible for 42% of medical releases.” She claimed that, “[d]ue to the physical demands put on active military personnel, MSK conditions like back and neck pain are double that of the general population. These conditions are a key issue for transition services, as 59% of veterans who report difficult adjustment to civilian life had chronic pain.”

Expressing concern that CAF members must receive a referral for chiropractic care for which an insurance claim can be made, which may lead to delays in receiving needed care, Dr. Azad pointed out that no provincial or national health regulation requires a referral “before accessing chiropractic care,” and contended that such an approach “is not best practice in the health insurance industry.” Dr. Azad characterized this referral requirement as a “barrier” to accessing care. She also stressed:

There's well-documented research that patient-centred care includes choice of provider. This results in improved outcomes. Some people respond well to physiotherapy. Some people respond well to chiropractic [care]. Some may need both. It seems disrespectful that our brave [CAF] members don't have the same choice and require a referral.

In a brief submitted to the Committee, the Canadian Chiropractic Association explained that, for CAF members to access chiropractic care for which an insurance claim can be made, they first require a physician’s referral to care provided off the military base. This requirement can involve:

[a] physician appointment where the physician will review the patient’s history, do an assessment, and diagnosis, and usually first try an on-base course of care. When the issue persists they may get a referral where the doctor of chiropractic [medicine] repeats the assessment process. This process takes significant time and delays access to care, allowing acute conditions to become more complex. [Canadian Chiropractic Association] members hear many stories of CAF members preferring to pay out of pocket rather than deal with the prolonged process of getting a referral.^[2]

In this context, the Canadian Chiropractic Association encouraged the Government of Canada to take two actions: reduce the likelihood of developing chronic MSK issues by ensuring that CAF members have timely access to chiropractic care; and remove the referral requirement for insurance coverage of chiropractic benefits.^[3]

Dr. Azad described the 10 chiropractic visits offered through Medavie Blue Cross benefits as “inadequate” for CAF members. In her view, this number of visits “might be enough to cover an acute case of injury, but we know that MSK conditions like low back pain can reoccur, and there is a chronicity to them. Veterans, for example, get access to 20 visits.” Relatedly, the Canadian Chiropractic Association’s brief proposed an increase in the number of chiropractic visits available to CAF members.^[4]

Arguing that “[c]hronic pain and mental health are directly connected,” Dr. Azad indicated that “65% of people who have chronic pain will also have a mental health issue.” She underscored that, because of the prevalence of MSK conditions among CAF members, “chiropractic [care] can play a role in improving health outcomes and quality of life.” Dr. Azad noted that, in the United States, chiropractic services are available on U.S. military bases as part of “interdisciplinary integrated models” that provide both mental and physical health treatment and care to U.S. military members. The Canadian Chiropractic Association’s brief proposed that such integrated models could be developed for CAF members and urged the CAF to “[o]ptimize team-based care and interprofessional collaboration to treat MSK condition[s].”^[5]

Dr. Azad also raised the importance of preventative care, suggesting that “[i]t would make sense” for massage therapy, in addition to chiropractic care, to be a benefit for which an insurance claim could be made.

Chaplain Services

Witnesses recognized that spiritual well-being is an important part of overall health and wellness and discussed the role of the Royal Canadian Chaplain Service in supporting CAF members. According to Dr. Andrew P.W. Bennett, Director of Cardus, the CAF’s unique work environment can lead CAF members to be exposed to physical and mental illness and injury, and they must have “access to high-quality care for their spiritual health.” He added that “[p]astoral care is also indispensable to aid in spiritual healing, healing that has beneficial outcomes for the whole person.”

Lieutenant-General Bourgon underscored that the CAF must respect every religion and stressed that, led by the Chaplain General, every chaplain “has to first respect the values of the CAF by serving every member and being inclusive. If a chaplain … cannot meet the CAF values because their faith restricts them from doing that, then honestly, the CAF is not the place for them.”

In Dr. Bennett’s view, chaplains must “be fully able to exercise their freedom of religion” and “[t]his freedom must not be unduly hindered such as through a mandated requirement to adhere to a prevailing secular creed or to conform to a political ideology of any stripe.” In this context, he said that the Minister of National Defence should “firmly and publicly reject the discriminatory sections of Recommendation 6, ‘Re-Defining Chaplaincy,’ contained in the April 25, 2022, final report of the Minister of National Defence’s advisory panel on systemic racism and discrimination.”^[6] As well, Dr. Bennett advocated the establishment of a permanent committee of religious leaders who would report to both the Minister of National Defence and the Chaplain General.

Noting that the CAF is “looking at a much more inclusive chaplain group,” Lieutenant-General Bourgon observed that both the number of chaplains and the non-traditional faith of chaplains have grown, and commented that the CAF now has “a Muslim chaplain, an Indigenous chaplain, and a humanist chaplain … .” She pointed out that chaplains have specialized training and, in many cases, have a background in social work that allows them to provide support “across the spectrum [of spiritual needs].”

Mental Health Services

Mental health conditions exist among military members globally. In Canada, CAF members and veterans tend to exhibit a higher prevalence of mental health conditions than the general population, including suicide.^[7] Several studies published between 2014 and 2021 indicate that CAF members and veterans are at a higher risk of death by suicide than the general population in Canada.^[8] Witnesses provided the Committee with information concerning the effects of mental health conditions on CAF members and veterans, challenges with accessing mental health supports and services, and certain existing and desired measures for addressing mental health conditions among CAF members and veterans.

Matthew McDaniel, National Clinical Director of the Veterans Transition Network, drew attention to recent progress in acknowledging the mental health challenges experienced by segments of the Canadian population, including CAF members. He expressed hope that, as part of a cultural shift within the CAF and society as a whole, discussions are being held about the need to address mental health challenges among CAF members. Moreover, Dr. Linna Tam-Seto, Assistant Professor at McMaster University and Researcher at the Canadian Institute for Military and Veteran Health Research, asserted that increased awareness about—and decreased stigma regarding—mental health conditions experienced by CAF members have contributed to a rise in the reporting of such conditions.

According to Duane Schippers, Deputy Veterans Ombud, women veterans have a higher likelihood of being diagnosed with post-traumatic stress disorder (PTSD) than women in Canada’s general population. He also noted that CAF women who leave military service as non-commissioned members “are three times more likely to die by suicide” when compared to those who leave as officers. Moreover, he estimated that men veterans have a 40% higher risk of dying by suicide than men in Canada’s general population.

Although the stigma associated with accessing mental health services has decreased over the last 20 years, Major-General Bilodeau contended that some CAF members continue to be concerned about career impacts if they access such services. He suggested that this issue should be addressed by ensuring that the CAF’s leadership continues to play an important role in leading efforts to reduce the stigma concerning, and normalizing access to, the CAF’s mental health services.

Dr. Catherine Phillips, Psychiatrist and Assistant Clinical Professor in the Department of Psychiatry at the University of Alberta’s Faculty of Medicine and Dentistry, submitted a brief to the Committee that discussed linkages between culture change and the provision of mental health services. The brief described Dr. Phillips’ working conditions as a Consultant Psychiatrist with Mental Health Services at the Edmonton Garrison, where she witnessed a “pervasive culture of bullying, harassment and mobbing of patients in their units, at times by health care providers,” that led to adverse outcomes from the perspective of patient care. Dr. Phillips’ brief also identified the existence of “nonverbal pressure to not diagnosis PTSD” and a disregard for recommendations by specialists regarding treatment.^[9]

Outlining the CAF’s initiatives and programs designed to address mental health challenges, Lieutenant-General Bourgon mentioned three programs: the Mental Health Program and the Road to Mental Readiness Program for CAF members and military families, and the Resilience Plus program for students at Canada’s military colleges. Laurie Ogilvie, Senior Vice President at Canadian Forces Morale and Welfare Services, described the Road to Mental Readiness Program as “mental health first aid,” indicating that this program teaches CAF members about signs and symptoms of, and “help-seeking strategies” for addressing, mental health conditions.

Nick Booth, True Patriot Love Foundation’s Chief Executive Officer, highlighted the COVID-19 pandemic–related cancellation or digitalization of certain mental health programs available to CAF members and veterans. He argued that some of these programs, including those for “people suffering from service-related mental health conditions,” should be restored and/or offered in-person, especially to individuals who have challenges in accessing mental health services virtually.

Witnesses identified a need to address gaps in mental health services available to CAF members and veterans. Colonel (Retired) Richard Pucci, who appeared as an individual, asserted that “[m]any [CAF] members retiring today do not have the same level of access” to psychologists or other mental health care providers as in previous years. Concerning adequate support for mental health conditions, Matthew McDaniel suggested that certain segments of the Canadian population including veterans—are “falling through the cracks.” That said, Colonel (Retired) Pucci acknowledged recent efforts by the CAF, Veterans Affairs Canada (VAC), firms and veterans support networks to increase the support provided to CAF members and veterans who are experiencing mental health conditions.

Focusing on CAF Reserve Force members, Gregory Lick, National Defence and Canadian Armed Forces Ombudsman, drew attention to a “systemic investigation” that the Office of the National Defence and Canadian Armed Forces Ombudsman conducted recently concerning the mental health of such members deployed on domestic operations. He said that these members are sometimes not aware of “all the benefits, services and supports they can receive as a result of injury—whether it's to mental health or physical health—acquired on a domestic operation.” As well, he called for periodic health assessments of these members to assess their mental and physical conditions, and to provide them with information about benefits, services and supports.

According to Major-General Bilodeau, the CAF conducts periodic mental health assessments of its recruits and members, including pre- and post-deployment, to identify the points in their careers at which members are “suffering from mental health issues,” and to provide them with adequate support for those issues. He also indicated that CAF members have access to mental health services through telemedicine. Furthermore, Brigadier-General Malcolm estimated that, as of 28 April 2023, the CAF had approximately 500 mental health service providers, including mental health nurses, psychiatrists, psychologists and social workers, across Canada.

Describing the process for providing treatment to CAF members deployed abroad who have an operational stress injury, Brigadier-General Malcolm said that the process could involve CAF medical technicians conducting assessments of, and providing treatment to, CAF members or referring them to “local civilian care,” when required. He also pointed out that CAF members could be repatriated to receive treatment at an operational stress injury clinic.

With a focus on mental health conditions among veterans, Steven Harris, VAC’s Assistant Deputy Minister of the Service Delivery Branch, and Colonel (Retired) Nishika Jardine, Veterans Ombud, stated that, in April 2022, VAC created a mental health program that allows veterans to submit disability claims for certain mental health conditions so that they receive “immediate” access to treatment. Colonel (Retired) Jardine suggested that timely access should be available to all veterans making disability claims, including those with non-mental health conditions. Steven Harris also discussed VAC’s centre of excellence on mental health conditions, the Atlas Institute for Veterans and Families, that conducts research on PTSD and other mental health conditions with the goal of assisting family physicians and other health care providers in providing treatment to veterans.

Commodore Daniel Bouchard, Commander of the Canadian Armed Forces Transition Group, referred to the CAF and VAC’s Operational Stress Injury Social Support Program, which includes peer support for CAF members, veterans and military families. Steven Harris commented that VAC has clinics and other facilities where veterans can seek treatment for occupational stress injuries and added that clinic members work alongside their counterparts in civilian health care systems to provide care.

Addressing “military sexual trauma” (MST), Mathew McDaniel underlined that, when compared to their counterparts who are men, “women veterans often struggle more significantly in their transition” to civilian life because they have a relatively higher rate of MST. Dr. Tam-Seto mentioned that veterans who have experienced MST are accessing treatment at operational stress injury social support clinics and emphasized the need for service providers to “understand the nuanced contexts of what it means to have acquired military sexual trauma, which is very different from civilian trauma.”

Steven Harris asserted that DND, the CAF and VAC are committed to supporting “veterans who have unfortunately been victims of sexual misconduct” and who suffer from MST. Lieutenant-General Bourgon noted that both the Operational Stress Injury Social Support Program and the Sexual Misconduct Support and Resource Centre have made efforts to develop a network for, and provide services to, CAF members affected by sexual misconduct and MST.

Finally, discussing crisis and suicide prevention services provided to CAF members, Myriam Lafond, Managing Director of Crisis Centre and Suicide Prevention of Haut-Richelieu Rouville, argued that “it’s much better” for the CAF to make referrals to crisis and suicide prevention centres than to hospitals. In her view, the centres are better able to “provide real psychological support, administer specific treatments to defuse the suicidal crisis and help [CAF members] to regain some control over the situation and the suffering they are enduring.”

Health Care Services for Canadian Armed Forces Women

Historically, military and veteran systems were designed by men for men even though military service affects men and women in different ways. Witnesses underscored that, while these systems are becoming more inclusive, they do not adequately consider women’s distinct physical or mental needs. In this context, they emphasized that a number of issues relating to health care services during both military service and while transitioning to civilian life need to be addressed.

During Service

Witnesses identified several areas where the CAF health care services could be improved for its members who are women or gender diverse. Dr. Maya Eichler, Canada Research Chair in Social Innovation and Community Engagement at Mount Saint Vincent University, contended that “[t]here is little to no support or research in place in Canada today to address women’s sex- and gender-specific needs, but also, women have had to work within a system that potentially causes additional harm, injury and illness because it was built without them in mind.”^[10] In Lieutenant-General Bourgon’s view, “[w]omen and gender-diverse personnel deserve to have their health and wellness made a national priority from the time they put on the uniform through to transition and retirement.”^[11]

Major-General Bilodeau commented that, within the CAF, data and screening for breast cancer and cervical cancer are “on par with Canadian society.” However, he also recognized that “we can do a lot better.” Referring to recent funding provided to the CAF to build a women’s health program, Sayward Montague, Director of Advocacy for the National Association of Federal Retirees, explained that “[t]he 2022 budget signalled a commitment to more equitable outcomes, with more than $144 million over five years and $31.6 million ongoing to expand the armed forces health services and physical fitness programs to be more responsive to women and gender-diverse military personnel.”^[12]

As well, witnesses suggested that Government of Canada funding should be allocated in ways that would close the gap in health data and research between CAF men and CAF women. Major-General Bilodeau asserted that “more research is required in order to inform better care for [CAF] women,” and mentioned future “engage[ment] with our research partners to fill those gaps from a research perspective and have better data to monitor the health of women as well as the efficacy of our preventive measures and treatment measures.” He added that “we need to have better quality and performance measurement regarding the health of our women.” In a brief submitted to the Committee, Dr. Karen Breeck, a former CAF medical officer who appeared an individual, underscored the importance of sex- and gender-based analysis and intersectional health research findings for informing military health care systems.^[13] In her brief, Dr. Breeck urged the CAF to “update the CFHS’s archaic electronic medical system” to facilitate improved collection of health data regarding CAF women, and to rely more heavily on patient feedback or “participatory research.”^[14]

Lieutenant-Colonel (Retired) Karen McCrimmon drew attention to the issue of inappropriate military equipment for women, asserting that “[p]hysical injuries, like musculoskeletal injuries, are still being caused today by equipment and uniforms that weren’t designed for a woman’s body. Uniforms and equipment are all replaced periodically so there needs to be a continual assessment of their suitability for women.”^[15] Dr. Breeck supported gender-based analysis of new procurement projects, from equipment to ship accommodations, and acknowledged that “[t]hese things are already taken into account on newer ships, but we still have a lot of older equipment.”

Describing the impact on women of using equipment designed for men, Christine Wood, who advocates on veterans issues, stated the following:

As the shortest and smallest person in my platoon, I wore the same size rucksack carrying the same equipment a large man would wear. After 15 gruelling weeks, I left St. Jean with my commission as an officer, along with stress fractures and plantar fasciitis in both feet. It took five months of physiotherapy to get myself back up and running.^[16]

She also underlined that, in her case, ill-fitting equipment contributed to pelvic floor weakness and related reproductive complications.

Witnesses also made comments about reproductive health among CAF women. According to Dr. Breeck, “[m]any military and veteran women are challenged to get pregnant, stay pregnant, stay healthy during and after their pregnancies and have healthy offspring.” She suggested that members who have experienced these challenges are uncertain about the role that the military workplace might have played. Dr. Breeck warned that “[t]he potential reproductive health impacts from military-specific workplace exposure to chemicals, extreme temperatures, pressures, vibrations, sound, radiation and traumas are simply not the same for men and women. It is critical that the risks and effects of non-traditional workplace exposures are better understood for [CAF] women.”

Lieutenant-General Bourgon claimed that the CAF is “examining prenatal and postnatal support and occupational assessments associated with fertility and reproduction.”^[17] Underlining the need for a “multidepartment collaborative approach” to women’s reproductive health in non-traditional sectors, Dr. Breeck urged the Minister of National Defence to “develop a strategic plan for the occupational health needs of all federally employed women” and proposed that the CAF should provide its personnel with insurance benefits to “freeze their sperm/eggs.”^[18]

Witnesses were concerned about the outsourcing of perinatal care for CAF women. Senator Patterson argued that the CAF “needs support to continue to develop [the women’s health program], which includes bringing [obstetricians/gynecologists, or OB/GYNs] on board.” Major-General Bilodeau noted that the CAF is “currently in the process of hiring specialists, OB/GYNs, who will help us provide advice to build a better program” for providing care to CAF members during the perinatal period. He mentioned that, in February 2023, Canada hosted Five Eyes partners to discuss the health issues of women who are serving in the military, and that the partners agreed to “keep working together to develop clinic practice guidelines that will allow us to move together in improving women’s health in the military.” Recognizing the benefits of pelvic floor therapy, Lieutenant-General Bourgon referenced initiatives that will allow “parents with their newborn [to] go to the gym and have physical fitness developed for them. It’s both prevention and recovery.”

Dr. Breeck also discussed health care services for CAF women and gender-diverse personnel while they are deployed. She explained that “[w]hen we’re deployed … we’re often isolated by ourselves and have to figure out how to do things.” She provided the example of a United Nations (UN) mission, where health resources or assets equivalent to those in Canada may not be available. She elaborated by saying:

[T]o my knowledge, [there are no] minimum medical standards of women’s health training for the UN-level health. … We often still don’t have the basics in some of the UN kit, so things like birth control pills or the kinds of medications that would be needed after a sexual assault, vaginal infection information or even just a speculum, instruments to be able to properly examine a woman’s vagina. … At one stage I was in Germany, and we would have women still having to come up from Afghanistan to Germany to get primary medical care that would have ideally been dealt with on site if we all had a higher level of awareness of the right products, the right treatments and how to deal with common women’s issues.

Dr. Breeck stressed the importance of having women’s health issues be normalized and fully integrated into the CAF health care system, including for personnel who are deployed. She suggested that “[a]ll deployable military health care providers should be capable of meeting both men’s and women’s health care needs.” In her view, standardizing medical care in an allied operating environment would also be beneficial.^[19]

Regarding the disclosure of a sexual assault, Major (Retired) Donna Riguidel stated that “there is still no mandatory training for that really important trauma first aid, that mental health first aid, when somebody comes forward.”^[20] Dr. Breeck proposed that the CAF “[f]ollow U.S. military precedent and offer barrier-free access to related medical care/supports (mental and physical) for those identifying as impacted by MST.”^[21] She also encouraged the Government of Canada to define whether operational stress injuries include MST so that related benefits and services can be provided, when appropriate.^[22]

During the Transition to Civilian Life

Witnesses underscored that, as with their military service, CAF men and women have different experiences as they transition to civilian life. Dr. Tam-Seto observed that “a lot of individuals who identify as women have difficulty accepting an identity as a veteran because of what society stereotypically sees veterans as.” Dr. Laura Kelly, Director of the Strategic Review and Analysis Directorate at the Office of the Veterans Ombuds, said that “women veterans are two to three times more likely to be medically released” than men veterans, and remarked that when “[c]ompared to women in the Canadian general population, women veterans … have an 80% to 90% higher risk of dying by suicide.”^[23] She added:

Compared with men veterans, women veterans are more likely to report chronic illness, respiratory conditions and gastrointestinal disorders. They are two times more likely to have an acute injury from training. They are at a two times higher risk of central nervous system conditions. They have higher rates of depression and are more likely to have a panic disorder, a social phobia, generalized anxiety disorder or PTSD. ….^[24]

According to witnesses, for CAF members who have experienced MST, the effects can last beyond their transition to civilian life.^[25] Discussing “sanctuary trauma,” which is a condition that arises when a belief that the CAF would keep members safe is “shattered,” Matthew McDaniel suggested that these members would benefit from specialized services and supports during the transition process.

Witnesses cautioned that the supports, benefits and services offered to those transitioning to civilian life are not tailored to the needs of CAF women or gender-diverse members. Steven Harris maintained that VAC has changed its benefits structure, including the “Table of Disabilities,”^[26] to “make sure there is equity and fairness.” That said, expressing frustration that the Table does not recognize “physical presentations” of PTSD, Christine Wood referred to her primary condition when saying that VAC recognizes PTSD but not “the physical illnesses that are consequential to PTSD, especially in women,” with the result that she has “been denied physiotherapy or [the services of] a chiropractor … .”^[27] In this context, Major (Retired) Riguidel argued:

We need more women-centred programming. OSISS [The Operational Stress Injury Social Support network], Soldier On and Wounded Warriors are not yet made for us. They occasionally try to host bolt-on programs and pop-ups, but they don’t have retreats or treatment dedicated to women veterans.^[28]

Referencing the Office of the Veterans Ombud’s 2021 investigative report entitled Peer Support for Veterans who have Experienced Military Sexual Trauma, Colonel (Retired) Jardine noted that the Government of Canada accepted the report's recommendations, and commented that a program providing peer support for veterans who have experienced MST is being implemented. However, she added that the Office has “yet to see” the publication of a gender-based analysis plus assessment of the program’s development and implementation.

Steven Harris highlighted VAC’s initiatives intended to support women veterans, including the establishment of the Office of Women 2SLGBTQI+ Veterans. He also asserted that VAC conducts “routine consultations” with such veterans about the challenges they experience while transitioning to civilian life.

Drawing attention to the gap in processing times for disability benefits claims being submitted by men veterans and women veterans, Steven Harris indicated that, in September 2021, VAC had dedicated a team to processing claims from the latter. He explained that this approach has helped to “nearly eliminate” this gap.^[29] According to Trudie MacKinnon, Acting Director General at VAC’s Centralized Operations Division, an MST unit was established “to deal with the files that were coming forward in regard to sexual trauma, sexual harassment, and gender-based discrimination in the Canadian Armed Forces. Since we established that unit in 2020, we have received approximately 3,580 claims … .”^[30]

However, Master Corporal Jacqueline Wojcichowsky contended that, because women are underrepresented at VAC, it is “especially difficult for female veterans to access the services and entitlements they require, because the male associates who are processing their files do not understand and therefore undervalue the trauma female soldiers have endured.”^[31]

Military Family Services

Military families play a critical role in supporting CAF members before, during and after their deployment. That said, they provide this support while themselves experiencing challenges, such as difficulties in accessing health care and other services, finding employment, being separated from their parents or spouse, and undergoing repeated relocation.^[32] Consequently, witnesses provided the Committee with their observations about the need to provide military families with health care, as well as other benefits, supports and services.

In Gregory Lick’s view, military families are the “backbone of the military member.” He mentioned that some military family members “take care of the dependants,” such as children, while CAF members are deployed in Canada or abroad. Furthermore, according to Nick Booth, approximately 10,000 military families relocate annually, with about 8,000 of these families moving to a different province or territory. He also observed that, due to operational requirements, about two-thirds of military families “experience periods of absence from their loved ones [who serve in the CAF].”

Lieutenant-General Bourgon stated that “[o]ne of the main reasons people leave the military is the impact of [their] service on their families.” She added that military families have challenges in such areas as accessing adequate health care services, finding spousal employment and securing affordable childcare. Moreover, Gregory Lick argued that the “treatment of [military] families” affects the CAF’s ability to recruit and retain members because family-related issues “can contribute significantly to members’ release.” He also described the treatment of military families as an “issue of national security.”

Concerning mental health, Dr. Tam-Seto asserted that Canada does not have “sufficient” mental health supports and services for the children and other members of military families. She contended that “[c]hildren's mental health care is not great at the best of times,” while Nick Booth also noted that “[t]his situation is not new nor unique to Canada.”

Colonel (Retired) Jardine indicated that, recently, military families, including veterans’ spouses, have spoken to the Office of the Veterans Ombud about being “left to struggle on their own” to address their mental health conditions. She also maintained that “we cannot continue to rely on” military families to support CAF members and veterans without addressing these families’ “mental health needs as a result of supporting a veteran during their service.” Moreover, she noted that, in 2021, the Office of the Veterans Ombud recommended that VAC “provide mental health support for [military] family members in their own right, for conditions related to their veteran's service.”

According to Laurie Ogilvie, most family-centred programs and services for military families are delivered by Canadian Forces Morale and Welfare Services or by not-for-profit organizations, such as Military Family Resource Centres. She described such services as mental health counselling for children, youth and adults, emergency family care assistance, intimate partner and family violence support, a “24-7” crisis and referral line, educational counselling and non-clinical psychosocial supports. As well, she mentioned that Canadian Forces Morale and Welfare Services cooperates with various stakeholders to “extend [its] capacity to offer [supports and] services” through, for example, a spousal employment network and virtual career fairs, telemedicine for relocating families, a military family doctor network and Kids Help Phone crisis text services.

Witnesses focused on the challenges that military families experience in accessing health care and other services, including when relocating to a different province or territory, and identified programs and other initiatives designed to address those challenges. Lieutenant-General Bourgon highlighted Seamless Canada, which DND and the CAF established in 2018 to improve access to supports and services when CAF members and military families are relocating within Canada. She outlined Seamless Canada’s three main areas of focus: childcare; health care; and spousal employment. Furthermore, Laurie Ogilvie and Steven Harris drew attention to the 2023 annual meeting of the Seamless Canada Steering Committee, during which Steering Committee members and provincial and territorial officials discussed such issues as provincial or territorial health cards for military family members and providing improved access to family physicians.

Regarding employment opportunities for military family members, Laurie Ogilvie noted that Canadian Forces Morale and Welfare Services employs many such individuals, and remarked that the spousal employment network assists with finding employment in a number of professions, from “lifeguards in the pools all the way up to executives.”

Lieutenant-General Bourgon argued that care for the children of CAF members, especially subsidized, is essential because it allows them “to be able to do their jobs and to be operationally effective” without having to “worry about what's going to happen to their kids.” However, Senator Patterson contended that, because child care is an area of provincial jurisdiction, finding and “retaining spaces” for the children of CAF members within a province’s child care system is usually not possible.

Concerning military families’ access to health care services, Laurie Ogilvie observed that one of the “biggest challenge[s] with health care right now” is the current shortage of family physicians and other health care providers in the communities where military families reside. She underscored that the shortage “is complicating access to medical care” for these families. Similarly, Nick Booth said that military families have challenges in accessing health care and other services, and indicated that they “may experience an unfamiliarity with civilian organizations and have little time to navigate this before moving on again.”

Laurie Ogilvie commented that Canadian Forces Morale and Welfare Services offers telemedicine to military families, including those who are relocating across Canada, to assist with accessing a family physician or other health care provider. She also stated that Canadian Forces Morale and Welfare Services was “successfully able to negotiate with all provinces and territories to waive the 90-day wait period for families to access medical care when they move to a new province.” Moreover, Steven Harris referred to VAC’s Veteran Family Telemedicine Service, which connects medically released CAF members and their families to health care providers, such as family physicians and nurses, “who are accessible via video, audio or secure text messaging.”

In addition to the family and employment-related supports and services provided by Military Family Resource Centres, Gregory Lick noted that these centres offer mental health services, including teen counsellors, to military families. However, he also acknowledged that “more needs to be done” to provide mental health supports and services to these families, and the centres “need greater funding to be able to support military families better.”

Finally, Nick Booth underlined the important role of Canada-based charities, such as the True Patriot Love Foundation, in funding programs that offer health and other services to CAF members, veterans and military families. Providing an example, he said that the True Patriot Love Foundation supports such families “through the Military Family Resource Centres and other local partners” with the aim of helping children and other military family members “navigate the issues of multiple deployments” or relocation “away from their home communit[ies].”

Transition Services

Each year, approximately 10,000 members release from the CAF.^[33] Witnesses made comments to the Committee about the challenges that CAF members experience during their transition to civilian life. In particular, they outlined that military release involves several life changes, identified a need to reduce the complexities associated with the transition process, and described particular challenges related to accessing transition services and ensuring continuous health care services throughout the transition process.

Military Release and Adjusting to Civilian Life

Gregory Lick emphasized the importance of ensuring that CAF members experience a seamless transition from military life to civilian life. Steven Harris underscored that both the CAF and VAC “are committed to supporting a seamless transition and improving outcomes for transitioning members.” He also asserted that the CAF’s and VAC’s ongoing efforts to reduce “the complexity of the transition process” have focused on enhancing the well-being of CAF members, veterans and military families.

Steven Harris noted that the transition process is experienced differently by each CAF member. He and Matthew McDaniel outlined a number of factors that could affect the transition to civilian life, including access to housing, community integration, employment, financial security, mental and physical health conditions, service history and military rank.

Witnesses suggested that, following their miliary service, CAF members may experience a number of difficulties in adjusting to civilian life, including in terms of their identity. Matthew McDaniel explained that, in addition to the change in employment for some CAF members or retirement for others, the transition can also involve psychological and social changes. Moreover, Gregory Lick argued that the CAF “forms a critical part” of the identity of many members, and indicated that some who are transitioning to civilian life tend to “lose [their] connection [to a shared military identity] while facing physical, mental or moral injuries.”

Similarly, Colonel (Retired) Jardine stressed that transitioning to civilian life can be “just as significant” for CAF members as undergoing basic training and then transitioning from civilian life to military life. She also pointed out that, once basic training is completed, that CAF member is “never truly civilian again,” but rather is a veteran after releasing from the CAF.

Citing the Office of the Veterans Ombud’s 2017 study about the transition to civilian life, Colonel (Retired) Jardine outlined several challenges that CAF members experience during the transition process, such as “finding a new sense of purpose, maintaining financial security, equating military experience with civilian work experience, and coping with the stigma around mental health.” Furthermore, in Matthew McDaniel’s opinion, there are “two major categories of concern in transitioning”: a change in culture when moving from military service to employment with “civilian populations”; and mental health, physical health and occupational stress injury concerns that require support and/or targeted interventions.

Access to Transition Services

According to Commodore Bouchard, the length of the transition to civilian life varies across CAF members. With a focus on medically releasing members, he maintained that some transition over a three-year period and others spend up to six years in the transition process. In addition, Commodore Bouchard estimated that, as of 28 April 2023, there were 1,502 ill and injured CAF members were posted to the Canadian Armed Forces Transition Group.

Robyn Hynes, Director General of Operations at the Office of the National Defence and Canadian Armed Forces Ombudsman, said that the medical release process for CAF members transitioning to civilian life has three main phases. She stated that the first phase comprises the period of time between when an injury occurs or a diagnosis is given and the decision by the director of military careers administration about whether the member will be medically released. According to Robyn Hynes, if a medical release will occur, the second phase is the period of time between when the member is informed about the medical release and the release occurs. Finally, she indicated that the third phase is the period between when the member is released and eligibility for “a number of benefits and services through the Canadian Armed Forces, SISIP [Financial], and Veterans Affairs Canada" begins, which may be up to two years following the release date.

Witnesses pointed out that not all CAF members have adequate access to transition services. Steven Harris contended that, although “[a] large number of members are able to navigate [the] transition [process] themselves or with minimal targeted assistance from available [CAF and VAC] services and supports,” others “may require more intensive or ongoing supports.” Calling for transition services to be “specialized” and “proactive” to meet individual needs, Matthew McDaniel observed that “most [CAF members] transition relatively successfully into civilian life,” although between 25% and 38% “report difficulty transitioning.”

Commodore Bouchard noted a number of transition services that the CAF provides, including transition advisors and service coordinators, to help CAF members and their families develop a transition plan. He particularly highlighted the role of service coordinators in ensuring that “the services [available to ill and injured CAF members] will transition with them if they are releasing from the Canadian Armed Forces.”

Lieutenant-General Bourgon claimed that CAF members who are medically released “aren't left to fend for themselves in the jungle,” with the CAF providing them with needed supports and services to “ensure that they’re ready to be released … .” Providing a different perspective, Gregory Lick commented that the Office of the National Defence and Canadian Armed Forces Ombudsman has identified several situations in which veterans did not have full access to all benefits and services upon being medically released, and added that there might also be veterans who are “not coming forward to indicate that they are unprepared for release, [and] that their benefits and services are not in place.”

Lieutenant-General Bourgon said that Canada’s 2017 defence policy—Strong, Secure, Engaged—instructed the CAF to establish the Canadian Armed Forces Transition Group to ensure the existence of a “seamless and successful transition to civilian life” for CAF members. Commodore Bouchard explained that this group replaced the Joint Members Support Unit, which was created in 2009 to support ill and injured members during their transition to civilian life.

Lieutenant-General Bourgon, Commodore Bouchard and Steven Harris noted that there are currently 32 transition centres located at CAF bases and wings across Canada, with Commodore Bouchard stating that the Canadian Armed Forces Transition Group oversees the work of those centres. According to Mark Roy, VAC’s Area Director for Central Ontario, these centres are staffed by CAF, VAC and Military Family Services employees. Steven Harris stated that the centres provide online and/or in-person transition training courses that address a wide range of topics and are mandatory for those who are releasing from the military.

Furthermore, underlining that the CAF and VAC have a “new military-civilian transition process to ensure a seamless, personalized and standardized process across all transition centres,” Colonel Helen Wright, Director of Force Health Protection at the CAF’s Canadian Forces Health Group, identified the seven areas of well-being in that process: family, finance, health, housing, life skills, “a sense of purpose” and social environment. As well, Colonel Wright commented that the centres have integrated support teams that assist in developing a transition plan that is both based on these seven areas and “tailored” to each CAF member transitioning to civilian life.^[34]

Colonel (Retired) Jardine discussed the supports that transition centres provide to ill and injured CAF members and veterans and indicated that providing such services to non-medically released veterans in “the same way that has been done for medically released veterans will go a long way to easing the transition from military back to civilian life.”

Steven Harris pointed out that VAC case managers work with releasing CAF members and veterans who need additional supports and services during and following their transition to civilian life to “identify their goals, needs, assessments and a plan to achieve independence, health and well-being.” Moreover, Jane Hicks, VAC’s Acting Director General for Service Delivery and Program Management, noted that VAC is “investing significant efforts in the transition process.” She highlighted that such efforts include informing CAF members and veterans about benefits and services that are available upon release from the CAF.

Providing a different perspective, Colonel (Retired) Jardine observed that, although the CAF and VAC provide “great support” to medically releasing CAF members, that “is not necessarily the case” for CAF members releasing for non-medical reasons. She was concerned that CAF members who release for non-medical reasons and who do not have sufficient years of service to be eligible for a CAF pension may not have access to a public service health care plan or “the pensioners’ dental services plan.” She also said that CAF members with fewer than 20 or 25 years of military service and perhaps with military service-related illnesses and injuries may experience delays in VAC’s adjudication of their disability claims.

Gregory Lick drew attention to seven recommendations regarding the transition to civilian life and operational stress injuries that the Office of the National Defence and Canadian Armed Forces Ombudsman included in several reports in 2016. Commenting that these recommendations were accepted by the Minister of National Defence, he underscored that—as of 12 June 2023—none of those recommendations had been “fully implemented.” According to him, one recommendation proposed that “no member of the Canadian Armed Forces should be medically released without all benefits and services, from all sources, including Veterans Affairs Canada, in place.”

Matthew McDaniel said that the Government should implement all recommendations contained in the Office of the National Defence and Canadian Armed Forces Ombudsman’s 2016 reports regarding the transition process and operational stress injuries. However, he acknowledged that implementing those recommendations “take[s] time.” Furthermore, he called for increased social supports and services to be provided to CAF members, veterans and military families because, “[w]hen service members leave the military, they often leave behind their dominant social support network,” which affects “their ability to cope with transition challenges.”

Referring to the CAF’s approach to the transition to civilian life as “holistic,” Commodore Bouchard stated that “we have Veterans Affairs Canada embedded with us to better support our members as they transition.” Steven Harris pointed out that, since 2015, the CAF and VAC have provided medically releasing CAF members with “enhanced transition services” that involve earlier engagement “to provide coordinated and integrated support.”

Acknowledging that, despite the CAF’s and VAC’s efforts to “provide transition services for a considerable [period of] time, historically, there was a potential gap for non-medically releasing members,” Steven Harris mentioned one initiative designed to address this gap: the 2019 creation of the joint CAF and VAC Military-to-Civilian Transition process for non‑medically releasing CAF members and their families. According to him, this process is “being implemented nationally and will be fully operational as of March 2024.” Moreover, Commodore Bouchard asserted that, once fully implemented, the process will be available to all CAF Regular Force members, with subsequent expansion to those in the Reserve Force.

Discussing employment services, Colonel (Retired) Jardine noted VAC’s career transition service, which assists CAF members and veterans “in their journey to civilian employment.” Steven Harris referred to VAC’s Education and Training Benefit, which provides funding for education and training to help ensure that veterans can have a “successful transition and position [themselves] to be more competitive in the civilian workforce.”

However, Colonel (Retired) Jardine underlined that a number of CAF members and veterans, particularly officers, have challenges with “translating military competencies to civilian competencies,” and with finding employment that is related to their military service. In her view, for financial reasons and “to meet the need for a new sense of purpose,” a large proportion of CAF members and veterans seek employment as part of their transition to civilian life. Furthermore, to facilitate access to civilian employment opportunities, Mathew McDaniel suggested that there is a need to help releasing CAF members to transfer their military skills, including in relation to teamwork, from the “military culture” to the “civilian culture.”

Finally, Colonel Lisa Noonan, Director of Transition Services and Policies at the Canadian Armed Forces Transition Group, said that, in 2020, the CAF established the Military Transition and Engagement Partnership to offer services to releasing CAF members.^[35] According to her, such services include access to “third party organizations” that provide transition, outreach, and other type of programs and services to “all the unique members of our CAF population,” including women, Indigenous peoples and people from “varying cultural backgrounds.”^[36]

Provision of Continuous Health Care Services

Witnesses drew attention to the challenges that CAF members and veterans experience in accessing health care services in civilian health care systems during and following their transition to civilian life. Describing the transition from the CAF’s health care system to a civilian health care system as “problematic,” Major-General Bilodeau underscored that the civilian systems are not able to meet the needs of releasing CAF members. In Dr. Tam-Seto’s view, civilian health care systems do not have the “military cultural competency” that is required for providing CAF members, veterans and military families “with quality care that meet their unique health needs, which have been shaped by military service.”

Comparing the services provided to medically released CAF members and those who are not medically released, Colonel (Retired) Pucci noted that VAC provides the former with case managers to assist with accessing and “manoeuvr[ing] through” a civilian health care system. However, he argued that CAF members who are releasing and who do not have physical or mental health conditions are “just put out onto the street, and [have] to look after [themselves]” to access civilian health care services.

Dr. Tam-Seto stated that, prior to transitioning to civilian life, some CAF members use personal connections, whether obtained through friends or family members, to help secure access to primary health care providers in a civilian health care system. She maintained that, for veterans generally and particularly for those with chronic or complex health conditions, the “abrupt stopping of services [following their transition to civilian life] creates real potential for a gap in their health care.” She also asserted that some veterans have had to find other means of receiving routine health care from providers in civilian health care systems, such as through urgent care or emergency rooms in hospitals, and walk-in clinics. Furthermore, in her view, “[i]t is not fair for veterans to have to go seeking out health care on their own, particularly for health issues they have acquired on the job,” and CAF members and veterans should be provided with a support system that facilitates their transition to civilian life.

According to Colonel (Retired) Pucci, veterans experience a number of challenges in receiving adequate health care services after transitioning to civilian life. He said that some veterans have to “travel long distances to access health facilities, which can be tiring, expensive and, of course, time consuming,” and noted the increased risk of health complications and delays in treatment resulting from long waiting times for medical appointments. Consequently, he called for the establishment of an “independent body” to facilitate CAF members’ transition from the military health care system to a civilian health care system, stressing that “what veterans want and need is access to [health] care upon retirement.” In his view, such a body, which would not be affiliated with the CAF or VAC, would oversee the work of a task force comprising health care sector representatives and veterans and would require the task force to conduct an assessment of primary care models for veterans within civilian health care systems and in other countries.

As well, witnesses focused on the issue of “attribution to service”^[37] for medically releasing CAF members, with Gregory Lick underscoring that “improving processes related to service attribution and faster benefits and adjudication decisions [regarding disability claims] would go a long way to improving the transition process” for such members. He also stated that the CAF “would be best suited to making” decisions regarding attribution to service, adding that:

… the earlier that service attribution of an injury is made before [members] release from the [CAF], the better and the more efficient the adjudication would be in VAC. What we've recommended before and what we continue to recommend is to have that service attribution done before [a member’s] release, so that the adjudication of whatever benefits [and health services the member] should receive is done much more quickly.

Colonel (Retired) Jardine identified a need for information about “how many [disability] claims [submitted to VAC by veterans] are denied because of attribution to service.” She also mentioned that “veterans service officers in the [Royal Canadian] Legion” could help veterans submit disability claims that are linked to attribution to service.

Dr. Tam-Seto suggested that the Government cooperate with provincial and territorial governments to facilitate access to civilian health care systems for CAF members and veterans. She also emphasized the need for the Government to extend military health care services for them “well beyond [their] date of release until they can find a primary provider within the civilian health care system.”

Major-General Bilodeau discussed a number of actions taken by the CAF, in collaboration with VAC and various other stakeholders, to facilitate CAF members’ transition to civilian health care systems. He noted a process that allows CAF members to “stay in uniform longer to ensure a safe transition,” and stated that this process “[enables] us to bridge the gap, so to speak, in light of the [health care] resource availability issues” in civilian health care systems.

In addition to acknowledging the “increased efforts” of some service providers in civilian health care systems to enhance “military-specific knowledge” among those who provide care to CAF members, veterans and military families, Dr. Tam-Seto asserted that “there is much to be done in the training and certification of health care providers.” Major-General Bilodeau referred to cooperation among the CAF, VAC and the College of Family Physicians of Canada to develop a document to “encourage” family physicians working in civilian health care systems to provide care to CAF members and veterans, and to inform those physicians about “what life is like for veterans.”

With a focus on the medical files of CAF members, Mark Roy contended that those files “are entirely accessible in electronic format,” and Steven Harris said that the files could “follow military personnel to some extent” from military life to civilian life. As well, Steven Harris highlighted that members’ medical files would not be transferred from the CAF to VAC if access to VAC’s health programs and services is not required. However, he noted that VAC could request these files if access to those programs and services were requested.

Dr. Tam Seto argued that there is no “consistent mechanism” through which a CAF member’s medical files can be transferred from the military health care system to a civilian health care system. Suggesting that such a transfer is not an “easy task,” Major-General Bilodeau maintained that the CAF has had to develop “13 different solutions, one for each province and territory.” He also pointed out that one challenge regarding such transfers is converting electronic files to paper copies, and then scanning those copies for the transfer to a provincial or territorial medical filing system.

Senator Patterson called for the implementation of a “seamless health record policy” that would facilitate the transfer of a CAF member’s medical files from the military health care system to a civilian health care system. Moreover, Nick Booth encouraged the creation of a digital repository, “a veteran health record digital safe”, that would facilitate the electronic transfer of medical files so that veterans could give civilian health care service providers access to their medical files. He also advocated a feasibility study concerning the transfer of a veteran’s medical files for “health care clinician use,” arguing that such a study could improve researchers’ understanding of issues relating to the transfer of medical files.

Observing that mismanaging the transfer of CAF members’ medical files could have negative impacts on their transition to civilian life, Major-General Bilodeau referred to a recently launched CAF initiative that facilitates VAC officials’ access to those files “in order to simplify data sharing” between the CAF and VAC. Furthermore, Steven Harris underscored that the CAF and VAC are expected to work together to ensure that VAC can access required medical files.

Laurie Ogilvie and Steven Harris discussed a telemedicine pilot project, introduced in 2022, that allows CAF members who are transitioning to civilian life, as well as veterans and military families, to access a network of health care providers, such as a physician or nurse practitioner. Steven Harris pointed out that the pilot project provides temporary health care services to releasing CAF members and their families while they wait for permanent access to services in a civilian health care system.

The Committee’s Thoughts and Recommendations

The CAF’s most valuable resource is its members. In the Committee’s view, the Government of Canada must demonstrate its dedication to safeguarding this irreplaceable resource by both prioritizing the health and well-being of CAF members and meeting the needs of their families. It is also imperative that, when a CAF member’s military service ends, the transition to civilian life is straightforward, with ample, timely and seamless access to the services, supports and benefits that they need and deserve.

Both human resource and financial constraints have affected the health care services provided to CAF members. In previous reports, the Committee has made recommendations regarding recruitment and retention issues in the CAF, and the implementation of these recommendations could help to address some of these constraints. However, ultimately, additional funding for such services will likely be required, including to develop and implement programs and other measures relating to mental health, and the health needs of both CAF women and military families.

The transition from military life to civilian life can be difficult for CAF members. The Committee believes that efforts to make the transition process as seamless as possible should involve a range of actions. In particular, these actions should include adequately preparing CAF members for release from their military service, strengthening collaboration between the CAF and VAC, ensuring that releasing CAF members have access to civilian health care systems prior ending their military service, augmenting social support services for CAF members, veterans and military families, and providing services that are tailored to the needs of CAF women and gender-diverse personnel.

Recognizing that the Government of Canada has taken certain steps to address some challenges relating to CAF health care and transition services, but that more actions are needed, the Committee recommends the following:

Recommendation 1

That the Government of Canada commit to making Canada an international leader in the research, diagnosis and on-going treatment of mental or physical injuries caused by military service, such that service members and veterans are fully supported, both during and after their service.

Recommendation 2

That the Government of Canada explore options to reform the current model of CAF healthcare funding, wherein provincial health agencies are often charging CAF members higher than normal service fees to get the medical treatment they require.

Recommendation 3

That the Government of Canada work with industry to expedite the approval of new technologies and modalities of treatments for the Canadian Armed Forces.

Recommendation 4

That the Government of Canada establish a consistent and overarching definition for operational stress injury, military sexual trauma and morale injury that can be used by health care and policy makers, particularly as a shared definition for program eligibility with the Canadian Armed Forces and Veteran Affairs Canada.

Recommendation 5

That the Government of Canada invest greater resources and funds into the research of health and mental health outcomes and impacts of CAF service on women to create necessary health and mental health resources, particularly surrounding fertility, menopause, perinatal challenges and menstrual suppression.

Recommendation 6

That the Government of Canada work with the Canadian Armed Forces to revise the process for booking appointments to reduce wait times for mental health and specialist health treatments.

Recommendation 7

That the Government of Canada explore options for expanding all on-base health services to the families of service members.

Recommendation 8

That the Government of Canada provide greater funding to the Military Family Resource Centres.

Recommendation 9

That the Government of Canada take active measures to ensure that service members who need it are connected to a family physician and relevant specialists upon their discharge to ensure continuity of care.

Recommendation 10

That the Government of Canada create a more efficient process for transferring health records between federal and provincial jurisdictions by working with Seamless Canada to modernize its use of technology and high security storage of data.

Recommendation 11

That the Government of Canada ensure that a determination of injury applicable to service from a CAF doctor or specialist be deemed sufficient for the purposes of Veterans Affairs Canada and that the veteran not require additional screening to access treatment, benefits, or supports.

Recommendation 12

That the Government of Canada work to ensure all relevant health resources are available for CAF members transitioning to VAC the moment they are discharged from the military.

Recommendation 13

That the Government of Canada give the Canadian Armed Forces the ability to retain medically released members until such time as all the benefits and services from the Canadian Armed Forces, Veterans Affairs Canada, and Service Income Security Insurance Plan have been confirmed and put in place.

Recommendation 14

That the Government of Canada collaborate with the relevant provincial and territorial licensing bodies to allow for the priority licensing of doctors from NATO allied countries that wish to join the Canadian Armed Forces.

Recommendation 15

That the Government of Canada work with the Canadian Armed Forces to ensure competitive health care wages and employment for CAF members, contractors and public sector employees.

Recommendation 16

That the Government of Canada retrain service personnel who have been injured, whenever possible, rather than release them for not meeting the universality of service doctrine.

Recommendation 17

That the Government of Canada undertake a comprehensive and comparative review of the health and transitioning services of allied nations to learn and potentially adopt practices that can benefit the quality of care both serving and retired members of the Canadian Armed Forces can receive.

Recommendation 18

That the Government of Canada, particularly the Department of National Defence and the Canadian Armed Forces, begin a consultation process with expert military medical practitioners, social workers, psychologists, and former members of the Canadian Armed Forces, to establish a nationwide data base of these critical professionals to ensure outgoing members have a seamless transition to health services when they leave the CAF.

Recommendation 19

That the Government of Canada prioritize efforts to reduce the wait times for CAF members, who are being medically discharged, to have their injury attributed to service in the forces.

Recommendation 20

That the Government of Canada increase its efforts to replace the aging medical infrastructure in the Canadian Armed Forces and the Department of National Defence.

Recommendation 21

That the Government of Canada move to implement a digital medical record system to replace the existing and antiquated health record-keeping system used by the Canadian Armed Forces and the Department of National Defence, where the medical information of members of the Canadian Armed Forces is readily accessible to employees from Veterans Affairs Canada, military medical personnel, and civilian medical practitioners, for the purpose of facilitating access to medical records across the entities, for the calculation of medical entitlements and for a seamless transition upon release from the CAF.

Recommendation 22

That the Government of Canada immediately implement the following recommendations, made by the Ombudsman’s Office, and already accepted by the Government of Canada, in the reports Canadian Rangers: A Systemic Investigation of the Factors That Impact Healthcare Entitlements and Related Benefits of the Rangers, and A Systemic Review of the Compensation Options for Ill and Injured Reservists:

• “That the Department of National Defence and the Canadian Armed Forces eliminate ambiguity and inconsistency in language in the policy framework for Reservists, with a focus on health care entitlements, as soon as possible.”
• “That the Department of National Defence and the Canadian Armed Forces ensure compliance with the existing illness and injury reporting process so that Canadian Rangers are not inadvertently barred from accessing their health care entitlements and related benefits.”
• “That the Department of National Defence and the Canadian Armed Forces ensure the delivery of health care to Canadian Rangers to which they are entitled by: engaging with Canadian Rangers with the view of identifying the barriers to their access to Canadian Armed Forces health care, and their health care needs within their social and cultural contexts; and identifying and implementing a service deliver y model for Canadian Armed Forces health care that is responsive to the identified needs of the Canadian Rangers.”
• “That the Department of National Defence and the Canadian Armed Forces take concrete steps to ensure Canadian Rangers have a clear understanding of the importance of reporting injuries, and to improve their knowledge and awareness of the health care entitlements and related benefits available to them by:
  • .... Amalgamating information on Canadian Ranger health care entitlements and related benefits;
  • .... distributing this information to Canadian Rangers in various languages and formats as necessary, by fall 2018;
  • .... and ensuring that this information is integrated into formal and any other relevant training offered to the Canadian Rangers, by fall 2018.”
• “The Department of National Defence and the Canadian Armed Forces improve the governance and administration of the Reserve Force Compensation process by: a) Creating a functional authority who is accountable for the Reserve Force Compensation process, and who can reinforce the applicable policies and directives in place; b) Amending Canadian Forces Military Personnel Instructions 20/04 to provide clarity and consistency in the cessation of service due to service-related injuries and illnesses; c) Streamlining the Reserve Force Compensation process by: i) Standardizing and simplifying forms; and ii) Ensuring that units forward claims directly to the Director Casualty Support Management for adjudication, within 30 days of the time the application was commenced; and d) creating a Defence Administrative Order and Directive to codify the Reserve Force Compensation process, including service standards or a performance measurement strategy to validate the effectiveness of the entire process.”
• “That the Department of National Defence and the Canadian Armed Forces take concrete steps to improve the knowledge and awareness of the compensation options available to ill and injured Reservists by: a) Making any relevant documents, policies, procedures and forms easily accessible on the internet and on the Defence Information Network; b) committing the resources required for the development and implementation of a communications plan, including i) activities, ii) products, iii) timelines, and iii) metrics to reach and inform Reservists about available compensation options; and c) formalizing training on Reserve Force Compensation and the Government Employees Compensation Act, and defining the roles and responsibilities for all Reservists and their leadership within these processes.”.

Recommendation 23

That the Government of Canada immediately implement the following recommendation, made by the Ombudsman’s Office, and already accepted by the Government of Canada, in the report Part-Time Soldiers with Full-Time Injuries: A Systemic Review of Canada’s Primary Reserve Force and Operational Stress Injuries:

• “That the Department of National Defence and the Canadian Armed Forces improve the clarity and administration of Reservists’ entitlement and eligibility for health care, periodic health assessments and future Reserve employment by: a) Completing the revision of Queen’s Regulations and Orders, Chapter 34—“Medical Services,” that has been under review since 2009, to clearly identify all entitlements to care for all Reservists; b) incorporating the requirement for Reservists to undergo routine periodic health assessments (or to have their medical readiness determined) into the revised Queen’s Regulations and Orders Chapter 34—“Medical Services” (along with associated policies and directives). Once this requirement is codified, ensure that the appropriate resources are in place to guarantee Reserve medical readiness; c) confirming in Canadian Forces Military Personnel Instruction 20/04 that Reservists whose Medical Employment Limitations so allow may be eligible to obtain new employment despite the existence of a temporary medical category.”
• “That the Department of National Defence and the Canadian Armed Forces take measurable steps to improve the knowledge and awareness of the entitlements available to all Reservists, especially those who may be ill and injured, by: a) Making any relevant documents, policies, procedures and forms easily accessible on the internet and on the Defence Information Network, and ensuring this information remains current; b) committing the resources required for the development and implementation of a communications plan. This would include activities, products, timelines and metrics to reach and inform Reservists; c) ensuring that training on entitlement to health care (currently provided by the Field Ambulance Medical Link Teams) is effective and mandatorily provided to Reserve units; and d) ensuring that Reserve units have the appropriate number of training days to provide mandatory training to their members, and that such training is completed.”.

Recommendation 24

That the Government of Canada, consistent with the best practices of the health insurance industry and for the prevention of chronic conditions, remove the requirement that Canadian Armed Forces members must obtain a physician’s referral to access chiropractic treatments that can be claimed through insurance. Moreover, the Government should increase the annual amount that can be claimed for such treatments.

Recommendation 25

That the Government of Canada evaluate and test the suitability of uniforms, equipment and other gear for Canadian Armed Forces women on a continual basis. Moreover, when conducting such evaluations, the Government should apply a gender-based analysis plus lens to ensure that Canadian Armed Forces women can carry out their duties safely and comfortably.

Recommendation 26

That the Government of Canada provide Canadian Armed Forces members with full access to reproductive care, including fertility preservation and treatment benefits.

Recommendation 27

That the Government of Canada establish standards designed to ensure that the medical assets and resources available to Canadian Armed Force women while they are deployed meet their needs, regardless of where they are serving, and integrate women’s health education into pre-deployment training.

Recommendation 28

That the Government of Canada, in collaboration with relevant stakeholders, take immediate steps to eliminate the stigma concerning mental health services for Canadian Armed Forces members and military families, including by amending Section 98 of the National Defence Act to remove the criminalization of self-harm for Canadian Armed Forces members.

Recommendation 29

That the Government of Canada increase awareness, among Canadian Armed Forces members, about the physical and mental health benefits, services and supports that they can receive during and following their release from the Canadian Armed Forces.

Recommendation 30

That the Government of Canada, respecting provincial and territorial jurisdictions and in cooperation with relevant stakeholders, ensure that mental health and other care providers at operational stress injury clinics have adequate training to provide treatments and programming that are tailored to situations involving military sexual trauma. As well, the Government should design and implement a mental health training program for Canadian Armed Forces members that focuses on responding to the disclosure of sexual assault.

Recommendation 31

That the Government of Canada work with provincial and territorial governments, as well as relevant other stakeholders, to ensure that all Canadian military family members have access to mental health services and supports that are both adequate and tailored to their needs.

Recommendation 32

That the Government of Canada, in collaboration with provincial and territorial governments, expedite its efforts to increase the availability of—and secure access to—affordable child care and family physicians for military families.

Recommendation 33

That the Government of Canada reaffirm the importance of spiritual and religious care for CAF members and their families and adopt a policy of inclusion in the Chaplain Services that ensures all CAF members are able to receive pastoral care in all religions, faiths, and spiritualities, and furthermore that Chaplains from all religions and faiths are welcome in the Chaplain Services and are protected by the Charter of Rights & Freedoms